We see the signs. We hear stories about doctors charged with overprescribing or selling prescriptions. We read headlines about an opioid crisis sweeping the country. Heroin in lower income communities; prescription pain medication in the higher echelons. Kids, we hear, can smuggle Xanax and Adderall to each other in their school bathrooms. 

Sometimes, we see people on highway corners, the intersection of Coit Road and President George Bush Tollway, with cardboard signs that say “every little bit helps.” Every so often, haunting news appears on our feeds. 

We know, to a point, that we are not all right. One in five people struggle with mental health, and between 2014 and 2016, a total of 37,370 people in Texas were admitted to state-funded substance abuse treatment programs in 2015. Often, the two overlap. There are signs that our neighbors are in need of help, and intricate systems set up to help them, funds from the state and county levels, and private donations. But is it enough?

The System

At this moment in time, the North Texas region is defining itself on a grand stage, with big dreams and a bright future, projecting an attractive face to big businesses and newcomers attracted by the glossy promises of economic prosperity. According to the U.S. Census Bureau, the population of Texas increased by 12.6 percent between 2010 and 2017. By 2050, they expect it to hit 54 million people. It’s already a struggle to provide services when the population of people who need them is growing. 

LifePath Systems is the designated local authority on mental health and substance abuse. CEO Randy Routon has been with LifePath Systems since its beginning, and Tammy Mahan, COO, for 24 years. 

“We think of mental health and substance abuse as brain health,” Routon explains, “Like any other organ, when you have problems, you need support and medical help. That’s difficult when you’re an invisible person in the community.” They, and other substance abuse centers in the area, are ports of last resort. The people who they work with are often in desperate situations, due to substance abuse, mental health, or often, both. 

“We don’t shun people because they have cancer,” Mahan says. Issues like mental health and substance abuse, she adds, should be no different.

Currently, the way we handle substance abuse and mental health—taken together under the umbrella of behavioral health—is a relatively new process. Once upon a time, LifePath was one of many providers of services for those in need. For about 20 years, Collin and seven surrounding counties pooled their funding for behavioral health, under a provider called NorthSTAR. It was distributed by ValueOptions of Texas, Inc., who contracted directly with individual providers in Collin County and others. However, in 2015, the Collin County Commissioners Court removed the county from that agreement. 

“In this system, services have been increasingly centralized, diminishing local control over how to most effectively and efficiently configure indigent behavioral health services,” they wrote in a March 2015 statement. “Individual proprietary contracts have clouded the transparency expected in a public system of care. Perhaps unintended consequences of this practice are fragmentation and duplication of services across among providers.” Instead, they suggested establishing their own separate Local Mental Health Authority (LMHA). They appointed Collin County MHMR, (LifePath Systems) to take over from NorthSTAR and hopefully, do a better job.

The board of trustees at LifePath Systems was formed and appointed by the Collin County Commissioners. They became responsible for providing indigent care, as well as distributing and utilizing county and state funding to the many contractors and nonprofits in the area who need it. 

It meant that on January 1, 2017, LifePath Systems took over management of Collin County’s funds and resources, as well as crisis response, mobile outreach, consumer benefits, and the entire range of services that NorthSTAR had been providing. They had to be able to serve people in their homes, offer community education and engagement, contract with the other nonprofits in the state and more, and do it better and with more transparency than it had been done before. 

“We grew $10 million in one day,” Routon says simply.

In August 2017, LifePath Systems opened a crisis center for residents of Collin County. This center features 22 beds with two separate units: an eight-bed Extended Observation Unit (EOU) and a 14-bed Crisis Respite Unit (CRU). The EOU is designed for emergency stabilization to individuals in behavioral health crisis in a secure, protected, clinically-staffed psychiatrically supervised environment with access to urgent and emergency medical evaluation and treatment. This unit is open and accepts admissions 24/7. “Our piece is crisis response,” Mahan says. 

In 2018, they served 8,000 people in face-to-face, in the fields of mental health and substance abuse, which both fall under the umbrella of behavioral health. They reported 300 people were getting medication for substance abuse, methadone for example. Through contractors, there were 466 people in outpatient, 360 in detox or residential services. The majority of their substance abuse services are contracted out.

Two years later, LifePath is proud of their crisis hotline; instead of calling 911 for substance abuse problems, they ask people to call them. They’re proud of a grant they have with the sheriff, to divert people struggling with mental illness out of jail, and the Open Access Clinic, for those who require state-funded assistance and are seeking mental health or substance abuse services.  They also have a new center, Legan Place, where they offer “coordinated specialty care” for people who could be in the early stages of psychosis.

The Strain

However, there are cracks in the system. There are still long waiting lists for certain services, and stretching state funding is LifePath’s most pressing challenge. “State funding is not good,” Routon says bluntly.

