Building Bridges to Nowhere.

For those not paying attention, there seems to be a big bipartisan push to cease locking people up for using drugs. Perhaps the key word in that sentence is “bipartisan.” Since lawmakers in Washington cannot agree on the simplest of issues, one must wonder how it is that they can come to an agreement on something as complex as drug addiction. For decades now, the consensus opinion among tough-on-crime politicians has been that people who use drugs are criminals who should be made to pay for their crimes. Now, all of a sudden, these same people are victims of a dreaded disease. What has changed? Well, here’s something that might shine a light on this perplexing question.
Imagine a waiting room with twenty chairs. The chairs are bolted to the floor, so cannot be moved. In the room is a water dispenser and nothing else. There are no televisions; there is no free WiFi; there are no out-of-date magazines. Now, imagine this room with thirty-seven people waiting. As previously mentioned, there are only twenty chairs. If you do the math, that means that seventeen people have no place to sit. Several of these individuals are lying on the floor. This floor is not carpeted and, due to the clientele, is fairly dirty. Indeed, the entire room is filthy. The waste baskets are overflowing with trash, and various liquids and food have been spilled on the floor that no one sees fit to sweep or mop up. There is one bathroom to serve these thirty-seven individuals, and it, too, is filthy.
So, is this a room where people are waiting to be processed into a jail? Sadly, no. Such people have rights and are protected by the Eighth Amendment of the United States Constitution which prohibits cruel and unusual punishment. If one were to look upon the aforementioned room, there would be no doubt that the treatment of those waiting was both cruel and unusual. Since, however, this room was the first stop of a facility that likes to consider itself a healthcare facility, the treatment of those unfortunate enough to have found themselves lying on that dirty floor was not punishment.
The Central City Addiction Recovery Center (CCARC) in Phoenix, while not a detention center, would probably never be defined as a health care facility by anyone who does not work there. Since the majority of the population it serves, however, is homeless, the powers-that-be at Community Bridges Inc. (the organization that operates the facility) don’t seem to mind that their clients are made to lie on dirty floors, use filthy restrooms, and wait for endless hours to receive services. This might have something to do with the actual “services” these individuals are waiting for.
After a wait that could literally take up to twelve hours, an individual will be taken to what is known as the Crisis Unit. While on this unit, the individual will be provided a bed or reclining chair. This room has a holding capacity of thirty-one people. This maximum number is inviolable, so there is no one lying on the floor. During their time on the Crisis Unit, clients have access to peanut butter and jelly or cheese sandwiches. There is also a water dispenser. The maximum time a client can remain on the Crisis Unit is twenty-three hours. While there, they are awakened every four hours to have their vital signs taken. Prior to being released, they are given an assessment by a behavioral health counselor. At the conclusion of this assessment, they are referred to a peer support specialist for placement counselling. They also have the option of self-discharging—or simply walking out. In a nut shell, these are the only “services” that the overwhelming majority of those thirty-seven souls could hope to have received.
Not only is the Community Bridges hierarchy unconcerned with a filthy, overcrowded waiting room, they also seem quite apathetic with regard to patient—and employee—safety. While patients lying on the floor is itself a safety hazard (one which caused the termination of a friend of mine about a year ago), it is far from the only hazard that exists at the Central City facility. The following is an excerpt from a CBI job description:
Assists in maintaining a safe, orderly, and therapeutic environment. Maintains patient safety and protects patient rights through observation and reporting patient behaviors, communications, interactions, and physical status. Recognizes patients who are behaving aggressively, acting as a danger to themselves or others, or are in a crisis or medical emergency situation. Provides intervention including, but not limited to, de-escalation techniques, redirecting of patient and/or participating in restraint or seclusion as needed per policy.
