ON EDGE: Mental healthcare safety net failing in Aurora, across Colorado

EDITOR’S NOTE: This story was amended from its original version, under the subheading: “A rainy day,”to clarify two parts of Aurora Mental Health Center financial reporting. The story now expands reasons why AuMHC officials object to the investigation’s use of state-reported cost analyses in looking at how much is spent annually on direct costs. AuMHC officials say overhead is commonly determined among non-profit agencies in documents filed with the IRS and through audited reports. In addition, agency officials said that the investigation’s reporting that AuMHC holds about $20 million in liquid assets is inaccurate. Audited records show the agency holds about $20 million in current assets. Agency officials say as much as half of those funds are in some way encumbered and not immediately available as cash. Further investigation by CoLab writer Susan Greene indicates there is no consensus on the time period funds can be converted to cash provide a “liquid” classification.

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This investigation is part of the ongoing “On Edge” series about Colorado’s mental health by the Colorado News Collaborative, a nonprofit that unites more than 160 communities and news outlets like Sentinel Colorado to ensure quality news for all Coloradans. The series title reflects a state that has the nation’s highest rate of adult mental illness and lowest access to care, and the fact that the state government is on the edge of either turning around its behavioral health care system or simply reorganizing a bureaucracy that is failing too many Coloradans.

Matt Vinnola lay curled up on a downtown sidewalk one Sunday in September, his eyes as blank as those of the stuffed lamb he was using as a pillow. The former honors student and youth Taekwondo champion seemed too out of it to shoo a fly off his lip or realize he was urinating through his shorts onto the concrete. If he noticed the woman offering Wet Wipes or the man trying to hand him a $5 bill, he showed no interest.

“Tell them, just tell them I don’t need help so stop it,” he grumbled to no one in plain sight.

The voices in Vinnola’s head whisper and yell. They can be so loud, so constant, he figures everyone can hear them. Chronic paranoid schizophrenia and an addiction to shooting up whatever he can find to still the voices have landed the 29-year-old Denverite in emergency rooms, psychiatric wards and jails so many times that his mother stopped counting.

Crisis after crisis, Janet van der Laak had to push the Mental Health Center of Denver to provide care for her son instead of finding reasons to deny it. Each time the center dropped him from treatment, Vinnola lost more faith in seeking help. And the more faith he lost, the harder his mother pressed because he was free falling, and she alone could not catch him.

“What kind of safety-net system blows off the hardest cases?” van der Laak once wrote in a note to herself. “Giving up on Matt, giving up on anyone in crisis should not be an option.”

As part of Sentinel Colorado’s ongoing “On Edge” coverage of mental health in Aurora and statewide, the Colorado News Collaborative has spent six months investigating a state behavioral health system that turns away some of the most vulnerable and at-risk Coloradans in crisis, with no recourse from state officials. The investigation has zeroed in on the 17 community mental health centers that are paid more than $437 million a year in tax dollars to serve as the foundation of Colorado’s safety net.

The investigation revealed that Colorado, the state with the nation’s highest rate of adult mental illness and lowest access to care, has been awarding these centers non-compete contracts and a privileged rate status for nearly 60 years, without apparent meaningful coordination or oversight.

The investigation shows that the centers – most now facing workforce shortages – collectively have treated fewer clients during the pandemic than before it, despite skyrocketing mental health needs. At the same time, more than half the centers have been sitting on liquid reserves of $10 million or more each. Denver’s center kept more than $40 million in liquid reserves while its clients faced record-long wait times for care.

The COLab  investigation also found that, starting long before the pandemic:

• The state’s payment system inadvertently created a financial incentive for the centers to take on fewer ill people and charge higher costs, while also protecting them from competition.

• The centers have been charging taxpayers up to 17 times more than independent Medicaid providers for the same services, but with little transparency about the expenses those rates are based on. At least one center in Aurora says the virtual overpayment helps to offset services they provide to the community without ways to be reimbursed.

• Several centers, including those in communities with sizable immigrant populations, have had no Spanish-speaking care providers.

• And some centers have been paid for programs they’ve not provided, with no pushback from the state agencies funding – and charged with regulating – them.

The investigation revealed that some of these and other questionable practices stem from a long record by the centers’ powerful trade association of pressuring the state to avoid reforms that would ensure greater transparency and accountability.

Even now, as Gov. Jared Polis’s administration is poised to launch a new cabinet-level department to carry out those reforms, we’ve found that state government, at the urging of the trade group, is backpedaling. Months before the new Behavioral Health Administration even launches in July, state officials already have ruled out key ways of regulating the centers more closely. They also have all but scrapped what was supposed to be a top safety-net priority for the new department: Stepping in when the centers fail clients like Vinnola and trying to catch them before they hit bottom.

