By Robert Landauer – editorial columnist for The Oregonian, November 20, 2001. Not available elsewhere online.

Reorganizations foster stress. They breed discontent. Workers’ gripes are common. Multnomah County’s redesign of its mental health and addiction services fits the pattern: rumors galore and reports of delays, false starts and warfare among leadership rivals.

Yet listen to an unusual change of pitch in this background noise: unsolicited calls from county residents with serious mental illnesses who say that the new system is treating them with more care, consideration and respect than they had ever encountered and that their health is better because of it.

This isn’t evidence that the reorganization, still in its early stages, will be as effective as needed. It is just anecdotes, two unexpected testimonials from out of the blue. But just before Thanksgiving, I’m grateful for these clues that the changes are starting to work for people who need public-agency help.

The first call came from a man who had just been released from a several-week stay in the Multnomah County Jail. Nothing unusual in that. He has been a guest in jails all over the West, he says, as a result of run-ins with police because of a nasty drug habit that aggravates a serious mental illness.

He called to compliment his jailers! The jail’s mental -health ward had treated him better than any jail in his life, he said. He got care and medications that had him coming out of jail healthier than he had been in a long time. He had hopes that his life would improve because he had not just been kicked out the door. A transition worker had connected him with housing, mental -health and addiction services.

The second call came from a high-tech product manager whose bipolar disorder has her swinging between extreme agitation/exhilaration and extreme depression when not sufficiently controlled by medication.

While shifting to safer medications, she became ill and teetered on the edge of a manic episode. She feared that she would have to wait weeks for an appointment because her mental -health practitioner was on vacation.

She called the county’s mental -health crisis line and was told that there was a new service, a walk-in clinic (four are operating) that she could go to that minute for help.

“I went right over and I was seen by medical staff right away, and the person who saw me was warm, reassuring, and I knew I was in a safe place — even though I got there an hour before the psychiatrist was due. I can’t tell you how good and safe that makes you feel when you feel that bad.

“I was the second person the psychiatrist saw, but before he saw me he came out to say hello and told me that he’d be with me shortly, and, again, that was extremely reassuring.”

She described to the psychiatrist the difficulties she was experiencing with the new drugs. The Sept. 11 terrorist attacks had “unhinged me a bit” because she worried about New York friends and relatives, she said, complicating the adjustment to the new medications. “He understood my problem immediately. He took authority to increase my dosage, and that helped my whole course of treatment.

“When you get really good attention like that, you feel better right away, because part of mental illness is fear and anxiety. You feel like you’re going to be able to cope even before the new medications kick in.”

I expected her story to end there. But she continued. Her remarks showed that what might have been an isolated episode is being transformed into continuity of care.

“When my personal therapist at the health center came back a week later, she was thrilled with the attention I had received. Now this therapist is on leave for two months, and she gave me a sheet telling me all the places I can get support. And both she and I feel much more secure. Just knowing that I have the support stops the panic and anxiety that can trigger the attacks.”

In these two anecdotes, we see seven gold nuggets amid the gravel of county mental -health reorganization: easy and timely access; prevention and early intervention; care coordination; treatment services; support services; acute care; and protective services. This might yet turn out to be a rich strike for the 13,000 clients who rely on this county’s mental-health services.

distributed to Cascadia admin staff, Winter of 2001

Introductory Points

• Planned events are moving along at a predictable rate
• The merger is on track. We expect to close by April or May
• We’re still negotiating with Multnomah County for the Primary Provider Contract
• Walk – In Clinic numbers are increasing, slowly at Gresham
• Mobile Team numbers are increasing
• Critical incidents have been minimal since merger
• Bridgeway II opens February 7
• Specific concerns can be addressed by supervisors

Q: What is the foreseeable future of Cascadia?

A: Most public health systems and certainly Portland’s public mental health systems are put together piecemeal. There is no “design,” or “reform,” or overarching planning effort. Typically a problem has presented itself in the form of an event or an advocate, and the bureaucracy has responded to the problem with an adjustment to its behavior. This stacking of adjustments is effective in the short run, responsive to community needs and immediate goals. But as a management tool, left unchecked for many years, these adjustments accumulate to

Our current “reform” is not a lot different. There has been substantial influence from previously unheard – not listened to – stakeholders, including some consumers of our mental health services, politicians from various parts of state and local government, advocates from allied social services, families and friends of people with mental illness. This has caused a more through investigation of the problem, and perhaps a more insightful adjustment.

The advantage of the adjustment is Cascadia, with its depth of knowledgably, its diversity, its ability to refer clients toward strengths, will better serve consumers of its mental health services.

