Summer Larsen had already been charged with murder, served two years in county jail, lost her house, her cars and a husband, violated her probation and started using drugs again by the time she found herself staring down the doors of WestCare’s community triage center in downtown Las Vegas.

Larsen, 35, said that when her probation officer dropped her at the center’s doors on Dec. 15, she saw it as her last chance. She said that she had “spiraled back out of control” once she got out of jail — using drugs again daily — and that her probation officer threatened to send her to prison for nine years for violating her probation.

The three-day stay in detox at WestCare was the first treatment she had ever received in the 19 years she spent addicted to meth and opiates. Larsen said one of the behavioral health technicians nicknamed her Teena Marie, after the R&B singer, because of her “sassy attitude.”

Three days after she left WestCare, Larsen landed back in county jail. She said she was “so far gone” at that point. After another 90 days in county jail, the judge told Larsen that she wanted her to participate in an inpatient treatment program, and that she could choose between the Salvation Army and WestCare. Larsen chose WestCare.

“It was such an impact on my life — just three days here on detox — impacted me to make a decision that I am not regretful for every day,” Larsen said.

In the 90-day inpatient program, Larsen has stayed sober, is thinking about going back to school and was even recently elected to a leadership position at her house. She said she wants to start going to school for psychology to help people in the same way that WestCare helped her, starting with that first day at the community triage center.

“This was my last chance, my last straw. It was here. I'd heard about WestCare in jail, but I was never given the opportunity,” Larsen said. “Being here they ask you, ‘Are you okay?’ and things that people I thought cared about me never even asked. This is my home for life.”

But the future of the same community triage center that put Larsen on the path to sobriety and a new life is uncertain. WestCare abruptly shut down a sister facility in Reno last month and has threatened to do the same to the Las Vegas triage center if it doesn’t receive $1.5 million in funding from the local governments and hospitals and the state by the end of the month.

The sudden closure of the Reno facility and WestCare’s appearance before the Clark County Commission earlier this month to discuss the future of the Las Vegas one have generally raised more questions than answers — questions about an audit and the $1 million that Clark County says WestCare owes them, the extent to which Medicaid can or should pay for the services that WestCare provides and, most broadly, where communication between the organization, the state and the local partners faltered, putting the future of the community triage centers in jeopardy.

The community triage center model

WestCare is a national nonprofit, with facilities in eighteen states and three U.S. Territories, but it got its start in Las Vegas in 1973 as a residential substance abuse treatment program called Fitzsimmons House, funded by a grant from the Teamsters Union. It opened the first 24/7 community triage center in 2003 to address an issue plaguing the Las Vegas community — a high number of people with substance abuse and mental health issues were taking up beds in emergency rooms because of a shortage of other resources in the community.

The goal of the center was to divert patients from those hospital rooms to the triage center, where they could receive more tailored and less costly treatment, freeing up the hospital beds for those who actually need emergency care. Las Vegas’s original community triage center was located on 4th Street before it moved to its current Maryland Parkway location in 2015. WestCare also opened a similar facility in Reno in 2008 to meet the demand for short-term behavioral health care there as well.

Most patients that come to the triage center today come by way of the hospitals, law enforcement or other first responders. Once the patients arrive at the facility, they are quickly triaged to make sure that they don’t have a life-threatening condition that needs to be dealt with first. Then, they head to the front desk to get checked in at the facility, are required to undergo a urine test to see what kind of substance abuse issues they may be dealing with and meet with a behavioral health specialist to get further personal information.

Once they sign all the necessary paperwork, they’re given a shower and a gown and shown to a bed in one of the several glass-paneled rooms within the triage center, where they typically stay anywhere from one to a few days. In the facility, nurses administer any medications needed to stabilize the patients as well as any medications necessary to help the patients detox from whatever drug they’re on.

WestCare spokesman Bob Vickrey said that staff also start planning for what will happen to someone after they leave the triage center as soon as he or she enters the facility, whether that’s a need for housing, ongoing psychiatric support or some other form of treatment. He also said the staff tries to get patients into some of the activities in the day room, such as recovery meetings, art classes or yoga sessions, after about 24 hours in the facility.

But after someone leaves, Vickrey said that WestCare doesn’t have the infrastructure to ensure that he or she went to a doctor’s appointment or a psychiatric visit. That’s why he said they try to get as many of the people as they can involved in one of WestCare’s outpatient groups, which lets them keep an eye on the person and make sure they’re getting connected to other resources in the community as needed.

“We try to keep them as close as we can,” Vickrey said.

