From The Oregonian, July 31, 2001

With the closing of the Crisis Triage Center, Multnomah County must rely on a fledgling patchwork of services to keep mental patients from jamming hospital emergency rooms.

Two key “patches” in that quilt are neighborhood walk-in clinics and mobile crisis response teams aimed at solving mental health problems before they turn critical.

Until now, mobile crisis response in the Portland area has been limited to a business-backed downtown effort called Project Respond. The county mental health redesign envisions a countywide expansion of that model. “Project Respond on steroids,” the county mental health redesign chief, Jim Gaynor , calls it.

Mobile crisis response uses two basic approaches. One responds to urgent calls from or about people in the midst of a crisis — someone acting out or making threats, for example. The aim is to defuse the crisis before it reaches the violent or dangerous stage in which an arrest or hospitalization is necessary.

The other involves outreach to shelters, parks, hotels and other places where chronically mentally ill and homeless people tend to gather. It brings health care and support to people who, for a variety of reasons, don’t show up for appointments.

Both approaches are “extremely well established” throughout the nation and most of Oregon but not yet in Multnomah County, said Dr. Peter Davidson, a psychiatrist on the county’s mental health redesign team. Their effectiveness in preventing mental health emergencies and reducing hospitalization is well-documented, he said.

“It’s not rocket science,” Davidson said. “The more likely people are to have a mental disorder, the less likely they are to take their pills and show up for appointments.”

Expecting homeless or chronically mentally ill people to thrive in an appointment-based health care system is unrealistic, he said.

Mobile teams try to respond to crises in the least intrusive setting — an apartment, for example, instead of a police van — to lessen the chance that a dispute will escalate out of control.

“A police hold is not anybody’s first choice,” said Elise Thompson, coordinator of Project Respond.

Mobile response is costly because a team of trained professionals must be ready to go around the clock, said Leslie Ford, chief executive officer of Network Behavioral HealthCare, which is working on the expansion. “That’s expensive, but not as expensive as taking folks to a hospital at $800 a day.”

Project Respond started in 1993. It is financed by the Association for Portland Progress, a business group, and the Portland Bureau of Housing and Community Development.

Each mobile team includes two mental health specialists. Project Respond is available from 8 a.m. to 10:45 p.m. seven days a week. The program won a national award in 1997 from the American Psychiatric Association.

With limited resources and an escalating demand for crisis response, Project Respond has not been able to do much outreach work, Thompson said.

The proposed expansion calls for four teams, based in downtown, Southeast Portland, east county and North/Northeast Portland. At least one team would be on call overnight.

Thompson hopes to have more teams ready by September, but for now the service remains limited to Project Respond downtown.

Ideally, mobile outreach works closely with walk-in clinics, shelters and other community services to keep patients from having to go to the hospital unnecessarily.

“In the past, we didn’t have a lot of other options besides taking them to Crisis Triage Center,” Thompson said.

Both walk-in clinics and mobile crisis outreach are part of the so-called Gap Plan, the first phase of the county’s 2-year-old effort to redesign its mental health system, expand outpatient services and curb unneeded use of costly hospital care.

From the Oregonian, July 20, 2001

The Multnomah County Board of Commissioners got its first detailed look Thursday at the numbers behind the county’s mental health system crisis — and the proposed redesign for dealing with it.

The board is scheduled to vote Aug. 9 on the so-called Gap Plan to deal with the imminent closure of the Crisis Triage Center at Providence Portland Medical Center.

The slew of numbers released by consultant Dale Jarvis add up to a business plan for the first phase of the mental health redesign that has been under discussion for more than two years.

The numbers portray a system in crisis, even without the closure of the triage center. They show an acute care system that relies too much on costly hospitalization and too little on more nimble ways of helping people in crisis. They show a fragmented yet redundant system of provider groups with little accountability or incentive to curb costs.

And it’s going broke.

“This system is in deep trouble,” said Jarvis, an accountant with the Seattle firm of MCPP Healthcare Consulting Inc. He was hired six weeks ago to crunch the numbers for the mental health system redesign.

Commissioners Serena Cruz and Maria Rojo de Steffey said they had many questions about the proposed plan, even while acknowledging the need for moving swiftly to avert a crisis. They said it would be premature to give a formal go-ahead to the plan’s specifics without further discussion.

But Diane Linn, chair of the Board of County Commissioners, said proceeding with the Gap Plan would not preclude tinkering with the redesign’s longer-range objectives and budgets over the next few weeks.

The immediate crisis is a gap between the closure of the Crisis Triage Center at the end of July and the planned mid-September opening of a 10-bed unit for evaluating adults and older teen-agers at Woodland Park Hospital in Northeast Portland.

The Crisis Triage Center, a clearinghouse for people having a mental health crisis, saw nearly 9,000 patients last year. The center evaluates patients and sends them to secure mental health units, if necessary, or stabilizes them before discharging them to other care.

The center’s contract with Multnomah County expired June 30, and negotiations to renew it broke down. Providence agreed to keep the center open an additional month to give county officials more time to shore up alternative sources of care.

“With the closing of the Crisis Triage Center, these gaps are going from problematic to critical,” the Jarvis proposal concluded.

Hospitals, county officials and mental health care providers are worried that emergency rooms will be flooded with patients in crisis.

Rising costs are the other concern. With hospitals shifting to individually negotiated contracts this year, the average cost of a hospital bed for an Oregon Health Plan patient is expected to jump from $423 a day to about $700.

Total hospital costs for mental health care are expected to rise from $9.9 million last year to $14.2 million this year — and possibly higher, Jarvis said.

Hospital care accounts for 20 percent of the mental health costs in Multnomah County, more than in any other part of the Northwest, Jarvis said. In Seattle, the figure is 13 percent.

Jarvis’ plan for the current fiscal year estimated acute care costs of $21.8 million. With an estimated $14.7 million in available money, that leaves a projected shortfall of $7.1 million.

Jarvis and the mental health redesign team recommended several ways of making up that deficit, including use of emergency reserve funds and a 5 percent cut in administrative budgets for the county Behavioral Health Division.

Even critics of the county’s mental health system seemed pleased to have real numbers to debate.

“We’ve been waiting for these numbers for two years,” said Jason Renaud, executive director of the National Alliance for the Mentally Ill of Multnomah County. “Now we’ve got them. That alone is spectacular.”

Whether the plan behind the numbers would work, only time will tell, he said.

“For better or worse, this is a plan,” said Dr. Constance Powell, a psychiatrist who will become president of the Oregon Medical Association next year. “Before this, it was all vapors — deep and meaningless statements about treating people well.”