By Alan Prendergast
By Michael Roberts
By Michael Roberts
By Amber Taufen
By Patricia Calhoun
By William Breathes
By Michael Roberts
By Melanie Asmar
Ask Sam Haigler how things are going and he'll give you that perplexed look, the one that seems to ask: What planet are you from, pal? Twenty years of battling chronic mental illness, just how well could things be?
"That's kind of a hard question for me to answer," he explains. "I hear voices. I can't get them to say who they are. It's been going on a long time."
For almost ten years, Haigler lived at the Highlands Personal Care Living Center, a huge boarding home in northwest Denver. But in early 1995 the city closed Highlands over a zoning dispute; the 47-year-old Haigler now lives at another boarding home, the Vernon L. Valdez Personal Care Center on West Colfax. The voices have traveled with him, especially one voice that comes over the radio.
"He talks along with the music," Haigler says. "He tells me to bend my thumb, bend my thumb. He chants it. But I won't cooperate.
"Then he says, 'When you bend your thumb, I'm having the police come over and cream you and take you to the jail and electrocute you.' After a while he convinced me of that--that the police were going to come."
One time Haigler came home from 7-Eleven with a package of cookies. He got ready for bed and turned the light off. The voice on the radio said, "Eat a cookie for $30,000. Eat a cookie for $30,000." Haigler wouldn't do it. The voice wouldn't leave him alone.
"He just kept going on about it," Haigler recalls. "And he's still on the radio. I have a problem with that."
In recent months Haigler has been troubled by voices of another kind. They are the voices of social workers and therapists, asking him if he would like to move out of Valdez. Like the one on the radio, these voices have been relentless.
When Highlands closed, they persuaded him to try living in his own apartment. It didn't work out; Haigler wasn't used to cooking for himself or being on his own, and he ended up being institutionalized for several weeks. Then he moved to Valdez, one of the few boarding homes left in the city; most of its residents suffer from paranoid schizophrenia, bipolar disorder, severe depression or other mental illnesses. Haigler wants to stay there, he says, but his case manager and others have continued to urge him to think about moving to a smaller group home operated by the Mental Health Corporation of Denver.
"They've brought up moving five or six different times," Haigler says. "I told them I'm not interested, but they keep evading what I say. I say I don't want to move, they just say something else about moving. They don't shut up about it."
Why all this interest in where Sam Haigler lives? Credit--or blame--the Goebel Services Plan, named after Ruth Goebel, a homeless woman who died on Denver's streets in 1983. As part of the settlement of a lengthy, complex class-action lawsuit brought on behalf of Goebel and other mentally ill Denver residents, in 1994 state and city officials agreed to commit millions of dollars to programs designed to "mainstream" the mentally ill, including moving them out of four large boarding homes--Highlands, Valdez, La Bonte and Pontiac--and into smaller group homes or their own apartments.
Forged out of long-simmering disputes over the care of Denver's most neglected citizens, the Goebel plan is a highly ambitious, three-year blueprint for liberating them from living conditions that many mental-health professionals consider to be substandard and even dangerous. The plan requires the City of Denver to develop 250 units of housing for the mentally ill and the state to provide 50 more. It requires the Mental Health Corporation of Denver--the nonprofit group that contracts with the state to implement the plan--to relocate as many of its boarding-home clients as are willing so that they can better "negotiate the community." MHCD is also expected to make various new services available to its 1,600-plus "Goebel clients" around the city--high-intensity treatment teams, independent-living teams, 24-hour mobile crisis-response teams, and so on--to ensure that they have an opportunity to live as independently as their circumstances will allow.
Noble as it sounds, carrying out the plan has proven to be more difficult than expected. While its backers claim much progress in two years--for example, the number of MHCD clients living in the four boarding homes targeted by the plan has dropped by two-thirds since 1994, largely because of the closure of Highlands--some truly formidable problems remain.
The city has yet to deliver on most of the promised housing, despite a court-ordered deadline looming only seven months from now. Many of the remaining 51 Goebel clients living in the boarding homes say they don't want to move, and several who did take the plunge have found themselves in a seemingly endless spiral of waiting lists, temporary housing, evictions and other setbacks that have landed them back in boarding homes or hospitalized, with no end in sight ("Out of Sight, Out of Mind," January 17).
The plan has also encountered resistance from the boarding-home operators, who are offering competing medical services and have challenged the removal of their residents. MHCD is now locked in a tug-of-war with the homes' operators over the remaining Goebel residents, with each side accusing the other of providing inadequate services, trying to coerce clients to stay put or to leave, or otherwise exploiting the mentally ill for their own gain.
