By Katie Kerwin McCrimmon

KEYSTONE — Medicaid patients who get access to “medical homes” are supposed to get better care and save taxpayers money, but so far, savings are minimal, prompting analysts to give Colorado a lower grade this year for delivering health care.

Policy experts at the Colorado Health Institute released their second edition of Reaching Our Peak: Scorecard for a Healthier Colorado today as the Colorado Health Symposium begins in Keystone.

Care coordinator Sarah Bryson helps patient Roger Mondragon in Fort Collins. Bryson visits the doctor with Mondragon, who has complex health problems. to keep him on track and out of the hospital.

Analysts evaluated policies and progress in five key areas: health care delivery, places we age, schools, workplaces and communities.

“The bottom line for Colorado: communities and schools improved, aging and the workplace stayed the same, and health care moved lower,” the study authors wrote.

Overall, the pace of reform is slow and progress is uneven.

“(That’s) in part because of the sheer size of the challenges, the reality of red tape, and the difficulty of getting everyone on the same page,” the report said.

The private sector and foundations have led the way as catalysts for improvement in health care while “the public sector often moves cautiously,” the authors found.

Source: Reaching Our Peak report from the Colorado Health Institute.

One of the areas of reform that has offered great hope — but so far is yielding little savings — is the medical home movement.

Little progress and minimal savings on health care delivery were what prompted the study authors to lower the grade this year over last.

Under the Affordable Care Act, Colorado has dramatically expanded its Medicaid population by about 30 percent to 1 million people this year.

More than half of Medicaid enrollees — about 612,000 — are part of an Accountable Care Collaborative, a program that aims to give patients better primary and preventive care, better disease management and help from care coordinators.

As the population of patients covered through the publicly funded program expands, scrutiny on Medicaid spending will increase, said lead author of the report, Sara Schmitt.

“We’re investing a lot on that (Accountable Care) model and the return has been relatively modest,” said Schmitt, director of community health policy for the Colorado Health Institute.

For example, in the 2012-13 fiscal year, Colorado saved $6 million for people who were enrolled in the Accountable Care Collaborative. But that’s a very small portion of the overall $7.5 billion budget for Colorado’s Medicaid department. And administrative costs for the program totaled more than $36 million.

The Reaching Our Peak report found that people with chronic conditions had lower rates of complications than those who weren’t in the collaborative. And while ER use increased among patients with medical homes, it went up less than for other patients. Overall, small improvements in cost and outcomes are beginning to emerge, the report found.

“Medical homes have been promoted — particularly among children — since late 2007,” Schmitt said. “Studies continue to show mixed results. We need to keep understanding the ways that homes can improve quality and control costs.”

A new report from the Colorado Health Institute rates policies and progress in five key areas: health care delivery, places we age, schools, workplaces and communities. Photo courtesy Brian Clark – Colorado health Institute.

Colorado Medicaid managers say the Accountable Care Collaborative should pay off over the long term and that the program offers local communities and providers incentives to improve care and patient outcomes.

“The ACC has exceeded our expectations through the first three yeas and preliminary data from fiscal year 2013-14 looks strong,” Marc Williams, spokesman for Colorado’s Medicaid program said.

Two years ago, he said the program resulted in a net savings of $3 million and last year the savings doubled to $6 million.

“We expect to see continued savings in future years as the program evolves and achieves greater integration and coordination of medical and non-medical services,” Williams said.

Beyond medical homes, Schmitt of the Colorado Health Institute, said the outlook is better. She cited increased use of Health Impact Assessments and greater access to fresh fruits and vegetables.

“We really saw growth in these areas,” Schmitt said.

With respect to schools and health, results are mixed. Studies show that higher taxes on sugar-sweetened beverages could cut consumption of the drinks that contribute most to obesity. But it’s clear that people in Coloradans have little appetite for additional taxes, and attempts in Colorado and elsewhere around the country to heavily tax soft drinks have failed.

Students in Greeley learn about the sugar content in various drinks. Photo courtesy Brian Clark – Colorado Health Institute.

In terms of healthy eating, the new “Breakfast After the Bell” program will kick off this year, and Schmitt said more kids will have access to nutritious meals through an expanded school lunch program.

On aging, Colorado is expecting a “silver tsunami” and it’s clear that more seniors will need support as they age.

