From The Portland Business Journal, May 30, 2010

Mental health care provider returns to profitability and starts building a cash reserve

Two years after a financial meltdown nearly destroyed Multnomah County’s safety net for the mentally ill, the nonprofit at the center of the crisis has rebounded.

Under Derald Walker’s leadership, Cascadia Behavioral Healthcare quietly turned itself around.

Cascadia Behavioral Healthcare Inc. is a shadow of its former self, and will bear the burden of its April 2008 near collapse for many years. Even at half its former size, however, the Portland nonprofit remains a key component of the county’s safety net.

It returned to profitability in March. CEO Derald Walker, appointed in the midst of the crisis to turn Cascadia around, hopes to build a $500,000 cash reserve by early 2011.

Two years ago, these results seemed inconceivable.

Cascadia Behavioral Healthcare runs clinics for people struggling with addiction, offered counseling to people with severe mental illness and housed poor people with mental illnesses.

But in spring 2008, poor bookkeeping put all that at risk.

State Medicaid officials had ordered Cascadia to repay $2.7 million when the nonprofit could not provide documents backing previous years’ claims. Capital Pacific Bank had demanded repayment of a $2 million loan.

Leslie Ford, who had been CEO since Cascadia Behavioral Healthcare was founded through the 2002 merger of several smaller nonprofits, had been forced out. Two consecutive chief financial officers hired to turn Cascadia around had quit, after declaring the company’s books a mess and uncovering still more liabilities.

By summer 2008, it appeared as though Cascadia Behavioral Healthcare’s programs would be dismantled and farmed out to other nonprofits.

Instead, the nonprofit is paying down its debt.

“They still have to watch their pennies,” said Kathy Tinkle, business services director for Multnomah County Human Services. “But they’ve made significant progress.”

Under Walker’s leadership, Cascadia obtained a $2.2 million loan from Multnomah County and the state. It negotiated its Medicaid assessment down to $1.2 million, payable over five years.

It also relinquished its role as Multnomah County’s pre-eminent mental health care provider by transferring several of its programs to other area nonprofits in order to cut expenses.

In August 2008, Lifeworks Northwest took over Cascadia’s Gresham clinic and Central City Concern took control of a downtown clinic at Southwest 12th and Stark streets. Luke-Dorf took control of Bridgeview, a residential treatment center.

Surrendering these programs cut Cascadia’s expenses, and the nonprofit cut costs still further by consolidating office space and leaving administrative jobs unfilled.

By drawing down the county-state loan, Cascadia invested in a $250,000 medical billing system aimed at further improving the nonprofit’s finances. The system prohibits Cascadia from submitting incomplete Medicaid claims, so that it can never again be reimbursed without adequate documentation, Walker said.

These cuts are paying off for the organization, but they have also left Cascadia much smaller.

It lost $2.1 million on revenues of $55.9 million in the year ending June 30, 2008, and lost $514,000 on revenues of $42.5 million the following year. Walker expects to end this fiscal year with a surplus of at least $200,000 from a budget of $38 million.

In 2008, Cascadia provided about 80 percent of Multnomah County’s mental health services. Now it provides only 32 percent of these services.

Meanwhile, county mental health officials have undergone their own transformation aimed at avoiding more surprises like the April 2008 Cascadia meltdown.

“We have realized that we can not be in a situation where we are so dependent on a single agency,” Tinkle said.

County mental health leaders now meet quarterly with their largest nonprofit contractors, and monthly with Cascadia, to track the performance health of the nonprofits that they fund.

Jason Renaud, volunteer and secretary of the board of the Mental Health Association of Portland, applauded Cascadia Behavioral Healthcare’s turnaround, and the county’s renewed oversight.

But he also lamented a mental health system that faces stagnant funding and growing demand.

Cascadia’s front-line workers, in particular, have borne a difficult burden through this transformation.

