Rehab Rebound: How One SUD Nonprofit Overcame a COVID-19 Outbreak, Stayed Afloat Financially

In late April, on his birthday, Michael Pickering — executive director of RAP, Inc. — got an unexpected surprise. It wasn’t a good one.

One of RAP’s substance use disorder (SUD) patients had become symptomatic with COVID-19. From there, things snowballed, with two dozen patients and staff testing positive for the coronavirus in the days that followed.

But since then, the small nonprofit provider has bounced back. RAP survived the outbreak and has stayed afloat financially amid COVID-19 by following the science, partnering with outside organizations and applying for every form of relief available to them.


While Pickering doesn’t assert to have all the answers, he recently provided insight into how RAP has navigated the past few months in a recent interview with Behavioral Health Business. Plus, he provided advice to other SUD providers facing similar struggles.

“Talk to your doctor and don’t get into the politics,” Pickering said. “And it may sound really stupid, but buy a lot of pizza. It makes staff feel appreciated, and it mitigates their risk of exposure because they don’t have to go out to lunch.”

Founded as Regional Addiction Prevention Inc. back in 1970, RAP treats patients with SUDs and other co-occurring conditions. It has a 42-bed long-term residential program, a 16-bed withdrawal management unit and a 4-person SUD crisis unit. Additionally, it offers outpatient and IOP services.


Before COVID-19 hit, RAP had plans to expand: It was all set to open a couple new transitional programs, one for men and one for women. However, in light of the coronavirus, those beds have been repurposed for isolation use.

Even before RAP’s residential outbreak, Pickering and his team swiftly responded to COVID-19 out of necessity. Many of RAP’s patients are homeless drug users, making them especially high risk for COVID-19. Plus, the close quarters of the nonprofit organization make social distancing somewhat difficult, as patients share rooms.

In addition to repurposing its transitional beds, RAP reduced its patient census, cutting residential programming by about 10 beds and reducing capacity there to about 32 patients. On top of that, RAP leadership decided to transition all non-essential employees to work remotely.

For those essential employees who continued working in-person, RAP had to fight to secure personal protective equipment (PPE).

“Nobody was thinking about congregate living environments for behavioral health at all,” Pickering told Behavioral Health Business. “People were just starting to talk about nursing homes, but the focus on disease prevention and treatment was really the hospital settings.”

So RAP got creative. It sourced hand sanitizer from a local distillery and masks from community volunteers. Additionally, the nonprofit got help securing PPE from Gardancia Inc., the largest behavioral health provider in Pennsylvania, Maryland and Delaware, with whom RAP has a management agreement.

Despite those precautions, COVID-19 swept the facility in late April, shortly after the Centers for Disease Control and Prevention (CDC) had recommended masking, but before patients started to take the recommendation seriously.

“[Patients] weren’t being as responsible about masking as everybody was being told to be,” Pickering said.

The first domino fell when a withdrawal management patient who had been stepped down to the residential level of care became symptomatic. Leadership is still unclear on how and when that patient became infected, as his diagnosis pre-dated the now common practices of testing and contact tracing.

Right away, RAP sought help from the D.C. Department of Health and Human Services (DHS), who had set up a number of “quarantine hotels” around the city, Pickering said. RAP transferred the symptomatic patient and his roommates there, in hopes of mitigating further spread across its facility.

But by that point, unbeknownst to Pickering, the virus had permeated the RAP patient and staff populations. They were dealt their second blow the next day, when a different patient went to the emergency room with chest pain, where he tested positive for COVID-19.

At that point, RAP leadership decided to pull the trigger on testing capabilities, which were newly available from LabCorp, a clinical laboratory company.

“We were able to get them within a day or so,” Pickering said. “We tested everybody, and that’s when we determined we had 13 positive patients and 11 positive staff.”

From there, Pickering contacted DHS, who picked up all RAP’s patients and transported them to quarantine hotels. Then, he temporarily closed RAP altogether.

“Patients who had been confirmed positive went to one of the DHS isolation sites, and folks who had not tested positive went to another hotel that was for individuals for observation,” Pickering said. “And staff my home for two weeks.”

During that 2-week period, RAP hired an outside crew to deep clean and disinfect all of its buildings. At the same time, tele-working staff continued to remotely provide virtual services to patients in quarantine hotels.

Meanwhile, Pickering looked to RAP’s integrated primary care team and medical director for peace of mind.

“In my first conversation with [our medical director,] when I was in full panic, he was just like, ‘Look, this is an infectious disease.’” Pickering said. “‘We know what to do. We just have to do that.’”

Reopening RAP, remaining financially viable

Today, RAP is back up and running, as it has been since its initial two-week shut down. Additionally, all of its COVID-19-positive patients and staff, none of whom were seriously ill, have recovered.

After it reopened, RAP put a number of new protocols in place, which continue to help protect patients today.

It has 14 isolation beds, with another 10 available at partner SUD treatment provider nearby. The providers are working together to take in new admissions, with funding for the isolation units coming from the city’s emergency dollars.

“So now if you walk in or are referred by another provider, we’re going to do your assessment, and we’re gonna test you,” Pickering said. “If you’re appropriate for residential treatment, we’re going to put you in one of these two isolation houses, observe you and test you again.”

After two negative tests, RAP will move patients into its residential treatment program — if there’s room. If there’s not, patients are transferred to another local residential provider, with whom RAP is working to meet the ever-increasing need in the community for SUD services.

Meanwhile, potential patients who test positive for COVID-19 are sent to DHS quarantine hotels before they can receive SUD treatment.

In addition to all that, RAP is enforcing temperature screenings, mask wearing and hand hygiene throughout its programs.

And as a result of the new protocols, RAP has only seen two patients test positive since its initial outbreak, Pickering said in early October.

However, sailing hasn’t exactly been smooth for RAP over the past several months, especially from a financial perspective.

In addition to already low rates and the fact that D.C. is an expensive market to do business in, the nonprofit is currently in the process of transitioning to a managed care payer system. The pandemic only exacerbated that financial strain, as it reduced revenues and increased expenses.

RAP’s strategy is to apply for every form of relief and grant money available, as well as to work with other SUD providers in its network to meet the need for services in the area. Employees have pitched in too, launching a GoFundMe for RAP, which has raised about $5,000 to date.

But still, RAP’s future remains uncertain, Pickering said.

“We’re counting pennies,” Pickering said. “It is not easy. We’re living on credit. I hope that there is some bright light ahead, but I’m worried, not just for myself, but for the network. We have a very thin SUD network in the district, and I’m worried about all of us.”

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