Historically, all the services provided by the triage centers were funded through a three-way so-called interlocal agreement, with the state chipping in a third, local governments chipping in a third and local hospitals chipping in a third. The idea was that many of the people coming in to receive services at the triage center were likely low-income and uninsured, so the three partners in the agreement agreed to foot the bill for the cost of care.

But the triage center’s funding model changed after Gov. Brian Sandoval made the decision to expand Medicaid eligibility in 2014, essentially filling in a coverage cap and allowing all low-income Nevadans to qualify for health insurance coverage. The uninsured rate in Nevada dropped dramatically, from about 19 percent in 2013 to 9 percent in 2016, according to the Kaiser Family Foundation.

With the reduction in the number of uninsured individuals, it was expected that WestCare would be able to bill Medicaid for many of the services it had already been providing at the triage center. In fact, WestCare offered to give a rebate to the agreement partners in Southern Nevada to the tune of about $655,000 for services that had been covered by Medicaid over the 2016 fiscal year.

But when Clark County conducted its own audit of the services provided over the same time period, it concluded that the local partners were owed about $1 million. The audit, which was completed in January, also said that there were “errors and unreliable data integrity on information maintained by WestCare,” which made it difficult to verify the accurate number of clients served by WestCare.

The audit also found that WestCare does not report the number of referrals from local hospitals, law enforcement and other first respondents, and that there is no way of tracking the number of referrals that are turned away. Vickrey said in an interview that patients are only turned away if all 50 beds in the facility are full, which he said doesn’t happen “too often,” or because a patient is too violent and a danger to themselves or others to remain in the facility, which he said is rare.

From WestCare’s perspective, there was no formal discussion about what was supposed to happen to the partner dollars they had been receiving once the nonprofit started accepting Medicaid at the triage centers, Vickrey said. The nonprofit had signed an interlocal agreement with the funding partners every year through the 2016 fiscal year, which provided the funding to sustain the triage center’s operations. But after that, the agreements stopped.

“I think the presumption was that Medicaid dollars were beginning to fill in for at least some of the services that the interlocal agreement was taking care of,” Vickrey said.

Vickrey said that WestCare’s understanding was that it was up to the local government partners to initiate the agreement, followed by the state and the local hospitals signing the agreement.

“I don’t know in the chain of communication where there was a breakdown,” Vickrey said.

WestCare’s Chief Financial Officer Ken Ortbals said that it wasn’t unusual for agreements to be signed late into the fiscal year just because of the sheer number of people who had to sign the document, so when one wasn’t signed at the beginning of the 2017 fiscal year — in July 2016 — the triage center just kept serving patients as it always had and expected the money would eventually come.

The funding partners and WestCare attended monthly oversight meetings to monitor the triage center’s activities, and Vickrey said that his sense from the meetings he attended wasn’t that the partners didn’t want to continue funding but more that they were apathetic and just taking their time.

But from where the county sits, not providing further funding to WestCare was part of a calculated decision to wait for the audit to be completed, as it was earlier this year. Assistant Clark County Manager Kevin Schiller said that the local jurisdictions were waiting for the results of the audit to be completed before they moved forward with any discussions about funding.

Schiller said the audit was “pretty difficult” to complete and that the auditors struggled with getting billable data from WestCare. Even after the audit, Schiller said that the county was still communicating and attempting to get more documentation related to the uncompensated care that WestCare provides to figure out exactly how much of the facility’s cost is not being covered by Medicaid.

Still, audit aside, WestCare has said that if it does not receive $1.5 million in funding to cover its costs of uncompensated care for the last fiscal year, it will have to shut its doors at the end of May.

A sudden closure in Reno

As the funding dispute continues in the south, the partners in the north — the local governments and hospitals — who were funding the community triage center there are grappling with a host of questions, namely, why did WestCare not alert anyone to their financial difficulties before they were forced to shut their doors in Reno in early April?

Vickrey said that there was no specific ask for funding from the partners in Northern Nevada, as WestCare is currently doing down south. However, he said that the partners were notified of WestCare’s funding difficulties via email.

But Elaine Wiseman, a Reno community development manager, said that she never received such an email from WestCare. She said the city only found out that WestCare was shutting its doors on the Reno triage center when city staff saw the moving trucks pull up outside of the triage center one day.

“I have city staff stationed down at that campus, and the city owns the building that they’re in,” Wiseman said. “I started getting phone calls and texts.”

Wiseman said that there was no interlocal agreement to fund the triage center in the north after the 2016 fiscal year either, although Reno had continued to provide about $150,000 a year in kind to WestCare to use a city building for the triage center. She said that there were conversations about Medicaid expansion and that the triage center’s need for other funding had gone down, but she doesn’t know what happened and why there was no agreement for the last two fiscal years.