They have not received pay hikes since 2008. With a recent increase in the portion that many pay for health insurance, a number are now taking home less than they did two years ago.

Walker also cut vacation days.

A new program that manages counselor productivity can allow some employees to boost take-home pay if they increase billings as a share of total hours worked. Though many workers have embraced the program, others grumble on the growing emphasis on money in a caring profession.

Since the nonprofit’s fiscal crisis, employees have had to accept paper checks because Cascadia does not have enough of a cash buffer to implement a direct deposit system.

But unlike the crisis of two years ago, these are challenges that observers expect Cascadia Behavioral Healthcare to survive.

“Unfortunately, any nonprofit with the county is in this boat,” Tinkle said. “Our dollars aren’t growing as fast as our personnel and expenses.”

From the Portland Skanner, May 27, 2010

Tyrone Waters

Tyrone Waters, a Gulf War veteran who has battled paranoid schizophrenia – often publicly – since 1995, this week released his first spoken word CD about the events leading up to his shooting by Portland Police during a mental breakdown outside his home in 2001. Recorded in the style of a phone call from the state hospital, the CD is available at Music Millennium and Reflections Coffee and Books. It’s titled, “You Would Be Paranoid Too If This Happened to You.”

Waters and his mother, retired state Sen. Avel Gordley, were honored with community service awards by the American Jail Association at its Annual Training and Jail Expo, Sunday, May 23, at the Oregon Convention Center. He is currently working as a life coach.

The Skanner News: What is it that prompted you to do this project?

Tyrone Waters: It’s something that I wanted to do for quite some time, since being incarcerated I made up my mind that it was a project that I was going to take on and do. And it took me some time to do because of my injuries from being shot by the police in my writing hand. But I was able to get it done. I didn’t do it in manuscript form because it was just too difficult to do with my injuries so I opted for a second choice which was to do it on an audio CD, which is how I was able to get it finished and completed this year.

TSN: What is your goal with this project? Are you looking at the other issues that we have bubbling over with law enforcement in this kind of situation?

TW: I’m wanting it to be an educational tool not only for people with mental illness but also for law enforcement, also for the employees that work at the state hospital and the jails so that they can start changing their attitude about how they conduct business and how they treat the mentally ill when they’re locked up. So it’s got several facets; it talks about schizophrenia and the symptoms of schizophrenia and the different medications that are available out there to treat the disease so that people can live successful lives on medications that work for them. So it’s also designed to help remove the stigma associated with mental illness because a lot of people don’t understand what it is all about. And really it’s a chemical imbalance in the brain and it can be treated with medication and people can live lifelong, just like they can with any other disease like hypertension or diabetes or other common ailments.

TSN: You are a really important person in the community and you come from a family that’s really important. I wonder if you have any real specific suggestions you would make right now to city leaders who are struggling with this issue.

TW: Yes. First of all I want to say that when I got out of the hospital in 2006 (soon after the death in Portland Police custody of paranoid schizophrenic James Chasse Jr., [a person with a diagnosis of schizophrenia], which was settled out of court last month). I talked directly to Rosie Sizer at the Chief’s Forum and let her know they needed to immediately implement training for officers to deal with the mentally ill in my situation. And that did not happen. Obviously. And so what I’m trying to say is that this type of activity has got to stop and by the grace of God I am still alive and here today. We have to call these officers, these individuals that are controlling our streets and responding to incidents, as well as the employees in the jails and at the state hospital and psychiatric facilities, we have to hold them to a higher standard.

My mom and I were at the American Jail Association Convention Sunday, and spoke out about the shootings that have happened in this town, and sharing my story as well, and my mom also coming forward and saying that she suffers from depression. We asked everyone there to raise their hand if they knew or were related to someone who had a mental illness – there were over 200 people there and every one in the room raised their hand.

TSN: This is such an interesting thing because as we’ve watched all the police shootings this year, a lot of us here at The Skanner NEWS office, we’ve thought, you know the police must have a really high rate of stress-related mental health problems that they never talk about – just like soldiers.

