Mental Health Association of Portland

By Kathy Aney, East Oregonian, April 27, 2013

The article is the fourth in a series on mental health. In recent days, the East Oregonian has written about state plans to close Blue Mountain Recovery Center in January and local efforts to save the mental hospital from extinction. This story is a look at how treatment methods have changed in the center’s 100 years of existence.

Pendleton’s 100-year-old mental hospital wasn’t located by the railroad tracks by chance.

“Back in the day, people came here by train,” said Kerry Kelly, director of the Blue Mountain Recovery Center. “They’d get out, enter the hospital and live out their lives.”

The hospital’s moniker has changed over the hospital’s century of existence, beginning as the Eastern Oregon State Hospital and renamed Eastern Oregon Psychiatric Center and later Blue Mountain Recovery Center.

Mental illness was a hazy concept in 1913 when the Pendleton hospital began accepting patients. The term “schizophrenic” had just been coined. That very year the state hospital in Salem changed its own name from the Oregon State Insane Asylum to the Oregon State Hospital.

It was a time when medical professionals struggled to untangle physical, psychiatric and social symptoms and pinpoint root causes, said Dr. Rupert Goetz, chief medical officer at the Oregon State Hospital in Salem.

“In the 1880s, the leading cause of admission for men at the Oregon State Hospital was alcoholism,” he said. “The leading cause of admission for women was menopause.”

Even into the ’30s at the Pendleton hospital, adolescence, occult study, senility, epilepsy, drinking moonshine and syphilis remained reasons for committing someone into state care.

“Our knowledge of brain chemistry then was pretty rudimentary,” Kelly said.

Psychiatrists treated patients with chemically-induced seizures, hydrotherapy, lobotomy and other methods that eventually fell out of favor.

“The worst of it was the lobotomy, where the front part of the brain is separated from the back part with a blade,” Goetz said. “Nowadays, we think of that as barbaric, but a lot of people jumped on the bandwagon.”

It was a dark time for psychiatric treatment, he said, but also a time of discovery that eventually led to more effective therapies. For decades, however, many mental hospitals were like Hotel California — “programmed to receive.”

“At one time, there was the belief that people could never recover,” Kelly said. “The idea was custodial care.”

What a difference a century makes.

A banner in one of the Blue Mountain Recovery Center’s group rooms illustrates a radical shift in philosophy. The words are bold, brimming with hope — “You don’t belong here.”

Residents aren’t called “patients” any more. They are clients, most who are seriously ill with schizophrenia, bipolar disorder or major depression. Despite the severity of their conditions, however, most leave between 90 and 100 days. The center treats about 60 clients at a time and employs 117 staff members.

Most of the clients have violated some kind of societal norm. Kelly told of a woman who broke into a house where she had once lived.

The owners came home from church to find the woman had hauled all of their furniture onto the front lawn for a yard sale.

“The idea is to get them stabilized and back to their lives,” Kelly said.

Medication is usually prescribed, but therapists also teach clients to recognize early warning signs and arm them with strategies to control their illness.

“It’s a long process,” Kelly said. “It’s like a diabetic learning to regulate blood sugar or people with hypertension limiting salt.”

On the second floor of the aging building, psychiatric social workers Dawn Doran and Kathleen Lewis worked with a group of four female clients.

“What do you do when negative things happen?” Doran asked them. “What can you do to make yourself feel better?”

The women flipped through magazines, clipping out pictures of activities that help get them into happier frames of mind. They stuck pictures to paper with glue sticks. One client cut out a dog, river scene and a man building fence in a pasture. Another chose a sentiment she liked: “It’s never too late, you’re never too old, you’re never too sick … to start over again.”

Over the rustling of paper, the discussion blossomed.

Clients meet with psychiatrists and attend an array of other groups designed to teach them about their illness, give structure and provide coping skills. They work on self esteem.

“One of the hardest things for people with mental illness is battling the stigma,” Kelly said. “It’s easy to say, ‘I have diabetes.’ It’s harder to say, ‘I have schizophrenia and I hear voices.’”

The focus is recovery, Goetz and Kelly said, though that rarely means the mental illness goes away completely.

“They may never return fully to the way they were, but that doesn’t mean they can’t be very productive people,” Kelly said. “People with mental illness can lead very fulfilling lives.”

From the East Oregonian, June 15, 2012

The fuzzy outlines of an operation to save the Blue Mountain Recovery Center are coming into focus.

The Pendleton psychiatric facility dodged extinction numerous times in the past 20 years, but is scheduled for closure again in 2015. A group of about 25 individuals, including Oregon Health Authority Director Bruce Goldberg, gathered Friday to devise another 11th hour save or a way to repurpose the center.

