By Scott Calvert, The Baltimore Sun
6:59 PM EST, November 7, 2010
Second of two parts; read the first part
For much of his adult life he'd been a slave to cocaine, marijuana, prescription pills and alcohol. Twice he had gone through weeks of intensive psychiatric and drug treatment at Baltimore Behavioral Health Inc., only to go back to using drugs on the streets.
By summer 2008, Stephen Brown was three months into his third stint at BBH. That's when the private treatment center in Southwest Baltimore deemed him ready for a new challenge: to manage a rented rowhouse where he would live with seven other patients. His duties included enforcing curfew, hunting for hidden drugs and unlocking a cabinet so residents could take their psychiatric medicine.
But he says the assignment, which paid him $120 every two weeks, caused serious stress. Not only did he receive no training, he says, but he was still in mental health treatment, still on antidepressants.
"I didn't really want to be house manager," said Brown, 53, a native of Trinidad. "I didn't want that kind of responsibility. It was too much for me, being a patient and just coming off 90 days clean from being on drugs. I accepted it because that's what they gave me. I said, 'Let me just try it and see.'"
The two-story brick house on South Fulton Avenue that he managed is part of a network of rowhouses that BBH rents in Southwest Baltimore. As of July, 150 of its roughly 800 outpatients were living in the houses, which are clustered in a battered working-class area where prostitutes ply corners before noon and city Health Department data show that more people die of overdoses than in almost any other part of Baltimore.
For BBH patients, many poor or homeless, the housing has meant not having to worry about finding a place to sleep. For BBH, it has attracted indigent patients whose outpatient care is usually paid for by taxpayers, according to interviews with former patients and staff at the West Pratt Street clinic. To help ensure that they attend treatment, BBH has vans that pick up patients in the morning for daily therapy.
But some former patients and staff as well as outside doctors say that BBH, which last year grossed $17 million, finds mental illness in patients whose main affliction is substance abuse. And state records show that drug users are three times more likely to be deemed mentally ill there than at treatment providers across Maryland.
The housing has become an integral part of BBH's model as a treatment center geared to helping people who struggle with both mental illness and drug addiction. Executives at the family-run nonprofit say their goal is to make treatment more successful by making it easier for patients to focus on getting well.
But a Baltimore Sun investigation has found that the arrangements raise concerns, including doubts about the wisdom of giving newly sober patients like Brown the key to the medicine cabinet. Among the findings:
•No aspect of the housing network falls under state regulation. Maryland's public mental health system has paid the tax-exempt provider more than $70 million over the past five years to treat thousands of patients, yet state health officials concede that they have no authority to regulate how the houses are run. Baltimore housing officials say that most houses leased to BBH were not properly registered.
•No houses rented by BBH have on-site professional staff. Instead patient-managers with as little as 60 days of sobriety are given the responsibility to enforce house rules and mediate disputes.
•The head of the state Mental Hygiene Administration, which oversees Maryland's public mental health system, says he worries that the housing may have been an "inducement" for some patients to enroll in state-funded outpatient treatment that they didn't need.
•BBH rents 10 houses from an investor group made up of three corporate drug salesmen, one of whom marketed prescription drugs to BBH. Separately, BBH has paid more than $2 million in house-finding fees since 2004 to a man who once ran several homes in Washington from which mental health officials ordered patients removed over issues of safety, disrepair and other "deficiencies."
•Though some former patients described houses in good condition, others complained that one had a rodent problem and no kitchen stove. Two residents of another house complained about living in a basement with no exit. And former patients and staff say illicit drug use is an enduring problem.
William "Kris" Hathaway, chief executive of BBH, declined requests for interviews and did not reply to eight written questions about the housing. In an e-mail in May, he told The Sun that BBH spent $3.4 million last year on "charitable services" such as patient housing. The services were "uncompensated," he said, meaning that they were not reimbursed and affected the nonprofit's bottom line.
Hathaway said giving patients a bed makes practical sense. "It is hard to focus on one's mental health or addiction issues when there is not a conducive living situation.
"It is otherwise ludicrous," he said, "to expect positive outcomes when the authorized level of care is outpatient-based for this segment of our population."
While Hathaway described the housing costs as uncompensated, there is an evident financial upside for BBH: For a given patient, the nonprofit has long been able to recoup several times the monthly rent it pays the landlords — $200 per patient, according to its housing director — by billing the public mental health system for treatment yielding payments of several thousand dollars a month.
Put another way, it might take BBH less than two days to gross an entire month's rent for a patient. For instance, the Medicaid program pays mental health providers $125 a day for "intensive outpatient" mental health treatment, a category into which BBH for years has placed many patients.