“Change is happening and progress has occurred. It’s just really slow,” Schmitt said.

A program called Colorado Choice Transitions is supposed to help move Medicaid patients from nursing homes to community-based centers. Colorado received a $22 million federal grant in 2011, but managers didn’t begin transitioning people until March of 2013. In the first 10 months of the program, Colorado moved 35 people from nursing facilities to the community.

“This program is far from its goal of moving 500 Medicaid enrollees to community-based housing by the end of the five-year grant in 2016,” the report found.

Schmitt said demand is already great for better aging options. But few centers exist so far.

Finally, wellness programs are popular in workplaces, but it’s not clear yet whether employees will take part or whether they’ll get healthier if they do.

“We just haven’t seen anything really illuminating taking hold yet,” Schmitt said. “Interest is high among employers for wellness programs. (But) the evidence base is not really emerging to show huge savings.”

It’s clear, said Schmitt, that change takes time.

“Overall I feel very positive about the direction in which we’re heading,” she said. “The business community really is focused on health and seeing that as an economic advantage for the state. We’re starting to see tracks in place that could have long-terms impacts.”

By Katie Kerwin McCrimmon

WHEAT RIDGE — Newly insured patients are pouring into Colorado’s safety net clinics, but in some cases, sparkling new exam space sits empty because there aren’t enough doctors to care for the influx of patients.

The Metro Community Provider Network (MCPN) this month celebrated its first anniversary at a large new state-of-the-art clinic in Wheat Ridge, the newest of its 22 locations in the Denver area. One pod is ready to serve older patients and those with mobility issues. Extra wide “barn” doors allow easy access for people in wheelchairs and there’s a special spot to park walkers and other devices for people with special needs.

Daniel SanJuan Ramirez, 11, and his brother, Erick, 3, visited a new Metro Community Provider Network clinic in Wheat Ridge on Tuesday.

Plenty of patients would be eager to get care here. There’s good bus service and easy access from Interstate 70. But the space remains empty.

For over a year, MCPN has been advertising for a geriatrician or an internal medicine doctor to oversee patients. Without one, CEO Dave Myers can’t open the space and so far, the response has been disheartening.

“Not even any nibbles,” Myers said, when asked if anyone has applied.

“We have been recruiting like mad. This building is part of a strategy for the entire western suburbs to create capacity and also to create a place where people want to come. This is a place I’d like to come,” he said of the airy, modern design, which is bathed in natural light.

Dave Myers, CEO of the Metro Community Provider Network, one of Colorado’s 18 Community Health Centers, shows off space at a new Wheat Ridge Clinic. Hiring doctors has been so tough that Myers has not been able to open all the “pods” in the building.

Colorado’s 18 Community Health Centers, which operate 167 clinics around the state, are thrilled that many of their previously uninsured patients now have Medicaid. For some, the majority of their patients used to be uninsured. Now that mix is shifting with more than half of patients covered through Medicaid. Colorado is one of the states that has expanded Medicaid and more than 160,000 newly eligible patients have gotten Medicaid coverage this year. The Community Health Centers operate in underserved areas across the state and care for one in 10 Coloradans and one in four Medicaid patients.

In the San Luis Valley, new access to public health insurance has been a financial lifesaver for a network of clinics there.

“The Medicaid expansion has been a blast of oxygen for Valley-Wide,” said Gigi Darricades, CEO of Valley-Wide Health Systems, which operates 12 primary care and seven dental clinics throughout southern Colorado. “It’s been a very emotional time. We’ve had patients in tears. It’s the first time they can get the health care they need.”

While patients can get care and Darricades can better pay her bills since more have insurance, she’s still struggling to find providers to care for all the patients.

“We employ 38 providers and are looking for four more,” Darricades said.

Attracting providers to rural Colorado is tough. Luring spouses or partners can be even tougher. And the salaries that providers want are loftier than ever since demand for doctors is so great.

The jump in patients who now have both private and public insurance is accelerating provider shortages around the state.

While the problem of too few doctors has long plagued rural Colorado, clinics in the Denver area are struggling now too. According to a 2013 study from the Colorado Health Institute, Colorado currently has 3,332 primary care physicians. The average age is 55 and many expect to retire within the next 10 years. (Click here to read Doctor shortages profound for Plains, Medicaid patients.)