"We're really pushing the issue of getting people moved out of the boarding homes," says MHCD deputy director Frank McGuirk. "This gets to be an economic issue for the owners; they're able to draw a more significant amount of [government] dollars for clients with disabilities. I think they see this as a threat to their livelihood."
Such talk infuriates Kay Robertson, who worked at Highlands in its last months and now manages Valdez. She claims it's MHCD staffers who are trying to dictate where her residents will live, in defiance of the spirit of the Goebel plan, which states that MHCD services will be offered "on a voluntary basis and with due regard for the class member's dignity and personal autonomy."
"They're coming in here and intimidating the residents," Robertson says. "They're telling them they have to move, whether they want to or not."
Providing the services mandated by the Goebel plan has been a sizable undertaking for MHCD; the annual budget for the services amounts to more than $17 million in new and redirected funding, much of it coming from Medicaid coffers. Goebel clients--defined as anyone who has received treatment for chronic mental illness while living in central or northwest Denver at any time since 1981--now represent roughly half of MHCD's total customer base. But the program also has brought additional scrutiny of the mental-health giant, which has been plagued by staff turnover and management shakeups in recent years.
Two months ago Colorado Mental Health Services director Tom Barrett put MHCD on notice that it was in violation of its contract with the state, after a random audit of MHCD client treatment charts revealed that several clients had only minimal contact with their case managers. Although the accuracy of the records is also being questioned, they reflect that one client received only 25 minutes of "case management services" over a three-month period. The Goebel plan, Barrett notes, calls for each client to receive upwards of nine hours of such services a month. "In many instances, they were receiving less than half of that," he says.
Charges that clients aren't receiving the expected services are also being raised by some of MHCD's own employees. A dispute over billing practices and the amount of time case managers are supposed to spend with clients prompted several resignations last month on one of the high-intensity treatment teams, which target those who are considered most "at risk," including homeless and dual-diagnosis clients (people with substance-abuse problems as well as mental illness). Some former staffers complain that MHCD emphasizes producing hefty billings over serving the clients.
"It was all about money," says former case manager Steve Thomas, who quit after confronting superiors with his complaints about a colleague's conduct. "It wasn't about saving someone's life. MHCD's motto is 'dedicated to quality mental health care.' It isn't quality. It's quantity. It should be 'dedicated to billing Medicaid and Medicare until they're bankrupt.'"
MHCD's McGuirk characterizes the staff complaints as "minor, isolated items that have been blown out of proportion." At the same time, he ac-knowledges that the corporation is in the process of making some "administrative changes" to address the state's concerns and to work more smoothly with its boarding-home clients. None of which, he adds, should obscure the fact that the Goebel program has its share of success stories: "There are lots of clients who've seemed beyond hope, sort of lost in the system, who have achieved much, much more than anyone thought they would."
But there are also clients who have found the plan to be an experiment in misery, a persistent threat to their established routines and familiar surroundings. Recently Sam Haigler's sister and brother-in-law, his personal representatives, wrote a letter to a psychologist at Valdez expressing their "disapproval and disbelief" that MHCD was still urging Sam to move out despite the previous apartment disaster.
"To put Sam back in an unsupervised living environment would be unconscionable and irresponsible and would endanger Sam and others," they wrote. "Leave him in a setting where he is functioning, protected, and of no potential danger to anyone."
Haigler says his case manager hasn't mentioned moving in the past few weeks. "Maybe they're getting the message," he says.
Keith Roland sent an even stronger message to MHCD concerning his son Donald, a forty-year-old schizophrenic who wanders through the dimly lit halls of Valdez wearing Denver Broncos sunglasses that hide his wide, childlike blue eyes. His cigarettes and coffee are tightly rationed by staff--because, he explains, "I give too many things away and I could burn the place down."
When MHCD staffers talked to him about moving to a smaller group home, Donald became so upset that he went outside and began shouting at his father--who wasn't there to hear him. When Keith Roland found out about it, he fired off a letter to MHCD stating that the corporation's actions "border on harassment."
"The main thing I'm concerned about is that Donald is happy where he is," Roland says. Valdez may not be a palace, he adds, but it's clean, safe, and close enough for Keith, who lives in Westminster, to make regular visits. "It's like a five-star hotel compared to some of the places Mental Health put him in."
MHCD responded to Roland's letter with a flurry of phone calls. One doctor proposed a meeting with all parties concerned, an opportunity to do a fresh evaluation of Donald and his needs. The elder Roland declined.
"Donald's been evaluated so many times," he says. "They need to leave him alone."
