In Villages, First Responders Frustrated By An Overburdened Health Care System

Sep 12, 2018

The Yukon-Kuskokwim Health Corporation in Bethel, Alaska. The organization's goal is to provide holistic mental health care to a remote region the size of Oregon, and that involves a myriad of challenges.
Credit Dean Swope/KYUK

A little after midnight at Mountain Village’s police station, Village Police Officer Anna Bill walks into a back room with a thick stack of papers. She’s holding a pile of Title 47s, a form that law enforcement uses to place involuntary holds on people who pose an immediate threat to themselves or others.

"This is just from the last couple months," Anna says. She thumps the papers down on the table in front of her. "And it's a whole stack."

By Anna’s count, over 50 Mountain Village residents have attempted suicide in the past year. She’s worked to save each one of them, and as the community’s first responder, she’s also the first person to decide whether a survivor needs further mental health treatment. If Anna suspects that they do, she calls the Yukon-Kuskokwim Health Corporation's Behavioral Health Department and arranges for a clinician to assess the individual by phone or video conference. If the suicide attempt survivor is still at risk, then Anna fills out a Title 47, and the patient is flown to Bethel’s hospital for treatment.

The problem, Anna says, is that plenty of survivors are sent right back to Mountain Village. She says that she’s helped save children who’ve attempted suicide multiple times, some as young as 11 or 12, who were sent home from the hospital the same day that they arrived.

"There's another one," Anna says as she leafs through the Title 47s. "Four repeats so far on just one person." She flips a page and looks startled. "Five!" she says. The girl who attempted suicide is just 15.

That patient is receiving residential treatment now, but Anna thinks that she should have gotten that level of intensive care a lot sooner. In villages throughout the Y-K Delta, first responders are trying to navigate a confusing and overburdened health care system, and Anna is just not convinced that the survivors she helps are getting the mental health care they need.

Anna eyes the pile of forms in front of her, looking tired. "A 15-year-old girl tried five times to commit suicide," she says. "Doesn't that scream more than help?"

When a suicide attempt survivor is "Titled," Behavioral Health employees at YKHC follow a specific protocol to treat them. "Once they arrive at the hospital, the clock starts," explained YKHC's Vice President of Hospital Services Jim Sweeney. Behavioral Health’s clinicians have up to 24 hours to assess whether patients pose an immediate threat to themselves or others. As soon as they don’t, Sweeney says that the hospital is legally required to release them, which is one of the reasons people who've attempted suicide sometimes fly back to their villages so quickly.

Sweeney added that Behavioral Health’s case managers try to keep track of these patients; they offer them counseling and psychiatric treatment, and they make follow up calls to see if they need more help. "That happens within a few days after they leave here," he said.

That’s the way it’s supposed to work. But over the past few months, KYUK has spoken to a half-dozen former employees of YKHC’s Behavioral Health Department, as well as other professionals who’ve worked closely with that division. All of them asked to remain anonymous. They said that patients who have attempted suicide rarely receive the follow up care they need. One former Behavioral Health employee said that over 90 percent of patients never receive a follow up call from the department’s case managers or intake coordinator. Several others said that patients routinely tell them they “just never heard back” from the Behavioral Health Department. When KYUK asked Jim Sweeney about this, he said that he’s never seen that happen.

"Could it happen? Sure," said Sweeney. "We're a human system. When we hear about it, when we know about it, we reach out to that person and we make sure that it won't happen again. But I think a lot of times it's rumor, it's innuendo. It's very hard to fight a negative like that."

Former Behavioral Health employees also said that suicide attempt survivors and other patients aren’t required to schedule follow-up appointments before the hospital releases them, which Sweeney confirmed. That isn’t allowed at other hospitals, such as Northstar Behavioral Hospital or the Alaska Psychiatric Institute (API). According to API's CEO, Ron Hale, Medicare and Medicaid require his staff to schedule follow-up appontments with patients before they can be released. "To be honest with you," he said, "it's just good patient care."

If you live in the villages, it can also be hard to schedule any follow-up care in the first place. Behavioral Health’s clinicians are routinely understaffed, and according to an anonymous source familiar with both organizations, the Lower Kuskokwim School District currently employs more Master's-level social workers than YKHC's Behavioral Health Department does.

Sweeney acknowledged that YKHC can struggle with retention. "It’s a different life out here," he said. "Sometimes it just isn’t what they [employees] expected it to be, and they don’t stay with us."

YKHC is trying to fix these issues. The hospital is constantly hiring, and its expansion project will include a designated space for behavioral health services. According to YKHC spokesperson Mitchell Forbes, the new unit will increase the number of beds the hospital allots to that department. 

YKHC is trying to provide holistic mental healthcare to a remote region the size of Oregon, which involves many challenges that are out of its control. According to Sweeney, about 50 percent of patients who pass through Behavioral Health decide against any follow-up treatment. YKHC also regularly refers patients to state hospitals for further care, but there’s often no place to put them.

"There’s just a state-wide shortage of beds for people like that," said Sweeney. "It does happen regularly."

API is one of those hospitals. The facility has weathered a series of scandals over the past year and is currently under investigation. Many of those controversies can be traced back to staffing issues, and CEO Ron Hale freely admits that his hospital struggles to retain enough personnel to care for its patients. "In order for me to provide safe staffing to the hospital, I've actually closed down 22 beds," he said.

According to Alison Kulas, the Executive Director of the State Suicide Prevention Council, Alaska's state-wide bed shortage comes down to the state’s budget. "I think that’s a huge issue, and we hear it a lot across the state," she said. "Unfortunately, I think a lot of times it does come down to funding, and we’re in challenging times here."

In the meantime, first responders in the Y-K Delta’s villages are doing what they can. In Mountain Village, Anna Bill tells me about one woman whose life she’s saved a few times this year.

"I go pick her up. She comes in. She gets 'Titled.' I send her off. She comes back that same day," she says. "That next week, or the week after, she's attempted it again. So I go back and pick her up, retitle her, send her off. She comes back again."

In the face of all these obstacles, Anna says, communities need to do what they can to care for suicide attempt survivors themselves. KYUK will explore Mountain Village's grassroots suicide prevention programs in part three of our four-part series.

This is part two of a four-part series on first responders in Mountain Village.

If you or one of your loved ones is struggling with suicidal thoughts, please call the Suicide Prevention Hotline at 1-800-273-8255. You can also call the YKHC Behavioral Health Department's Crisis Response Line at 907-543-6499 or toll-free at 1-844-543-6499.