Feud Threatens Touted Mental-Health Model

For years Ventura County has provided a promising model for how to help mentally ill people who are slipping away from reality.

Troubled teens who see no way out of a paralyzing depression are given medications and receive help with school, with the courts and with their own scared families. Schizophrenics haunted by terrifying voices are hospitalized, offered an array of services, and then, if possible, eased back into society.

It is a system that is far from perfect. Since care began to shift from state hospitals to communities in the 1970s, Ventura, like other counties, has struggled to provide for the mentally ill.

Many still wander the streets alone, confused and delusional. There is not enough supervised housing, critics say, and mentally ill people too often end up jailed or dead.

But there is consensus that Ventura, perhaps more than any other county in California, has made progress. The county’s team approach to managing mental illness has resulted in decreased group-home placements for children, better school attendance and a lower rate of patients involved in criminal activity, according to an independent study.

“Ventura’s system of care does very well. Enormously well,” said Sandra Naylor Goodwin, director of the California Institute for Mental Health, a Sacramento group that advocates research and training in the mental health field. “Enough to convince not only the mental health community but the Department of Finance that this is a program to get behind.”

But now there are fears that bureaucratic infighting is tarnishing Ventura County’s progressive reputation. And questions have been raised about whether the so-called Ventura Model for treating the mentally ill will survive as a program worthy of imitation.

The dispute pits ousted mental health director Stephen G. Kaplan and Health Care Agency Director Pierre Durand against each other--the subordinate and his boss. It pits liberal forces on the Board of Supervisors against the conservatives. And it pits those who advocate care at considerable expense against those who demand accountability for every dollar spent.

It is, essentially, a turf war. And it is the messiest battle to consume county government in years.

“People are devouring each other. The system is being devoured,” said Supervisor John K. Flynn.

Proponents of the model, led by Kaplan, County Supervisors Susan Lacey and Kathy Long and state Sen. Cathie Wright (R-Simi Valley), say the system is helping thousands of mentally ill people regain a more normal life.

Instead of languishing in locked psychiatric wards, the mentally ill are now living in the community, holding down jobs and forming friendships.

Supporters worry that the recent ouster of Kaplan and two of his aides in the county’s Behavioral Health Department signals that a change for the worse is underway.

“We have been a model in so many ways for so many years. People have been so creative,” said Penny Matthews, who left the department in November for family reasons after 17 years. “To have it torn apart is sad. It feels like all of our hard work is going down the drain.”

But supporters of Durand, who forced Kaplan’s resignation last week, say employees are overreacting. Kaplan’s departure, they say, does not mean the Ventura Model is being thrown out.

Kaplan was ousted for giving bad advice to supervisors when he encouraged them to merge his department with the county’s social services agency, say Durand’s supporters, led by Supervisors Frank Schillo and Judy Mikels. Kaplan’s inaccurate analysis, they say, prompted a federal review that could cost the county up to $15 million in lost federal funding.

Durand is making changes in Ventura’s program, but it is little more than fine-tuning to give more emphasis to the doctor’s role in managing those with schizophrenia, depression and manic-depression, supporters say.

Durand and two other key supporters of the change are planning a news conference for today to further explain their vision of the revamped mental health agency.

The changes, they insist, are necessary to bring Ventura County into compliance with Medicare billing rules.

“We have a clean slate,” Schillo said. “We can take the best of the Ventura Model and make changes that will make it even better.”

Troubles on Heels of Durand Takeover

The current dispute began to build even before Kaplan’s tenure as director of Behavioral Health. It started in 1995, when former Health Care Agency Director Phillip K. Wessels died, and Durand, his top deputy, was promoted.

The sprawling agency, which operates the Ventura County Medical Center, the coroner’s office and the mental health department, is the county’s largest, with a $201-million budget and 1,579 employees.

Durand was already a star. He and Wessels had been called upon in the mid-1980s to take over a county hospital suffering from a $12-million deficit. The hospital was being run in an almost primitive fashion, Matthews recalls.

“If you went to the emergency room, you couldn’t pay for your treatment because there was no mechanism in place to take the money,” she said. “When Pierre took over, he did a good job of putting the hospital back into the black.”

Durand, a former chief deputy in the auditor-controller’s office, purchased a $2.5-million computer system to streamline claims, laid off 200 of the agency’s 1,200 employees and shut down a quarter of the medical center’s beds. He started a network of clinics to expand services to the poor and obtained a managed-care license to operate an HMO for county employees that saved the county $400,000 a year in benefit costs.

His financial expertise gave him considerable clout with the Board of Supervisors. By the time he took over the Health Care Agency, the board had gained two like-minded fiscal conservatives--Schillo and Mikels.

Lin Koester, who had earned a reputation as a disciplined budget manager during 16 years as city manager of Simi Valley, had also just been appointed county chief administrative officer.

