Panhandle Situation Table

The Panhandle Situation Table is a deeply collaborative, multi-agency, risk-driven initiative that allows agencies to work together and mobilize in new ways, to rapidly triage situations of Acutely Elevated Risk to connect individuals/families to the support they need. Adapting the situation table's evidence-based model to meet our rural needs breaks down barriers between agencies and advances partnerships. It strengthens relationships, helping the system work across traditional silos to benefit our community's most vulnerable members. In short, it is a process to meet people in need where they are.

The Panhandle Situation Table meets virtually every Tuesday at 9:00 AM, beginning with updates from the previous week's situations and any new introduction to new members. As this process is meant to reduce elevated risk, we do not perform case management but provide services immediately to reduce risk.

After updates, new situations may be brought to the Table through a four-filter process that accommodates confidentiality and ensures that each situation meets Acutely Elevated Risk criteria.

Encompassing several service sectors, the goal of the Panhandle Situation Table is to reduce the risk of immediate adverse events occurring to individuals and families deemed at acutely elevated risk (AER). To be deemed at acutely elevated risk and be accepted by the Situation Table, individuals/families must exhibit more than one risk factor and cross more than one service sector. To reduce the risk of immediate adverse events occurring, "situations" are connected to services within 1-2 weeks of Table acceptance and measured weekly using our data collection tool provided by QRT. Our goal for 2023 is to reduce this risk for a minimum of 42 individuals and families.

Since launching the Situation Table on August 26, 2022, we have had 24 situations brought to the Table. Eleven of those have been successfully connected to services, and risk reduction occurred; 3 have been informed of services but are not ready to receive them; 4 have refused services; 4 are currently open; and two were deemed not a situation as it did not meet the threshold of crossing several service sectors, though resources were provided and risk lowered. Through this collaboration, we can help individuals and families at risk, even when they are not brought to the Table. The connections made are reaching beyond the weekly situation table meetings.  

Panhandle Public Health District (PPHD) is a rural local public health district serving the 12 counties of the Nebraska Panhandle: Banner, Box Butte, Cheyenne, Dawes, Deuel, Garden, Grant, Kimball, Morrill, Scotts Bluff, Sheridan, and Sioux and covering 14,964 square miles.

PPHD's Community Health Assessment data collected in 2019 reflects the following about adverse childhood experiences: 10.34 percent of respondents had four or more ACES, with the Average number of ACES among all respondents being 1.64.  1,414 Panhandle community members from various backgrounds completed the survey.

Approximately 23.28 percent of the population we serve is less than 18 years old. In the under-18 population, 14.4 percent live in poverty, compared to 12.2 percent across Nebraska (2015-2020 ACS 5-year estimates). The counties with the highest levels of child poverty include Sheridan county at 35.90 percent and Grant county at 18.5 percent.

Although the area we service does not historically see high case rates of overdoses and overdose deaths, we were identified as one of the five highest-risk areas for a drug overdose in Nebraska. Additional data putting the Panhandle at risk include: Panhandle suicide rates are traditionally above the Nebraska average. In 2020, the all-ages suicide rate was 16.5, and Nebraska's was 14.9. The 5-year average was also above Nebraska's average of 14.4 at 20.3 individuals/100,000 people. For ages 10-24, the 5-year average was 11.2/per 100,000 people. There were seven overdoses between 11/21-4/22; three were from opioids and two from benzodiazepines.

It should also be noted that PPHD's service area is considered a behavioral health and mental health provider desert. Eighty-eight of Nebraska's 93 counties are designated mental health shortage areas by the U.S. Health Resources and Services Administration, according to the Behavior Health Education Center of Nebraska. And according to the Rural Health Information Hub, every county in the district is a designated mental health provider shortage area. Source: https://www.ruralhealthinfo.org/charts/7?state=NE

In 2018, in response to the opioid epidemic, the State of Nebraska devised and implemented strategic plans to decrease opioid use and misuse with the use of funds through SAHMSA. PPHD has a continued, contracted partnership with the State of Nebraska through Region 1 Behavioral Health that has allowed us to educate and implement programs and processes in response. Some of these have included but have not been limited to drug monitoring systems (PDMP) for healthcare providers and pharmacies, education and promotion of medication-assisted treatment (MAT), community and school awareness and prevention efforts through education and training opportunities, disbursement of medication safety measures utilizing lockboxes, medication disposal systems, and naloxone to first responders and schools.