The Metro Community Provider Network serves patients in suburbs on the western, eastern and southern borders of Denver. Today MCPN employs enough providers to cover 40 full-time positions, but the long-anticipated dearth of doctors has hit hard.

“We have the capacity to add another 40 FTE…but there just are not enough providers coming out to meet the demand. It’s an important issue for us in meeting the need for our patients,” said Myers of MCPN.

In northern Colorado at Sunrise Community Health, the story is much the same with spikes in patient loads, new clinics under construction and worries about tapping enough doctors and mid-level nurses. In 2013, Sunrise cared for nearly 35,000 patients, more than triple the number that Sunrise served in 2000. The patient load that year was about 11,000.

“We have built new buildings each year…We are ready to accept new patients. We are poised to add 30 to 35 new FTE. We just opened our new Loveland Community Health Center,” said Mitzi Moran, Sunrise’s CEO.

Moran oversees nine clinics in Greeley, Evans and Loveland.

Community Health Center managers say they attract medical providers who have a “Peace Corps” mindset and who are attracted to the mission of caring for people in underserved communities. Many patients live in poverty and have complex health problems.

“For many, it’s ‘Do I pay the rent this month? Do I buy food?’ ” Moran said.

Those with diabetes may skip their medication or a visit to the doctor to buy other necessities instead.

“Then their diabetes gets out of control. It’s difficult to serve that population. You can’t just say, here’s a scrip,” Moran said. “It’s difficult serving people who are really ill, but it’s so rewarding.

“There is something unique about being in a safety net (system). You are serving people who, in many cases, have nowhere else to go. That appeals to a certain type of provider.”

In order to attract doctors and other providers, Moran and Myers said that rather than hiking salaries, they are trying to give providers what they want: more support staff and the hours they want.

“We want a competitive, fair salary. We try to offer a work/life balance,” Moran said. “As clinicians on our team, they get to be clinicians. They don’t have to run a business. All their energy can go toward patient care.”

For the moment, directors at clinics around the state say patients are able to get appointments if they need them.

In the past, some Community Health Centers have had waiting lists. Myers of MCPN said his clinics have plenty of spots for children and pregnant women.

“We can take all comers,” he said.

For adults who need care right away, MCPN has an adult walk-in center in Aurora and plans to open one in Wheat Ridge. The walk-in clinic is open until 8 p.m. on weekdays and from 9 a.m. to 5 p.m. on Saturdays. Patients might have to wait hours to be seen, but they can get same-day care.

At Sunrise, since the system has recently added providers, there are no waiting lists.

“Right now, we can see you,” Moran said. “Twelve months from now, if I don’t have another pod, maybe not.”

Moran said she’s managing to keep up with patient demand, but just barely.

In northwestern Colorado, the Northwest Colorado Visiting Nurse Association has just opened a new Steamboat clinic that doubled its capacity, said Lisa Brown CEO of the VNA.

In the San Luis Valley, a “Convenient Care Clinic” is open seven days a week until 7 p.m. Patients can get same-day service there. Those who need to see their primary care provider might have to wait three weeks or so to do that, said Darricades, CEO of Valley-Wide.

In this new era, as health reform takes hold, some patients are overjoyed, some safety net providers are overwhelmed, doctors are in great demand and managers are grateful for Medicaid.

“We don’t have to go into debt to make payroll this week. That’s a huge relief,” Darricades said. “Our model of care is expensive because we have so many sites.”

She’s hoping Valley-Wide can keep its remote locations open.

“It’s important. Otherwise people are going to end up in the hospital.”

For Moran of Sunrise Community Health, these are exciting times, but challenging too.

She said patients are “grateful and confused.”

Juan Gomez, 23, is a farm worker who recently earned his master’s in public health and serves on Sunrise’s board, where he has been a patient since 2000.

Gomez said people in his community don’t really understand health reform.

“They have been struggling a lot. They don’t know the system,” he said. “People don’t know how to start, who to talk to to get enrolled.”

Added Moran: “Just because someone becomes insured, that doesn’t mean other issues go away. Yes, (insurance) is helpful, but it doesn’t solve poverty.”

By Sharon Adams

Colorado recently submitted a revised State Health Innovation Plan to the federal government. It’s an enhancement of the original plan submitted in 2012. The Innovation Center at the Centers for Medicare and Medicaid Services is providing grant money to states with fully developed, promising plans aimed at improving health and lowering costs. The next step is for Colorado health leaders to submit proposals by next month so we can fund our plan and put it into action.

