A landmark law passed by the Kansas Legislature could play a pivotal role in helping shore up the state’s long overburdened and underfunded mental health system by helping mental health centers expand and improve their services. Combined with local coordination in places such as Sedgwick County, the new approach could benefit taxpayers and improve the quality of life for thousands of Kansans. But the road to mending Kansas’ mental health system will be a long one, and victory is not assured.
For nearly seven years in the 2010s, following a 14-year career as a journalist at The Kansas City Star, I worked as a mental health advocate, helping people with serious mental illnesses promote policies to improve the services they receive – and their lives. Their stories fueled that advocacy.
They spoke about suicide attempts, time spent in state-run mental health facilities, in jails, and on the streets. There were stories about their recovery, about the support they received, about what helped them live with their mental illness, about what worked and what didn’t.
They bravely told these stories to the media, to service organizations and to neighborhood groups. But their aim, always, was to reach legislators in Topeka with a singular message: Our behavioral health system needs your help. It needs money to fund services that will help people with serious mental illnesses stay out of state hospitals, jails and emergency rooms. The legislators listened, but as a body they failed year after year to give the system the surge of adrenalin it so desperately needed.
Then last year, five years after I’d left my job as an advocate, that surge finally arrived. On nearly unanimous, bipartisan votes in the House and Senate, Kansas lawmakers approved legislation designed to help mental health centers expand and improve the services they deliver to adults with serious and persistent mental illnesses and children with serious emotional disturbances.
The new law creates a process by which the mental health centers can become Certified Community Behavioral Health Centers or CCBHCs, establishing a lengthy list of qualifications for them to meet.
Most important, it changes how mental health centers are reimbursed, making it possible for them to receive Medicaid dollars that reflect the true cost of their services.
To those who worked in the trenches of mental health advocacy much longer than I ever did, and to the legislators who fought for their cause, this was a major policy victory. Rep. Brenda Landwehr, a Republican from Wichita, said as much at a signing ceremony last year with Democratic Gov. Laura Kelly, calling it “the biggest change in mental health in Kansas in 30 years.”
And to some longtime consumers of mental health, it brings hope that a system they’ve often struggled to navigate will deliver the help they need. This includes people like Shannon Littlejohn, whose husband, Jess, lives with bipolar disorder.
“Thank goodness that people are looking at this, that our Legislature is looking at this,” says Shannon Littlejohn, who works as a contract copy editor for The Journal.
This article will be the first time Shannon and Jess have shared their story publicly. The Journal doesn’t typically use its own staff as sources, but decided to do so in this case because their experience sheds light on the strains within the system and because of the importance of building public understanding of how a functioning mental health system is needed to serve the Kansans we live, work and socialize with every day. If the mental health system affects our colleagues here at The Journal, it is quite likely to affect your family or friends as well.
The Littlejohns, together, hope that their stories, along with others, can help inform how that system performs.
“I think we’re desperate for it,” Shannon says of the legislative remedy “Our homeless population is so hard up, and low-income people too. I think those CCBHCs will help that. I see great hope in that.”
‘I Can’t Imagine Being Them’
About 10 years ago, Shannon recognized that her husband of 30 years needed help. Jess had begun to spend money the Wichita couple had tucked away for emergencies. He impulsively bought a car, a purchase that Shannon says they would normally have discussed first. A quiet man, he became excessively talkative. He would go shopping and come home with hats he didn’t need. Shannon eventually took her husband to what is now known as Ascension Via Christi St. Joseph, a hospital in south Wichita, where a psychiatrist diagnosed him with bipolar disorder.
This emerging manic phase didn’t alarm Jess. “It was very much, ‘I am in charge and I can do anything,’” Jess recalls. “I was having the time of my life. I was really having a good time. That doesn’t mean Shannon was.”
