FORT COLLINS — At age 11, Jim Lucas was a star swimmer who finished second in state in the 100-meter free. His swimming could have taken him to college and beyond.

But the arc of his life would soon change. A man who lived directly across the street from his elementary school playground lured Lucas to his house when he was 12, then raped him.

“He bought me gifts and told me I could be a kid model for Sears and J.C. Penney,” Lucas said. “He molested me, then beat the sh** out of me. He was laughing at me. I felt so ashamed and dirty that I didn’t tell anyone about it for 25 years.

“I didn’t know how to process that. I wasn’t even sexually mature,” Lucas said.

He didn’t think of telling his parents who were both alcoholics. He remembers his father beating his mom until she fled Wyoming with five young kids. The family lived in a children’s home in Longmont, then settled in Fort Collins in 1966 in a neighborhood with tall, leafy elm trees and an old-fashioned cable car line near Colorado State University. City Park was an oasis nearby with an Olympic-sized pool. Lucas spent hours there in the summer, swimming with friends and building his collection of blue ribbons.

Jim Lucas, top, with two of his sisters as a child.

After the rapes, Lucas would sometimes see his attacker. Once the man chased him, screaming, “I’m going to kill you.” Lucas said that he ran away and dove under a car, watching as the man’s feet pounded by inches away. During the rapes, the man laughed at how hard Lucas’ heart was beating. Once again, hiding under that car, Lucas’ heart pounded with fear.

He became depressed and instead of getting help, Lucas became a self-described criminal and a hard-core drug user.

“I used pot, alcohol, cocaine, LSD, hell, even lighter fluid,” Lucas said. “I overcompensated trying to be a man by doing stupid things.”

He broke into his first house at age 13, and dropped out of high school in the 11^th grade, just short of finishing. By 19, he got his girlfriend pregnant with their first child.

At 35, estranged from his wife and two kids, Lucas found a new drug of choice: meth. For 15 years, his meth habit escalated to the point that he ended up living in a shack in his mother’s backyard and had a psychotic break. Lucas found himself running outside his home naked, convinced that friends were trying to kill him. Lower than he’d ever been, Lucas knew he had to change his life or he would die. He calculated that in his final year on meth, he spent $24,900 buying it.

‘High utilizers’ cost taxpayers millions

People like Lucas also cost taxpayers huge sums of money.

In Fort Collins, a group of experts from diverse agencies calculated just how much. In a single year, Lucas and 11 others who have both severe mental illnesses and extreme substance use disorders cost the systems in Fort Collins and Larimer County about $425,000 or about $35,500 each. This was their tab for services from psychiatric treatment to ambulance rides and expensive stays in detox and hospital ERs.

A new report, The Status of Behavioral Health Care in Colorado, has found that small groups of “high utilizers” throughout the state are costing Medicaid millions of dollars in part because our substance use, physical and mental health systems are so fractured. Data from Colorado’s Behavioral Health Transformation Council found that 140 people cost Colorado Medicaid programs $4.2 million in a year. These most challenging patients accessed care in multiple disparate systems from mental health and treatment programs to primary care, hospitals, corrections, juvenile justice, child welfare and special education programs. A lack of coordination among these systems means many clients get expensive, redundant care while failing to improve.

The concept of identifying the most expensive clients in health systems and giving them higher quality, team-based care to improve their health and save money has become known as “hot spotting” after Dr. Atul Gawande wrote a story about this idea in January for the New Yorker. Gawande profiled a New Jersey man who used data to find patients who were getting lousy health care while costing millions. The central question of his story was: “Can we lower medical costs by giving the neediest patients better care?”

Jim Lucas looked like Ernie on My Three Sons when a predator living directly across the street from his elementary school in Fort Collins lured him to his home and raped him. Lucas was too ashamed to tell anyone about the attacks or get help. Instead, he became a self-described criminal and drug user.