This strain impacts the way LifePath is able to provide its essential services. As in an emergency room, the most severe needs must be met first. If someone calls the hotline and their emergency meets the standards for the Open Access Clinic, the mobile crisis team is dispatched. They’ll respond within an hour if it’s life or death; if it’s less of an emergency, they will respond within eight hours. Their mobile crisis teams are already busy. 

LifePath then tries to find each client the help they need. Nonprofits like Nexus Recovery, Homeward Bound Inc., and Turtle Creek Recovery Center can offer limited numbers of detox beds for people suffering through dangerous withdrawal from alcohol or heroin, and the Samaritan Inn, Collin County’s only shelter, can sometimes help with transitional housing. Ideally, every person is cared for.

“In some areas we need to bolster [our resources] just for today’s population,” he admits. Sometimes there’s just not quite enough resources to go around. “If everyone we want to call us starts calling [our hotline], we’ll need more people.” The county is already over one million people. Soon, he adds, we’ll need more of everything. 

Mahan says that they aren’t yet forced to turn people away at the highest level of care. They’re working to respond to hospitals quickly, and they’re grateful for the funding they do have. But one major pitfall for Collin County is its lack of a public hospital, and there are not enough psychiatric inpatient beds. Sometimes people who need specialized care end up stuck in the ER because the county has a shortage of private inpatient beds. They’re desperately needed, but they just aren’t profitable enough for private hospitals to justify, Routon explains. 

“We have state funds to pay for detox, but sometimes there’s no available beds in the area,” Mahan adds. “We send a lot to Dallas, even up to Texoma. Wherever we can.”

Homelessness is also a growing problem, and Collin County only has The Samaritan Inn.

“We’re well off in terms of median income but there are people here that are struggling, individuals, families …” Mahan trails off. “Nexus is just for women. It’s especially hard to find a bed for an adult male.” Sometimes, the problems compound, and they face a waiting list to get people into detox and residential treatment programs. 

In terms of days to wait, “It’s never more than single digits,” Mahan says. Detox is five days and inpatient can be up to 30 days. Yet, waiting for detox means putting off a critical medical necessity. 

One former LifePath employee was particularly appalled that those in need ever faced a waiting list for detox at all. They compared it to leaving a bleeding gunshot victim in the streets. 

“People come in ready to go to treatment and if we can’t send them, because we have limited slots, or we’re out of money—well, people who are coming in, wanting treatment, won’t want treatment in a week. They need it now,” the former employee said. “If we don’t have space for them, we lose them.” Furthermore, often clients who come in have been through some kind of trauma. “You have to be prepared to deal with what they tell you,” they caution. Trauma-informed care is hard to deliver within the constraints of a deadline. 

The former employee lived in Plano during the city’s well known heroin epidemic of the 1990s, when there was a huge spike in teenagers and young adults overdosing on black tar heroin. Not only was the crisis appalling, it also put Plano on the national stage. 

“People don’t want the community to be known for having a drug problem,” a local doctor told Rolling Stone at the time. “The city council, the police department, big business, whatever. They don’t want to talk about it.” Eventually, the local police formed the Plano Heroin Task Force, leading to 13 arrests, and the city was briefly the poster child for rampant substance abuse hidden away in idyllic suburbs. 

Collin County’s difficulties, more than anything else, seem to be symptomatic of a statewide problem. In October 2018, The Austin Statesman reported that the average wait for a person seeking state-funded residential inpatient treatment in Texas was 31 days, according to data from the Texas Health and Human Services Commission. The wait to get into a detox program—deemed medically necessary—was between six and 22 days. 

Thus begins a frustrating dance of shuffling resources and people, of balancing budget and safety to get everyone where they need to be. It’s not without its pitfalls. 

“I can’t tell you how many times I referred people to ER and they didn’t go because they didn’t want the bill that goes with it,” the former LifePath employee recalled. “They can’t just stop drinking; they could have a seizure and die. It’s unethical to tell them to keep drinking, but you can’t tell them to stop drinking. They need detox.” But if there are no beds at a nonprofit, and they can’t handle the bill, then what options are left to them? 

For example, despite all the shuffling, sometimes Collin County patients end up at the nearest public hospital, Parkland Memorial Hospital. 

Parkland Memorial Hospital is the public hospital of Dallas County, among the busiest public hospitals in the nation, with more than one million patients every year. But Mahan stresses that Parkland is not for Collin County residents. It’s no surprise. Between Parkland and counties like Collin, there has long been a bone of contention. For Collin County residents who can’t foot looming private hospital bills, yet need the ER, they often will choose not to go at all—or, they and people like them will go to Parkland, the nearest public hospital where they can get the treatment they need. But often, Parkland and Dallas County taxpayers are left eating the cost of out-of-county visitors.

