From the Oregonian, March 24, 2000. Not available elsewhere online.

County officials, surprised, see a new political problem rather than hoped-for suggested improvements.

When the Multnomah County Board of Commissioners appointed a mental health task force last year, the goal was clear: Figure out a way to improve the county’s deteriorating mental health system.

Board Chairwoman Beverly Stein had high hopes that the 12-member, citizen-led group would cut through the morass that the mental health system has become and shed light on new approaches to serving the mentally ill.

But a report issued by the panel at a meeting Wednesday night sparked a heated debate after a draft version called for the county to shake up the management of the Community and Family Services department. The department handles mental health issues.

The task force singled out managers in the department as “inept and inattentive.” Before the meeting, task force Chairwoman Elsa Porter went as far as naming Community and Family Services Director Lolenzo Poe and behavioral health manager Floyd Martinez as the problems.

Now Stein and the board have a political hot potato on their hands. Some question whether the task force is addressing a fundamental issue in mental health services or just creating a new problem.

Stein downplayed the report, saying it’s still a draft until the group officially reports to the board Thursday. She said she was surprised to see language critical of county management.

“I thought the language was quite inflammatory,” she said. “They certainly have the right to comment on issues that they think are pertinent, and I appreciate their honesty. But these are serious kinds of allegations that have been made.”

Stein will look into allegations

Stein said she supports Poe and Martinez and will stand by them. But she plans to investigate allegations by some of the task force members.

The board appointed the task force in August and asked members to examine the county’s mental health system. The goal was to come up with ideas on how to improve the system that has fallen apart in the last 2 1/2 years.

Mental health providers have lost funding during that time as the state has moved from fee-for-service to managed care funding formulas when that demand for services has increased.

Case loads have tripled in some agencies, with some caseworkers now responsible for 100 clients at a time, but support services for the mentally ill have been cut. More than 10,000 county residents receive publicly funded mental health services, but no one is certain how many people are served or how much it costs.

The task force met first in the fall, conducting much work in subcommittee meetings. Most members had not seen the draft report until Wednesday morning. Discussions at Wednesday night’s meeting at Portland State University were part substantive debate over policy recommendations and part wordsmithing of the final 13-page report and a chart headlined “The Ideal Mental Health System.”

The task force did not provide copies of the draft to the audience, even after State Sen. Avel Gordly, D-Portland, who had testified about problems a relative had experienced with mental health services, requested copies for the audience of about 60.

Meeting turns tense

Gordly took the matter into her own hands, handing a copy she had obtained to a staff member from Stein’s office and asking him to go to a quick-print shop. Within a half-hour, copies were available to everyone in the room.

The meeting turned tense over discussion of the draft’s strong criticism of unnamed county social services administrators. Some audience members interrupted discussion to defend county officials “It impugns everyone in (the department of) family services,” said Kathleen Saadat, who works for the county.

Some task force members clearly were uncomfortable with the draft report’s assertion that “the system has fallen victim to inept and inattentive leadership,” among other statements.

“It really sounds like we are trying to get somebody,” said task force member Sandy Hayden.

Constance Powell, a task force member who was most critical of county leaders at the Wednesday meeting, said Thursday that five county-funded employees at different work levels have raised issues privately about county management. She says Poe and Martinez are responsible.

“They are the leaders, so they would be the accountable people,” she said.

Having a task force deal with such a monumental issue hasn’t fazed Stein or the four county commissioners. All are big proponents of citizen involvement in government.

But the findings mark one of the first times a committee has called for changes in the county’s leadership structure. “This is not something that we anticipated,” said Bill Farver, Stein’s top aide. “We obviously are going to have to ask them for more specifics on what they mean.”

Stein remains undaunted, saying that the alternative would be to keep the public from being involved.

“You take some risks in terms of what’s going to emerge,” she said. “I don’t have a problem with that. On the other hand, I’m not compelled to do anything the task force says. I appreciate all the work they’ve done but the board will make the final decision here.”

The task force will go before the board with its final report on Thursday. Poe, Martinez and other family services staff will have a chance to address the findings on April 13.

By Robert Landauer – editorial columnist for The Oregonian, part of the series – “Rescuing the mentally ill,” March 24, 2000. Not available elsewhere online.