 

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If you’re experiencing a mental health crisis, call the Colorado Crisis hotline at 1-844-493-TALK(8255). There is no wrong reason to reach out.

Colorado’s ‘safety net’ unravels

The community mental health movement took root in the 1960s when President John Kennedy called to deinstitutionalize people with mental illnesses. Private nonprofits popped up around Colorado to offer the mental health services – and, eventually, addiction counseling – needed to keep people out of hospitals and in their communities.

Those organizations eventually became the 17 regional community mental health centers (CMHCs) the state has relied on for more than a half-century to treat Coloradans who are indigent, on Medicaid or underinsured and can’t pay for private treatment, and to stabilize people in crisis. They are each contracted to provide inpatient hospitalization, intensive outpatient treatment, outpatient psychiatric care, counseling, and other forms of assistance to residents of the counties they’re responsible for serving.

The centers have helped generations of people throughout Colorado, especially those with less complex mental health needs. According to the state, they collectively served 158,911 clients in the fiscal year ending in June.

“Colorado is lucky to have the system it has built with such a strong network of CMHCs,” Doyle Forrestal, CEO of the centers’ trade group, the Colorado Behavioral Healthcare Council, wrote in an email.

Still, the investigation found vast disparities in the quality and speed of the centers’ services.

Last summer, a Greeley resident with severe depression could see a psychiatrist within a few weeks of calling the center there, but someone just as depressed in Rio Blanco or Moffat counties had to wait nine or 11 months, respectively, for the same kind of appointment, if Mind Springs Health – the center serving those counties – agreed to schedule one at all.

Multiple sources say at least four of the centers are providing addiction counseling by staffers who aren’t certified to counsel addicts. Reporters involved in the investigation spoke with people who either work in or with three centers that rely on clinicians with no pediatric training to prescribe medications to kids. Clients of four centers told us their clinics are so slow to renew prescriptions that they tailspin biochemically as they wait. And we found centers serving six communities with high immigrant populations that have no bilingual clinicians, leaving Spanish and other non-English speakers virtually iced out of care.

Annie Diaz of Cortez treated about 80 clients at a time as a counselor for Axis Health System – so many, she says she struggled to remember their names and problems. “I did the best that I could under the circumstances, but it wasn’t my best, and it wasn’t good enough,” she said.

Some centers’ staffers describe pressure to drop their toughest cases.

A former case manager at Mind Springs in Summit County says administrators made her stop treating an acutely ill client earlier this year because he made inappropriate racial comments. She says she objected because she knew he had no other support system, but she complied for fear of losing her job.

The client killed himself shortly after.

“I blame myself for that every single day,” says the case manager, who quit right after his suicide. She asked to remain anonymous for fear the client’s death will hurt her career.

Mind Springs cited privacy reasons for refusing to discuss the case.

Emma Harmon, a single mother and Medicaid recipient in Durango, called Axis Health System when she was so depressed she was thinking about suicide several times an hour. She says the center made her wait six weeks for an intake appointment, then three more to meet with someone for a treatment plan. She asked to see a psychiatrist in the meantime, but she was told he was busy. Her mother took her to the hospital, which released her because she hadn’t actually hurt herself.

Axis’ spokeswoman would not comment on Harmon’s case.

“I was on the brink of death – so, so close to killing myself, and they said, ‘You’re fine’ and never followed up with me,” Harmon says. “The way things seem to work there, you’d actually have to have killed yourself before they’d meet with you.”

A rainy day

Colorado Behavioral Healthcare Council, the centers’ trade group, represents them in negotiations with Colorado’s Department of Health Care Policy and Financing, which provides about two-thirds of their public funding through Medicaid, and with the Office of Behavioral Health, which provides approximately the remaining third through a complex web involving 18 state agencies and more than 75 programs. The state has handed the centers decades of automatic contract renewals despite long-standing local concerns about their services.

Commissioners in most of Colorado’s 64 counties have over the years complained that their law enforcement and human service officials end up handling mental health crises when the centers fail to do so. Parents raise their hands at support group meetings to describe the desperation of having to send teenagers across the state experiencing psychotic breakdowns because there were no adolescent psychiatric beds open near them. Some people with severe depression are limited to two or three therapy appointments, but prescribed drugs indefinitely, with little follow-up.

State mental health officials have long been aware of these and other problems.

“The centers and the state have been failing people,” says Robert Werthwein, director of the Office of Behavioral Health, which will morph into the Behavioral Health Administration when the new department launches in July.

The Council – whose members pay an average $66,000 in dues annually – has, in the meantime, spent years lobbying and litigating to limit the number of independent contractors the state authorizes to receive Medicaid dollars.

