Editor's note: This story is part of a semester-long collaboration of nine senior journalism students called Project 573. Now in its second year, the project lets students with different journalism backgrounds (print, photojournalism, radio, television and strategic communication) work together to shed light on a topic that doesn't get much attention.
This year's topic is mental illness in mid-Missouri. People living with mental illness face a harsh reality. Stigma surrounds disorders and diminishing resources make help harder to find. While much of society ignores the problems, dedicated individuals work to fill the gaps.
Cathy Richards’ first four-year term as Boone County public administrator comes to an end this year. She is seeking reelection, but will face competition from an unlikely candidate — a retired public administrator who previously endorsed Richards’ campaign.
Connie Hendren served as Boone County’s public administrator for 16 years before retiring after 2008. She supported Richards as her replacement at that time. She since changed her mind.
“I would like to go back in and bring things back to where they once operated, which was efficiently and cooperatively,” Hendren said. “And I would like to work with the clients again.”
Hendren acknowledges that the client base has grown since her retirement (official, annual reports say the increase has been 18 clients), but believes Richards has over-exaggerated the increase in workload.
“I’m not aware of any of the resources that were there when I left that are not still there,” Hendren said. “I think that’s a specific that needs to be named. It’s very hard to justify.”
Hendren believes her personal experience with mental illness is important. Since the spring of 2007, she has served as guardian and conservator for her sister, who is five years younger and lives with bipolar disorder.
The election will be held in August.
An Unsung System tells the stories of these individuals. In upcoming weeks, you will find many of the stories in the Missourian, as well as on KBIA and KOMU. The entire project can be found at www.unsungsystem.project573.com.
COLUMBIA — Today’s task seems complicated.
Boone County Public Administrator Cathy Richards has a client who received a rent rebate, a check from the Missouri Department of Revenue that gives the elderly and disabled a return on a portion of their annual rent expenses.
Richards knows the rebate — usually between $500 and $750 — can mean a lot to a client: a new pair of shoes, a visit to an eye doctor or a birthday present for a family member.
But Richards also knows the money will increase this client’s personal checking account past $1,000. And that’s a problem, because $999.99 is the cut-off point for receiving Medicaid benefits.
Richards knows what to do. Since starting her job in 2009, she has encountered this problem many times. She takes a seat in the third-floor Boone County courtroom that is home to the probate court, the branch of jurisdiction that deals specifically with the clients Boone County voters elected Richards to serve.
Richards waits patiently for a judge’s approval on a petition that will allow the rent rebate to be moved into the Midwest Special Needs Trust, a nonprofit agency that cannot hurt the client’s chances of receiving Medicaid assistance because it operates independently from state government.
Making the most of a client’s money is just one of the ways Richards and her staff work to support Boone County clients who require the office’s assistance.
“You’ll never get it all,” the 59-year-old says of her job responsibilities. “Because something pops up all the time.”
The somethings stem from the more than 400 people who live under the care of the Boone County public administrator. These individuals — known as clients or wards — have been deemed incapable of living completely independent lives by the county’s probate court.
Some are children without parents. Some are elderly, also alone. But most, the office estimates 90 percent, live with mental illness.
In serving that 90 percent, Richards walks the thin line between fiery advocate, compassionate caretaker and no-nonsense business manager.
But her job is getting harder. The number of Boone County clients has increased by 136 in the past 10 years. While the number has grown, local, state and federal governments continue to put funding for mental health services at the bottom of the priority list.
The repercussion is the public administrator’s office trying to do more with less, an effort that is largely unknown to the Boone County taxpayers who pay the bill.
The unknown office
Some call to ask for directions. Others want to file complaints about road surfaces or driving conditions.
Employees in the Boone County public administrator’s office laugh about the random phone calls they have received from people who misunderstand its role.
“A lot of people don’t know what we do,” said Johanna Sickler, an office accountant.