“The Oregonian has found no one during the last three months who can say reliably how much money is spent in Multnomah County on mental -health support”

Confused thought processes and bizarre, self-destructive behavior typify certain mental illnesses. That also describes the way public agencies in Multnomah County deliver services to residents with severe brain disorders.

City police, county jailers, the Oregon Health Plan, housing and development agencies, employment and vocational rehabilitation services, social workers, probation and parole officers, judges, Oregon Health Sciences University, Portland State University, hospitals, the crisis triage center, schools, alcohol and drug counselors, the education service district and many, many private contractors and charitable groups all deliver mental health services.

And they fail.

The reason is that they are fragments. They are not integrated and coordinated, so they fail to conduct successful recovery efforts for many of the 10,000-plus low-income county residents receiving public assistance to cope with their mental illnesses.

The extent of this organizational meltdown is frightening.

For example, The Oregonian has found no one during the last three months who can say reliably how much money is spent in Multnomah County on mental -health support, what share goes to administration vs. direct services and what the outcomes are for different types of patients and agencies.

Lacking information, agencies build budgets and operate independently. No one prioritizes to produce better human and financial value for the services clients need and taxpayers buy.

No coach designs overall strategy. No manager breaks bureaucratic barriers and forces interagency cooperation. Skilled and dedicated doctors, nurses, social workers and police end up dealing with the mentally ill one-on-one — but not as a disciplined team.

The early intervention and unbroken chain of care essential to keep the mentally ill healthy disintegrate under those conditions. So thousands of the mentally ill continue to relapse into crises that could have been prevented or eased.

What should be done? Here are some suggestions:

Link the fragments

The core challenge in Multnomah County is to link the service fragments into a mental -health system that is coordinated, responsive and accountable.

The county should start by reorganizing the entire administration of public mental -health services. With other local governments’ participation, it should centralize responsibility for all mental -health services in a permanent task force operating out of the Behavioral Health Division. That would, at least, eliminate multiple layers of administration, freeing resources to cut front-line workers’ huge caseloads.

Get a Medicaid waiver

To gain utmost flexibility and effectiveness, the county should seek a local waiver allowing it to apply Medicaid money to mental -health medical treatment and to related, critical support services. This specialized waiver within the waiver that the federal government granted the state to operate the Oregon Health Plan would recognize that patients need more than medication management to recover and thrive.

Merge bureaucratic empires

As a start and as a minimum, merge the county’s mental-health and alcohol/drug empires. It is self-defeating, wasteful and cruel to separate the treatment of patients with co-occurring mental disorders and addictions.

Seek intelligence, not just data

Build a data warehouse with a strong clinical base to support a shared information system. Mental -health systems cannot run well without accurate, timely, and complete information. When doctors, hospitals, housing agencies, vocational rehabilitation services, alcohol and drug counselors, police, judges, jailers and probation officers don’t share information, patients cannot get the coordinated care they need.

The mentally ill are not alone in being badly served by data systems that don’t talk with one another. Taxpayers are penalized, too, because the billing and clinical information is not now compressed and spin-dried to reveal which prevention and treatment programs are most cost-effective. This information allows us to make intelligent choices on how much, where and when to spend public resources.

Bluntly stated, a data system fails us unless it shows how much of what we do for the mentally ill makes a positive difference. Without that evidence, much current spending is wasted.

Only when the major tasks are done can other critical elements be properly integrated. Among them:

• Year-round countywide mobile response teams must step in as early as possible when mental -health crises are signaled. This includes mental -health professionals who can respond to any brewing threat to landlord/tenant or employer/worker relationships.
• Cooperating agencies must repair the delivery network’s neglect of racial and ethnic minorities’ special language and cultural needs. Spanish speakers, for example, are the county’s fastest-growing minority, yet a shameful inability to communicate with them in mental -health emergencies and in continuing care smothers minority clients’ chances of recovery.
• Early assistance must move higher among local mental -health priorities. Programs such as Healthy Start, which provides two years of training and support to disadvantaged mothers, reduces child abuse and mental / behavioral disorders. Research increasingly demonstrates very favorable returns on selective early investments.
• Computer technology, available at libraries, should be used to help families gain access to mental -health support services, now hidden in a bureaucratic jungle that many find impenetrable. Websites such as Family Care America (www.familycareamerica.com) could provide families with the most suitable resources in their ZIP codes.