Eventually, Shannon’s worries prevailed, and Jess agreed to get help. For a time, he received outpatient services at Sedgwick County’s Comcare mental health center. Both Jess and Shannon say they were mostly pleased with the help received there, as well as at
St. Joseph and Osawatomie State Hospital, where Jess was admitted a number of times up through 2013. But Shannon, at least, also could see that the system they were depending on was under tremendous strain.
Periodically, that strain manifested itself in substandard care. There was a time when Jess returned from Osawatomie in a semicatatonic state after receiving an antipsychotic medicine, which Shannon suspects was administered in order to discharge him, not to provide therapy. (Jess believes the medication was necessary to initially bring him down from his mania.)
There were times when Jess would become anxious at the sight of others leaving Comcare to be transported from Wichita to Osawatomie, a practice he found disturbing and retraumatizing. And there was the time a decade ago when Shannon arrived at Comcare to pick up her husband only to be told that he’d asked to leave on his own. He wanted to catch a bus, the staff told her. She found him, 15 panicked minutes later, walking along McLean Boulevard.
“I just flipped out,” Shannon recalls. She’d asked the staff to not let him leave on his own. “But he talked a good game and probably seemed like he could get on the bus, so I don’t fault them too much.” Nevertheless, it was her first glimpse at a system that she suspected was taking on more than it could handle. “You did get the sense that they were overworked,” she says. “I can’t imagine being them. It’s a difficult job.”
And it remains difficult. Joan Tammany, Comcare’s executive director since 2017, says that nearly 38% of the center’s 561 positions remain vacant. The shortage is driven largely by Comcare’s inability to pay wages that compete with states such as Oklahoma, which has lured away some of Tammany’s staff, or other Wichita employers. Whatever the reason, Tammany says the shortage is “the most dire crisis we’ve ever had.”
“We talk about it regularly,” she says.
“The burnout is quicker. When three people are covering what six people used to do, it’s no longer feast or famine. It’s feast all the time.”
The shortage also means that some Comcare clients must wait for services. Although the center is able to see people for initial assessments, clients needing children’s case management, outpatient therapy or addiction services often end up on waitlists. Those with insurance are sometimes referred to other providers when appropriate.
Compounding matters in the last two years: More people are coming to the center in crisis. “So it’s a higher need, a higher complexity,” Tammany says.
The strain on the behavioral health system extends beyond Comcare. At the St. Joseph emergency room, roughly 60 patients a day, close to half of the hospital’s total, arrive in the grip of a mental health crisis or substance use disorder. Some are suicidal. Some have overdosed on drugs or alcohol. Those high on meth are potentially violent. Many need to be admitted to the full-service community hospital’s behavioral health units. But even with 101 beds on two floors, those units struggle to keep up with the demand.
“We run at about 98% occupancy,” says Robyn Chadwick, the hospital’s president. “We are constantly taxed with trying to discharge patients so that the patients we see in the ER are moved upstairs. If we were a restaurant, we’d have a constant waitlist.”
Five miles from St. Joseph, Sedgwick County Sheriff Jeff Easter administers a jail that he often calls “the county’s largest mental health facility.” For example, late last year, on Nov. 22, the jail housed 1,486 inmates. Of those:
- 49 and were housed in a special pod to provide them with full-time psychiatric care.
- 31% were receiving psychotropic drugs or struggling with a mental health issue.
- 73% had a substance use disorder.
Many of these inmates have been arrested for low-level, nonviolent crimes and Easter doesn’t believe they belong in jail. And if the county had the capacity to meet their mental health needs, they wouldn’t be there. They would be receiving treatment that allows them to live in healthier environments. “We have a problem with not enough mental health workers in the state,” he says. “Let alone Wichita.”
’Now we can Compete…’
The staff shortage isn’t unique to Comcare: Collectively, the state’s 26 community mental health centers have more than 5,000 positions on the books but carry a 12% vacancy rate. A 2018 study commissioned by BHECON (The Behavioral Health + Economics Network, pronounced “beacon”) found that Kansas had 17 health care professionals for every 10,000 residents, fewer than the national average of 20. From case managers to therapists to psychiatrists, the centers struggle to attract enough people to fill their ranks.
