“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.