Podcast Transcript: Episode 279 – Improving Behavioral Health Through Transport

The complete transcript for Episode 279 is below the fold…

We’re joined by Gail Nehls and Leslie Patterson of Envida, a nonprofit transportation and home care organization. We chat about how transportation can help those with behavioral health concerns such as opioid addictions and schizophrenia, how innovation can change people’s health outcomes, and the systems people need in rural areas to thrive.

JW: Gail Nehls and Leslie Patterson, welcome to the Talking Headways podcast. So before we get started, can you tell us a little bit about yourselves? We’ll start with Gail.

GN (1m 23s): So I’m Gail Nehls and I’m the CEO of Envida. We are a nonprofit in Colorado Springs that delivers specialized transportation, non-emergent medical transportation, and  rural transportation to our community as well as provide home care services in a seven County area. And I’ve been leading the organization for approximately eight years and grown from a half a million to about a $5 million organization with a larger geographic footprint and serving more people that need support for their healthcare needs.

JW: Cool. And Leslie?

LP: Hi, so my background is behavioral health – I have a master’s in counseling. In the past I have worked in the systems in our community to help find solutions for behavioral health problems. I was hired on by Envida because they were taking on helping clients to access transportation to their behavioral health appointments.

JW (2m 20s): Cool. So how did y’all meet? Did Gail just reach out and say, Hey Leslie come on, hang out with us.

GN (2m 24s): Well, let’s talk about that. Like why did we decide to embark on behavioral health in rural areas? Because world transportation is difficult, number one. And from a behavioral health perspective, when people are in crisis overdosing, having mental episodes, how does the community react to that and preserve people’s lives? And so we applied for a FTA grant, federal transit administration grant, and were awarded one of their innovation and mobility grants in 2019. As part of our application, we wanted to hire what we were calling a healthcare mobility manager. And it was to look at navigating the complex systems that are set up to support people, or not support people, with behavioral health issues. And so we have people on our staff that were used to working with people that are less advantaged or have chronic disease. So we reached out and were looking for someone with a behavioral health background and I believe Leslie responded to a job posting.

LP (3m 34s): Yeah, I know someone in the organization knows my background in behavioral health and the systems that I’ve created. And so when she was reading the grant, she said she thought of me.

JW (3m 49s): Cool. So what are those systems?

LP (3m 52s): One is called a recovery community organization where it’s all things recovery. So to help people navigate when they have this in particular with substance use and how do they get from point A to point B when they have somebody who’s dealing with that. And then another one is I started a recovery high school here in the Springs and then I’ve consulted with schools on how to integrate behavioral health into the school systems.

JW (4m 17s): Cool. So can you all lay out the geography for me a little bit? What’s the area like? And I know it’s Colorado Springs, but also some of the mountain areas around there.

GN: Right. So is a really important aspect is the geography. Most recently we were in El Paso County with our specialized transit in the Colorado Springs area and our rural transit out in El Paso County and now going into Teller County for behavioral health and other supportive services. El Paso counties in the middle of the state that encompasses some of the Plains of Colorado as well as the foothills of the front range of the Rocky mountains and Teller has Pikes peak in it. So Teller County is like a 500 square mile County, El Paso county’s like a 2000 square mile County. The population in Teller is about 25,000 people and in El Paso County we’re about I think 700,000 from a County level. So that’s from a broad overview of demographically and geographically, I guess some numbers there for you.

JW: And what are some of the distances between the two places for the two counties, for example, I know kind of because I’ve driven through there before, but I’m guessing a lot of folks might not have.

GN (5m 31s): Right. It’s a beautiful drive from Colorado Springs up to Woodland park. You’re going through this beautiful Canyon area and climbing about 2000 feet. And so the distance there is about, I’d say a 30 minute drive from Colorado Springs up to Woodland Park to Teller County area which also includes Cripple Creek. My reference, from some old songs from I guess from the 70s or 80s or whatever, you know, gold mining towns and also in Teller County, I believe at the start of the South Platte river there’s rock climbing up there; they’re very rural and we have a population of a lot of vets within El Paso County. And there’s about a 12% veteran population in Teller County.