Collaboration is the culture in the Panhandle. The Panhandle Partnership, a non-profit membership-based organization, paved the way for the collaboration that comes naturally today. Since 1998, the Partnership has catalyzed collaboration in developing creative opportunities for enhancing family and community life in Western Nebraska. The Partnership's vision is Collective Impact for Thriving and Equitable Panhandle Communities, and the mission is We build collaboration among agencies, networks, and the broader community to find creative solutions to improve the quality of life and communities in the Panhandle.

Despite the high level of collaboration and coordinated efforts across the Panhandle, silos remained within our communities: those individuals and families most at risk for an overdose or other serious adverse events and the providers and services who could assist in prevention or treatment. These silos and the knowledge that behavioral and mental health issues, adverse childhood events, poverty, and homelessness can increase rates of substance abuse prompted PPHD to seek resources to break these barriers; thus, the Panhandle Situation Table was introduced. In doing so, regional service providers are able to assess and assist in service and treatment implementation quickly.

In the past, individuals or families who may be faced with high-risk adverse events were often given a list of providers who may be able to help address their concerns and issues. However, because crises can interfere with the ability to process anything above survival, these individuals/families often did not reach out and get connected to services unless law enforcement, child protective services, or other outside agencies were involved. The innovation behind the Panhandle Situation Table is an actionable process that has proven successful in removing the barriers and disconnection between those individuals and families at-risk for crisis and the ability to obtain assistance and services before a crisis occurs. The Situation Table puts the initiation of services on the agencies, not the AER individuals and families. It is a deeply collaborative, multi-agency, risk-driven initiative that allows agencies to work together and mobilize in new ways, to rapidly triage situations of Acutely Elevated Risk to connect individuals/families to the support they need.

The Panhandle Situation Table is unique in that we cover a rural and sizeable geographical area comprised of many small towns and villages that lack resources to tackle acutely elevated-risk individuals. Because of the area we encompass, we meet weekly via virtual meetings, which has allowed partners to be present at times; in-person meetings would not have been possible. Another unique feature of our Table is that several service sectors in attendance provide nearly identical services. We have engaged these partners as critical players because each service provider covers predetermined areas. For example, one of our service providers in Scottsbluff can assist "situations" in behavioral and mental health, substance abuse, dual diagnosis, and emergency housing. Another service provider in our Northern Panhandle region can also provide behavioral and mental health services and referrals for housing assistance. Each of these entities provides some of the same services; however, our reliance on them at the Table is essential to ensure all areas of the Panhandle have the same level of access.

New situations are brought to the Virtual Table from partners across the Panhandle through a four-filter process that protects the individual/families confidentiality as well as ensures that each situation meets the acute-elevated risk criteria:

1. Significant interest - Significant interest refers to the broad array of potential situations that practitioners in any sector may encounter, presenting as accumulating risks to the immediate well-being of individuals or families. This first criterion essentially reinforces the Table's limited role in recognizing and acting collectively only in those situations where service gaps and system failings have brought individuals and/or families to the AER threshold. It also underscores the unique and continuing opportunity to recognize and advance opportunities for systemic reform while providing immediate solutions and connections to reduce the AER in any specific situation.

2. Probability of harm occurring - There is a reasonable expectation of harm to individuals if nothing is done.

3. Severe intensity of harm - The harm would constitute damage or detriment and not a mere inconvenience to the individual. It is reasonable to assume that consideration at the Situation Table might help to minimize or prevent the anticipated harm.

4. Multidisciplinary nature of elevated risk - The risk factors are beyond the Originating Agency's scope or mandate to mitigate the elevated level of risk. Evident, operating risk factors cut across multiple human service disciplines, and traditional inter-agency approaches have been considered or attempted.