Moreover, patients say BBH now requires them to pay about $150 or $200 a month in rent, meaning that BBH passes on most or all of the monthly rent to the patients.
'A huge, huge, huge problem'
Advocates of affordable housing say BBH's system is one piece of a patchwork of residential options that have emerged in the 20 years since the state cut residential services for recovering addicts.
A lack of housing-based drug treatment is a major issue, said Greg Warren, president of Baltimore Substance Abuse Systems Inc., a quasi-public agency that distributes more than $50 million, mostly state grants, to city providers that treat addicts lacking insurance. (BBH has never applied for a grant from the agency.)
Jane Plapinger, president of Baltimore Mental Health Systems Inc., the city's mental health authority, called housing "a huge, huge, huge problem for people in this city who are mentally ill. The reality is, clients will go anywhere for housing because they're desperate."
For some who enroll at BBH, the prospect of a clean bed, rather than treatment, has long been a prime attraction, according to former patients and staff.
"You're homeless, nowhere else to go," said James Scriven, explaining why he went there after he got out of jail in 2004.
The motivation matters to Dr. Brian Hepburn, executive director of the Mental Hygiene Administration, which funds BBH through Medicaid, the state-federal program for the poor and disabled. He expressed concern that the housing might act as an "inducement" for some patients to seek treatment or to stay in treatment that they may not need.
Reports of drug use at the housing punctuate Hepburn's concern. "For some people," he said, "it sounds like what they're doing is using the program as a safe place to go to get shelter … and continue to use" illicit drugs.
Housing is critical for individuals in recovery, Hepburn agreed, "but we're paying for health care, not for shelter, a bed and a safe place."
Recently, Hepburn said BBH has assured the state that no one living in the houses is required to enroll there for treatment.
State officials acknowledge that they can't know whether BBH's rental houses constitute a "safe place," because the state has no regulatory oversight. That worries Nancy Grimm, director of the state Office of Health Care Quality.
"Not licensing those homes takes us out of the loop," Grimm said. "Maybe we should be licensing them."
The lack of oversight means BBH has wide latitude to operate the houses as it deems appropriate. That includes the freedom to put newly sober patients such as Stephen Brown into manager roles.
Others question the wisdom of that practice. Gaudenzia Inc., which offers mental health and addiction treatment services, would never delegate such responsibility to a recent drug user, said Gale Saler, director of its Chesapeake region.
"We wouldn't give someone with 60 days' sobriety access to someone else's medication," she said. At Gaudenzia, even entry-level staff must document a full year of sobriety. Two months is too soon, she said. Some patients are still "white-knuckled, holding on by the skin of their teeth. Recovery is hard."
"Certainly, 60 days seems short to me," said Warren of the city's drug and alcohol treatment agency. In July, the agency got authority from the state to begin using grant money to pay for housing, but Warren says he first wants clarity on quality standards. "I believe there needs to be oversight over supportive housing when and if public taxpayer dollars are being spent."
At present, the only government oversight of BBH rental houses, comes from Baltimore's housing agency and is limited to compliance with zoning and building codes. Occupancy levels in the homes fluctuate and range from under 10 to more than 20.
BBH has said it complies with all local requirements. City records show that, as of last summer, 16 of 21 houses identified as BBH houses were not registered by the owners, as is required for any non-owner-occupied house.
When asked about the 16 houses, city officials said that they sent $100 citations to the owners and that three of those properties have subsequently been registered.
BBH declined to tell The Sun where its houses are or how many it rents for patients. In an interview last year, Terry T. Brown, a vice president and the nonprofit's public face, gave a range of 20 to 30, though some have apparently been closed. The company's housing director, Joy Smith, said at the time that most were within 16 blocks of the BBH campus on West Pratt Street. BBH also operates a 59-bed shelter on South Poppleton Street, where many new patients spend a night or two before moving to the rental houses.
The Sun was able to identify more than 20 houses where BBH patients live or have lived, mostly in areas marked by street-corner drug dealing. Ten are in one neighborhood, New Southwest/Mount Clare.
Even neighbors do not know much about the homes. "We weren't even advised when the first ones moved in," said Ann Ames, a resident active in the community association. She said she and her neighbors have had "very little problem" with the BBH houses.
'That's what addicts do'
Some former house managers and patients described houses that were tidy, well-run operations where drug use was not tolerated and residents supported one another. Others said drug use was a recurring problem at certain houses, undermining the treatment paid for by taxpayers.
