Most people who walk in the door of a small, brick building labeled "24/7 Crisis Center" are depressed, suicidal, or experiencing audio or visual hallucinations. Others are young adults going through the first breakup of their lives, feeling so distraught they want to talk to a therapist.
Every crisis is "self-defined," and Colorado's 12 walk-in centers have had almost 68,000 visits since they opened four years ago.
The centers — along with a statewide crisis hotline, mobile crisis teams and five-day stabilization clinics — were created in response to the 2012 Aurora theater shooting, a mass murder committed by a University of Colorado graduate student who, according to his attorneys, was "in the throes of a psychotic episode."
Now, four years after Colorado's $33 million mental health crisis system was set up, it will undergo radical change, The Colorado Sun reports.
State officials, who are seeking new contractors to oversee the system, say an overhaul is needed to improve mobile-crisis response, incorporate local mental health services that already exist and, more broadly, put separate people in charge of financial and clinical decisions.
"We see this as an evolution to the crisis system," said Dr. Robert Werthwein, director of the state Office of Behavioral Health.
But for those who manage the current system, the overhaul is an affront to their progress. There are now four contractors that manage four mental health crisis regions, and none of them bid on the new contract. The new system will transform the four regions into seven, in part to align with the state's Medicaid government insurance regions. It will break up the metro-area region into three regions.
Each of the seven could have its own contractor, or one agency could oversee all seven, under the rules.
The current contractors — which are coalitions formed by groups of local mental health centers — are accusing the state of tearing up the process instead of simply tweaking what is flawed. They filed a formal appeal to the state, which was rejected, and planned to appeal in Denver District Court.
Meanwhile, responses to the state's request for proposals were due the week of Nov. 4, and state officials hope to have new contractors by the end of the year.
"You are not going to have statewide crisis services," said Rick Doucet, CEO of the Community Reach Center, which runs a walk-in crisis center, a five-day stabilization center, a mobile-response unit and a respite center in the north Denver suburbs. "You are going to have probably a hodgepodge of services offered across the state. There won't be much in the way of integration or communication and it definitely is going to damage the metro area."
Colorado Crisis Connection, the contractor for the Denver metro region, was created by six mental health centers, including the Mental Health Center of Denver and Community Reach Center.
The agency, which holds the state contract, subcontracts to its own mental health centers to provide crisis care. Many of the mental health centers, including Community Reach Center, increased their services to provide mobile response teams and walk-in clinics four years ago.
The legislation that created Colorado's crisis system also created a new source of funding for mental health centers willing to expand their services to fit the requirements of the law. The system received a boost in 2017 with legislation that made it illegal for Colorado to lock people in jail on mental health holds if they had not committed a crime.
"That was a pot of money that allowed us to expand," said Doucet, noting that the state funding has helped fund crisis services for people who had no insurance or were underinsured.
Under the new plan, developed by the state Office of Behavioral Health, the contractor will hire a variety of mental health providers in a region, including some that already exist and others that might open. In Douglas County, for example, a mobile-crisis unit that already exists could receive state funding to become part of the crisis system.
It removes the conflict of interest that exists in allowing coalitions of mental health centers to make decisions on how to spend state money at the same time they are making decisions about what is the best for patients, Werthwein said.
Werthwein said the state "has to take some ownership" for the system's flaws because the rules weren't specific enough. He is particularly disappointed with the network of mobile crisis teams, which two-thirds of the time have responded not to a home, dorm room or workplace as intended, but to emergency departments and mental health centers, according to state data.
State officials also were distressed about the findings of a sample analysis of calls to the hotline. In several instances, the hotline dispatcher wanted mobile teams to respond, yet the teams chose not to go out on the call. "That's a problem when two behavioral health entities are conflicting on whether they need to go out," Werthwein said.
Doucet, however, said state officials should allow mental health providers who know the community to make decisions about when to respond. They get to know frequent callers and know whether a mobile unit might escalate the situation, for example.
He also took issue with the implication that mental health providers cannot properly manage spending and patient welfare at the same time. For decades, they have served state Medicaid clients.
The crisis system, billed as revolutionary and Colorado's first statewide network for mental crisis help, now has 107 beds where patients can stay up to five days, 12 walk-in centers and a handful of respite care centers where people can voluntarily check in for 14 days.
The system, though, lacks accountability and "has not been managed well" to make sure its contractors are in compliance, according to an independent review that noted that the state Office of Behavioral Health has only two employees responsible for the system.
The review also suggested the state align its crisis regions with its Medicaid regions, since Medicaid is one of the largest insurance payers for mental health services in the state. The shift would reduce duplication, including in billing, and could improve data collection.
The state and current contractors also are battling over administrative costs.
The current contractors say they have kept overhead expenses to under 10 percent and contend that breaking the four crisis regions into seven will mean more overhead. The state's request for proposals said the new contractors cannot spend more than 25 percent on administrative costs.
The current contractors and the state also are at odds over the allocation of funds to each region. The state claims the remodeled system will dispense funds more evenly, tying regional allocations to population. Contractors, though, said rural areas will get the short end of the deal.