What works in behavioral health MIH: Nicole Picknell’s playbook from South County Fire

The moves that cut repeat 911 use and the habits that keep a mobile integrated health program from working.

Traditional EMS assesses, transports, and clears. It’s a sequence that excels with one-time emergencies, but struggles with the recurring, low-acuity calls that come from housing issues, behavioral health issues, and substance use disorder. In southwest Snohomish County Washington, South County Fire has created a Community Resource Paramedicine (CRP) program that closes this gap, and at EMS World Expo, medical services officer Nicole Picknell walked through the innovations that help them handle those recurring, low-acuity calls. Starting in 2013 with a single grant-supported paramedic, South County Fire now has a 24/7 CRP program serving over 3,000 people each year. Among high-utilizer clients, CRP care leads to 911 calls dropping by more than half – Picknell put the current figure near 60 percent.

Change the sequence

In the familiar EMS sequence, “transport” is a familiar pain point. Picknell is used to ambulance crews waiting three to seven hours before a hospital’s ED can take charge of their patient. That patient leaves the ED with a packet reading “please call your doctor”, and is back in trouble two days later.

South County’s sequence is: assess, stabilize, connect, and follow up. An ambulance transport is just one way to stabilize a patient, connecting that patient with community resources is just as important as clearing their immediate crisis.

What works: care coordination between crews in the field. For example: one senior patient called five times a day for help with the stairs in their apartment complex. The line crew didn’t have time to contact the apartment manager and ask them to install a handrail, but the CRP team did. The crews coordinated, and now the patient calls once every three months.

What doesn’t: only addressing “major” crises. When a person calls 911 they might be dealing with suicidal ideation, their third overdose this month, or a simple fall. Whatever they call for help with, that is their crisis.

Find the partners you need, including the patient

South County Fire’s CRP program involves four types of responding units. Police, Fire, and EMS get the initial call, get in the door and handle the initial crisis. Community resource paramedics – paramedics and EMTs – assess, treat, and navigate the patient’s needs. Community health workers follow up and stabilize over time, building trust and connecting resources. Behavioral health partners connect the patient with the right medications, crisis centers and behavioral health centers.

What works: crisis intervention training, like that provided by the University of Washington’s BHCORE Center, helps initial responders lay the groundwork for their partners’ follow-up. Crews can also train each-other; for example, behavioral health partners can provide communication and de-escalation techniques, while Police and Fire can provide proper protocol and safety procedures

What does not: leaving out the patient. Something Picknell learned from her behavioral health partners was the importance of talking through a patient’s care plan with the patient, and listening to their concerns. As she says: “They needed to be listened to … I couldn’t force them into the right idea.”

Build the handoff before you need it

Alternative destinations only work if the crew already has a relationship, so South County Fire does the legwork ahead of time. Using HealthCall, they set up a one-page online referral form that law enforcement could use on-scene from their phone. They sought a grant from the Verdant Health Commission to fund a hotel housing program, among various alternative destinations. To overcome transportation barriers, they leveraged a member-funded firefighter foundation to cover Uber rides.

What works: a warm handoff. For opioid overdose case, South County Fire’s CORE program dispatches a CRP who can start buprenorphine in the field when the person consents, is not on methadone, and scores above 5 on the Clinical Opiate Withdrawal Scale. They establish a handoff map that allows for same-day connections to detox, recovery and crisis services. Patients have started actively asking for transport to these alternative destinations.

What does not: assuming 988 will take these calls off 911. Co-presenter Kimberly Hendrickson noted a few hundred thousand 988 contacts a year in Washington, against more than a million behavioral health calls through 911. People still dial the number that always answers.

Keep the grant with a number and a story

The department pays for the core, about $600,000, plus vehicles, while grants carry the rest. To secure those grants, Picknell has adopted an uncomplicated approach: first, find a successful grant from another MIH program, and copy it. Second, attach your program’s data; for example, when seeking funding for 24/7 coverage, South County Fire noted that off-hours accounted for 77% of their total referrals. Finally, add an impact story, like the story of the senior who needed a handrail. Picknell keeps a file of these stories, so she can show how the program is making a difference whenever she needs to.

What works: measure avoided transports, repeat 911 use before and after, and completed handoffs. Also, pull the records that funding partners can’t already see in dispatch. For South County Fire, Picknell pulled referral and outcomes details from HealthCall. Finally, don’t just send metrics to grant partners, use that meaningful data to improve your own program.

What does not: starting from a blank start. Picknell encouraged using what already works, and invited her audience to email her for information about her program, including their algorithm, referral form, and grant language.

Five moves to utilize

1. Start with the problem you can already see. Repeat callers, low-acuity transports, and the hours those referrals arrive.
2. Define your response unit. Map out which crews respond when, and what authority each member has on scene.
3. Create a handoff plan. Identify crisis centers, detox centers and shelters; secure transportation and plan for a warm handoff.
4. Invest in training. Crew members may need months of training and coaching before they can fully leverage critical techniques like de-escalation and trauma-informed communication.
5. Say yes, then name what the yes requires. A flat no is how the work stalls. When you see a need, start by saying “yes, we can fill that need, so long as we have X and Y to keep things effective and safe.”

The story of South County Fire’s CPR program is not just one of fewer transports. Firefighters assigned to the team have called it the best work of their careers. A paramedic who retired this year told Picknell the time with her team was the biggest impact of his life, and that it made him better on the line. At EMS World, Picknell left the room with a test: what need is already in your 911 system that assessment, connection, and follow-up would solve better than another trip to the emergency department?

Where to start
Nicole Picknell, PM, South County Fire: npicknell@southcountyfire.org. Battalion Chief Keith Sharp leads the Community Resource Paramedic Division: ksharp@southsnofire.org.

Drawn from “Using MIH to Respond to Behavioral Health Needs: South County Fire’s Community Resource Paramedic Program,” EMS World Expo, Orlando, October 2, 2026. Presenter Nicole Picknell; co-presenter Kimberly Hendrickson, University of Washington BHCORE.