For most of the fourteen months he worked at MHCD, Steve Thomas was known as a hardworking, conscientious case manager who cared more about his clients than the bottom line. Then he became a whistleblower, trying to get his supervisors to look into what he considered to be improper billing practices and possible Medicaid fraud. Now he is viewed in some quarters as a classic Disgruntled Former Employee.
A former child actor and model, Thomas says he still makes enough in residuals from his appearances on TV shows such as Police Woman and CHiPs to devote much of his adult life to volunteer work. The job at MHCD paid less than $25,000 a year and required little more than a bachelor's degree and rudimentary training, but he saw it as an opportunity to "make a difference in people's lives."
Thomas says he quickly became "obsessed" with the job, often working overtime without bothering to put in for additional compensation. On his eight-member high-intensity treatment team, case management involved everything from therapy sessions with clients to helping them find a place to live, taking them shopping, linking them to other health services, or simply lending a sympathetic ear. Given the critical needs of the Goebel clients, the job placed endless demands on Thomas and other members of his team.
Yet some aspects of the work rankled Thomas from the start. The team's performance was routinely evaluated, not on the basis of how many of their clients were faring well and staying out of the hospital, but on how many billable contacts with clients they were making. Each member was expected to meet weekly and monthly productivity goals; the entire team was supposed to be billing a total of around $61,000 a month.
"It was like a sales job--you had to make your quota," Thomas says. "I thought I was in the movie Glengarry Glen Ross."
In theory, all the Goebel clients are entitled to the same services. But because of the differences in their disability benefits, they couldn't all be billed the same way. Medicaid would pay for therapy and other case-management services, at a rate that averaged around $38 per "contact"--whether that contact was a five-minute phone call or a two-hour shopping trip. Medicare, though, would pay only for therapy. Services for indigent clients who had no benefits were paid through a special fund that was often exhausted before the end of the month, Thomas says.
Thomas soon discovered that Medicaid clients were highly prized by some MHCD staffers; one supervisor, he says, even referred to Medicaid clients as "cash cows." "There's no question, that was the terminology," he says. "Everybody knew she said it. And they would laugh. They'd make moo-moo sounds or say 'ka-ching!' when one of them walked in. I could clearly see who was Medicaid and who wasn't by how they were treated when they came through the door."
And what about those Goebel clients who weren't covered by Medicaid? "It was like, tough darts, buddy," Thomas says. "I had a client who was self-paid--which means he didn't have any benefits--and he was chronically homeless. I was told, 'Don't worry about him; he'll figure out a way to get by.'"
Other members of Thomas's team have echoed his charges. "When I first started, I was told to have more contact with Medicaid clients than [with those with] Medicare," says another case manager, who requested anonymity. "Who's to say the Medicare clients didn't need more help? One time I was called by a Medicaid client and I asked someone to take a message. I was told, 'You need to talk to this client. She's Medicaid. You can bill for this.' I was busy doing something else, but I lost a billable contact."
Deputy director McGuirk says that it's MHCD policy to treat all of its Goebel clients equally, regardless of their benefits, and that he's unaware of any supervisor using terms such as "cash cows" or "ka-ching!" in reference to the mentally ill.
"It's disappointing to me that staff have taken on that kind of perception," McGuirk says. Implicit in the Goebel plan, he explains, was the expectation that Medicaid revenue would play a large part in funding all the programs, and the concept of "billable contacts" was structured accordingly. "But somehow that gets translated down that the emphasis is on client contacts for revenue purposes. We want to de-emphasize the revenue-generation aspect of it, because there's opportunity for people to misinterpret what it means."
He adds, "If people are really using 'cash cow' language, that's extremely unfortunate. What we have, I think, is a team that has gotten, through whatever internal dynamics, into sort of a bad place."
In time, Thomas's dissatisfaction with what was going on at MHCD became focused on the activities of a colleague, case manager Michael Steinert. Steinert was considered one of the most productive members of the high-intensity team, but Thomas believed his productivity was achieved by billing for numerous brief phone contacts and that he wasn't spending as much time with clients as were other members of the team. On at least one occasion, he claims, Steinert's contact records reflect that he was conferring with clients at the same time that he was talking to Thomas.
"I looked at some of his contact sheets," Thomas says, "and they were mostly five- or ten-minute contacts, which make the bills high, while most of the rest of us were out working like dogs."
In early October, Thomas and five other members of his team signed a memo to a supervisor complaining about Steinert. They claimed that Steinert's outside activities, including a second job at a corrections facility and classes he was taking toward a master's degree, were interfering with the team's ability to get its work done; that he was frequently unavailable for emergency after-hours calls and rarely was in the office on Sundays, when he was scheduled to work a ten-hour shift; that he seemed to receive preferential treatment in scheduling shift changes or vacations; and that client care seemed to be suffering.