These are the facts:
The Missouri General Assembly established the office of public administrator in 1880. Now, all of the state’s 114 counties, along with the city of St. Louis, have their own public administrator. Every public administrator but three (Jackson County, St. Charles County and the City of St. Louis) is chosen by election every four years.
One responsibility of the office is assuming control of homes, bank accounts and other estate items that cannot be passed along after someone in the county dies.
The more important, time-consuming duty is providing the most freedom and best lifestyle to the clients who are still living.
There were 398 clients assigned to Cathy Richards’ care in some way at the start of 2012. The clients live in houses, apartments, residential care facilities and state psychiatric centers that are spread across Missouri.
An estimated 90 percent of her clients are mentally ill, a percentage that is similar for most of Missouri's public administrators.
“Most of the people this office takes care of have a chronic, persistent mental health condition, often with co-occurring disabilities,” said Terry Edwards, acting president of the Missouri Association of Public Administrators and current Platte County public administrator.
Richards’ clients who live with mental illness fit no particular mold.
They include a young woman who has been diagnosed with paranoid schizophrenia, whose mother, living with the same illness, is a client in another county. They include a soldier who battles post-traumatic stress disorder.
Some of Richards’ mentally ill clients have committed dangerous crimes and are watched around the clock at Fulton State Hospital. Others live in apartments and go to work every day.
All go through the same legal proceedings to get to Richards.
The process starts when someone’s struggle with severe mental illness becomes public in some way. An arrest is made. A hospitalization occurs. A concerned neighbor calls a hotline. A family member needs help in order to cope.
A county’s probate court determines if an intervention is necessary.
The court has three options once it determines that a person with mental illness is a risk to himself or herself or others:
- The court can appoint a conservator to manage the person’s finances.
- It can strip the person of his or her rights and assign a guardian to act in the person’s best interest.
- It can order that the person receives both a guardian and conservator.
These three court-ordered approaches can be varied slightly to meet a client’s individual needs.
“The state takes it very seriously, taking away someone’s rights," Richards said. “I mean that’s a big thing. But when it finally ends up in court, you know pretty darn well (the state) has tried everything to have (clients) keep their rights. But they just can’t make good, informed decisions without harming themselves or others.”
Ideally, when the court orders that a conservator, guardian or some combination of the two is required, a family member or friend can apply and be granted permission to serve the role.
“The court wants it to go that way,” Richards said. “The court really wants the family to take them.”
But families and friends who want to help are often not able to keep up with the paperwork demanded of conservators (regular reports must be filed to the probate court). They are also not as familiar with navigating the network of care options and treatment programs available for a person with mental illness.
Richards says some friends and family make it work. But she has also watched some try their best before eventually asking her to step in.
For family and friends, the transition can be a relief. No longer burdened by organizing and maintaining care while managing finances, they can return to simply loving their loved ones.
“I tell them often,” Edwards, the president of the state’s organized body of public administrators, said. “Let me be the protective wall that will take care of your family member. And you get to be family.”
Distancing duty and compassion
Cathy Richards grew up on her family’s farm outside of Harrisburg. The granddaughter of a midwife and the sixth of eight children, she said her family prioritized taking care of one another.
After graduating from Harrisburg High School, Richards and her first husband (she has since divorced and remarried) raised two children. It was not until her kids were grown that she became the first in her family to finish college, graduating from Columbia College with an associate’s degree in fine arts in her early 40s.
She continued her education at William Woods University. She earned a bachelor’s degree in business management in 2006, but had then realized she gravitated toward topics that involved interaction and relationships. She took a few nursing classes before deciding to pursue a master's in counseling — a degree she will finish at Stephens College this year.
She thinks coming to college later in life helped her adjust to being a public administrator. Her counseling and nursing experience help her talk to her clients. She looks for common ground, stays friendly and approachable. She cares.
But she also keeps a distance.
She sees how hard it is for families to provide for loved ones who have severe mental illness. She admires their persistence and dedication. But she knows she could never take the same approach to the hundreds of people her office oversees. For that reason, she keeps her relationships with clients professional instead of personal.
