Rep. Shane Sandridge, R-Colorado Springs, listens as Rep. Judy Amabile, D-Boulder, speaks on the House floor April 19, 2022. (Faith Miller/Colorado Newsline)
Ever since state Rep. Judy Amabile first experienced how difficult it was to find care for someone with serious mental health needs, she’s been a fierce advocate for expanding access to treatment.
Amabile’s adult son began struggling with schizoaffective disorder — which can include symptoms of schizophrenia, like hallucinations and delusions, and symptoms of bipolar disorder, like mania and depression — 12 years ago. His parents struggled for years to find him the long-term care he needed.
“What he needed was never available to him, at least that we could figure out,” Amabile said in a recent interview. “He did have several of these short-term hospital stays, and we would be begging, ‘Please don’t let him go. He’s not ready to go.’ … The longest hospital stay he ever had was six days, and that was after a very tumultuous series of events — he tried to buy a gun to kill himself, he brandished a knife.”
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After bouts of homelessness and encounters with law enforcement, Amabile’s son now has stable housing and employment, she said. But she hopes legislation she sponsored this year will benefit other Coloradans with complex mental health and substance use-related needs.
House Bill 22-1303 — also sponsored by Reps. Shane Sandridge, a Colorado Springs Republican, along with Sens. Faith Winter, a Westminster Democrat, and Jim Smallwood, a Republican from Parker — will use about $17 million in federal COVID-19 relief money to add 16 beds for people accused of committing crimes who have been deemed incompetent to stand trial. Those beds would be located at the Colorado Mental Health Institute at Fort Logan. The bill would also provide $37 million in federal funding to add 125 beds at residential facilities throughout the state for people needing long-term supportive services.
Such “beds” are more than just a frame and mattress — they represent the cost of housing and treating people with a complex array of mental health disorders, many of whom have limited health insurance coverage or none at all.
HB-1303 passed the state Legislature in the last, harried days of the 2022 session, and Gov. Jared Polis added his signature Wednesday. It will initially pay for the new treatment beds using federal COVID-19 relief money Colorado received through the American Rescue Plan Act, which Congress passed in spring of last year.
Lawmakers set aside $400 million of those federal funds for behavioral health programs, since the state has seen record numbers of overdose deaths and rising mental health concerns since the pandemic began in 2020. While these problems aren’t new to Colorado — a state that Mental Health America ranked in last place overall for adult mental health — lawmakers are hoping to leverage the pandemic relief money to turn the tide in this escalating crisis.
“It was a marathon to get the powers that be to agree to it,” Amabile told Newsline in April. “There were a lot of competing interests for the money.” Another obstacle, she said, was the fact that the federal relief money was one-time spending. After fiscal year 2023-2024, the state will be on the hook for the new behavioral health investments.
Competency restoration backlog
At the outset, the 16 new beds at Fort Logan included in HB-1303 will be specifically designated for so-called civil commitments of people involved in the criminal justice system.
“Many people with serious mental illness are not capable of assisting their own defense, and so they get sent to the state hospital, where they try to restore people to competency,” Amabile explained. The suspect in a mass shooting last year at a Boulder King Soopers, who pled guilty by reason of insanity, is one high-profile example, but people can be ordered to undergo competency restoration for much less serious crimes.
Once the state’s backlog of competency services is eliminated, the 16 beds can be used for civil patients, who are not necessarily facing criminal charges but still urgently need treatment. But the backlog is severe.
People ordered to undergo competency restoration before standing trial faced an average wait time of 88.8 days as of March, according to data provided by Madlynn Ruble, deputy director of communications for the Colorado Department of Human Services. That’s an increase from 11.9 days in March 2021 and 44.7 days in March 2020.
There were 363 people on the wait list as of March 2022, compared with 142 in March 2021 and 66 in March 2020, Ruble said in an email. Amabile said she’s heard of people having to wait more than a year to receive court-ordered competency restoration services.