With passage of the certified center legislation, lawmakers signaled a commitment to address this problem. The new system will work like this: To gain certification and the funding that comes with it, each mental health center will have to provide a number of enhanced services. Among them: 24/7 crisis, mobile crisis and crisis stabilization services; integrated physical and behavioral health services; outpatient substance use services; community-based services for veterans; and increased coordination with criminal justice agencies.
Although a number of mental health centers have some of these services in place, not all have them at the level the legislation requires. Most will need to boost their training and add staff in order to meet the legislative requirements.
“CCBHCs are what the mental health centers become after lifting weights and working extremely hard through training and education to be the best versions of themselves,” says Kyle Kessler, executive director of the Association of Community Mental Health Centers of Kansas Inc. (Disclosure: While working as a mental health advocate, I occasionally worked with Kessler and the association.)
Creating this best version will take money. The state estimates that, beginning with the current fiscal year, the annual expense could range from $43 million to $74.2 million, money that would come from multiple funding sources, including federal grants and enhanced Medicaid rates. Kessler says this estimate is well off the mark, noting that it assumes all 26 mental health centers will make the transition to become certified centers by July 1 – far more than the five to 10, including Comcare, that are poised to do so. “We won’t have a good read on long-term costs for probably a year or year and a half,” he says.
The mental health centers are especially encouraged by a significant change in how the money will be distributed. For decades, they have operated under a fee-for-service system whereby the state establishes Medicaid rates for certain services and reimburses them according to those rates. This system has not only failed to keep pace with the increasing cost of delivering services, but it has also left the centers powerless to advocate for a reimbursement that reflects those services’ true costs. The centers, for example, can bill for the time a client visits with a case manager, but not for the time it takes to schedule the visit, travel to the client’s house or for the case manager to document the visit.
Under the new legislation, the centers will be reimbursed through a cost-based system, allowing them to calculate what it will actually cost to deliver the higher-quality services that the certification will require. Every year, the state will work with each center to ensure that funding is appropriate for the services provided. Kessler applauds this new approach, saying it will help the centers address staff shortages that have been driven, in part, by competition from Kansas’ four border states. All four have either expanded Medicaid eligibility (which increases the revenue mental health centers can generate), implemented the certified center model or both.
“Now we can compete for case managers, psychiatrists and psychiatric nurses,” Kessler says.
Light at the End of the Tunnel
Sedgwick County is among those centers that have begun to fulfill the requirements set forth in the certified center legislation.
That work has been years in the making, and recently gained momentum with the creation of the Mental Health and Substance Abuse Coalition.
In 2019, Chadwick, Easter and Tammany, of Comcare, joined representatives from social service agencies, behavioral health organizations, law enforcement and local government to form the coalition, whose purpose is to determine what the community must do to reduce the number of people whose behavioral health crises cause them to end up in jail, the emergency room or on the streets. The coalition’s strategic plan calls for reducing barriers to care, improving coordination among service providers and attracting more behavioral health workers.
The plan also proposes the creation of a “one-stop shop,” similar to a facility that some coalition members have toured in San Antonio called Haven for Hope. The 37-acre campus serves as a homeless shelter while also providing space for more than 70 social service organizations that provide services to help people once their crises are stabilized, such as supportive housing and employment. Haven for Hope, coupled with a nearby crisis stabilization center, has been credited with driving down the city’s rates of homelessness and significantly reducing the county’s jail population.
Coalition members concede that San Antonio has benefited greatly from private funders who’ve helped raise more than $100 million into Haven for Hope, and they realize that even a fraction of that investment could prove hard to come by in Sedgwick County. But they also recognize that San Antonio’s system has been 17 years in the making and believe that neither time nor budget restrictions should deter the community from taking action now.
“The efforts we’re putting in place are trying to address the confluence of mental health and substance abuse as early as we can so it doesn’t reach a crisis point,” Chadwick says.
