Falling through the cracks in Nevada’s mental health system

By: - September 4, 2019 6:22 am
lawrence banks

Lawrence Banks at the table where he often waits for rides after work. (Photo: Dana Gentry)

Lawrence Banks can’t tell time, but when the “Judge Judy” program ends, Banks knows he has to leave for work.

“I used to take the big bus. Now I take the little bus,” he told the Current during an interview.  

But in between taking the big bus and the little bus (the Regional Transportation Commission’s paratransit service) Banks, who has a mental impairment, walked to work at Outback Steakhouse, where he’s been employed washing dishes for some 20 years.

At 4:30, when his shift ends, Banks often enjoys a meal courtesy of his employer. Then he sits and waits, sometimes until midnight, hoping a colleague will offer him a ride home.  

That’s where Assemblywoman Dina Neal noticed him.  

“He was just sitting there. It made me so sad,” said Neal, who sprang into action for Banks, a constituent in her district. “I think Mr. Banks has fallen through the cracks.” 

There are a lot of cracks for people like Banks to fall through in Nevada. According to a 2018 report produced by Mental Health America, a non-profit addressing needs of those living with mental illness, Nevada’s system of mental health services ranks last in the nation.

Neal reached out to Richard Whitley, Director of the Department of Health and Human Services, who in turn contacted officials in his own departments.   

“Staff from both agencies (Aging and Disability Services and Welfare and Supportive Services) met yesterday with the client and the employer and have added services,” Whitley wrote to Neal earlier this month. “They were able to assist with transportation to and from work and with adding some additional financial supports.” 

At Neal and Whitley’s request, the Regional Transportation Commission arranged rides for Banks.  

“I used to wait for the big bus. But people complained that I was asking for rides,” Banks told the Current. “But I didn’t ask them. They offered.” 

“In the past, transportation arrangements were made to and from work, however he (Banks) would often change his mind in favor of walking and asked that the RTC rides be canceled,” Aging and Disability Services Administrator Dena Schmidt told Neal in an email. “He has once again committed to using RTC for rides to and from work and these rides have been arranged.”

Banks maintains he never asked his caseworkers to cancel the paratransit service that provides federally-subsidized rides at a cost of less than $3 to the client.  

“Sometimes they can be so rude to me,” he says of his caseworkers. “Then they are nice.”  

“Apparently, he had a caseworker who used to call the job; ask has he been to work, did he show up yesterday, but this caseworker stop calling about 2 years ago or more,” Neal wrote in the email to Whitley and others. 

“His long term staff of 10-12 years checks on him periodically at work,” Schmidt responded to Neal. “How he speaks can create confusion and give the impression that he was lacking supports. With all of this in mind, we are still going to complete an audit of the providers for this individual to ensure he has been receiving the services and supports he was supposed to.”

Schmidt wrote that Regional Center Quality Assurance and Community Services staff will review billings submitted by Banks’ Jobs and Day Training provider and Supported Living Arrangement provider to ensure services are being performed in accordance with the state’s plan for Banks and review his trust fund “with the provider to ensure monies are being used appropriately for living expenses and personal needs.” 

Does the state ensure all clients’ finances are properly spent?

“The service coordinators regularly review billing and trust account ledgers for people on their caseload. Quality Assurance and/or fiscal staff review a sample of bills and trust accounts each year, and when a possible concern has been reported,” a state spokesperson said.  

Misappropriations of client money are rare, according to the state.

Nevada’s mental health system has been the subject of three bruising audits performed by the Legislative Audit Division, which detailed squalid conditions in residential facilities, over-billing by contractors, including clinicians, and a department in which 31 of 55 psychologist and psychiatrist positions were vacant at the beginning of this year. 

Neal, whose father, former state Sen. Joe Neal, is the partial namesake for Southern Nevada’s Rawson-Neal hospital which provides care to mental health patients, praised the agencies for stepping up to help Banks. 

“Everyone was so great,” Neal told the Current, lauding the help Banks received from the RTC, Workforce Connections and the Department of Health and Human Services. 

“The Nevada Department of Health and Human Services (DHHS) is dedicated to assisting all Nevadans and we appreciate Assemblywoman Neal’s commitment to serving the community and bringing to our attention the opportunity to assist this client,” Whitley said in a statement to the Current.

But what about the thousands of mentally impaired Nevadans who haven’t caught the attention of a lawmaker?  

The support services Banks and others receive are vital, often making the difference between successful, independent living and homelessness. More than a quarter of adults in shelters suffer serious mental illness, according to the National Alliance of Mental Health

With so much at stake, how many mental health clients are getting the services available to them and how many, like Banks, fall through the cracks for a time? And is the state doing all it can to provide services? 

“By asking questions, and gathering information, Assemblywoman Neal has made the Department aware of improvements that can be made to better serve all those who utilize our support services,” Whitley said in a statement, but declined to offer specific examples. “This encounter illustrates an opportunity for the Department, and DHHS will work to better serve our clients by developing a process to ensure they are receiving all the support services they are eligible for and working with employers to provide the resources they need to help their employees be successful.”

Drinking from a fire hose

The National Institutes of Mental Health estimates one in six U.S. adults has a mental illness.

In Nevada, which has a population of roughly 3 million, that’s half a million people living with a mental impairment.

