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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.