EASTHAM — Even in the best of circumstances, accessing mental and behavioral health care can become a Herculean journey. The country’s mental health care system is byzantine, there are rarely enough providers, and getting insurance to pay for care can feel like a crapshoot. Rural areas have additional struggles, and there is more demand for mental health care on the Outer Cape than there are clinicians to provide it.

In response to this long-running crisis, the health directors in the four Outer Cape towns banded together and worked with the nonprofit Outer Cape Community Solutions to win a $381,375 grant from Barnstable County in June 2023. The grant money, part of the county’s $41-million share of the American Rescue Plan Act, was largely dedicated to hiring and supervising a full-time behavioral health clinician and a public health nurse for the four towns of the Outer Cape. Eastham took the lead on managing the grant and related contracts, and Outer Cape Health Services won a pair of 18-month contracts to hire and manage the new positions.

Cassie Baker, a licensed independent clinical social worker, and Kerry Cox, a registered nurse, were hired in February. Their services must be free, according to the request for proposals Eastham published in July 2023, and residents of the four towns do not need to show proof of insurance to meet with them.

“I think of them as the dynamic duo, because they’re out in the community,” said Eastham Health Director Hillary Greenberg-Lemos. “They’ve seen residents in each of the towns, and they seem to be making headway.”

Outer Cape Health Services did not make Baker available for an interview, but she did speak to Provincetown’s board of health on Oct. 17.

“Oftentimes I find people are looking for just some short-term support, and if I have residents who are in need of longer-term support, I bridge that gap,” Baker told the board. “I will work with them to identify a therapist in the community or through a virtual platform if they’re able to access that.”

The scope of services outlined in Eastham’s RFP says that the behavioral health clinician will provide “short term outpatient therapy sessions” — generally 6 to 10 meetings per patient — “while waiting for secured longer-term therapy.”

“The program objective is for each caseload to include ten patients per town at any one time (40 patients total),” the RFP says.

This generally follows the outlines of Provincetown’s five-year mental health plan, first presented in February 2021, which called for crisis counselors who could meet with clients quickly when the need was urgent and then “bridge” them into more stable long-term care over the course of weeks or months.

Baker told the board of health that since she started in February she had seen patients struggling with a range of issues including depression, anxiety, trauma, grief, ADHD, substance use, and adjustment disorder. She can meet with patients at their homes, OCHS offices, or virtually, whatever works best for the person receiving care.

This care model fills a significant gap because “it’s an outreach service — it has the availability to be therapy at home, which almost no agency provides,” said Bri Smith, director of behavioral health at OCHS, who supervises Baker and Cox.

Managing the Caseload

Given that Baker’s services are free and there is a high demand for mental health care, Smith and the health depts. had to decide how to avoid a rush that could backlog the new clinician.

“We know that there’s a tremendous need,” Smith told the Independent. “So, being thoughtful about how we are able to triage and being realistic about the resources that we have has been important.”

For now, town staff or other human services workers have to refer patients to Baker, Greenberg-Lemos confirmed.

“If you needed some mental health help, you couldn’t call up Cassie directly,” she said. “You would go through someone, or someone would recognize within the town structure that you needed help.

“I would say if [someone is] distressed in any of the towns, they can reach out to police, they can reach out to fire, they can reach out to the health dept., they can reach out to community development,” she added. “Any of us know how to funnel them to the right place.”

Baker told Provincetown’s board of health that the decision to limit who could make referrals for care was “just to make sure I had capacity.”

Baker received 20 referrals from Provincetown between February and October, Smith told the Independent, including from the town’s health dept., police, recreation dept., and council on aging, Wellfleet’s police dept., and Outer Cape Health Services, which also has the contract for the town’s “community navigator” program.

In Eastham, Baker logged 17 referrals in that same period, including from Eastham’s police and fire depts., the Visiting Nurse Association, and the OCHS community navigator.

Smith did not provide the number of referrals for Truro or Wellfleet but said the numbers were similar across all four towns, as an equal sharing of resources was a stipulation of the original grant agreement.

“It’s possible there could be a time when there’s a wait to see Cassie in one town, but immediate availability for her to be seen elsewhere,” Smith said. “That’s the administrative piece that is done in the background.”

That time has not yet come, Smith added; so far, Baker has been able to provide counseling services to every person referred to her.

Next Steps

With the program now running, “the next phase of work with the towns is to say, ‘OK, now that we have a solid footing as to what this looks like and what that referral process is like, how do we open that up in a wider way?’ ” Smith told the Independent.

Smith told Provincetown’s board of health that while the initial referral process had been designed to prevent the new clinician from being “overrun,” the towns and OCHS were “moving in the direction” of more open referrals.

The ARPA funds will expire in 2025, and developing a funding plan to keep the nurse and counselor available is “on the front burner right now,” Smith said.

“I know all four towns are seeing the value in the service,” Greenberg-Lemos said, “and I believe all four towns have put into their budget” plans to continue funding the two positions for another year.

While budget conversations are ongoing, draft budgets are typically presented to select boards for their approval in a series of hearings in late winter, followed by town meeting votes in spring.