JW: Are they mostly air force vets?

GN: No, it’s amazing. There’s a lot of army here too. And surprisingly there’s Navy people, you’re like, I don’t know how they got there maybe they’re done with water.

JW (6m 26s): Yeah they probably want to run away from the water. Yeah. Well. So that speaks to a really interesting issue about transportation – generally is that if it’s spread out and there is a lot of elevation change and it’s in rural areas, traditionally they can’t be served with traditional transit or fixed route transit. So how did you get started with Envida and moving towards the transportation solutions that you all are working on now?

GN (6m 48s): Thank you Jeff. I think that that is a good question and part of it was after five years attending some meetings in the community and people kept talking about how there wasn’t any transportation in rural El Paso County, we decided to step up and take some calculated risks and apply for some grants. And we were frankly surprised that we were able to combine federal, state and local grants to deliver a rural route, which is like a 30 mile route from Colorado Springs to the Plains of Eastern El Paso County. We learned a lot by delivering and implementing that service. And so that’s why we felt confident to apply for the federal grant to look at providing rides to behavioral health clients in a more innovative approach in Teller County. Cause you’re right. Fixed routes? That would be ridiculous. When you really get on the bus, it’s very expensive to do that: run regularly because as most people in transit know, when people ride a bus the most important characteristic is frequency. And it’s hard to justify running up and down a path when you’re probably gonna get three miles to a gallon and no one riding a bus.

So after what we learned in how to communicate with rural communities, what people want and what they’re going to do should be the same. So we attend numerous community meetings and often there are anywhere from 10 to 30 groups represented from churches, Kiwanis clubs, federally qualified health centers, domestic violence groups, substance abuse groups, and food support networks and housing networks. Anyway, we attend these kinds of meetings and gather what the community is looking for and asking for. And we developed a service. And in preparation for this call with you, Jeff, I reached out to one of our organizations that administrates the Medicaid in our area. And she suggested that we talk about how well we listen to what the people want and tailor our services to what they want and need. And what we also found though is often what people articulate is not what they’re gonna do. And so we just kind of roll the dice and begin the service and reevaluate in the three to six months timeframe, acting continuously to meet the needs of the community. And what we’re finding is we do a more of a deviated fixed route if there is a population density of a town. And then we’re doing more demand response if they’re scheduling. But what’s unique in what we’re talking about today is how to work with behavioral health. Because people don’t schedule their opioid abuse crisis. They don’t schedule their schizophrenic episode. And so how do we as a community support their health needs? And in many of the rural counties, what we’ve seen here in Colorado, it’s these emergency EMT districts that support them. And I think of course that’s important for the EMT is to be there during the crisis and to take them to the mental health hospital, which might also often be in Colorado Springs, but when they’re released after maybe 72 hour, sometimes their only way to get home is then from that EMT. And that’s a very expensive ride. And so we are looking at how do we support people getting back home in a less costly, less resource intense way. But also, you’re not going to send an Uber or Lyft, you know, to travel 40 miles or 50 miles and sometimes on a dirt road for five miles. So what does that look like? And that’s what we’re trying to implement and listen to in the communities that we’re working in.

JW (10m 33s): And that’s an interesting point. I think I read somewhere where you had mentioned that basically an Uber or Lyft or any sort of ride hailing trip would be about $160 round trip to get from where people are and to where they’re going. And so how much does it cost to take a trip on your service?

