Heralded just nine months ago as a “comprehensive system of care” and a “holistic approach” to behavioral health care, two of Nevada’s five certified community behavioral health clinics are no more after the state revoked one facility’s certification and another voluntarily agreed to give up its status.

The state found that one of the clinics, operated in Las Vegas by the non-profit WestCare, failed to adequately treat high-risk clients at the appropriate intensity, refer patients with severe mental illness to a partner organization to receive rehabilitation and coordinate with primary care doctors to ensure patients are receiving treatment for physical health concerns. In one case, inspectors found that a client diagnosed with major depression disorder and a history of thyroid disease wasn’t receiving a continuity of care through a primary care doctor.

Nevada is one of eight states that was chosen by the federal government to participate in a two-year Certified Community Behavioral Health Clinic (CCBHC) demonstration program starting in June 2017 and identified five clinics to participate: two in Las Vegas, one in Reno, one in Elko and one in Fallon. In exchange for providing an expansive array of mental health and addiction services, basic primary care screening and coordination with primary care providers, the clinics receive an enhanced Medicaid payment rate based on anticipated costs of care.

“Essentially, a demonstration waiver is what I’d call a rigorous research project at a clinical level,” said Stephanie Woodard, a clinical psychologist with the state Division of Public and Behavioral Health.

The clinics have been described as “behavioral health homes” for clients, with the goal of providing crisis mental health services, outpatient treatment and referrals to other providers in the community, including primary care doctors, psychiatric rehabilitation services and peer, family support and counselor services. There’s a specific list of nine-essential services they have to provide and a laundry-list of other criteria they must meet in order to qualify as a CCBHC and receive the additional funding.

Woodard said three of the CCBHC clinics are doing “exceptionally well” and the state hasn’t had any issues with them. Two of the other clinics, both operated by WestCare, have struggled under what Woodard described as a “huge lift” for clinics.

“There were so many pieces,” Woodard said. “It was a big undertaking for any clinic.”

The state revoked the CCBHC certification for WestCare’s Las Vegas clinic last week, saying that the clinic failed to fix the deficiencies identified in the state’s November inspection. WestCare spokesman Bob Vickery said Wednesday that the organization has appealed the revocation to the state.

“When the CCBHC designation was awarded to WestCare, unlike other CCBHC designees, we had not one but two locations to stand up, one in the north in Reno and one in Las Vegas. It’s a pretty heavy lift to meet all of the criteria. What’s going on with that is WestCare worked diligently to get everything in order in place to meet all of the requirements, and I think the state had some questions about that,” Vickery said. “We’ve elected to appeal the decision to the state regarding the CCBHC. In the end, we believe we will prevail.”

WestCare also decided to voluntarily close its second clinic in Reno earlier this month, noting in a March 14 letter to the state that their ability to provide the level of services required under the certified community behavioral health clinic model was “significantly diminished” after it lost a clinical supervisor and three clinical social worker interns. WestCare Senior Vice President Jason Engel wrote in the letter that the organization decided to relinquish its CCBHC certification, recognizing that it would take time to recruit, hire and train staff to replace the staff members necessary to provide the level of care required, but would continue to operate its community triage center and other programs in Reno.

But Vickery said on Wednesday that WestCare wants to wait and see what the state has in mind through the appeals process before deciding future plans for its Reno operations, but that regardless of the CCBHC designation, WestCare will continue to provide all the same services it has been both in Las Vegas and Reno.

“We will continue to provide not only those nine essential services, but we will continue to provide services to folks in any capacity we have,” Vickery said. “The thing with CCBHC is it’s a heavy lift. It requires the designees to get a lot of things in place in order to be in compliance with that.”

To that end, inspectors with the Bureau of Health Care Quality and Compliance said in a March 20 letter that the Las Vegas clinic had failed to “fully provide” the services required of a CCBHC and revoked the clinic’s certification effective immediately. Inspectors said that a visit to the clinic on Feb. 7 and 8 revealed that they failed to resolve the issues noted in a December corrective action plan.

For instance, the corrective action plan revealed that the Las Vegas clinic did not have the necessary agreements in place with other community organizations to provide an array of services, including Medication Assisted Treatment, Child Psychiatry, Psychosocial Rehab and Basic Skills Training. Inspectors noted that WestCare was “actively collaborating” with the federally-qualified health center FirstMed and that an agreement would be in place in 45 days, a timeframe the state deemed “unacceptable.”

“These services should already be in place,” the corrective action plan stated.

A spokeswoman for FirstMed said Thursday that the health center has never had an agreement with WestCare, nor do they plan to enter into an agreement with WestCare.

Inspectors also found that WestCare had not trained staff in certain required evidence-based practices, despite the fact that those practices had been selected in August 2015 with the full knowledge of the CCBHCs, that patients were only being provided with primary care coordination if they did not have a designated primary care provider and that clients with severe mental illness were not being referred out for more intensive rehabilitation.

Woodard said that with any other program, the state may have had greater latitude to work with WestCare to reach compliance. But Nevada has to maintain fidelity to the CCBHC model, she said.

“To move forward with a CCBHC that wasn’t meeting certification criteria could’ve jeopardized the demonstration program for the state, which we obviously wouldn’t want to have happen,” Woodard said.

Woodard said that other states have had CCBHCs drop out of the demonstration program too, and that WestCare continues to be “really valued partners” for the state, calling them a “vital substance abuse treatment system in the communities they serve.”

For their part, Vickery said that WestCare can now “absolutely” say that it has put in place every requirement for a CCBHC. He said he doesn’t know how the state will view it, but that WestCare has “done our due diligence and made all the corrections necessary.”

“CCBHC is an important designation because it does bring more people to us and allows a greater array of services and continuum of care,” Vickery said. “But the big issue right now for Las Vegas especially is we need to find a way to serve these folks that otherwise will never get treatment.”

Updated 3-29-2018 at 3:22 p.m. to include additional information from FirstMed.