In Crisis, One Year Later: A Fragmented System Remains, But There Are Bright Spots

Aug 14, 2015

Shannon Guevara with her youngest daughter and grandson.
Credit Katherine Jones / Idaho Statesman

Shannon Guevara stood in a courtroom in front of her peers — a group of people who, like her, had committed felonies but whose severe mental illnesses made them eligible for a special court. She talked about her four kids, her husband, the classes she was mandated to attend after being convicted of a drug crime. And she beamed, because on this June afternoon, she was another step closer to a happy ending.

Guevara had been sitting in the same Canyon County courthouse less than a year earlier, hoping a judge would sentence her to the court. She had been diagnosed with bipolar disorder and had tried for years to self-medicate with methamphetamine. Her husband eventually called the police, who caught her wandering the streets near her neighborhood with a drug baggie.

Having already spent time in prison for drugs, Guevara wanted to avoid returning; prison only worsened her depression and manic episodes. She wanted psychiatric care for her bipolar disorder, the coping skills to keep from using again and the kind of every-single-day tasks and accountability she knew she needed.

A judge agreed and sentenced her to the special court last fall.

A Nampa housewife in her mid-30s, Guevara is one of several Idahoans profiled last fall in “In Crisis,” an in-depth series about Idaho’s fragmented mental health system by the Idaho Statesman and Boise State Public Radio. Afterward, Guevara received a letter from a girl with whom she had used drugs. The girl, now sober for years, told Guevara, “You know, I didn’t ever think of you as somebody who had a story behind you.”

A year later, Guevara and others have made progress in getting treatment for their mental illnesses.

But there still are flaws in the state’s mental-health system.

THE COURTS

Guevara said she was nervous, withdrawn and distrustful when she started mental health court. She decided she could benefit from counseling to work out issues from her past, and the court provided it.

“Now, everybody is telling me how they’ve seen such a change in me,” she said. “I’ve had instances where I’ve ran into people I used to use with, and I’ve been able to turn away from them. ... I love the life I have now, instead of despising it.”

The court taught her to cope with major life changes, such as getting the news that her teenage son was going to be a father.

She also is making plans for after she graduates from mental health court. Her husband’s health insurance policy will help cover her medication, and her court supervisors are looking into low-income counseling options for her.

One of her fellow mental health court participants is Curtis O’Daniel, a Boise man in his early 40s who had just begun the court in Ada County last year. O’Daniel is “doing well,” according to his mother, Patsy McGourty. He recently advanced to the third phase of the program. Ada County Mental Health Coordinator Kelly Jennings said O’Daniel recently won a spot in the court’s “honor box” to recognize his willingness to help other participants.

THE HOSPITALS

Shawna Ervin, of Nampa, had just finished a partial hospitalization program through West Valley Medical Center when we wrote about her last fall. She hoped that program would cut back on her repeated hospitalizations.

Ervin’s husband died unexpectedly in January. Managing her mental illness without his support has been “very hard,” she says now. She is working on her mental health so that she can be there for her children.

She said she has been to the hospital four times this year. But she thinks the partial hospitalization program helped, saying her hospital stays would have been twice as numerous had she lost her husband before the program.

Amy Hicks, who runs the program, said more people from the court system and government agencies are now turning to it.

“We have people that have really embraced being healthy, as opposed to identifying themselves as ill,” she said.

THE SYSTEM: COPS AND COURTS

Little has changed in the world of mental health court, Jennings said. There still are dozens of people a year who graduate from the court with a fresh start. But gaps remain in the public support system — a barely-there public transit system, an inadequate pot of money for housing assistance, a pared-down staff to perform the state’s role in the programs — that make it harder for participants to succeed at a rigorous schedule of classes, drug tests and doctor’s appointments.

New resources are emerging at the first-responder level, though.

Teresa Shackelford, a social worker for the Idaho Department of Health and Welfare who works on a mobile crisis unit, said police officers report that the number of mental-health related calls is “leaps and bounds” higher now than in the past several years. They have had a growing need for help to manage the flood.

