Despite the cliché, big ideas don’t always come to us in a Eureka moment. Sometimes it takes a confluence of events, a steady accretion of data, to crystallize a path forward out of a problem.
For Megan Tanous, Chief Development Officer for the St. Luke’s Wood River Foundation (disclosure: Tanous is the author’s spouse), that confluence came in the fall of 2022. A close friend with young children had recently lost her husband in a biking accident, and Tanous witnessed first-hand and could understand on a personal level the vulnerability of children to traumatic events. At the same time, physician colleagues at the St. Luke’s Wood River Medical Center—family practice and E.R. doctors alike—had been relaying to her that they needed help in handling the increasing influx of behavioral health cases, particularly coming out of the COVID pandemic. The Emergency Room had long been the de facto crisis center for mental health issues, but such cases, Tanous points out, are very resource heavy. An E.R. isn’t really a sustainable model for addressing the problem.
Then there was a movie screening of Ken Burns’ film, “Hiding in Plain Sight.” Tanous was seated next to Tyler Norris, a community health and development consultant. After the film, the two started talking about what a solution to a wave of mental health concerns might look like.
For years, a number of nonprofit organizations—the Crisis Hotline, the 5B Suicide Prevention Alliance, St. Luke’s Center for Community Health, The Hunger Coalition, and others—had been independently working to provide solutions for those they encountered. But the epiphany Tanous and Norris had was that a long-term solution had to take a collaborative approach; it was too big of a problem for any one entity to solve alone. They would have to create an “integrated ecosystem of mental well-being services and programs,” Tanous explained.
The Data
Every three years, tax-exempt hospitals must conduct what is called a Community Health Needs Assessment (CHNA). It is a systemized process of engaging community members, identifying health care needs, and determining and prioritizing solutions to fill those needs. The CHNA for Blaine County considers a broad range of factors that affect community health, including housing concerns, employment, and access to health care. This is what is known as a “Social Determinants of Health” framework.
Megan Tanous, Chief Development Officer, St. Luke’s Wood River Foundation
“During my entire career at St. Luke’s, in every cycle of the CHNA, mental health has popped up as one of the top needs for the community,” Tanous noted.
In the most recent CHNA (2023), the findings pointed to three priorities: access to health-related services; addressing mental well-being, including suicide and substance abuse issues; and the high cost of living, including housing, childcare, and early learning.
Access to health care and oral health care is affected by several factors: long waits for appointments, difficulty in paying for services, and little or no insurance for health care services. The Hispanic/Latino population in Blaine County is disproportionately uninsured compared to the rest of the state. Nearly 48% of the uninsured in Blaine County are Hispanic/Latino. Language and cultural barriers can also play a role in inhibiting access.
The second key finding—mental well-being concerns—cited, in particular, difficulty in accessing affordable mental health care and treatment for substance abuse. Blaine County has a shortage in mental health professionals, with only 247 professionals per 100,000 people compared to the statewide ratio of 308 per 100,000.
What’s more, according to the South Central Public Health District’s 2023 Suicide Prevention Gap and Needs Analysis, Idaho has one of the higher death-from-suicide rates in the nation. Over the years 2018-2022, the aggregate average death-by-suicide rate for the state was 24 per 100,000 people. The average for Public Health District 5, which includes Blaine County, was even higher—26.5 deaths-by-suicide per 100,000 people. Both are significantly higher than the national rate, which hovers around 14 per 100,000.
Survey data showed that community members were specifically concerned about substance abuse, access to substance abuse treatments, stigmas associated with such treatments, and the connection between substance abuse and mental health. Survey respondents stressed that the two were commonly linked and so had to be solved in tandem.
Finally, the assessment found that the high cost of living in the county is adding to stress on families. The county has experienced rapid growth without the commensurate growth in housing, which, naturally, drives up the costs of both renting and home ownership. Survey respondents indicated that high housing costs directly affected their ability to meet other household expenses, such as those for dependent care, food, and health care.