GN (10m 49s): Well, we’re implementing that right now. So we are looking at what is a Ford Explorer look like with you know, high clearance and with a trained driver that can handle, you know, someone who might go into crisis when even if they were released, that’s not to preclude that they might have another episode in the next hour or two, and to make sure that we have a trained driver and of course all the background checks and familiarity with who could support the driver and the person that they’re transporting if there was some kind of emergency. So we haven’t rolled out the cost yet, we’re still building the cost. We have an infrastructure grant from the FTA and it will be looking for other funding to support the operating costs of that. So let’s talk about what are the factors that go into the cost. So not only is it the fixed asset of the vehicle, you know, the variable because of the driver’s time, because there’s not many volunteers that are going to sign up for this kind of thing. And I’m not sure we really want a volunteer – at least one that is not trained. And so we’re looking at those in the insurances. I can tell you that insurance is no small matter in transport. And we are looking at, you know, the supportive infrastructure for the phones or radio systems or tracking system to support that driver on the road with a passenger. So I would suspect, I mean, so we can develop a per mile cost, a per hour cost and, it’ll be, I think part of what we’re doing with the FDA dollars is to inform people at the state and federal level what does that look like in rural? I know we will save money if we are supporting the EMT vehicles that they could be deployed most appropriately cause they are a very expensive vehicle, so I mean is it $50 a ride? $100 a ride? It’s gonna really depend on the mileage that we’re going to have to travel and the amount of time we spend with a person riding with us.

JW (12m 43s): How intense is the issue in the area that you live in and work in?

GN: That’s a really great question. Leslie please.

LP: So obviously the opioid epidemic has hit us also, but when you have rural areas, you tend to have higher incidents of behavioral health. I mean there’s this assumption, is it because they don’t have access to the care or is it because they don’t get the care? And so when we’re looking at the people that we’re servicing, we’re going through the emergency departments up to Teller to find out who those people are because they already have relationships with them and they have told us that it is very prevalent and the need is very high up there because once they have a crisis, like Gail mentioned, the intention is that they have to get to follow up care and follow up care is really a mandatory part of the behavioral health continuum. And many of them, because they don’t have transportation, they can’t. So then they’re going back into crisis. So absolutely there’s a problem. How many of those people are repeat? We don’t know yet. And it could be a large percentage or the same people continuously going into crisis

JW (13m 51s): Do we know the percentage of folks in that situation that don’t have transportation? Do you have any numbers on that?

LP: That’s what we’re collecting right now. I’m meeting with three organizations tomorrow to pull up that data. UPRAD, we do know that they did anywhere from 600 to 700 rides last year that were in EMT rides.

GN:So UPRAD is…

LP: Oh sorry. The Ute Pass, which is Teller county’s ambulance district. And the information we got last week was Teller County data is 18% experience mental health distress – frequent mental health distress

JW: And have the cases been going up or has it leveled off or is it something that you expect will increase over time?

LP: Well, I think it’s similar to like child abuse reporting, you know, because the information is out there more and more people are talking about it. Is it really that there’s more or is it because there’s more awareness and trying to reduce stigma so more people are getting help?

GN (14m 52s): I’d also like to bring out that in El Paso County, in Teller County, there’s a high incident rates of suicide. And personally at our agency we’ve experienced key senior staff member commit suicide. We’ve had other staff members, family members commit suicide. So what we’re seeing is a personal matter for us as an agency and anything we can do to support people with suicidal thoughts and divert them to get help so that they don’t commit suicide. We’re looking at the overdoses from the opioids in the prescribed opioids. We’re looking at alcoholism and there’s a lot of isolation with people in the rural areas. I mean, I think eventually they may choose that, but it only exacerbates some of these mental health and behavioral health conditions.

JW (15m 39s): Well, that’s why transportation so important because it can connect people together and also like you said, bring them to their appointments and such

GN (15m 46s): and, and I think, you know too Jeff, that from a transportation perspective and people and specialized transit, it’s that relationship between the driver and the rider that really is important for older adults as well as people with developmental disabilities. And I think we can only conclude that it’s also going to be very important for people with behavioral health. They’re going to trust the person that’s driving with them. They might even speak more freely with the driver than their behavioral health therapists. And so we really are going to take the effort to train our drivers because they might be acting as their therapists.

JW (16m 21s): I’ve seen a lot of news about this in the UK as well where there’s like the loneliness epidemic for older residents. And the other thing that kind of struck me from when I was reading up on some background articles about what you all are doing is the connection to, you know, aging populations too and thinking about how older folks want to age in place. But maybe they can, or maybe they can’t or maybe you can help them do that, and might be actually cheaper because there might not be a higher cost for putting folks in a home when they can age in place and have transportation options that might be actually cheaper.