In the 2022-2023 fiscal year, which begins July 1, the state is expecting to pay $12 million in fines and fees associated with failing to meet court-ordered deadlines for such competency restoration services. In 2011, Disability Law Colorado sued the state over its long wait times for mental health treatment, and DHS is still accruing fines required under a consent decree the parties reached in 2018. Under the consent decree, DHS is supposed to get people into treatment within seven to 21 days, and the state is fined up to $500 per person per day it does not meet that deadline.
Most of the beds for competency restoration are currently located at the Colorado Mental Health Institute at Pueblo. At full capacity, the Pueblo facility has space for 517 people, but just 342 clients were admitted as of late April 2022. Staffing shortages and a construction project that has closed some wings of the facility have kept it from operating at full capacity, Ruble told Newsline.
Other beds for competency restoration are provided through jail-based programs including the Restoring Individuals Safely and Effectively (RISE) Program in Boulder and Arapahoe counties. There were 53 clients at the RISE Program in Arapahoe County and 18 at the program in Boulder County as of late April. Nine clients were admitted at the Denver County Jail’s program.
DHS also contracts with two private hospitals to provide competency restoration. As of late April, Peak View Behavioral Health in Colorado Springs had 26 clients admitted and Denver Health had 28 clients admitted.
In addition to HB-1303’s 16 beds at Fort Logan, which are being paid for with COVID-19 relief money, lawmakers approved funding in the state budget for another 44 beds for competency restoration services, also at Fort Logan.
The 44 beds in the state budget are expected to come with an annual price tag of $11.7 million, plus salary and benefits for 96 full-time state workers. Unlike the beds provided in HB-1303, they are being paid for with money from the state’s general fund, which is filled mostly with revenue from income and sales taxes.
All told, the state will theoretically be able to serve many more people undergoing court-ordered treatment — if it can hire enough nurses and other medical staff amid a dire shortage of health care workers. A separate bill could help with that by investing about $72 million in federal relief money into expanding the state’s mental health workforce.
Another bill Amabile sponsored this year provides $29 million of federal money for DHS to contract with private providers for approximately 90 additional treatment beds around the state in the next fiscal year. The beds can either be used for competency restoration services or to treat people with mental health needs who aren’t necessarily facing criminal charges.
‘Step-up’ and ‘step-down’ beds for less severe cases
Like Amabile, former Boulder resident Sylvia Tawse has an adult son with schizoaffective disorder. Over the years, he’s been hospitalized 22 times for acute behavioral health needs, she told Newsline. Tawse’s son has been at the Boulder County Jail for the last 14 months, she said, and received competency restoration treatment through the RISE Program.
Tawse’s son was discharged from a Colorado Springs hospital more than a year ago in the midst of a psychotic episode — even though she’d urged the hospital’s medical director to keep him for longer than a six-day stay, she said.
“He didn’t know how to get himself home (to Boulder),” Tawse said, adding that she had to scramble to find someone to pick him up. “There’s no requirement for a continuum of care, so a hospital can just arbitrarily decide, ‘OK, we need this bed opened up, you’re going out the door.'”
Three days after being discharged from the Colorado Springs hospital, Tawse’s son ended up walking from downtown Boulder to Tawse’s farm in Longmont. It was a cold April day, and he was wearing nothing but boxer shorts, she said. He arrived sunburned from head to toe with blood blisters covering his feet. When Tawse offered him a glass of water, he physically attacked her, she said.
There’s no requirement for a continuum of care, so a hospital can just arbitrarily decide, 'OK, we need this bed opened up, you’re going out the door.'
– Sylvia Tawse
Tawse’s son ran into a field, Tawse said, and later cooperated with police when they arrived to arrest him. After 14 months in jail, he was recently deemed mentally competent to face criminal charges. It’s still unclear whether he will be able to receive the long-term care he needs, Tawse said, though she hopes the Colorado Mental Health Institute at Pueblo will have a bed for her son.