One of Steinert's clients had recently been moved into an apartment with only a mattress and no food, they reported; another was expected to shop at 7-Eleven "because Mike does not take him to the store." Others didn't appear to be receiving sufficient contact with him to function in their current living situations.
Around the same time, Thomas hired a private investigator at his own expense to conduct surveillance on Steinert on Sundays. "We found out he wasn't working on Sundays. He wasn't even coming into the office," Thomas says.
Thomas's sleuthing eventually led to a meeting with assistant deputy director Andrew Keller, who informed him that MHCD was considering terminating him for his "unprofessional behavior" in having Steinert followed. Thomas was stunned.
"It was crazy," he says. "He's sitting there saying, 'Maybe we can reduce it to probation,' and I'm saying, 'I didn't do anything wrong.'"
Rather than wait for MHCD to decide his fate, Thomas resigned earlier this month. Steinert turned in his resignation two weeks later, following a meeting with MHCD management.
Steinert says he did nothing wrong, either. He resigned, he says, because "I didn't feel I had to defend myself against this. It had gone too far as it was. I was ready to move on, and the attention that Steve brought on me by basically violating my rights and having me followed brought up a lot of issues."
Steinert says that his colleagues never brought their concerns to him and that he never even saw the memo or the complaints it raised. He describes the dispute as a difference in "style" of case management that had nothing to do with client care.
"I was taking care of my caseload," he insists. "Everybody has a different style of doing it. You can take on any number of things when you're dealing with a person with a chronic mental illness. There's just tons of things you could help with. Some people can't get it done in fifty hours a week; others seem to keep their caseload in check and get more creative."
While there may have been "some miscommunication" about his being allowed to work at home on Sundays, he says, his supervisors knew about his outside activities and approved his work schedule. And he denies that any of his clients were deprived of essential services; for example, the man who was moved into an apartment with only a mattress "purchases his own food and eats with his girlfriend at her apartment," and the move occurred on a weekend, when he couldn't obtain furniture from MHCD's warehouse. The real issue, in his view, is the lack of experience among most case managers--Steinert himself worked at MHCD for only a year and a half but says he has five years in the mental-health field--and the mixed signals they receive about how they're supposed to be treating their clients.
"We got a lot of different messages from administrators about how to manage our caseload," he says. "A good number of the people are relatively green, fresh out of school--and may not even have a bachelor's in the human services area. Some of them have trouble maintaining boundaries."
MHCD's McGuirk says he investigated the complaints against Steinert thoroughly and found no evidence of improper billing. "We're satisfied that client care has not been compromised," he says. "The individual involved resigned, following discussion of the issues. That's as much as I want to say about that."
In all, six out of eight members of Thomas's team have resigned or put in for transfers in recent months. McGuirk says the problems that surfaced there are isolated ones and don't reflect the overall accomplishments of the team, which moved more than thirty clients out of boarding homes over the past two years and placed twenty in apartments.
But Thomas and his colleagues aren't the only ones raising questions about MHCD's billing practices. For years boarding-home operators have complained about excessive or double billing of their residents for cursory visits by MHCD staff. Harold Harmer, the owner of Highlands, charges that MHCD staffers used to show up at social functions at the home long enough to say hello and gather the names of those present--and then billed each eligible resident's coverage for a "group activity" or "group therapy" visit.
"I still get mad when I think about it," says Harmer. "They were just ripping these people off."
Kay Robertson of Valdez tells of a visit last summer by an MHCD psychiatrist who met with five residents individually, for fifteen or twenty minutes each, and billed Medicare a total of $1,030--which works out to about $10 a minute. Other sources report an excursion to a Colorado Rockies game for which one case manager billed for every client present, whether the clients were assigned to him or not.
The recent state audit revealed other irregularities, including the case of the boarding-home client who'd apparently received only 25 minutes of case management over a three-month period. Still, Tom Barrett of Colorado Mental Health Services, the state agency overseeing the MHCD contract, says that the Medicaid billing is closely monitored by the state and that he's convinced the corporation is performing up to expectations.
"This is a very major program," Barrett notes. "There are some problems. But if you look at putting up $7 million a year in new services, plus reallocating millions more and having to do it very quickly, with lots of oversight and documentation--I think they've done a good job here."
McGuirk says the 25-minute case is "totally unacceptable" but that most of the deficiencies found in the audit had to do with a lack of proper documentation, not a lack of contact. MHCD recently turned to an outside transcription service to prepare its case notes, he explains, and that resulted in a backlog of notes not finding their way into the proper files. In order to beef up its client contact to meet the contract's requirements, MHCD is now stressing the amount of time a case manager spends with each Goebel client rather than the number of billable contacts.
