Attorney Lynda Krause sat with her arms crossed in the reception area of Valley Mental Health's Midvale offices and watched her sister have a meltdown.
“I don’t want to die,” a crying Carol Prewitt said as she paced up and down in front of receptionists frantically trying to locate her therapist. “Take me to a hospital. My heart hurts. I feel sick.”
Earlier that day in late April 2010, 44-year-old Prewitt had called Krause’s husband, terrified she was dying of a heart attack. Prewitt—who is bipolar, has borderline personality disorder and a history of drug abuse—had spent the previous night smoking methamphetamine.
“Why don’t you call Debra Falvo?” Krause told the receptionist sarcastically. After months of mounting frustration with Valley Mental Health, Krause had dumped Prewitt on Valley’s doorstep. “This is her baby.”
Debra Falvo is chief executive officer of Valley Mental Health. The counties of Salt Lake, Tooele, and Summit as well as the State of Utah all subcontract with Valley for treatment of 22,000 mentally ill clients and substance abusers. Valley comprises 46 percent of Utah’s mental-health system and receives around $90 million in Medicaid funds from those contracts.
Krause held Falvo responsible for Prewitt’s crisis. She also blamed Valley’s board, the state, Salt Lake County—all three of which have oversight responsibilities of Valley Mental Health—and her sister’s own choices for her ever-deteriorating situation. In October 2009, Falvo announced sweeping changes to Valley Mental Health, Utah’s largest treatment provider, because of a forecasted budget shortfall of between $8 million to $10 million. She announced the changes without warning the county—which she partly blamed for the upcoming shortfall—of the details of those cuts. She intended to lay off 125 of 740 full-time employees, downsize the number of licensed social workers, and close four programs in eight weeks. Clients used to years of individual therapy sessions were now faced with group sessions and short-term, part-day hospitalization if they were in crisis. There would be no transition program to help what Krause calls “the most fragile and sensitive members of our community,” through the profoundly traumatic changes happening in just a few months.
Pathways to Recovery, a day-treatment center for mentally ill adults, was among the programs slated for closure. Pathways helped Prewitt stabilize for the first time in 13 years, her sister says. Krause brought her sister to Utah in August after Prewitt had lived for 10 years in a Las Vegas apartment “so filthy and in such a dangerous neighborhood you would rather be on the street,” Krause says. A psychiatrist told Krause that Prewitt’s brain was severely damaged from more than a decade of inadequate treatment for mania and depression, compounded by self-medicating with street drugs. Krause had a stark choice. “She was like a puppy in the road. Leave her to die or bring her home.”
Prewitt attended Pathways for several months. Because its highly structured, morning-to-night classes run by therapists filled her days, she started to inch towards stabilization. “I woke up in the morning, and I couldn’t wait to get there,” Prewitt recalls. Two months later, when Falvo announced its fast-tracked closure in favor of a client-run drop-in center and therapy classes run by case managers, many of Pathways’ chronically mentally ill clients, like Prewitt, suddenly faced losing their support system. In the final weeks before Pathways closed, Prewitt became increasingly more anxiety ridden. In each panic attack, Prewitt says, “I feel like I’m going to die.” In January, she locked herself away with another Pathways client in Prewitt’s apartment and took prescription drugs.
“Carol is one of many,” says National Alliance on Mental Illness [NAMI] Utah Executive Director Sherri Wittwer. “Pathways meant something to a lot of people. That’s why there’s been such a sense of loss.” Since January, the number of mentally ill and their families seeking help from NAMI, a nonprofit with a $750,000 annual budget, “have definitely increased,” she says.
Six months after Falvo’s bombshell, the darkest irony at the heart of what Valley calls its “reconfiguration” is that part of its purpose was to introduce “person-centered” care. This involves putting the client in control of his or her treatment. The net effect for many, however, was quite the opposite. Along with staff firings and complaints by many Valley employees of feeling terrorized, the change alienated clients and provoked genuine fears among Valley clinicians that the most vulnerable in their charge would slip through the cracks and disappear because of the reduction in services.
What some Valley insiders describe as the “callous” way the closures were handled and the traumatic impact it had on staff and vulnerable clients raises questions about the lack of oversight that has dogged Valley Mental Health since 1986, when Salt Lake County and the state made it a stand-alone, private nonprofit.