GN (16m 50s): I think you bring out another great point about the aging in place. I mean now as people are retiring in their sixties they moved to these mountain communities that frankly are beautiful, but as they age and maybe a spouse or some other partner passes and they’re left alone, you know, what do they do when they’re 75 or 85, but that’s what we’re seeing is what the numbers in the census data reveals. But most of them want to stay where they are. They chose to stay there. It’s cheaper for them to stay there. So how we support people staying where they want to stay in a cheaper medical model is important and that’s what we’re trying to solve with this rural transportation.

JW (17m 32s): What’s the timeline look like over the next 20 years for the demographics? Changing the need for more folks to potentially age in place and potentially more of them retiring to the mountains?

GN (17m 45s): Well I think, I don’t remember the number right now, but maybe we can look up where Colorado is expecting to boom with people moving here that are older and so percentage wise the state is looking at what does that look like and how are we going to support these people. And frankly, even if they do move to the rural communities, they’re like 80 and want to, people will say: well they should move into the cities where they can get more support and more services. But there’s also a housing pricing and affordability crisis too. And I don’t think we can move them all and even if we wanted to. So it is, I think it does behoove us all to figure out how to support people where they want to live that’s affordable. And it is about that connection piece that transportation provides.

JW (18m 34s): Do y’all have any favorite stories of folks that got help from your organization and have been really thriving because of it?

JP: Our transportation manager – we had a snow day and so he needed to be on the road because a couple people had to cancel. And he had worked with this gentleman with a previous job in a transportation situation and he was very depressed and very overweight and said that he smelled and just, you know, wasn’t taking care of himself. Pretty classic signs for depression. And that when he went out on this route last week, he picked up this same gentleman and he didn’t think the gentleman recognized him, but he’s certainly recognizes gentlemen. And he had lost all this weight. He was clean, he was shaven, he was showered and…

GN (19m 26s): He used a walker instead of a wheelchair

JP: Thats right he used a walker. He was in a wheelchair and this time he was in a Walker and we believe he had said, or rather Phil had said that he had been in a nursing home that did not take very good care of their clients and had been moved to another facility but was still requiring transportation. So I think a few of those factors come into play, or you know when somebody has access and can get out into their community – you had mentioned the isolation piece – that we see a reduced risk of substance use and mental health issues because they’re out in the community and they’re making connections with other people.

GN (19m 56s): Here’s another one, Jeff. We had a woman who is deaf living out on the Eastern El Paso County and the plains. She wanted to get into town so she could go to SilverSneakers at the Y and so she did. She’s deaf so she started texting and one member of the staff to schedule rides and meet her needs – and I think we have great people here at Envida – so they took up the call, and text with her to schedule rides and get her to the SilverSneakers appointments. Now she is happy to go to SilverSneakers. She’s getting her husband to join SilverSneakers. She also now has instituted a monthly shopping trip into the Colorado Springs area where they have lunch and they go back and they have a day out. I mean it’s just so, I guess, rewarding. We like what we do and we think what we’re doing is meaningful. It’s just a couple of the stories

JW (20m 50s): I can tell you guys care a lot and it seems like it impacts you too. I mean how does it impact you all personally? I mean I know you mentioned you had folks in the office that you had worried about or you know had their own issues, but how about you all?

GN (21m 1s): I want to say leading an organization through the suicide of the CFO is really difficult and so it just renewed my commitment to looking at and working with behavioral health. It also renews my commitment to see collaborations with other groups that are trying to solve these complex social issues. And I think what I’m saying is I doubled down on thinking of new ways to solve these problems, to be entrepreneurial, to take more risks and then really to just be grateful for what we have. It’s really difficult to suffer such a personal loss of someone in an organization that’s key and is highly visible. And I think everyone here, was caught walking through the fire, and we’re now on the other side of it. It has renewed commitment and frankly, engagement to our mission. It’s personal.

