CVCS substance abuse program closing worries health leaders

By Cynthia Pegram
Lynchburg News & Advance
Published: May 26, 2008

When its 28-day residential program for substance abuse treatment in downtown Lynchburg closes at the end of June, Central Virginia Community Services will join the majority of the state’s 40 community services boards in looking for that care for people of high need and low income.

About 367 people a year use the program in the Courtland Center, one of three residential substance abuse programs operated there by the agency, according to updated figures.

Not everyone stays the maximum, but some in the 28-day stay can muster only $10 a day. The program is a major money loser. The agency says it costs about $7,000 to provide a 28-day stay, which it can no longer afford.

If CVCS ran the Courtland Center next year, as is, “with three residential programs, we would lose $1.5 million,” said Nancy Cottingham, CVCS executive director.

The three programs serve about 2,600 men and women a year.

The medical detox unit and the 15-day crisis stabilization programs remain in operation — both will use 16 of the Courtland’s 42 available beds, Cottingham said. The programs can receive Medicaid reimbursement, something not available to the 28-day format.

“Without the 28-day program, we would break even and possibly have additional funds to apply to other services,” she said. “Detox loses money, too.”

A 28-day residential substance abuse treatment is one of the oldest programs provided by CVCS — often called its old name, Arise.

Jon Winder, a counselor in private practice, used to direct the Arise program when it was in Forest off U.S. 221. Courtland Center opened in 2002.

In an e-mail, Winder wrote: “As a private counselor and as a mental health consultant for the Emergency Room, I have referred many patients to the facility. Ironically, Arise usually had a 4-6 week waiting list.”

In his experience, the 28-day concept has worked, “though research has shown that the longer a person is in treatment, the more positive the outcome, insurance companies and managed care do not agree with this for economical reasons.”

But having 15 days is better than no opportunity, he wrote, as many people need a clean break “to gain a new perspective to begin recovery.”

Winder, who is active in advocacy issues, wrote that while it may make financial sense, “from an humanitarian and ethical point of view it does not.”

He believes shorter stays will have a ripple effect on families.

Without the 28-day program, there will be “more ER admissions, more hospital admission, and unfortunately, more incarceration of people with substance abuse disorders who need treatment and not incarceration,” he wrote.

Bill Semones, Centra’s vice present for mental health, said closing the 28-day program “is important — it’s one less resource in the community for us to send patients.”

While nothing is magic about 28 days, he said, longer stays in formalized substance abuse treatment programs increase the success rate.

Centra’s Pathways at Virginia Baptist Hospital on Rivermont Avenue is no longer a residential program, but intensive outpatient with a hotel model. Those in treatment pay to stay at Pathways and are usually from out of the area or would have a long drive each day. For people who live in the area, Pathways is usually an intensive outpatient program.

“Pathways is, at best, a break-even program,” Semones said.

Centra also has an inpatient psychiatric unit, which accepts patients with mental health and substance abuse disorders. Centra also can provide medical detox.

Semones said Centra had trouble getting people into the Arise program because it was often full or patients were deemed not appropriate, or they would go on a waiting list for outpatient services at CVCS.

The problem is little money is available to treat people for substance abuse, Semones said. “Nobody wants to pay for it.”

When Courtland Center was launched, it was a one-stop shopping for treatment, including the entangled issues of substance abuse and mental illness.

This year, CVCS became owner, with a mortgage, of the historic old building. It was purchased through an elaborate legal process that first allowed use of tax credits to refurbish the building.

Now, plans call for the Arise residential areas to be used for office space. Of the 38 employees affected, only seven haven’t found jobs in the agency, Cottingham said. And those get the first chance at any opening that comes up for which they qualify.

Availability of 28-day programs is diminishing all over the nation, said Dr. H. Westley Clark, director of the Center for Substance Abuse Treatment for SAMHSA, the federal Substance Abuse and Mental Health Services Administration.

“It generally takes more than 28 days” and the programs tend to be costly, he said.

Clark said some findings reveal a benefit in 28 days, but “often it is not long enough to reduce the risk of relapse — it takes longer than that. It’s too little time to learn new behavior.”

Detox can take as long as 14 days. And some substances, like alcohol, create additional barriers to treatment by interfering with learning, reasoning, and mental processing.

Whatever treatment option is used must consider the unique character of the person, “not just a cookie cutter approach. That was one of the limitations of the older 28-day programs. Everyone got the same thing; it turned out to be an impediment,” he said.

Other residential treatment options can be established, including halfway houses and therapeutic communities, he said. Those include programs like the nationally available Oxford House, an independent group setting in which people live and work with ongoing supports.

SAMHSA allocates a block grant of about $42 million to Virginia for substance abuse treatment. It’s the federal draw for many agencies for their programs. Another $10 million comes in through other federal sources for substance abuse treatment.

In Lynchburg, CVCS receives about $500,000 a year from SAMHSA for programs for children and adolescents.

Many community services boards, such as Richmond’s Behavioral Health Authority, contract out residential substance abuse treatment services, said Jim May, director of the Substance Abuse program

“We do not directly operate residential treatment programs,” May said.

When a Richmond Behavioral Health Authority needs residential care services, then it’s purchased from a private nonprofit. The agency then has the daily rate fee to pay per client, but not the operating cost of running a program.

The person doesn’t enter that treatment with the expectation of 28 days, but rather for the expectation that treatment will be for the time it takes to stabilize the patient, May said.

Sometimes that includes pre-authorizing a certain number of bed days.

“If it is clinically indicated, we can re-authorize if needed later on,” he said.

May estimates that between 150 and 170 clients will be referred for in-patient care from his agency by year’s end.

He said they follow the American Society of Addiction standards to start treatment at the most therapeutic level.

He was surprised to learn of the closing of the CVCS program. “A lot of people are familiar with the program, it’s been around for a long time, it has a good reputation.”

Frank DeForest, clinical services director for the Rappahannock CSB, said his agency does not run a residential program, but uses its own funds plus federal funds to pay for detox, residential treatment or a halfway house.

Rappahannock has referred a few people to the Lynchburg program, particularly the medical detox program, he said.

But in his area a number of community services boards underwrote the establishing of a regional detox center, New Hope, on the grounds of Western State Hospital. It charges the CSBs about $56 a day. But, they’ve recently been referring to the CVCS detox program because it includes medical oversight, treatment during withdrawal and also allows smoking.

His agency most often uses Boxwood Treatment Center operated by Rappahannock-Rapidan CSB, and a program in Fredericksburg, Serenity Home.

DeForest said they use substance abuse case managers for the clients and do not run at a deficit. “We’re pretty frugal.”

“We don’t send to residential unless we’ve already tried less intensive services,” he said. “We also are not going to repeatedly send people back if they have not followed through.”