So what’s in the plan exactly? It’s hard to sum up 217 pages, but in a nutshell, the plan hinges upon first developing integrated behavioral and physical health care systems rooted in primary care medical homes. To do this, we’ll need to adapt the way we deliver care so we identify and address mental and behavioral health issues at the same time we’re seeing people for an annual exam or common cold. Since our current reimbursement structure doesn’t support this model, we’ll need to simultaneously change how we pay for care so that clinics serving as medical homes can afford this integrated approach.

The reality is that many Community Safety Net Clinics (CSNCs) are already working towards integrating behavioral health because they understand the value it brings to their patients. A few, like Marillac Clinic in Grand Junction, have been modeling this for years.

About one in four visits at Marillac are team-based meaning that both a primary care provider and a behavioral health provider see the patient simultaneously, addressing the whole person at once. Marillac has found that moving to this truly integrated model of care, rather than merely co-locating behavioral health providers in the same facility, makes each visit more effective and efficient for providers. More importantly, patients benefit immensely because underlying issues are addressed that may be manifesting in acute illnesses or exacerbating chronic disease conditions.

Marillac doesn’t get paid to provide behavioral health services but they have made it a care delivery priority. They provide behavioral health services through their general operating funds — a combination of Medicaid reimbursements, patient sliding fee payments, grants, donations and in-kind support. And while it hasn’t always been easy, they have been fortunate enough to be able to find good behavioral health providers who are a fit for their team. Many other clinics have a difficult time just finding behavioral health specialists, and an even harder time finding licensed and credentialed providers reimbursable under Medicaid. That coupled with the fact that many CSNCs need Spanish-speaking behavioral health providers makes it even more challenging.

Because of these current payment barriers and provider shortages, Colorado has yet to see widespread integration of physical and behavioral health services. Simply beginning to pay for integration won’t cover the significant up-front costs and challenges of hiring staff in order to change the way clinics do business. Providing important behavioral health assessments and services when needed will require, among other things, updating Electronic Health Records, hiring and training staff and modifying patient flow.

Despite the challenges of implementing our SIM plan, the potential rewards for patients, families and our health care system are exciting. Many stakeholders, including ClinicNET and representatives from a wide variety of health care provider groups and communities were involved in informing and developing Colorado’s plan. I’m hopeful that these same thought leaders combined with the determination of CSNCs and providers statewide to deliver integrated physical and behavioral healthcare in a medical home will anticipate and overcome inherent challenges and put this plan into action for the improved health and wellbeing of all Coloradans.  www.coloradosim.org

Sharon Adams is the Executive Director of ClinicNET, which works to ensure that Colorado’s vulnerable populations get affordable, high-quality care from safety net clinics.

By Kristin Jones

Rocky Mountain PBS I-News

Gov. John Hickenlooper signed a bill Friday morning that bans the practice of keeping seriously mentally ill prisoners in solitary confinement.

The bill, which passed with strong bi-partisan support, won the support of advocates and rights groups like the American Civil Liberties Union, who say the isolation of prisoners with mental illness violates the constitution’s ban on cruel and unusual punishment and endangers public safety.

Erin Hedden’s hands are cuffed and chained to a waist belt during an interview at Pueblo County, Colo., jail on April 4, 2014. Hedden said she has bipolar disorder and used crystal methamphetamine to self medicate after she lost her insurance and couldn’t afford medication to treat her illness. She’s serving a four-year jail sentence after she crashed her car while driving on drugs, killing a 69-year-old woman. (Joe Mahoney/Rocky Mountain PBS I-News)

But as Rocky Mountain PBS I-News has reported, state prisons aren’t the only place in Colorado where offenders with mental illness are subject to lengthy periods of solitary confinement. In the state’s county jails, solitary confinement – or administrative segregation – remains common for inmates with serious mental illness. The isolation can last days, months, or even years.

In jails, this practice is left intact by the latest state law.

The new legislation came on the heels of a series of tragedies in Colorado, including the killing last year of prisons chief Tom Clements by a man who had been released directly from long-term solitary confinement into the community. In an irony often noted, Clements had worked to reduce the use of administrative segregation in state prisons.