The conservative alliance formed by Durand, Koester, Schillo, Mikels, and, occasionally, Flynn, a crossover Democrat, became a powerful force in county government. But in the Health Care Agency, Durand found himself up against another county force: Randy Feltman, who was then director of the mental health department.

Feltman had his own considerable reputation, as an architect of the Ventura Model. Feltman had had an integral role in developing the program in 1984, when it was for children only, and his involvement continued when it was expanded to include adults three years later.

Then-Assemblywoman Wright wrote the legislation that gave Ventura County $1.5 million to try out the program as a demonstration project in 1984. Lacey was instrumental in getting the county board support for the program. Today, the county receives $5.3 million a year in special funding to serve as a model for other counties.

Feltman’s success brought him respect and powerful political connections across the state and nation. But Feltman eventually had a problem. He butted heads with his new boss, Durand.

Feltman won’t talk about his relationship with Durand, who declined to be interviewed for this story. But according to Matthews, Feltman believed Durand was micro-managing the mental health department. Durand demanded, for instance, that employee travel be curtailed, although Ventura County was obligated to provide assistance to other counties adopting Ventura’s mental health reforms, Matthews said.

The two continued to clash, partly because of their different styles. Feltman was personable and ran a relaxed operation, she said, while Durand was no-nonsense and made fiscal accountability a priority.

“Randy was trying to fight him. He was not a yes man,” Matthews said.

But Feltman’s supporters say he paid a price. When Durand merged alcohol and drug programs with the mental health department in 1996, he passed over Feltman to name Kaplan as director of the new Behavioral Health Department.

Feltman was given a deputy director’s position in the Health Care Agency for a few months, then moved to Koester’s office to supervise a reorganization of the county’s welfare system, where he has flourished.

That left Kaplan in charge of mental health. He soon began having problems with Durand, often disagreeing over how the mental health department’s budget should be spent, sources say.

“Durand’s priority is the medical center,” one source said. “It’s bigger, far more visible. That’s where he made his mark.”

According to Matthews, Kaplan began looking for a way out. He approached Durand about the possibility of making Behavioral Health a stand-alone agency and was turned down cold, she said.

“Pierre almost never talked to him again after that,” Matthews said. “That was Steve’s death knell.”

Kaplan then pursued the idea of merging his department with the Public Social Services Agency. Publicly, Kaplan presented the merger as a chance to improve public services by combining agencies that often serve the same clients.

But privately, colleagues say, he also saw it as way to wrest his department free from the Health Care Agency. “That would be an added bonus,” Matthews said.

Gathering Support for Merger

Kaplan and Barbara Fitzgerald, director of the Public Social Services Agency, began quietly gathering information on how to make the merger work. Both say they consulted with state health care billing officials, who assured them there would be no problem.

But they failed to check with federal Medicare officials, the source of the money--an oversight that would cost them dearly. Meanwhile, Lacey began advocating the idea of the merger, and by April 7 she had three votes.

She made the motion to combine the departments, creating a new Human Services Agency. Flynn and Long supported the motion, and Schillo and Mikels opposed it. The supervisors had held only one public hearing on the matter--on the day of the vote--and each speaker was limited to one minute.

The mega-agency was created against the advice of Koester, who recommended taking more time to study the issue. The board majority also ignored a consultant’s report that had warned two weeks earlier that the county could lose up to $15 million in medical funding if the merger was not done right.

Schillo called the merger “a coup” by Lacey. Mikels fired off furious letters to newspapers about what she called an exercise in empire-building. From that point, the war went public.

Merger opponents, including members of the patient-advocacy group Alliance for the Mentally Ill, attended every meeting of the Board of Supervisors to blast the move. Psychiatrists were making their displeasure with the merger known by calling and writing letters to federal officials.

It soon became clear that the consultant’s call for caution turned out to be right: Federal officials told the county that the way it intended to manage the consolidation was not legal. Without federal approval, the county could lose between $11 million and $15 million a year in health-care payments for treating mental patients, federal officials told the county.

Lacey and other county officials tried to negotiate a management plan acceptable to the U.S. Health Care Financing Administration. But they were turned down three times.

On Dec. 22, four supervisors voted to rescind the board’s earlier action and returned the mental health department to the Health Care Agency. Lacey dissented. Schillo criticized Kaplan for failing to properly inform the board about problems with the merger and said he should be held accountable for exposing the county to the potential loss of money.

Within a month of the merger’s failure, Durand forced Kaplan to take a 30-day leave. Kaplan’s top deputies, Kevin DeWitt and Judy Balcerzak, were also ousted. A draft organizational chart elevating psychiatrist David Gudeman and other doctors into management roles was circulated.

Schillo said it was an appropriate response.

“In business if you screw up, you are called to account. Why should government be any different?” he said. “These people are saying, ‘I’m a victim.’ Nah, there are no victims here.”

Differing Views on Dispute’s Effect

Does a change in leadership in the Behavioral Health Department mean that services for 8,000 mentally ill people will be affected? It is too early to tell. But both sides in the dispute are putting their spin on predictions.