In Fort Collins, a coalition of specialists came up with the similar idea about six years ago to give better, more intensive care to people like Lucas. They had received a grant from a coalition of four Colorado foundations who came together and pledged $4.25 million to support better integration of mental health care. The funders are the Caring for Colorado Foundation, the Colorado Health Foundation, The Colorado Trust and The Denver Foundation. The Fort Collins team had learned about a program pioneered at the Dartmouth Medical School called Integrated Dual Disorders Treatment (IDDT) and fashioned their own version of the tested program. Mental illness and substance abuse often go hand in hand. The IDDT approach turns traditional behavioral health care on its head.

In the past, when people like Lucas fell off the wagon, started showing up drunk in public, landed in jail or the hospital, and failed to show up for appointments with therapists, the system used to label them “non-compliant” and let them disappear into the abyss.

The new approach is based to some extent on a philosophy of “radical realism.” The program assumes that the toughest patients by definition will not seek care themselves. They often will relapse. They will disappoint therapists who expect them to show up for appointments. They will wind up back in jail and detox. They will be at different stages of recovery and they will need long-term care. And, surprisingly, over time, intense care will actually save money.

Indeed, Fort Collins’ program managers were already saving money by the end of their first year. By the end of the third year, they found that each client was costing the system $10,000 per year, instead of $35,500. That $10,000  included housing and positive care, like tending to long-ignored medical problems or owning up to past offenses and serving jail time. The program resulted in a 65 percent reduction in emergency services and hospitalization, a 39 percent reduction in jail and prison days and an overall estimated savings to the community of $780,000.

Not ‘crazy’ – “These people have mental health disorders”

Lucas, now 51 and clean for the first time in decades, calls his compadres  in Fort Collins “the dirty dozen.”  Others affectionately call them “the wrecking crew.”

The Fort Collins program officially began in 2008 after team members found the first 12 clients and tallied up their baseline costs from the previous year. The Community Dual Disorders Team (CDDT) uses intensive case management and therapeutic support to try to help the toughest of the tough clients. The goal is pretty simple, while the execution is much more complex: stubbornly stick with the clients to improve outcomes and save money. CDDT is a partnership between the Larimer Center for Mental Health, the Fort Collins Housing Authority and the Health District of Northern Larimer County.

In the CDDT program, case managers, outreach workers, behavioral health and substance use experts learned that it was their job to go out and find the clients even if that meant hanging out with them at Fort Collins’ “Hobo Park” and accepting that they were not going to stop using drugs cold turkey. Sometimes, providing them with sleeping bags so they could stay alive on the streets or encouraging them to gradually cut their drug or alcohol intake was a good incremental step.

Preliminary results from three years of the Community Dual Disorders Treatment program in Fort Collins shows dramatic reductions in services from hospitalization to detox programs. Source: The Mental Health and Substance Abuse Partnership and the Health District of Northern Larimer County. (Click on image to enlarge).

David Jones is CDDT’s program supervisor and a substance abuse expert for the Larimer Center for Mental Health.

He used to work in Greeley in the same building with the detox center.  One man would show up severely drunk every week or 10 days.

“He was a member of what we affectionately called the ‘wrecking crew,’” Jones said. “Their lives are just wrecks and there were no options. I would see him all the time. He was drunk in public, passing out on is feet and slamming his face into the cement.”

The man frequently was injured and insisted on sleeping outside even in frigid winter weather.

“He lost all the toes on one foot to frostbite,” Jones recalled.

Finally, the CDDT program started, giving a long-term treatment option to the man. He struggles with bi-polar disorder and alcoholism and joined Lucas as one of the first dozen in the program. Jones and others on the team held out little hope that he would improve. The original 12 all received housing vouchers for their own apartments, but many couldn’t live by the rules and were evicted. This man ended up back on the streets.

“He drank and drank. We’d have to go find him and support him however we could,” Jones said.

The participants are supposed to come to group therapy twice a week. Sometimes they show. Sometimes they don’t. Some sit in the back and refuse to talk. Finally, after about 2½ years, the man started coming to group. They took it as a sign that he was ready for some help. Outreach workers then found a place for him in a group home. The problem: it was a sober living house, the former frat house where CSU student, Samantha Spady died of severe alcohol poisoning in 2004. The therapists expected their client to last a week or two, then be tossed out for drinking again. To their amazement, he has stayed in the house sober for six months. Workers then found his family in the Denver area and reunited them for the first time in years.

