Multnomah County was well aware of financial troubles at Cascadia Behavioral Healthcare over a year ago, as shown in a brief assessment from MTM Services of North Carolina.

READ – Cascadia Assessment Report for Multnomah County

The assessment shows a snapshot of Cascadia at the time, including comments on

High administrative and overhead costs.
Difficulty with communications and performance between programs.
Low clinical productivity as measured by other, similar organizations.
Inadequate and unstable billing and and ‘enterprise’ computer systems.
Wayward compliance with computer documentation.
Missing or incomplete treatment plans for 42% of Cascadia’s open and current clients.

The assessment also includes a proposal to assist Cascadia to remedy the problems listed. I’m uncertain who had access to this assessment or what steps were taken in response to it.

TO All staff
FROM Derald Walker, Chief Executive Officer of Cascadia Behavioral Healthcare
DATE June 27, 2008
SUBJECT Latest news

I’m writing to summarize what’s going on, including the departure of many Cascadia employees. (Please see the note on this below.)

I hope you trust that I clearly understand how difficult this for all of us, and for our consumers and their families. Thank you for your efforts in maintaining the continuity and quality of care that our consumers need and deserve. The stories I hear from the field, from employees and from consumers and families, are a continuing source of inspiration.

For today the best I can do is to attempt to keep you up to date, and let you know what I know and what I do not know. Please advise if you notice any details that are missing or in need of correction.

This is what I know:

· Gresham and Garlington remain on Multnomah County’s plan for transfer, but the timelines and the names of the replacement providers are still being discussed between the County and potential providers. Nothing is yet settled.
· We continue to work with Marion County. No decisions have been made.
· Due to a better understanding of what services Cascadia will offer in the future, and where, new client intake has resumed. Cascadia now accepts new clients as follows:
· We accept new MH child and adult counseling clients at our Woodland Park site.
· We accept new MH adult psychiatric clients at our Downtown site.
· We accept new MH adult psychiatric clients at our Plaza site.
· We accept new MH clients at our Gresham or Garlington sites on a case by case basis.
· We continue to receive broad support for maintaining our housing system.
· A & D and other intakes have never changed and remain open to new intakes.
· The plan is to transfer one Multnomah County ACT team to Central City Concern, although final arrangements between Multnomah County and CCC are still being discussed. The timing is not yet set.
· The programs at the Beaverton and Hillsboro Centers, TAY, MIOS, TNP, House of Umoja, and Bridgeview are scheduled to transition to other providers in the next few days.
· Members of the Cascadia Consumer/Survivors Advisory Council will host an open public conversation next week at the Garlington Center, sponsored by the Northwest Health Foundation, to discuss the future of local community-based behavioral health. Contact Della at Garlington for details (dellaf@cascadiabhc.org). I’ve heard of some interest in having a similar event, focused on the issues specifically impacting Gresham/East Multnomah County. Nothing is yet planned, but if this interests you please advise our Director of Consumer & Family Involvement, Sharon Gary-Smith (sharong@cascadiabhc.org); or ask consumers or family members to contact her.
· Cascadia Senior leadership (Chip, Enrique, Barb and me) are holding twice-weekly meetings with NAMI, other consumer advocates, and Multnomah County for the purpose of coordinating efforts to transfer contracts in a way that supports the best interests of consumers, the community, and employees.
· We are honoring our Memorandum of Understanding with Multnomah County, and our partnership with the county that the agreement represents, yet we remain flexible and open to continuing any contracts, if that would be in the best interest of the consumers and the community; and if in so doing, such changes would be advisable for Cascadia’s financial health.

Beyond all this there are few issues that are unsettled and that need attention in the coming days and weeks.

This is what I do not know:

· The final plans for paying back the loan from Multnomah County and State.
· The details of the planned transfer of Gresham and Garlington clinics. We do not know the timeline or the replacement providers.

All in all, as difficult as this is, I see that we are making incremental progress in some areas, but the complexity of the situation and the ever changing nature of this process makes it difficult to provide accurate predictions on the timing and ultimate outcome on just about all fronts.

Finally, I want to note that with the closure of our Beaverton and Hillsboro Centers, TAY, MIOS, TNP, House of Umoja, and Bridgeview, and with some resignations across our multi-county enterprise, some wonderful people are leaving Cascadia. I wish you all the very best in the future and thank you for your dedicated service. Also, I hear that many employees have elected to not leave the company and have taken new positions in other Cascadia programs. I also wish the best to you, and find some comfort in knowing that the talent and compassion you all hold will remain in the community.

+ + + +

TO All staff
FROM Derald Walker, Chief Executive Officer of Cascadia Behavioral Healthcare
DATE June 27, 2008 – later in the day
SUBJECT Latest news – supplement

In my recent update I asked you to advise me if there were any details missing or in need of correction. Thank you for doing just that.

I’ve heard from people involved in our residential sites that I failed to mention these essential services in my update. This was an error and I apologize for the oversight. The following item should have appeared in the list of the things I know:

Residential services at Bridgeview are scheduled to be transferred to Luke Dorf as of July 7. Other than this change, our portfolio of residential services will remain as it is.

From OPB.com, June 26, 2008

When Cascadia Behavioral Health ran into financial trouble this past spring, Multnomah County officials divvied up Cascadia’s caseload among the few alternative mental health providers.

The county presented a plan last week that’s big on promises – in terms of redistributing thirty percent of mental health services. But as Rob Manning reports, following through is not so simple.

+ + + +

The trouble is figuring out which other providers are willing and able to take on Cascadia’s enormous patient load. Other mental health non-profits are also struggling financially, and have to look at their own bottom lines.

And some agencies have other problems.

For instance, the Tigard-based non-profit, Luke Dorf, is slated to take over the transitional care facility called “Bridgeview” from Cascadia. But Luke Dorf is currently facing a state investigation – not for financial problems – but because one of its voluntarily committed patients walked out of a secure facility in Cornelius.

