In a low-ceilinged room at Pinnacle House, about a dozen clients of the day treatment center sat in rows, eating a lunch of tacos, corn and pieces of pineapple that had been sliced by one of their social workers.
Within days, the program for people who have mental-health disorders would be disbanded as operator Little Rock Community Mental Health Center prepared to close its doors.
Discussing the transition, a man in a dun-colored camouflage hat said he'd heard another treatment program in the area would offer better facilities.
"I'm not sure [how I feel]. They just announced it last week," said the 48-year-old man, who is not being identified because center officials allowed the Arkansas Democrat-Gazette to interview patients only with a guarantee of anonymity.
"I don't know what questions to ask. I don't know what to expect," the man said.
A 65-year-old woman in a teal top and black mascara said she had attended the program since 2008 after leaving an abusive relationship, but she wasn't concerned.
"It'll still be the same. We'll still be a big family," the woman said. "Our staff, they take care of us."
Officials at Little Rock Community Mental Health Center have cited financial insolvency as the reason for its closure, attributing the nonprofit's struggles to changing payment models and administrative costs.
But the shuttering, scheduled for Monday, creates uncertainty in the lives of its clients, many of whom have low incomes, are homeless, have challenging mental disorders such as schizophrenia or some combination of such disorders.
While there are more than 90 behavioral health providers in Pulaski County, advocates say the loss of this center -- long-established, and where it was relatively easy to get an appointment -- opens a gap in the treatment landscape.
"It's going to have a huge impact on the services for individuals with serious mental illness ... You're just going to tax them more, and really stress them out," said Disability Rights Arkansas executive director Tom Masseau.
"[One of my clients said,] 'Yeah, this is the last time I'm going to be able to see my doctor,'" said Kyle Francis, a social worker with Jericho Way Day Resource Center, which works with people who are homeless.
"I always referred [clients] to Little Rock Community Mental Health ... It felt like we had a pretty good little system going."
Since the closure was reported to the state Department of Human Services last month, Little Rock Community Mental Health Center staff members (and the department, for some patient groups) have been working to notify about 2,500 clients that day treatment, outpatient and pharmacy services will end.
Those efforts have been complicated by inconsistent messaging from the center, and by the nature of its clients , who may not have fixed addresses or regular cellphone service.
"With this population, there's going to be a certain number of clients that it's harder to get a hold of," said the center's coordinator of services, Jesse Hubberd.
"We recognize that there's some clients we're not going to be able to get in touch with, unfortunately."
State procedures regarding the closure of a behavioral health facility also ask patients to select and follow up with a new provider -- offering choice, but also putting the onus to restart treatment on people who are ill.
"Many of these folks have been with the same providers for years and years and years," said Sarah Hirsch, who is CEO of the Professional Counseling Associates community mental-health center in North Little Rock. "They are very hesitant about coming across the river."
In a warm, crowded waiting room at Little Rock Community Mental Health Center in mid-September, a man in a red shirt and baseball cap approached a glass window to tell Hubberd that he had tried to call another doctor's office to establish himself as a new patient.
After two weeks, he'd heard nothing, and Hubberd promised to help him follow up.
'EVERY HAIL MARY'
Little Rock Community Mental Health Center opened in 1967 as an offshoot of the State Hospital and was converted to a nonprofit in the 1990s.
The Pinnacle House property on W. Daisy L. Gatson Bates Drive was purchased by the group for $955,000 in 2007, according to Pulaski County property records. The main clinic and pharmacy moved to its current North University Avenue site in 2014.
The center's longtime executive director, Thomas Grunden, says financial issues there have been compounding for some years, describing "just a continued, rolling-forward deficit" he linked to administrative costs.
In terms of specific challenges, he said management of matters such as ensuring reimbursements for patients who were dually enrolled in Medicare and Medicaid had become problematic.
For the fiscal year that began July 1, the center also has not been the beneficiary of a contract it once held to be the designated community mental-health center providing indigent care in the southern region of Pulaski County.
At the "last minute," Grunden said, a plan to apply for that contract as a partner with its current holder, Centers for Youth and Families, broke down, in part because of what he said was that organization's own unsustainable debt load.
Hubberd said that since then, "I have thrown every hail Mary I could find -- none of them were received."
"I've spent pretty much every night for about three weeks creating different proposals, looking at different avenues we could go down. But none of them were legitimately an option," he said.
He had been preparing the food served at the day treatment program to save money, cooking at night because Pinnacle House did not have a functional stove.
Financial documents for Little Rock Community Mental Health Center do show some metrics suggestive of tight circumstances, according to audit statements available on public databases.
Reported net assets fell from $490,215 to $110,943 during the three-year period from the end of June 2015 to June 2018, while cash at the year's end dropped from $698,086 to $86,621.
During that period, the center's total expenses increased from $10,695,676 to $12,486,647, while unrestricted support, a measure of several kinds of income, grew by slightly less than $1 million.
Responding to the newspaper's request for the organization's tax filing for the fiscal year ending in 2018, a request that nonprofits must comply with under federal disclosure requirements, Grunden said through an intermediary: "no comment."
Behavioral health services have recently been a subject of angst among Arkansas providers as the Human Services Department has reorganized its payment models and shifted to a managed-care system for Medicaid beneficiaries.
Some administrators have claimed that the changes cut into funding or have caused problems with payments, while the department's officials point to an increased number of providers and efforts they say have reduced barriers to care.
The department had not formally discussed the possibility of Little Rock Community Mental Health Center's closure related to financial issues before being notified it would end operations, department officials said.
State records regarding the closure released through an Arkansas Freedom of Information Act request and other documents obtained by the Democrat-Gazette show a bumpy transition that's been troubled by communication problems.