Prewitt and Krause ended up in a counseling session with two Valley therapists, a case manager and a psychiatric nurse. “I’m sorry you’re in this situation,” Krause told her sister. “You made a bad choice, but really, honey, Valley set you up for failure.”
Patrick Fleming is Salt Lake County’s director of division of substance abuse. A private nonprofit, he says, means that in exchange for a community mission, a volunteer board and a philanthropic commitment, the corporation does not pay sales and property taxes. Valley currently owns $70 million in property assets. For some critics, it’s become so large and powerful they question whether it can be held accountable.
Valley is one of 19 treatment providers Fleming oversees that are contracted to care for county substance abusers. “Valley delivers some of the very best services you are going to find anywhere,” he says. But, he argues the nonprofit’s leadership has lost sight of its community mission. “Maybe the business game became too important.” Fleming sees “the wielding of a budget shortfall as a convenient excuse to change a delivery system.” Bottom line, Fleming concludes, “You don’t use scare tactics to force clients and staff” into accepting change, particularly when those tactics turn out to be based on inaccurate forecasts.
Valley’s $8 million deficit never came to pass. Falvo says some budget assumptions did not occur. After the cutbacks and with money from Valley Foundation, its fundraising arm, the treatment provider’s books are, for now, balanced. What the October-trumpeted changes did provoke, however, is more attention to Valley’s leadership. Fleming and county mental-health director Tim Whalen says that the county’s oversight of Valley has increased. “There will be no more tail wagging the dog,” Fleming says. “That’s over.”
Fleming’s boss, Salt Lake County Mayor Peter Corroon, describes Valley’s October announcements as “a communications breakdown” rather than an oversight issue. The county, he says, is responsible for setting policy for mental-health services. “A major budgetary and policy decision was made [by Valley] without significant consultation.” Valley, he says, provides services and does it well. “That’s why we haven’t made any changes.”
At the height of the closure controversy, Salt Lake Tribune columnist Peg McEntee profiled Falvo, who took over as Valley chief executive in 2005. The former nurse said she often visited clinics to “get my clients’ fix.” That claim rang hollow among some of Valley staffers who work on the frontlines of Utah’s mental-health care.
A Valley clinician, who spoke on condition of anonymity, asserted that the October-flagged changes “came from a small cadre of administrative people with limited clinical experience.” He contrasted that cadre to the advisers surrounding former President George W. Bush’s White House when “it decided to go into Iraq,” he said. “The top level executives, who are pretty insular, made sure they had people who agreed with their view and made some pretty serious mistakes.”
Prewitt and Krause ended up in a counseling session with two Valley therapists, a case manager and a psychiatric nurse. “I’m sorry you’re in this situation,” Krause told her sister. “You made a bad choice, but really, honey, Valley set you up for failure.” None of Valley’s staff said a word.
The Utah Division of Substance Abuse and Mental Health audits Valley Mental Health every year. That audit, which Valley insiders characterize as at best cursory, nevertheless required in 2006 that Valley and other treatment providers introduce person-centered planning. Clinicians had to listen to consumers’ aspirations, rather than simply dictate their care. “What would clients like their life to be like?” explains Rick Hendy, who monitors community mental-health centers for the state. “We expect clinicians to get in touch with [clients’] dreams.” The state wouldn’t pay for “maintaining” clients anymore, he continues. “We are interested in treatment that helps people with recovery.”
Valley clinicians argue, however, that person-centered care is something they have provided all along—it’s just the labels that have changed. They believe this new approach is more about cost-cutting and shifting responsibility for particularly difficult clients to community resources than it is letting patients and their families take control of their care.
The state criticized Valley for failing to introduce person-centered-planning in the 2007-08 audits. Come October 2009, if Valley had not fully implemented the care delivery system change, it potentially faced its funding being compromised. Valley decided to drive through changes it had thus far failed to make by closing units, layoffs and having staff re-interview for their positions. A key rehiring criteria, Falvo says, was whether staff were opposed to the new system. “This was an opportunity to encourage [staff] to move forward [with the state-imposed changes], as some of their colleagues already had,” Falvo says.