Washington County Sheriff Rob Gordon has been a critic of Luke Dorf’s Connell House, because it is an insecure location for some potentially dangerous people. He says that recent escape is an example.

Rob Gordon: “When a person is in a secure facility, that brings a picture to people’s mind. I’m not sure that being able to escape that easily, with just the assistance of a chair, and not being discovered, and not telling us, would fit my definition of ‘secure’.”

Gordon and Luke Dorf leaders disagree over whether the state investigation should lead to big changes at Connell.

But when it comes to running a non-secure place, like Bridgeview, Gordon doesn’t have a problem with Luke Dorf.

Rob Gordon: “The short answer is Luke Dorf has a fairly high reputation with us and with other law enforcement agencies as a very competent provider of mental health services. And in some ways, I think they’re being unfairly cast as the villain in this.”

That’s only a small piece of the complex Cascadia puzzle, and some of the other big pieces are still being put together.

Two of Cascadia’s biggest clinics – in Gresham and Northeast Portland – serve nearly 600 clients. At least, on paper.

In the wake of Cascadia’s financial meltdown, some non-profit providers are wondering if they should take over Cascadia’s clinics and questioning the accuracy of those numbers. If the numbers are off, there won’t be sufficient income to support costs.

Multnomah County officials are hoping to settle the Gresham clinic’s future in the next week or so. The Northeast Portland building, though, is likely to close, raising the possibility of unwelcome changes for mentally ill clients.

Cascadia’s whole transition is expected to be complete by November.

An invitation to a public meeting was emailed to some community individuals on June 25.

+ + + +

Members of the Cascadia Consumer/Survivors Advisory Council invite you to be part of an open public conversation, sponsored by the Northwest Health Foundation. We’ll discuss the future of local community-based mental health.

Obviously one Garlington Center meeting room will not have room for many Cascadia employees or consumers. Plus, most of us are working at that time seeing clients, supporting our operations, or otherwise going about our daily work. But I do want you to know that you and other Cascadia consumers are welcome, if you can make it. I already have confirmations from Multnomah County representatives, members of the Oregon Legislature, Mayor Potter’s office, several community leaders, and other advocates.

We hope to see you next Monday, June 30, 11 AM to 1 PM, at the Garlington Center large meeting room, 3034 NE Martin Luther King, Jr. Boulevard, Portland, OR 97212.

David Maisel’s book of photographs, Library of Dust, will be published by Chronicle Books in August 2008.

from the Utne Reader, November 2006

The urns in an abandoned hospital ward are anonymous, but the ashes shout out in bursts of dazzling color.

The hospital is decaying. Crumbled plaster rests as rubble on linoleum floors that have burst at the seams, succumbing to the pressure of a buckling foundation. Yielding paint sloughs from the walls. Evidence of patients once treated here lies scattered-a deck of cards, a sodden book, a rusted razor blade. It seems impossible that the heart of this institution still functions, that somewhere at the end of a long corridor doctors and nurses still practice medicine. In these deserted wings, part of the Oregon State Insane Asylum as it stood in 1883, the only hint of life is a collection of crude copper urns that house the cremated remains of those who died here-thousands of patients treated over a century’s time-stacked three deep on plain wooden shelves.

When photographer and visual artist David Maisel, best known for documenting human impact on natural landscapes, first learned of the cremains 20 months ago, he sensed that they would be the centerpiece of his next project. ‘I’ve spent many years obsessively photographing copper mines . . . so there’s something about copper that I gravitate toward,’ he says. ‘But I didn’t have any sense of what these canisters would really look like.’ Compelled, Maisel wrote a letter explaining his work to the institution, located in Salem and now known as the Oregon State Hospital. To his surprise, permission to see the remains was granted.

Abandoned or forgotten by relatives, the canisters house the unclaimed remains of patients treated between 1883 and the 1970s. Left to an institution not well equipped to provide long-term storage, the remains accumulated in a basement room until 1976, when they were interred in an underground vault where moisture went to work on the copper cans, destroying precious labels. A few years ago, upon discovering the damage, the cash-strapped hospital transferred the remains into a storage room in a shut-down wing. In 2005 a series of Pulitzer Prize-winning editorials published by the Portland-based Oregonian drew attention to the struggling hospital, Oregon’s primary public psychiatric institution, and made the displaced remains a symbol of state neglect and pejorative public attitudes toward mental health throughout history.

Maisel saw more than decay or mistreatment. Left to languish over time, the copper cans and their contents have literally erupted with color: marine blues, steely crimsons, salted grays and whites. Mineral crusts and burnished colors bleed gorgeously from the welded seams. ‘I’m not a believer,’ Maisel says soberly. ‘But they have a kind of continuity . . . a sense that the individual is somehow continuing, even if it’s in an inorganic state.’ During Maisel’s first visit to the hospital, as he considered the canisters’ inhabitants, a young man on a cleanup crew sent in from a local penitentiary paused for a moment at the door and peered inside.

‘The library of dust,’ he whispered.

Maisel has since arranged three more trips to the hospital, each time spending several days photographing the canisters in natural light to avoid augmenting or altering the images. He is a careful archivist, cataloging the photos with respect to the numbers stamped into the lids (ranging from 01 to 5,118). The reverence with which he approaches the project has fostered a positive relationship with the hospital, which has mobilized on the heels of the Oregonian coverage to acknowledge its imperfect past as part of crafting a better future. The state is moving along with plans for a new facility, and the hospital has invited citizens to share ideas for a proper memorial for the remains.

In an essay about the project posted on his website, the artist articulates one vision of the library as a ‘microcosm of the hospital itself’: each canister assigned to a numbered shelf, analogous to indistinguishable rooms in partitioned wards-an emblem of the institutionalization of identity, in which names become numbers and personal details slip away. The canisters, however, seem to resist this loss, each eruption of color and crust suggesting an individual identity that’s both ethereal and organic.