In a 2017 Dallas Morning News article, Parkland Memorial Hospital CEO Dr. Cerise expressed his frustration that poor residents of surrounding suburban counties like Collin, Denton, Ellis and Kaufman, were coming to Parkland—and their counties are not reimbursing them for the cost, leaving it to Dallas taxpayers. In that year, Dallas News reported that these unfunded patients had cost $27.4 million, a 72 percent rise since 2012. Parkland reported a loss of $6 million alone on Collin County residents who visited nearly 6,000 times. 

“You hear about people showing up at Parkland looking for medical care,” Mahan says. “I don’t know the numbers.” 

“Parkland has pushed a political agenda that people [counties] should pay “x” amount so [out-of-county] people stop coming to Parkland, but that’s a hot fight when you start telling other counties how much they should pay,” Routon adds. 

So if someone can’t afford to cover their ER bill, but doesn’t meet the standard for indigent care in Collin County; if there are no beds available in our shelters or our treatment centers; if they’re facing down a detox with the risk of death, and they can’t go to Parkland … what can they do? 

Mahan and Routon’s jobs are to find solutions and to place people where they can get the help they need. After their years in the realms of psychiatric care, they both understand the severity of the issues they are dealing with. 

LifePath decides what the budget should be, and presents it to the County Commissioners, and Mahan says that in comparison to other counties, Collin County commissioners are “very supportive.” 

And yet, signs point to an uncomfortable answer: it’s still not enough. 

Routon wishes that there was a way to encourage private hospitals to increase their inpatient and detox beds. “They’re great hospitals, lots of resources, but they’re reluctant to get into that area. It’s not profitable for them.” Mahan wonders if there is a way that cities could contribute; the city of San Antonio supports a sobering center to help get people off Riverwalk who could be dealing with substance abuse, and Harris County collaborates with Houston for additional services. It would all depend on what citizens of Collin County want. 

“There’s also a national workforce shortage in psychiatric services,” Routon adds. “Especially in the lower-paid jobs. They have a hard time living in Collin County.” 

“Yes, and affordable rent [in Collin County] is very difficult,” Mahan says, of clients and staff. Often, their crucial support staff, about 150 people, can’t find places to live in Collin County. There are many problems that come to mind.

But their biggest and most pressing concern is whether legislature will be able to keep up with Collin county’s growth. “Legislature has begun a process of looking at needs throughout the state; they have a 10 year plan,” he says. “But our needs…they aren’t even going to study that until 2025.” 

The Stigma

Can we wait five years, not to start implementing change, but to simply start paying attention? Are we, now two years into LifePath Systems’ tenure as the authority on behavior health, in a solid holding pattern? Are we equipped to care for our indigent and our sick? Some nonprofits, Grace to Change, located in McKinney, for example, reported in August that they had run out of their state funds—85 percent of their total budget—a full month before the beginning of the next fiscal year. They asked donors and supporters to help keep them afloat in the meantime. Assuming the projections are right, and the population booms as its expected to, will the dam hold?

“It’s definitely not enough,” Routon says. “Substance abuse may not be on your doorstep and if it’s not, be grateful. But it is at someone’s. For us to be the kind of community we want to be, it’s incumbent on us to take care of [that person].” 

To an outsider, it appears to be a thinly veiled crisis. Nonprofit workers are facing down an oncoming storm. They want to stay hopeful, and keep faith alive, but reading between the lines, there’s worry, and some exhaustion. They are our safety net, and they are straining under growing weight. 

“Drug addicts don’t want to be drug addicts,” one founder of a substance abuse counselling center says. It’s critical that people suffering from addiction have somewhere to go for help. “[Otherwise] people have nowhere to go but back to their drug environments. If they do that, they will use again.” 

There are a million pressure points in the system, from boosting the hotline so that more people get into treatment faster, sparing them the trauma of a 911 call, to finding more beds for those who need detox, or simply, shelter for the night. Kids and schools need to be educated about the dangers, and people with addictions need to be provided long-term care and counseling. The population of people in need won’t shrink; addiction is a lifelong battle. When it comes to heroin, for example, our brains remember the high, triggering cravings years later, even after they get clean. It never quite lets go.

“We’ve been here since ’84 and we work as hard as we can, and the growth is passing us all the time,” Routon says. “If the explosion continues, there’s going to be a lack of resources. Give us a million dollars today, but it takes us six months to get programs running. We have to do it now. We can’t wait until it hits.” 

Originally published in the February 2020 issue of Local Profile under the title “Invisible People”

Alexandra Cronin

Alexandra Cronin has been the senior editor at Local Profile since 2016. She loves great coffee, good food and average wine.