“The centers pretty much have a corner on their local markets and don’t want competition,” says Byron Pelton, a Logan County commissioner and member of the state task force aiming to increase access to behavioral health care.

The Council also has pushed to preserve its members’ favored Medicaid reimbursement rate status with the state. The Mental Health Center of Denver receives $592 in Medicaid reimbursement for an hour of counseling, for example, compared to the $91 Medicaid pays an independent clinician for the same service. And the Denver center receives $818 for an hour of crisis intervention compared to the $47.50 an hour paid the private provider.

Aurora Mental Health Center officials said what appears to be inflated payments help equalize myriad services they provide that they are not reimbursed for. Others say lumping payments for services together, at best, provides a clouded picture of how much varied types of care are really costing state taxpayers.

Those reimbursement rates are based on a formula – developed by the centers’ trade group in conjunction with the state – that divides a center’s overall expenses for any given year by the total number of services it provided the year prior. The higher a center’s spending and the lower the number of times it treats clients, the more money it will receive through Medicaid reimbursement. The methodology effectively creates an incentive for centers to be less efficient with their spending and to limit or even refuse client care.

“It is hard to imagine how that formula is in the best interest of Coloradans, especially when there are so many people waiting for care,” says Nancy VanDeMark, former director of the Colorado Office of Behavioral Health who now works as a consultant.

North Range Behavioral Health in Greeley and Mental Health Center of Denver have the lowest and highest reimbursement rates among the 17 centers, respectively, according to cost reports submitted to the Department of Health Care Policy and Financing. Greeley charges Medicaid $228 for an hour of counseling compared to Denver’s $592 for an hour of the same service.

MHCD, like Aurora, says  it needs the higher rates to bankroll the array of programs the centers are required by contract to provide and to subsidize others that don’t make money, such as food pantries and homeless shelters.

Forrestal, the Council’s CEO, refused multiple requests for an interview. In a series of email exchanges, she said comparing the centers’ reimbursement rates to those of independent Medicaid providers is unfair because centers offer a greater “depth and breadth” of services. Besides, she wrote, “Behavioral health has been significantly underfunded, and without (the Council’s) efforts to secure additional funding, there would be no new money for (the centers) to expand services or build new programs.”

The trade group recently hired the state’s assistant Medicaid director, Laurel Karabatsos, as a consultant only months after she left the Department of Health Care Policy and Financing (HCPF), and she has been attending meetings with that agency about changing the future payment methodology. Karabatsos has not sought an opinion from the state’s Independent Ethics Commission about whether that job breaks the state’s revolving-door ethics law prohibiting state employees from taking jobs in industries they regulate, and HCPF sees no conflict of interest.

The centers have received far more public funding since Colorado enacted Medicaid expansion in 2013, and watchdogs say some are wasting it with inefficiencies and other questionable spending.

According to a cost report it filed with the state that serves as the basis for its reimbursement, the Aurora Mental Health Center spent an additional 48 cents on administrative costs for every dollar it spent on direct care in 2020. That’s in sharp contrast to North Range Behavioral Health in Greeley – the most efficient of all the centers statewide – which in the same year, records show, spent an additional 8 cents on administrative costs for every dollar spent on direct care.

Aurora Mental Health officials say they vehemently disagree with using that measure, which comes from information provided to state auditors, as a gauge of overhead and administrative costs. Aurora’s high ratio of costs for direct services to non-service costs, demonstrated in attached charts, compares to all other statewide agencies using the same metrics.

AUMHC CFO Loretta Buckman said audited overhead rates, using customary calculations, the same for all the centers, are very different, and in Aurora’s case far lower. Recent audited state reports reveal that number for overhead as about 20% of all costs.

Kelly Phillips-Henry, CEO of the Aurora center, attributes her demonstrably higher relative costs in part to updating technology, including the systems required to convert to telehealth care. Some of the expense, too, AuMHC officials said, is attributed to providing management for a growing number of direct and indirect services in collaboration with local city, police and school agencies.

Former state Human Services director Reggie Bicha long has frowned on an overuse of mental health funding for things rather than people. He points specifically to the aquaponics greenhouse at the Mental Health Center of Denver’s Dahlia campus, which recirculates water through fish tanks and garden beds.

“It’s a wonderful little concept,” he says. “But from an organization that was constantly saying they needed more financial resources, I wasn’t seeing nearly that kind of creativity put into fighting severe mental illness, reducing suicide rates, keeping people out of hospitals and jails and institutions.”

The $15.6 million Dahlia campus was funded partly through the center and private donations, but mainly through Denver Urban Renewal Authority bonds.