EXTRA – Mental Health Association of Portland’s advocacy for OSH Patient Remains
EXTRA – David Maisel at the Miller Block Gallery in Boston
EXTRA – David Maisel’s Library of Dust on Boing Boing
EXTRA – Read Doug Bates and Ric Attig’s series on Oregon’s Forgotten Hospital

from The Oregonian, June 25 2008

Some 900 clients are getting new care providers because of Cascadia Behavioral Healthcare’s financial meltdown, a difficult process

Multnomah County’s plan to move more than 900 mental health care users from financially troubled Cascadia Behavioral Healthcare to new providers carries serious medical risks.

Oregon’s biggest mental health provider, Cascadia is financially overextended, losing about $400,000 a month and risking bankruptcy unless it can cut staff and increase efficiency, county officials say. To stabilize Cascadia and ease problems if the nonprofit collapses, they say, they must move clients.

But changing clinics or counselors can damage people’s hard-won progress. Avoiding breaks in care is vital for people with schizophrenia, multiple psychiatric diagnoses or poorly controlled depression. It often takes years to find the right medicines, counselors and routines that can help them live and thrive independently.

“Folks who have conditions like this adapt very poorly to changes in the system of care,” said Dr. George Keepers, chairman of the Psychiatry Department at Oregon Health & Science University. “This stuff is not good for people.”

At any time, Cascadia helps 6,000 Multnomah County residents deal with issues from addiction recovery to psychotic crises. Many should move to a new provider without a hiccup.

But for some, especially the most vulnerable, as little as a week without medication or a few missed appointments could spur a big setback — in the worst case, a psychotic episode. That could mean more hospitalizations, more people slipping into homelessness and other problems rippling out into the community.

“If that goes badly, and it often does, people can free-fall in terms of level of functioning,” said Derald Walker, the clinical psychologist who took over Cascadia in April.

Mental illness is so complex and individual it’s hard to pinpoint who might have setbacks, Walker said. But he recalled a Clark County woman whose case showed the dangers of off-and-on medical care.

Walker met the woman when, as a college freshman, she withdrew from friends, grew emotionally explosive and began hearing voices. He diagnosed her first schizophrenic break and had her hospitalized involuntarily. Tranquilizers and antipsychotic pills helped the young woman improve enough to move home. But she didn’t understand she was ill, didn’t like the drug side effects and didn’t want to live with her parents again. She secretly quit taking her medication and started sneaking out at night. This led to a cycle of hospitalizations, homecomings and returns to the street, which slowly made the woman sicker.

“She was pretty much always psychotic” after five years, Walker said. “She got pregnant by a transient and started doing street drugs. The last time I heard of her, I think she got HIV. It was in the ’80s. She could very well be dead by now.”

It’s not unusual for uncontrolled mental health problems to spill into homelessness, addiction, poverty or other physical health problems — all risks of a health care interruption. Because of such concerns, Keepers said, “the average life span of somebody with a serious mental illness is dramatically shorter than someone in the general population.” In some cases, patients’ only access to health services is through their mental health providers.

Even if care isn’t interrupted, getting a new provider can pose problems.

“Once you’ve established that you’ll be a caregiver to somebody who has some dependency on you, if you break that trust, it’s the worst thing that can happen,” said Patricia Backlar, a Portland State University bioethicist who is on the county’s Adult Mental Health and Substance Abuse Advisory Council.

Backlar, who wrote “The Family Face of Schizophrenia” and has a son with the illness, said society has an obligation to help “people who on occasion can’t necessarily care for themselves,” and see that care through. With severe mental illness, she said, “to thrive, you really do need some continuity of caregiving.”

If detailed medical notes don’t move with the patient, for instance, a new caregiver may try therapies or drugs that already have failed.

And changes force patients to find the time, trust and emotional strength to start a tough process again.

“It’s hard to tell your story and have people set up a plan, say, ‘We’re going to do this,’ and then three months later start over again,” said D-Borah Forrest, who gets care for anxiety, insomnia and post-traumatic stress disorder at Cascadia. “I figure, why bother? It just becomes too overwhelming.”

Forrest’s counselor took another job last week. But she feels lucky: The county’s plan lets Cascadia keep the Southeast Portland clinic where Forrest goes, and one of her group-class leaders will take over as her counselor.

But she worries about other Cascadia users, especially in areas where another company is taking over.

“It’s hard for a lot of us to change where we have to be and when we have to be there,” she said. “If we don’t have that structure, the disease gets worse. . . . We start kind of wandering.”

Health providers and county officials say they are working to give a clear road map to every person changing providers so they don’t get lost in transition.

Cascadia clients will get letters detailing changes in their care, Walker said. Staff are working to schedule prompt appointments for people switching counselors and to transfer records, including medication notes. Walker and county officials are urging new providers to hire Cascadia employees for the same jobs, though no one can force that.

The timeline adds urgency: With Cascadia losing money every week, the county and the nonprofit want to make the changes as soon as possible.

“It’s a big chore that they have on their hands,” said OHSU’s Keepers, who is not involved in the process. “Especially since Cascadia is such a big mental health provider. There are a lot of people at risk.”

From the Oregonian, June 23, 2008

County changes raise the anxiety level at a Northeast Portland clubhouse for people with mental illness

Connie Carter was about 19 when she started hearing voices. She remembers her fear when she was checked into Dammasch State Hospital, the Wilsonville mental institution that closed in 1995.

“I thought they would give me shock treatments,” she says. “But they pushed me in the shower and put shampoo on my head.”

Carter’s experience 30 years ago was jarring, but at David’s Harp, it is not extraordinary. That’s why she comes to this outer Northeast Portland clubhouse for people with mental illnesses — to be with people who understand her.

David’s Harp, founded in 1978, is among Oregon’s oldest examples of the community safety net hastily sewn when people were discharged en masse from mental hospitals with little provision for their care. Now the clubhouse is also an example of the people and programs caught in the turmoil as Multnomah County restructures its mental health system in the wake of financial problems at Cascadia Behavioral Healthcare. Cascadia staffs David’s Harp, which is an independent nonprofit.

The county announced last week that several major clinics would shift from Cascadia’s management to other providers, setting off a domino effect of uncertainty for staff and clients at smaller programs such as David’s Harp.

