Oak Place is a crisis-stabilization home for people in mental crises. Nationally recognized as a model program, it’s on the brink of closing because of financial problems since Medicaid won’t pay for the center’s services.
Brian Powers/The Register
CENTERVILLE, Ia. — An innovative program that provides mental-health help in a rural area desperate for such services is on the cusp of closure, partly because state officials haven’t arranged a way for it to bill Medicaid.
Numerous southern Iowans who’ve used the Oak Place center are stepping forward to explain why they want it to stay open, pushing aside fears about being identified publicly as people who were hamstrung by depression or anxiety — and who sought help.
“Just because they’ve got a wire loose that needs to be tightened doesn’t make them any less of a person,” said James Alexander, who stayed at the center in 2015 and continues to drop in regularly.
The center, which is staffed by nurses and therapists, opened three years ago in a converted ranch home. It has drawn wide praise as an economical way for a rural area to address critical shortages of inpatient psychiatric facilities and other mental-health services. But it has struggled to draw enough money from Iowa’s convoluted method of paying for mental-health care.
Oak Place’s director predicts the center will close by late October. For residents of this area who suffer mental-health crises, that would mean the resumption of a humiliating routine: They would once again spend hours in the back of sheriff’s squad cars, being hauled to faraway hospitals with psychiatric units.
Oak Place is one of 11 “crisis-stabilization” centers set up around Iowa in the past few years. It offers clients an informal place to stay while nurses and therapists help them get back on track so they can return home or move into an apartment. Officials say that after the center opened, the number of Appanoose County residents who had to be committed to psychiatric hospitals dropped nearly 80 percent.
The program’s services continue after patients are stabilized enough to move out of the home. Clients are encouraged to stay in touch with the staff by phone or to drop by in person, so they can head off problems before their lives spin back out of control.
The center is packed every Wednesday, when clients gather for a weekly lunch. On a recent Wednesday, Alexander sat in the house’s screened back porch, eating a bratwurst and potato chips and drinking a Diet Coke. He gestured to other former residents, chatting with one another and the staff as they ate lunch on the porch, in the living room or on the backyard patio.
“How many people do you see here — 20, 25?” he said. “Look at all these people — all these people this place has saved.”
‘An example to the state’
Like most rural Iowa counties, Appanoose County has no inpatient psychiatric facility and few outpatient mental-health services. Oak Place’s fans include patients, the sheriff, court officials and health-care professionals.
“We wanted to be an example to the state — and maybe even nationally — of what a rural community could do with a little money and a few resources,” said Jackie Sharp, a therapist who leads the project.
Oak Place has been held up as a national model of how rural areas can deal with a chronic lack of mental-health services. No one disputes that such centers can save money, hassles and heartache.
Despite the widespread praise, however, Oak Place has been unable to draw enough money from Iowa’s methods of financing mental-health treatment.
One of the main sticking points is that Medicaid, the giant state and federal health-care program for poor or disabled people, has yet to pay for any services at Oak Place or similar centers. State officials acknowledge that some of those services should qualify for Medicaid reimbursement, but state administrators have yet to write rules under which such payments could be made.
Oak Place supporters note an irony: If the facility closes, many of its clients are likely to need hospitalization, for which Medicaid will pay more than $900 per day per person. That amount alone equals three-quarters of Oak Place’s daily budget.
The center serves people from four southern Iowa counties. Its clients tend to stay in the house for a week or two while they overcome immediate mental-health crises. Afterward, they’re welcome to visit or call any time, to speak to a nurse or therapist about their problems and progress.
‘They straightened me up’
Oak Place’s clients are remarkably open about their experiences. Almost all of them who attended a recent Wednesday lunch said they would be comfortable being named by the Register as people who sought mental-health help there.
Alexander, 51, said he has severe attention deficit disorder on top of a genetic condition that gnarled his hands and feet. Two years ago, he was depressed, jobless and about to be evicted from his apartment for lack of rent money. He’d stopped taking his psychiatric medication.
“I pretty much gave up on life. I didn’t know what was going to happen to me,” he said.
A therapist recommended he go to Oak Place, which took him in for about two months. The center’s staff drove him to doctors’ appointments, made sure he took his medicine — and made him feel valued.