Other states, however, have pursued system-delivery changes with far less haste. Seattle’s King County in 2008 embarked on a four-year mental-health care system change that won praise from Fleming for its wide-ranging consultation- and client-driven focus.
On Oct. 22, Falvo met with the county’s then-recently appointed county mental-health director Whalen, an hour before the Valley Mental Health monthly board meeting. She told him she planned to close Pathways, two outpatient clinics, an adolescent substance-abuse program [ASAP] and the Alcohol and Drug Unit. When they entered the Valley Mental Health boardroom 15 minutes late for the meeting, both were red-faced from arguing, recalls Fleming.
Falvo acknowledges that the county “felt attacked.” Whalen and Fleming were incensed that not only had Falvo failed to consult them on the cuts, but that she was also partly blaming the county for them.
Falvo acknowledges that the county “felt attacked.” Whalen and Fleming were incensed that not only had Falvo failed to consult them on the cuts, but that she was also partly blaming the county for them. Yet two weeks earlier, Corroon had announced a small tax hike and reduced county employee benefits that were meant to preserve safety-net services like mental-health care from cuts in 2010.
When Fleming heard that Valley planned to kill off in December the ASAP, which Valley was being paid $3.5 million by the county to continue until June, “I felt insulted.” Fleming says he told Valley’s chief clinical officer Richard Hatch, “You will deliver services to the end of the contract, period.” The county demanded Valley slow down the rest of its closure program, to which Falvo reluctantly agreed.
“Frankly, I think that made it more painful for staff and for clients,” Falvo says. “It was like being little slices, little slices, but we heard them, we said OK, we slowed it down.”
Falvo is surprised the county claims no advance knowledge of the cuts. Whalen, she acknowledges, believes he should have been informed of the cuts’ details. As long as Valley meets its contractual obligations to the county, Falvo says it’s “a matter of opinion about how much detail” the county should be provided.
Consternation among both Valley staff and clients was quickly evident. A Valley psychiatrist, Charlotte Gant, sent Falvo an e-mail titled “From the trenches.” Falvo persuaded Gant to let her disseminate it among the staff. “I’ve never seen anything like it,” Gant wrote her. Loyal staff were convinced “you and some of your advisers—whom many dislike intensely—are on some kind of power trip,” which Falvo denied in her response.
Communication from Valley’s leadership, Gant continued, “served to confuse and make people feel like pawns, totally devalued.” Staff, many of whom faced both re-interviewing for their jobs and later competing with other Valley employees for those same positions, struggled to function with termination hanging over their heads “and it is already having very negative effects on some very vulnerable patients.”
Valley’s outpatient clinics often referred the most vulnerable and difficult patients, many with both mental illness and addiction issues, to Pathways, according to former Pathways staff. In summer 2009, Pathways had 430 people enrolled with around 90 to 110 people visiting every day to talk to therapists, attend classes and socialize. “The model of Pathways is not where the industry is moving,” Falvo says. “It had evolved some, but the model wasn’t there.” Nevertheless, Pathways consistently outperformed its parent company, Valley Mental Health, in a 2009 client consumer satisfaction survey.
Dissatisfaction, however, was apparent among Pathways’ clients on Oct. 27, not with the treatment center but with Valley management. That day Valley held one of a series of “town hall” meetings at Pathways to update clients on changes “and to seek your feedback.” Newly appointed adult clinical services director Jona Nusink Curry led the meeting and bore the brunt of client confusion, frustration and fear. Pathways’ staff watched in silence from the back of Pathways’ lunch hall as she told the 100-odd clients “you are the expert in your life.” They would be in charge of their care. Clients lined up with questions and angry comments for the executives. Vietnamese and Bosnian clients who had been attending Pathways for years were left voiceless, since no translators had been arranged.
“Pathways changed our lives,” one client said. “It made us more functional.” Although Valley Mental Health claimed to be seeking client feedback, Pathways staff noted that no one from administration took notes.
“Why are we trying to fix something that’s not broken?” one client asked to cheers. An executive replied, “What we’re trying to do is make something even better.”
Then 39-year-old Julie stepped up to the microphone. Pathways helped her stay in the present and taught her how to deal with voices other people couldn’t hear. “I don’t want to go to the hospital, and I don’t want to kill anybody,” she said.
