RESOLUTION NO. 00-161

The Multnomah County Board of Commissioners Finds:

A. On May 4, 2000 the Board of County Commissioners adopted Resolution No. 00-063 creating a Mental Health Design Team “to work with county, state, and community personnel to develop short and long term action plans to improve County mental health services.”

B. The Design Team has determined that an underlying vision and a unifying philosophy is needed to guide system design efforts. This vision and philosophy should apply to services for adults, children and adolescents at all levels of care.

C. The Design Team has recommended that the Board of County Commissioners adopt the vision statement expressed in a “Consumer and Family Centered Mental Health System”.

The Multnomah County Board of Commissioners Resolves:

1. The values and principles described in the attached document “Consumer and Family Centered Mental Health System” will provide the underlying vision and unifying philosophy for the mental health system in Multnomah County.

2. County Departments that provide mental health services will distribute this document to all employees and to appropriate contractors, advisory board members and other partners.

3. County Departments that directly provide mental health services will incorporate these values and principles into those services to the fullest extent possible.

4. County Departments that contract for mental health services will include these values and principles in all relevant contracts and will insure that these values and principles are incorporated into the services delivered through those contracts.

5. The Department of Community and Family services will provide leadership in the collaborative development of a training program to increase system-wide understanding of these values and principles. Planning and implementation of this training program will include consumers, members of their support teams, families and providers.

6. The County will work with community advocates and organizations to encourage State and Federal policy makers to develop and fund programs which are consistent with this vision statement.

ADOPTED this 28th day of September 2000.

BOARD OF COUNTY COMMISSIONERS FOR MULTNOMAH COUNTY, OREGON
Beverly Stein, Chair
REVIEWED: Thomas Sponsler, County Attorney

From The Portland Business Journal, September 22, 2000

A child and adolescent treatment program at Hospital & Health Center is in turmoil-and facing physician backlashafter the swift exit of four prominent child and adolescent psychiatrists.

State children’s agencies and mental health professionals are also disturbed by the staff turnover, which has left the 17-bed Legacy unit without a child psychiatrist.

“We’re concerned,” said Nancy Allen, regional resource liaison for Service to Children and Families. “They [Legacy] are adamantly reassuring me that they have things in the works to bring child psychiatrists on. But there aren’t that many around and they had the best. I’ve been trying to find out what is going on.”

At this point, she said the state agency is taking a wait-and-see attitude.

“I don’t think CareMark would put kids in jeopardy,” she said of the company which manages the joint program for Legacy and Adventist Health.

Allen and other children’s advocates say they’re baffled by the firings and resignations, which gutted the unit. No reasons were given by hospital management. The child/adolescent unit was apparently making a profit and had ongoing contracts with CAPP Care, Ceres and PacificCare.

Insiders say the unit has been in some turmoil since Legacy management revealed its intention to move to hospital employed physicians for that unit. Until now, Legacy has used private practitioners to staff the unit.

Word of the policy change got out about six months ago. Then in August, a prominent member of the team, Dr. Keith Cheng, resigned in what was viewed as a forced resignation. Insiders say the treatment of Cheng generated low morale in the department.

“Essentially he was pushed out,” said one Legacy employee, who asked not to be named. “It was getting nasty up there.”

Legacy spokeswoman Claudia Brown said Legacy is committed to keeping the program. New child psychiatrists are being recruited, she said.

“This is not related to any change in philosophy or program,” she said. “It’s safe to say we’ve had an upset in the physician ranks and we are currently recruiting child psychiatrists. We are confident that the unit will very soon be back up to snuff and we have no plans of discontinuing this service through CareMark. As early as next week we hope to provide full service from age 5 to 18 years.”

The departures forced Legacy to temporarily increase its minimum admittance age from 10 to 12 years old, said Brown. The policy change led the state Services to Children and Families this week to send a child to Providence Portland Medical Center’s 25-bed child psych unit instead.

The American Academy of Child and Adolescent Psychiatry guidelines recommend a child 14 and younger should be treated with a psychiatrist specialized in child and adolescent psychiatry For now, two general psychiatrists are covering the Legacy unit.