“The people here treat you like a person instead of like a number,” he said. “They straightened me up.”
Organizers didn’t change the 87-year-old house much when they turned it into a mental-health center three years ago. The three-bedroom home has wood paneling on the walls and is furnished with cushy couches and chairs, a standard kitchen table and basic bedroom furniture. A living-room candy dish is stocked with Smarties. Smokers can step out back to gather around a patio table. Residents help prepare meals, clean the rooms and do laundry.
Oak Place client Phoebe Holmes, 40, said visiting the center is much different from being committed to a hospital psychiatric unit. In hospitals, the walls seem to close in, which compounds her anxiety, she said, and staff members tend to be formal and clinical.
“It’s like you’re a piece of furniture they walk by,” she said.
Holmes, who identified herself as a former longtime methamphetamine user, lives 40 miles away in Ottumwa, which is the largest town in the four-county region served by Oak Place. She visits the center about once every two months, and she calls the staff regularly. Sometimes the nurses listen to her recount successes she’s had in maintaining sobriety or in keeping contact with her three sons. Sometimes, she said, the nurses just listen to her cry.
“They’ve left a footprint on my heart,” she said.
Tim Stonehouse celebrated his 55th birthday at the Wednesday lunch with his fellow Oak Place clients. Stonehouse, who has bipolar disorder, credits the center’s staff with helping him stay on his medication and out of trouble. In the past, he said, he sometimes convinced himself he no longer needed the pills.
He would stop taking them, and then he would become manic. “I was a mad bull,” he said.
Stonehouse said he was referred to the center last year after he became enraged at his teenage son and tore up the boy’s room. He’s been coming back for informal visits ever since. “This is my cooling-off place,” he said.
Stonehouse smiled and joked throughout the recent lunch. He frequently touched fellow residents on the shoulder or hugged them. Such touching is not allowed in hospital psychiatric units, he said, as other residents nodded in agreement.
Relief for sheriff’s department
Sharp, the center’s director, said that when they arrive, more than half of clients either lack homes or are coming from volatile family situations to which they can’t safely return. The center helps them find alternative housing, and it can also help them find work.
She said when the project was proposed, some Centerville residents worried it would bring trouble to the quiet neighborhood surrounding the house.
“There were visions of homeless people hanging around, drugs, all those old stigmas,” she said.
But there have never been any serious fights or other major problems at the center, she said. Centerville Police Chief Tom Demry later confirmed her account.
Appanoose County Sheriff Gary Anderson said the center’s presence has brought dramatic relief to his department. His nine deputies used to spend vastly more time transporting patients to distant hospitals where they had been committed for psychiatric treatment. He noted that southeast Iowa’s shortage of open hospital beds has worsened in recent years, since the state shuttered its Mount Pleasant mental hospital and the Oskaloosa hospital closed its geriatric psychiatry unit.
Anderson ruefully recalled a day when one of his deputies was driving a mental-health patient to the hospital in Spencer, which is 275 miles to the northwest, near the South Dakota border. On the highway, that deputy passed another Appanoose County deputy who was bringing a patient back from Spencer to Centerville, which is less than 20 miles from Missouri.
Greg Milani, who is Appanoose County’s sole magistrate, signs most of the area’s mental-health commitment papers. He recalls many nights when he was repeatedly awakened to deal with mentally ill residents who needed to be sent to a facility because they weren’t safe at home. Since the Oak Place center opened, he frequently goes a week or longer without receiving such a call.
Milani still commits people to inpatient psychiatric units if they have severe delusions or if they are being physically aggressive toward others or are trying to harm themselves. But most people don’t need to be committed to a hospital for problems like depression, anxiety or family strife, he said. They can voluntarily go to the crisis center instead.
Before Oak Place opened, many psychiatric patients would return from faraway inpatient units with no solid arrangements made for follow-up care, Milani said. Their mental illnesses would spiral, and he’d soon be asked to commit them again.
That rarely happens with people who use the crisis center, because they’re encouraged to continue consulting with the nurses and therapists there, he said. “We usually don’t see them again.”
The sheriff and the magistrate expressed frustration that mentally ill residents could soon be placed back on the involuntary commitment merry-go-round because of a lack of money from other government agencies for Oak Place.