A few days later, the loss of faith by frontline staff in Valley’s leadership was apparent at a human-resources committee meeting. Committee members, Nusink Curry among them, “expressed a great deal of anxiety about the way the reorganization has been presented to employees.” Staff thought executives, the minutes state, “don’t know what they are doing, even though [the executives] say they have been working on the plan for three years.”
Other Valley outpatient units on the kill-list were saved, although some were severely pruned by a Valley administration facing resistance from Salt Lake County. At Pathways, staff and client morale plummeted, according to Valley e-mails provided to City Weekly by former staff members, as the realization set in they would not be spared from closure.
Most of the information the staff received about their future came from the town-hall meetings for clients. Staff struggled to believe Valley’s message that holding down costs, increasing the client-to-staff ratio and decreasing services somehow translated into the new philosophy of person-centered care.
Pathways therapist Frank Clayton, who teaches courses called Happiness 101, had been at the agency a year when he learned it was closing. He admires Pathways’ manager Sheryl Salmon. “She set the tone for how humanely clients were treated,” he says.
“Clients were left in limbo for months. They had no access to somebody who could answer their questions.” As tension increased, clients started dwindling. “When you apply pressure, they do what they do, they isolate, they act out,” Clayton says.
Clayton decided not to re-interview for his job, a decision that solidified as he watched how the closure was being handled. “Clients were left in limbo for months. They had no access to somebody who could answer their questions.” As tension increased, clients started dwindling. “When you apply pressure, they do what they do, they isolate, they act out,” Clayton says.
Falvo tried to put the best face on the restructuring by proclaiming in internal communications in early November “very positive feedback” from community partners. This was news to Salt Lake County and mental health care advocates. Minutes from a Nov. 19 Valley Mental Health HR meeting reflected further turmoil. Clients didn’t understand the new model: “The trust level [among staff] at VMH is non-existent and morale is at rock bottom. Person-center care is good, but it should start at the top.”
Falvo attended a second Pathways town hall meeting in mid-December. The atmosphere was distinctly darker. Clients were confused about when they would find out about their new care team. “I told my therapist stuff over five years,” one client complained. “Now I have to repeat it all to someone else?” Therapy would only be available “when medically necessary,” Falvo said.
“You don’t care,” a client shouted out.
IT HURTS TO SAY GOODBYE
Pathways took on a funereal atmosphere in early January. Some staff who got rehired suffered from survivors’ guilt and received dirty looks from colleagues heading toward unemployment. A client handed Clayton a farewell card. “I’ve got to go,” he told the client and turned away in tears.
Pathways staff at Salmon’s farewell party, days before the unit closed, bit down on angry tongues. “They could have changed this model,” one said. “Instead, they bring down the ax.”
Falvo is unrepentant. She recalls a woman at a Pathways town hall standing up in tears. The woman, Falvo says, said that, “ ‘Pathways is my life.’ At that moment, I knew closing it was the exact right thing to do because treatment should never be your life.”
But for many of Pathways’ severely mentally ill clients, long-term, day-to-night treatment was essential for their care and inevitably led to close relationships with staff. “It hurts,” 30-year-old client Kristie Tribe said at Salmon’s farewell. “I don’t want to say goodbye.”
Her friend, 67-year-old Dee King, a former trucker and now legally blind, had no idea who would be managing her case come Feb. 1 when the treatment center closed. She was more concerned, she said, “about the clients who aren’t as tough as I am surviving the closure.”
Julie, who had spoken up vehemently against the changes at a town-hall meeting, was scared. She couldn’t hug her two daughters, she said, “because my skin is too sensitive.” Her 65-year-old mother, Joyce Johnson, expressed concern. “Now I can’t go to work and feel comfortable she’s safe,” she said.
Salmon gave a brief speech, noting Pathways had sponsored 32,000 groups and classes. A Bosnian client took the microphone and sang a lament. Client Julie told those listening, “The only thing you can count on is change. It’s very hard for people like me to do.” Tribe said she’d written a poem about Salmon but lost it on the bus. “In a way, I owe my life to you.”
On Pathways’ final day, Julie went to say goodbye to Salmon. She grabbed hold of her, and sobbing, cried out, “How am I going to manage? I can’t do this all by myself.”