The current corrections chief, Rick Raemisch, has continued the work that his predecessor started, publicly calling for a rethinking of the practice of solitary confinement in general, and pledging to remove seriously mentally ill inmates from isolation in the state prisons.

His concerns were echoed by Colorado legislators who worried about the damaging effects of solitary confinement on mental health, and the risks to the public from prisoners who will someday be released.

The law now etches some of Raemisch’s policies in stone, and adds funding and a level of oversight. Prisoners with mental illness won’t be kept in confinement for longer than 30 days, and will be guaranteed a period of therapeutic activity and out-of-cell time each week.

The Colorado chapter of the ACLU took the lead in campaigning against the isolation of mentally ill prisoners. Denise Maes, the organization’s public policy director, told I-News the law signed today “makes a very important policy statement that it’s wrong to place seriously mentally ill offenders in solitary confinement.”

Now, Maes said, the ACLU-Colorado intends to turn its attention to the isolation of mentally ill inmates in county jails. But she acknowledged that a policy change there may be a heavier lift.

“Municipal jails are just a hodgepodge of different activities not very well regulated by the state,” said Maes. At the same time, a shortage of psychiatric beds and a lack of funding for alternative mental-health treatment put a huge burden on jails, she said. Resources are thin.

Still, said Maes, the same arguments that changed the policies in the state prisons also apply to jails.

“Keeping a seriously mentally ill offender in solitary confinement is unconstitutional, and at some point the state has to have the resources to deal with it. Otherwise, they’ll be faced with it in court,” said Maes. “Communities have to find the resources.”

Contact Kristin Jones at kristinjones@rmpbs.org.

By Kristin Jones

Rocky Mountain PBS I-News

Danielle Nordeen drives a 16-year-old Toyota Camry that doesn’t handle well on snowy mountain passes. In January, Nordeen had to make the drive from her home in Grand Junction to Pueblo often enough that she developed a strategy: Find a semi with its hazard lights on and follow it closely, prompting the other drivers to direct their wrath toward the trucker rather than her.

A 300-mile solo drive across the state in winter can be stressful under the best circumstances, but Nordeen’s reason for making the drive twice a week for three weeks was devastating: She was visiting her son in a psychiatric ward, after he lashed out at school and later threatened to kill himself and staff at a crisis-stabilization center.

Her son is 7.

Across the state, the same story plays out. A shortage of treatment options for people with mental illnesses means waiting months to see a psychiatrist, or driving hundreds of miles for a psychiatric bed. Police and emergency rooms bear the brunt of a splintered system that juggles crises, but falls short on treatment.

The questions that swirled after the brutal massacre at an Aurora movie theater in 2012 are the same ones that followed Jared Loughner’s attack on Gabriel Giffords and her staff in 2011. They came even louder after the elementary school killings in Connecticut. They circulate privately after suicides. The signs of mental illness and the threats were apparent: Why didn’t anyone intervene?

Medical professionals and advocates cite a combination of barriers: Adults have the right to refuse intervention. Parents are often reluctant to call 911 when it can mean that their children are cuffed by police. Schools, employers and hospitals are too quick to say it’s not their problem. Acquaintances and friends feel ill-equipped to act.

“We regularly hear people say things like, ‘I knew something was wrong, but I didn’t know what to do,’ ” says Carl Clark, who heads the Mental Health Center of Denver, which counsels workplaces after suicides.

In response to the mass shooting in Aurora, the state recently passed a law that expands the duty of therapists to warn of threats against an institution like a school or theater, not just against a person. A plan for new crisis centers in Colorado — while stalled — is intended to relieve the burden on first responders.

Legal improvements, better education and increased capacity “don’t guarantee that bad things won’t happen,” says Clark. “But we’re going to decrease the likelihood it’s going to happen.”

Routine care can also be hard to come by, particularly in rural areas where psychiatrist shortages are acute.

“There are people saying there’s something going wrong and I have to get treatment,” says Clark. When treatment isn’t immediately available, “they throw up their hands and give up.”

For some people who live with mental illnesses and their families, efforts to make intervention easier can miss the point. They want help, they say. What they need is more support for treatment and recovery in the communities where they live.

Jennifer Hill, who manages a mental-health advocacy organization called the Colorado Mental Wellness Network and has personal experience with recovering from illness, says that recovery is stymied by a system that can seem to offer lock-up or nothing.