State Sen. David Nelson, R-Pendleton, guided the free-flowing discussion between an eclectic group of health care, business, government and law enforcement professionals in the St. Anthony Hospital Blues Room. About half-way through the 1 1/2-hour-long meeting, Kevin Campbell, CEO of the non-profit Greater Oregon Behavioral Health Inc. — known as GOBHI — turned some heads by suggesting that the center could go private. Campbell said letting the facility fade away can’t be an option.

The two-story hospital at 2600 Westgate, formerly the Eastern Oregon Psychiatric Center, sits on 7.43 acres next to the Eastern Oregon Correctional Institution and treats up to 60 patients at a time. It employs 143.

“The footprint of the Blue Mountain Recovery Center is bigger than just Pendleton,” he said.

Relying on the center are 10 smaller private mental health facilities in other Eastern Oregon communities, such as McNary Place in Umatilla, a Lifeways operation, and Columbia Care in Boardman. He said all of the smaller mental health facilities depend on Blue Mountain and could dry on the vine for lack of referrals. Together, they provide more than 100 beds.

“So are you saying you want to run Blue Mountain?” Goldberg asked Campbell. “The state could sell the hospital to you and you’d operate and run it?”

“Talk to us,” said Campbell.

Pendleton Mayor Phillip Houk seemed to like the idea. He had prodded Goldberg earlier in the meeting, calling BMRC a “blue ribbon facility” that has helped a lot of people. He asked Goldberg if the community was spinning its wheels trying to keep the center open.

“It is likely to close,” Goldberg said. “Having said that, there have been times in the past when it was likely to close and it did not.”

Goldberg confirmed that construction has begun on a new 174-bed state psychiatric hospital in Junction City that would replace the 60 beds at the Pendleton hospital and 90 beds rented from Portland hospitals.

The Pendleton hospital, built in the early 1940s, needs an overhaul. Aging plumbing and electrical systems, lead pipes, lead-based paint, asbestos and remodeling would cost $11 million to mitigate. Recruiting psychiatrists to rural Eastern Oregon is difficult.

The discussion ranged from telemedical technology that could abate the need for psychiatrists moving to Pendleton to the burden mental illness puts on law enforcement. But, Campbell’s idea sparked the most hope.

“I believe we need to take proactive steps rather than keep trying to stop the clock,” he said.

“We are ready to sharpen our pencils,” Goldberg promised.

The two and their organizations will talk over the summer, they said. The group planned to reconvene in the fall.

Campbell also serves as CEO of the Eastern Oregon Coordinated Care Organization, a player in the state’s effort to revamp its system of delivering health care to Oregon Health Plan enrollees.

By Amanda Waldroupe, for The Lund Report, March 8, 2012

Services are largely preserved, but four wards at the new Oregon State Hospital won’t open until at least 2013

The Oregon State Hospital in Salem (photo courtesy of Oregon State Hospital)

The state’s rebalanced budget, one of the last bills the Legislature passed before adjourning Monday evening, largely spares the Oregon Health Authority from deep cuts.

Out of an $11.9 billion budget passed by the Legislature last year, $26 million general fund dollars were cut. But $15.4 million in other funds were added to the budget, meaning there was less than a $10 million cut.

There are two major themes characterizing the budget developed by the three co-chairs of the budget writing Ways and Means committee. The first was instructing state agencies to eliminate middle management positions in an effort to streamline state agencies and save money. The Oregon Health Authority is expected to save a little over $5 million by eliminating such positions (the number of which is still unclear at this point).

The second was tapping into the state’s rainy day fund and other available reserves to lessen program cuts.

One way this creative money shifting was used in the Oregon Health Authority’s budget was to direct $16.8 million of the tax revenue collected from insurance companies and use it for children’s healthcare programs, including the Oregon Health Plan Plus programs and the Family Health Insurance Assistance Program.

The budget also uses $5.7 million from a housing trust fund within the state’s community mental health programs to continue funding community services to children and adults with mental illness at the same level. Community mental health and addictions services thus escaped the chopping block.

And no cuts were made to any services associated with the Oregon Health Plan, including dental, mental health, addiction, or prescription drug benefits. The Oregon Health Plan’s delivery system is undergoing a massive overhaul as the result of the passage of House Bill 3650 and Senate Bill 1580, which create Coordinated Care Organizations (CCOs) that will integrate physical, mental and dental care for the 600,000 people on the Oregon Health Plan.