Cascadia currently provides about 80 percent of the county’s adult mental health services, including housing, treatment and crisis services for mental illness and for drug and alcohol addiction.

A new plan sets a goal of having no more than 40 percent of county-funded mental health services provided by any single agency.

As late as Thursday, confusion remained over who would staff David’s Harp. But Karl Brimner, the county’s director of mental health and addiction services, said it now appears the Harp will stay with Cascadia.

Officials are still working out whether clients can keep going to the Harp and get their health care and case management at a clinic that Cascadia no longer manages. Most of the 110 people who go to the Harp see doctors and case managers at a Gresham clinic that will be managed by a new provider. Brimner said he favors letting clients use more than one provider if necessary.

“I see it as: How do we make this system work for the people getting services from it,” he said.

Client angst began in mid-April when Cascadia’s financial troubles surfaced.

“It’s been such a long time period where people have had to sit with so much unrest,” said Mary Kautzer, Cascadia’s program manager for David’s Harp. Clients — many whose peace of mind depends on familiarity and routine — have reported mounting anxiety and difficulty sleeping and eating, she said.

“I’d get mighty depressed if I didn’t have this place to come to,” said Don Rossetto, a Harp regular for 28 years.

Parkrose United Methodist Church launched the Harp 30 years ago with dozens of volunteers — some who still volunteer today — to give people a haven to make friends and enjoy activities. The Harp took over the church’s annex and became a nonprofit. Kautzer signed on as program manager right out of graduate school in 1982 and never left, staying on even as Mount Hood Mental Health and then Cascadia took control of county services. Cascadia works with the Harp’s board to run the program.

“We’ve been pretty much operating with a handshake for years,” said Thomas Price, an attorney and the Harp’s board chairman. “It’s a relationship of trust.”

An annual budget of $130,000 pays Kautzer for one day a week, a part-time supervisor and three full-time staff members. The six-day-a-week program provides a meal, outings, group discussions and second-hand clothing. Staff people say they find hope in helping people live independently.

“I just have such a personal investment in the lives of these people,” Kautzer said. “You just want to take care of them.”

The feeling is mutual. Recently, Rossetto and Connie Carter shared a table for bingo. Next to Carter was Michael Bohan, who eyed bottled water that he hoped to win.

Staffer Celeste Connell tracked bingo cards for a client who is deaf and for Rossetto and another client who are blind.

Juanita Elliott signed up on the chore board as bingo caller. So she spun what the clients call the “mixer-upper,” extracted the first bingo ball and called out the number.

“I got bingo!” Carter announced later when she won, one of several players to win that night.

She hopped up in her scarf-bedecked, wide-brimmed straw hat and chose shampoo as her prize.

Soon, Rossetto won. Connell described the prize options to him. He chose a Tom Petty tape — he’s into vintage rock ‘n’ roll.

The bingo game ended, but Bohan didn’t win his bottled water. So Carter handed him her shampoo.

“You didn’t win, so you can have it,” she told him.

“Thank you,” he said, and slipped the bottle into his backpack.

But Rossetto was troubled. He asked Connell whether he could share something with her. She sat close. He explained that a woman at the clubhouse the other day insulted him and made him cry. Connell reassured him.

“I feel better, Celeste,” Rossetto said. “You know, this keeps me out of the hospital and I like coming here. I like everyone here. You’re like my fourth family.”

From News From Indian Country, June 21 2009

Artifacts including dish fragments, glass, clothing and clay pipes found on the site of Oregon State Hospital may date to a prominent Salem pioneer’s 1850s-era homestead.

While the finds excite archaeologists, they could have an affect on construction of a new hospital to replace the aging buildings in use.

Aimee Finley, projects manager for the Portland-based Applied Archaeological Research, says the 1852 Morgan “Lute” Savage homestead is the best guess so far.

The firm said the site “represents one of a very few 1850s-era domestic sites discovered in the Willamette Valley,” adding that “It has the potential to yield information important in a wide variety of research dimensions related to the establishment of the American society at the end of the Oregon Trail.”

The report called for follow-up excavations.

The firm’s report, given to Salem’s Statesman-Journal newspaper, says researchers gathered the artifacts in January as part of a state-sponsored check prior to construction.

Implications of the finds on construction plans are not clear. “Ultimately, the decision on what happens resides with the state,” Finley said.

Laws protect cultural resources on public and private property. Some construction projects, especially in the West, have been slowed or scrapped because of Indian grave sites, forgotten villages and other buried cultural resources.

The recent state hospital searches also turned up some chips from the making of prehistoric stone tools. “We found just isolated instances of that, not enough to characterize it as an archaeological site at this stage,” Finley said.

If the firm concludes that parts of the campus are archaeologically important, it probably will recommend they not be disturbed.

The State Office of Historic Preservation will decide.

Consultants confined their survey to 102 acres earmarked for construction on the 144-acre property.

Some objects were on top of the ground. Searchers also dug 93 “shovel test pits.”

She said the pits determine if there is an archaeological site and just provide a sample.

“Obviously, we didn’t dig every square foot of the property. We identify areas based on their various characteristics that would have a high probability of containing archaeological sites. Then we dig these probes,” she said.”

Everything found will be sent to the State Museum of Anthropology at the University of Oregon. There may be more to be found.

“Mid-nineteenth century domestic sites often contain shaft features such as wells and privies, or other subsurface features such as trash pits and root cellars,” she said.

“These types of spaces often were used as refuse receptacles after they completed their use lives. The site might also contain architectural features such as corner piers, chimney bases, and foundation remnants.”

“When we look at the historical maps and read historical accounts, they indicate that there is a homestead there,” Finley said. “Right now, the link has not been proven, it’s merely suggested,” she said, but cannot be discounted.

Nearly 190 objects were collected, including nine old-fashioned “Prosser” buttons probably from coats, shirts and blouses.

Most of the artifacts were broken.