Saint Mary’s CEO Helen Lidholm said that at a recent meeting of the northern agreement partners, none of the hospitals, Reno or Washoe County said that they had ever received a call from WestCare asking them to fill any financial gaps or push the state to make payments to help sustain the triage center’s operations.

Sheila Leslie, a former assemblywoman and Washoe County’s regional behavioral health program coordinator, said that she doesn’t understand why WestCare didn’t say anything when their last agreement ran out at the end of fiscal year 2016.

“I still can’t fathom as a nonprofit director getting a line of credit for a program when you have no agreement for repayment,” Leslie said.

Leslie said that, prior to the closure, she had heard complaints that patients were waiting a long time to get into the triage center and walking away.

“So we knew it was not working well, but we had no idea they were about to close their doors,” Leslie said. “That came as a shock to everyone.”

Leslie is now responsible for coordinating the meetings between the hospitals, local governments, law enforcement and others about opening a new community triage center in Reno. She said she’s in the process of setting up a meeting with state Medicaid officials so that organizations interested in applying to become the new triage center have a full picture of the funding model and what they can expect in the way of reimbursements before they submit their proposals.

“We’re doing our due diligence with what services we need and how those might be paid for,” Leslie said. “Local hospitals have been involved in the meetings, local jurisdictions — everybody wants to help. It’s been gratifying to see the level of engagement in the community that exists. People want to collaborate.”

In the meantime, the Northern Nevada community is seeing the impact of the closure of the triage center. Leslie, who also manages the Mobile Outreach Safety Team, said that members of the team are seeing more people going into the emergency room to receive services. Lidholm, with Saint Mary’s, said that the hospital has seen an influx of patients with mental health issues since WestCare closed, and is caring for 16 to 18 medically stable mental health patients everyday that have no insurance or are insured by Medicaid.

“These patients stay for days, weeks and even months because there are no options in the community where we can safely discharge them to,” Lidholm said in an email.

Washoe County Sheriff’s Office Captain Jeff Clark said that the jail has also had to pick up much of the slack after WestCare’s closure, bringing in people with substance abuse issues into civil protective custody in the jail where law enforcement typically would have taken them to WestCare to detox.

“We have seen in upticks in civil protective custody. Based on the weather and stuff, it’s not a substantial increase to the point where we’re getting concerned but we know it’s coming, with the summer months, special events and stuff like that, it’s definitely coming,” Clark said. “So we are preparing our staff for that and our medical team for that.”

Clark said that he is aware of an email sent by WestCare, but that there was no talk of closure and WestCare didn’t ask for additional financial resources from the community. He said that he found out that the triage center had suddenly closed when he got a call after a Reno police officer showed up to drop someone off and found a paper sign on the door.

“There was a void left in the community for those certain type of people that needed help and we just felt very, I don’t know, compromised. It was very unsettling,” Clark said. “We would’ve liked to have them coming and saying, ‘We have a problem. We’re behind in our budget,’ whatever the case may be. Come to the community, look for grants and find ways to fill those gaps. Worst case scenario, and they were unable to make this work, ‘We’re closing our doors in a month.’ Local resources would at least be prepared for it. All of a sudden just shutting the doors and hanging a paper sign up was not a positive mark on WestCare for sure.”

Ask WestCare, and no one really has an answer to why they didn’t sound the alarm in Reno and directly go to the local partners for help before shutting their doors. They do, however, admit that WestCare did not do a good job in alerting the community and that the closure was not handled well.

“I’m not sure to be honest with you,” Vickrey said. “In hindsight, and I mean this with all my heart, I, personally, would’ve personally done an ambassadorship mission to Reno and made the rounds. You know, as a person who believes the interlocal agreement is there and will continue to work for the CTC. I think my hope was the partners would then come to the table, everybody, because we need all of them to come to the table to fund.”

Ortbals, WestCare’s chief financial officer, said that he wishes he had been in the car with Vickrey on that ambassadorship mission.

“Looking back, yeah, you’re asking a great question, and it makes sense that you’re asking that question,” Ortbals said. “I wish, I look back, and I think, ‘Man, I wish we had been more aggressive at times.’ We just kind of put our heads down and just served the clients, so, when I think about it and second guess, that’s something I think about.”

What happens next in Las Vegas

The question now is will the Las Vegas community triage center go the way of Reno, or will the local governments and the local hospitals put up the funding to keep the center open past the end of the month despite their concerns about the money they say WestCare owes them.

For its part, the state has said that it has its matching dollars for the triage center set aside and that all it needs is for the local government and the hospitals to put up their share of the money. In fact, the state actually contributed about $125,000 in matching funds in the 2017 fiscal year even though there was no interlocal agreement in place after the city of Las Vegas and the local hospitals put up some matching funds.