Shackelford started last September working on a pilot with a few members of Ada County Paramedics who saw an opportunity. The teams go out to help people in crisis. For example, a team will respond to a 911 call about a suicidal subject before police or doctors have to put the person on a mental hold. The purpose of a mental hold is to keep someone in a supervised place like a hospital emergency room until a court-designated person can evaluate whether the person needs to be institutionalized.

New resources are emerging at the first-responder level, though.

Teresa Shackelford, a social worker for the Idaho Department of Health and Welfare who works on a mobile crisis unit, said police officers report that the number of mental-health related calls is “leaps and bounds” higher now than in the past several years. They have had a growing need for help to manage the flood.

Shackelford started last September working on a pilot with a few members of Ada County Paramedics who saw an opportunity. The teams go out to help people in crisis. For example, a team will respond to a 911 call about a suicidal subject before police or doctors have to put the person on a mental hold. The purpose of a mental hold is to keep someone in a supervised place like a hospital emergency room until a court-designated person can evaluate whether the person needs to be institutionalized.

“It’s the most restrictive treatment there is,” Shackelford said.

When someone goes through a tough breakup, gets drunk and sends a suicidal text message, it may be a psychiatric emergency yet not warrant a mental hold. The teams in the pilot program often can divert people in crisis from such holds.

The rapid response keeps residents from having to go to the emergency room — a savings of $2,500 per person, Shackelford said.

“It saves the court a lot of money, it saves the patient a lot of money, and sometimes in many cases if they don’t have to go to the hospital at all, it keeps them in their house, it keeps them from losing their job,” she said.

In a recent eight-hour shift, the Psychiatric Emergency Team responded to 20 people. The teams do not operate 24 hours a day, because there is not yet staffing for all-hours assistance.

The pilot project is limited because it has no funding. Shackelford said the group is presenting its results to the local behavioral health board this month, hoping to get some ideas for funding sources that could pay for one or two full-time positions.

THE SYSTEM: OPTUM

As it nears the end of Year Two of a three-year state contract, complaints persist about Optum Idaho, the contractor for privatized Medicaid mental health. Some complaints differ from those voiced in the series.

Optum Idaho manages Idaho’s mental-health and substance-abuse treatment services for Medicaid beneficiaries, acting as an insurance company to approve services and pay the service providers on behalf of patients.

Optum has mostly fixed a couple of big problems that providers pointed out last fall : patient records going to the wrong providers, which prompted a federal privacy investigation; and “penny payments” that sent providers a fraction of the money they were owed.

There are “huge inconsistencies of what to expect with them,” said Nikki George, who owns Boise-based Access Behavioral Health, one of the largest providers in the state. The policies change all the time, she said, and it is hard to guess when Access will get paid for its work. George said getting Optum to approve a patient’s care is tricky, so her company’s supervisors are now spending time on paperwork that should go to supervising employees.

Vanessa Johnson, director of local community-based services for Access Behavioral Health, said there has been no change in cuts to “community based rehabilitation services,” or CBRS, formerly called psychosocial rehabilitation. CBRS is a type of rehabilitation service for people who need to regain or develop skills they lack because of chronic mental illness. Children and adolescentsreceived it frequently when the state managed its local contractors before hiring Optum.

But starting in 2013, Optum implemented “evidence-based” requirements for children and teens to receive CBRS. That resulted in many CBRS requests being denied, because Optum’s medical staff determined their effectiveness was not supported by research.

“Ultimately, we’re able to go through enough appeals processes that eventually we’re able to get services,” George said. “But by that time, enough time has passed — the client is in crisis. Their needs are intensified, or they’ve already gone into the state hospital.”

Johnson said Treasure Valley hospital beds for adults and children who need intensive psychiatric care remain scarce, while demand has grown.