"I never knew I was supposed to spend 9.7 hours a month with a client," says one case manager. "Now they have a memo out about it. Before, all they told me was to bring in $7,000 a month or so."
"We're reworking our whole set of expectations about client care," McGuirk vows. "We're moving aggressively to re-energize our whole delivery effort."
Part of that effort involves more frequent visits to the boarding homes. McGuirk says the case managers are supposed to be giving clients the opportunity to explore other living arrangements, not coercing them.
"Obviously, we don't want to take clients away against their will," he says. "But we do want them to have an understanding of the options that are out there--that life can be okay, even better, outside the board and care homes."
But some case managers paint a different picture of what's happening on the front lines, saying the push to move people out has caused them to question the therapeutic nature of their work. Steve Thomas says he had a schizophrenic client at the La Bonte Personal Care home who was easily upset by any prospect of change; the man broke down in tears during one visit to a smaller group home operated by MHCD.
"Forcing him out of La Bonte, it was like we were forcing him into the hospital," Thomas says. "It seemed like a strange thing to do, but they were telling us we had to have him out. I never understood that. These are still human beings. They're not numbers on a check."
The sign posted in Kay Robertson's cramped office reads: "If you are grouchy, irritable, or just plain mean, there will be a $10 charge for putting up with you."
The mock warning doesn't seem to deter any of the residents of the Valdez boarding home. They wander into the office all through the day with problems great and small, seeking advice, a compliment, a quick answer. Robertson handles them all with brisk matronly calm--and a hint of quiet exasperation, as if trapped in a play of uncertain origin, the scenes alternately heartbreaking and inadvertently comical.
While she shuffles through paperwork, a short, wizened codger tiptoes in and solemnly presents her with two stuffed animals--a white bunny and a pink elephant that look like they were obtained from a crane machine in an arcade. She thanks him and adds them to her growing collection. Ten minutes later he's back with a teddy bear. She thanks him again.
"Where are these coming from, dear?" she asks.
The old man grins mysteriously. "People give them to me," he says.
Another resident comes in fuming about a missing check. Robertson coaches him through a phone call to his case manager, and he ends up leaving a polite message. A heavyset young man sticks his head in the door and announces that he's going for a walk.
"No dumpsters, okay? I don't want you getting into any dumpsters," Robertson says.
The young man blinks hard. "Who's saying that?"
"I'm saying that. You're nice and clean, and I want you to stay that way."
"Go to the kitchen and ask them for a loaf of bread to feed the ducks."
"I'm not going that way," the man says.
"Which way are you going?"
He points away from Sloan's Lake, toward West Colfax. "Over there."
"You mean over by the pawnshop? Don't you try to charge anything."
"I'm just going to price things, that's all."
After he departs, Robertson slumps in her chair. "This place," she says, "is a huge nursery school."
Robertson worked at Highlands in its last months before taking on the job of managing Valdez. She believes there will always be a need for boarding homes, which have become, almost by default, a refuge for the mentally ill, particularly those shunned by their families or cast out of state facilities after years of institutionalization. They may not be anyone's ideal of comfort or privacy--at its peak, Valdez had as many as four residents sharing a single room--but they do offer hot meals and a bed, at a price someone living on a government disability check can afford.
Yet many advocates for the mentally ill regard the homes as little more than warehouses where residents are allowed to stagnate rather than learn skills that could help them cope with their illness. "The whole notion of having huge numbers of needy people stacked up in that kind of facility is a recipe for disaster," declares Kathleen Mullen, the attorney for the plaintiff class in the Goebel lawsuit. "They're not facilities that can meet the needs of folks appropriately."
Mental-health professionals concede that Valdez and La Bonte are relatively clean, well-maintained homes--but under the Goebel plan, they're considered substandard housing. Highlands was arguably much worse, yet its closure last year touched off a scramble that persists to this day for affordable housing for its 120 residents. Owner Harold Harmer, who has since converted the property into condominiums, is still pursuing a lawsuit against the city, claiming that officials were determined to shut him down in order to implement the Goebel plan.
Mullen notes that the Goebel settlement doesn't give officials the right to close down the homes, but it does require the state to make a concerted effort to place residents elsewhere--even if that means overcoming the initial resistance of people who say they're perfectly content with their current home.