“You’re in or you’re out,” Hill says.

Better treatment requires more than an infusion of resources and improved access, says Hill. People won’t sign up for treatment that isn’t therapeutic.

“It’s treating people with dignity and respect,” says Hill, “and not treating them like they’re dangerous and horrible people.”

No shelter

The other second-graders have watched the police take Danielle Nordeen’s son away in handcuffs.

The latest crisis was set off when one of the other children reminded him of that very fact. The 7-year-old tore posters from the wall, kicked and hit the teachers, flooded the toilets. The Grand Junction elementary school went on lockdown.

Nordeen showed up to find her boy rolling around in dirty water in the bathroom.

Danielle Nordeen plays a board game with her son at their Grand Junction home. (Joe Mahoney/Rocky Mountain PBS I-News)

When a local crisis center placed him on an emergency psychiatric hold for his threats, only Parkview Hospital in Pueblo had a bed available. Nordeen works a low-wage job in Grand Junction, and had to return to work after leaving him there, or risk losing her apartment.

“I literally just felt like I was dropping him off and walking away,” says Nordeen, holding back tears, “which as a mom, that’s the hardest thing I’ve ever had to do.”

The number of people placed into involuntary mental-health treatment has jumped in recent years. Court filings show a 35 percent jump in 72-hour holds, short- and long-term certifications, and other court-ordered treatment between fiscal years 2009 and 2013. Mental health providers reported 31,317 emergency mental-health holds in fiscal year 2013, according to state officials, a 21 percent increase from just a year earlier.

But the growing demand for beds hasn’t been met by an increase in availability. Instead, the options for low-income Coloradans in particular have shrunk as beds at the two state psychiatric hospitals have closed. In 2014, the state mental health institutes at Fort Logan and Pueblo have 553 beds, down from 734 in 2000.

All told, there are only 1,093 inpatient psychiatric beds in all hospitals around the state, according to the state Department of Human Services, around 20 percent fewer than five years ago. That’s about 21 beds for every 100,000 Coloradans, among the worst rates in the U.S.

The state is in the process of evaluating what services might be lacking across its various regions. In part, says Dr. Patrick Fox, an official with human services, the hope is that private-sector psychiatric hospitals will meet some of the need. He gave the example of Clear View Behavioral Health, which broke ground in April on a 92-bed hospital east of Loveland expected to open in 2015.

For now, hospital administrators and family members describe large geographic swaths of scarcity. In Grand Junction, West Springs Hospital is the only psychiatric hospital between Salt Lake City and Denver. The hospital, which has 32 beds, opened in 2005, at the same time as neighboring St. Mary’s Hospital closed its inpatient psychiatric beds.

Like other private-sector hospitals across the state, St. Mary’s found that providing psychiatric services on top of other medical services was too costly. Even after closing its psychiatric department, the hospital absorbs about $300,000 in unreimbursed expenses each year related to providing mental-health services, says Dan Prinster, the hospital’s vice president for business development.

Now, West Springs finds that it’s often filled to capacity, and has to turn people away. Kim Boe, the hospital’s vice president, says the wait list generally hovers between six and eight people each day.

Another trauma

The vast majority of people with mental illnesses are not violent, but those who are receive more than their fair share of headlines and news broadcasts. The rate of violence among people with severe mental illnesses ranges from 8 percent for those receiving outpatient treatment to 37 percent among patients in the throes of their first episode of psychosis, according to a research review by Jeffrey Swanson, a Duke University psychiatry professor whose work on the issue is widely cited.

Suicide has a much closer tie with mental illness. More than 90 percent of those who take their own lives have depression or another mental disorder, or a substance abuse issue, according to one epidemiological study cited by the National Institute of Mental Health.

Much of the demand for psychiatric beds comes from people who pose a danger to themselves. The scarcity can make an already precarious situation even more traumatizing.

Grand Junction resident Rebecca Edwards has had a long history of mental illness, including depression, and has been through the whole gamut of available care. After she was administered electro-convulsive therapy a few years ago at Porter Hospital, she didn’t recognize the symptoms of a stroke that permanently affected her speech. She thought she was experiencing the side effects of shock therapy.

Edwards says she’s grateful for the mental health treatment that has allowed her to live in the community, supported by her peers. But when the stress of moving to an assisted-living situation in July sent her into a deep depression, she needed more intensive treatment.