Earlier this year, Chris Schussler shared a rowhouse in the 1300 block of Hollins St. with 13 other men in treatment at BBH. He found it a decent place, even though he saw four housemates drinking and smoking crack cocaine.
Drug use at BBH houses "obviously does happen," said Schussler, who said he went to BBH after spending three weeks at Sheppard Pratt's inpatient psychiatric unit in Towson.
"You have people coming in, and they're just looking for a place to stay," he said. "They're not here for any programs. They're just here to get some food, some warmth and a bed. That's no secret; that's anyplace."
Sometimes patient-managers themselves use drugs, patients say.
"A lot of times, the house manager is getting high, so they're in cahoots together," said Kevin Brown, a patient during 2007 who is not related to Stephen Brown or Terry Brown. (Stephen Brown says he never used drugs while a patient-manager.)
Kevin Brown and others said it was not hard to evade detection. "They really don't have random urinalysis," he said. "It's more or less if somebody gives you up. If a person is getting high and hiding it well, they go through the whole program high."
Hathaway did not reply to Sun inquiries about BBH's drug-testing policy. While the state does not require the nonprofit to test, regulators say that BBH executives have told them that patients are screened when the staff suspects drug use.
"Yes, people use in the houses," said Tommy Thompson, 48, who lived in three BBH houses in 2008 and 2009. "But we're addicts. That's what addicts do. Everybody is not going to stop at the same time."
Drug use "wasn't too bad," recalled Wayne Mason, 50, a former patient and house manager. When it did happen, he said, he called BBH staff members and the patient would be given a drug test.
"Nine times out of 10," someone who relapsed was evicted from housing for 30 to 90 days, he said, though after a first offense they could continue with addiction and mental health therapy.
Mason said watching over patients with erratic behavior, including some who broke into an abandoned house, was a taller order. "I had a guy on the roof — he was hollering at the moon," Mason said. Another patient "used to throw stuff out the window and run downstairs and try to catch it."
But Mason welcomed the challenge. "I thought, 'If I can be responsible for 15 men, I can be responsible for myself,'" he said, noting that he'll mark three years of sobriety in December.
Shirley Sturgill, 38, a former patient who managed one of the three BBH houses in which she lived, praised the therapy regimen. "This is the only one that worked for me," she said.
But Sturgill, who has a temporary catering job, said housing drew patients for the wrong reasons: "Some people just go there for a room and a bed. Then they come out and start using again."
The worst house, she said, was one in the 100 block of S. Arlington Ave., where 10 women shared one bathroom. Because there was no kitchen stove, they used a hot plate and microwave to cook.
"And it had rats," Sturgill said. "And it flooded." Residents slipped out at night through a basement door and "wouldn't be there in the morning." BBH patients no longer live in the house.
For her, managing a house brought a sense of responsibility: "People are looking up to me, so it made me stay on the right path," she said. "It made me feel like a role model."
But Stephen Brown, who took on the manager role with trepidation, eventually found the stress too great. He tired of having to calm quarreling residents. It irked him when he had to ask dealers to stop selling drugs in the alley and had to report the same resident twice for using heroin in the bathroom.
His fears never subsided during the weeks in 2008 when he ran the house on Fulton Avenue. Most worrisome was guarding the key to the medication cabinet. "Suppose my mental situation goes off and I say, 'Look, man, take all you want.' Or somebody gets aggravated," he said.
"You won't take a person who's a patient and put them responsible for another patient," he said, the words tumbling out and his voice growing louder. "That don't make no sense, because I take medication just like everybody else."
Today, Brown lives in supportive housing outside BBH's network. He works as a cook for a catering company in Baltimore. Despite unpleasant memories of being a manager, he speaks highly of his therapy at BBH and says he hasn't used drugs since he began his third stint there in spring 2008.
Smith, BBH's housing director, said she always looked for rental houses that were safe and comfortable, with decent kitchen and laundry facilities, and common areas for watching television. Last year Smith gave The Sun a tour of a three-story house on Calhoun Street. At the time, 12 men lived there and five were sharing one bedroom.
Given rampant drug dealing in the area, she encouraged patients to walk in groups. She urged them to avoid drug "holes" by sticking to busy streets or to ride in a BBH van.
In choosing house managers, BBH applied what Smith called "pretty rigorous criteria. At first you have to have at least 60 days of clean time. Then you have to have been a leader in the community, group [therapy]-compliant, medication-compliant.
"Once they're house manager," she added, "they're put in charge of monitoring the patients in the house."