Filter One is the initial assessment done outside the Table by the group introducing the individual/family situation so they are prepared to introduce the situation to the Table. Filter Two is the situation being brought to the Table's attention. During filter two, only unidentifiable information is introduced (male/female, age range, etc.), including articulation of risk factors (alcohol/drug use, unemployment, housing needs, domestic abuse, truancy, physical violence, basic needs, etc.) and any known prior efforts to mitigate risks. At this point, Table consensus must be reached that we are crossing several service sectors, and the individual/family is at acutely elevated risk to move on to filter three. Filter three provides the identification of the individual/family, as well as any necessary demographic information. During filter three, the group is asked for recognition and whether current or past services are in place. Service sectors identified as being able to assist the situation begin taking notes. After all situations are brought to the Table, a filter four meeting is held for each situation, with only those service sectors bringing assistance participating in filter four meetings. During this phase, initial plans are made to contact the at-risk individuals in person or by phone and initiate services.

The Situation Table is unique in that it treats the whole situation, encompassing dozens of risk factors that can impact the health and well-being of an individual, family, and community. Service providers, including law enforcement involvement, differ from their traditional role, focusing on offering support, and reinforcing community trust and legitimacy.

Of the 20 closed situations brought to the Table, 65% have been connected to services and have a lowered risk. With limited current data and the complexity of the risk factors, it is unclear precisely how many individuals' needs can be met by implementing the Panhandle Situation Table. As discussed above, our area is considered at high-risk for overdose and overdose deaths. The root cause of this consideration is likely a correlation between mental and behavioral health issues, poverty, and a lack of available resources, as well as cultural beliefs, attitudes, and stigma.

PPHD has provided and continues to provide substance abuse prevention efforts, including education on substances and their abuse, education to combat stigma, medication disposal systems, lockboxes, Narcan training and dispensing, and mental health and suicide awareness. Though these efforts have all had success, we knew that as a region, we could still not address the need for near-crisis individuals to be met where they were with services needed to prevent a crisis. It truly is the collaboration that allows us to meet the needs of acutely elevated-risk individuals and families; we have minimal resources and do not have detox or crisis stabilization in the Panhandle. 

By design, implementing the Panhandle Situation Table has allowed us to collaborate with community and regional partners and service providers and focus our efforts on individuals and families who are most at risk for experiencing health inequities. Through focused and intentional efforts, the Table has grown to represent vast service sectors, community groups, public agencies, and mental health providers. The filter four process introduces families and individuals anonymously, taking away the opportunity for any negativity that may be associated with the situation through past experiences.

The Table is a weekly collaborative, actionable meeting between several service sectors and public officers. These include but are not limited to: law enforcement and justice systems, first responders, hospital systems, social service agencies, family/child abuse advocacy agencies, housing assistance agencies, transportation services, schools, mental and behavioral health providers, alcohol and drug counselors, employment services, veterans assistance services.

PPHD directly coordinates the Situation Table, including all planning, invites, meeting outlines and processes, data collection, and post-meeting information hub. The Panhandle Situation Table's training and implementation were based on the Centre of Responsibility Model and Community Safety and Well-Being (CSWB) model, introduced initially in Canada in 2011 and in the United States in Chelsea, Massachusetts, in 2014. Since its inception, this evidence-based application of the CSWB has consistently led to sustainable changes in multi-sector collaboration in service of at-risk individuals, families, and communities. Measurement data obtained on Canadian outcomes exist in qualitative and quantitative forms and is reviewed and endorsed by several committees, such as the Parliamentary Standing Committee on Public Safety and National Security. (Source: globalcommunitysafety.com)

Outside stakeholders are the key to the Panhandle Situation Table's success. PPHD has established partnerships with many entities and groups participating in our Situation Table meetings. To ensure success, we connected with partners early on, promoted and meetings, and began marketing early on. We engaged partners via email, in-person meetings, and phone calls to expand and foster current relationships. This allowed us to provide education and information about the Panhandle Situation Table's goal and purpose and how imperative their involvement was to garner support and success. It also allowed us to create a shared vision with our stakeholders and service sector providers to provide actionable measures and goals to meet these acutely elevated-risk individuals where they are and provide immediate services to reduce risk. We started the conversations approximately nine months before we hosted the training and began heavily marketing in May 2022 via virtual postcards, personal meetings, email invitations, and phone calls. We provided information and in-person invites at collaborative meetings throughout the Panhandle.After several months of marketing the Panhandle Situation, we successfully hosted a 2-day in-person training.

