The Fifth Branch: The Last Line of Care

Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode above!

Dan Gorenstein: A couple quick things before we start.

This is part 3 of a 3-part series, if you haven’t heard the first two episodes, we suggest check those out before listening to this.

Also, today’s episode contains some strong language.

DG: In the summer of 2022, Durham, North Carolina began to dispatch social workers and EMTs instead of police to certain 911 crisis calls.

Protest clip: We stand for … George Floyd! We stand for … George Floyd!

DG: This new city department – called HEART – was part of a national movement, sparked by the Black Lives Matter protests and a national reckoning over policing.

Protest tape: Are we next? Are we next?

HEART’s mission was clear: reduce police violence against people in a mental health crisis.

But that has changed.

Ryan Smith: I think that we have pretty early on, and certainly now see, our work is much broader in scope than that.

DG: HEART Director Ryan Smith and I were talking about HEART’s work a few weeks back.

DG: If the police’s job is to enforce the law; the fire department’s job is to put out fires; the EMT’s job is to provide medical care. What’s the 2 to 3 word description of HEART’s job? 

RS: Oh man, I hate these questions.

DG: Ryan paused.

He’d already said HEART’s priority is – and will continue to be – responding to someone’s crisis.

And then hook those people up to services that deal with the underlying problems that led to that 911 call.

Mental illness. Addiction. Poverty.

RS: I don’t know if I’ve shared this story. There was a person a few months ago unsheltered. Dealing with mental illness and substance use.

DG: The HEART staff who connect people to services – care navigators – talked to him about what he needed and found him a bed. 

RS: He had a bunch of dental pain and problems. We were working to make a dental appointment. We made an appointment to get him a cell phone. He went to the shelter. He was there. And, you know we let go at that moment.

DG: By that Ryan means HEART followed its protocol: handed off its responsibility to the shelter – a provider that offers more long-term support. How it’s supposed to work. But the safety net is so full of holes, people keep falling through.

A few weeks later a coworker, sends Ryan an obituary.

RS: He wasn’t at the shelter anymore. He was crossing a busy road late at night and was hit and killed by a driver.

I wondered what if we had held on a little bit longer when he went into the shelter? Here was someone who came in, really wanted the help. We were getting them on a path. And they’re not here anymore. And I think about the reality of that work.

DG: Welcome to the third and final episode of The Fifth Branch, a special series from Tradeoffs and The Marshall Project on what it looks like when one community dramatically changes how it responds to people in crisis.

The reality is these handoffs from HEART to another provider often fail.

A person misses an appointment, breaks some rule; most social services and city agencies can walk away.

And usually, people land right back with HEART.

39 people account for 1,201 calls. 8% of all of their calls for 39 people.

A pernicious cycle.

RS: I knew that it would be hard. I knew that it would be messy. But that it would be the hardest thing that we do? That’s the thing that surprised me.

DG: The department, as a first responder, has made strides. Answering 15,000 911 calls over its first two years. But has managed to connect just one of five people to long-term care.

This, Ryan explains, is why HEART’s scope has grown.

We circle back to the question: in two or three words, what does HEART do?

RS: We are the last line of care.

DG: The problem? HEART is supposed to be at the front of the line responding to a person’s crisis and then to turn that care over.

If HEART is also at the end of the line, something has gone wrong. And that raises difficult questions.

Today, is it the job of first responders to make these connections? Where does traditional crisis response end and social service work begin? What will it take for HEART to stop being the last line of care?

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

******

DG: Tradeoffs producer Ryan Levi spent a lot of his time in Durham out in the field watching HEART respond to people in crisis.

In this episode, Ryan brings us inside HEART’s cramped City Hall offices where a handful of staff spend 12 hours a day trying to put people on a path from crisis to stability. And where HEART’s leaders are grappling with the fact that too often they are falling short of their own goals.

Here’s Ryan.

RL: Sammetta Cutler’s bird name fits.

Sammetta Cutler: I’m mother hen. I look at everybody like they’re my children. (laughs)

RL: All HEART staff have these bird nicknames that capture some part of how they show up.