For the union representing workers at the Denver center, it is a sore point that CEO Carl Clark made $819,340 in 2019 – the most recent year for which data is publicly available – including $331,583 in bonuses. That’s 10 times more than an average clinician there earned that year. Clark defends his earnings, noting his pay is set by his board, not by him.

He made upwards of two and a half times more than the $301,337 average total compensation for CEOs of community mental health centers in Colorado in 2019, our analysis of financial disclosures found.

At Aurora Mental Health Center, CEO Kelly made $312,612 as reported in IRS financial documents.

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Sample CEO and Top Exec Samples

Agency	Position/Title	Annual Salary	Source
Mental Health Center of Denver	CEO	$819,340	IRS
Aurora Mental Health Center	CEO	$312,612	IRS
Colorado Department of Public Health and Environment	Director: Ryan Jillian Hunsaker	$175,104	GovSalaries.com
Colorado Department of Public Health and Environment	State Epidemiologist: Herlihy Rachel Katherine. MD	$186,576	State of Colorado
Office of the Governor	Chief of Staff: Kaufmann Lisa	$175,100	GovSalaries.com
University of Colorado Boulder	Chancellor: Distefano Philip	$505,187	GovSalaries.com
Department of Human Services	Executive Director: Barnes Michelle M	$175,104	GovSalaries.com
Average Non-profit CEO, statewide		$126,377	epnonprofit.org
Average Non-profit CEO, Denver metro		$132,245	epnonprofit.org
Average Non-profit CEO, Health and Mental Health Industry: Statewide		$130,508	epnonprofit.org
City of Aurora	City manager/CEO	$247,184	City of Aurora
City of Aurora	Police Chief	$205,763	City of Aurora
STRIDE Community Health Centers	CEO	$225,932	IRS
STRIDE Community Health Centers	Medical Director	$258,590	IRS
Jeffco Schools	Superintendent	$165,401	GovSalaries.com
City of Denver	Police Chief	$221,251	GovSalaries.com
Aurora Public Schools	Superintendent	$274,776	GovSalaries.com
Colorado Department of Public Health and Environment	Director HCPF Healthcare Policy & FInancing	$204,000	GovSalaries.com
Mile High United Way	CEO	$386,624	IRS

The table shows a variety of top execs for statewide and regional agencies, governments and organizations. CEO salaries for mental health directors often far outpace that of other top officials, despite those agencies having far larger budgets, more employees and often requiring more extensive academic credentials. TABLE BY SENTINEL COLORADO

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The Denver center’s audited financial report also shows it sat on $41 million in liquid assets in 2020. Clark says his board likes to keep sizable reserves on hand as a “rainy-day fund.”

Since the pandemic hit in 2020, Denverites have faced the longest-ever wait times for care as pandemic-related depression and anxiety rates skyrocketed. And Denver’s is not the only center sitting on reserves. Nine others kept at least $10 million in liquid assets last year while their wait times also grew and the state plummeted to the bottom of national ranking for access to care.

“If the CMHCs are not willing to reinvest their reserves to expand access to care now, then when?” VanDeMark asks.

Aurora Mental Health Center officials said the reported reserves are misleading for their agency. They reported selling three buildings in that fiscal year, pumping up reserves by about $8 million only temporarily because the money is earmarked for reinvestment into other physical sites and resources. Officials also said that much of the reserves must be set aside to provide for repayment as anticipated but unrequited state funding. They did not say how much of the current estimated $20 million in cash reserves was actually liquid and available to the center.

Bucknam said only half the $20 million reported as assets meet an accounting definition of “liquid.” Others are encumbered in some fashion and not available as cash in short order.

As the pandemic gripped Colorado in early 2020, the centers halted most of their services temporarily, then moved to telehealth. Yet, they still managed to treat more patients in that fiscal year ending in June 2020 than they did the following fiscal year when the statewide caseload dropped by 7,200.

The Council attributes the decline to what Forrestal calls a “dire behavioral health workforce crisis,” which she writes has left more than 1,000 job vacancies among its members.

“There simply is not enough workforce to meet demand.”

Union members counter that the center could retain more staff by raising salaries far more significantly than it has – and by using bonus pay for executives like Clark to do so.

If you’re experiencing a mental health crisis, call the Colorado Crisis hotline at 1-844-493-TALK(8255). There is no wrong reason to reach out.

Leaving holes in the safety net

Despite the workforce shortage, the Council has fought a proposal that the soon-to-be-launched Behavioral Health Administration offer “care coordination” – regional teams to work with some of the hardest-to-serve clients to make sure they’re not dropped from the centers’ care and don’t otherwise fall through the cracks. The proposal was meant to help people like Vinnola that centers commonly refuse to treat if they have pending criminal charges, or show up high or delusional or are otherwise hard to manage.