This training provided information to ensure an in-depth, solid understanding of the model, how it works, its history, the risk-tracking data, and how it fits in the broader CSWB; Guide table participants (and back-up and/or assist participants) all the way through to table launch and beyond;

Provide an understanding of the additional community roles required for a successful Situation Table and pathways to Systemic Reform, including how the table can work with the System Leaders Group (SLG), the Risk Tracking Data, and the broader community ambitions related to the Table operations.

During the training, the importance of collaboration was stressed. What became apparent early on in the process was the significant effectiveness of collaborative interventions on three fronts – we saw the same results here including Collaboration amongst human service providers was not anything new, but the manner, recognized urgency ,and frequency of the collaborations was. This was collaboration at a new level and all-time high for everyone involved. The execution of these new collaborative interventions and the multi-faceted supports that followed saw expeditious reductions in risk for individuals and families, which in turn reflected exceptional reductions in calls for police, crime and victimization levels, prosecutions, child welfare apprehensions, and hospital visits. Many involved were pleasantly surprised to learn the vast majority of those at risk, both wanted and welcomed collaborative supports when these were offered in the compassionate and supportive manner of a Table-led intervention. This was in direct contrast to many previous single agency requests for meetings or service follow ups with clients, that often were refused outright, or to which clients simply did not show up for a variety of reasons.

The shift described in the training pieces are a great way to understand the situation table and are shared here.

-Our human services systems are based largely on reactions and responses to crisis. You get hurt, you go to the hospital. If there is a crime, someone is arrested. If there are child-care concerns in a home, a child could be removed, and so on.

The notion of Risk Driven Intervention is the opportunity to identify acute risk in our day-to-day work for individuals and/or families, and to collaboratively intervene before a crisis and a mandated or emergent response is required. The intervention triggered by Situation Table triage, or Door Knock', can typically occur at a client's home or at an agency office, and involves timely connections by a collaborative team of professionals to as many services and supports required in order to mitigate the risks the client is facing.

Unlike most reactive responses from various parts of the system, these collaborative interventions are pre-emptive and supportive (not punitive). They are about offering and connecting people to all essential services, with the aim to avoid sanctions that could otherwise have taken the form of punitive and less constructive actions such as arrest, continuing health decline, further victimization, child apprehension, eviction, or school suspension.

Just as important to the Big Picture, the introduction of collaborative Situation Tables has been a leading driver to the broader adoption of CSWB thinking and practice in virtually every community that has embraced the model. In Ontario, this led to the development and introduction of new legislation, adopted in 2018, that requires by provincial mandate that every municipal entity, and by choice, any First Nation community, to develop comprehensive and collaborative CSWB plans, built on data and evidence, and wherever available, informed by the anonymized risk-driven data generated by the work of Situation Tables. -

The training went very well, and because we had a high level of engagement from service providers in attendance, we were able to launch the Panhandle Situation Table, introduce our first situation, and successfully connect an individual with services at the conclusion of our training.

Leveraging funding through contracted grants between Panhandle Public Health District and Region 1 Behavioral Health, and the State Opioid Response Program, implementing the Panhandle Situation Table began with a two-day in-person training provided by Operation 2 Save Lives and QRT. Outlining the purpose, process, goals, and need for successful collaboration. PPHD marketed the Situation Table to nearly 120 regional services, providing information and graphics to ensure our collaborative partners and service sectors attended training well. Marketing was successful, as several regional and community service sectors and partners joined our training. The Panhandle Situation Table was able to end our training with the introduction of our first two situations, both of which were successfully connected to services. This two-day training was completed in August 2022. The total cost for the training to implement the Panhandle Situation Table was $26,000.