Those who support Durand’s changes say services will improve because Durand will emphasize a medical approach to care. Mental illnesses are primarily a medical problem caused by brain disorders, Durand’s supporters say, so it makes sense to focus on medical solutions.

Ed Nani, president of the Alliance for the Mentally Ill, agrees. He has long questioned whether Ventura’s team approach works for everyone.

Under the model, 13 teams of social workers, nurses and psychologists work closely with psychiatrists to develop a treatment plan for each patient. Social workers help patients prepare for jobs and get them to interviews. A nurse keeps track of physical health, and a psychologist offers therapy. A psychiatrist diagnoses illnesses and dispenses medications. The teams meet daily to discuss their patients’ progress.

The people who benefit most are those who recognize their illnesses and take their daily medications, said Nani, whose group represents parents of children with mental illness.

Those suffering from more severe illness need closer medical supervision or even hospitalization, he said.

Nani said he feels fortunate. His 33-year-old son, a schizophrenic, lives at the Las Posadas rehabilitation center. The 30-bed Camarillo facility is “the Cadillac of care” for people with serious mental illness, Nani said.

He believes that money spent to provide social services on the teams might be better used to build more shelters.

Mental health officials, however, say the current model is working and should not be changed. Doctors already make all medical decisions, including prescribing medications. Giving them increased control over other team members would violate the spirit of the team approach, they say.

Sharon Robinson said she hopes the system remains intact. The help her 22-year-old schizophrenic son, Jeff, receives from his team gives her hope that he will one day get a job, obtain his driver’s license and move out on his own.

“If he stays on the right medication and is helped along the way, I’m optimistic that some of these things are going to come to pass,” said the Ventura mother.

The fighting is far from over. Wright recently accused Durand of siphoning money from the mental health department to cover expenses at the county hospital. At her insistence, the state Department of Mental Health will audit the Behavioral Health Department’s finances and programs.

Other financial reviews are underway by county and federal agencies. The political alliances are hardening. Mikels and Long must decide whether part of the merger can be salvaged.

Meanwhile, mental health advocates across the state are wondering what went wrong in Ventura. Ventura County’s system “is the way we think we ought to do business,” said Catherine Camp, executive director of the California Mental Health Directors Assn.

“I have faith the Board of Supervisors will work out what is needed,” Camp said. “But I hope it won’t take so long that the services fall apart.”

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

The Battle Over Mental Health

The controversy over the best way to deliver services to the mentally ill has produced high-level political warfare and broken the county’s decision-makers into rival camps.

FOR MERGER

BOARD CHAIRWOMAN SUSAN LACEY: Lacey was the leading advocate of last year’s failed attempt to merge the county’s mental health and social service agencies. She is an ally of Stephen G. Kaplan, former director of the mental health department, and Randy Feltman, deputy director of welfare reform.

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STEPHEN G. KAPLAN: Kaplan resigned as director of the county’s mental health department last week. Supporters say he was forced out by his boss, Health Care Agency Director Pierre Durand, because he attempted to remove his department from Durand’s control. Durand’s camp says Kaplan was ousted because he misinformed the county supervisors about whether the merger would work.

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BARBARA FITZGERALD: Fitzgerald, director of the Human Services Agency, was a strong advocate of the merger. She is aligned politically with Lacey and the two other Democrats on the board of supervisors, Kathy Long and John Flynn.

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SUPERVISOR KATHY LONG: Long favored the merger in Apil, but voted to rescind it eight months later. She is part of a group looking into salvaging part of the merger.

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SUPERVISOR JOHN FLYNN: Flynn voted in favor of the merger. When it became clear that the federal government considered the new structure unacceptable, Flynn changed his vote.

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AGAINST MERGER

PIERRE DURAND: Durand has managed the mental health department and the county hospital since 1995. He is a fiscal watchdog who put the county’s financially ailing public hospital back on solid footing. He was opposed to the merger and is aligned politically with Lin Koester and the board’s conservative minority, Supervisors Judy Mikels and Frank Schillo.

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LIN KOESTER: Named chief administrative officer in 1995, Koester is considered a no-nonsense fiscal manager, a former Navy officer who emphasizes discipline, order and hard work. Koester recommended that the board do more study before moving forward with a merger. He is allied with Durand.

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SUPERVISOR FRANK SCHILLO: Schillo and Judy Mikels opposed the merger, contending it was pushed through with no public review. Schillo has publicly criticized Kaplan and Fitzgerald for giving the board bad informatoin about whether the merger would work. Schillo says Kap lan was ousted because his faulty analysis put the county at risk of losing up to $15 million in federal funding.

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SUPERVISOR JUDY MIKELS: Mikels harshly criticized the merger, calling it an exercise in empire-building. Mikels and Schillo support the changes Durand is making in the mental health department, saying they are necessary to make Kaplan accountable for the merger’s failure and to meet Medicare certification requirements.