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Colorado set up its mental health crisis system four years ago in response to a mass shooting. It’s about to transform.

State officials say the transformation will increase services and improve mobile response. But the contractors running the system since it began predict uncoordinated “hodgepodge.”

A sign, visible to drivers on West 84th Avenue in Westminster, points to the 24/7 Walk-in Crisis Center among the other services offered at the Centura Health Complex. (Eric Lubbers, The Colorado Sun)
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WESTMINSTER — Most people who walk in the door of a small, brick building labeled “24/7 Crisis Center” are depressed, suicidal, or experiencing audio or visual hallucinations. Others are young adults going through the first breakup of their lives, feeling so distraught they want to talk to a therapist.

Every crisis is “self-defined,” and Colorado’s 12 walk-in centers have had almost 68,000 visits since they opened four years ago.

The centers — along with a statewide crisis hotline, mobile crisis teams and five-day stabilization clinics — were created in response to the 2012 Aurora theater shooting, a mass murder committed by a University of Colorado graduate student whose attorneys said was “in the throes of a psychotic episode.”

Now, four years after Colorado’s $33 million mental health crisis system was set up, it will undergo radical change.

State officials, who are seeking new contractors to oversee the system, say an overhaul is needed to improve mobile-crisis response, incorporate local mental health services that already exist and, more broadly, put separate people in charge of financial and clinical decisions.

A side entrance for law enforcement — positioned away from the waiting rooms and processing area — at the Community Reach Center in Westminster on Nov. 2, 2018. (Eric Lubbers, The Colorado Sun)

“We see this as an evolution to the crisis system,” said Dr. Robert Werthwein, who became director of the state Office of Behavioral Health about a year ago.

But for those who manage the current system, the overhaul is an affront to their progress. There are now four contractors that manage four mental health crisis regions, and none of them bid on the new contract. The new system will transform the four regions into seven, in part to align with the state’s Medicaid government insurance regions, and break up the metro-area region into three.

Each of the seven could have its own contractor, or one agency could oversee all seven, under the rules.

The current contractors — which are coalitions formed by groups of local mental health centers — are accusing the state of tearing up the process instead of simply tweaking what is flawed. They filed a formal appeal to the state, which was rejected, and are now working to file an appeal this week in Denver District Court.

Meanwhile, responses to the state’s request for proposals were due last week and state officials hope to have new contractors by the end of the year.

“You are not going to have statewide crisis services,” said Rick Doucet, CEO of the Community Reach Center, which runs a walk-in crisis center, a five-day stabilization center, a mobile-response unit and a respite center in the north Denver suburbs. “You are going to have probably a hodgepodge of services offered across the state. There won’t be much in the way of integration or communication and it definitely is going to damage the metro area.”

Community Crisis Connection, the contractor for the Denver metro region, was created by six mental health centers, including the Mental Health Center of Denver and Community Reach Center.

The agency, which holds the state contract, subcontracts to their own mental health centers to provide crisis care. Many of the mental health centers, including Community Reach Center, increased their services to provide mobile response teams and walk-in clinics four years ago.

In Westminster, Community Reach moved into space used by St. Anthony Hospital before the hospital relocated to its current campus. Community Reach’s 24-hour, walk-in crisis center was once a wound clinic.

The stabilization unit, where people can stay for up to five days, was a labor and delivery wing.

The legislation that created Colorado’s crisis system also created a new source of funding for mental health centers willing to expand their services to fit the requirements of the law. The system received a boost in 2017 with legislation that made it illegal for Colorado to lock people in jail on mental health holds if they had not committed a crime.

“That was a pot of money that allowed us to expand,” said Doucet, noting that the state funding has helped fund crisis services for people who had no insurance or were underinsured.

Jaime Brewer, director of crisis services for Community Reach Center, laughs in the waiting room at the center as communications manager Lindy Lewis looks on. (Eric Lubbers, The Colorado Sun)

State “has to take some ownership” over flaws in the previous system

Under the new plan, developed by the state Office of Behavioral Health, the contractor will hire a variety of mental health providers in their region, including some that already exist and others that might open. In Douglas County, for example, a mobile-crisis unit that already exists could receive state funding to become part of the crisis system.

It removes the conflict of interest that exists in allowing coalitions of mental health centers to make decisions on how to spend state money at the same time they are making decisions about what is the best for patients, Werthwein said.

“One of the challenges we’re hoping to overcome is the person who is responsible fiscally is not also making the clinical decisions,” he said. “It’s healthy to have those separate.”

Werthwein said the state “has to take some ownership” for the system’s flaws because the rules weren’t specific enough. He is particularly disappointed with the network of mobile crisis teams, which two-thirds of the time have responded not to a home, dorm room or workplace as intended, but to emergency departments and mental health centers, according to state data.