Collaboration is a way of business in the Panhandle. The goals and objectives of our Table began with our desire to support substance use disorder (SUD) and behavioral and mental health-related situations. We could see challenges in each facet of the Panhandle through the eyes of our partners. What drew our partners and us to the situation table is that it is an action-based meeting encompassing dozens of risk factors that can impact the health and well-being of an individual, family, and community. There has been a movement across the Panhandle within our law enforcement community shifting to hold a level of community support, not only enforcement. One example is that Alliance PD was the first police department in Nebraska to be trained in PAARI (Police Assisted Addiction and Recovery Initiative). The Situation Table follows this with law enforcement engagement differing from their traditional one, focusing on offering support.

One of the most successful components of introducing and coordinating the Panhandle Situation Table has been the connections between Table partners and the overall collaborative atmosphere of our team. Being in a service-desert, and not having resources available such as a homeless shelter, has proven very difficult to ensure the safety and well-being of some of our most at-risk individuals. In the past, one of our local police departments, in an attempt to help and keep homeless individuals from being on the streets in freezing temperatures, would be nearly forced to detain these individuals. With the advent of the Panhandle Situation Table and the connections made, officers can now directly contact service providers offering emergency assistance. They know what services are available and whom they can contact for assistance. Not only does this provide that emergency housing assistance, but it also opens many doors for opportunities to develop relationships that may provide further assistance in rooting out the causes of homelessness. In this way, too, local law enforcement agencies are able to promote their departments as helpers and not enforcers positively.

The Panhandle Situation Table aims to reduce the risk of immediate adverse events occurring to individuals and families deemed at acutely elevated risk (AER). To be deemed at acutely elevated risk and be accepted by the Situation Table, individuals/families must exhibit more than one risk factor and cross more than one service sector. To reduce the risk of immediate adverse events occurring, "situations" are connected to services within 1-2 weeks of Table acceptance and measured weekly using our data collection tool provided by QRT. Our goal for 2023 is to reduce this risk for a minimum of 42 individuals and families.

This weekly virtual meeting has allowed partnerships to be made, collaboration to continue, and success to be met to decrease those deemed at acutely elevated risk. Although our region has service limitations, the work that the Panhandle Situation Table has done collaboratively has enhanced the services we are able to provide, as well as provided insight and data into areas where development and expansion are feasible for future services.

As part of the training, data collection resources were provided to Panhandle Public Health as the Table coordinators. Weekly, our recorder inputs data from each situation presented into a shareable, de-identifiable spreadsheet. This spreadsheet is editable to include all service providers who continue to join our Table.

Data collected includes de-identifiable information of the individual, i.e. male/female, age range, location; agency or individual bringing the situation to the table; risk factors such as alcohol abuse, truancy, crime victimization, housing, parenting, substance abuse, domestic violence, unemployment; service sectors involved in connecting the individual to services and the organization taking the lead.

We are currently in the process of creating a quarterly survey to provide to those sitting at the Panhandle Situation Table. This will help ensure that we, as a Table, are meeting the objectives and goals, maintaining fidelity, as well as provide feedback on improvement. This can range from selecting a different day/time to meet to improve the process of engaging new partners.

The data provides real-time, meaningful feedback that provides information regarding communities/localities where higher incidences of situations have been brought to the Table, as well as high levels of engagement and connection to service providers. We are able to capture who (region/county/community) is bringing situations to our Table, service providers connected those situations to services immediately, and results of lowered risk because of connection to services. It also allows us to see where we may be missing key service partners, where services need to be expanded, and what services our region does not have the capacity to provide.

Utilizing the data collection tool provided by QRT, we have been able to identify housing, mental health needs, and alcohol and drug use as our highest risk factors. Alliance Police Department and Box Butte General Hospital have identified and brought the most situations to our Table. Western Community Health Resources have initiated and provided the most services.

By reviewing our data, we are able to provide insight into the risk categories highest in our region and anticipate needs. This has been useful in quickly identifying any missing sectors and inviting them to the Table. Data collection has also given us the opportunity to provide evidence to the communities, entities, and individuals PPHD services to promote the Panhandle Situation Table's Success.