But, like the county, the state has concerns about both the level of uncompensated care that the triage center is providing and how to even independently verify that number. WestCare has said that 47 percent of the care it provides to patients is uncompensated, although the number of uninsured individuals in the state is much smaller and the amount of uncompensated care that the county’s public hospital, University Medical Center, provides is about 15 percent.

“They’ve reported back to us that 40 to 50 percent of the people they’re seeing are uninsured,” said Julie Kotchevar, administrator of the Division of Public and Behavioral Health. “That doesn’t true up with what should be there.”

To help ensure that everyone who qualifies for Medicaid is getting enrolled, the state recently upped the number of days it is stationing a Medicaid eligibility worker at the triage center from two days a week to five days a week. Kotchevar said that although the state did not reduce its budget related to the community triage center funding after Medicaid expansion went into effect, the state still had the expectation that the center would be able to increasingly rely on Medicaid dollars.

“WestCare made these statements that they felt like they were going to be able to bill more and the reliance on the partnership would decline,” Kotchevar said. “The struggle that we’ve had is getting data to demonstrate why people are not Medicaid eligible or if they are, why they’re not getting compensation from us or private insurance. What costs are [WestCare] grouping into uncompensated care?”

It’s the same concern that the county has. Schiller said that the county has also been unable to independently validate WestCare’s 47 percent uncompensated care figure because there’s nowhere to independently validate it.

Asked about the uncompensated care rate, WestCare officials said it comes down to difficulties with enrolling and billing for Medicaid.

“Part of the challenge is bringing in Medicaid was that it was new to us,” Ortbals said. “We didn’t have enough historical information to say, ‘Looking forward this is what we think we’re going to need for uncompensated care.’”

Ortbals said that, after the audit came out, he had his staff go through patient by patient to see whether they were covered by Medicaid or with some other type funding. Their ultimate goal, he said, is to figure out how to get more people enrolled under Medicaid and bill Medicaid better to decrease their reliance on the dollars from the local partners.

“When Medicaid expansion allowed for us to expand our scope of services through Medicaid expansion, there was a tremendous groundswell that Medicaid was going to be the end all be all,” Vickrey said. “That was not only in our minds as providers, that was in the minds of the government entities as well, the city and the county. I think they were hoping for the same thing."

That wasn’t just a perception within the triage center, either. Bill Welch, the president and CEO of the Nevada Hospital Association, said that increased funding from Medicaid expansion has also not been sufficient for the hospitals and that there are a lot of people who the hospitals think may be qualified for Medicaid who end up not qualifying. Still, he said it was the local hospitals’ expectation at the time Medicaid expansion went into effect that Medicaid funding would be sufficient to sustain the triage center.

With the closure of the triage center looming, Welch said the local hospitals recently met with WestCare and are in the process of drafting and signing onto a letter of intent, promising to put up their share of the funds so long as the local government and the state contribute their part. The hope is that the letter will be presented at a meeting of the Clark County Commission on Tuesday, where the triage center’s fate will likely be decided.

Welch said the letter of intent will also require WestCare to develop a plan for financial stability moving forward and require them to be subjected to an oversight committee of the funding partners who will oversee the triage center’s budget development, approval and management process.

“There’s no question that we need a community triage center in town,” Welch said. “We need one in Las Vegas, and we need one in the north.”

Schiller said that he will recommend that the commission, if it chooses to act at all, fund WestCare on a shorter time frame, anywhere from three to six months, to give the county time to further audit the nonprofit and figure out how to reduce its uncompensated care rate. He said that he expects the $1 million that the county says WestCare owes the funding partners will be a part of future discussions.

Of course, the commission could also decide to part ways with WestCare and establish an agreement with a different provider to provide triage services. Schiller noted that although WestCare is the only licensed triage center in the state, there are other facilities that are in the process of applying.

There’s also a question of whether other local governments will decide to step up and provide any of the funding. The city of Las Vegas said in a statement that WestCare has “yet to provide documents accounting for the funds that the city has provided” and that “verifying the city funds are being spent appropriately is a priority at the city of Las Vegas.”

The cities of North Las Vegas and Henderson did not respond to emailed requests for comment on the agreement with WestCare.

WestCare’s hope is that the County Commission will approve its funding request on Tuesday, which could then open the door for discussions on how to move forward and possibly implement a new interlocal agreement providing for the funding of the triage center moving forward.

“My hope that we put this back into place and the partnership is there and so it’s not only for this fiscal year, but then very quickly we move together with the partnership together to redo and implement a [memorandum of understanding] that will enable all of this partnership to continue into the future, continue running this, and help the community,” Ortbals said.