The report says the site may represent “a potential source of important information related to institutional care and patient therapies during the late nineteenth century at the OSH” as well as details about the homestead.

Recently, the entire campus was added to the National Register of Historic Places at the urging of local history buffs.

Snippets of Savage’s life show up in old newspaper stories.

He was born near Syracuse, N.Y., in 1816 and lived in the Midwest, arriving in the Oregon country by covered wagon in 1847.

He went to California in 1849 to seek gold and was “well rewarded” for his efforts, one clipping says.

Back in Oregon he fought in Oregon’s Indian wars and later became a flour mill operator, city water works developer, land baron and state senator.

He apparently settled on his large donation land claim in 1852 and sold it to the state in 1864.

He died in 1880.

READ – Cultural Resources Investigation of the Oregon State Hospital Property, Marion County, Oregon, February 2008

From OPB.com, June 18, 2008

LISTEN to this article.

Mental health clients in the Portland are trying to figure out where they’ll be getting their care today.

Monday local government officials unveiled the blueprint for the area’s mental health care future.

The plan, on its face, shrinks the troubled nonprofit provider, Cascadia Behavioral Healthcare, by about a third. But since Cascadia is the largest mental health care provider in the state, the restructuring will have huge ripple effects.

+++

Since late April, taxpayers have given Cascadia more than $3 million in loans and cash advances.

Everyone involved acknowledges that without the bailout, the regional mental health system would have failed.

No one knows exactly what that would have looked like.

But many clinically depressed and schizophrenic patients would have missed their treatments. Even more recovering drug addicts and alcoholics would have been without help.

Suzanne Nord: “The ultimate thing is to provide housing and keep people off the streets.”

Recently, Suzanne Nord rolled into the Benson High gym in her wheelchair. She was one of more than a-hundred people who came to meet with Cascadia and county officials about how the current crisis will affect her life. She lives in an apartment complex Cascadia runs for the mentally ill.

Suzanne Nord: “I don’t want to be on the streets. That will make me crazier than I am already. To keep people out from under cars, and out from behind dumpsters, you need a place to sleep, that you feel safe. And that’s the beginning of being a human being again.”

Caring for people like Nord is exactly why the state and county needed to bail out Cascadia, officials say.

But if you look at the nonprofit’s books, its financial mismanagement and misplaced priorities left the government with little choice.

Derald Walker took over as the chief executive at Cascadia this year.

He says today’s crisis isn’t unique to Oregon.

Derald Walker: “Increasingly, running nonprofit healthcare is demanding. If you look at the number of places similar to Cascadia across the country, the numbers that are folding is very high.”

For the mentally ill, it’s especially difficult. Their costs are dramatically higher than most for things like medication, therapy, and in-patient housing. And the mentally ill are far more likely to live below the poverty line and be without job-sponsored health care.

Which is where the financial mismanagement comes in.

Because so many of Cascadia’s clients are poor, Walker says, they rely on Medicaid to pay their bills.

Derald Walker: “And Congress, in 2001, passed a bill that increased the accountability for Medicaid funding considerably, that required more data.”

Walker says Cascadia had more than a little bit of trouble meeting those new requirements.

Derald Walker: “It’s not like doing an appendectomy where you have some specific tangible costs, like operating rooms or the cost for a pacemaker. People with chronic mental problems need more services that are difficult to document and they don’t involve direct face-to-face contact that you can always document.”

Already, Cascadia owes another $2 million to the state because it can’t prove it provided some services over the past three years.

Trisha Baxter is the administrator for the state’s Office of Payment Accuracy and Recovery.

Trisha Baxter: “At this point, Cascadia owes that to the state. If they can come up with additional documentation, then we’d be so happy. There is no doubt that those services were delivered, but we don’t have the documentation to back up the payment of those claims.”

Despite those challenges, most of the other health providers in the state, and in fact in the country, successfully switched over to the new system.

In fact, the county says it actually gave Cascadia a chunk of money to help with the transition.

But Cascadia didn’t just use the funding to try to transition to a new billing system.

The nonprofit used much of the money to help it take over a number of the region’s smaller nonprofits.

Cascadia was formed in 2001 from three local mental health providers – and it continued to grow over the next several years by merging with other operators.

Phil Broyles: “I think they got too large too fast.

Phil Broyles is a former clinician for Cascadia.

Phil Broyles: “They didn’t have the proper systems in place to handle the number of clients they have taken on and all that. I think it was poor planning, I don’t think they planned for this big of an organization.”

Many people inside and outside Cascadia agree.

They say the organization continued to rely on costly, and mistake-prone, paper billing for years.

Cascadia CEO Derald Walker says the idea behind the growth wasn’t entirely flawed.

Derald Walker: “In the world of nonprofit healthcare, size actually can be in your favor because you are not duplicating administrative costs. But with 20/20 hindsight probably they did grow too fast and at some point, they should have consolidated their gains and made sure their financial reporting and such was equal to the size of the organization.”

Walker says since he wasn’t around when those decisions were made he’s not in a position to defend them.

And now, Cascadia is left picking up the pieces.

The transition plan will reduce the number of contracts from Cascadia’s portfolio – meaning it will also reduce the county’s reliance on one dominant operator.

Cascadia employees are being asked to learn new accounting rules – and some say they are being pressured to work harder and bill more. When Cascadia was days away from collapse, many workers stopped showing up for work.

Here’s former clinician Phil Broyles again. He still works for Cascadia’s housing office as a landlord, but says he resigned as a clinician after seeing other employees get pressured to increase their billing.

Phil Broyles: “Nonprofits are supposed to be nonprofits. Their bottom line is to provide a service to the community. And when you operate it like a company that sells widgets, then people get hurt.”

And it’s those people who will be most affected by Cascadia’s troubles. Under the county’s new plan for Cascadia, half the children it serves must transfer to a new provider.

And some patients in Gresham and Portland will need to work with another health care operation.

Right now, the county is accepting input from the public about the plan.

Within a few weeks, officials hope to shrink the nonprofit, reduce the county’s reliance on one mental health provider, and most importantly, stabilize care for the mentally ill.