Many Multnomah County residents who receive public services for mental illnesses can be rescued from the worst symptoms of their treatable brain disorders, and taxpayers can get better value for the support they extend.

That will happen only if all mental -health providers are harnessed to pull as a team and if they are given the information to make excellent choices.

From the Oregonian, March 23, 2000. Not available elsewhere online.

A group finds that the system needs more money and better accountability and coordination.

A Multnomah County task force on mental health issues said Wednesday that the current system needs more money, improved accountability and more coordination between physical and mental health care treatments to help end the deterioration of services.

The task force adopted recommendations in those areas as it wrapped up six months of study of the county’s mental health service system. The recommendations go to the Multnomah County Board of Commissioners next week. The county commission will hold a public hearing April 24.

The county-appointed task force debated a statement in a draft version of its report that took the position that poor leadership has contributed to the decline in mental health services. The tense debate over that proposed language ended with a decision to tone down the document.

The draft included a strong criticism of unnamed county government officials and called for new leadership within the county’s mental health system.

“Unaccountably, the system has fallen victim to inept and inattentive leadership,” the task force said in a report adopted Wednesday. “A sense of powerlessness pervades the agency together with a culture of defensiveness and blame.”

Committee Chairwoman Elsa Porter said before the meeting that the report was referring to Lolenzo Poe and Floyd Martinez, who work in the county’s Community and Family Services Department. Poe has been in charge of the department for more than six years, while Martinez serves as manager of the department’s behavioral health division.

“The basic driver of getting things accomplished in the mental health field is going to come from people who can collaborate, cooperate and who are open to sharing information,” Porter said. “Unfortunately, we don’t have that now. People need to stop being defensive and listen.

“They are still working off the old bureaucratic management system,” Porter said. “Their employees are intimidated into not giving input or ideas. (Poe and Martinez ) don’t listen.”

Poe scoffed at the task force’s contentions, saying he has a sterling record of achievement.

“I’ve had six years of excellent evaluations based on my leadership and I’m willing to submit to a survey” of CFS employees to prove it, he said.

“Let’s not hide behind accusations and innuendo,” he said. “I want to know where the proof is. I think it’s all personal.”

Martinez said before the Wednesday meeting that the statement was a total surprise.

“I think there is no substantiation,” he said. “If the task force wants to talk about leadership, I’ll be more than happy to do so. I have 32 years of leadership in this field, all in places bigger than this.”

But while some task force members wanted to tone down the language, Constance Powell said she felt strongly that the issue should be addressed. She said a style of management creates fear and intimidation for some employees, who she said were afraid to speak to the task force. “They slip us notes,” she said.

The 12-member task force, formed last August, set out to offer suggestions on how to improve a system that has deteriorated since late 1997. That’s when the state began a shift from fee-for-service to managed care and expanded eligibility for mental health services. It found its path strewn with obstacles because of inadequate data about program costs and services.

Many task force recommendations are merely foundations for improvements to a system that serves an estimated 10,000 or more county residents.

The recommendations include:

• Establishing a single mental health department “where accountability and responsibility can clearly be placed.”
• Eliminating both the county’s managed care organization, named CAAPCare, and the for-profit managed care organization Regence and Family Care, named Ceres. The organizations should be replaced with a single management agency.
• Improving care through better coordination, linking alcohol and drug treatments with mental health services.
• Organizing meetings with state officials, legislators and insurance plans and creating a forum for discussing issues specific to minority patients in mental health services.
• Establishing a strong central data authority to coordinate an effective data collection system.
• Creating a job of assistant to the chairman of the county’s Board of Commissioners responsible for children’s services.
• Supporting additional funding as soon as possible and using new state dollars to improve housing and crisis care services. The task force hopes the state will provide $2 million in the next two years.

By Robert Landauer – editorial columnist for The Oregonian, part of the series – “Rescuing the mentally ill,” March 23, 2000. Not available elsewhere online.

Parents leaving hospitals with newborns get less support than new-car owners leaving auto showrooms.

Manuals and toll-free telephone lines aid owners when cars malfunction. But many parents don’t know where to turn when relationships with infants or toddlers turn unworkably rough.

What begins as a family issue often grows into a community problem. Research from many fields — including insights into brain development from developmental biology and neurochemistry– confirms that these early interactions can affect how the child functions socially throughout life.

