From The Portland Business Journal, September 16, 2001

The area’s mental health care system is in a state of disrepair, but county officials have created a stop-gap plan

Anyone involved in the local mental health system as a client, provider, administrator or family member has been familiar with the litany of faults and failures of the system for years.

But it took a one-two punch–closure of Sellwood’s Pacific Gateway Hospital, where a Mexican national died this spring, and the subsequent collapse of Multnomah County’s Crisis Triage Center–to point out the grave structural defects in the system to the rest of us.

Critics say problems in the health care system can be traced to 1998, when the county switched from fee-for-service contracts to managed care. Additional system stresses include the expansion of mental health services covered under the Oregon Health Plan and cost controls placed on nonprofits that deliver mental health care services in the community.

Residents of Multnomah County access mental health care at a rate twice the state’s per capita average. The average cost of an acute care bed in area hospitals was $422.50 through June of 2001. But new per-diem rates negotiated with local hospitals bring that cost up to almost $700 a day.

“It’s keeping me awake at night,” admitted Diane Linn, Multnomah county commissioner chair. “We’ve really been struggling with this.”

The problems attending the grim statistics are large and complicated, involving various agencies, each with its own bureaucracy; a difficult and expensive client base with which to work; and a virtually nonexistent data collection system.

Add in the larger social issues, such as the lack of affordable housing, the stigma still attached to mental illness and ambivalence toward the poor and homeless, and it’s clear there are no easy answers.

The county spends almost 20 percent of its mental health care budget on hospitalizing mentally ill patients because cheaper and more effective care alternatives have been cut.

Linn believes the system is failing in its responsibility to its most vulnerable citizens.

“If you look at it from the perspective of the person who needs to use this system, it’s awful,” she said.

The closure of Crisis Triage Center–the centralized care center for Multnomah County–has further complicated the situation. The CTC opened in 1997 as a state-of-the-art psychiatric triage facility, located at Providence Portland Medical Center. It served everyone from private clients to Oregon Health Plan enrollees in psychological crisis.

The CTC contract with Multnomah County expired June 30, and talks to renew it broke down over escalating costs. The closure of the CTC on Aug. 1 left emergency personnel with no designated place to take area residents in psychiatric crisis.

The closure of Pacific Gateway Hospital, following the death of Jose Victor Santos Mejia Poot this spring, further added to the gap.

The county has redesigned a system that would redirect dollars from acute care facilities like emergency rooms and hospital beds to neighborhood clinical services and outreach professional services.

The county’s “gap” plan establishes four walk-in, no-appointment clinics and mobile crisis teams to replace the failed Crisis Triage Center.

It also calls for adding a secure evaluation facility to replace the 66-bed psychiatric ward at Pacific Gateway in the near future. The gap plan addresses the first 90 days of the newly redesigned county system. Phase two, which should be adopted this month, covers days 91 through 365.

The improvements can’t come too quickly for emergency services that end up with seriously mentally ill clients in their care while an overcrowded system tries to find a place for them for longer-term care.

“Now officers must go to the nearest emergency room and wait,” said Ed Riddell, head of the Portland Police Bureaus’ Crisis Intervention Team. “And the wait is often four hours or more.”

Riddell points out that officers waiting in emergency rooms with mental health patients is awkward and keeps them from doing police work.

Three of four walk-in clinics opened Aug. 1, and another one in downtown Portland is expected to open in September. Clinics offer services in a more welcoming, less anxiety-producing environment, said Jim Hlava, program director of rehabilitation services at Network Behavioral HealthCare Inc., which operates the walk-in clinics.

“There are other existing programs here,” he explained. “We have peer counseling. We have a meals program. Some of the clients who walk in here are homeless and they haven’t had a bath or a shower in awhile. We’ve got a shower and that helps bring down someone’s anxiety or agitation. If you’re feeling a little bit better about yourself you’re not as angry and agitated.”

That’s the approach favored by Barry Kast, an administrator with the State of Oregon Health Services, which includes mental health.

“The key to a successful mental health program is that you’re combining a health program with other services, such as income support, housing, employment,” he said.

Adding to the county’s troubles with the redesign is the discovery of a $4.7 million revenue shortfall.

Estimates of county reimbursement through the Oregon Health Plan were both too high in the number of clients served and the reimbursement per client the state would provide.

To get clinics and mobile teams up and running, the county plan calls for dipping into the existing mental health care reserves for a one-time bailout of $1.72 million.

“We’re pretty much shoulder to shoulder with chair Diane Linn, and her staff,” Kast said. “She has quite courageously taken on what has been a decade or two of struggling to find the right system for the county. It’s a very difficult problem.”