From Forest Grove News-Times, June 17, 2008

Washington County shifts services to other mental health contractors starting July 1

Officials expect a smooth transition when Washington County cuts ties with struggling mental health provider Cascadia Behavioral Healthcare on July 1.

The county has managed to shift services provided by Cascadia to two other mental health contractors – employees and all.

“That’s a big relief for us that that is going to work out and consumers really shouldn’t experience any issues with this transition,” said Rod Branyan, Washington County’s director of health and human services.

Cascadia provides services to about 23,000 mentally ill clients across the state, offering crisis intervention, treatment, walk-in clinics, housing, counseling, case management and outreach. The majority of services are provided in Multnomah County.

But in April, financial turmoil struck the organization, sending county governments into a tailspin trying to sort out how to take care of the patients if Cascadia fell apart.

Cascadia has contracts with Washington County that amount to about $2 million. One of those contracts is for mobile, emergency mental-health counseling, a vital service that Branyan said the county couldn’t afford to do without.

Two Portland nonprofits will take over Cascadia’s services at the end of the month.

CODA will take over Cascadia’s Hillsboro facility, and a program providing drug and alcohol treatment to the county’s drug court program.

Lifeworks NW will take over Cascadia’s Beaverton facility, including the mobile emergency care unit.

“Part of the problem that Multnomah County had was that such a significant percentage of the services provided in Multnomah County were provided by Cascadia,” Branyan said. “But in our case they were a much smaller percentage.

“It would still be a strain though, unless Cascadia staff were already willing to transfer,” Branyan said.

Mary Monnat, CEO of Lifeworks NW, agreed that bringing the employees along will ease the transition for the nonprofits and the clients they serve.

“We’re very grateful that we were able retain their whole team,” Monnat said.

From the Oregonian, June 17, 2008

The struggling mental health provider will keep control of three clinics

Multnomah County announced a reorganization of its local mental health system Monday, substantially scaling back contracts with struggling Cascadia Behavioral Healthcare and setting the stage for a potentially difficult transition for clients with mental illness.

By transferring roughly a third of its business with Cascadia to other companies, the county is realizing a long-held goal of shrinking the state’s largest provider of mental health services.

The changes won’t begin immediately, allowing time to tell clients about any direct effects on them. “People need to continue going to Cascadia for services,” said Joanne Fuller, county human services director.

Nevertheless, the shift may prove rough, both for smaller providers asked to quickly take over new sites, programs and employees, as well as for patients who must give up established relationships with counselors and clinics.

“Transition is always traumatic for people with severe mental illness,” said Jason Renaud, a volunteer with Mental Health Association of Portland.

The reorganization will strip two of five clinics from Cascadia’s control: The Garlington Center in Northeast Portland will close and other agencies will serve its 237 adult clients. The county plans to keep the 358-client Gresham clinic open, but Cascadia will no longer run it.

Cascadia also will lose responsibility for a number of programs, including Bridgeview Community, transitional housing in Portland that helps seriously mentally ill people prepare for independent living; specialty mental health programs aimed at Latino and African American clients; and some youth programs.

At least three smaller nonprofit companies will take on some of Cascadia’s services and clients — Central City Concern, Lifeworks Northwest and Luke-Dorf Inc.

Cascadia’s size became an issue in April when the nonprofit company’s near-collapse required a last-minute government-backed loan of $2.5 million. Cascadia currently provides about 80 percent of the county’s adult mental health services, including housing, treatment and crisis services for mental illness and drug and alcohol addiction.

The new plan sets a goal of having no more than 40 percent of county-funded mental health services with any single agency, though Cascadia will still have more than that even with the proposed reduction.

“This is not the last plan your going to see,” said County Chairman Ted Wheeler.

Downsizing the company represents a substantial philosophical shift from 2002, when Multnomah County was instrumental in creating Cascadia by encouraging the merger of the county’s three largest mental health providers.

County leaders, believing a large provider would lead to improved care, continued to foster its growth by directing an increasing number of contracts to Cascadia, allowing it to swell to a $58 million-a-year enterprise.

“County vulnerable”

The relationship changed when Karl Brimner took over as county mental health director in 2006. Brimner was skeptical of the size and influence of Cascadia and worried that company’s leaders were increasingly struggling to manage such a complex organization.

“Karl was uncomfortable with the mental health system being so dependent on one provider,” Fuller said. “He thought it made the county vulnerable.”

The county ended the practice of awarding contracts to Cascadia without bids, increased scrutiny of how the company was executing its contracts and at one point stopped referring all new clients unless Cascadia dealt with financial and caseload problems, Fuller said.

In January — months before the company’s own board of directors had an inkling of the severity of the financial problems — a top county mental health employee predicted that Cascadia would collapse and ask for a government bailout.

If Cascadia did, the employee — Patrick Payton — recommended that the county move contracts to other providers and demand “a role in Cascadia’s executive decisions to a degree and for a period to be dictated by the county,” according to internal e-mails released in response to a public records request.

When Cascadia executives indeed approached county leaders in April for a loan, the county talked not only about reducing its contracts with Cascadia, but also cutting off the agency altogether.

“While we have left the option of a smaller, stronger Cascadia ‘on the table,’ this document addresses the probability that circumstances will compel us to completely dismantle Cascadia’s service system,” said an April 26 memo from Payton. “The county could be forced to manage Cascadia on a temporary basis while one or more of these options are implemented.”

In the end, county officials decided to keep some services with Cascadia, particularly residential services and crisis services that Cascadia specializes in. The agency will also maintain control of its downtown clinic, its Woodland Park clinic and its urgent walk-in clinic. Together, the clinics treat more than 1,800 clients.

And though Cascadia’s finances are now in better shape, a financial report accompanying Monday’s reorganization said any unplanned costs could force Cascadia to seek additional government loans.

“They’re operating very close to the edge,” said Jim Scherzinger, deputy director of the state Department of Human Services.