“Like a weed, the longer (antisocial behavior) grows, the stronger it gets, the harder it is to kill,” clinical psychologist Patti Chamberlain told an Oregon Department of Corrections seminar on Feb. 29. She and colleagues at the Oregon Social Learning Center in Eugene are pioneers in prevention and treatment research in children with mental illnesses and behavioral disorders.

One thing stands out in her remarks: The earlier the intervention, the fewer the barriers that are likely to trip up rehabilitation and recovery.

A 1999 Rand report, “Investing in Our Children: What We Know and Don’t Know About the Costs and Benefits of Early Childhood Interventions,” agrees. It concludes that good treatment programs that begin early can improve children’s emotional development, educational outcomes, job success and economic self-sufficiency. They can reduce substance abuse, criminal activity and child abuse. And their savings can cover their costs.

Every carefully targeted dollar spent now saves $2 to $4 later, says Mary Mertz, assistant supervisor of the Portland Early Intervention Program. It assesses 1,000 children up to age 5 each year. Ten percent have mental -health issues. But funding for treatment slots is slipping — down from 50 to 25 preschoolers — even as more children are identified as eligible for treatment.

A perverse pattern becomes clear. It starts with a lack of training to help parents develop nurturing relationships with their children. It continues by failing to help parents understand what kinds of behavior ought to signal them to look for help and where to find it.

Then, when preschool caregivers experience similar problems, many are unequipped to cope. Their remedy of last resort: Drop-kick troublemakers out of their program.

The pattern of neglecting early intervention continues when children get to school. Counselors and nurses, trained to spot children who should be referred for mental -health diagnosis and treatment, have been getting cut left and right, says Tina Garcia, Oregon’s associate superintendent of student services.

Ten years ago, for example, all of Portland’s elementary schools had a full-time child development specialist. Now, following budget cuts, one-third have no such help, and another one-third have only part-time help.

The disregard continues with adolescents even though many serious mental illnesses first become evident in teen-age years. Eighteen percent of visits to school-based health centers in Oregon produce mental -health diagnoses. The Legislature and local school districts fund only 44 of the centers statewide even though demand indicates twice as many would open almost instantly if funding were available.

What should be done in Multnomah County to help troubled children?

First, intervene early. With infants and toddlers this is likely to be significantly effective, take less time and have fewer lingering complications than help that is delayed, researchers agree.

Second, take mental-health services to places that care for children — homes, nursery schools and child-care settings of all types, Head Start programs — instead of waiting for advanced-stage problems to be referred.

Third, use mental-health workers to teach caregivers to cope with the behavior issues they face. This capacity-building is essential because public budgets ration mental -health professionals and because child-care workers need more training than all but a few employers can afford. Supporting those who care for numerous children five days a week could become the county’s most effective mental -health strategy.

Fourth, enlist financial support so that private-sector mental -health professionals can reach out further to help parents, caregivers and teachers respond effectively to children’s behavior. One example: The Coalition for Children and Families of the Oregon Psychoanalytic Foundation will open a line this month in Portland to assist a limited number of family child-care providers who don’t know where to turn for referrals or when to refer.

Putting all these efforts together would signal that we mean to pay as much attention to our young children as to our new cars.

By Robert Landauer – editorial columnist for The Oregonian, part of the series – “Rescuing the mentally ill,” March 22, 2000. Not available elsewhere online.

A new Multnomah County mental health court is in the offing as many more of the mentally ill populate local jails. Cautions are in order to protect ill individuals from harmful side effects of the state’s benevolence:

This specialty court is likely to stress voluntary diversion into treatment, preferably long before defendants enter pleas on misdemeanor crimes. To make informed rulings, judges will need defendants’ medical and mental health histories, records of alcohol/drug addictions and awareness of housing, jobs, skills-training, entitlement and language and cultural factors that affect treatment success.

This requires a far better cross-agency information system than now provided — one that emphasizes treatment results instead of billing practices.

Even if judges get all this information, they don’t know which treatments or sentences work best.

This is inefficient. It also is unacceptable for the special-needs population whose lawbreaking has more to do with illness than criminal intent.

There is a nation-leading opportunity — first in Multnomah County, then the rest of the state — to overcome these defects. It urgently requires continuing, top-level political, financial and interagency support to create a new information system:

Multnomah County Circuit Judge Michael Marcus leads a project to build a Criminal Sanctions Effectiveness Measurement.

