At any given time, the PERSAD Center has 40 to 70 LGBTQ people on its waitlist for the specialized counseling it offers in Western Pennsylvania.
Those waitlisted often face a lag of months before gaining access to PERSAD’s services.
Since 1972, the center has provided counseling services, prevention programs and advocacy efforts for the LGBTQ and HIV/AIDS-impacted communities. But under high demand, PERSAD recently has had to formalize an attendance policy that some clients feel is harmful.
Under the nonprofit’s “no-show” attendance policy, clients get discharged from services if they miss three appointments in six months. This policy is not new, but PERSAD only began reviewing the policy with patients and asking them to sign it in the fall.
And concern over this policy is not the only upheaval occurring at PERSAD.
Chuck Albrecht, who was hired as PERSAD executive director in January 2018, suddenly left the position on Nov. 30, during the reporting of this story. Board member Martin Healey was elected board president on Dec. 18. Board treasurer Gene Welsh, who is Healey’s partner, and board co-president Charity Imbrie are serving as co-directors of PERSAD while the organization searches for Albrecht’s replacement.
Director of Clinical Programs Kimberly Henry described Albrecht’s departure as a “mutual decision” between him and the board of directors. She said Albrecht was not “the best match” for PERSAD. Imbrie said Henry’s statement was misinformed, but that she wanted to maintain employee confidentiality and not comment on why Albrecht left the center.
Healey has served as a board member to PERSAD for three years. Before that, he worked on the organization’s development committee for two years. He’s also served as board member for the Delta Foundation, a leading Pittsburgh LGTBQ+ advocacy group, for two years. Healey plans to continue to serve on the Delta Foundation board as he helms the PERSAD board.
The Delta Foundation has faced controversy in recent years, especially concerning its management of Pittsburgh’s PRIDE march. As the foundation has found sponsors and increased attendance from 6,000 to 175,000, some Pittsburghers are concerned that PRIDE has become too catered to the mainstream, making it less inviting to the people it was originally intended to embrace.
Ciora Thomas is founder and director of SisTers PGH, a nonprofit that serves transgender and gender non-conforming youth in Pittsburgh with a focus on transgender women of color. She has concerns about PERSAD and the Delta Foundation and said collaboration between the two organizations would be “catastrophic.”
“PERSAD Center and the Delta Foundation, they’re the white gatekeepers of Pittsburgh,” she said. “They can’t access black people. They don’t know how to access us. ...The only way they allow us on their platform is to tokenize us.”
Healey sees his involvement in both nonprofits as an asset.
“It’s where you want to be: If you’re in the room and talking to people, you’re helping move it in the best way. It’s our hearts that bring us in the rooms together,” he said.
Healey said he believes the connections he’s made to different leaders through his work with the Delta Foundation allows him to “to pick up the phone and get financial and community support” for PERSAD. He doesn’t believe working in a silo is beneficial and hopes to see collaboration between the organizations.
The board of directors discussed the relationship between Healey and Welsh prior to their vote to name Welsh as a co-director as Healey led the board. Healey said he sees their relationship as another benefit.
“We met on the board and, through philanthropic work, we developed a relationship. If anything, it helps the organization. We motivate each other. Our relationship is key in moving the organization forward,” Healey said.
No-show policy concerns
Prior to Albrecht’s departure, Albrecht told PublicSource that no-shows happen regularly at PERSAD and are a detriment to other clients waiting to see a professional at the center’s service locations in Pittsburgh and Washington, Pa.
Henry said the no-show policy had nothing to do with Albrecht’s departure. The PERSAD board of directors voted for the no-show policy. According to Imbrie, the policy was created after PERSAD looked to other attendance policies in the area and found they were the only organization without a no-show policy.
Healey said the board had a robust conversation about those most marginalized when deciding on the no-show policy.
“The folks who are financially vulnerable are the people who show up to their appointments,” he said.
Henry said she has not reviewed a single complaint from patients about the no-show policy. Imbrie said clients have “very little interaction with executive directors” and “we have heard very little about” the no-show policy.
Elliot Goodman, a PERSAD client, experiences intense anxiety and has trouble driving due to a sleep disorder. Sometimes his partner drives him to work because he cannot. When asked to sign the attendance policy contract, Goodman worried he’d get discharged from services. He thought the policy would force him to drive when he shouldn’t, putting him and others on the road in danger because he fears losing PERSAD’s services.
“When I don’t sleep all night, I am not safe to drive. I can’t drive. I refused to sign,” Goodman said. “I get sick a lot. It’s really hard for me to know 100 percent when I am going to make it in every week for six months.”
Sue Kerr is a social worker who receives counseling services from PERSAD. She’s also a donor and fundraiser for the organization. She believes the policy creates more anxiety.
“I'm considering cutting back my therapy to 1x month versus 1x week, so I don't unintentionally jeopardize my access to psychiatric services. That's a terrible decision for me to make. But I'm genuinely concerned,” Kerr wrote in an email.
‘Skin in the game’
For the Pittsburgh region, PERSAD is a beacon. Area hospitals and other organizations offer counseling or outreach services, but none serve the LGBTQ population specifically. In the 2016-2017 fiscal year (the most recent available), PERSAD provided professional counseling services to 1,454 clients from Pittsburgh and beyond.