TW: They do. They have mental health problems and they’re not open about it, it’s like a silent taboo in their community, it goes untalked about unless you are someone that’s not on the force or in law enforcement that’s just out in the community, then it’s talked about, then the finger pointing and the blaming goes on. But if you’re in law enforcement then it’s a hush-hush type of thing. And I think the reason why it’s not talked about is because if we actually knew how many officers suffered from some form of mental health problem, what would that say to the community? They would be fearful that they could just lose their job, or that it could ruin their career.

TSN: Like in the military.

TW: Right.

From the Willamette Week, May 28, 2010

A Multnomah County grand jury has found no criminal liability in the Portland police’s fatal shooting of Keaton Dupree Otis. The May 12 shooting death of the 25-year-old Otis during a traffic stop in the Lloyd District was the third fatal shooting by Portland police this year

There have been no criminal indictments in any of those shootings, which has been the case involving every grand jury in recent memory that’s looked at a fatal police shooting in Multnomah County. One recent difference has been the release of grand jury transcripts in the two fatal shootings this year.

A press release last night from the county district attorney’s office, which said 44 witnesses testified to the grand jury in the latest shooting, said a motion to disclose the transcripts of grand jury testimony in the Otis case will come before the court on June 3.

READ – Grand jury: No criminal liability in deadly police shooting of Otis, KGW.com
READ – No criminal liability in deadly police shooting, grand jury decides, KATU.com

READ – Portland police: Man killed by police did shoot officer in leg, KATU.com
READ – Parents say son suffered from ‘mood disorder’, KATU.com
READ – Group raises questions about latest police shooting, KATU.com
READ – Latest shooting doesn’t change chief’s philosophy, KATU.com
READ – Adams, new police chief discuss latest fatal shooting, KATU.com
READ – Portland grand jury finds no criminal wrongdoing in police shooting of Keaton Otis on May 12, The Oregonian
READ – Grand Jury finds no criminal liability in Keaton Otis death, KOIN.com
READ – Police identify man shot by officers, KOIN.com
READ – Officer shot in the legs in Lloyd area traffic stop released from hospital, KOIN.com
READ – Otis family statement, KOIN.com
READ – Albina Ministerial Alliance to investigate Otis shooting, KOIN.com
READ – Grand jury clears police [in Keaton Otis shooting], Portland Observer
READ – Albina Ministerial Alliance reacts to Chasse settlement, new chief, police shooting, Portland Observer
READ – More details on last night’s police shooting [of Keaton Otis], Portland Observer
READ – Radio Dispatch for May 12, 2010 A, from the Portland Police Bureau
READ – Radio Dispatch for May 12, 2010 B
READ – Police cleared in Otis shooting death, Portland Tribune
READ – Chief Reacts To Jury’s Decision, KPTV.com

The shooting of Keaton Otis from pdx97217 on Vimeo.

PPB Press Conference on Keaton Otis Shooting, May 12 2010 from pdx97217 on Vimeo.

From The Portland Mercury, May 27, 2010

Sinking Ship – Prisons Try to Improve Mental Health Services; They Cut Them Instead

There are 13,982 inmates currently residing in all 14 of Oregon’s prisons. Of those prisoners, 6,844 (or 49 percent) have a diagnosed mental illness.

Concerned about the treatment of inmates who have both a mental illness and a drug addiction, the state mandated in January that prisons double their mental health programs’ staffing ratio to one staffer for every 10 inmates. Ironically, the move backfired.

Anticipated cuts of up to 25 percent of its budget thanks to the financial crisis, the Oregon Department of Corrections says it will be too expensive to double its mental health staff. Instead, it is cutting the entire transitional treatment program for prisoners suffering from co-occurring mental illnesses and drug addictions. The result will be devastating, say public defenders and mental health advocates.