The first goal is to find how different types of offenders respond to the various treatments and sentences.

Marcus recently took an early model of the measurement tool on what literally was a trial run:

“When I first ran the tool on the bench against real data on Jan. 26 — the first time such a technology was used anywhere in the known universe — I sent an e-mail to (several hundred) judges all over the world . . . analogizing the event to the Wright Brothers’ first flights at Kitty Hawk. On the one hand, I am confident that this step will have as much impact on criminal justice and its culture as Kitty Hawk had on transportation. On the other hand, we have about as far to go to a completely functional tool as the Wright Brothers had to go to a Boeing 737.”

This is the take-off stage. Incomplete data limit the sentencing-support tool’s useful range. But fuel is being added. Detailed information on a larger pool of offenders and available sentencing/treatment options is being collected, sorted and sifted in Multnomah County, and then compared with results.

Oregon’s Department of Corrections, with more than 9,000 inmates (18 percent with serious mental illnesses), no doubt will want to adapt this tool. It could be adjusted easily to assess effectiveness of programs in prison and to fine-tune others that Corrections workers are developing to help inmates succeed after release.

Information systems can and should help judges, medical staff and social workers choose the best matches of treatment programs or sentences for mentally ill defendants and clients as well as others.

It is critical, though, not to confuse output with outcomes. Turning data into intelligence will be futile if resources aren’t there to allow suitable referrals.

That is the deplorable situation now for the mentally ill in Multnomah County: Average funds available per client plunged from $440 in October 1995 to $244 in May 1999. Social workers and probation officers each are working with more than a hundred clients. Caseloads are two, three, even four times nationally recommended standards.

Overall, mental -health workers here are rushing from crisis to crisis. They have little time to devote to the early interventions and consistent support that keep patients stable in the community. Indeed, a woman movingly told a county task force recently that her mental illness hospitalizations, which used to occur once every 21/2 years, now come about every six months. The likely cause: Her breakdowns rose along with her social worker’s caseload; it is so high now that they only have occasional, cursory meetings, no time even to go out together for coffee.

So the mentally ill crowd our county jails. They get superior treatment there — it’s a progressive place — and their illness symptoms often improve greatly during their average three-week stay.

But jail shouldn’t be Multnomah County’s mental -health treatment center of choice because care that begins at the jailhouse entrance usually ends at the jailhouse exit.

Consistent, hands-on compassionate, care for people with treatable brain disorders will keep many from ever having to stand before a judge in mental -illness court.

It is important, though, that we know more about profiles of the mentally ill who do get arrested and jailed.

The sentencing-effectiveness tool will spotlight what best protects public safety and aids rehabilitation and recovery. Its development is an enlightened, urgent priority.

It would be wasteful and cruel to continue to sentence the mentally ill in the dark.

By Robert Landauer – editorial columnist for The Oregonian, part of the series – “Rescuing the mentally ill,” March 20, 2000. Not available elsewhere online.

The dedication of Nadine Place and Rita Mae Manor brought Independence Day from July to January for a small group of Multnomah County residents.

The new residential care facilities in Southeast Portland enabled 15 severely mentally ill persons to step down from more intensive levels of care, called lockdowns. But barriers down the line produce a relentless traffic jam.

For at least two years lack of bed space has plagued operations at the Oregon State Hospital in Portland.

About 30 patients have been identified as eligible for treatment at the highly secure extended-care center. There is no room, so these seriously ill patients are on a waiting list.

At the same time, roughly 40 patients have benefited as much as is likely from hospitalization. They are ready to move on, perhaps to secure, but less restrictive, facilities like Faulkner Place at 13317 SE Powell Blvd. There, aided by medications, life-skills training and intensive individual and group therapy, many residents eventually graduate to community-based, small-group, structured living arrangements.

But the secure step-down programs are full, too. So the State Hospital was able to release only about a dozen patients a month until . . .

The beds at Nadine Place and Rita Mae are speeding the traffic flow, at least for now, allowing the State Hospital to increase its releases to 20 patients a month in January and February.

But the new treatment homes don’t meet every patient’s needs.

Amy (name changed) came to Faulkner Place from the Oregon State Hospital in August 1995. She has a thought disorder, schizophrenia. She feared that others were plotting to injure her. She sidestepped meaningful human contact. She cheated over whether she had taken medications. Delusions of grandeur led her to believe that she held medical degrees and was a staff member of the State Hospital where she had been treated.