“We should be going where behavioral health specialists don’t exist already,” he said. “They should be getting out to where there is a gap. To me, that’s not adding to the services available to citizens.”

State officials also were distressed about the findings of a sample analysis of calls to the hotline. In several instances, the hotline dispatcher wanted mobile teams to respond, yet the teams chose not to go out on the call. “That’s a problem when two behavioral health entities are conflicting on whether they need to go out,” Werthwein said. “We need to really tighten that up.”

Werthwein said he heard similar stories from members of his staff and others. One of his employees called the hotline for a friend who was suicidal, but the mobile team refused to come out after questioning her about whether substance abuse was involved. The woman ended up taking her friend to a hospital emergency department. Three days later, the mobile unit called and offered to come by, Werthwein said.

In another case, a person called on behalf of a neighbor who was suicidal and wouldn’t leave home. The caller was told the person who was suicidal needed to make the call, which is not true, Werthwein said.

“I don’t mean to sound too critical of our current provider, but we need to grow,” he said. “We’ve got to evolve as a system because we can’t have these scenarios continue.”

Doucet, however, said state officials should allow mental health providers who know the community to make decisions about when to respond. They get to know frequent callers and know whether a mobile unit might escalate the situation, for example.

“There are lots of issues they don’t understand because they are not in the communities. We are,” Doucet said.

He also took issue with the implication that mental health providers cannot properly manage spending and patient welfare at the same time. For decades, they have served state Medicaid clients. “We have actually proved we saved the state money for years,” he said. “Our goal is to be transparent as well as be efficient providers of the services. We feel that is our job.”

A sign explains the Crisis Residential Respite Service, an off-site housing program where patients 18 and older can stay for up to two weeks. (Eric Lubbers, The Colorado Sun)

Gains have been “revolutionary” under the current system, but compliance is a problem

The crisis system, billed as revolutionary and Colorado’s first statewide network for mental crisis help, now has 107 beds where patients can stay up to five days, 12 walk-in centers and a handful of respite care centers where people can voluntarily check in for 14 days.

The system, though, lacks accountability and “has not been managed well” to make sure its contractors are in compliance, according to an independent review that noted that the state Office of Behavioral Health has only two employees responsible for the system.

The review also suggested the state align its crisis regions with its Medicaid regions, since Medicaid is one of the largest insurance payers for mental health services in the state. The shift would reduce duplication, including in billing, and could improve data collection.

The report criticized the state’s mobile services, adding that “there are too many stories where mobile services refused to respond, took too long, would only meet an individual at the emergency department.”

“If we did a do-over for mobile services, what would it look like? It’s time to answer that question,” said the June report.

Sarah Vaine, assistant county manager for Summit County and member of a state steering committee that evaluated the system this year, is among those who support the proposed changes. Aligning the crisis regions with the state’s Medicaid regions could mean better data regarding who is using the system and their health outcomes, she said.

Also, Vaine believes the overhaul will allow more local mental health providers to participate in the crisis system. In Summit County, Spanish-speaking mental health organizations have “felt pushed out,” she said.

The entrance to the 24-hour, walk-in crisis center, tucked behind the 84th Avenue Neighborhood Health Center in Westminster on Nov. 2, 2018. (Eric Lubbers, The Colorado Sun)

Splitting care zones will increase overhead and hurt rural care, contractors say

The state and current contractors also are battling over administrative costs.

The current contractors say they have kept overhead expenses to under 10 percent and contend that breaking the four crisis regions into seven will mean more overhead. The state’s request for proposals said the new contractors cannot spend more than 25 percent on administrative costs.

“The only way you can do that, if you don’t add more money into the program, is to reduce the money for direct care,” said Doyle Forrestal, the CEO of the Colorado Behavioral Healthcare Council, which represents mental health providers across the state. “The system was very underfunded to begin with.”

But state officials say the contractors are mistaken. The state is accounting for spending on building space, computers and paper in its upper limit of 25 percent, items the contractors don’t include when they say their overhead is under 10 percent, Werthwein said.

The current contractors and the state also are at odds over the allocation of funds to each region. The state claims the remodeled system will dispense funds more evenly, tying regional allocations to population.

Contractors, though, said rural areas will get the short end of the deal. Greeley, Burlington and surrounding areas will have $1 million fewer dollars for direct care, according to their calculations. “The thing that drives me crazy is that the realignment of the map is not to improve patient care — it’s for the bureaucrats,” Forrestal said.

The seven new geographic service zones for Colorado’s mental health crisis network. (Colorado Department of Human Services)

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