“It’s going to increase the number of people who relapse when they reenter the community,” says Bob Joondeph, executive director of Disability Rights Oregon.

“People are going to cycle back [into prison],” agrees Chris Bouneff, the executive director of the Oregon chapter of the National Alliance on Mental Illness.

Three Oregon prisons currently provide 157 beds for the treatment program, which lasts six months or longer and involves group therapy, drug and mental health treatment, and life skills that help prisoners manage their addictions and illnesses. Prisoners are also referred to treatment programs and other services outside of prison.

The department of corrections stopped accepting new inmates into the program this month, and will shut it down by the end of the year.

“Almost all of our clients have co-occurring disorders,” says Heather Ackles, Metropolitan Public Defender’s alternative sentences advocate. The need for the program is dire, she says. “It’s really a shame.”

Doubling its mental health staff represented a “huge expense,” says Jana Russell, the administrator of the department of corrections’ behavioral health programs. Instead of increasing the program’s funding, the program’s resources are being reallocated to “the highest need,” Russell says.

“We had to make some very big and important decisions about how to manage this population,” she says.

Russell is not happy about the cut, but states that her first priority is funding treatment for inmates while they are prisoners, rather than programs that help inmates transition back into civilian life.

Russell says mentally ill inmates in Oregon’s prison system frequently inflict self-harm, attempt suicide, and experience psychosis.

“The first priority is keeping staff safe, and services that allow people to reenter and not re-offend are second,” says Joondeph of Disability Rights Oregon.

It’s possible the program will be restored in the future, but the department of corrections could not provide information on how much more money would be needed to reinstate the program, or even how much the program currently costs to run.

Putting together a line-item budget for the department of corrections’ mental health and drug addiction treatment programs would be an “administrative nightmare,” says Martha McDaniel, the department’s budget manager, and it would make the budget less flexible.

Meanwhile, inmates who would have been in the co-occurring treatment program will be housed with the general prison population, or in other mental health or drug treatment programs.

“The treatment won’t be as broad,” Russell admits.

But Joondeph and Bouneff are skeptical of how effective the care will be for inmates with co-occurring disorders.

Joondeph says, “The vast majority of people in the corrections system with mental illnesses have accompanying substance abuse issues. They need to be addressed together, equally.”

READ – Improving Oregon’s alcohol & drug strategy

Testimony to the Oregon House of Representatives by Anthony Aldeguer, from May 25, 2010

Madam Chair and Fellow Committee Members,

I am honored to be granted this privilege to speak before you. I am a patient at Oregon State Hospital. I come before you to speak on behalf of myself, my peers and more importantly to give voice to those peers whose voices are not being heard as many of them are fearful of retaliation and/or unable to advocate for themselves.

The need for quality care, treatment and rehabilitation at Oregon State Hospital will be the focus of my testimony.

For many years Oregon State Hospital has been lobbying for additional funding to improve patient care. There is a proven track record that even after having received additional funding, the overall hospital culture has not changed. Improvements in the quality of patients’ care have little to do with money. Instead, it has everything to do with humane treatment of us patients such as compassion, empathy and empowerment so we can become active participants in our recovery.

One contributing factor that affects the quality of patient health care at Oregon State Hospital is related to chronic under-staffing and mandated overtime.

Staff are mandated to work numerous overtimes which has an adverse effect on their mental and physical well-being.

Specifically, it affects staff’s morale and their alertness when attending to patients’ care and needs.
Therefore, an immediate intervention to improve the inadequate staffing situation at the hospital is imperative.

From my own personal experience I can say that the therapeutic treatment milieu differs significantly from one forensic ward to another. The staff on one ward may be dedicated to creating a healthy milieu, while on another ward staff may operate on the premise that patients need to be controlled.

We believe that organizational change needs to happen on all levels. Ward staff need to be held accountable for their actions, otherwise the maladaptive patterns will be repeated over and over again. Furthermore, any newly hired staff will adapt to this dysfunctional culture.

