Lon Moore's struggle with schizoaffective disorder grew so intense in 2001, he faced an experience he never wants again - lying in a hospital, overcome with suicidal thoughts.
But even after 13 years, Moore still worries he could slip back into despair without services like Recovery Zone, a therapeutic day program he attends in Louisville for adults with debilitating mental illness.
Without the program, "I wouldn't have anything to do," he said. "And you can get into trouble ... when you have a mental illness and there is nothing to do."
For many adults with severe and chronic mental disorders, access to such daytime therapeutic services is on a steep decline in Kentucky, leaving what some fear is a gap in care that isolates the mentally ill at home or drives them out into the streets, hospitals or jail.
The Kentucky Association of Regional Programs reports that 33 of the roughly 50 programs offered across the state have closed in the past 18 months while four others have reduced their hours by half.
That reflects a shift away from using day programs in the field of behavioral health that community mental health centers must embrace, according to the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities.
But advocates also say the centers have struggled to get enough coverage authorized under Kentucky's Medicaid managed-care system to keep the services operating. That has forced programs to close before new services are available to replace them, they argue.
Steve Shannon, executive director of the regional programs group, estimates that closings have impacted more than 1,000 people statewide - many suffering with schizophrenia, schizoaffective disorder, bi-polar disorder or major depression.
At Seven Counties Services, the community mental health center for the Louisville region, three day programs were consolidated into one this year, scaling back services for 70 to 90 clients in Bullitt, Spencer, Shelby, Henry, Oldham and Trimble counties.
Recovery Zone in Louisville is now the only traditional therapeutic recovery program offered through the center, although Seven Counties has launched alternative recovery programs in the affected counties.
Therapeutic rehabilitation programs typically involve a mixture of group therapy, life skills training and professional assistance with symptoms and medication management.
Clients attend several days each week, providing a full day of interaction with therapists, social workers and others with mental disorders.
Gunning said families count on the programs for respite, and for people with severe mental illness, they provide "someplace to be, something that gives meaning to them."
Yet, according to Dr. Allen Brenzel, medical director of the Department for Behavioral Health, the field of behavioral health has been shifting away from day programs, which he described as an indefinite intervention that "actually leads people to staying in the status quo."
Every center in Kentucky received state funding in 2013 to set up new services such as case management, job coaching, in-home support and psychiatric aid, he said, adding that the goal is to push intensive services out to the patient rather than bringing them into facilities and day programs.
Still, critics argue that services previously covered under Medicaid were increasingly denied after Kentucky expanded Medicaid managed care in 2011, contracting with outside firms to run the system and save taxpayer money.
"The programs were closed because the (Medicaid companies) weren't paying for them any longer," Shannon said. "All that took place before new services were available to meet the need."
Of the four companies that run Kentucky's Medicaid system, mental health advocates say Coventry Cares - and its subsidiary MHNet - are by far the worst about denying coverage or reducing hours for therapeutic day programs.
Coventry and MHNet are owned by insurance provider Aetna, which reported $1.9 billion in net income last year.
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