Mental Health Association of Portland

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 Oregonian, July 10 2008

Too much trust in leaders, too little oversight put Cascadia Behavioral on financial brink for years

The books were a mess. Staff shifted money around day to day just to keep clinics running and employees paid. The company was hemorrhaging cash and had maxed out its line of credit.

Less than two days into his new job as chief financial officer, Scott Dickison concluded that Cascadia Behavioral Healthcare, Oregon’s biggest provider of mental health services, was on the brink of collapse. He quit before his first week was up.

Before he left last October, he fired off a grim memo to Cascadia’s leaders. The company had “significantly more financial, operational, and system failures than had been disclosed to me,” he wrote.

More than 20,000 people relied on Cascadia’s extensive network of addiction treatment, counseling, emergency care and housing in Oregon’s five largest counties. But the people in charge of Cascadia ignored Dickison’s abrupt departure.

Leslie Ford, chief executive officer at the time, said she doesn’t remember him raising any particular concerns.

Wayne Miya [pictured right], then chairman of Cascadia’s board of directors, said he trusted Ford and her tightknit team of longtime colleagues who insisted that the company’s thin bottom line was standard in the nonprofit world and that their finances were actually improving.

“It didn’t set off that many alarms,” Miya recalled.

Six months later, Cascadia collapsed.

Risky financial practices and little government oversight had put Cascadia on the edge of bankruptcy for years, an investigation by The Oregonian found.

The company borrowed heavily and begged for government aid just to keep afloat, even for such basics as payroll. Cascadia’s leaders ignored or hid their teetering finances until it was too late to do anything about them.

Multnomah County managers, who had entrusted 80 percent of their mental health services to Cascadia, helped prop up the company by rubber-stamping its requests and downplaying escalating problems, at times actively suppressing staff warnings.

“It’s not that people didn’t listen, it’s not that people didn’t take it seriously,” said Rose Galante, a county contract specialist who warned her supervisors about Cascadia’s financial maneuvering. “People ignored it. They heard it, and they ignored it.”

“Fred Meyer model”

Ford described her business plan for Cascadia as “the Fred Meyer model” of mental health care — a one-stop shopping safety net to fill gaps in services — and Multnomah County not only endorsed her vision but also became a partner in building the company’s nearly $60 million-a-year enterprise.

That cozy connection gave Cascadia’s executives the clout to push for special favors from the county when they started to lose money, including advance payments and money retroactively awarded to contracts.

Cascadia had formed in the course of less than a year starting in 2001 through a merger of the county’s three largest mental health nonprofits. Ford was CEO of the healthiest and best-regarded of the companies and was the obvious choice to lead the new operation.

Peter Davidson, the county’s mental health director then, helped orchestrate the merger, pressuring the smaller nonprofits enough that they thought they would lose contracts if they didn’t join up.

Cascadia suffered financially almost from the start — closing clinics and laying off hundreds of employees — to consolidate work, pay off some of its initial debt and cope with cuts to the state’s mental health system.

After a brief period of stability, the company began bouncing from one financial crisis to another, even as it continued to take on an increasingly large stake in the local mental health system.

Nancy Winters, director of the county’s Mental Health and Addiction Services Division, told her staff in a 2005 e-mail to shore up Cascadia’s finances: “We will try to pay them a little more every time we end up with some money to do that with.”

Winters had spent nearly a decade working at Ford’s predecessor company and counted Ford as a close friend. But Ford’s connections went even higher: She once held a fundraiser at her home, attended by several top Cascadia executives, for County Chairwoman Diane Linn, one of Cascadia’s staunchest allies.

“We were just doling out money all the time, stripping money out of one place where we planned to spend it and giving it to Cascadia,” said Al Stickel, the former chief financial officer for the county Human Services Department, which included the mental health division.

“Cascadia was known to be extremely well-connected in the political environment of the county,” he said, “that if we said no, they would call up a commissioner, and the next thing you know, we would have a commissioner asking us why are we denying payment to Cascadia.”

Stickel made the comments in a deposition for a whistle-blower lawsuit filed against the county by a former employee who managed business operations for the mental health division. She accused Cascadia of fraud for allegedly misrepresenting requests for extra money, then was fired less than a month later. Her lawsuit was dismissed, though she has appealed that decision.

Although he shared the concerns about Cascadia’s financial management, Stickel said he didn’t like raising the specter of fraud. “Well, it may be,” Stickel said he told the employee. “But it isn’t our fraud, and we don’t have any authority over that. That’s not our issue.”

The same hands-off approach played out when Galante, who worked as a county fiscal compliance specialist before retiring recently, reviewed Cascadia’s contracts in 2005. She determined that the company’s operations broke state and federal contracting rules, standard accounting practices and presented “an unacceptable risk to the citizens of this county.”

When Cascadia managers pushed backed angrily, Galante said, her bosses told her to give the company a “temporary pass” in the follow-up report rather than a finding of noncompliance, which would have allowed the county to terminate its contracts with Cascadia. The county never conducted another review.