The upheaval triggered a protest from the four remaining Legacy adult psychiatrists, who are expected to appeal to administrators to investigate the child and adolescent program before it is dismantled.

On top of that, Oregon Health Sciences University has temporarily suspended its child psychiatry residency program there because of staff and management issues relating to child and adolescent services. The health systems are in negotiations, and OHSU released a statement saying “We are confident that the psychiatric residency position at Legacy/Emanuel will be resumed in the near future.”

The departure of Cheng, clinical director of adolescent psychiatry since 1993 and an OHSU faculty member, and others comes at a critical time.

The child psych unit, along with one at Providence Portland Medical Center, hasbeen running near capacity since January Providence has seen an average increase of 28 percent in inpatient admitting, from 12 to 15 kids to 20 since the same time last year because there are fewer treatment options for kids, said spokeswoman Lisa Godwin.

“There’s not that much out there right now, ” said Carolyn Wiley, nurse manager for Providence’s children and adolescent inpatient mental health unit. “This represents a rise in the crumbling of the mental health system.”

Both hospitals admit children from 10 to 18 years suffering from depression, drug and alcohol substance abuse problems, and psychiatric disorders. The average age at Legacy’s unit is 12 to 13 years, Brown said.

Many of the children are covered by CAPP Care, which covers mental health benefits for teens covered by Medicaid, and Ceres, the mental health benefit program offered through the Oregon Health Plan.

Patrick Payton, Ceres regional director of managed care, said the staff issues at the Legacy unit would have little or no impact on its referrals because hospitalization of children is rare.

“We look to the system to make those adjustments and manage their staff,” he said. “Periodic adjustment are made. You have a brief period of adjustment and then things are back to normal.”

Doctors say about six months ago CareMark sought to hire hospitalbased physicians, rather than use psychiatrists from private practice. Since July, one doctor after another has left. Dr. John Beamer took a three-month leave of absence. Dr David White resigned. Dr. Cheng’s contract was not renewed. A fourth doctor, Edward Stanford, was placed on 90-day notice earlier this week.

Stanford, who treats children covered by CAPP Care and PacifiCare kids which makes up about 50 percent of the Legacy cases, had apparently refused to cover for any doctor who wasn’t a child and adolescent psychiatrist.

Other staff members said the child psychiatrists were upset that the unit’s medical director Dr. Norwood Knight-Richardson was reducing Cheng’s responsibilities. None of the doctors, including KnightRichardson, returned calls.

Brown admitted it will be difficult to recruit child psychiatrists so quickly.

“I’m sure it’s not easy to find someone in a subspeciality like that,” she said.

Created in August and September of 2000. Adopted by Multnomah County as Resolution 00-161

This document expresses the underlying vision and unifying philosophy that will guide the design and operation of public mental health services in Multnomah County. Consumers receiving mental health services (including adults, adolescents, children and families as appropriate) are at the center of the mental health system. The system is organized and operated to meet their needs. While there may be resource constraints the ultimate goal of the system is to improve the lives of those receiving mental health services.

The services for children, adolescents and their families will focus on a developmental model of intervention and on age and developmentally appropriate outcomes for children within the contexts of their individual family situations. The services for adults will be recovery-oriented with a focus on developing natural systems of support and self-determination. Within the adult and children service systems there may be different providers, programs and types of services but common values and principles will anchor and unify all mental health services.

Our vision for mental health services has three sections: attitudes and values; the service system; and accountability and management.

A. The attitudes and values of the mental health system support and encourage consumers to achieve their full potential.

1. Everyone receiving services in the Multnomah County Mental Health System is supported and encouraged to reach his or her full potential. Consumers are supported by attitudes and services that communicate hope, focus on strengths, nurture recovery, promote optimal development and support achievement of goals. Respect and dignity will be embraced throughout the County’s caring and flexible system.

2. The services provided by the mental health system in Multnomah County are individualized, and in the case of children, child-centered and family-focused. The needs, goals and preferences of consumers dictate the types and mix of services provided.

3. The mental health system is community based, with the location of services and decision-making resting at the community (i.e. local) level.< br />
4. Agencies, programs, services and staff are culturally competent; that is, sensitive and responsive to all the elements of consumers’ identities, including but not limited to age, ethnicity, race, religion, gender, sexual orientation, disability and culture.