“We have several clients who ... need to be in state hospital” due to severe illnesses, she said. But when the state psychiatric hospitals in Blackfoot and Orofino are full, Johnson said, it occasionally creates a domino effect: Local hospitals take on the overflow, making those hospitals too full to accept patients in crisis, so those patients spend days in the emergency room before they’re sent home.

In the past two years, Johnson said, Access Behavioral Health has increased by 42 percent the number of hours it spends on crisis intervention for a subset of patients affected by Optum’s cutbacks on certain services. Meanwhile, the company is providing 59 percent less of those community-based services, she said.

Idaho Behavioral Health CEO Tami Jones said her company, also based in Boise, has cut 30 percent of its staff in the past year and closed its Emmett office.

A big reason, Jones said, is an Optum requirement to put clients in family therapy before Optum will authorize community-based rehabilitation.

“Oftentimes that’s a huge issue,” Jones said. “Parents are not invested. So getting them to come in for family therapy, it’s like pulling hens’ teeth. ... We’ve lost a lot of clients whose services were denied because families [won’t go to therapy].”

Optum Idaho insists that all changes are part of its “commitment to ensuring that people are getting access to the right care at the right time,” said Becky diVittorio, executive director.

She said the Medicaid program Optum is creating in Idaho is more of a “member-centric” system that puts a focus on customized treatment plans — building goals based on a person’s strengths.

“We take provider payments very seriously. We work to ensure providers are paid in a timely and accurate fashion,” diVittorio said.

She said Optum has exceeded its contractual obligations to pay almost all “clean claims” — those for which it doesn’t need to request more information, for example — within 30 calendar days. In the first quarter of 2015, it paid all claims within 90 calendar days, she said.

“We have contracts with our providers, and we have a contract with the state,” diVittorio said. “We meet those agreements that we have, and we have supports in place for providers. ... That’s really important to us.”

She added that the company has provided mental-health first aid training to 200 people statewide in nine separate trainings. Idaho Medicaid members also are using peer-support services — akin to a supportive mentorship — at a growing rate, with usage increasing by 50 percent in the last six months of 2014.

Optum has increased the number of people receiving family therapy threefold, she said, to more than 14,000 people in the latest fiscal year. Optum increased the number receiving individual therapy by 41 percent, to more than 30,000 people.

But the Idaho Legislature in March directed its staff, through the Office of Performance Evaluations, to study the state’s $10.5 million-a-month contract with Optum. A report is expected in January.

“Frankly, I think we may well have written a contract that was very difficult for any vendor to fulfill,” Rep. John Rusche, D-Lewiston, told Boise State Public Radio in March.

Ross Edmunds, who runs the Idaho Department of Health and Welfare’s behavioral health division, said there hasn’t been much of a change — increase or decrease — in the number of people being hospitalized for mental-health crisis in the past year.

But he points to progress:

•  The settlement of a longtime lawsuit over the state’s services for children with serious emotional disturbances.

•  New behavioral health boards are operating as a result of state overhauls, and the board for a district that includes Ada County has signed a contract with the Central District Health Department to create a less fragmented social-service safety net for people with mental illnesses and substance-abuse disorders. For example, when a person with addiction leaves inpatient care, he may now end up sleeping on his dealer’s couch. The health department and the board are tasked with finding ways to ensure that person can find housing instead.

•  The state’s first mental-health crisis center is open in Idaho Falls, and another is slated to open this year in Coeur d’Alene. They offer an alternative to the emergency room, or jail, for people in crisis. The department will request funding from the Idaho Legislature for a third center in the next budget cycle, he said.

Edmunds says that despite complaints from its local mental-health contractors, the state is satisfied that Optum has improved the effectiveness of Idaho’s limited mental-health Medicaid dollars, and companies that provide services seem to be adapting.

“I don’t hear near as much, quite honestly, from providers,” he said.

“My impression is Optum is consistent” when it comes to payments and approved services, he said. “Some of the waves in the ocean are kind of smoothing out.”

"In Crisis" is a series produced in collaboration by the Idaho Statesman and Boise State Public Radio. You can see all of the pieces, here.

 

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