Though the contribution per patient has dropped, according to Kast, the state has allocated an additional $1.5 million to help meet the extra costs, on top of the money already earmarked for Multnomah County health services.

“I have to tell you that I think the general community still struggles with the whole issue as a great big terrible, frustrating, tragic mystery,” said Linn. “There is a terrible stigma attached to mental illness, and that complicates the problem.”

In addition to walk-in clinics, the plan calls for a county-run crisis phone service, to attach mobile outreach crisis teams to each clinic, as well as a contract for a new secure evaluation facility to replace Pacific Gateway.

The plan calls for a centralized mental health care administration, the installation of a data system, provider contracts increasing the accountability for outcomes and incentives to avoid acute hospital care.

“We as a community have the responsibility to manage this,” Linn said. “For me that is very close to home.”

From The Portland Business Journal, September 16, 2001

The Crisis Triage Center was the centralized care center for Multnomah County mentally ill needing urgent care. The center served more than 8,700 people in the last fiscal year and still it turned away another 400 patients in emergency vehicles because it was full.

The closure of the Crisis Triage Center on Aug. 1, left emergency personnel with no designated place to take area residents in psychiatric crisis.

“They are going to ERs of the hospitals in the area,” said Kent Ballantyne, a senior vice president with the Oregon Hospital Association. “We are triaging those patients through the acute care setting, which is an expensive and inappropriate place to do this kind of care.”

Ed Riddell, the head of the Portland Police Crisis Intervention Bureau, called the closure “devastating” to police officers because of the extended period of time officers have to wait in emergency rooms with patients in custody before patients can be seen or transferred to a more appropriate setting.

Dr. Christopher Richard, head of OHSU emergency room operations, said the closure of both the CTC and Pacific Gateway has resulted in significantly longer emergency room waits for all patients.

“The ER is not a destination,” he said. “If we can keep our length of stay down to the traditional three or four hours, we’re much better off. Unfortunately, our length of stay has gone way up and it’s a problem.”

In an attempt to treat mental illness less expensively, walk-in clinics were established in three different areas of Multnomah County the same day the CTC closed; another is due to open this month.

Eventually, each of the clinics will also have a mobile team of mental health care professionals attached to it and they, rather than the police, will respond to requests for urgent and emergent mental health crises.

Mobile mental health teams are vital to community-based mental health services, according to Jason Renaud, executive director for the National Alliance of the Mentally Ill of Multnomah County.

“They depend on building a friendship, a relationship with people,” he said. “And these are very sick people who don’t want to be in treatment and routinely hang up the phone, slam the door, walk away, don’t take their medication, don’t want to be involved. These teams are very effective at getting these folks involved.”

The Crisis Triage Center opened on Jan. 13, 1997 as a state-of-the-art psychiatric triage facility which was located on the Providence Portland Medical Center campus in Northeast Portland. It served everyone from private clients to Oregon Health Plan enrollees in psychological crisis. The CTC contract with Multnomah County expired June 30th and talks to renew it broke down over escalating costs.

The CTC was too expensive, according to county officials, and provided less crisis response services than originally agreed to. In addition to the cost overruns, the county redesign task force found that the usefulness of the CTC was compromised because more appropriate, less costly alternatives were not available to provide adjunct services.

Jim Hlava, program director of rehabilitation services for Network Behavioral HealthCare Inc., said business has been brisk at his clinic at 43rd and Division in Southeast Portland, and that is true for the clinics in North Portland and Gresham as well.

The building, which will house another clinic in the downtown area, is still undergoing renovations and should open this month.

However, the clinics are already helping to keep patients out of hospitals.

“We’re part of the solution,” he said. “We’re seeing between 10 and 20 patients here a day, and we originally thought there would be between five and 10 patients a day across all of the clinics. So we’re busy, but we’re not overwhelmed.”

Hospitalization is less likely to happen if clients can request services in a clinic setting when they need it but the clinics send their emergency cases to local ERs if they can’t be stabilized there.

“If clients are a danger to themselves or others, we send for the police,” he said. “That’s the system that’s in place right now because we don’t have our crisis services completely up and running.”

The county is also in negotiations with Woodland Park hospital to contract for psychiatric beds, but the talks have been clouded by recent allegations of safety and patient care by former employees.

A preliminary investigation found some procedural and record keeping problems but a final report will not be available until later this month.

Pacific Gateway, meanwhile, may reopen under different management.

“The potential buyer intends to operate the hospital as a behavioral health facility,” said Beth Page, a spokesperson for Ardent Health Services, who owns and operated the facility.