The trade group has sought to block the proposal, saying the centers already coordinate care for their clients and that the state stepping in to do so could divert funding away from their own services. The Council’s opposition comes after it has spent years fiercely opposing attempts to add “no reject, no eject clauses” to centers’ contracts preventing them from refusing to serve the sickest clients or dropping clients who are difficult to serve.

The Council has an unlikely ally in Vincent Atchity, president and CEO of Mental Health Colorado, the leading statewide group advocating for people with mental health challenges. On the task force responsible for recommending reforms, Atchity voted against making care coordination a priority for the new department as what he calls “an attempted appeasement of the (centers) that objected strongly to” it. He describes his vote as “more about diplomacy than actual opposition.”

The no-voters were outnumbered by task force members who supported prioritizing care coordination as perhaps the most important aspect of a reform package the state has made a point of branding “Putting People First.”

Nevertheless, a state report released in early November outlining how the new department will function does not, in 109 pages, mention the kind of hands-on care coordination the task force approved. It instead lists detailed plans for what officials call “care navigation” – ways to help the public on the phone or online find behavioral health providers.

Werthwein – who until this fall was a vocal proponent of providing care coordination – at first said his office intentionally left plans for it out of the report because details about how to staff and fund it “have not yet been worked out.” In that same interview, however, he called the omission “an oversight” and insisted the new department will be prioritizing hands-on care coordination and will revise the report accordingly.

But so far, the so-called “care coordination working group” Werthwein’s office has gathered to address the issue has made no mention of plans for person-to-person care coordination. Instead, the group is focused only on making the state mental health care system more user-friendly technologically.

At least for now, there is no significant plan recognizing that sometimes the centers fail people, and when they do, somebody ought to step in and keep those people from free falling.

What’s unknown

Werthwein’s Office of Behavioral Health says it does not know how many indigent Coloradans the centers are serving or how many people with private insurance policies that don’t cover mental health care the centers are allowing to pay on a sliding scale.

State officials also say they don’t know what happens to tax dollars centers receive for services they end up not providing. The Center for Mental Health in Montrose, for example, was paid to set up a mobile crisis program in the six counties it covers. For logistical reasons, that program didn’t serve San Miguel County. County Commissioner Hilary Cooper spent months trying to figure out where money for her county’s piece of that program went.

“They showed me a bunch of fancy budget slides and explained that it’s really too layered and complicated for someone like (me) to understand, and in the end, I got no answers,” she says.

The Center’s CEO, Shelly Spalding, did not, in response, indicate where her organization spent that money.

“I think we’re transparent. But maybe other people don’t think we’re being transparent enough. Maybe things are being lost in translation,” she said.

Summit County officials say they could not get an answer from Mind Springs Health about what it did with state money it was supposed to spend on a detox program there, which it shut down without telling them. They also say that, despite years of questioning, Mind Springs has never said how much in public funding it was – and should have been – spending in the county.

CEO Sharon Raggio told them, and us, that there is no such information because Mind Springs does not track services or spending per county, but rather more generally in the 10 West Slope counties it’s responsible for covering.

“It’s like a frigging ridiculous mystery when you ask about it,” says Assistant Summit County Manager Sarah Vaine, who refers to Raggio as “a liar” and to Mind Springs as “The Mob.” “The way the state contracts work and the way the money flows is so confusing. And I think the community mental health centers benefit hugely from that confusion because it makes it harder to hold them accountable,” Vaine adds.

The centers also benefit from their status as private 501(c)3 nonprofits, which, unlike government agencies, are not subject to open records laws. Federal tax law makes it so the centers can – and do, as we’ve discovered during the investigation – refuse to provide information about how they spend public funding beyond the few financial disclosures required by the IRS and state.

Voters in several counties, including Summit, have over the past five years passed tax measures to pay for mental health services they say they aren’t getting from the centers. And one, Eagle County, is for the first time in the 60-year history of Colorado’s safety-net system breaking off from its center, Mind Springs, to create its own – one that officials there say will be more responsive to their residents. Eagle County’s will be the only center in the state that won’t be joining the trade group.

County governments have spent years urging state government to reform Colorado’s safety-net system so taxpayers don’t have to double-pay for services. They embrace the creation of the Behavioral Health Administration, which is supposed to give county governments and the public “a better sense of the dollars flowing into their community, and the outcomes resulting from those investments,” according to a state report released in November.

Still, many county officials worry the new department will not be able to monitor centers closely enough because it still won’t have control over their Medicaid contracts. That responsibility will remain within the separate Department of Health Care Policy and Finance (HCPF).

“If no single agency is actually responsible for these pieces, we fear there won’t be real oversight and we’ll just see a repeat of what we have now,” says Gini Pingenot of Colorado Counties Inc., a consortium of county governments.