Rather than buy houses, BBH rents them from private owners. For years it used a middleman named Mark Spence to find rental houses in Baltimore. Tax filings show the nonprofit has paid Spence more than $2 million since 2004 for housing services.
Terry T. Brown, the BBH vice president, said last year that the relationship with Spence had changed. "He's now finding we don't do as much business with him as we did in the beginning," Brown said.
Even so, BBH paid Spence $182,000 last year.
Brown and Smith said they were unaware that seven years ago, Washington's mental health agency ordered all mentally ill clients pulled out of Spence-run homes in the District of Columbia.
"This action has become necessary due to observance of deficiencies during site visits," wrote Edith Makenta of the District of Columbia's Department of Mental Health, in a 2003 memo. She cited "housing safety issues/lack of repairs, issues with money and food, seizure of consumer personal belongings [and] changing of door locks prohibiting access to their housing."
Spence, who filed for personal bankruptcy last year, could not be reached for comment.
Cesare Vaughan was one of the property owners who did business with Spence in Baltimore. He said their association began several years ago when Spence rented four of his rental properties in succession, filling them with BBH patients. BBH paid Spence, and Spence in turn paid monthly rent to Vaughan.
Vaughan said doing business with Spence initially carried great appeal. "I had three-year leases from him, guaranteed rent," he said. "It's almost like you're paying my mortgage for me."
Over the past five years, BBH has increasingly put patients into houses owned or co-owned by three sales representatives for Johnson & Johnson. In response to questions about the salesmen's business dealings with BBH, Kara Russell, a spokeswoman for the pharmaceutical giant, said the rental arrangements "do not pose a conflict of interest, per our business conduct policies."
From 2007 to the end of 2009, BBH paid the men more than $700,000, according to its tax filings. One drug rep, Stephen Andrews, said in an interview this year that the sum "sounds about right." But after mortgage payments and other expenses, he said, they netted around $150,000.
Andrews said the housing venture sprang from a 2005 conversation between Terry Brown and Dan Walker, a drug rep who used to call on BBH as a salesman for a schizophrenia drug. According to Andrews, Brown said BBH was looking for good housing at reasonable rents.
When Brown asked Walker if he knew anyone who could help, Walker said he might be interested, Andrews recalled. Around that time, Andrews said, Walker's drug rep territory was switched to Towson and points north. That meant Walker stopped calling on BBH as a drug salesman.
Walker, who did not return phone messages, partnered with fellow drug reps Andrews and Matt Piron and other investors. In 2005, they bought their first two houses, one in the 200 block of S. Gilmor St. for $47,500 and a larger one in the 300 block for $78,000.
While Joy Smith said BBH pays $200 per month per patient, Andrews called that figure an average. He said the owners and BBH negotiate rent for each house without applying a per-patient formula.
"We don't want to be in the business of counting patients," said Andrews, who lives in Middletown, Del.
The purchase of each new house would start with a request from BBH, Andrews said: "They tell us, 'We need a house,' [and] we purchase one." They would then settle on rent and a "comfortable number" of residents, he said.
The BBH houses have been well-tended, Andrews said: "These patients take care of our houses better than any tenant you could ever possibly want."
Last year, the City of Baltimore sued Andrews, Walker and another part-owner, Brian Clark, over alleged violations at one house, the three-story house on South Calhoun Street. The case was dropped after repairs were made and kitchens were installed on the two upper floors.
Besides failing to register BBH houses as rentals, some of the owners neglected to seek approval to exceed occupancy caps that limit four unrelated people to a single dwelling, city housing officials said. A few houses, like the one on Calhoun Street, contain multiple units that can each hold four residents, but most were modest rowhouses consisting of one unit.
Federal law allows more than four recovering addicts or mentally ill people to share a home, but the owner is supposed to apply for a "reasonable accommodation." Even then, a house must meet space requirements. A bedroom with one occupant needs 70 square feet, and 50 more square feet for each additional occupant.
"You're not protected by anything from putting 12 people into a building that can only fit six," said Michael Braverman, Baltimore's deputy housing commissioner.
For Andrews and his fellow investors, the housing venture was purely a real estate deal, he told The Sun. Their plan was to keep BBH as a tenant as long as possible, with the hope of turning a profit when they sold the houses. But that was before the real estate market crashed and Southwest Baltimore's resurgence stalled.
Meanwhile, BBH demanded a one-third rent reduction earlier this year as several multiyear leases ended. That means that their 10 houses are suddenly far less profitable and will likely generate combined gross profits this year of just $50,000, he said.
"At one point, when this thing was lucrative, we were trying to get as many [houses] as we could," Andrews said. "We've kind of stopped."
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