She was not aware of her severe illness. If she did not take her medications, it was clear she could put herself in harm’s way in the community.

By the fall of 1997, Amy’s progress indicated that she was ready to step down to an unlocked setting. No suitable options could be found.

Now, 2 1/2 years later, Amy continues to improve greatly, but still lives in a lockdown. She is one of a number of patients from various extended care facilities competing for very few bed spaces.

Amy and those waiting to take her place pay a personal price for this traffic jam. The meter runs for taxpayers, too.

Oregon State Hospital care for adults averages $314.70 a day, or $114,865 per year. The federal government pays no portion of the State Hospital tab.

As patients step down to secure facilities like Faulkner Place, costs step down with them — averaging $228.69 a day, or $83,471 a year. Federal programs now chip in $93 a day, lowering Oregon taxpayers’ direct bill to $135 a day, or $49,275 a year.

One more step down, to very intensive residential care facilities like Nadine Place, daily costs plunge again, to $125.98 ($45,982 a year). Here federal programs pick up 60 percent of the cost, so Oregon taxpayers kick in $18,393.

At this point patients’ march toward independence slows or stops as they compete for housing with the working poor, the developmentally disabled and low-income seniors. The federal government picks up no part of step-down treatment at this level, so Oregon taxpayers contribute from $83.25 a day down to $18.54 a day at the lowest level of support.

As many as 14,600 Multnomah County residents suffer from a serious mental illness; 10,469 of them received some state-funded services in fiscal 1998-99; and 7,852 need subsidized rent.

Almost 3,000 need a specialized housing program. But only 772 beds in Multnomah County meet the criteria, says a Housing Working Group of the county’s Adult Behavioral Health Division. Specialized housing programs are all at or above 95 percent occupancy. Wait lists run as long as two to three years.

It is a tough task to provide affordable, permanent, service-enhanced housing to persons with mental illnesses, many of them also with physical illnesses and alcohol/drug addictions.

These county residents are poor as well as sick. Most live on just over $500 a month from Social Security. “Living on a fifth of the median income, they can’t afford market rents when even median-income people can’t afford them,” says Marge Ille, of the Housing Authority of Portland

For the mentally ill on Social Security, $150 to $160 is the ceiling of affordability, based on federal guidelines. There is no clean, safe, decent, market-rate housing at that price here.

Even the $250 a month residents pay at Nadine Place barely covers operating costs for the nonprofit Network Behavioral Health Care Inc. — a bargain for the residents. They have 24-hour supervised housing, treatment, skills training and medications management. They have about half of their Social Security allowance left to apply to food, transportation, clothing, recreation, and non-covered treatment-related costs (special diets, massage, acupuncture). Many will probably step down toward less-costly community support. Some will get paying jobs.

Supported housing is a good deal for the community, too.

What happens when the housing needs of the mentally ill in Multnomah County are not met? “2,170 individuals are left to wander our streets, fill our hospital and jail beds, and to somehow fade from a field of vision so as not to trouble the souls of our general citizenry,” says the Housing Work Group.

Progress requires immense public/nonprofit collaboration. The state, Multnomah County and Portland all have housing specialists who help the mentally ill. Churches and charities pitch in, too. But no one is turning data into intelligence that tells us how best to spend the next housing dollar here:

On adult foster-care housing? On more studio or single-room-occupancy beds? On housing where mental illness and addictions are treated at the same time? Or would it be wisest to reduce social worker caseloads so that landlords don’t withdraw their apartments from the already shallow pool available to the mentally ill?

Briefly, no one is in charge.

We have fragments.

We need coordination, a team.

Lack of housing wastes precious resources.

Providing more housing will save money and restore lives.

By Robert Landauer – editorial columnist for The Oregonian, part of the series – “Rescuing the mentally ill,” March 19, 2000. Not available elsewhere online.

Over the past three months, Robert M. Landauer, The Oregonian’s editorial columnist, has examined the efforts of public agencies in Multnomah County to treat the indigent mentally ill. His research found a broken system seriously in need of rethinking. This series written for the editorial board recounts that research and offers recommendations on how to fix the system.

“The state, cities, school systems and private service providers share responsibility for a system that can’t reliably tell you how much it spends, how many people it serves and what the outcomes are for those who are enrolled.”