The federal government has practically promised it will give Oregon $2.5 billion dollars over the next five years to help fund CCOs; any cuts or changes to the Oregon Health Plan may have jeopardized those funds, or CCO implementation.

The Oregon Health Plan’s prioritized list of services, which provide coverage to 600,000 people also was not cut, and includes services for extremely vulnerable patients such as incontinence and cochlear implants for children.

Last session, 13 of the 39 prioritized services were cut, which sparked controversy and concern from organizations and advocates who argued that extremely ill, unhealthy and vulnerable patients were unfairly impacted.

Perhaps the biggest cut was postponing the opening of four new wards at the Oregon State Hospital. Those wards were expected to open this year but instead will open sometime in 2013. The postponement will save the state $19.6 million in general fund dollars. The Blue Mountain Recovery Center, a psychiatric hospital located in Pendleton, will remain open (an earlier budget proposal suggested closing the facility entirely).

Spokespeople from the Oregon Health Authority did not return a call for comment regarding the agency’s rebalanced budget, and the budget’s effect on services and programs.

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Surprise! As the Oregon State Legislature begins to engage with a $3.5 billion shortfall in the 2011-13 biennium the Oregon State Hospital project at Junction City appears to be dissolving…

That’s okay because since it’s inception as an employment program by State Senator Peter Courtney independent advocates for mental health services have been skeptical of the $300 million project. Those dollars spent on treating people in community settings could PREVENT hundreds of hospitalizations each year and untold suffering.

It’s fine to retreat and re-evaluate a bad idea. The issue is that last session the state legislature, thanks to Peter Courtney pledged to DO SOMETHING about Oregon’s mental health crisis. If that $300 million dissolves away from Junction City and away from mental health services entirely, that pledge will be worthless and not one but TWO session of the state legislature will have been wasted.

Below is a document distributed by the Oregon State Addictions and Mental Health Division, January 18, 2011. To see in original format, Revised Forecast of Need for State Hospital Beds – 2010.

READ – New report: Controversial Oregon mental hospital in Junction City should be half as big as planned, Oregonian, January 18, 2011
READ – State recommends smaller mental hospital at Junction City, Salem Statesman Journal, January 18, 2011

Addictions and Mental Health Division – 2010 Revised Forecast of Need For State Hospital Beds – January 18, 2011

This is an updated forecast of the needed hospital and community-based treatment beds for people living with mental illness in Oregon through 2030.

This forecast updates the 2005 Framework Master Plan Phase II report. That forecast called for approximately 1012 total beds within and without community settings. Similarly, this forecast calls for 960 total beds.

Staff looked at the forecasting methodology and the assumptions used in the master plan and found that there is a need to change two significant factors to more accurately project the bed need.

1. The forecast used in this paper is history based. This is a change from the “population” based forecast used in the 2005 forecast. The “History Based Forecast” uses real hospital utilization data to forecast the number and types of individuals projected to need hospital level of care by 2030. Population based projection has proved to be less reliable when comparing projections to actual use.

2. The forecast used in this paper also moved from using average length of stay in a state hospital facility to using average daily population (ADP), based on average hospital daily utilization over a year. ADP can be better used to trend and forecast capacity needs in the future. ADP is linked to flow into and out of the hospital.

Additionally, under this forecast, a team of experts from AMH, OSH and the DHS/OHA Forecasting Unit revised the forecast of the need for hospital beds through 2030. Hospital level of care is defined as requiring 24-hour nursing and psychiatric care, on-site credentialed professional staff, organized medical staff, treatment planning, pharmacy, laboratory, on-site food and nutritional services, as well as vocational and educational services. Given the assumed closures of the OSH Portland campus and the Blue Mountain Recovery Center, there will be a continued need for hospital level of care in order to meet the intensive needs of a relatively small subset of individuals with mental health disorders.

The 2005 Framework Master Plan Phase II Report was prepared by the Reach New Heights consulting group. They have provided feedback on this updated forecast and their concerns were reviewed by the group. The consensus from AMH and the Forecasting Unit is that the proposed forecasting method is a more accurate tool.

Addictions and Mental Health Division (AMH) 2010 Revised Forecast of Need For State Hospital Beds

Forecasted Bed Need by 2030
2005 Forecast shows a need for 620 Beds – OSH Salem
2010 Forecast shows a need for 620 Beds – OSH Salem
2005 Forecast shows a need for 360 Beds – OSH Junction City
2010 Forecast shows a need for 174Beds – OSH Junction City

There continues to be a need for hospital-level care and transitional care at the proposed Junction City campus.