Perhaps most alarming to those working on this effort was what children were saying about their mental health. In an ongoing, 5-year study conducted by Boise State University’s Communities for Youth in partnership with St. Luke’s Wood River, children in grades 6 through 12 were surveyed about stress in their lives, sleep habits, feelings of social isolation, and depression as evaluated with the well-established “PHQ-9” clinical scale. Across all grades (6-12), more than 30% of girls reported feelings of “moderate to severe depression.” The range for boys was between 12% and 20%. In every grade, girls showed higher rates of depression than did boys. Survey results from eighth graders were the most concerning: 45% of girls and 20% of boys reported feelings of moderate to severe depression.
Enter the Foundation
The St. Luke’s Wood River Foundation—having committed $100,000 in 2022 to explore the problem—proceeded to do extensive asset mapping: interviewing key leaders in local organizations such as the Crisis Hotline. St. Luke’s Center for Community Health, 5B Suicide Prevention Alliance, The Hunger Coalition, among others, to determine the gaps in services. In addition, the Foundation formed a convening committee of thought leaders to advance solutions. Representatives from organizations across the valley—St. Luke’s Center for Community Health, St. Luke’s Wood River Foundation, Blaine County Sheriff’s Office, St. Luke’s Health System, Blaine County Recreation District The Hunger Coalition, and others—began working together to develop solutions to the problem. Jenna Vagias, an experienced leader in the nonprofit educational world, was tapped to be director of what has become the Blaine County Well-Being Initiative, or MWBI.
St. Luke’s Wood River Foundation President Pete Smith
Earlier this year, the St. Luke’s Wood River Foundation stepped up their commitment to the project with a $4.43 million donation. Foundation Board President Pete Smith said at the announcement: “It is overwhelmingly clear—from community health assessments, rising emergency department admissions, physician concerns, and community feedback—that addressing mental well-being is an urgent priority. We at the St. Luke’s Wood River Foundation feel a deep responsibility to sustain this work.”
Solutions
The MWBI, led by Vagias, is a collaborative effort that stretches across 50 pledged partners, organizations from healthcare, local government, business, and religions. By structuring the effort horizontally in this way, Vagias and her team hope to have a presence at all community touch points. Simultaneously, the solutions the MWBI has identified in its strategic plan attack the problem in a vertical fashion: from prevention and education to treatment access and capacity, to crisis response, and finally a long-term infrastructure to provide ongoing support and care for the community.
First and foremost is prevention. “How do we create an environment that is protective?” said Vagias. In particular, this means building community-wide events and opportunities for people to connect. Vagias and her team are engaging businesses and other local organizations to build a “teen-welcoming” environment, which includes developing spaces up and down the valley to facilitate community engagement at all levels.
Second, the MWBI is focused on community education, with an eye toward developing resiliency and healthy communication skills. As Vagias put it, “How do I show up for others?” The effort will target key leaders in the county, including teachers, coaches, and first responders. There will also be free speaker series, films, and other events to facilitate conversations about mental health, addiction, and seeking help.
A third goal of the MWBI is to increase access to and capacity for mental health treatment. Through philanthropic giving, the Foundation has expanded counseling services offered at the St. Luke’s Center for Community Health. In addition, the initiative has put in place a Spanish language virtual mental health coaching program called Sanarai. As Vagias said, this fills a “gaping hole” in the spectrum of behavioral services available in the county.
The group is also looking at innovative ways to increase behavioral health services in the private sector. Much of this work is focused on ways to lower financial barriers for patients, primarily through assisting with the complex web of insurance billing.
All of this early work by the MWBI, Tanous noted, was a “catalyst for the St. Luke’s Health System investing in a locum adult psychiatrist.” Subsequently, the health system also hired a permanent adult psychiatrist, Dr. Chris Doxey. And this fall, St. Luke’s will bring on a child psychiatrist in Dr. Katie Quayle. As Michelle Ross, Administrator of Behavioral Health for the St. Luke’s Health System noted, “This is the first time this community will have a dedicated child and adolescent psychiatrist.”