Now, this paragraph does not appear in the job description of a Registered Nurse, an Emergency Medical Technician, or a Medical Assistant, all of which are positions found on the CCARC roster. Which position at Community Bridges is expected to maintain patient safety? Which employee on the crisis floor is supposed to recognize patients in crisis and provide intervention? It is the Milieu Specialist. The proverbial fly in the buttermilk is that CCARC does not have any such position on its roster. Does this mean that the facility never deals with patients in crisis who may be a danger to themselves or others? Of course not! It simply means that Community Bridges executives are not as concerned with the safety or the rights of their CCARC patients as they seem to be with patients from other facilities they operate. The reality is that the Crisis Unit at the Central City facility quite often goes unmonitored by any specific employee. And no one in charge seems to have a problem with this, just like no one in charge seems to have a problem with a filthy, seriously overcrowded waiting room.
So, who is to blame for an untimely response by staff members if one patient attacks another patient? With no one assigned to observe the crisis floor from that floor, no one can be expected to be on the spot if something happens that jeopardizes that all-important “safe, orderly, therapeutic environment.” Indeed, the first thing one notices upon entering the Crisis Unit at the Central City facility is the absence of someone actually working on the floor. At both ends of the unit, there are closed-in areas. It is in these areas that all of the crisis staff spend most of their time. While there seems to be no shortage of employees available to wake patients up at all hours to take vital signs, as soon as this task is accomplished, those employees run back to their little cubby holes. Meanwhile, out on the crisis floor things are happening that no one seems to be aware of. I’ve seen fights break out, patients assaulted, patients smoking, patients switching beds, and I’ve even walked in on a patient who was lying on the floor in the restroom. In other words, with no one assigned to be on the floor at all times, the CCARC is a catastrophe waiting to happen.
That dangerously overcrowded waiting room, however, was not the only problem. The complete lack of cleanliness in a room that was the first stop of what is ostensibly considered to be a health care facility would no doubt have prompted the facility to be shut down if the wrong person was to have seen it. The reason the intake lobby is so filthy at certain times of the early morning is that there is a three-hour gap between the second shift housekeepers and the first shift. This gap also occurs between first shift and second shift. In other words, between 3:00 p.m. and 6:00 p.m., there is no one in CCARC whose specific job it is to keep the place clean. Nor is there anyone working from 4:00 a.m. to 7:00 a.m. While the only likely reason for this has to have something to do with cost cutting, there are probably not many people who would accept this as a reason why a healthcare facility should be allowed to be filthy for six hours a day. Anyone who does not believe that this actually occurs need simply visit the facility at six in either the morning or evening. I would be willing to bet that the degree of squalor one is likely find at these hours could well cause the facility to be sanctioned by the city or state. That is, of course, unless the powers-that-be have the same sort of arrangement with the department of health as they seem to have with the police department. For sadly, no matter how filthy or overcrowded the waiting room is, when a police officer stops by to drop off someone that has been picked up for being publicly intoxicated, he or she seems not to notice that patients are sleeping on the floor and in the parking lot. I suppose that, so long as Community Bridges makes it possible for police officers to avoid the paperwork associated with arresting a drunk, that department can be counted upon to look the other way with regard to the numerous infractions that Community Bridges might be guilty of.
In contrast to the lack of available staff where housekeeping is concerned, there are certain positions that Community Bridges would never allow to go unmanned. In order for someone to receive what meager services are offered by this organization, he or she must undergo an intake interview. This is the first step in what some employees consider to be the welfare fraud that is systemic within the organization. More specifically, Community Bridges defrauds the state’s Medicaid system (or AHCCCS). Since employees are not privy to the numbers, they often perform their duties in blissful ignorance of the burden they are imposing on the state’s taxpayers. Whatever that burden is regarding the intake interview could easily be determined by anyone in authority outside of the organization who wished to find out. Such an outsider, though, would need to spend some time in the overcrowded waiting room to get an idea of the actual scope of the organization’s fraudulent practices.
Imagine (if you possibly can) this scenario. A patient walks into CCARC at 11:00 p.m. on Monday night and asks to receive services. For purposes of expedience, let’s call this patient Joe. Upon entering, Joe will be questioned by the medic at the reception desk. Joe’s vital signs will be taken by this individual, and Joe will be told to have a seat and wait. It would not be unheard of for Joe to sit in the waiting room until nine or ten the next morning. Joe will then be taken into another room where he will undergo another intake interview, during which several of the same questions will be asked of him. At the conclusion of this interview, Joe will be made to surrender all of his clothing and personal property and be dressed in disposable scrubs. Joe will then be taken onto the crisis floor where he will be placed in a bed and given a sheet, blanket, and pillow case.