Of the forecasted 794 beds, the Salem campus will have 620 beds which we are targeting for completion at the end of 2011. The Junction City site should have 174 beds. That is a total reduction of 186 beds in Junction City.

Cost considerations relating to Junction City

In December 2010, Greg Roberts, OSH Superintendent, and Lee Hullinger, OSH Chief Financial Officer, jointly developed a staffing model for a proposed 174-bed facility in Junction City. Roberts based clinical staffing on US Department of Justice recommended classifications and ratios and Hullinger modeled non-clinical staffing to maximize efficiencies for Junction City to operate as a satellite campus with ongoing resources and senior management provided from the OSH Salem campus. Projected staffing totals for Junction City amount to 522 full-time equivalent employees equating to a staff to patient ratio of 3.00-to-1.

This recommendation assumes that the operating costs for OSH Portland and Blue Mountain would offset the operating costs for Junction City. If Junction City were not built, it would be necessary to increase staffing and operating costs for OSH Portland by $11.0 million and for Blue Mountain by $17.0 million. If this is considered in the overall cost to operate Junction City, the increase is $11.0 million.

OSH Portland has 92 beds in leased space, and the lease expires in March 2015. The current space is old and unsuited to the needs of a modern psychiatric hospital. It does not support 20 hours of active psychiatric treatment as required by US Department of Justice, and it is not possible to operate essential vocational services in the space available. The continued use of this space requires an agreement with the landlord to a long term lease and to provide additional space to support active treatment and vocational services. It also requires extensive remodeling, estimated at $13.0 million at the state’s expense, invested in property not owned by the state.

The continued use of the Portland facility beyond 2015 is not recommended.

The 60 beds at the Blue Mountain Recovery Center in Pendleton are in a building that is more than 60 years old and has exceeded its physical life cycle. The rough order of magnitude for remodeling Blue Mountain is $11.0 million. This assumes remodeling patient space and the kitchen. Given that the building is over 60 years old there are many factors that require engineering studies prior to creating an estimate that can be used for budget purposes. These include poor condition of plumbing, potential for lead water pipes, lead-based paint, asbestos, quality of electrical system and potential for seismic upgrades. There is also the factor of added costs if the facility is in use while the work is being done.

The attached graphic makes it clear that the hospital at Junction City must be built with at least 152 beds to replace the 152 beds lost as both OSH Portland and Blue Mountain are closed. Once those units are closed, there would be insufficient capacity to serve adults who are civilly committed, found guilty except for insanity or otherwise so ill that they require treatment provided by psychiatrist-led treatment teams with 24-hour nursing in a state hospital to stabilize their symptoms and prepare them to live safely and successfully in the community.

Projected operating costs for a 174-bed Junction City facility total $101.0 million and may be off-set by projected savings of $35.0 million for OSH Portland and $27.0 million for Blue Mountain, assuming both campuses were closed. All cost estimates are based on 24-months. The estimated biennial operating cost for a 174- bed Junction City facility is $11.0 million more than the costs for the closed facilities after staffing is increased to meet US Department of Justice standards.

The following table summarizes this information:

Addictions and Mental Health Division (AMH)
2010 Revised Forecast of Need For State Hospital Beds

Projected staffing & operation costs: $101.0 million
– less projected savings of closing OSH Portland ($35.0 million)
– less projected savings of closing Blue Mountain ($27.0 million)
– less projected cost to increase staffing for OSH Portland to meet US Department of Justice standards ($11.0 million)
– less projected cost to increase staffing for Blue Mountain to meet US Department of Justice standards ($17.0 million)
Biennial operating cost in addition to the savings from the closure of Portland and Blue Mountain – $11.0 million
Taken collectively over the next five years, these recommendations will allow Oregon to meet the forecasted need for hospital level of care, replace the Portland Campus of OSH and Blue Mountain and utilize community resources to meet the newly forecasted need.

Selecting the Junction City Site

Following the release of the Phase II Master Plan, the Governor and legislative leadership created a joint siting workgroup. The workgroup selected criteria to be used in evaluating possible sites for two state hospitals. The criteria included the cost of the site, the location of the site in terms of the ability to recruit and retain staff, the nearness to the families of persons served in the state hospital and the availability of transportation. The Legislature selected the existing OSH Salem campus on the south side of Center Street and the Junction City site on land owned by the Department of Corrections. These two sites met most of the criteria and were the most cost effective.

Notes to the Financing Plan

Note 1: If the state elected not to build Junction City, it would be necessary to keep both OSH Portland and BMRC open. In order to do that it would be necessary to increase the staffing levels to those acceptable to the US Department of Justice. This would cost $11.0 million for Portland and $17.0 million for BMRC, a total of $28.0 million.