Q: What does “client for life” mean?

The key principle to hold onto is we’re shifting clinical perspective from “episode of treatment” to “duration of engagement.” Engagement could mean a single contact – or it could mean many years of contact, depending on the individual.

Our goal is to see consumers not just as billing codes, but as people. Our challenge is to move from traditional mental health where consumers are patients, where contact comes after crisis and is minimized, where interventions are often temporary or offloading, to Public Mental Health which is system smart and system dynamic, which does long-term planning and presents a relationship of interventions and natural systems of support within the individuals own community.

The County is creating a Primary Provider Policy Manual, which will be available as a draft very soon.

Q: What does the new Verity model mean to me as a staff member of Cascadia?

A: KIM BURGESS WILL ANSWER

Q: Will our health benefits be changing with the merger?

A: We have put our health benefits out to bid and we will be hearing from our broker in the near future concerning which companies bid on us and what the rates will be. Our hope is that as a larger company we can attract more competitive rates, however, because our utilization of health services is so high we may not make any progress on this issue.

Q: How does the merger effect seniority?

A: Original dates of hire have been transferred to Cascadia and as Unity merges, we plan to take the same steps with Unity staff.

Q: Will any facilities at Cascadia close?

A: They already have. We have consolidated the administrative offices for Cascadia downtown at the Unity offices on Fifth Avenue. This has allowed us to close our administrative offices for Network on Milwaukie Avenue.

There are no plans to close any residences or any clinics.

Q: When will Unity be fully merged with Cascadia?

A: The legal paperwork will be finished April or May. But to be fully merged is more than a legal proceeding. It means becoming one entity, one corporation, having one mission and one set of goals. We’re merging the cultures of three – or five – organizations. This is going to take time and trust.

Q: The County recently audited Cascadia programs. What was the result of the audit?

A: Cascadia’s children’s intakes were shut down at the request of Multnomah County from December 3 until we strategized a way of resolving several problems. Intakes were reopened on December 17. The problems that the audit revealed were real and substantive. We’ve made remedies and will be watching the programs carefully.

Q: Each agency has similar programming. How will these programs be merged?

A: Yes. There will be consolidation of similar programs. It’s through this reorganization that funding can be freed up to provide additional services for consumers.

Q: Will there be staff cuts in the future, capitalizing on the savings with the new administrative structure?

A: Staffing patterns will change as needed.

Q: Will any programs at Cascadia close?

A: Programming at Cascadia is an evolving process. There are no programs planned to close, but we do intend to be active and assertive in finding out what works best and moving toward that best practice.

Q: Are other mergers being planned?

A: Administrative staff is rolling out the merger of Cascadia and Unity now. Nothing will be planned until that merger is finalized and settled.

Q: What’s the impact of the Walk-In Clinics on hospitalization?

A: We’re collecting data and the County is collecting data to answer this question. What we know is the number of people coming to the Clinics is increasing slowly, and those people generally reflect the population of the area.

Q: What is the status of the Secure Evaluation Facility?

A: Currently the County is looking at two possible configurations. One is to locate the SEF at the Donald Long Center, in an unoccupied set of pods. This location has transport and possibly neighborhood problems. The second option is to physically enlarge Hooper Center and provide services there. With CCC there is the positive potential of service integration with Detox, but the construction would take several months.

Q: How will salary equity be resolved?

A: The HR department has been, and will continue to be, involved in an exhaustive effort to review equity between positions as well as individuals. This is a project that takes some time but we have already made some adjustments and will continue to do so as finances allow. We are very committed to this effort.

Q: Will vacation and sick leave hours carry over? Will there be a change in vacation and sick leave hours?

A: For Unity staff represented by the union, we will adhere to the contract language. For other employees we are putting together a proposal that combines both Mt. Hood and Network leave policies. We are hoping to have combined leave (folding sick and vacation leave together) but having holidays be separate from the leave bank. We will be explaining all this in much more detail in the next two months.

Q: Will my agency retirement plan be recognized and continued by Cascadia?

For Cascadia employees, retirement plans have been recognized and are continuing under a new plan titled Columbia Funds. It is anticipated that the same will be true for Unity employees at the time of the merger.

Q: Will there eventually be one phone system for Cascadia? Will there be a single staff directory?

A: We’re in the process of joining Mt Hood and Network’s data systems. When Unity merges, we’ll begin integrating with their data system. There should be one staff telephone and email directory very soon.

Q: Will there be a Cascadia web site?

A: There is a start-up page at www.cascadiabhc.org. Admin staff are working on building a larger, more robust site now.