JW (21m 57s): I think you know, for a lot of folks that work in transit or transportation, I think they get into it because they do care. And I know that a lot of the folks I talked to in cities, that’s one of the reasons they get into it is because they care so much. But sometimes you are thinking about all the frequencies and you’re thinking about the number of buses you’re getting on the road and painting the lanes red and all those things. But there’s a lot of human stories behind it. There’s a lot of people that you help when you’re out there doing the work that you’re doing.

GN (22m 23s): We’re going out and another route to the rural El Paso County, we’re going to be stopping at the high school. I mean those students on a day off go into Colorado Springs to get medical appointments or even to get jobs. And so we think that’s important too, to keep people that want to live in rural Colorado, to still, you know, have a livelihood and get the services they need, and for these students to be independent. I think that means a lot.

JW (22m 52s): We all talk about federal grants and opportunities for funding: the need to figure out how to expand the service. What’s something that state or local or even federal government can do to kind of push these types of programs forward? Is it providing more funding for them or is it trying to help find these innovative programs that are thinking outside the box? I mean, before the show I told you that we had the folks from Geisinger health on and they were telling me how they can reduce healthcare costs overall just by providing transportation for folks. Because if you miss an appointment for your chemo, you’re costing the health system and yourself a lot more than what the ride possibly cost. So if they can just provide the ride, you know, you’re, you’re actually saving money and you’re actually being helpful to the community as a whole. So I’m curious how you know the setup for funding or the setup for policy can be changed in your opinion.

GN (23m 40s): So you’re right, we do look at, and I think we’ll be able to quantify, a savings from the emergency to a more on demand, lower costs kind of service. And we can quantify, but usually the health systems are not free with that kind of information about what a loss appointment costs. It’s not until they think a little larger, like Geisinger in those ways. I’m going to be speaking next week with the FTA administrator, Jane Williams, and one of the points I want to bring out is as non-profits look at sustainability, I think we all will be getting more entrepreneurial and I appreciate the FTA funneling money into these innovations and these experimentations. I mean let’s face it, it might not be successful. I have no idea what it’s really going to cost. I mean I know we can save money from an EMT, right? But is that really going to help people not commit suicide or to get the services they need so they can then participate most-fully in their life? Or even get a job? I don’t know that, but I do appreciate the FDA looking at it and taking a risk on funding these kinds of projects and then hopefully we’ll be able to prove something and move forward on another grant that we’ll look at something else. I just returned from a conference in DC called the health data Palooza national health policy conference. There’s a lot of data being collected and there’s some really smart people that are doing the data and analysis and a lot of the universities are helping out, so I would hope that you know, the next grant that Envida applies for, we’re looking to team with the university to take some of the data that we’re compiling and to help us with our academic rigor about what we’re researching in the models were setting up because the intent is not only to do this one pilot, but it is about replicating and scaling what we’re trying here and could it be successful in other parts of the country.

JW (25m 45s): That’s a really good point about collecting information. I have a friend who lives in a Midwestern city and is a doctor and he is always annoyed that he can’t get the right data for instances of throat cancers and they’re not at the right geography and they’re not at the way that you can analyze them correctly and some health centers participate and some don’t.

GN (26m 3s): Right.

JW (26m 3s): And it seems difficult to get, so it feels like, you know, if you can start some momentum for gathering that data, especially in rural transportation in rural transportation as it pertains to behavioral health, I think that can be a real benefit, especially given the amount of need there is I imagine around the country.

GN (26m 19s): And thank you. That is, you know, I come back from this conference with Leslie and another colleague, Dave, and I go, look what we’re doing. I mean, not that we’re an academic institution, but if we can start framing the way we’re thinking and our results so that we can hand it off to another institution or at the next grant we can say, look, we started thinking this way but we’re not as sophisticated as we can be can you come onboard and help us. We think what we’re doing is important and can inform policy.

JW: Yeah, for sure. So what’s next up for you all? What’s the next part of the process?