On Aug. 23, the provider filed notice with the department's Aging, Adult and Behavioral Health Services Division that it would close Sept. 23, in compliance with a 30-day notice required by the state.
On Sept. 5, just shy of two weeks after the department had been notified that the center would shut down, the division's assistant director, Patricia Gann, wrote to other officials and said she was trying to confirm reports that the center would close the following day.
Grunden later rebutted those reports in a phone call with Gann, but officials visited the center and Pinnacle House on Sept. 6 and reported areas of concern, according to departmental emails.
At the time of that visit, there were no notices in entrances notifying clients of the closure, which the center had been directed to post in a letter dated Aug. 30.
On-site, they encountered a nurse who was "unable to administer meds due to not having client access."
"There was a patient in the waiting room at LRCMHC stating, 'She did not get her injection yesterday and if she did not get it today she would get sick and have to go into the hospital," wrote Douglas Freeman, assistant director for the department's Division of Provider Services and Quality Assurance, in an email to other staff members.
Officials were assured by center employees that the notices would be posted and patients would be served, and a later email from Gann asked to have the facility checked daily.
Direct communication with clients also has been inconsistent, including in Aug. 23 and Aug. 26 letters that were provided to the newspaper by a patient.
"The last day at this clinic to be Sept. 23rd However this could occur sooner," says one letter bearing a Little Rock Community Health Mental Center logo.
It includes an address for Centers for Youth and Families at a facility not set to fully open until next month .
Grunden said in a text message that the correspondence "is even written on old stationery and was done by someone not representing the center but themselves," and that it potentially violates the center's ethics code and state regulations.
The center would stay open until the date announced, he said. A different, longer and more formal letter, signed by the director, was released with state records.
A tentative plan for Centers for Youth and Families to offer day treatment in partnership with Professional Counseling Associates -- where at least one Pinnacle House client thought that clients would go -- fell though, according to Centers for Youth and Families spokesman and consultant, Bill Paschall.
On Sept. 16, the organization hosted 10 day treatment clients at the Freeway Medical Tower, a temporary solution until a full program can be mounted at its new west Little Rock site, he said.
A final wrinkle in the closure is the transfer of $2.8 million in housing grants that were administered by Little Rock Community Health Mental Center.
Patricia Campbell, a regional spokeswoman for the U.S. Department of Housing and Urban Development, said those grants currently provide housing assistance to 267 people.
The federal housing office and its Little Rock field office are working to find another agency in the area to take over the grants to ensure that those individuals' housing services aren't interrupted, she said.
At a recent public meeting of a Pulaski County Quorum Court committee, county community services director Fredrick Love told justices of the peace that the county may assume control of those grants.
Love said that night that he was not ready to discuss the matter with the newspaper, and he did not immediately return a phone message last week.
Hubberd said that the center's day treatment clients initially were "very afraid -- they were very concerned" when they heard about Pinnacle House closing and that therapists have been working to try to ease their anxiety and assist when possible.
"We talk about it every day, kind of go through what the steps are going to look like, [what] the process is going to look like."
ON HIGH ALERT
Little Rock Community Mental Health Center's closure arrives during an intermittent national conversation about access to behavioral health care.
The subject has been a topic of discourse in Arkansas, where a state-run helpline to connect people with mental-health and substance-abuse providers (844-763-0198) opened last month.
Since the announcement of the health center's closure, area professionals who work with groups with behavioral health needs say they have remained on high alert.
Those clients "getting lost in the shuffle -- not understanding the process or having anybody to help them walk through it, I think -- those are all concerns that we have," said Dianne Skaggs, executive director of the Mental Health Council of Arkansas.
At Professional Counseling Associates, Hirsch said the group is trying to be "vigilant," prioritizing immediate appointments for people who call who were the closing center's clients and developing talking points to make sure no one is turned away.
"I think the major thing we're hearing ... in terms of a transfer of services, particularly for our outpatient adults, is transportation -- and the fear of change," she said.
At Jericho Way Day Resource Center, Francis said he is considering asking clients whether they need help connecting to services.
"If they do get in somewhere different, then get acclimated to it, I think that'd be all right," he said. "I just hope the transition from [Little Rock Community Mental Health Center] to Living Hope [Southeast], or wherever, actually happens."
Several advocates noted that if the center's former clients can't access needed medications or services, they run the risk of ending up in emergency rooms or of interacting with law enforcement agencies.
For people who were served under a $1.9 million contract for indigent behavioral health services in southern Pulaski County, a care coordinator has been working to connect with those clients, Paschall said.
He thought the hiring of some of the center's former clinical staff members would expedite that process, and Hubberd said familiar faces likely would put some clients at ease.
The new 17,000-square-foot Centers for Youth and Families offices are expected to include day treatment and should fully open in west Little Rock by early to mid-October, Paschall said.
He added that a few intake and outpatient services were being offered at the site, but said that the provider was still gaining approval for a pharmacy license and associated Medicaid number.
On the newspaper's recent visit to that location, which is tucked in back of a shopping center near North Rodney Parham Road, a temporary sign hung from a balcony, a few cars sat in the driveway and a ladder leaned against a full dumpster, showing evidence that work looked to be in progress.
Gann said in an interview that it remains Little Rock Community Mental Health Center's responsibility to try to appropriately transition clients, transfer their medical records and make sure they have access to medication.
That is a requirement of the closing center's certification and also a matter of professional ethics for clinicians, she said, adding that the Human Services Department would continue to work to monitor the process.
A report documenting where clients were in the transition was due to the state last week.
Waiting for an appointment at the mental-health center's University Avenue offices shortly after the closure was announced, a thirtyish woman in a shiny green blouse said she had heard rumors of instability there.
She was one of a few in the room who learned that day that the center would close.
"My most concern was, what do we do if we need someone to talk to?" she asked.