County governments specifically have urged the state to audit the centers’ finances and conduct performance audits to make sure they are complying with contract requirements and not being double-paid by the multiple state agencies and programs that fund them.

There are no plans for the new department to do so, despite state officials’ insistence that it will prioritize making the centers more transparent and accountable.

Bicha, the former state human services director, notes there long has been “significant political pressure” from the trade group not to monitor centers that closely.

“The Council has a tremendous amount of influence,” he says.

If you’re experiencing a mental health crisis, call the Colorado Crisis hotline at 1-844-493-TALK(8255). There is no wrong reason to reach out.

Free falling

Before it sought and received lawmakers’ approval to create the new department, the state Behavioral Health Task Force heard more than 200 Coloradans statewide testify about the mental health reforms they want – and desperately need – from state government.

Matt Vinnola’s mom was one of them.

Her son was in jail at the time in 2019, awaiting a competency evaluation after having been involuntarily hospitalized eight times in a year. The Denver car saleswoman had come, she said, as “Matt’s mom, advocate and voice.”

Janet Van der Laak wanted to know why she could make a routine doctor’s appointment for her husband, but not an appointment at Mental Health Center of Denver for her adult son who is delusional, unable to remember his birthday or home address, and so sick he doesn’t always know he is sick.

She wanted to know what families like hers are supposed to do when the centers drop their loved ones from treatment.

She wanted to know what the centers are doing with hundreds of millions of tax dollars if not treating severely sick people like her son.

“MHCD dropped him… How do you drop someone who’s gravely disabled? How do you deny someone services like that?” van der Laak asked the task force. “We’re leaving out a huge, vulnerable population that we’re not treating.”

The Mental Health Center of Denver’s Clark says privacy laws keep him from discussing Vinnola’s case. “Could things have been dropped? It’s possible for them to have been dropped,” he says, adding that if a client is not seeking care for himself, the center “need(s) to focus on someone who wants treatment.”

Five months after van der Laak’s testimony, one of her older sons, Aaron Ruiz, ended his life in March 2020.

Relatives say the family had not been aware of Ruiz’s mental health challenges, and had been focused on Vinnola’s for the 10 years since he developed symptoms of paranoid schizophrenia.

Five months later, Van der Laak took her life by suicide. She was 49.

It has been more than a year since the only real voice Vinnola would listen to stopped saying come on, hijito, let’s go get you some help. He has been plummeting since his brother’s and mother’s suicides, both of which took place while he was home. He had a long jail stint last fall and winter, and for about seven months now, has been living on the streets, off his medication and untreated.

His father and stepfather have, as of our last conversations with them, lost track of him.

When time allows, his father goes looking for the son whose mental health van der Laak put before everything else, including her own. He searches Denver’s homeless encampments, occupied by many who also need a safety net, but have learned they can’t count on one.

He drives by the condo where van der Laak used to live. The neighbors there sometimes spot Vinnola strung out and sleeping on the sidewalk out front, waiting for her to come back.

Freelance reporter LJ Dawson contributed to this report. Susan Greene can be reached at susan@colabnews.co. This story is part of a statewide reporting project by the Colorado News Collaborative called On Edge. The project is supported in part by the Rosalynn Carter Fellowship for Mental Health Reporting and a grant honoring the memory of the late Benjamin von Sternenfels Rosenthal. Our intent is to foster conversation about mental health in a state where stigma and a lack of access run high. To learn more about COLab, visit colabnews.co.

Aurora’s unique growing pains

Aurora Mental Health Center officials are fast to offer a short list of critical observations about their industry and about their community. Top among them is, “We’re an industry undergoing a lot of change right now,” said AuMHC CEO Kelly Phillips-Henry.

Change has been the mantra for AuMHC for its 30-year history. The once small community mental health project has evolved into a vast array of services, with annual revenues and expenditures averaging about $50 million a year.

It operates on about the same budget as the Tri-County Health Department, the largest in the state, serving 1.2 million people across three sprawling counties.

AuMHC reports it provided treatment to just over 19,000 people with almost a half-million appointments.

Detailing exactly who, how many times, for what kind of treatment, by whom and how frequently isn’t easy to report, officials here, across the state and across the industry say.

Interests inside and outside of the industry say they want to see reporting of all kinds of data change as the state rolls out a new office focusing on mental health.

Change in the industry has come slowly since thousands of mentally ill people were released from institutions across the nation in the 1960s. The intent and theory was that psychiatric medicine had advanced to the point that the vast majority of mentally ill people could be treated as outpatients, rather than institutionalized for life.

No one denies that the results of that sea change have been mixed at best.