Of those, less than 1.5 percent avail themselves of the services offered by the Nevada Department of Health and Human Services.

Nationally, 41 percent of adults with a mental health condition received services in the past year, according to NAMI.

Nevada’s mental health

Nevada ranks last among the states in a 2018 evaluation by Mental Health America. The non-profit determines its overall ranking based on a number of criteria, including:

  • Adults with any mental illness
  • Adults with drug or alcohol dependence
  • Adults with serious thoughts of suicide
  • Youth with a “major depressive episode” in the last year 
  • Youth with drug or alcohol dependence
  • Adults with a mental illness who did not receive treatment 
  • Adults with a mental illness reporting they have unmet needs
  • Adults with a mental illness who are uninsured or could not afford to see a doctor
  • Youth with major depressive episodes who did not receive mental health services 
  • Students referred for an Individualized Education Program because of identified emotional disturbance   

According to a 2018 evaluation by the non-profit Mental Health America, Nevada had a higher prevalence of mental illness than 43 other states and the District of Columbia, and ranked 47th in access to care.

Nevada’s mental health services ranked 51st overall.

But the crisis is not reflected in state funding for mental health services.

“For fiscal years 2018 and 2019, NNAMHS and SNAMHS were approved for a combined total of 970 and 958 positions. For the 2018–2019 Biennium, the agencies’ workforce was reduced by 5% overall with 51 positions less than fiscal year 2017 levels of 1,009 authorized positions,” the state’s October 2018 audit says. “The Division explained the reduction in budgeted staff was due to the effects of decreased patient demand caused by a shift in services to the community as a result of the Affordable Care Act. In addition, staff reductions were the result of the elimination of several programs and operating locations, and operational efficiencies.”

The budget passed by the 2019 Legislature increases funding of mental health services by roughly $7.5 million.

The state serves 7,150 individuals at three regional Developmental Service centers — in Las Vegas, Washoe County and one covering rural Nevada, according to Jessica Adams of the Aging and Disability Service. Each client has a service coordinator and those involved with Supported Employment from a partnering provider have a job coach employed by the provider.  

The state employs 180 service coordinators, who have an average caseload of 42 clients, and coordinate housing, work, recreational and financial matters for clients, who may receive services — including housing assistance — from the state.

The Supported Living Arrangement program serves individuals of all ages who have an open case with Developmental Services and:

  • Are Medicaid eligible
  • Have the desire and ability to participate in supportive living arrangement services and adhere to guidelines
  • Can be safely supported in a community residential setting with either intermittent or 24-hour support

Supported Living Arrangements (SLA) make independent living possible “in a variety of residential settings in the community,” according to the state.  

Layers of providers, all with their own unique Medicaid billing code, engage in services with clients, including overseeing their finances.  

“Residential and community living providers assist with training and support in areas such as social skills, behavior skills, personal grooming, home maintenance, medical needs, shopping and recreation,” according to a DHHS spokesperson. 

The SLA provider employs a residential support manager, essentially a case manager. 

The government provides job development training to more than 2,600 clients throughout the state.  

Training includes career planning, day habilitation, pre-vocational services and supported employment. 

“The outcome for all supported employment is for individuals to obtain sustained employment, paid at or above minimum wage, in an integrated community setting,” a state spokesperson said.

Southern Nevada’s Workforce Connections also assists mentally impaired job seekers. 

“Under the ADA, we do not ask anyone if they have a disability, only they can disclose this information,” said Jeramey Pickett of Workforce Connections, which conducts needs assessments with its clients. 

Those who disclose a disability can receive free vocational training.

What is the state doing to make employers aware that mentally impaired Nevadans are ready and able to work? 

“Jobs and Day Training (JDT) providers specializing in Supported Employment do contact employers throughout the state to discuss the assistance that can be provided should they hire someone with an intellectual or developmental disability, and the Aging and Disability Services Division Developmental Services program intake teams at each regional center perform outreach to schools, doctors, hospitals and other community resources to educate them on available services to people with an intellectual or developmental disability,’ a state spokesperson told the Current via email.

Some employers make a conscious effort to hire mentally impaired workers, according to the state, including a Starbucks coffee roasting facility in Minden, Nevada.  

“A gas station in Ely purchased a specific type of bagged ice maker that could be easily operated. A Port of Subs customized a job clearing tables and cleaning the dining room so the person could excel without assistance,” says Shannon Litz, a spokesperson for Whitley, the Director of the Department of Public and Behavioral Health. “Smiling with Hope Pizza in Reno trains and employs people with intellectual or developmental disabilities. There are countless stories like this that are often more significant than the numbers they employ.”

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Dana Gentry
Dana Gentry

Dana Gentry is a native Las Vegan and award-winning investigative journalist. She is a graduate of Bishop Gorman High School and holds a Bachelor's degree in Communications from the University of Nevada, Las Vegas. Gentry began her career in broadcasting as an intern at Channel 8, KLAS-TV. She later became a reporter at Channel 8, working with Las Vegas TV news legends Bob Stoldal and the late Ned Day. Gentry left her reporting job in 1985 to focus on motherhood. She returned to TV news in 2001 to launch "Face to Face with Jon Ralston" and the weekly business programs In Business Las Vegas and Vegas Inc, which she co-anchored with Jeff Gillan. Dana has four adult children, two grandsons, three dogs, three cats and a cockatoo named Casper.