As part of the reorganization, Cascadia has agreed to make additional changes, such as reducing administrative spending, increasing productivity and drafting a plan to lay off employees. In addition, Cascadia must agree to continued financial monitoring by the county and state and accept more restrictions on its remaining contracts that will allow the governments to end them at any time.

“Our first and foremost challenge is to make sure we’re financially healthy under the new structure and to work with the county and the new providers to make sure that the transition is as positive as possible,” said Derald Walker, Cascadia’s CEO.

Cascadia also had significant contracts with Washington and Marion counties and the state. Washington County announced it was moving its $2 million in contracts with Cascadia to other providers starting next month.

EXTRA – Multnomah County Proposes Slashing Cascadia By A Third, OPB.com, June 16, 2008

EXTRA – State, county carve up Cascadia, Portland Tribune, June 16, 2008

EXTRA – Cascadia to shrink 30 percent under county deal, Portland Business Journal, June 16, 2008

Here is the County’s Reorganization Plan for Cascadia (1 MB PDF) assembled document consisting of

The Cascadia Plan, June 16 2008

A Memorandum of Understanding between the State of Oregon, Multnomah County and Cascadia Behavioral Healthcare, June 16 2008

Cascadia Behavioral Heath Financial Condition, memo from June 11

Our response to these documents.

1. The reorganization of Cascadia is tantamount to the reorganization of the county mental health system.

2. The goals and outcomes of the plan reflect the interests of county and state government. The outreach and contact the reorganization leaders had with those affected by the system’s change was not sufficient. According to the Surgeon General’s mental health report of 2002, 2.2% of the general population has a severe and persistent mental illness, and each of those persons has 4.5 persons who are closely attached to them – friends and family members. In Multnomah County this equals approximately 15,000 and 67,500 = 82,500. The largest County meeting in the past year about this issue drew less that 1/1000 of this number and the majority of persons at that meeting (at Benson High School) were employees of Cascadia or Multnomah County. The goals and outcomes selected may have been considerably different if those directly affected by the reorganization were brought to the discussion as equal stakeholders.

3. The plan as released is without sufficient background data, such as accounting and clinical measures, and for many items without measurable outcomes.

4. The reorganization still leaves Cascadia in financial jeopardy and other community agencies scrambling to build space and hire staff. The agencies named in the report are mature and capable of growth, but providers for at least two large communities – Gresham and inner N and NE Portland – are to be named later.

5. The plan is ambitious and intrepid but leaves behind the question of whether the County has the capacity to monitor contracts.

Your comments?

Morrow County Courthouse

The eight-bed treatment center for mentally ill men that Morrow-Wheeler Behavioral Health (MWBH) tried to build near Fossil, and now Boardman, may have finally met its demise amid a firestorm of public opposition.

The organization’s director, Kimberly Lindsay, said she and the board of directors decided not to build the facility in Boardman after more than 40 people called to express their opposition to the project.

Lindsay said the organization did not want to force the center onto a community that doesn’t want it, even though she believes many of the people who opposed the project were misled about the center and the type of people who would have been treated there.

The calls Lindsay and the board members received, she said, were often from people who recently had been visited by someone who was giving out information about the proposed project. Some of the information was correct, Lindsay said, and some was incorrect or misleading.

For example, some people were told the patients who would be treated at the center were criminal sex offenders, which is untrue, Lindsay said.

“There is a big difference between a sexually inappropriate episode because of an untreated mental illness and a sex-related crime,” she said.

The men who would have been chosen for the treatment center are in recovery from mental illness and are receiving appropriate treatment and medication, she said. They have been civilly committed, which means they were deemed a danger to themselves or others at some time because of mental illness, but they are not institutionalized because they committed a crime.

Furthermore, she said, the men who would have been chosen for the site have no history of relapse and no history of trying to escape.

The state has chosen to build more community-based treatment centers, Lindsay said, because the Oregon State Hospital is old and crowded.

“Many of the patients have been on the list for a secure residential facility for years, but there is no place to go,” Lindsay said.

Boardman already is home to a residential treatment facility for mentally ill patients called Columbia River Ranch, but, unlike the proposed facility, the patients are free to move around the community.

Lindsay said the center would have brought $65,000 a month to the community in payroll alone. The center also would have bought its prescriptions in town, which would have come to about $500 a month, and its groceries, which would have come to about $3,000 to $4,000 a month. Construction of the building would have brought $1.2 million to area contractors.

Ken Palke, Oregon Department of Human Services communications officer, said residential treatment centers are a step in the recovery process for mentally ill patients.

The rigid treatment regimes of the state hospital, Palke said, do not encourage self-reliance and transition back to the community.

“We cannot warehouse people in the state hospital – this isn’t the 19th century,” Palke said.

The chairman of the MWBH board of directors and Wheeler County District Attorney Tom Cutsforth said when the organization attempted to build the center near Fossil, nearby residents threatened to burn the building down. One resident said he would shoot the patients if he happened to see them on the street, Cutsforth said.

Cutsforth said he supported the project because it would have brought much-needed money and jobs to the county.

“The county that needs the most economic help is Wheeler,” Cutsforth said. “There are residential treatment centers all over Eastern Oregon, but they just never told anyone, I guess.”

Cutsforth, who has been Wheeler County’s DA for 18 years, said he now is facing a recall effort primarily because of his involvement in the project. The recall petition states Cutsforth “failed to adequately represent the residents of Wheeler county,” and failed “to involve the community over a pending project that will alter the character of Wheeler County.”

Cutsforth and Wheeler County Sheriff Dave Rouse both were appointed to the board of MWBH because of their positions with the county.

Rouse, Cutsforth said, resigned because of the public’s violent response to the project.

“It’s a NIMBY (not in my backyard) thing. They are just not going to let it happen here,” Cutsforth said.

Lindsay said the organization has no plans to re-site the project.

EXTRA – Outcry dooms treatment center in Wheeler County, the Oregonian May 30, 2008
EXTRA – Storm of community opposition halts plans for treatment center, AP May 31, 2008

from OPB.com, June 12, 2008

Oregonians with serious mental illness and addictions are dying much younger than the state’s general population.