Public agencies in Multnomah County have created a cruel and dangerous obstacle course for the mentally ill.

More than 10,000 county residents who receive public assistance to deal with their severe, persistent mental illnesses are as likely to encounter hurdles as help in a treatment and service system that is in appalling disarray.

Over three months The Oregonian has identified five areas where our local governments could remove or lower barriers that trip the mentally ill’s progress toward rehabilitation and recovery. The most conspicuous hazards are:

1. A crippling shortage of affordable housing for Multnomah County’s low-income mentally ill. Their inability to quickly find what little housing is available compounds the difficulties.  Without stable, long-term, affordable housing for the seriously mentally ill, treatment unravels and usually fails.
2. Criminalization of mental illness. Police, sheriff’s deputies and the Multnomah County Jail are being vastly overused to deal with the county’s chronically mentally ill. Money could better be spent on services to keep the mentally ill out of jail.
3. Sentencing the mentally ill without knowing which punishments or treatments are most likely to stop them from repeating their offenses. Information on which sanctions are effective and which are unproductive are buried, unused, in justice system records.
4. Failing to operate an adequate early warning system geared to prevention and treatment of mental illness in children who show profoundly troubling symptoms. Early intervention consistently offers the best prospect for good results.
5. Organizational meltdown that obstructs delivery of help to the mentally ill. Topheavy layers of administrative staff at public agencies and contractors materially reduce the number of people who directly help clients regain and sustain mental health.

A complicating factor: The information systems that mental -health workers use typically fail to give them the detailed clinical information they need to be effective with clients.

The county is the primary service coordinator. But the state, cities, school systems and private service providers share responsibility for a system that can’t reliably tell you how much it spends, how many people it serves and what the outcomes are for those who are enrolled.

What problems are most pressing?

• No one is in charge, so no one is finally accountable for results. The buck of responsibility has nowhere to stop.
• The system is so broken into unconnected parts that even workers who toil in it struggle to identify who can give assistance that clients require.
• The fragmentation baffles, frustrates and defeats patients. Only the most persistent are likely to navigate the many agencies and complex procedures to find all the help they need.
• The first tasks of all medical systems are to prevent illness when that is possible and to improve the well-being of patients when it is not. Yet the information produced by agencies that serve the mentally ill is not designed to accomplish these core missions.
• Instead, the data that the public agencies and contractors churn out — statistics, for example, about costs and patient visits — produce an audit trail for billing and to prevent fraud.
• The clinical information that is available is so incomplete, inexact or irrelevant that it reveals little about what aids or blocks mentally ill clients’ progress. This intelligence on the needs of clients is as vital for results-oriented budgeting as it is for individualized treatment of the clients.
• Those who deal with the mentally ill get to share little of the information that anyone else produces. The data systems aren’t linked.
• So physicians, psychologists and social workers, housing agencies and public employment services, police, judges and jailers make decisions about patients while blind to vital intelligence about them.
• Parents, nursery school staff and Head Start instructors regularly spot children whose extreme behavior patterns might signal mental illness or be precursors to it.
• Very conservative estimates indicate that at least 18 percent to 20 percent of local children ages 0-6 who should be getting specialized mental health attention fail to get it — with consequences that upset their success in school, personal relationships and the work force.
• Many severely and persistently mentally ill adults, probably a majority of 70 percent or more, also have drug or alcohol addictions. The co-occurring illnesses need to be treated together. Separate fiefdoms at local and state levels make that a rarity.
• Caseloads for those who coordinate services for the mentally ill have grown dangerously larger in the Portland area than nationally recommended standards. Social workers with unreasonably high caseloads constantly chase mental health emergencies. Their time dwindles, even disappears, for contact with clients who are not conspicuously in crisis but who require consistent, caring attention to remain stable.

All of this conspires to complicate, and often defeat, public-agency clients’ chances to regain mental stability.

These defects in mental -health system organization, administration and information are correctable.

By fixing those flaws, we could help most of our neighbors enrolled in the system to live useful, happy and, yes, normal lives in our community. And many others, candidates for mental illnesses in the future, could be diverted from that sad personal and publicly costly fate.

The failure to provide that help — available at our fingertips — indicts us as co-conspirators in the theft of much of what makes life worth living for these victims of brain disorders that can be remedied by a combination of medical and support services.