An increase in staffing, new committees and an electronic record system do not change the culture of the hospital. Staff attitudes cannot be changed through that.

We support the Oregon State Hospital Advisory Board that was created by the Legislature in 2009 to improve the safety, security and care of patients at Oregon State Hospital. Without the Advisory Board’s and the United States Department of Justice’s ongoing review of the hospital operations, there will be a continuation of dysfunctional leadership.

It takes commitment, leadership and a hospital vision to change a culture. The primary goal of treatment should not be to control the patient’s behavior. Instead, the goal of patient treatment needs to move into the direction of assisting us to gain greater control of our lives.

In addition, we think that the current practices of the Psychiatric Security Review Board need to be addressed.

For example, when we ask at our hearing what we need to do to be granted a community placement evaluation; board members respond by saying:

“If you do ‘A, B, C’, we will grant you the community placement evaluation upon your return to see us.” However, when we return, we are told: “We see that you fulfilled what we asked of you nine months ago, yet before we grant you the placement evaluation, we also want you to do ‘X, Y, Z’.”

Consequently, we are held in the hospital longer than necessary. This practice of the Psychiatric Security Review Board undermines the morale of patients; it leads to losing hope and ultimately to stagnation in our recovery process.

My peers and I sincerely thank you for allowing me to bring these issues to your attention today.

Thank you very much for your time.

Anthony Aldeguer has been a Oregon State Hospital patient for 2 1/2 years.

READ – Hearing, new numbers suggest problems are far from solved at the Oregon State Hospital, The Oregonian, May 26 2010

From the Salem Statesmen Journal

Guest opinion by Jason Renaud, published in the Salem Statesman Journal, May 25, 2010

Advocates for persons with mental illness remain unconvinced the state should return to the bad practices of the 19th century by both building and committing a future hundred years of resources to state psychiatric hospitals.

This financial and political commitment, from politicians aligned with public employee unions, from tired and cynical mental health administrators, from local construction and property interests, is impossible for us, unpaid advocates concerned for the welfare and civil rights of persons who have mental illness, to block or even track.

To us — to many of us — it’s millions of dollars of precious public money dumped at the wrong end of the continuum.

We know excellent outpatient care costs one-tenth of hospital care — but that’s not what gets bought.

We know in-patient treatment needs to be integrated with family, housing, employment, that health and re-entry is the only goal — but that’s not what gets done.

We know addiction treatment is done best by peers in a 12 Step community such as AA — but walls and barbed wire defeat indigenous programs of recovery.

Over and over, the new OSH is sold as a jobs program, as a stimulus to local business, as a long-term plan for economic stability for Salem and perhaps Junction City.

But it’s really a prison for people with a treatable illness.

Persons with mental illness are the most discriminated against persons in the world — in all places and throughout the ages.

Every horror story in literature is about mental illness. In housing, education, in the law, health care, in employment — they are legally discriminated against. They are intentionally impoverished. They are attacked. They are isolated and abused.

So I am not surprised at this small-minded corruption. This hate and disregard is expected from our legislature and local commissioners. There is no counterbalancing force.

At some point, arguably, they may have said, we have the moral high ground; we are helping people, or we are protecting people.

Neither of those ideals have been true for a long time at OSH, and no one outside of those directly benefiting from the continued existence of the hospital would say those things. No one wants their children at the state hospital.

So, to me, those advocating for the perpetuation of the hospital are hypocrites at best.

Until a counterbalancing force is produced to offset the demands of the construction crews, the hospital will grow and grow, demanding those outpatient dollars with more threats of hatred and fear and dread.

Jason Renaud of the Mental Health Association of Portland thinks the state is making a mistake by moving forward with a $458 million plan to build two new hospitals to replace the 127-year-old Oregon State Hospital in Salem. Renaud favors dramatic downsizing of the state hospital, and he calls for state leaders to expand community-based outpatient treatment, housing and support services for people with mental illness.