by Kaitlin Durbin, Cleveland.com
Plans for a 24-hour behavioral health crisis center in Cuyahoga County may be back on track under a revised deal that reduces risk to public tax dollars and eases concerns from the county’s Alcohol, Drug Addiction and Mental Health Services Board.
ADAMHS Board CEO Jason Joyce had been saying for weeks that the project posed too great a risk to move forward, warning it would require devastating cuts to the county’s broader care network and could leave the agency — and by extension the county — responsible for millions of dollars if it does not perform as expected.
He’d said he couldn’t recommend it and suggested that the ADAMHS Board might need to pull out of the project altogether, effectively dooming it.
Now, however, Joyce says he and Eric Morse, president and CEO of The Centers, which will run the crisis center, have hammered out “the elements of a really good deal” that right-sizes the ADAMHS Board’s financial commitment while protecting the broader provider network. Joyce will be urging his governing board to accept it.
There has been a lot of uncertainty and tension getting to this point, Joyce acknowledged in a joint interview with Morse and cleveland.com/The Plain Dealer.
“But now that we’ve gone through that, we’re aligned; we’re partnered,” he said. “We have a shared sort of vision and agreement that ...this is an important service.”
The terms
A significant shift in responsibility for the crisis center seems to be at the heart of the new agreement, which was outlined in a memo sent to County Council and board members on Thursday.
Morse previously stressed that The Centers agreed to run the crisis center, but that it was “technically an ADAMHS Board project.” That structure implied ongoing responsibility to fund the center and cover any shortfalls, which made Joyce uneasy, given the ADAMHS Board’s financial struggles and limitations on how levy dollars can be spent.
Under the new agreement, though, The Centers assumes nearly all financial risk, including repaying the $6.8 million in construction funding from the state if the crisis center doesn’t open by the end of September, doesn’t meet the state’s terms, or isn’t operating for at least 10 years.
The ADAMHS Board’s only obligation would be to provide $4.5 million in funding next year — down from the previously promised $10 million and a later revised estimate of about $6 million. After that, ADAMHS Board funding would not be guaranteed, it would be dependent on annual reviews of the crisis center’s performance and sustainability.
“This approach is more in line with how the ADAMHS Board typically funds its provider network,” the memo to County Council says.
The new agreement would also reduce the projected impact on other providers. It would require just $6 million in cuts next year, instead of the nearly $12 million that Joyce and providers feared would devastate programs.
They wouldn’t be across the board cuts again, either.
Joyce said providers will have to submit applications and undergo review before funding is awarded. That review will consider each program’s performance and whether services are being duplicated in the network. It will also challenge providers to ensure they’re maximizing state and federal funding before relying on ADAMHS Board dollars, which are intended to cover the uninsured, underinsured or services not otherwise reimbursed.
“We want to look at each program on its own merit to see what’s working...” Joyce said. “That’s going to be a more thoughtful, thorough process.”
Some of those cuts are needed regardless of whether the crisis center moves forward, Joyce stressed. The agency is running a $7 million deficit this year that was covered with reserve dollars, but those funds have largely been depleted, leaving them no choice but to cut spending in the future.
However, he feels the new agreement is “a lot more reasonable.”
The ADAMHS Board’s governing board will meet March 25 to discuss the agreement and could either decide on it then or set a future date for a vote. Joyce said that third-party assessments of the project’s construction schedule and how many people will use it — both key to The Centers’ funding plan — are expected to be returned Friday and could factor into the board’s decision.
Even if passed, though, the project’s future is still far from certain. County funding and long-term financial support would still need to fall into place.
The Centers’ gamble
Under the new deal, the ADAMHS Board would also help The Centers secure additional funding for the crisis center, including advocating for $12 million in county opioid settlement dollars to support the first three years of operations. The plan calls for $4.9 million in county funding in the first year, $3.1 million in the second and $4 million in the third.
Joyce was blunt about its importance: “There’s not another way to close the gap of $12 million over three years.”
So far, County Council has not scheduled a vote on that funding.
Council members were previously hesitant about the gift. They questioned the crisis center’s long-term viability given it has no clear funding plan beyond the first three years — a concern which could now be heightened by the ADAMHS Board’s one-year guarantee, instead of three.
But Morse says he’s still confident the crisis center will prove itself in that time, which could help attract longer-term funding from the state, hospitals or other partners. There have already been signals at the state level to increase support, he said.
Right now, Ohio lacks a sustainable reimbursement model for crisis services, meaning centers cannot fully bill Medicaid for the kind of 24/7 care being proposed. But Morse said state officials tell him they are exploring ways to create a dedicated payment structure, which could eventually reduce reliance on local funding.
The crisis center may also perform better than expected, he said, noting that early revenue projections for use of the facility and the pharmacy have been conservative.
“We might make more money than we think we’ll make,” he said. “If this is demonstrated as a true value to the community, I’m pretty confident things will come together.”
For now, though, he still faces a funding gap that could limit the range of services the crisis center can offer.
The original plan calls for 40 crisis chairs on the first floor, where individuals can be assessed and stabilized within 23 hours before leaving with referrals for follow-up services. The second floor would provide residential care, including 16 psychiatric stabilization beds.
With less money coming from the ADAMHS Board, however, Morse said the residential portion is in jeopardy. He’s reaching out to other funders to plug the roughly $1.5 million gap, but the new agreement with the ADAMHS Board also leaves room for a “revised crisis model” without it — but it would come with tradeoffs.
If The Centers scales back services, it would have to give up the state’s $6.8 million in construction funds, which it would then need to make up from other sources. Those funds have not yet been fully spent, but construction is already underway and is on track to be completed by September. In that case, the project wouldn’t be dictated by the state, allowing The Centers more flexibility in the types of services offered in the future, depending on revenue and performance.
On the other hand, if The Centers is able to plug the shortfall, it could accept the state’s funding and open as planned, with the full scope of services to help residents in various levels of crisis. But it would be required to maintain those services for 10 years or risk repaying a prorated portion of the state funds.
In either scenario, the 24-hour stabilization chairs that are central to the crisis center plan will be provided regardless, Morse and Joyce assured.
The first step in the process, though, is securing the ADAMHS Board funding, which Morse hopes will trigger support from other donors over the next few months. He said he continues to meet with potential funders to line up backing if the board commits.
Even so, he acknowledges it will take broader support for the crisis center to succeed long-term.
“It’s a community project,” Morse said. “The whole community is going to benefit from this, and it’s going to take the whole community to make this project work in the end.”
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