SC: I feel support should never stop. Support is ongoing. If I want to buy some toilet paper and I don’t have a dollar to get a roll, that’s a crisis. Crisis comes every day and you need that support.

RL: The 61-year-old with silver hair and long purple-painted fingernails wakes up early every morning. She says she fires off ‘good morning texts’ for 45 minutes. I even get them. Very mother hen.

SC: So they can know. No matter what you’re going through, there’s somebody that wish you a good day. And if that’s all you need to change your day from negative to positive, then I want to give them that inspiration to do that.

RL: When one of HEART’s first responders meets a person on a 911 call who needs more help, they refer them to Sammetta or someone else on the department’s Care Navigation unit.

It’s Sammetta’s job then to link them to longer-term care and support.

To do that, she spends a lot of time on the phone.

SC: Good morning Tiffany. This is Sammetta from HEART. 

RL: Reaching out to new referrals…

SC: I’m just trying to follow up with you…

RL: Following up on active cases…

HEART client: When I got locked up, they had to stop my services. 

SC: Uh huh.

RL: Trying to shake loose resources from social service agencies…

SC: I’m trying to prevent her from being unsheltered, living in a park with an autistic child.

Social service agency: I do understand is it’s just very challenging right now.

RL: Spending hours every day looking to connect people to care is different from how I expected a city agency of first-responders to spend their time.

Ryan Smith told me that when he designed the program, he knew his team would meet people with problems bigger than anything social workers could solve out of a van.

But he wanted to avoid the department from sliding into long-term care, so Ryan limited care navigation to 30 days.

RS: We’re not there to provide all the services. We’re there to try to make the most of sometimes our underfunded, fragmented system of support. That’s why we have care navigation.

RL: But over and over again in these first two years, HEART’s care navigation efforts have run into a wall.

HEART has connected just 20% of people to follow-up care.

Some of that is because one of every three people HEART meets on a 911 call never respond when navigators reach back out.

Some of that is because housing and mental health services in Durham are really limited.

For example, Durham’s shelters are full. Last week, 69 people and 32 families were waiting for beds.

A 2019 report estimated Durham needed at least 577 new housing units for people with complex health issues. They’ve added 6.

HEART’s Sammetta Cutler says running into this wall hurts most when people really want the help.

SC: Even with care navigation, when we refer someone, these people need immediate help. They don’t need to wait for an authorization so an agency can start working with them. They need it yesterday. I’m homeless, sleeping in the park, and you tell me. Oh, yeah, well, when we get authorized, maybe two weeks to 30 days, and I’m in the motherfucking park. Excuse my language.

RL: Two years in, HEART now appreciates what it means to work with social service partners, often that are overworked, starved for money and move at their own deliberate pace.

Sometimes Sammetta gets so frustrated with the other agencies – their red tape, their unanswered phone calls – she wishes HEART could cut out the middle man, run their own housing program.

That’s exactly what Sammetta wanted to have on hand when she met Sarah Hall.

SC: I saw a lot of myself in her. She was very eager and very independent and knew what she wanted in life, and she just needed some help.

Sarah Hall: So I got signed up with her, and ever since then, she talks to me every morning, giving me encouragement and trying to connect me with other agencies.

RL: Before meeting Sammetta, Sarah had hit a rough patch. She’d spent most of the last two years living in her silver SUV.

SH: I literally was sleeping in my car, waking up with my toes, not feeling my feet, my toes frozen. My hands was frozen, like I was sick.

RL: This past winter, the 39-year-old stayed at an emergency shelter HEART helped stand up during one of the coldest weekends of the year.

Sarah met a few folks from HEART who had lived on the streets, been locked up, been addicted — just like her.

SH: They just kind of opened up that cloud. They ripped the darkness out of it and just put a sun right in the middle of it. And it was like, dang. Okay, so if they can do it, I can do something better than what I’m doing today. So let me just try.

RL: A local drug treatment program helped Sarah get sober and offered her a temporary place to stay.

That’s when she went to see Sammetta. 

SC: When she got with me, it was about how can you help me get where I need to be so I don’t have to go back to living in my car. I immediately go into robot mode to get a solution.