Holly Chapman Blank, a 49-year-old with bookish glasses, was another Pathways client who feared its end. Pathways “opened a new world for me,” she says. When she started, she was so introverted, “I was worse than a wallflower, I was the wall.” She found “empowerment and responsibility” at Fresh Start, a series of client-run classes and activities that replaced the socialization aspect of Pathways’ services. While higher-functioning Pathways clients have continued to attend Fresh Start and Wellness for Recovery—which provides support classes on schizophrenia and diabetes as well as leadership skills—“a lot of lower functioning clients haven’t come back,” she says. “Pathways meant a lot to them.”
Three months after Pathways’ closure, many former clients remain angry about both the closure and what has replaced it. Sasha, who requested her last name not be used, has yet to be assigned to one of the care-coordinating teams Valley said every client would receive, one of many “bright pretty promises” made at the town-hall meetings she says were never fulfilled. Last fall, 35-year-old Sasha started classes at the University of Utah. The closure of Pathways, where she’d been a client for eight years, made her question going on. “I don’t fit in anywhere,” she says. “Where am I supposed to go for support?”
Fresh Start, she says, “doesn’t help me to shower when I’m too paranoid to get into the bathroom.” When Pathways was open, she could talk to a therapist without an appointment. “Now I’m isolated, I have no one to talk to.”
Tribe is “disgusted” with the changes. At Pathways, “I was doing good, on my meds, going to groups. I never had any friends, then I went to Pathways and I met friends.” Tribe stays in her South Salt Lake apartment with her boyfriend and struggles with paranoid hallucinations. “It’s killing me not doing anything,” she says. “I just sleep all day.”
Prewitt, meanwhile, attends one Wellness two-hour class a week. She can’t bear Fresh Start because her higher-functioning peers, who run the classes, “don’t listen to us,” she says. “They just talk to us.” She stays in her apartment and her drug use escalates her fears of going out, her sister says. Where once Prewitt had Pathways’ socialization to get her out of her home, she now feels, her sister says, “she has nowhere to go.”
The jury is still out, Salt Lake County’s mental health director Whalen says, on whether Valley’s reconfiguration “will be a success.” Out of the four programs slated for closure, only Pathways closed. Out of the 125 intended layoffs, 91 employees left, but Falvo is unable, or unwilling, to say how many were laid off.
Whalen says Falvo told him that the county “can come on in, the lights are on, we can look where we want.” Two staff under Whalen are reviewing clinical and billing records. “I want to make sure we’re getting what we purchase,” he says. Falvo is less than thrilled. “I’m always concerned about additional, repetitive oversight.”
At the end of 2010, Valley Mental Health will bid for the Salt Lake County mental-health contract. Before October 2009, says Pat Fleming, Valley was a “shoo-in” for being the sole source provider for Salt Lake County’s mental-health needs. Post-reconfiguration, he says, the county seems more interested in bringing market forces to bear, “as they can only improve services.” Along with the county looking at what other treatment providers offer, the question of whether the contract should be broken up—or “unbundled”—hangs over Valley’s future.
Falvo says, “I don’t believe personally [that unbundling] is the best way to provide care for people with serious mental illness.”
She acknowledges some staff have “trust issues” with her, and that employees and clients are nervous. “Everybody keeps saying slow down. If we slow down, we will get passed by.”
Krause, meanwhile, continues to battle with Valley Mental Health to find care for her sister. Prewitt was kicked out of one county-funded evening alcohol and drug program she attended for six months because she talked about feeling suicidal. The county referred Prewitt to an intensive Valley program called Mentally Ill Chemically Addicted, only for a furious Krause to discover Valley had just closed it.
Krause and Prewitt attended a meeting with county officials to review Prewitt’s care by Valley. Prewitt spent the meeting with her head in her hands, crying. “But can you help me?” she said. “I need help.” In a subsequent meeting, chief clinical officer Richard Hatch told Prewitt she would be entering Valley programs that in the past Krause had been told her sister was too severely disabled for. While Prewitt is “greatly optimistic,” her sister says, Krause is concerned that Valley is just getting her hopes up.
“I feel helpless,” Krause says. “I never thought I’d have to fight the system that’s supposed to care for my sister. I kick, I claw, I scratch for help, I don’t know what else I can do.”