Michelle Ross, Administrator of Behavioral Health, St. Luke’s Health System
Quayle, who was a pediatrician in the Wood River Valley from 2018 to 2022, said she “would often see kids struggle with mental health. They might even be diagnosed, but they weren’t doing well.” Quayle felt that there was a gap in her training, and so she decided to pursue an accelerated three-year fellowship and residency in child and adult psychiatry through University Hospitals Cleveland Medical Center. “It changed how I view patients, changed how I approach family and health,” Quayle said. She recognizes that there are some universal issues for children, such as the effects of social media and screens, but that there are some challenges unique to rural communities like Blaine County. These include a higher risk for gun danger, as well as the greater stigma that mental health issues can have in small communities.
Crisis Response
Unfortunately, prevention, education, and treatment do not catch everyone struggling with mental health. Some will and do fall through the system and reach a crisis point. What then?
Perhaps surprisingly, one of the key players in the MWBI is the recently elected Blaine County Sheriff Morgan Ballis. Ballis recognized early on that his team of law enforcement officers would need to be a part of the solution.
“When we look at a crisis response model, there’s three general areas that we look at: it’s someone to call, someone to come, and somewhere to go,” Ballis explained. “The call part has already been addressed and has been addressed for a while. Of course, you can call 911 (Blaine County Dispatch). And then there’s 988 (the Suicide and Crisis Lifeline launched in 2022) and the Crisis Hotline (a local support group).”
As far as the “someone to come” part, “There has always been someone to come; that’s been primarily law enforcement and fire EMS,” Ballis noted. “And what we recognize is that we need to train those first responders to better recognize underlying mental health issues, concurrent issues that have to do with substance use and diagnosed psychiatric conditions. We need to better understand how to support those individuals.”
To this end, Ballis has enlisted Detective Carrie Taylor to provide Crisis Intervention Training, which is open to all law enforcement agencies and medical first responders in the county. The goal, Ballis said, is to “help those first responders to not necessarily show up and be able to diagnose someone, but to recognize—based off a person’s actions, by what they’re saying, their physical state—that there is something else going on that is likely contributing to the situation.”
The long-term goal of the MWBI is to establish a mobile response team. The model the team is looking at would pair a law enforcement officer with a behavioral health clinician. So, in appropriate situations, county dispatch (911) or even 988 dispatchers could send this team to respond and hopefully defuse the issue. What’s more, the clinician would be able to follow up after the crisis to establish a care plan for the individual in crisis.
The idea is to ensure that the “somewhere to go” is the right place for that individual. In the past, the default has always been the county jail or the hospital ER. While the ER team does what they can to treat these patients, they are not equipped to follow up days, weeks, or months later with treatment plans, services, and other resources. And clearly, jail is not a place for treating behavioral health issues.
The last piece of the MWBI strategic plan is to build the infrastructure to sustain long term solutions to the mental health problems in the county. This entails establishing a nonprofit organization to coordinate all of these efforts and provide consistent communications to promote the available services.
The G.I. Joe Fallacy
Yale professor and psychologist Dr. Laurie Santos studies, among other things, the science of “happiness.” She first coined the phrase the “G.I. Joe Fallacy,” referring to the 1980s television show that ended each episode with the tagline: “Now you know. And knowing is half the battle.” What Santos discovered is that “knowing” is not half the battle in overcoming certain biases and problems, particularly when it comes to behavior. Recognition of a problem is a single step in a long series of steps to “rewire ourselves,” that is, to change behaviors and habits that will help us be happier. The same is true when trying to achieve a population-level impact on mental well-being. The stakeholders in the Mental Well-Being Initiative have identified the behavioral health issues the community faces. But moving beyond the “knowing,” they have begun the hard work: parsing the complex issues and integrating solutions across organizations and socio-economic groups.
“Over the last 25 years, the community, through its generosity of time and money, has built a remarkable medical center,” Foundation leader Tanous said. “As it happened, the focus was on physical health. What we’ve learned as a community is that mental health is integral not only to our physical health, but also to our overall well-being. This is our challenge, but it’s one being taken on by a lot of committed and talented folks. I have no doubt we’ll get there.”