RL: Sammetta helped Sarah look for apartments and programs that would help her pay rent. Sarah also wanted long-term support, someone to lean on as she made all these changes.

SC: I was in this place that can help her. This place can help her. Let me give her this information so she can get on the ball.

RL: Despite all their work, nothing. Crickets.

SH: She has contacted them 2 or 3 times, left messages. I’ve also called left messages and not gotten a response.

RL: That was four months ago, long past when HEART’s care navigation ended.

SH: You start to get to a point where you feel like, what am I doing? Like, this is not working. And it kind of pisses you off because when you really trying to diligently do the right thing and not go the wrong way, it is real, real frustrating when you cannot get the assistance that you need. You just feel like it’s not going to happen.

RL: Sammetta gets Sarah’s frustration. Sammetta’s been incarcerated, addicted to crack cocaine, homeless. And she worries Sarah’s window may close.

SC: She’s a recovering addict. And when we are newcomers in the world of recovery, we can. Sometimes when things don’t go our way, we get angry. And sometimes that can mean us do something to get fast money or start hanging around the wrong people.

RL: Even though Sarah’s case is technically closed, Sammetta keeps poking around, staying in touch.

SC: I’m not supposed to do that, but I am who I am.

RL: Think about Sarah’s situation, for a second, from HEART’s perspective.

If Sarah stays stuck, there’s a chance she ends up back living in her car. Maybe she gets sick, maybe turns back to using and drinking.

HEART’s Ryan Smith thinks a lot about people like Sarah.

How long before someone in this kind of spot ends up on the other end of a 911 call, or worse?

RS: If someone continues to sleep outdoors, is dealing with severe persistent illness, is not getting any medical attention, is eating trash out of the garbage that is going to end very poorly for that human.

RL: Ryan says this is the “last line of care” dilemma the department faces every day.

RS: We are a 50-person department responding to calls across the city. We don’t control all of the other agencies that we’re working with. We don’t have access to all of the housing that we need. And yet still, when there’s an emergency call, we’re the ones showing up trying to figure out how to do our best with a system that is not resourced enough.

RL: Ryan tells me people in the office can feel demoralized, especially like with Sarah, where housing can be near impossible to find.

The state of the social safety net – with people falling through it all the time – is a kind of “band-aid” problem for HEART.

Ryan hears people in the office say, “It feels like we’re just a band-aid. I don’t want to just be a band-aid.”

The uncomfortable truth, though, is to offer a more permanent fix means – on occasion – to do the work of a social service agency. 

RS: I feel very clear of where our boundaries are. And yet this role of being kind of a last line of care means that we’re in this state of pushing up against those boundaries and trying to figure out how to advocate for a broader solution.

DG: When we come back: How HEART hopes to strengthen the social safety net? And Ryan Smith grapples with how far he can push the department’s boundaries.

MIDROLL

DG: Welcome back.

HEART faces two interconnected problems.

The city department has learned just how hard it is to connect people to care because of how easy it is for people like Sarah Hall to slip through one of the many gaps in the social safety net.

Second, HEART ends up answering 911 calls for a tiny sliver of people again and again. Part of that can be pinned on the same dearth of resources that trip up folks like Sarah. But part of that is simply because this small group of people live extraordinarily complex lives.

To address this dual problem, HEART has tweaked its own operations and decided to do work outside their lane as first-responders.

Is it enough to more reliably connect people and stop being ‘the last line of care?’

Tradeoffs producer Ryan Levi picks up our story.

RL: HEART, this year, is rolling out a series of internal moves that the department’s Ryan Smith believes will help connect more people to more care.

At the top of the list: more quickly match care navigators to people in crisis. 

RS: Each of these encounters is precious. The second there is that initial disconnect from the first response team, we have an increased likelihood that we won’t be able to make that connection.

RL: Instead of contacting someone within 48 hours of a 911 call, Ryan says navigators will try to meet the person immediately. They’re building a social service database to get a better handle on available resources. And Ryan knows anecdotally that barriers to better connection include things like eligibility, waitlists and providers not returning calls. But to get the city or other providers to make changes, he needs more than stories.