“Then once we have someone stabilized, we’re not saying, ‘OK, our work is done.’ We’re really looking at: ‘What does this human being need to get out of the cycle and not be in a crisis and end up on the streets?’”
One significant investment toward improving the community’s crisis-response system is already on the books. The county’s 2022 budget sets aside $15 million for the relocation and expansion of its Community Crisis Center. Operated by Comcare mental health center, the center gives mental health providers, first responders and individuals a place to take people who are experiencing a mental health or substance use crisis. The new center will increase its existing capacity by more than 40%, providing space for an additional four crisis observation recliners, six crisis stabilization beds (for stays of 72 hours or longer), and five sobering and detox beds. Tammany says that since opening in 2015, the center has helped the community and state avoid an estimated $12 million in jail and hospital expenses. A larger facility, Tammany says, would add to those savings.
And that gives Sedgwick County Commissioner David Dennis, a champion of the center, hope. “I’ve been working on this for four years now,” Dennis says. “I’m starting to see light at the end of the tunnel.”
Change Won’t Come Overnight
The certified center legislation promises to further brighten that light. “This is real exciting stuff for Kansas,” Tammany says. “Now we can look at salary enrichment and service enrichment. That’s where the value comes with the community. We can get creative with our services.”
Comcare, for instance, has mobile crisis units that respond to mental health emergencies in Sedgwick County. Two of those teams are staffed entirely by Comcare and respond to crises that do not require the presence of law enforcement officials. A third team, called ICT-1, consists of a Comcare mental health worker who is embedded with a paramedic and a Wichita police officer. Those mobile units, Tammany says, have seen a 17% increase in demand over the last year. And they’ve had success with keeping more people out of the hospital. Not long ago, about a quarter of the people the mobile crisis units saw would require hospitalization. Today that figure stands at 20%.
But even with that success, Easter believes more help is needed, especially for the ICT-1 unit.
“They’re doing a wonderful job, but it’s only one unit,” he says. “They may respond to this one call, but in the city there are four others. So they take one of the five. It’s a great concept. The problem is: EMS is short, paramedics are short and Comcare is short.”
Shannon Littlejohn eagerly welcomes any effort to improve the coordination between law enforcement and mental health personnel. She recalls a time when she had to call 911 when her husband was becoming increasingly agitated about going to the hospital – a few months after police had shot and killed a woman with bipolar disorder who was armed with a knife. Two officers showed up, one a veteran, the other much younger. “When they came, one was very calm and the other had his hand on his holster the whole time,” Littlejohn says. “I think, ‘God, that could’ve escalated had the older one not been there.’”
Only time will tell whether the certified center legislation will enable Comcare and Sedgwick County to meet the demand that Easter describes and ease the worries of people like Littlejohn. But examples of certified center models adopted in neighboring states demonstrate that it could be enough to significantly bolster behavioral health services in the county and across Kansas, and could give communities tools to improve their crisis responses. That, in turn, should reduce the number of people with a serious mental illness in jails, emergency rooms and on the streets.
Consider: In 2017, Missouri and Oklahoma were selected to serve as certified center demonstration states by the Substance Abuse and Mental Health Services Agency, a branch of the U.S. Department of Health and Human Services.
Since then, the two states, along with six others selected, have reported that they have an increased capacity to provide timely service and that more clients are seeking follow-up care. In some communities, this has resulted in fewer incarcerations and fewer visits to emergency rooms for mental health crises.
The National Council on Mental Wellbeing, a Washington, D.C., advocacy organization that has played a critical role in promoting the certified center model, released a report last year summarizing the impact the model has had on these states. Three such centers in Oklahoma, it says, “reduced the proportion of their clients seen in emergency departments by 18-47% and those admitted to inpatient care by 20-69%.”
Results are also encouraging in Missouri, where certified centers have increased their capacity to serve clients by 27%, from 119,022 in 2017 to 150,578 in 2021. The state also reported that emergency department visits and hospitalizations had dropped by 76%.