GN: Well I think we all know implementation is the hard part. It’s easy to plan. So we’re going to do the work and when we started the work, these grants that we are putting together about three quarters of $1 million over a two year timeframe – and now probably more like an 18 month time frame – we will be compiling our data about what the implementation looks like. We’ll be listening to the people we’re serving to see if we are meeting the needs. And I believe on the next round of FTA innovation grants we will be applying again. And I will be looking to team with a university to help us – to help us structure our thinking, to help prove what can work. Right now where we are is a calculated risk; we’re rolling the dice where we’re not afraid of failure and not looking for it though either. And I think we want to leverage what we’re doing thus far and take it to another level here in our community and so maybe we expand to not only behavioral health, but physical health and all kinds of transportation that can help reduce isolation for people. We’re not fixed route people, we’re not urbanized center. I think the place where Envida’s nonprofit and our mission is to go where the for-profits aren’t going to go, where the public agencies can’t afford to deploy, and we’d take them too long with all the deliberation that they have to go through and the political process and I believe as a nonprofit it’s our role to step into the market and be innovative.

LP (28m 23s): I just want to add one piece to that. We are serving the clients and the providers both quantitatively and qualitatively. Because I think many times what happens is we hear what the bureaucracy is driving or what organizations are saying, but rarely are we getting down to the boots on the ground and the people who are like, this is really what I need. I know this is what’s being provided, but it’s not what I need. And so I think working with Teller County, especially because it’s a small community, that we can really get into the community and find out, okay, what really is going on here? Because we’re going to be riding the buses with the clients and asking them, tell us your story. Where are you running into the roadblocks? What could help you, what could not? And so I think that will help drive us in the future of, you know, not putting money where we assumed remained an assumption that it was needed, but we can actually drive where the people are telling us the needs are.

JW (29m 20s): I’m interested. Leslie, from the behavioral health profession as a whole, you know, what is, what are their thoughts on this idea generally of the need for transportation. And I know they understand isolation and the needs of the patients, but what about the transportation and connecting those two dots?

LP (29m 34s): So I serve on a task force that our governor, he’s tasked the state with redesigning the behavioral health system because we know we’re not meeting the needs of our clients. And so we’re looking at all of those areas. There’s a lot of assumptions. I’ve worked in the field for, you know, a couple decades. And what we find out is there’s various reasons why people don’t get the help that they need. A huge part of it is stigma. Another piece of it is transportation. Another piece of it is because they don’t believe that they can access. So there’s so many variables that go into behavioral health. So in my situation, you just try some solutions and say, does that one work? Now that one really didn’t make an effect. Okay, let’s try a different solution. Let’s see if that makes a difference. And so I think that’s what ties so well with Teller County is because we have a population and a community who desperately need some solutions. And so we try it and then we can make adjustments. But nationally, I mean this is a topic that’s everywhere. We’re seeing a huge increase in behavioral health needs and we have a very small population of professionals who can meet those needs.

JW: So Gail where can folks find information about what you all are up to and what you’re doing and the plans for the future?

GN (30m 56s): Well I guess our website would be the first one, envitacares.org, but I can say we are redesigning the website around these behavioral health services. In fact, I just got a quote today on what that would cost. So I think in the next six months we will be redesigning. There should be something more available about how to access behavioral health transportation. Because we’re implementing a new technological solution with an on demand software from route match where people with behavioral health, what we’ve heard and observed, they prefer some of the amenities that a mobile app can provide. And so be able to request your ride when they need it without having to talk to someone would be a benefit. So at any rate, we are looking to deploy this new technology and we will have that on our website as a way to access services with us.

JW: So what’s the website URL? Do you have that?

GN: Yes. envidacares.org.

LP (31m 59s): If you get anybody who is interested in this, we would love to hear some solutions that they’re working through.

JW: So you want to hear from folks?

GN: Yeah, yeah. It’s hard.

LP: Yeah. We don’t have all the answers. You know, I love hearing people’s ideas and like we hadn’t thought about that, we were bouncing ideas off of each other on a regular basis. Like do you think this will work? And it’s like, well we’ll find out.

JW: Awesome. Well, Gail and Leslie, thank you so much for joining me. I really appreciate it.

GN (32m 27s): It was a pleasure to meet you, Jeff. Thank you for asking.

LP: Thank you, Jeff.