RS: I feel like I’ve got one arm tied behind my back right now because I know that we have problems, but I don’t know exactly what to ask for and how much to ask for. I can’t make a compelling case to city leadership in the absence of the data, and I need the data.

RL: Starting this summer, HEART staff will have to document what services they tried to connect someone to, and if they failed, why.

RL: HEART’s external work — basically trying to patch up the safety net — is where they are stepping over the line of traditional crisis response. 

Take David Prater, who we met last episode. David’s primary job is to ride around the city and respond to 911 calls. But sometimes he does what I call social services R and D — social services research and development.

David Prater: Well, if everybody’s ready, I think we can go ahead and go ahead and begin.

RL: I tagged along with him on a visit to a kinda group home for formerly homeless veterans. We’re in the living room of a small house on a leafy cul de sac. Five guys sit in a circle, a few folks from HEART are here too. David sits on the floor, his laptop open.

DP: It’s our belief that Durham can do more to support the homeless.

RL: David explains to the vets, this is his third listening session with homeless people in the city. He’s trying to learn how Durham can better meet their needs.

Over the next hour …

Veteran 1: I don’t have a clear conscious about everybody I shot every time because they, uh, you realize that they are human beings.

RL: The guys talk about the horrors of war they still carry. The toll being homeless takes. 

Veteran 2: I always hear people talk about suicide. I’m like, man, I’m never going to, you know, kill my own self. But that crossed my mind one day.

RL: How hard it is to get help.

Veteran 3: You have to talk to different people and go to different places to get anything done. It seems like it takes forever for anything to happen.

RL: David takes it all down.

In the car on the way back to City Hall, I push David. Why should he – a first-responder – be doing what amounts to focus group work?

RS: Why do you feel so strongly that it is also part of your role in HEART to be trying to answer these questions around homelessness?

DP: These stories that we’re hearing from these gentlemen tonight about the connection of mental health and housing, the impact that appropriate supports can have on their mental health, on their emotional well-being. When we can take those stories into the spaces that decisions are made, that is the most powerful advocacy tool.

RL: Along with police, fire, EMS and 911, HEART is the fifth branch of the city’s public safety response team. As a city agency, their insights, concerns and suggestions matter. What David learned here tonight will end up in a report for the City Council.

DP: And that’s a unique opportunity that our department has because of where we’re positioned.

RL: HEART believes part of its mission must be to identify social safety net problems and propose solutions. It’s solving another crisis, just at a more systems-level scale. A great example: In under a week, Ryan Smith pulled together city partners to stand up two heated tents for 24 people on one of the coldest weekends of the year.

RS: It is completely beyond the scope of our department to step in and provide shelter space and to be a cold weather emergency shelter provider. And yet this last winter, we did that for one weekend.

RL: Ryan justifies this as the prevention arm of his department. HEART’s version of cops talking to school kids about bullying and firefighters running fire drills. Ryan gets it. The pop-up shelter, the focus groups, this work falls over the line of HEART’s core work. But he stresses they’re often in-and-out, short-lived campaigns that are designed to prevent future crises.

This spring, though, HEART stood up an unapologetically, full-on, long-term social service agency-like pilot program.

RS: I’ve worried a lot about Martin.

RL: “Martin” is the name Ryan uses for a man who’s lived on the streets of Durham for more than a decade. Martin struggles with mental illness, usually unmedicated. City officials have held meetings just about Martin.

RS: There was a clear gap. No one was working with Martin.

RL: Martin’s too sick to jump through the necessary hoops to apply for housing, but he’s not sick enough to be admitted to a psychiatric hospital against his will. His case helped convince Ryan that HEART needed to leap over their first-responder boundary.

RS: We have to stand in this gap because at the end of the day, we’re going to keep getting 911 calls.

RL: Martin is one of the 39 people who have generated 1,201 911 calls — 8% of HEART’s call volume. And he’s now one of five people who the department is meeting with several times a week as part of this new pilot. HEART hopes more time with Martin will get him the treatment, housing and support he needs.