What she got instead was a disorienting ride across the mountains with strangers in the middle of the night. Placed in an involuntary mental-health hold because she was suicidal, Edwards was handcuffed. She landed at a hospital in Colorado Springs.

“I felt very afraid, very alone,” says Edwards. “When you get taken away from that support, it’s hard to deal with. It made me feel a lot more hopeless, like I was alone in my struggle with depression.”

Boarding in the emergency room

If people at the receiving end of flawed mental-health services feel frustrated, it’s a feeling often shared by those at the giving end.

Matt Skwiot is an emergency room doctor at Grand River Hospital in Rifle, an oil and gas town between Glenwood Springs and Grand Junction with a population of under 10,000. He sees workers injured by explosions, car accident victims, elderly people with broken hips

And like other ERs, this one has become a holding pen for people in a psychiatric crisis.

About once a week at Grand River Hospital, there’s just no psychiatric facility available to take a patient. So a room in the ER is cleared of equipment with cords and other tools that could be used in a suicide attempt. Security is called, and a camera is monitored.

For as long as three days, the patients are kept alone in the room. None sees a psychiatrist, says Skwiot. And then, once they’re stable, they’re sent home.

“You’re trying to provide a safe place, you’re trying to provide the best care that you can,” says Skwiot. But ER doctors don’t have the training or skills to give people the therapy and other support they need.

“If it was me locked up in this room for 72 hours, with minimal interaction, minimal stimulation, I’m already depressed and suicidal, that seems like it … would make things worse,” Skwiot says.

Before the violence                      

On a sunny Monday in April two months after he came back from the hospital in Pueblo, Nordeen was playing with her son at a park behind their home. The gap-toothed kid was affectionate and energetic, alternately asking for and receiving hugs from his mom, and shouting captain’s orders in a game of pirates.

Things were calm and happy. But Nordeen felt like the family was in a holding pattern. Her son was out of school, with a psychiatrist’s note saying that school’s stresses would be too much for him. Nordeen was apprehensive about sending him back, and worried about the future.

“What’s scary,” says Nordeen, “is that who’s to say he’s not going to be one of those kids that follows through on his threats?”

Echoing complaints of people in similar situations, she says she can’t find the support she needs.

“I almost feel like I’ve exhausted every option in Grand Junction,” says Nordeen. “Because there’s not a lot of options available.”

Community-based mental health treatment and support is chronically underfunded, mental health advocates say. An analysis by Rocky Mountain PBS I-News found that overall funding for mental health in the state hasn’t kept up with inflation since the 1980s. A well-intentioned push to remove people from institutionalized care led to the closing of state psychiatric hospitals beds, but equal attention was never given to building a replacement.

As a result, community mental health services continue to defer to first responders and emergency services when the threat of violence looms.

In Colorado Springs, the mother of Anthony Martinez says she has struggled for years to help her son get adequate treatment for schizophrenia. When he’s stable, Martinez, 34, is good-natured and loving. When he’s not, he can be violent. He’s been in and out of the state hospital in Pueblo, and sometimes jail, for years.

In August, Martinez was released from the state psychiatric hospital to live with his mother, along with his sister, her husband and their two young children. The family was told that no other place — including group homes — would take him.

Dan Drayer, spokesman for the state Department of Human Services, said he couldn’t discuss a patient’s case. He said that Martinez was not available for an interview.

In November, the family called 911 after Martinez threatened a family friend. When he returned home, they consulted with a community mental health center, expressing fears about their safety.

They were told to call the police again if they felt unsafe.

By January, Martinez was holding a large kitchen knife up to his mother’s face, threatening to kill her. With coaxing, Martinez laid down his knife, and was taken back to the state hospital.

The experience left Martinez’s mother, Patty Blakney, shaken and angry that her son had been discharged from the hospital while he was still unstable.

“I’m scared to have him living with me,” she says. “I’m not saying cage him. But what would help us would be a place where he’s going to live, where he’s not going to hurt someone, where they’re making sure he’s on his medication.”

They haven’t found it yet.

Health News Colorado brings you this report in partnership with Rocky Mountain PBS I-News. Learn more at rmpbs.org/news. Contract Kristin Jones at kristinjones@rmpbs.org.