“Everyone thinks it’s a miracle. He’s 54. At one time, he was married. He has a grown child out there somewhere and a mother and a sister. He used to work. He always drank. It just escalated. Alcoholism is a progressively worsening disease,” Jones said.

“These are just people. They’re not bad. That’s what alcoholism does to you. They’re not crazy people. They’re people with mental health disorders.”

Success has not come for all the participants. For one man, all Jones could do was give his family a tragic update.

The man was in his late 20s and struggling with schizophrenia. Stuck in the Larimer County jail, the man could only get out if he qualified for CDDT. Jones interviewed him and decided to take him. He found him a spot in a sober living house, but that didn’t work.

“He fell right back into the old ways of doing things, blowing BACs (blood alcohol concentrations) of .5 above. This is going to kill most people. One night, he ended up drinking a lot and crashed his bike and hit his head,” Jones said.

The fall weather was cold enough that the man died of exposure. Jones found the man’s family in the Denver area and let his mother know what had happened.

“I made the phone call and let her know that he had passed away. For me, it was important for them to have some closure. It was a terrible, tragic end, but it was still important to reunite him with his family.”

History of trauma

Today, the CDDT program has 21 clients, four of whom are women. The team plans to expand to 30 by October, 2012. This year’s costs for psychiatrists, therapists, housing vouchers, staff time and overhead added up to about $308,000.

All of the clients have a severe and persistent mental illness, the most common of which are schizophrenia, bi-polar disorder or depression. Alcohol is the primary drug of choice. One client had never been treated for depression and anxiety and had previously tried to see a psychiatrist, but had been told he’d have to wait six weeks for an appointment. Instead, he went to the liquor store.

“I don’t have to wait six weeks to get a bottle,” he told the CDDT workers. “I don’t need treatment. I need a reason to stay sober.”

Jones and other CDDT managers say that one of the biggest struggles is building a trusting relationship with the clients. Most say they want better lives. But, in the past, every time they’ve screwed up,  people they trusted have understandably given up on them.

Now, there’s no such thing.

“Once you’re in CDDT, you’re always in CDDT. We don’t discharge you if you’re bad. The only way you’re done is if you die or you ask us to discharge you. That hasn’t happened yet,” Jones said. “These are the most challenging of the challenging people. Their wounds go very, very deep. It’s extremely common that trauma is a part of their history. For some, it was chronic trauma where they were abused repeatedly by a person of trust – whether it be parents, neighbors or other children. These folks have been abused a lot, then they learn to abuse themselves.

“Even when they come in to CDDT, they sabotage their treatment. They don’t believe they’re worth our time. It takes a lot of persistence and compassion because they’re not always very compliant or friendly,” Jones said.

Of the original 12, eight are still engaged with the program. Four have left the state, three to go to more intensive treatment programs and one to reunite with family members.  Some are back in jail, like a man named Allen. (Click here to see a video about Allen.

“Some have new charges. Others are taking responsibility for outstanding charges. We want them to take responsibility for prior acts,” said Samantha Murphy, manager of the Mental Health and Substance Abuse Partnership for the

Health District of Northern Larimer County.

Murphy says those who are in jail are still in touch with CDDT and plan to reconnect with team members once they’re out.

“They use the program as a touchstone. It’s not necessarily the greatest outcome (to end up back in jail), but it illustrates that sometimes it’s a step forward and a step backward,” Murphy said.

Lin Wilder, director of community impact and health promotion for the Health District of Northern Larimer County, echoed the idea that results can take years.

“It’s a fundamental change in how we look at these most severe folks. It’s a long process and you have to go to them and meet them where they are,” she said. “Under the old way, the minute they dropped out, we would say, ‘OK, you’re not holding up your half of the bargain’ and we’d let them disappear into the woodwork. These folks are at different stages of readiness for progress.”

Letting them disappear has not worked.

“If we continue to ignore them, they’ll continue to tax the community,” Murphy said.

“And they are people,” said Wilder. “They are suffering from two diseases: mental illness and substance abuse. They are suffering and they have a right to treatment.

“We are committed to this program. We’ve already seen such incredible outcomes,” Wilder said. “We need to grow slowly over time. We know there are a lot more people who need these services.”