In the 1970s, it became apparent in the metro area that large numbers of people were unable to get the mental health services they needed, so mental health centers like the one in Aurora began to be created.

Officials going back to the mental health center’s beginning, and industry icon Randy Stith, pressed relentlessly to expand the project to accommodate a growing need in services and shrinking access to treatment.

After decades of growth and expansion, Aurora has for the past decade been poised and compelled to market a growing variety of treatment options within the program.

Even before the pandemic, changes in private insurance, under Obamacare, the expansion of Medicaid and mushrooming drug addiction in the region began challenging the center’s capacity, officials said.

The pandemic has brought critical challenges to the industry and Aurora, officials there say.

Huge efforts to decrease the stigma of admitting mental illness and seeking treatment suddenly became unnecessary when the pandemic got underway in earnest, Philips-Henry said.

“That was a huge win,” she said, and it also created a “tsunami” of people in need.

“This is a national problem, not just a Colorado problem,” Phillips-Henry said. “There just aren’t enough resources to go around.”

Not only was Aurora understaffed for the massive requests for help from all kinds of age groups suffering from a wide range of problems, but the pandemic itself prevented the center from offering treatments.

“Suddenly everyone was talking about how it’s OK to ask for help,” said Chief Operating Officer Kathleen Snell.

Even though the center was able to quickly turn from in-person appointments to a variety of tele-health offerings, demand immediately rushed past the resources.

They said that not only did more people almost immediately seek out services, more people came looking for help who were suffering more serious maladies and addictions.

What was a growing shortage of providers quickly became a crisis, officials said.

Today, the center has 107 vacancies for providers, ranging from peer counselors to medical doctors, but mostly encompassing providers who can offer physiological treatment.

If all the vacancies were filled? Phillips-Henry estimates they would still need about 50 more providers to meet Aurora’s growing need.

Still, Snell said the center offers same-day, in-person triage during business hours. Non-crisis cases are then seen within an average of about two weeks at the longest, Snell said.

But the need isn’t just for individuals reaching out for help with depression, anxiety, addiction or an increasing number of more serious afflictions. The need is in the community for those who don’t directly ask for help.

The CoLab investigation into statewide spending on community mental health centers revealed that the rate centers like Aurora are reimbursed for hourly services is vastly higher than what Medicaid allows for reimbursement to private practice providers.

AuMHC officials say it’s the growing community-wide need for services the center is not reimbursed for that drives that high rate from the state.

“Mental health centers provide services to the community that private providers don’t and nobody else does,” Snell said.

The center is still providing treatment to 77 victims from the 2012 Aurora theater shooting.

“Nobody reimburses us for that,” Phillps-Henry said.

The center has sent teams to schools across Aurora after the most recent school-related shootings at Aurora Central and Hinkley high schools.

“We’re the only ones who provide services like that,” Phillips-Henry said.

State and other financial documents show that while about 65% of the center’s funding comes from the large Medicaid reimbursements, client payments and private insurance fees, another $19 million a year comes from grants and other sources, some targeted at community wide programs.

Top officials at AuMHC say they’re the first to admit that how the state funds centers like Aurora’s is a convoluted, inefficient and confusing system.

“More than anyone” we want to see funding reform, said center chief financial officer Loretta Buckman.

She and others also said they regard the center’s records and data forthcoming and available, welcoming additional requirements for transparency.

There is no clear way, through the center’s annual financial filings to the IRS, to a variety of state agencies, to information on its website, or data supplied to its own auditing firm to easily understand the hard dollar cost to taxpayers for a wide range of services provided.

Part of the problem is because larger centers like AuMHC provide far more services than counseling and treatment appointments for the public.

Aurora Mental Health Center operates a subsidized housing program, in conjunction with the Aurora Housing Authority, managing subsidized rent for more than 400 people in the region.

The Center is also the umbrella organization for the Asian Pacific Partnership in the metro area, a community program providing support for a wide range of Asian-American, immigrant and refugee issues.

The agency is responsible for a 16-bed critical care facility on the Anschutz Campus, the region’s detox center and teams that work with police and others for people in crisis.

Center officials say they want to do more, but they need more resources.

For the past two years, center officials have been working with members of the Aurora City Council and others in formulating a ballot question to ask Aurora voters to raise sales taxes to provide for more regional services.

Some members of the city council pushed back on tax revenues being directed to the center without new and reformed oversight and transparency built into the mental health center structure.

Currently, the center is run by the CEO, Phillips-Henry, advised by a volunteer board of community members. As a non-profit organization, reporting and publication requirements are nothing like those regulating transparency for government agencies.

Critics say that more, direct tax revenue should come with more transparency in spending and accountability to city taxpayers.