As mentioned previously, employees are not privy to the cost of the process that Joe has already undergone. Suffice it to say however that, while Joe will likely never see a bill, AHCCCS most certainly will. And that bill may be sent to AHCCCS even if, after having completed the intake interview, Joe decides to simply leave the facility without receiving any services. It is a particularly disturbing fact, therefore, that perhaps over half of the aforementioned thirty-seven souls who were packed into the CCARC waiting room departed the facility prior to the second interview without receiving any service beyond that of having had a roof over their heads for the night. Indeed, it is this particular practice that prompts so many employees of Community Bridges to consider the facility a homeless shelter. Despite the fact, though, that no services were received, taxpayers may be charged for the initial intake. If that intake cost more than $5.00 (a decent enough price for having provided the roof for the night), then it was overpriced. Sadly, while no one cares that there was no one around to clean the facility for several hours of Joe’s wait, it is highly unlikely that Joe would have been allowed not to have been given his intake interview. You see, it is far more important to have employees present who can provide Community Bridges with billable hours than it is to have janitors around to keep the place clean.
Let’s move on to the Crisis Unit itself. For, if Joe does not number himself among the fifty or sixty percent of CCARC patrons who are satisfied with spending the night in the waiting room, it is quite likely that he will expect some sort of actual service in exchange for his overly long wait. Now that he is on the unit, he is allowed to sleep in a bed. For the most part (with the exception of the previously mentioned six hours a day of no janitorial coverage), Joe will have a clean bathroom to use, peanut butter or cheese sandwiches to eat, and water to drink. All of this would probably go for about $10.00 a night if Community Bridges was in actuality what so many perceive it to be in practice—a homeless shelter. Sadly, however, the taxpayers of Arizona are not let off the hook quite so easily. During his stay on the Crisis Unit, Joe will be awakened every four hours to have his vital signs taken. To Joe, this will amount to little more than brief interruptions of his sleep. To taxpayers, however, it will be much more.
Anyone who has ever received an itemized hospital bill has been exposed to the ridiculously high amounts that are charged for any healthcare procedure. Since Joe is participating in a healthcare procedure every four hours, one can only imagine that the meter is constantly running during his stay on the unit. Yet another procedure he will undergo (whether he wants to or not) is an assessment by a Behavioral Health Counselor for the purpose of determining whether or not he is entertaining suicidal or homicidal thoughts. I don’t imagine that I even have to allude to the cost of this procedure to the taxpayer. By the end of his stay, it is likely that Joe will have rung up quite a tab. And the service he received? Well, it was pretty much nothing more than an interrupted night’s sleep and a couple of sandwiches. Once again, anything over $10.00 charged to the state’s healthcare system would be a travesty. Anyone, however, who believes that the system is charged only $10.00 for this has probably not been paying attention to the healthcare debate that has been going on in this country for the past several decades.
Okay, it’s been twenty-three hours, so Joe has reached his time limit for staying in the Crisis Unit. He is homeless (as are most of CCARC’s patrons), so has no place to go. He has two options. He can self-discharge, which is the term used for simply walking out, or he can participate in yet another “service” provided by Community Bridges designed to defraud the healthcare system. It’s called placement. The organization may or may not receive some sort of remuneration for each individual they “place” into one of the recovery homes that appear on the lists that are given to clients to choose from. I have asked several of the Peer Support employees if they have ever been to the ones they assure patients are excellent choices, and the answer is almost always no. Since I would certainly like to believe that, if after having seen these places, they would immediately cease recommending them, I cannot imagine why physical visits to such places are not a prerequisite to work in Peer Support. But I digress.