“And we are hopeful these negotiations will be concluded in the near future.”

From The Portland Business Journal, September 16, 2001

When the state pulled the operating license for Pacific Gateway hospital after the death of a Mexican national this spring, the county was left without a secure evaluation and holding facility, according to Diane Linn, Multnomah County chair.

And while other hospitals have designated psychiatric beds, there just aren’t enough of them to go around, according to Dr. Christopher Richard, head of emergency room operations at OHSU.

“We have an inpatient unit here, and there are other units in the city but we’re sending people to Salem and Eugene because there are no available beds,” he said.

“We’ve even sent patients as far away as Seattle. When there is nothing available in town, we basically get the map out and we go to the nearest place.”

Worse yet, the cost of housing patients in an acute care bed is astronomical and ineffective for long-term management of mental illness.

Jason Renaud, executive director for the National Alliance of the Mentally Ill, said the current system drains money away from more promising treatment options.

“We’re paying $800 a day for a patient staying in a hospital,” he said. “What can you get at the Hilton for $800 a day? You get a private nurse and a masseuse, food, medication and the Hilton room, too. We need to reclaim that money and funnel it back into the infrastructure.”

The solution proposed by the county–of finding a substitute psychiatric unit that can serve as a holding, evaluating and prescribing area–seems obvious, but circumstances have already made it more difficult for county officials to find an easy answer.

The county is in negotiations with Woodland Park hospital to contract for a county psychiatric unit but the talks have been clouded by recent allegations by three former employees of safety violations and poor patient care.

The Oregon Office of Mental Health Services made an unannounced on-site inspection of Woodland Park in August and a resulting report has turned up critical concerns about patient safety and care. The state has given the hospital 30 days to comply with “six critical areas of noncompliance.”

“We were on track with Woodland in our contract negotiations to provide the holding beds for acute care,” said Linn. “But with the allegations of these former employees and some issues that have surfaced in their psychiatric ward, we have had no choice but to step back and take a good, hard look at that. And frankly, practically speaking that creates another delay.”

Linn said the county will not sign a contract with Woodland Park until quality of care; safety and how people are managed there are assured. On the other hand, she said, the need dictates that talks with Woodland Park must continue in the meantime.

Meanwhile, the former county fallback, Pacific Gateway, may reopen under different management.

“The potential buyer intends to operate the hospital as a behavioral health facility,” said Beth Page, a spokesperson for Ardent Health Services, owner of the facility. “And we are hopeful these negotiations will be concluded in the near future.”

However it still could be some time before the hospital could contribute to the pool of resources.

According to Dr. Peter Davidson, clinical director of the county’s redesign project, the building itself needs major physical renovations before it could meet county and state operating standards.

From the Portland Business Journal, September 14, 2001. Not available elsewhere online.

The Crisis Triage Center was the centralized care center for Multnomah County mentally ill needing urgent care. The center served more than 8,700 people in the last fiscal year and still it turned away another 400 patients in emergency vehicles because it was full.

The closure of the Crisis Triage Center on Aug. 1, left emergency personnel with no designated place to take area residents in psychiatric crisis.

“They are going to ERs of the hospitals in the area,” said Kent Ballantyne, a senior vice president with the Oregon Hospital Association. “We are triaging those patients through the acute care setting, which is an expensive and inappropriate place to do this kind of care.”

Ed Riddell, the head of the Portland Police Crisis Intervention Bureau, called the closure “devastating” to police officers because of the extended period of time officers have to wait in emergency rooms with patients in custody before patients can be seen or transferred to a more appropriate setting.

Dr. Christopher Richard, head of OHSU emergency room operations, said the closure of both the CTC and Pacific Gateway has resulted in significantly longer emergency room waits for all patients.

“The ER is not a destination,” he said. “If we can keep our length of stay down to the traditional three or four hours, we’re much better off. Unfortunately, our length of stay has gone way up and it’s a problem.”

In an attempt to treat mental illness less expensively, walk-in clinics were established in three different areas of Multnomah County the same day the CTC closed; another is due to open this month.

Eventually, each of the clinics will also have a mobile team of mental health care professionals attached to it and they, rather than the police, will respond to requests for urgent and emergent mental health crises.

Mobile mental health teams are vital to community-based mental health services, according to Jason Renaud, Executive Director for the National Alliance of the Mentally III of Multnomah County.

“They depend on building a friendship, a relationship with people,” he said. “And these are very sick people who don’t want to be in treatment and routinely hang up the phone, slam the door, walk away, don’t take their medication, don’t want to be involved. These teams are very effective at getting these folks involved.”