“My concern with this whole thing is they want to put a dollar amount on it, but it’s hard to put a value on what we’re seeing,” Milani said.
Snag on Medicaid payments
Oak Place’s financial problems have several causes. One is that a two-year, $243,500 startup grant from the organization that runs Centerville’s Mercy Medical Center has run out.
Another major problem is that Medicaid has yet to start covering any of the center’s services, as organizers had expected it would.
The Iowa Department of Human Services, which oversees Medicaid, also coordinates the state’s mental-health system. Department leaders have urged local officials to create innovative services to ease pressure on the state’s dwindling supply of inpatient psychiatric units. Such improvements were the focus of a major overhaul of Iowa’s mental-health system, starting in 2014, in which counties formed 14 regional authorities.
The counties were to pool property taxes, which had long been used to support mental-health services. But the system also was expected to gain a major infusion of Medicaid money, mostly from the federal government. That’s because thousands of Iowans with chronic mental-health issues became newly eligible for Medicaid in 2014 as part of the Affordable Care Act.
Department of Human Services spokeswoman Amy McCoy acknowledged that her agency has yet to write rules allowing Medicaid payments for mental-health crisis centers like Oak Place. McCoy said the department sees such centers as a key part of the new mental-health system, and it is working to set up payment procedures so Medicaid money could flow to them.
“There certainly is a desire to get that set up as quickly as possible,” she said. “Hopefully, we’ll have those in place in enough time for Oak Place to continue its operations.”
Iowa’s Medicaid program is being administered by three private management companies, which follow rules set by DHS. All three companies said last week they believe in the value of crisis-stabilization centers, and they would pay the centers for services if the state sets rules allowing it.
“These services meet critical member needs in local communities by providing people access to direct assistance as an alternative to more restrictive, higher-cost inpatient services,” a spokeswoman for Amerigroup wrote in an email to the Register. The other companies, UnitedHealthcare and AmeriHealth Caritas, took similar stances.
While potential Medicaid support remains snagged, the Centerville center faces imminent loss of its sole remaining source of money. That source is property tax revenue distributed by a four-county mental-health authority, the South Central Behavioral Health Region.
Facing the loss of its startup grant, Oak Place asked the regional authority for an increase in its monthly support, from $32,000 to $40,000, starting in July. The authority balked, and instead proposed splitting the crisis-stabilization program into three locations.
Sharp contends that’s impractical, because the main cost of Oak Place is having nurses there around the clock. It would be almost as expensive to run a two-bed center as it would be to run the current five-bed center, she said.
Smaller programs sought
Jerry Parker, a Wapello County supervisor who serves on the board of the regional mental-health authority, agrees with Oak Place supporters that the center provides a valuable service. But he doesn’t think the authority should have automatically approved an increase in support from $32,000 to $40,000 per month.
“As elected officials, we should say, ‘OK, that’s about a 25 percent increase. Let’s look at what other alternatives might be available,’” Parker said in an interview.
Parker said that on an average day, only two people from the four-county region are staying overnight at the Oak Place center. The regional authority decided to seek a new program, in which smaller crisis-stabilization programs would be set up in three counties, Appanoose, Mahaska and Wapello. They would have a total of seven beds, he said. They also would be encouraged to seek clients from outside the region, who could bring in more reimbursement, he said.
The Centerville agency running Oak Place is welcome to bid on the new proposal, he said. In the meantime, the regional authority is willing to continue paying the agency $32,000 per month to run Oak Place for 90 days, he said.
“Nobody is putting them out of business,” he said.
Sharp sees no practical way to split her small program into three pieces using the same amount of money. Unless the Medicaid billing issue is resolved quickly, she said, the center is likely to close at the end of October.
People who rely on Oak Place have been stunned to hear it could disappear soon.
“It was like a million bricks had just crumbled on top of me,” said Amber McLain, who credits the program with teaching her to cope with borderline personality disorder.
McLain, 26, has often been hospitalized, but didn’t accept her diagnosis until she started participating in the Centerville program.
“This place has helped so many people, and it’s a home for so many people who don’t have family,” she said. If it closes, she said, “a lot of people aren’t going to get the help they need. It’s absolutely devastating to even think about it.”