Perhaps more important than the horrendous recovery homes that are forced down the throats of clients during the placement process is the fact that, in most cases involving regular clients (those who visit the facility almost daily), the entire process is little more than a game. This game is no doubt financial with regard to the recovery homes themselves—who no doubt benefit from anyone whose government-provided income could pay for their “services.” As previously mentioned, Community Bridges might benefit financially from this game, as does the transport company that provides transportation from CCARC to the placement destinations (the name of which I am purposely leaving out because this isn’t about them). What employees don’t seem to realize, however, is the fact that patients are playing this game as well. Since so many of them are just looking for a place to sleep for the night, they need only ask for placement and they will be allowed to remain in the facility until the transport company comes to pick them up. Since this can take several hours, patients are typically allowed to remain sleeping until after sunrise, at which time they either depart the unit or allow the transport company to give them a free ride to whichever part of the city they wish to go (under the guise that they are being transported to a recovery home). When they return to CCARC later that night and no one questions their actions, they simply engage in another round of the game. I’m sure that, if someone were to take a closer look at this game, all of the agencies that profit from it would have questions to answer. No questions would be as difficult to answer, though, than the ones asked of Community Bridges. The reason for this difficulty is almost definitely due to the fact that, while the powers-that-be in Community Bridges know exactly what is really going on, no one ever tries to rectify the problem. As a result, if Community Bridges only receives a pittance from this game, that pittance would have to be considered welfare fraud since it is almost always AHCCCS that ends up paying the bill.
Regardless, though, of whether Joe participates in the placement scam or simply self-discharges, he will likely return later on that day and undergo the entire process again. And, if he is like several of the patrons of CCARC, he will do this several nights a week in perpetuity. Indeed, several of the thirty-seven mentioned earlier were regular customers who were there to either sleep in the waiting room or get a bed and a shower on the Crisis Unit. In other words, they were simply making use of the Community Bridges homeless shelter. Sadly, despite the serious overcrowding and dismal conditions, many would be back the next night prepared to do it all again. Perhaps that is why those in charge of the organization don’t care about what really goes on at their facilities. So long as people keep coming back, the business model must be working.
How is it that Community Bridges is able to operate its homeless shelter in such a way as to burden the state’s healthcare system? One need only look at the title of the facility in question to answer that. Despite the fact that nothing about the scenario involving Joe may indicate this, he was being treated for substance abuse. All of the clients at CCARC are treated for substance abuse. For those paying attention, the A-R-C of the facility’s title stands for addiction recovery center. This being the case, everyone seeking “services” at the facility are ostensibly seeking addiction-recovery services. Whether or not sitting in a waiting room for eight or nine hours and then walking out has anything to do with recovering from a drug addiction…well, I suppose one must be an expert in the subject of addiction to see the connection. Either that or addiction recovery is simply the front used by Community Bridges to justify using Medicaid dollars to subsidize their homeless shelters.
Is this a unique situation, or are there more entrepreneurs making money off of the misery of others? One can only wonder. But here is something to think about. A major aspect of the Affordable Care Act (or Obamacare) is the expansion of Medicaid in the states that have chosen to participate. The states that choose not to expand their Medicaid services are typically controlled by Republicans. But recall if you will the opening paragraph of this piece. Could the almost inexplicable bipartisan trend in Washington to show compassion to those addicted to drugs have something to do with providing opportunities for forward-thinking business men and women to dip into the very Medicaid expansion dollars that they fought so hard to prevent? Again, one can only wonder.
In his bestselling book Freakonomics, economist Steven D. Levitt posits a connection between a rapidly decreasing crime rate in the late 1990s and the ruling in the 1970s in Roe v. Wade. His contention was that, since so many purposely discontinued pregnancies involve children that are not wanted, and unwanted children are more likely to get involved with the criminal justice system, there is a correlation. Despite how sound this highly acclaimed economist’s contention may have sounded to readers, I seriously doubt that there were many calling for criminal justice dollars to go toward funding abortions. Abortions are funded, however, by healthcare dollars (much to the chagrin of those who vote Republican). Whether or not this “social problem” should be burdening the healthcare industry is a question for much greater minds than mine. Anyone, however, who believes it should not needs to be paying more attention to the fact that some of their conservative politicians seem to have no problem with healthcare dollars funding the social problem of homelessness. And, in the case of Community Bridges, that funding is not doing much at all to solve the problem.