Collectively, the National Council report says, the eight demonstration states “reported positive outcomes for CCBHC clients, including reductions in emergency department visits, hospital inpatient visits and readmission rates, which suggests that CCBHC services and supports generated cost offsets by reducing use of more expensive care settings.”
These results also underscore what’s at stake for Kansas as it prepares to invest in behavioral health care at levels similar to Oklahoma’s and Missouri’s. Namely, it will finally be able to compete with those states for behavioral health workers. In testimony last year before the Special Committee on Mental Health Modernization and Reform, Kessler says the association believes that certified centers will help with the recruitment and retention process for all areas of the behavioral health workforce.
Although she cautions that change will not come immediately, Tammany is optimistic that the certified center legislation will give Comcare the resources it needs to address its staff shortage and improve its delivery of services. “It will provide us the opportunity to hopefully make some market adjustments on salaries and make it more attractive,” she says. “That in itself will provide continuity for our patient care.”
A System on the Mend
Even with legislation paving the way for certified centers, improved coordination in Sedgwick County and the community’s plans for expanding its crisis center, steep challenges remain.
A chronic bed shortage at state mental hospitals, for example, recently compelled law enforcement officials to detain people whom judges and mental health professionals have deemed to be a danger to themselves or others. State laws call for taking these people in crisis to a state mental health facility. But the hospitals, law enforcement officials say, are rebuffing them. A letter signed by dozens of sheriffs, including Easter, prompted a response from state officials, but the issue of bed shortages remains, contributing to the burden of providing high quality care to those in crisis.
Another challenge: a lack of long-term care for people with substance use disorders, intellectual disabilities and dementia. Without proper care and treatment for these people, many can end up behaving in ways that lead to encounters with law enforcement or trips to the emergency room. Ascension Via Christi’s Chadwick says the state is especially ill-equipped to deal with substance abuse.
She notes that there are two privately run drug and alcohol treatment facilities in Sedgwick County, but if you don’t have adequate insurance or deep pockets, you can’t receive their services. This robs communities of the ability to help people when they finally admit they need it: “If you don’t have insurance or have Medicaid we’re going to say, ‘You have to hang on to that desire to get help for two months? Don’t drink or do drugs for two months?’ ”
And so people addicted to meth or opioids or alcohol cycle in and out of emergency rooms and jails. “We do not have enough treatment facilities for people who don’t have enough money,” Chadwick says.
And then there’s the challenge of keeping the momentum going for tackling large, complex problems. Sedgwick County appears to have that momentum now. It has put crucial pieces in place to address the challenges ahead. It has built a coalition and is working to bring more partners on board. It has a plan. It has taken steps toward implementing that plan by launching a search for land for a new crisis center. And it has support coming from Topeka.
People like Easter are encouraged that local and state officials finally recognize that the behavioral health system – not just the mental health centers, but the hospitals, courts, jails, homeless shelters and every other institution that serves people in crisis – needs urgent help.
“The legislators are listening,” Easter says. “We weren’t seeing that prior to last year and this year. There were lots of committee meetings, lots of ideas coming out. It’s moving in the right direction. Some people aren’t patient enough and want it all done now. But it took a long time for the system to get where it is – broke. It’s going to take a long time to get it back up running again.”
Hunter Funk, a reporter with KSN-TV in Wichita, contributed to this story.
This article follows up on an October 2021 story on mental health solutions in San Antonio for the Wichita Journalism Collaborative.
Discussion Guide
- How would you diagnose the situation facing the mental health system in Kansas?
- What aspects of the challenges are technical? Which are adaptive? What tough interpretations might need to be considered?
- Is this a story about leadership success or failure? Please explain your answer.
A version of this article appears in the Winter 2022 issue of The Journal, a publication of the Kansas Leadership Center. To learn more about KLC, visit http://kansasleadershipcenter.org. Order your copy of the magazine at the KLC Store or subscribe to the print edition.
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