“I’m not here to justify my son’s actions,” she said. “I don’t blame him, because he was completely out of his mind. … I blame that medical director, though, at the hospital who three days before ignored what I was trying to explain to him and warn him, and I blame him for callously just discharging my son to the streets of a city he didn’t know.”
The 125 long-term beds will be “step-up” or “step-down” beds meant for people with serious mental illness, a substance use disorder, or both, who need long-term residential care but aren’t at the point of requiring acute care in a hospital. Some of those patients might have Medicaid and be eligible for federal reimbursement, but others will require the state to cover the costs of their care.
The beds are meant to fill a gap that Amabile and Tawse encountered when their sons were discharged from the hospital after experiencing a mental health crisis. After an emergency room visit, they still needed continuing residential care to get stable. That less intensive level of care is known to advocates as the “missing middle,” and it’s severely lacking in Colorado.
Amabile and her husband once spent $60,000 to send their son to a private facility in Houston for six weeks, she said, only to have him discharged when “they didn’t want him anymore.”
If someone had said, “‘Come up with $5 million and we will cure your kid,’ we would go out and rob banks to get the money,” she reflected. “But it’s not that simple.”
Mental Health America’s 2022 State of Mental Health in America report, which used data from 2018-2019, ranked Colorado in last place overall for adult mental health. The ranking accounted for a variety of factors related to the prevalence of mental illness and access to care. Among the states and the District of Columbia, Colorado had the fourth-highest percentage of adults who reported being unable to access the care that they needed.
Amabile and other advocates fought for the funding to add step-up and step-down care for people leaving hospitals or for those who may not be at the point of crisis that would require an emergency room visit — as in, an imminent danger to themselves or others. The locations for the 125 beds haven’t been identified yet, HB-1303 directs the state to locate them across Colorado, either by renovating existing facilities, creating new space or contracting with private providers. Some of the beds may be used for competency restoration for people facing less-serious criminal charges.
The residential facilities must offer medication assistance, intensive case management, life skills training and direct care, including help with daily activities such as bathing, using the bathroom and eating.
“The idea here is that you can stay as long as you need to be there,” Amabile said. “You have a place to be, it’s a therapeutic environment, you have access to care, and you could stay there for a month or two months or three months if that’s what you need to get stabilized.”
The high price tag for HB-1303 — and the need for increased state investment to pay for the new beds after 2024 — caused some Republicans to balk, but Amabile’s co-prime sponsor, Rep. Shane Sandridge of Colorado Springs, urged his GOP colleagues to support the bill.
“There’s certain things that the government has to pay for. … This is something that unfortunately, the government has to pay for,” Sandridge said during House debate April 19, arguing that the legislation would help the state address homelessness, mental illness and substance use.
HB-1303 secured final House approval on May 10 by a vote of 51-14, with 10 Republicans and all Democrats voting “yes.” In the Senate, it passed 32-3, with Republican Sens. Chris Holbert of Douglas County, Paul Lundeen of Monument and Jerry Sonnenberg of Sterling voting “no.”
Outside the Capitol, supporters of the bill included the Colorado Hospital Association, the League of Women Voters of Colorado, the Colorado Association of Family and Children’s Agencies, and the Colorado Center on Law and Policy, a progressive advocacy organization. The Mesa County Department of Human Services opposed the legislation.
The lack of support Tawse and her husband found for their son in Colorado was part of their motivation to move recently to Taos, New Mexico, after retiring, she said. While she applauds the investments made this session in behavioral health, she emphasizes that the new beds are just a drop in the bucket compared with what’s really needed.
“Because of stigma with mental health, we allow inhumane practices, inhumane policies, and an anemic level of care in facilities to be our shame in Colorado,” Tawse said. “Adding 141 beds is a great step forward, and I hope we take that step forward 100 more times.”
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