In the same year, PERSAD provided case management services to “34 individuals who are HIV positive, 14 participants in our senior program, and 22 counseling center clients who experience chronic mental illness,” according to a PERSAD annual report. Case management services were newly added in the 2016-17 year. About 1 in 5 clients that year were transgender, some identifying as non-binary.
The policy in question defines a “no-show” as not arriving to the appointment, canceling with less than a 24-hour notice or arriving 15 or more minutes late and, therefore, unable to be seen.
PERSAD charges 20 percent of a client’s insurance copay for therapy services the first time they don’t show up to an appointment. A second no-show results in a 40 percent charge of the copay. A third no-show leads to discharge. For psychiatric services, PERSAD will discharge clients after two missed appointments. Medicaid and Medicare patients are not charged a fee. If a patient’s copay is $0, they also do not pay a fee.
For PERSAD’s uninsured clients, a no-show will cost 40 percent of a flat fee between $45 and almost $120. The fee depends on the length of the therapy session.
Clients can re-apply for services after a 90-day period.
The center documented 884 no-shows from January to July 2018; some of the no-shows in that total are from the same clients. Albrecht told PublicSource in November that PERSAD has discharged four clients for three no-shows since October. Most no-shows, he said, are because the clients "don't feel like it." He pointed out that nearly three-quarters of no-show clients have no copay, so they have "no skin in the game financially.”
Henry pointed out that clients can “always come back in 90 days.”
PERSAD is looking for grants to offer transportation to clients who need it, though Albrecht previously said he had no reason to believe it was a primary factor driving no-shows.
The center’s director of clinical services gets a weekly report of no-shows and has a conversation with each client once they are in danger of being discharged, Albrecht said. Before PERSAD started enforcing the attendance policy more consistently in October, some clients had nine no-shows documented.
In response, Albrecht said it was no longer up to a therapist's discretion if a client’s attendance warrants a penalty. However, after his departure, Imbrie said this statement is not accurate and PERSAD does make exceptions based on therapist recommendations.
‘Using their voice’
A study published in the Journal of Community Psychology found after the introduction of a new no-show policy where clients had to consult with staff about attendance, the no-show percentage reduced by 32 percent. Another study conducted in 1995 found a no-show fee of $30 reduced no-shows by half. A study conducted in an urban residency clinic concluded that a multi-method intervention reduced no-shows. Patients who missed appointments were interviewed and asked about their scheduling issues. The clinic then double-booked patients with a no-show history, so they had more than one appointment they could go to within the week or day. The clinic also allowed patients to seek and receive care at a time of their choosing. This open scheduling promotes patient-driven choice of appointments instead of pre-arranged sessions.
Nick Summa is a marriage and family therapist with a private practice. He worked at PERSAD from 2013 to June 2018 and said the number of waitlisted people created a need for the policy. “When there’s a no-show, that’s a spot that someone can be filling. PERSAD receives 10 to 15 phone calls for services a day,” he said.
Summa added that earlier versions of the no-show policy did not include patients paying 20 to 40 percent of their copays for missed appointments.
Pat Madigan is a community outreach coordinator for the Pennsylvania Mental Health Consumers' Association, a statewide member organization providing support to people who experience mental illness.
Madigan felt the policy was too harsh for an already vulnerable population. “[P]olicy that is punitive to individuals seeking help is not what human services, whether county or state level, should be doing,” she wrote in an email. “I’m glad that individuals are using their voice in saying no to this policy.”
A PERSAD client who wished to remain anonymous for fear of losing services, also expressed concerned for those most marginalized within the LGBTQ community. “Three strikes, you’re out is ridiculous. We’re not talking DUIs here. We’re talking people getting critical services and, unfortunately, community mental health pretty well equals your clients are going to miss a bunch of appointments.”
There’s a host of reasons for attendance issues at community-based mental health organizations.
As one such example, homelessness among the LGBTQ population is significant. In 2016, 35 percent of homeless individuals in Allegheny County identified as LGBTQ. PERSAD’s annual report did not include how many of their clients experience homelessness.
According to a literature review of research into no-shows for appointments, younger adults and individuals of lower socioeconomic status are most likely to not show up. According to one study about psychiatric services, patients who miss an appointment are more unwell and more impaired.
“The underlying problems that lead someone to therapy often create other barriers to care — lack of resources, poor physical health, anxiety & depression symptoms, homelessness, etc.,” Kerr wrote. “...I've missed appointments because I've been physically sick, because I had car problems, because I was stuck in traffic due to an accident and, on occasion, because I've been crippled with anxiety.”
Before Healey’s appointment and Albrecht’s firing, Kerr wanted to see PERSAD discuss the attendance policy with clientele.
“Why didn’t they have a conversation about this? Bring the clients to the table with board members and staff. Talk about the things they could do to address barriers, to meet what the goal is,” Kerr said.
But now, she feels differently. The priority should be finding a new executive director, she said.
“I am not sure if this would be a good time to start a policy conversation. ...I think they should put [the no-show policy] on hold… and it’s not, it's still in place,” Kerr said, adding that she is having a ‘crisis of confidence’ about the board. “Now that I know the board has this other stuff going on, I wouldn’t recommend anyone working with the board on anything.”
When asked if the center would consider a meeting to discuss the no-show policy and Albrecht’s departure, Imbrie said no.
Brittany Hailer is a freelance journalist based in Pittsburgh. She can be reached at firstname.lastname@example.org.
This story was fact-checked by Harinee Suthakar.