Leaders of AuMHC said last week they were unaware of that issue, and said possible tax increase questions were postponed because of the pandemic and the political shakeout from that.

A similar issue is in front of the city council now, as the city weighs what to do with a relative windfall of federal and state money made possible by pandemic relief programs. The cash offers new incentives to provide additional mental health services, especially for people experiencing homelessness and marginalized by the pandemic.

AuHMC has been pushing for a new, centralized services center, looking to the city and other sources for investment into the facility.

A proposed 50,000-square-foot Potomac Campus “would serve all of our acute care needs,” Philips-Henry told the Aurora City Council last month when the body signaled they would commit $8 million to $10 million of federal pandemic funds to aid construction of the new building. In all, the facility is estimated to cost nearly $30 million and open to patients in late 2023.

The monetary vow was somewhat of a breakthrough as city governments, which traditionally don’t take on health and human services costs like counties do, have been more involved in funding mental health services. In Aurora, that’s played out in a couple of different ways, from capital costs to weighing tax proposals like neighboring Denver.

City council member Curtis Gardner proposed a 0.025% increase to the city’s sales tax earlier this summer that would go strictly to youth services and substance abuse programs, and even further back the council considered whether to support a similar ballot measure from Aurora Mental Health.

Gardner wasn’t able to garner enough support from his colleagues to put the question to voters.

Some city lawmakers say they question whether vesting one agency, outside of their control, is the best way to provide for the growing need for services, especially in light of a burgeoning problem with homelessness, which appears to be the responsibility of city governments.

But cities like Aurora aren’t the only entities building internal mental health resources as the need grows and the lack of access becomes critical.

Youth mental health issues are a main focus of both Aurora school districts, Cherry Creek and Aurora Public Schools. Mental health, particularly teen suicide prevention, was on the radar before the pandemic but has become especially pressing as the number of children and young adults experiencing psychological problems has skyrocketed during the pandemic.

“I truly think we’re in the middle of a mental health crisis,” Cherry Creek director of community partnerships for crisis intervention Steve Nederveld told The Sentinel.

That the region’s resources are not keeping up with demand is a frequent refrain. Children’s Hospital Colorado declared a “state of emergency” for pediatric mental health in the spring, saying that the levels of demand for services are unprecedented and there are often not enough behavioral health beds for children who need treatment.

Reeling from a flood of need and a relative dearth of resources, Aurora Public Schools and Cherry Creek are devoting substantial amounts of money to mental health resources. APS used money from a $35 million 2018 mill levy to increase mental health resources, and is devoting funding from federal coronavirus relief funds to the issue as well. Cherry Creek is taking the nearly unprecedented step of building a $7 million mental health day treatment facility for students. It is being built in part because the surrounding hospitals and other care facilities simply don’t have the capacity to meet the need, district officials say.

Cherry Creek has at least three full time mental health providers in each high school, two at each middle school and one at each elementary school, Nederveld said. These include psychologists, counselors and social workers. At APS, early childcare centers and elementary schools have at least one mental health professional in each building, according to district spokesperson Corey Christiansen.

Additionally, both districts partner with the Aurora Mental Health Center and others for extra support. Over half of Cherry Creek’s schools have a therapist from either Aurora Mental Health or AllHealth Network who can provide psychotherapy to students, and the district is hoping to increase that to every school in the next couple years. APS has at least one part-time provider from AMHC or HealthOne at every campus.

For students who are having severe issues, the districts will work to connect them with a local facility that can give them the support they need — at least, that’s how it’s supposed to work.

Nederveld said that Cherry Creek is able to meet student mental health needs that can be handled by a school-based team in a timely manner, though it could still use more staff. However, it is struggling to help students who are identified as needing intensive treatment that the district can’t provide itself because all of the places it normally refers to are completely booked up and have significant backlogs. The combination of an increase in student mental health problems and the staff shortages in the school and healthcare fields caused by the pandemic have created a “perfect storm,” he said.

Both school districts and AHMC said that staffing shortages are a significant problem for them. AMHC increased its school based therapists during the pandemic and said that’s one area where it’s been fairly successful in hiring, but shortages are still an ongoing problem.

“We would be ready tomorrow if 20, 40, 60 licensed clinicians walked in our door to hire every single one of them and deploy them in a variety of places across our system,” Snell said in an interview. “That is truly our biggest challenge.”

Philips-Henry said AuMHC will continue to reach out to schools and the rest of the community to expand services, but not with fewer dollars.

“If you undid the (mental health center) system, it would be catastrophic,” Philips-Henry said.

— Sentinel staff writers Kara Mason and Carina Julig

If you’re experiencing a mental health crisis, call the Colorado Crisis hotline at 1-844-493-TALK(8255). There is no wrong reason to reach out.