The Crisis Triage Center opened on Jan. 13, 1997 as a state-of-the-art psychiatric triage facility which was located on the Providence Portland Medical Center campus in Northeast Portland. It served everyone from private clients to Oregon Health Plan enrollees in psychological crisis. The CTC contract with Multnomah County expired June 30th and talks to renew it broke down over escalating costs.

The CTC was too expensive, according to county officials, and provided less crisis response services than originally agreed to. In addition to the cost over-runs, the county redesign task force found that the usefulness of the CTC was compromised because more appropriate, less costly alternatives were not available to provide adjunct services.

Jim Hlava, program director of rehabilitation services for Network Behavioral HealthCare Inc., said business has been brisk at his clinic at 43rd and Division in Southeast Portland, and that is true for the clinics in North Portland and Gresham as well.

The building, which will house another clinic in the downtown area, is still undergoing renovations and should open this month.

However, the clinics are already helping to keep patients out of hospitals.

“We’re part of the solution,” he said. “We’re seeing between 10 and 20 patients here a day, and we originally thought there would be between five and 10 patients a day across all of the clinics. So we’re busy, but we’re not over-whelmed.”

Hospitalization is less likely to happen if clients can request services in a clinic setting when they need it but the clinics send their emergency cases to local ERs if they can’t be stabilized there.

“If clients are a danger to themselves or others, we send for the police,” he said. “That’s the system that’s in place right now because we don’t have our crisis services completely up and running.”

The county is also in negotiations with Woodland Park hospital to contract for psychiatric beds, but the talks have been clouded by recent allegations of safety and patient care by former employees.

A preliminary investigation found some procedural and record keeping problems but a final report will not be available until later this month.

Pacific Gateway, meanwhile, may reopen under different management.

“The potential buyer intends to operate the hospital as a behavioral health facility,” said Beth Page, a spokesperson for Ardent Health Services, who owns and operated the facility.

“And we are hopeful these negotiations will be concluded in the near future.”

From the Portland Business Journal, September 14, 2001. Not available elsewhere online.

When the state pulled the operating license for Pacific Gateway hospital after the death of a Mexican national this spring, the county was left without a secure evaluation and holding facility, according to Diane Linn, Multnomah County chair.

And while other hospitals have designated psychiatric beds, there just aren’t enough of them to go around, according to Dr. Christopher Richard, head of emergency room operations at OHSU.

“We have an inpatient unit here, and there are other units in the city but we’re sending people to Salem and Eugene because there are no available beds,” he said.

“We’ve even sent patients as far away as Seattle. When there is nothing available in town, we basically get the map out and we go to the nearest place.” Worse yet, the cost of housing patients in an acute care bed is astronomical and ineffective for long-term management of mental illness.

Jason Renaud, executive director for the National Alliance of the Mentally III of Multnomah County, said the current system drains money away from more promising treatment options.

“Say we’re paying $800 a day for a patient staying in a hospital,” he said. “What can you get at the Hilton for $800 a day? You get a private nurse and a masseuse, food, medication and the Hilton room, too. We need to reclaim that money and funnel it back into the infrastructure. The solution proposed by the county – of finding a substitute psychiatric unit that can serve as a holding, evaluating and prescribing area-seems obvious, but circumstances have already made it more difficult for county officials to find an easy answer.

The county is in negotiations with Woodland Park hospital to contract for a county psychiatric unit but the talks have been clouded by recent allegations by three former employees of safety violations and poor patient care.

The Oregon Office of Mental Health Services made an unannounced on-site inspection of Woodland Park in August and a resulting report has turned up critical concerns about patient safety and care. The state has given the hospital 30 days to comply with “six critical areas of noncompliance.”

“We were on track with Woodland in our contract negotiations to provide the holding beds for acute care,” said Linn. “But with the allegations of these former employees and some issues that have surfaced in their psychiatric ward, we have had no choice but to step back and take a good, hard look at that. And frankly, practically speaking that creates another delay.”

Linn said the county will not sign a contract with Woodland Park until quality of care; safety and how people are managed there are assured. On the other hand, she said, the need dictates that talks with Woodland Park must continue in the meantime.

Meanwhile, the former county fallback, Pacific Gateway, may reopen under different management.

“The potential buyer intends to operate the hospital as a behavioral health facility,” said Beth Page, a spokesperson for Ardent Health Services, owner of the facility “And we are hopeful these negotiations will be concluded in the near future.”

However it still could be some time before the hospital could contribute to the pool of resources.

According to Dr. Peter Davidson, clinical director of the county’s redesign project, the building itself needs major physical renovations before it could meet county and state operating standards.