A new study from Oregon’s Department of Human Services found that 89-percent of people treated for both mental illness and substance abuse die before age 50.

The premature deaths are often due to chronic diseases and complications from smoking, obesity and psychiatric medications.

People being treated for mental illness and substance abuse also have higher risks of dying by suicide, homicide, and accidents.

Ken Palke: “What that tells us is, is that this is a very vulnerable group of people and that persons with mental illness have some work to do, and we in the health community have some work to do in getting the word out about wellness.”

Ken Palke is with the Department of Human Services. He says his agency is starting a grassroots health campaign aimed at that vulnerable population.

The campaign emphasizes peer-to-peer support and includes outreach to help people coordinate their own health care. The department is seeking funding for the initiative.

EXTRA – State wellness effort seeks to halt early deaths of people with mental illness
EXTRA – State Wellness Initiative with tools, reports and research, presentations, articles, and useful links
EXTRA – For more information about this initiative, contact Ken Palke.
EXTRA – Reuters – Mentally ill undertreated globally: study

UPDATE Email from Derald Walker, CEO of Cascadia to all staff, June 12, 2008 – SUBJECT: We’ve reached an agreement

from the Portland Business Journal May 16, 2008 (how did we miss this?)

Beleaguered nonprofit’s new boss faces big task

Derald Walker doesn’t want to be known as the last CEO of Cascadia Behavioral Healthcare.

He’s pragmatic enough to know, however, that that’s a distinct possibility unless he can quickly turn around the fortunes of the ailing agency, Oregon’s largest adult mental-health services provider.

“The $64,000 question remains: Is it too late, or with progress being made, will Cascadia continue to stabilize financially?” asked Walker.

He’s stepped in to lead the agency, the state’s largest provider of adult mental health services, as it teeters on the brink of financial ruin following changes to how it gets paid by Multnomah County, compounded by years of skimpy payments for services.

The $58 million agency’s entire executive staff has turned over, and it employs 20 percent fewer workers than it did a year ago due to layoffs and a freeze on replacing workers who quit.

In just three weeks, Walker — who has worked in the mental health field 32 years — has been consumed by a whirlwind of meetings with state and county officials, employees and client advocacy groups — most of which have been tense, to say the least.

Walker has his share of challenges.

* A $2.5 million line of credit from the county and the state will ensure the nonprofit will meet payroll only through the end of June.

Jana McLellen, deputy chief operating officer for the Multnomah County, said it’s not inconceivable that the county could contract with other agencies to provide services currently furnished by Cascadia once those contracts expire in June.

* Capital Pacific Bank also called in a $2 million loan it made to the agency in April, taking most of Cascadia’s liquid cash in the process.
* Former employees criticized Cascadia’s bulky management structure, its leaders’ lavish spending on consultants and other non-core expenses, weak board leadership, and the rocky roll out of its digital billing system.
* The agency still owes the federal Centers for Medicaid and Medicare Services about $1.8 million for improper billings accrued in 2001, and the nonprofit is facing a drive to unionize workers.

Walker, a veteran mental health executive, started work at Cascadia in February 2008 as vice president for clinical services and was promoted April 23 to CEO, replacing Leslie Ford. He routinely works 14-hour days to make the hard changes necessary to keep the agency intact.

He’s wasted no time in shaking up senior leadership, naming a new chief clinical officer, a new IT director and eliminating the chief operating officer position, now vacant. He also spun off the agency’s social venture that helps its customers gain job skills, WellSpring, to another agency.

But the potential loss of state contracts following the end of Cascadia’s fiscal year on June 30 is a looming threat. The agency relies on county funds for the biggest slice of its budget — and it has proven a risky business strategy.

“When most of your dollars come from counties you get strangled,” said Portland health care consultant Robert McGuirk. “You don’t get the dollars to make capital investments. County dollars don’t fully fund administrative and general costs, let alone a bottom line.”

Walker agreed that the agency must diversify its client base. He also said Cascadia needs to cultivate philanthropy.

Former employees have criticized Cascadia’s bulky management structure, its leaders’ lavish spending on consultants and other non-core expenses, weak board leadership, and the rocky roll out of its digital billing system.

The agency also still owes the federal Centers for Medicaid and Medicare Services about $1.8 million for improper billings accrued in 2001, and the nonprofit is facing a drive to unionize workers.

Many of Cascadia’s current problems can be traced to Multnomah Country’s 2006 transition to a payment system under which providers are only reimbursed for direct services, a switch from the model in which it got a lump sum to care for a population.

Ironically Cascadia gobbled up several other agencies that ran into financial trouble during the county’s last funding change several years ago.

Cascadia is not the only agency that has struggled under the new funding model.

“It’s a huge challenge. There are five hydraulics you have to get right to get paid,” including getting prior authorization for care, documenting accurately and filling out the claim correctly, said Mary Monnat, CEO for LifeWorks Northwest, a Portland based mental health provider with an annual budget of $25 million.

Walker, though, ticks off several developments that bode well for Cascadia.

It collected its largest sum of accounts receivable in its history this month. Also, front-line workers have boosted the portion of their time dedicated to billable services from 30 percent in June to 50 percent today.

Workers at mental health nonprofits must spend a minimum of 50 percent of their time engaged in billable services to achieve financial viability under the fee-for-service model, county officials said.

“Cascadia is an incredibly valuable community service. While there are things we might have done differently in hindsight, to re-build this system would be expensive and time consuming, and there’s no guarantee it would be successful,” Walker said.

Even if Cascadia is able to weather its current challenges, like other mental health agencies it will remain vulnerable to federal and state cuts to Medicaid. More than 70 percent of the region’s Medicaid patients with mental health issues get care through Cascadia. The Bush administration has proposed Medicaid cuts that would cost Oregon more than $865 million over five years.

“It would be disastrous, devastating,” said Monnat of the proposed cuts. “Any remnant of a safety net we have would be unraveled.”