RS: It’s the right thing to do by Martin, and Martin deserves that kind of care. And we’re doing it so that we can help generate insights about what types of system level changes and investments we need that will, over time, lower the need for us to fill this kind of gap.

RL: The department declined my request to shadow staff who work with Martin over concerns that a stranger with a microphone might antagonize his paranoia. Still, Ryan reports they’re making progress. After weeks of painstakingly building trust, staff helped Martin get an ID — a key first step for him to sign up for services.

RS: I remember thinking what a huge accomplishment that I was very proud of our team. And knowing full well that most others probably couldn’t see or appreciate how much work went into that.

RL: Ryan’s sure right about that.

John Warasilla: Once you’ve gone to that point that you’re putting in those kind of investments, people are going to expect results out of it. And the results we were seeing were not satisfactory.

RL: John Warasila is an architect and a real estate developer in downtown Durham. Martin often takes over a 5 x 20 foot corral where John’s business tenants take out their trash. Sometimes he scatters that trash, sometimes he screams at people.

JW: How is it that one individual can disrupt 20 people’s lives and investments and well-being and that’s okay?

RL: Now, John likes HEART.

He likes the idea that someone other than police can show up and de-escalate certain situations.

JW: There’s no reason for someone to get shot for having a temper tantrum. No one wants to live in that society, right?

RL: In the couple months since I met John, he’s kept me posted on Martin, sent pictures of Martin surrounded by garbage, a story from a neighbor who says they saw Martin scream at a young family and start masturbating in front of them.

John appreciates that HEART is investing time and resources into helping Martin, but he questions the value.

JW: They will tell us we’re working on it. They tell us this list of things they’re doing. At the end of the day, it’s not resolved. So at a certain point you’re like, I appreciate all the effort that’s going into this, but this is not functioning as a solution.

RL: Ryan Smith understands John’s frustration. He shares it. HEART is making a bet this pilot could help break the crisis cycle for people like Martin. If there was an easy fix, then Martin would have more than his ID card by now. Ryan has the city’s backing to take these intentional steps into social service work.

Bo Ferguson: If they are in a space that feels like an experiment in the realm of meeting people’s emergency needs, I’m comfortable we can learn something from it that’ll be useful.

RL:  This is Bo Ferguson.Durham’s deputy city manager for public safety and Ryan’s boss.

Bo is like a lifeguard at the beach, keeping an eye on Ryan to keep him from swimming out farther than he should.

Bo says other agencies and city departments have mostly welcomed HEART’s help and that makes it easier to let Ryan keep swimming.

BF: I’m comfortable acknowledging the line is fuzzy and the line can move and has moved because we’re such a young program, we’re still learning how to operate in this space.

RL: I think this is a point worth underlining. HEART is two years old. It’s been citywide for less than 12 months. Figuring out where HEART can have the biggest impact means trying things, experimenting. But Bo reserves the right to call Ryan back to the beach.

BF: I’m not prepared to tell you long term if care navigation is an important component of what we do. As an administrator who has to figure out where best to put the next dollar, that’s certainly one of the questions I think it’s important for us to be able to answer.

RL: Bo says he supports care navigation. But – ultimately – the City Council and the people of Durham must decide if they want HEART to continue to spend time – and money – on this difficult task.

RL: Another financial decision the city may confront: should Durham cut its police budget as HEART picks up a growing share of 911 calls.

Remember this all started in 2020 after protestors painted DEFUND on Main Street with an arrow pointing to police headquarters. And the word FUND with an arrow pointing to the department of social services.

Bo – who oversees all the public safety branches – says no service is static. He’s constantly reviewing the city’s needs.

BF: It is a reality of our job in management to always look at what the workload is for our staff and what resources we need to meet that workload. And that’s no different with policing, but I don’t think we’re close to that yet.

RL: Durham, in fact, just boosted officer salaries this summer.

Police Chief Patrice Andrews is one of HEART’s biggest cheerleaders in town.

Patrice Andrews: I think that HEART should be two times as big as it is now the need and the demand is there.

RL: But Patrice warns, along with Bo and Ryan Smith, there’s a danger to pitting the police against HEART.

