What do you say to a friend, loved one or stranger you believe is going to end their life, even if they aren’t telling you directly?
Jen Fanning, executive director of the Grand County Rural Health Network in Hot Sulphur Springs, knows the answer to that question intimately.
Seven years ago, she was at home when an acquaintance she knew to be seriously depressed came to visit. The two talked for a while and as he was leaving, he said something that set off her alarm bells.
“I can’t remember his exact words, but it was something like ‘Everyone will be better off if I’m not here anymore, so I think I’m gonna do something about it,’” she said.
Fanning jumped into action, saying phrases she’d practiced in a mental health training course she’d taken days earlier: “I need you to stop. I need you to turn around. And I need you to look me in the eye and tell me if you have plans to kill yourself.”
When her friend answered with uncertainty, she said something else she’d just practiced: “Then I need you to come back inside. We need to talk through this. Because I can’t let you walk through that door if the answer is ‘I don’t know.’”
Fanning was able to get her friend back inside. Within hours, “We had a safety plan. We had people he could call. We’d found a network who could support him,” she said. And when he left, she felt confident that he wasn’t going to take his own life.
She knew what to do because she’d taken Mental Health First Aid class administered through the National Council for Mental Wellbeing. According to statistics the Rural Health Network recently released, it’s training Grand County still desperately needs. In the first half of 2023, local EMS responded to 145 calls regarding substance abuse, and since 2020, drug-related deaths have more than doubled, with five from overdose, eight related to chronic alcohol use and nine from suicide in a county of around 16,000 people best known for its outdoor recreation.
If Fanning, Mind Springs Health, Grand County Public Health and 27 other community partners have their way, soon many more adults in their corner of the high country will go through the same training. The need for residents who can help one another alongside standard services is identified in an updated mental health and wellness action plan that relies little on outside funding and heavily on the insights of residents with “lived experience.”
Clearing confusion to streamline services
Historically, funding for mental health services in Grand County has come from over 50 regional, state and federal agencies, each with their own set of rules and conditions.
The rural health network says this has made it difficult for providers to understand how individuals fit into the funding and for people seeking services to know how to get them.
In 2013, local nonprofits, government agencies, schools and health providers began discussing a strategic plan to address mental health. It started with infant and maternal services, Fanning said, and had “some significant wins.”
Chief among them were putting childhood mental health consultants in the area’s school readiness program Grand Beginnings, which serves both Grand and Jackson counties; offering regular Mental Health First Aid trainings like the one Fanning completed; and creating a one-stop mental health resource, buildinghopegrand.com, which offers everything from ways to assess a person’s mental health risk to where to go for immediate or longterm help to methods for avoiding a mental health crisis.
But there were other issues to address.
“Mental health is so big and all-encompassing, and there are so many factors that impact it,” Fanning said.
Some of the causes in the high country include an ever-growing wealth gap that starkly divides the haves and have-nots, lack of affordable housing, substance abuse issues, isolation and the stigma of admitting a mental health problem.
Meanwhile, finding therapists and professional mental health providers in mountain towns has long been an issue. Insurance practices that make providers spend more hours on paperwork than with patients are one part of the problem. And in recent years, many communities have built mental health services on marijuana taxes, which are falling.
But once the Grand County partners saw how effective they could be, they wanted to “keep peeling back the layers of the onion,” said Fanning. “We wanted to address our community’s needs and get to the core of the mental health problem.”
That led to a second overhaul of their mental health plan in 2018. Major outcomes included creating an intervention program for those experiencing acute suicidal ideation, short-term funding for transportation to services outside of the county, family visits by nurses and bringing Teen Mental Health First Aid training to West Grand High School in Kremmling.
But in 2020, the compounding effects of COVID-19 and the East Troublesome Fire “changed our mental health,” Fanning said. COVID had already created a sense of isolation along with increased substance use and abuse and had led to a spike in depression. The fire then amplified all of these, causing trauma for many. “When I hear heavy wind like what I heard the night the fire ran, I experience PTSD. I know I’m not alone,” Fanning added.
By the time the fire hit, several mental health partners had been meeting weekly to discuss how they could support each other’s agencies, said Abbie Baker, Grand County Public Health director and epidemiologist.
The group included Fraser Medical Center, Byers Peak Medicine, Denver Health East Grand, Middle Park Health, Grand County EMS, Grand County Coroner, Regional Emergency Preparedness Coordinator, Mind Springs Health and community members impacted by mental health, she added. The work continued with the fire, and many of the services associated with 2020’s most devastating events were folded into the next iteration of the behavioral health plan.