"There has to be a neutral opportunity for these clients to experience the services they're entitled to," she says. "And I mean a real opportunity--not just asking someone if they want to move, but identifying appropriate placements and working with the people. If someone says, 'Heck no, I want to go back to Valdez,' they can make that choice. But how do they make that choice if the only option they've had for fifteen years has been to be stuck in Highlands or Valdez?"
Neutrality, though, is hard to come by in the debate over the mentally ill; everyone, it seems, has an agenda. MHCD officials say they have higher expectations of what their clients can achieve than do the boarding-home operators, with their nursery-school approach. McGuirk even talks about discouraging use of the term "chronically mentally ill," since it tends to lower expectations. But Robertson and other critics say MHCD is ignoring the wishes of their residents--and their right to live where they please.
McGuirk notes that boarding-home operators often manage their residents' money for them and receive their disability checks as the designated payee. "That creates a kind of leverage that can be coercive," he says. "I've heard of operators making statements to residents like, 'If you leave, you won't be able to come back'--that kind of not-so-veiled threat."
Yet MHCD is also the designated payee for hundreds of its clients. The corporation has an aggressive "benefits acquisition team"--and that, the home operators charge, gives them enormous power over a client.
"I've got one guy who's lived here since '82," says Phil Valdez, operator of the La Bonte boarding home (and son of Vernon Valdez, owner of the Valdez home). "He's his own payee; he gets his check in his own name. But he has a speech impediment, and it's very hard to understand him. A year ago Mental Health wanted to move him to the Barth Hotel. How did they know he wanted to go there? When it was time to move, he got upset and they called it off. But yesterday he got a letter from Social Security, informing him that MHCD was now his payee.
"What right do they have to change his payeeship, so that he's under their control? If he'd had a hospitalization or incarceration, was being exploited financially, was squandering his money or didn't pay his rent, then that would be grounds for Social Security to review it. But for them to arbitrarily take it over, it doesn't seem right."
Valdez concedes the Goebel plan poses an economic threat to his business, but he says he's more concerned about the impact it's had on his residents. "For the corporation to assert that they have to get their care from them and they have to live in certain locations is a violation of their rights," he says.
Robertson has her stories, too, of MHCD staffers cajoling or alarming her residents with moving plans. She mentions one man who's been moved in and out of Valdez a couple of times by MHCD and is now gearing up for another move.
"First he said to me, 'Valdez has very bad memories for me and I'm ready to go,'" she recalls. "I said, 'Really? What are the bad memories?' And he said, 'I don't know. That's what they told me.'"
Robertson admits she told that resident that if he left again, he couldn't come back--because, she explains, his return would mean he'd been evicted over another violent episode, as has happened in the past. "If he gets put out of another place for hitting somebody, he can't come back here," she says. "And if nowhere else will take him, his alternatives are [state mental-health agencies at] Fort Logan or Pueblo. And Fort Logan is out of the question; the waiting list is enormous."
In recent months the feud between the homes and MHCD has been further complicated by the arrival of the BLC Group, a change of private practitioners who've sought to offer on-site health services to Valdez residents at the invitation of the boarding home's owners. Under the Goebel arrangement, MHCD is charged with supervising the psychiatric care and medication of the clients and brokering other medical services, and the corporation didn't take kindly to BLC's effort to take over those functions.
The situation quickly devolved into a testy exchange of letters between attorneys, with MHCD ordering the interlopers to cease and desist from endangering its clients, and the BLC Group--which includes a couple of psychologists, a psychiatrist, a physician and a nurse's aide--hollering that MHCD was interfering with its clients' right to choose their own health provider. A truce was reached last month when both sides agreed that MHCD would continue to be the sole prescriber of medication at Valdez, while BLC would be allowed to offer other medical services.
"We had to work with attorneys to get a stipulation that they would stop medicating our clients," says McGuirk. "We've had to take a hard look at honoring client choice, on one hand, and not being able to allow another group to provide services when our staff has similar responsibilities."
McGuirk claims that a BLC doctor overmedicated one of the Valdez residents--a charge hotly denied by BLC psychologist M.J. Philippus, who says MHCD has failed to see that the boarding-home residents receive regular physical exams and dental care.
"These people are wrecks," Philippus grumbles. "Mental Health has never done a damn thing except give them pills."
Philippus's partner, psychologist B.L. Cordova, says the group has encountered a series of rotten teeth, bad feet and weak eyes at Valdez; many of their clients are indigent, he adds, and wary of hospitals and doctors' offices. "We've had to hustle things," he says. "We have a guy who needs teeth, and we found a dentist who was willing to forgo the exam fee."