Cutting her budget, Patrice says, means it would be harder to fill officer vacancies at a time when the city is growing and demands for services are rising.

She says Durham – and any city doing this work – must balance responding to crisis and responding to lawlessness.

PA: We can do both because you need a level of law enforcement in the society, but you also need that side of public safety that really is all about taking care of our populations of people that are most vulnerable.

RL: Connecting people to care, on most days, is agonizing work.

There are the constant disappointments, like hitting deadend after deadend with Sarah Hall. 

There are the one step-forward, two steps back frustrations, like working with Martin.

There is the tragedy like that man who was run over and killed in the street.

These incredibly high-stakes are why, Ryan says, HEART strays from its traditional role, it’s a moral duty.

RS: Some of the people that we encounter most often in this work are in such precarious, vulnerable positions with seemingly no one else in their corner that if we don’t continue to show up, then it does feel, and we do worry, that it’s a matter of life and death.

RL: Ryan believes the best way to help more people is if HEART stops being the last line of care.

He hopes all of their experiments, side projects and unorthodox work helps spark the imagination of city leaders and the social service sector that more is possible.

RS: It’s all about building a coalition, bringing data, helping people think about what that is, bringing partners to the table and then making it happen, and finding people who can run that.

RL: It’s going to take these stronger alliances like Ryan helped forge between HEART and Durham PD. Ryan’s bird nickname, you may remember, is Chickadee. That’s what chickadees do — build alliances to solve problems.

RS: You know, I didn’t realize that at first. I thought it was just kind of a cute throwaway name, like, oh, the chickadee, it’s just tiny little bird. I thought people were having fun with it. And as I learned more about the chickadee. Yeah, it felt like it fit really well.

DG: Tradeoffs Producer, Ryan Levi.

MIDROLL

DG: As we wrap up The Fifth Branch, I’m joined once again by Christie Thompson, a staff writer with our reporting partner, The Marshall Project, a nonprofit newsroom that covers the criminal justice system. Christie has been reporting on the state of alternative crisis response across the country, and today she’s talking with us about how other cities are thinking about the scope of their programs. Hi, Christie.

CT: Hey, Dan.

DG: As we just heard, Durham made the decision early on to make connecting people to longer term care part of HEART’s mission. How common is that, Christie, among these alternative response programs?

CT: It’s pretty common when I talk to people who are supporting these programs across the country, they said that most teams were trying to create some kind of follow up service to help connect people with longer term shelter or treatment or care.

DG: And have these other programs struggled as much as Durham has to make these connections for the people that they’re meeting?

CT: Absolutely. There was a survey of the Street Response team in Portland that talked to all of the first responders on the ground, and they said that on the vast majority of the calls they were responding to, they came up against this gap in social services for the people that they were working with.

There was another study that recently came out from San Francisco that was really interesting about their Street Crisis Response Team, and it highlighted this interesting dynamic where other first responders like police or 911 dispatchers, they were the ones who were frustrated with how little the street crisis teams could do to provide long term support.

You know, it seemed like they were sort of expecting these teams to solve a whole range of social ills, and that it was impacting their confidence in these programs. When they sent out these teams and felt like long term, not much had changed.

DG: So Durham is kind of getting into the social service business sometimes to try to get around this broken social safety net. What are other cities that you talk to doing when they run up into this same sort of problem?

CT: You know, many programs are providing short term supplies for people, whether that be tents or food or clothing. In Olympia, just a bit north of Portland, they realized that they were seeing the same people over and over again. So they started what they call a familiar faces program, where certain high need people get assigned a peer navigator who had lived through homelessness or poverty and would help them access housing and mental health care and other supports. And they also provide a lot of just basic transportation for people to doctor’s appointments and methadone clinics and things like that.

DG: And I’ve also heard, Christie, that you’ve got some cities around the country that are standing up so-called crisis stabilization centers. What are these? How do they work?

CT: Yeah. One thing that a lot of programs have faced is that when you have somebody who’s in crisis on the street, you need somewhere to take them that isn’t a jail cell but isn’t necessarily an inpatient hospital.