“It’s not our job to be their family,” she said. “It’s our job to help them live as independently as they can.”
She expresses compassion through hard work, not hugs.
“My responsibility is to make sure the major things are taken care of — health, welfare, all of that,” she said. “I look at it more as a duty, as a job responsibility, than I do on the personal side. I have to distance myself from that.”
Ideally, every client eventually leaves the public administrator’s care. As an individual gets better through treatment programs, a friend or family member can petition to take over conservator or guardianship. A client whose health has improved steadily over the course of time can petition the probate court every six months for a restoration of his or her individual rights.
But until they leave, clients live in a network designed for their care.
They have caseworkers and social workers to help with everyday situations. They have deputy administrators who check in and help create treatment plans that hopefully lead to recovery.
They have a public administrator who has been assigned to work in their best interest overseeing and influencing everything from the top.
For Richards’ office, the process starts as soon as a client is added to the caseload.
New clients often need a new place to live. Richards keeps a 96-page, dog-eared document in her desk. The list names every facility in the state where clients could be placed. The facilities, spread throughout Missouri, vary in size and services offered.
Richards, along with the two deputy administrators who work with her, balance location with client needs. Once a client is placed, Richards and her deputies try to check on the client four times a year. One of the visits must be made in person.
It’s not unusual to see clients more frequently. Richards makes trips to Sedalia once a month, driving west on Interstate 70 often enough to notice whether the Missouri River is high or low when she crosses the bridge.
She makes the trip to see a client with behavioral problems. He does better when she visits more often.
Most clients do.
Richards and the deputy administrators have driven enough Missouri highways to spend just more than $10,000 on gas each of the past three years.
The meetings are important. Richards and the deputy administrators examine the client and the facility. They speak with a client’s caseworker about recent visits to doctors and changes that should be made to treatment plans.
A client who is improving might need to move to a less-restricted housing option. A client having problems might need to be relocated to a place that offers different services.
While Richards and her deputies travel, the office’s other employees work from the courthouse, processing all the paperwork and bookkeeping that comes with client finances.
Clients who are unable to manage their finances are still allowed to have personal bank accounts. Some receive portions of their own money to spend as they wish. Others come to the office to pick up a weekly allowance.
Every time a client wishes to make a purchase that costs more than $75, the public administrator’s office must petition the probate court for approval.
“Clients live on a budget,” said Sickler, the only full-time accountant in the office. “We have to keep them on that budget.”
Managing the money helps keeps a client out of financial trouble. It keeps the purchase of a pay-per-view movie from cutting into money meant for groceries. It minimizes the chances of a credit card racking up excessive charges.
Just as much of a concern is protecting clients from people looking to take advantage. Clients with significant amounts of money are insured under a bond held in Richards’ name. If the money disappears, she is held responsible.
The office also oversees the payment of a client's bills, ranging from big expenses (rent checks, hospital visits) to small (vaccines for pets, cable payments and bus tickets).
Every year, the office must file reports with the probate court that list every client’s individual assets.
“The probate court is like an auditor for us,” Richards said. “I like the idea that there’s another pair of eyes because there’s an awful lot of money that comes and goes out of here.”
Case number rising
The unofficial number of Boone County’s total client population fluctuates as clients enter and leave the supervision of the office during the year. But from annual reports filed by Richards’ office, the number of clients in Boone County has grown by 18 since Richards took office in January 2009.
That means Richards and her two deputy administrators are in charge of overseeing about 132 clients each — even more now that additional clients have been added since the report (Richards believes the current count has passed 400).
The president of the Missouri Association of Public Administrators believes a 1-to-132 proportion is “terrible.”
Edwards served as a deputy administrator for Clay County for 14 years before taking the head position in Platte County eight years ago. She knows firsthand the problem of an overloaded office.
Her Platte County office oversees 225 clients with the help of four deputies. She and the deputies are each responsible for 45 clients, and she says that is too many. She believes the perfect number is 25 to 35 clients per administrator or deputy.