Attorney Mullen says her own review of medical records indicates that MHCD hasn't done "sufficient followup on dental services" for its boarding-home clients. At the same time, she wonders if the folks at Valdez are in a position to give their "informed consent" to a change in their health service. Nothing in the Goebel plan addresses the notion that other health providers might want to compete with the state's contractor for the right to treat the mentally ill.
The turf war has left some Valdez residents confused about who is doing what for them--and to them. Probably no one is more frustrated than Raymond Lyle, who's battled paranoid schizophrenia for decades. Committed to the state hospital in Pueblo after an assault conviction in the 1970s, Lyle later won conditional release and has spent most of the last fifteen years quietly at Valdez. In late 1993, after another stint in Pueblo, he was again allowed to return to Valdez.
But a few weeks ago MHCD requested that the terms of his conditional release be changed. Lyle's case manager told him that she had a court order requiring him to leave Valdez.
"They said I had to move out or go back to Pueblo," says Lyle, the brother of heavyweight boxing great Ron Lyle. "They never explained their reasons. They just said they had a court order. It got me all upset."
McGuirk says the decision to move Lyle was based, at least in part, on BLC's presence at Valdez. "Our medical director is legally responsible for the care of this client in the community," he says. "If we perceive that the clinical care is inappropriate, then we're going to look at changing the circumstances."
Recently, though, Lyle's case manager told him he wouldn't have to move--at least not for now. "They tell me one thing one day, something else the next day," Lyle says. "It's kind of getting on my nerves."
Even more curious than the flip-flop was the kind of placement MHCD was requesting for Lyle; they wanted to move him to another large boarding home, Monarch Manor. Although Monarch isn't one of the four homes specifically targeted in the Goebel settlement, it's hardly an improvement over Valdez or La Bonte. Mullen says the idea of moving Goebel clients from one large home to another doesn't constitute "appropriate placement" under the plan.
Robertson says she knows of other Valdez residents who've been relocated to other boarding homes by MHCD. In one case, she says, a man came to Valdez from a homeless shelter only to be returned to the shelter. McGuirk says it's not MHCD policy to seek placements at either sort of facility, and he denies that the corporation is waging some sort of campaign to drain Valdez of all its residents.
"I've heard people say in meetings that the agenda is to close the boarding homes," he says. "Well, that's not my agenda. I think they have a role. There will be some handful of clients for whom this is what they prefer, no matter what options we present. There's only so far we can go in convincing a client who doesn't want to move."
In fact, the corporation is still making considerable use of Valdez as a kind of holding tank for certain Goebel clients. The latest quarterly report by the state on the Goebel plan notes a persistent problem with "backfilling"--meaning clients are still being referred to Valdez and the other homes by various mental-health agencies despite the clear mandate to move them out. In most cases, the referrals are being made because of a lack of alternative housing.
A surprising number of the referrals have been made by MHCD itself. By Robertson's calculations, the corporation has made more than sixty referrals to Valdez since the plan was finalized, including seventeen placements in the three months following the closure of Highlands. Many of the subsequent referrals involve individuals who have been taken out of Valdez and then returned two or three times after abandoning or being evicted from the apartments MHCD found for them.
James Kuroki shows off the "big, spacious closets" in the room he shares with one other resident at Laradon, an eleven-bed group home for Goebel clients in Globeville. Opened in May, Laradon is a clean, well-lighted place: new oak furniture, sunny balconies, a pool table, laundry facilities, a community kitchen and several common areas stocked with televisions and VCRs. The equivalent of four and a half full-time MHCD employees supervises the operation; three of them rotate in 24-hour shifts and sleep on the premises.
"It sure is nice here," Kuroki says. "I'd recommend it to anyone who wanted a chance. But they can't let just anyone in here. They have to prove themselves."
Kuroki has spent most of the past two decades in the state hospital in Pueblo. Although he says he's 72 years old, he appears to be in his late forties. Two years ago MHCD moved him into his own apartment in Capitol Hill, but strangers kept taking advantage of him, and he wound up back at Valdez. He likes Laradon much better--"The food is better, the employees are better, we can afford it and they have programs," he says--but he believes his stay here will be only temporary.
"Eventually, I would like to move to my own apartment," Kuroki says. "I did it before. But bad things happened. I had a bad neighbor that came by. I moved out."
Laradon represents a growing trend in the care of the mentally ill: small, intensively staffed group homes. Some people with chronic mental illnesses fare well on their own, with only minimal supervision of medication; under the Goebel plan, six have even become homeowners. But for those who have difficulty "negotiating the community" by themselves, the ready-made community provided by places like Laradon may be a stopgap solution. MHCD has established four group facilities since the Goebel plan began, and officials acknowledge that there's a crying need for more.