Note 2: Beginning in April 2011 the monthly lease payment for Portland OSH increases from $113,000 per month to $128,000. The biennial lease amount will be $3,072,000 for most of 2011-13.

Note 3: The anticipated full biennial debt service for a smaller Junction City facility is estimated to be $19.7 million when all construction is completed.

Community-based care

The updated forecast identifies the need for additional beds in the community that will make it possible to move people out of the hospital. Thirty-two Secure Residential Treatment beds were identified in the Master Plan but not funded through the Replacement Project. Addictions and Mental Health has opened one
16-bed facility and is in the process of developing 16 additional beds in the community by July 1, 2011.

The Oregon State Hospital and Addictions and Mental Health, in partnership with Seniors and People with Disabilities, are developing a plan to move neuro-geriatric patients out of the hospital and into community long-term care placements. The plan calls for reducing hospital level of care beds by 70 and utilizing community long-term care facilities and programs to serve these individuals in a less restrictive community setting. There will be new costs to the system to develop and implement a new model for serving individuals disabled by age-related disorders or by brain injuries who are not successfully served in current community-based programs.

In addition, Addictions and Mental Health is responsible for developing or reprogramming capacity to serve the continued growth in the forensic population. This need is forecast to grow an additional 64 forensic beds by 2030. The estimated cost for the 10 community forensic beds needed in 2011-13 is $ .7 million for start up and $1.6 for operating costs. The remaining 51 beds will either be built in future years, or the capacity will result from reprogramming or using existing capacity more efficiently.

Addictions and Mental Health started a new program, known as the Adult Mental Health Initiative (AMHI), to manage utilization of residential facilities at the local level. The goals are to reduce length of stay in community-based mental health facilities, to increase the rate of discharge of patients from the state hospital system into the community, and to organize services that support individuals living in the most integrated and independent environment. The effective management of the current residential capacity will result in shorter lengths of stay. This results in more people being served at this level of care within the existing bed capacity. For these efforts to be effective, there must be a continued investment in mental health services through the Oregon Health Plan and the Community Mental Health Programs.

Alternate options

The first option considered was to proceed as recommended by the Phase II Master Plan. Further analysis made it clear that there is no longer a need for 980 hospital beds.

The second option considered was to build multiple 16-bed hospital facilities and 100 secure residential treatment beds in 16-bed facilities spread throughout the state. It is not cost effective to attempt to staff and provide hospital level of care in stand alone 16-bed facilities. It is necessary for the facilities to be stand alone administratively and operationally in order to obtain Medicaid financing. The cost for five of these facilities (needed for 75 hospital level beds) and regional medical supports is estimated to be more than $92.5 million. The cost for seven 16-bed Secure Residential Treatment Facilities needed for 100 transition beds is $2.5million for start up and $45.3 million per biennium for operations. The total cost of this option is $140.3 million. These scenarios assume entities other than the state will build the facilities with minimal state-paid start up. To do otherwise would require bond financing to construct these facilities. Neither of these scenarios provide cost-effective services.

Advocates for community-based services have been vocal in their support of 16-bed facilities in the community as a better alternative in terms of Medicaid financing and smaller size. This alternative is not workable for individuals who require hospital level of care. While 16-bed Secure Residential Treatment Facilities may be preferable to larger institutions, stand alone facilities cannot easily provide the robust level of treatment and rehabilitative services that prepare people to live in less structured, more independent environments. Addictions and Mental Health is committed to community-based services that are more integrated and support individuals in their own homes.

The third option considered was to build a 242-bed facility in Junction City. The refined analysis suggests that this is still more beds than Oregon needs. The costs for 242 beds are estimated to be $123.5 million without owners’ project management, staffing and Behavioral Health Integration Project costs.

These three options are not recommended.

Conclusion

The 2010 updated forecast shows that the need for treatment facilities for people living with mental illness is close to what was predicted in 2005. Additionally, a certain percentage of that population will continue to need hospital-level care that it is not feasible to provide in community settings.

At the same time, the Addictions and Mental Health Division remains committed to ensuring that people who do not need hospital level care can receive treatment in the least restrictive environment possible. Therefore, while the overall forecast for mental health treatment beds remains stable, where those beds are allocated has been changed.

There is a need to build capacity for 794 beds in the state hospital system. That is a reduction of 186 hospital-level beds from the 2005 forecast. The 620 beds in Salem are targeted for completion at the end of 2011. The remainder will be in a 174-bed facility in Junction City.