EASTHAM — Even in the best of circumstances, accessing mental and behavioral health care can become a Herculean journey. The country’s mental health care system is byzantine, there are rarely enough providers, and getting insurance to pay for care can feel like a crapshoot. Rural areas have additional struggles, and there is more demand for mental health care on the Outer Cape than there are clinicians to provide it.

In response to this long-running crisis, the health directors in the four Outer Cape towns banded together and worked with the nonprofit Outer Cape Community Solutions to win a $381,375 grant from Barnstable County in June 2023. The grant money, part of the county’s $41-million share of the American Rescue Plan Act, was largely dedicated to hiring and supervising a full-time behavioral health clinician and a public health nurse for the four towns of the Outer Cape. Eastham took the lead on managing the grant and related contracts, and Outer Cape Health Services won a pair of 18-month contracts to hire and manage the new positions.

Cassie Baker, a licensed independent clinical social worker, and Kerry Cox, a registered nurse, were hired in February. Their services must be free, according to the request for proposals Eastham published in July 2023, and residents of the four towns do not need to show proof of insurance to meet with them.

“I think of them as the dynamic duo, because they’re out in the community,” said Eastham Health Director Hillary Greenberg-Lemos. “They’ve seen residents in each of the towns, and they seem to be making headway.”

Outer Cape Health Services did not make Baker available for an interview, but she did speak to Provincetown’s board of health on Oct. 17.

“Oftentimes I find people are looking for just some short-term support, and if I have residents who are in need of longer-term support, I bridge that gap,” Baker told the board. “I will work with them to identify a therapist in the community or through a virtual platform if they’re able to access that.”

The scope of services outlined in Eastham’s RFP says that the behavioral health clinician will provide “short term outpatient therapy sessions” — generally 6 to 10 meetings per patient — “while waiting for secured longer-term therapy.”

“The program objective is for each caseload to include ten patients per town at any one time (40 patients total),” the RFP says.

This generally follows the outlines of Provincetown’s five-year mental health plan, first presented in February 2021, which called for crisis counselors who could meet with clients quickly when the need was urgent and then “bridge” them into more stable long-term care over the course of weeks or months.

Baker told the board of health that since she started in February she had seen patients struggling with a range of issues including depression, anxiety, trauma, grief, ADHD, substance use, and adjustment disorder. She can meet with patients at their homes, OCHS offices, or virtually, whatever works best for the person receiving care.

This care model fills a significant gap because “it’s an outreach service — it has the availability to be therapy at home, which almost no agency provides,” said Bri Smith, director of behavioral health at OCHS, who supervises Baker and Cox.

Managing the Caseload

Given that Baker’s services are free and there is a high demand for mental health care, Smith and the health depts. had to decide how to avoid a rush that could backlog the new clinician.

“We know that there’s a tremendous need,” Smith told the Independent. “So, being thoughtful about how we are able to triage and being realistic about the resources that we have has been important.”

For now, town staff or other human services workers have to refer patients to Baker, Greenberg-Lemos confirmed.

“If you needed some mental health help, you couldn’t call up Cassie directly,” she said. “You would go through someone, or someone would recognize within the town structure that you needed help.

“I would say if [someone is] distressed in any of the towns, they can reach out to police, they can reach out to fire, they can reach out to the health dept., they can reach out to community development,” she added. “Any of us know how to funnel them to the right place.”

Baker told Provincetown’s board of health that the decision to limit who could make referrals for care was “just to make sure I had capacity.”

Baker received 20 referrals from Provincetown between February and October, Smith told the Independent, including from the town’s health dept., police, recreation dept., and council on aging, Wellfleet’s police dept., and Outer Cape Health Services, which also has the contract for the town’s “community navigator” program.

In Eastham, Baker logged 17 referrals in that same period, including from Eastham’s police and fire depts., the Visiting Nurse Association, and the OCHS community navigator.

Smith did not provide the number of referrals for Truro or Wellfleet but said the numbers were similar across all four towns, as an equal sharing of resources was a stipulation of the original grant agreement.

“It’s possible there could be a time when there’s a wait to see Cassie in one town, but immediate availability for her to be seen elsewhere,” Smith said. “That’s the administrative piece that is done in the background.”

That time has not yet come, Smith added; so far, Baker has been able to provide counseling services to every person referred to her.

Next Steps

With the program now running, “the next phase of work with the towns is to say, ‘OK, now that we have a solid footing as to what this looks like and what that referral process is like, how do we open that up in a wider way?’ ” Smith told the Independent.

Smith told Provincetown’s board of health that while the initial referral process had been designed to prevent the new clinician from being “overrun,” the towns and OCHS were “moving in the direction” of more open referrals.

The ARPA funds will expire in 2025, and developing a funding plan to keep the nurse and counselor available is “on the front burner right now,” Smith said.

“I know all four towns are seeing the value in the service,” Greenberg-Lemos said, “and I believe all four towns have put into their budget” plans to continue funding the two positions for another year.

While budget conversations are ongoing, draft budgets are typically presented to select boards for their approval in a series of hearings in late winter, followed by town meeting votes in spring.