"When we settled this case initially," says Kathleen Mullen, "the state's position was that the vast majority of these people could live independently, in their own apartments. I said, 'Not on your life. These folks have been institutionalized for so long that they are going to need at least a transition to a group setting before they can make the leap.' They said, 'No, no, that's not true'--and then, after they moved them from Highlands and found out it wouldn't work, there was a revision to the plan."
Kuroki says his case manager told him four things needed to happen before he could have his own apartment again. "First, I have to find an apartment," he explains. "Second, I have to find something to do to keep me out of trouble. Third, I need to know my way around Denver. Fourth, I need to know my safety plan."
Fifth, the City of Denver may need to do a few things, too. Out of the 250 units of housing the city is supposed to make available under the Goebel plan, to date only 27 have been delivered. The lack of affordable housing has resulted in a long waiting list of Goebel clients who want their own apartments and a similar logjam of people waiting for a bed to open up in the group homes.
Several factors have been blamed for the delay, including protracted negotiations over 100 subsidized housing vouchers and neighborhood opposition to group homes for the mentally ill. After months of haggling, the city is expected to finalize an agreement with the Denver Housing Authority for the vouchers before the end of the year, but the lack of group homes remains an ongoing problem.
"The city is having a difficult time identifying sites for the group homes because of zoning and residential issues," notes the state's Tom Barrett. "The fact is these homes are generally well-maintained, and once people are there, it works quite well; but the resistance usually comes before people move in."
In the meantime, many of the Goebel people are stuck in a holding pattern. Like Kuroki, Howard Pyle likes Laradon just fine; the place offers him "more freedom," he says, than he ever had at any of the boarding homes or institutions he's stayed at since a "significant car accident" 26 years ago sent him on a dizzying journey through the mental-health system. But he, too, longs for something more; if he stayed at Laradon too long, he frets, "I think either the staff would get to their wits' end or I would."
"There are so many options," Pyle says. "I'd like to write short stories and sell them to magazines. I know that I'm not considered able, but I'd like to do more painting. I'm a surrealist. The world needs another Dali."
Although Pyle describes the group home as a "stepping stone to the future," he's understandably cautious about his prospects. "Look at it this way," he says. "The future is a mystery. The past is history. And today is a gift--that's why they call it the present."
Even those Goebel clients who've been fortunate enough to obtain some degree of independence know their circumstances can change overnight. For the Goebel plan to succeed will require an enormous, ongoing commitment of funding and training--and not even the best of intentions can fully overcome the challenges many of the boarding-home refugees now face.
Consider the odyssey of Richard Deem. A former Highlands resident, Deem was one of the first Goebel clients to be moved into his own apartment--proof that the leap to independent living was possible. But Deem has had a rough year since he was interviewed by Westword in January. Battling manic depression and schizophrenia, he's been hospitalized three or four times in recent months, he says, and has spent weeks in a bed at a crisis center. Soon he will be moving out of his Capitol Hill apartment and into the Barth Hotel downtown, which his therapists believe will provide him with a more congenial environment.
"They say I have to move out because I became too isolated in my apartment," Deem says. "I have hallucinations. I've had them for 37 years. I can't get rid of them. I can't. It's gotten worse."
A former seminary student and an avid reader, Deem liked staying in his apartment, reading his books, watching TV and listening to the radio. But the loneliness became too much for him to bear. He says he has friends in the apartment building, but he hasn't seen them recently. At the Barth, he'll have a private room and lots of neighbors, but he'll have to give away most of his books.
"I'll keep some of them, the most important ones," he says, gesturing at a single shelf stocked with the I Ching, The Concise Dictionary of the Christian Church, a catechism and books on the Civil War and the Soviet Union.
Although he doesn't know quite what to expect, Deem says he isn't worried about the coming move. "I will miss my friends in the apartment house," he says. "But I can communicate with them telepathically. It's a gift from God. I also have ESP and clairvoyance. Those are gifts from Christ. And my hand"--he holds up a weathered palm--"has the Stigmata."
At the moment, the sacred marks Deem sees on his hand are just as real to him as the Barth Hotel. Maybe more so. It's a gift to be reckoned with, just like moving day and all the other challenges and mysteries posed by the Goebel plan. There are no quick fixes, no tidy and lasting solutions to the problems of the mentally ill.
Sometimes, though, a little common sense goes a long way. Last week, for the first time, Sam Haigler told the staff at Valdez about the troubling voice on the radio in his room. Haigler didn't want to turn off the radio because it belongs to his roommate, who'd told him not to touch it.
Now the radio is removed from the room every evening at ten o'clock, so Sam Haigler can get some rest.
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