“I’ve been the deputy and the public administrator,” Edwards said. “I know once you get a caseload that is 40 to 50 people long, you’re putting out fires.”
A fire is a metaphor for a client in crisis. While caseworkers and social workers are the first line of response, the public administrator must also drop everything to best serve clients in emergency situations.
Hospitalization might be needed. A change in prescription medicine could be required. An assignment of a different caseworker could be the answer. The public administrator has to approve it all.
Richards said facilities have called as many as 30 times in one day when a client is in crisis.
“It just stops us in our tracks,” she said.
Richards has tried to streamline the way her office works to make the most of valuable time. She hired Sickler, whose presence helps keep paperwork from piling up. She also got the office its first scanner and started the process of digitizing records. She installed a computer program that lets her and her deputies access clients’ records from home during emergencies.
Other attempts have not been successful.
Richards asked to add another deputy position in the 2012 budget. The county commission denied the request.
Most public administrators take on a smaller client base than their deputies in order to deal with the administrative duties that come with running the office.
That is not an option for Richards.
“In order to manage the office and do what I’m supposed to be doing, getting money funding, keeping up on everything like I am supposed to do, I should have less,” Richards said. “But how much do you place on one individual?”
Fewer beds, services shuffled
When she talks about the Missouri Department of Mental Health, Richards chooses her words carefully. She wants it to be clear that the department does good work. She is adamant that it’s not the workers inside the department but the budget makers in charge of the purse strings that generate her frustration.
“The Department of Mental Heath has a lot of good people,” Richards said. “And we would not be able to do much without them. Our concern is everything being taken away from them. They have to do as they’re being told.”
While Missouri’s public administrators do not get money directly from the Mental Health Department, their clients benefit from the services and programs the department provides. Department money helps the agencies that dispatch caseworkers to clients as well as the housing options listed on Richards’ big, thick 96-page list.
The department — along with other states across the nation — has cut back and closed large, state-run psychiatric facilities. Placing and moving clients into facilities that provide appropriate care has become more difficult.
Fulton State Hospital, St. Joseph Hospital, the Nevada Rehabilitation Center and Farmington State Hospital have all seen cuts from the state in the past two years.
The closings save the states money because they steer the relocation of the mentally ill toward general hospitals and nursing homes that receive twice as much Medicaid reimbursements as psychiatric centers alone.
Richards said the problem is that many of her clients require long-term psychiatric care. General hospitals and nursing homes are not as suited to provide the advanced treatment needed for illnesses such as schizophrenia.
Since the state-run psychiatric facilities closed and cut bed counts, few alternative options replaced them, she said.
This makes it harder to place the clients coming into the system for the first time and harder to move the clients on the path to recovery into less-restrictive alternatives.
“You’re competing with every other public administrator to get that place,” Richards said. “All 114 countries are wanting somewhere to place their people. What might be an ideal place for them, there’s no room.”
A fight continues
Richards is in constant battle.
Since taking on the role of public administrator, she has been fighting to serve the population that society chooses to ignore.
She fights herself as she balances compassion with distance. She knows the perfect combination leads to the best results for her clients.
As the Boone County client base slowly ticks upward, she fights to make sure more clients have what they need to live well.
It’s getting harder in more ways than one.
The rent rebate that Richards’ client received, the reason she appeared in probate court on a recent Friday morning, might not be available for much longer. Missouri lawmakers held a special session this year to look at ways to balance the state budget. One proposal suggested cutting the rent rebate program.
The rebate survived, but Richards and other state public administrators fear it could be eliminated soon.
She knows the removal of the program would be one more change that makes the lives of her clients a little tougher. But that’s a worry for the future.
Today, the rent rebate program is alive and well. And the check Richards holds in her hand is destined for a special trust that will let her client keep both cash and Medicaid eligibility.
A quick signature from a judge, and Richards is out the door and onto her next mission.