Providing the following, which was an actual situation brought to our table, helps to highlight how the Table can immediately reflect, adjust, and improve our outcomes:

Situation introduced (Situation 22-11, 10/4/22) - 20-25-year-old male, living in Alliance with his grandparents and introduced by Alliance Police Department. Risk factors involved: alcohol abuse, diagnosed mental health concerns, threat to public health and safety, drug abuse, the perpetrator of physical violence, criminal involvement. Brief statement provided by Alliance PD states that the individual has physically assaulted grandparents in the past, mental health issues escalating and grandparents fearful of the individual, both harming himself and them. Upon consensus from the group, this individual met the requirements of acutely elevated risk. De-identifiable information was provided, including his name, current address, and grandparent's names. One of our Table's drug and alcohol counselors had recognition of this individual and was aware of past services in place. Western Community Health Resources (WCHR) took the lead, as they are able to offer mental and behavioral health services. It was apparent during our filter 4 meeting, however, that this individual was in need of alternative housing, for which we did not have a partner at the Table. It was decided that inviting Northwest Community Action Partnership (NCAP) to the Table and filter 4 meeting would be beneficial in this situation. As such, PPHD coordinated the effort to reach out, inform and invite NCAP to our Situation Table and filter 4 meeting. The day immediately following the Situation Table meeting, a filter 4 meeting was held for this "situation", including NCAP, WCHR, Alliance Police Department, and the drug and alcohol counselor who held recognition. During this filter 4 meeting, the service sector involved were able to form a plan for providing immediate mental health and housing services for this individual, and a decision was made on how best to make contact. Updated to the Table the following week, this situation was closed, as he had been connected to services, therefore reducing his overall risk.

As you can see from the above example, a key partner was missing from our table. By educating, informing, and personally inviting this service sector to our Table, we successfully connected an acutely elevated-risk individual to services almost immediately. As a result of this success and seeing how well the Panhandle Situation Table works to reduce risk, NCAP has remained committed to being at our weekly meetings and providing services, as needed, to those in their area.

At this time, as part of the coordination efforts that Panhandle Public Health provides for the Panhandle Situation Table, we input and analyze the data to provide to Table participants, our governing board, the grant funders, as well as regional stakeholders. In doing so, we can build upon the success of the Panhandle Situation Table to apply for future funding that may help build infrastructure and services that we do not currently have in our area.

As the Panhandle Situation Table is a continuous collaborative process, we strive to engage, inform, and communicate with service sectors and the public. PPHD ensures the Table's process fidelity and confidentiality by doing so in a coordinated and meaningful way and will continue to uphold the methodology of the Situation Table. 

We will first look at the evidence and data to better understand where and how the system needs strengthening. One of the primary sources for identifying systemic opportunities in our community can be seen by reviewing the Risk Data that Situation Tables collect weekly. Several variables complement the RTD; all centered around the associated risks and risk categories for people in AER.

To ensure the fidelity of the program and provide partners with the opportunity to be certified in the training, we have access to the Global Network and QRT online resource site. A complete online course alternative that provides comprehensive and in-depth training so that any Table members who were unable to attend the in-person sessions can also gain a thorough understanding of the Situation Table – how it fits in the broader concepts of Community Safety and Well-Being (CSWB), how it navigates within privacy protocols, the Four Filters, and the table operations. 

The sustainability of the Panhandle Situation Table relies heavily on the continued engagement and collaboration of partners and service providers at the Table. This can be achieved through ongoing efforts to educate, inform, and provide positive results from those situations brought to the table and the services provided to them. Community and service outreach will be a continuous requirement, as well as efforts to build and improve service availability and infrastructure. In planning for the future of the Panhandle Situation Table, we anticipate growth to occur, especially in our more populated towns. Once they are feasibly ready, we may need to establish additional Situation Tables. Panhandle Public Health District will continue to coordinate the Panhandle Situation Table and provide ongoing efforts to grow its capability and success in partnership with our communities and service providers. The sustainability of PPHD's role in the coordination of the Table requires ongoing funding. We have anticipated these needs and have secured financial support through Opioid Response Grants, as well as the Nebraska Opioid Settlement Fund.