So a lot of cities are creating these crisis stabilization units as a sort of middle ground, where somebody who’s in mental distress can go voluntarily and stay safe. So Houston has one of these, Albuquerque just opened one, and a lot of cities like Seattle are planning them now.

DG: Christie, when you talk to folks in Olympia or other cities grappling with this kind of like merry go round of folks who are maybe spared a police encounter but still living in daily crisis, what do they say? How are these programs ultimately defining a win?

CT: I think these programs are at a place where they’re trying to be really clear about their mission, you know, to their community members, but also to other first responders like police. They’re trying to be clear that they are not a catchall silver bullet solution to these massive problems of homelessness, to the mental health crisis, to addiction.

You know, their goal is to reduce police contact with vulnerable people. And so any time that they can respond to somebody and provide even short term assistance and keep that person from ending up in jail that day, that’s a success.

DG: Christie Thompson, thank you so much for your reporting on this very important topic.

CT: Thanks for having me.

DG: Before we go, I want to bring Tradeoffs producer Ryan Levi back one more time for a few final thoughts. Hey, Ryan.

RL: Hey there, Dan.

DG: You’ve shown us over these three episodes, Ryan, how HEART grew from an idea a few years ago to a 50 person team answering thousands of 911 calls today. But as we’ve said, it’s still very early days for HEART. What’s next?

RL: So the goal is to get to 24/7 coverage. Right now, HEART is only staffed 9 a.m. to midnight. The earliest that expansion could happen, Dan, is next year, and HEART estimates it would cost another $1.5 million on top of their existing $5 million budget to have at least one team available all day.

DG: And after your reporting on these programs, Ryan, and six months of diving deep on Durham specifically, what makes Durham stand out? What has allowed this mid-sized Southern city to build one of the most respected programs in the country?

RL: One thing Durham talks about a lot is how important it is to be its own independent public safety agency. Most cities, Dan, their programs are housed in the police department, fire department, health department, or they contract out to nonprofits.

Only Durham, Albuquerque and Cambridge, Massachusetts, have their own Community Safety Departments — truly a separate fifth branch. HEART’s leaders say being in another branch forces you to compete to be a priority. When you’re on your own, you can design the program how you want, make changes as you figure out what works, what doesn’t. It’s a lot easier to grow and direct your own future.

DG: Final question, Ryan. We’ve covered so much ground in this series, but of course, there’s lots that never makes it into the episodes. Is there one moment, one idea that we haven’t talked about but that you think is really important, that you want to share?

RL: There is a conversation I had on one of my ride-alongs with Allison Casey. She’s an EMT with HEART, actually their first EMT. And she helped me put this moment with the creation of all these programs like HEART in some more context.

Allison Casey: I think a lot about the history of EMS in this country and how EMS was only standardized as a standard 911 response in the ‘70s …

RL: Alison told me that before the ‘70s, police were sometimes the main responders to medical emergencies. She said one estimate suggests up to 2,000 people a year died because of that. Today, it’s really hard to imagine a world without EMS, Dan, and it makes me wonder if that could be the case in a few decades about the fifth branch, about HEART. That’s certainly how Allison feels.

AC: I think the only limit is our imagination for the ways that we can improve what community safety actually looks like and what public safety actually looks like. And I think we’re leading the way in that. So that’s a very cool thing to be a part of.

RL: Obviously, there are a lot of questions to answer and barriers to overcome before HEART or anything like it can be as ubiquitous as EMS. But after a year of reporting on this stuff, you know, it’s clear to me people call 911 for a whole lot of reasons other than fires, medical emergencies or crimes. And you need responders for those calls too. It seems to me like what they’re doing in Durham, what they’re doing in other cities across the country is a way forward.

DG: Tradeoffs producer Ryan Levi. Thank you so much for all that you have put into this incredibly important series.

RL: Happy to do it, Dan. Thank you.

DG: You can find all three episodes of the Fifth Branch, plus pictures from Durham and more information on the series at tradeoffs.org/thefifthbranch. I’m Dan Gorenstein, you’re listening to The Fifth Branch, a special series from Trade-offs and the Marshall Project.

This project was supported in part by The Just Trust and the Sozosei Foundation.