5. Adult consumers may choose to identify friends, family members or others to participate in planning for their care and service delivery. The families and/or surrogate families of children receiving mental health services are full participants in all aspects of the planning and delivery of services.

6. Mental health services for children and adolescents will be guided by the best interests of the child or adolescent. Services will support, assist and strengthen the family system. This may include identifying and addressing changes needed to better support the child’s optimal development.

B. It is the goal of the mental health system to work toward the provision of a wide range of services that support recovery and optimal human development.

1. Services for adults maximize the opportunity for self-sufficiency, autonomy and a self-directed practice of recovery. Services for children reflect the “System of Care “ principles. Services and models for adults and children will evolve in response to consumer needs and evidence-based changes in best practices.

2. Services are provided in the least restrictive setting that is clinically appropriate and meets consumers’ needs. Services to achieve stabilization and recovery at lower levels of care are prioritized so that they are available when needed, thereby reducing utilization of higher levels of care such as crisis services and hospitalization. Services are organized to avoid inappropriate use of the criminal and juvenile justice systems as a substitute for mental health care.

3. Every person receiving mental health services has access to competent diagnosis and an appropriate an d affordable menu of treatment. Access to and coordination with competent, comprehensive physical health care is arranged.

4. Every consumer is assured of having a prompt and clinically appropriate response to his or her crisis and acute care needs.

5. Adult consumers have access to a range of safe, affordable housing options and the support services needed to successfully retain their housing over time.

6. Every person receiving mental health services has access to suitable employment, training and/or education services in order to reach his or her full potential for independence and contribution to society.

7. Every person receiving mental health services has access to a network of natural supports including transportation and affordable social, cultural, physical and recreational and/or faith-based activities that promote integration into the community, optimal development and recovery.

8. Competent care management services are provided based on need. Case managers insure that multiple services are delivered in a coordinated and therapeutic manner and that consumers can navigate smoothly through the system.

9. Services from multiple agencies including the education, criminal justice, juvenile justice, child-welfare, health and chemical dependency systems are coordinated and/or integrated to better serve consumers.

10. In order to support prevention and effective treatment, the mental health system provides consultation to other health and social service providers.

11. Mental health services include outreach and education in order to increase early identification and intervention and to increase appropriate continuation in care, leading to earlier recovery.

12. Consumers and families are able to access services easily. They are offered at convenient and accessible locations and times.

13. Services include consumers as providers and include opportunities for peer support and self-help. Services for children include opportunities for family peer support.

C. The mental health system is publicly accountable and well managed.

1. In order to be truly accountable the mental health system is organized with clear lines of responsibility and authority. The policy, planning, resource allocation and evaluation functions are centralized and consolidated and/or coordinated.

2. Consumers, providers, families and a wide range of stakeholders are involved in policy development, program planning, service delivery and evaluation for the mental health system.

3. The mental health system is publicly accountable for the resources that have been entrusted to it. Service delivery systems are integrated administratively to eliminate expensive fragmentation and duplication. Financial risk and incentives are utilized as tools to achieve system goals.

4. At all levels, the system is accountable for service delivery and outcomes. Clear, quantifiable measures are established to show efficiency and effectiveness. These measures include consumer satisfaction and improving the quality of life for people receiving services. The system uses data to monitor costs and outcomes and to improve quality and access.

5. A centralized data system is structured to increase coordination across service systems and provide the demographic, financial, service and outcome data necessary for system reporting, management and accountability.

6. The mental health system supports a positive working environment for its providers and staff. Competitive salaries and benefits, training and education and reasonable workloads reduce turnover and support the provision of high quality services and positive interactions with consumers

7. The system vigorously pursues new resources and partnerships that will help to meet the mental health needs of County residents. The system is expert at blending funds from a variety of sources to meet consumer needs.

8. Advocacy for the needs and rights of those with mental health disabilities is an important component of system management. Stigma and discrimination make recovery more difficult. Education and advocacy is carried out in order to increase understanding and support for consumers and families and their needs.

9. Critical incidents are investigated and, where appropriate, result in corrective action. A fair and consistent process exists to respond to grievances and complaints.