Murphy said the biggest lesson she has learned so far is to be sure that the person is ready for a particular intervention. For instance, providing apartments to each of the original 12 men turned out to be too abrupt a change from living on the streets. Most felt cut off and isolated, then broke the rules and got kicked out of their apartments.

Wilder said it’s key to provide help when clients are ready for action.

As the Fort Collins team members evaluate their results, they are trying to closely follow the Dartmouth model. They also learned from programs in Fargo, N.D., and Ohio. Programs based on the Dartmouth model are now spreading throughout Colorado.

‘Didn’t want to feel the pain’

For Jim Lucas, the community team literally saved his life. After experiencing his psychotic break in March of 2009, Lucas met with his therapists at CDDT and decided to begin weaning himself from meth. He told everybody he was going into rehab. By September, he had dramatically reduced his daily habit and checked himself in to a 45-day program. Lucas was the first of the “dirty dozen” to clean himself up and stay sober.

“It’s the first time I did anything right in my life,” said Lucas.

He’s not sure why the rehab worked when he had promised himself so many other times that he would stop. There was the time he woke up lying across the train tracks. He could have died, sliced in two, just like an alcoholic relative of his father’s. There was also the time he nearly died in a meth fire while he was supposed to be staying at his grandmother’s house, caring for her.

“I really didn’t try in the past. I just got to the point that I knew if I didn’t stop I was going to end up dead. I didn’t want my kids to have that kind of legacy for their dad.”

Clean for over two years, Jim Lucas has rediscovered his artistic talents and now enjoys painting. He is training to become a peer counselor so he can help others overcome trauma, substance use and mental illness. (Click on image to enlarge.)

Lucas doesn’t look like a meth user any more. But check his teeth. They’re fake. None of the real ones are left. Lucas looks back at pictures of himself. He’s tall — 6 foot 3 — and had gotten down to 168 pounds.

“I looked like I had cancer and was losing the battle,” Lucas said.

He would get high and stay up for three days, manically riding his bike around town to pick up supplies to cook more meth or sell other drugs.

A trip back to the shed where he was living brings back horrible memories. It’s grey on the outside and pitch black inside. There’s trash everywhere and a filthy old mattress where Lucas once slept. The shed once served as a small cow barn for Lucas’ grandfather decades ago. There’s no light, no plumbing and on a icy-cold winter day, it’s drafty and freezing. Lucas’ mother is a recovering alcoholic and lives in a small grey farmhouse next to the shed. He thinks she knew well that he was in deep trouble. But, she allowed him to live in the yard because at least she knew he was alive. Lucas now can see who he was.

“Here I am in my 40s, living in my mom’s back yard, riding my bicycle. And I’m a friggin’ drug addict with no teeth.”

He knew that the drugs were killing him.

“I just hoped that I would die high so I didn’t have to feel any of that pain.”

Now into his third year without meth, alcohol or illegal drugs and finally getting medication for depression, Lucas is strong enough to revisit the places where he grew up. There’s the first house where his family found refuge. It had a solarium and a huge lot full of trees.

“I thought I lived in the forest.”

The pool at City Park has changed. Now it has a giant slide. His elementary school is still there. And hauntingly, so is the house where Jerry lived,  with a picture window eerily overlooking the playground.

Lucas never understood the connection between the rape and his decision to become a “criminal” and drug user until a therapist asked him to focus on his most painful memory.  She pointed out the sharp turn his life took after the attacks.

Lucas finally could forgive himself for some of his actions and began to see the roots of his destruction in his own behavior.

Today, he lives in his own apartment and is training to become a peer counselor. He hangs out with a new pet, a Chihuahua mix named Chewy, and has discovered a passion for photography and art.

Lucas always had a talent for drawing, but recently a friend offered him easels, brushes and paint. Peaceful landscapes have popped into his head. Now, he’s painting scenes full of mountains, storm clouds and western buck and rail fences.

“I feel a lot better. I’m not working yet, but I’m almost there,” he said.

Lucas experienced an epiphany the other day during a peer training class. A women in a video spoke a line that summed up his life.

“Broken people do broken things.”