Putting the public in public health planning
In 2023, Grand County wanted to include more community members in its mental health planning.
“In the world of health and the general world of equity right now, that’s one of the key ways of making sure that it’s not just a bunch of people who think they know better coming together and making up plans,” said Fanning.
Using two small grants, they began bringing the community together with “people in power at decision-making tables to help make real change,” she added.
The planners took an all-hands-on-deck approach, aligning around initiatives and needs identified by government agencies, school districts, law enforcement, first responders, medical providers, nonprofit agencies and Winter Park Resort.
From education and outreach to provider recruitment and retention strategies, the goal was to continue increasing awareness and access to mental health and substance use recovery resources, and to ensure Grand County residents knew how to support each other in times of crisis.
Among the dozens of parties who participated was the county’s robust library district, which “kept popping up on various mental health strategic plans across different forums because it’s a hub whose role is to serve the community,” said Polly Gallagher, executive director. “We felt that if our name was going to keep popping up, we needed to be a part of the discussion.”
A library becomes a mental health resource
As planning continued, Gallagher and her staff started participating in discussions.
With five libraries spread across the county, the best way to do this was by offering resources and spaces for people struggling with mental health issues to learn, connect and find alternatives, she added.
“Books. We have books,” she said. “And they can be a resource. But we also have snowshoes, so if [a business like Tame Wellness, which offers substance abuse counseling and year-round sober events] is leading an alcohol-free snowshoe hike, we can loan you those. We have meeting rooms that are free of charge from 7 a.m. to 10 p.m., so it could be that organizations providing drug and alcohol counseling or drug testing could meet here.”
While some services in the new behavioral health plan are already in motion, others are on a three- to five-year timeline.
Current services include a co-response to mental health and substance abuse crisis between Mind Springs Health and local law enforcement; fentanyl harm reduction resources (including ready access to Naloxone, a medicine that rapidly reverses an opioid overdose by pushing opioids out of receptors in the brain); and fentanyl-awareness presentations at high schools.
Long-term strategies include establishing sober living communities and reducing barriers to in-patient treatment through discharge support coordination and financial support.
Fanning said sober living houses are popping up in Colorado’s high country, including one in Craig and another in Routt County. And although Grand County “isn’t committing to any model yet,” they are exploring the options.
The model for the Routt County house is “really amazing, because the facilitators don’t want to own the house,” Fanning added.
“They want a long-term lease. We’re talking 10 to 20 years. And studies show the model works, because it’s the residents’ job to take care of the house and surroundings. So, you know, they’re model tenets compared to seasonal tourists, which makes it easier for the landlords to sign up for that program.” And it takes the onus off the partners to buy a house during a housing crisis.
Many say it’s time for more rural residents to step in and start playing a role in their neighbors’ mental health.
That’s happening in various places across Colorado.
Kimberly Behounek, director of behavioral health at Gunnison Valley Health, said prior to 2021, the lack of access to outpatient care and mobile crisis services in Gunnison and Hinsdale counties was resulting in people in her community going without services.
Like Grand County, their needs were revealed in community assessments. It took a partnership with many organizations to then create a “line of services,” complete with outpatient clinics in four locations, clinicians embedded in every school within the Gunnison Watershed School District and things like free peer support and mobile crisis services to help, Behounek said.
“We started tracking emergency room utilization in 2021 and continue to date in an effort to provide the right care and follow up post discharge,” she added. “From 2021 to 2022 we saw a drop by 71 admissions. Year-to-date for 2023 from 2022 we saw a drop of 50 admissions. The length of stay has also shortened each year, which is essential for a critical access emergency room with limited beds. We attribute the changes to our efforts to have peer support specialists in the emergency room and making post discharge follow-up calls to connect to the proper level of care ongoing.”
Other counties are continuing to do their part as well.
And in 2023, the Grand County Rural Health Network trained 75 people in Mental Health First Aid. Fanning said the goal is to offer the classes at least every other month, so community members can provide their neighbors appropriate support until professional help arrives. It’s just one way a community is tackling its mental health problems with the help of people who’ve felt them directly.
“One of our partners, Colorado Cross Disability Coalition, has a motto – ‘nothing about us without us,'” she added. It means “real, lasting change simply cannot occur without voices at the table of people who are impacted by the issues. Only then can policy makers, decision makers and people in positions of power and authority truly understand the issue and create solutions with minimal unintended consequences.”