Financial “balancing act”

Many of the reservations about Cascadia’s finances led back to the company’s chief financial officer, Debra Humphrey-Keever.

In 2005, the company had started the year with savings in its bank account and ended the year leaning on its line of credit. Covering payroll had become a monthly ordeal.

But under Humphrey-Keever’s direction, Cascadia was skilled at shifting money around to meet costs, internal records and interviews indicate. Sometimes she slowed down bill payments, sometimes the company borrowed from the bank, sometimes Cascadia requested extra money or advance payments from the county.

“It was a constant balancing act,” Humphrey-Keever said last month.

The company later took money from restricted accounts to pay unrelated debts, commingled various funds and spent government money it was supposed to pass along to subcontractors, according to Cascadia records and interviews.

Humphrey-Keever confirmed all happened at least once.

One reason that strategy was successful was that Humphrey-Keever — who had run the nonprofit’s finances since before the merger — was the only one who fully understood how the “mom and pop” financial systems worked, Ford said.

Though Cascadia had long since become a large company, it was still operated like a small nonprofit. Billing and accounting systems were paper-based or run through nonintegrated computer systems, making it error-prone and difficult to quickly track down information.

“She had a lot up in her head that wasn’t documented and would have been hard to re-create,” Ford said.

Cascadia still acted like a healthy company. It continued to grow its portfolio. Top executives received unusual dispensations: Both the head of housing and the head of information technology kept their jobs after moving to New Mexico and France, respectively. The company regularly gave bonuses to executives and other employees — including $15,000 to Ford — leading the controller to e-mail a reminder one Christmas that the company was in no position to hand out bonuses given its struggles to meet payroll.

Cascadia’s auditor, Jones & Roth, gave the company clean reviews during annual audits required for recipients of federal money. “We did not identify any deficiencies in internal control over financial reporting that we consider to be material weaknesses,” said the most recent audit in March.

Billing system changes

Cascadia’s downfall accelerated when the county overhauled its billing system.

Under the previous model, the county gave Cascadia and other providers money upfront for each client they served. The provider then had responsibility for all of the client’s care. But the companies couldn’t easily show how they spent the money, and the county was losing Medicaid money as a result.

In 2005, the county began planning a switch to “fee-for-service” payments, reimbursing contractors for specific work — such as an hour of counseling — only after detailing who they saw and what they did.

Controller Roger Helt urged Cascadia’s leaders to take the change seriously, calling it “a major problem.” Helt previously worked as the chief financial officer at the failed Unity Inc. — the county’s largest mental health provider before Cascadia took it over — and warned that Unity’s demise was tied to a similar shift in county payments.

“Cascadia is not in a position to weather much in the way of either delayed or reduced payments,” he wrote in an e-mail to Ford and Humphrey-Keever.

Ford, who would later blame the company’s collapse on the switch to fee-for-service, initially appeared to dismiss the concern, telling Cascadia board members that the change would be “to our benefit” during a September 2005 meeting.

But Cascadia struggled badly with the new fee system — it had trouble tracking billable hours, for example — and was described by a top county official as “among the most ill prepared of all our providers.”

By last summer, Ford and Humphrey-Keever realized they needed help. They brought in consultants to evaluate employee productivity, began aggressively seeking a second loan and a searched for a replacement for Humphrey-Keever.

The county, too, began to tighten oversight, ending the practice of awarding contracts to Cascadia without bids and then cutting off new clients in the fall until the company dealt with financial and caseload problems.

Karl Brimner, the current county mental health director, assigned an aide to plan moving the county’s mental health services away from Cascadia. The employee predicted in a September e-mail to county mental health managers that Cascadia would seek a government rescue.

Despite the concern, neither Brimner nor Joanne Fuller, director of county human services, said they had any idea that Cascadia could fail until the company announced it couldn’t pay its bank loan this past spring.

Fuller said she, too, had concerns about Cascadia’s size and the quality of its services but didn’t doubt the information that CEO Ford provided — as recently as January — asserting that the company simply had a cash flow problem because of the fee-for-service switch.

Ford said she wasn’t trying to hide the company’s problems. “I was definitely giving them the story as I understood it,” she said. “I wasn’t, in retrospect, accurate, but I was doing my best.”

Last month, Fuller apologized to county commissioners for not asking harder questions. “If we had been more aggressive at that point, I think we would have uncovered more information,” she said.

Lack of skepticism

That’s the line many people are repeating today.

Even now, Multnomah County officials don’t know how many cash advances — usually about $500,000 each time — they provided to Cascadia over the years or how many contracts they increased after the fact. The transactions weren’t always recorded, Ford acknowledged.

Miya, Cascadia’s board chairman until his resignation in June, said he didn’t know until too late that the company was moving around money.

He described the board as an unpaid, volunteer group trying to help a worthy cause and trusting the people who had successfully steered the company through tough times.

That trust was all the more striking because of Miya’s previous tenure as board chairman of Unity, which collapsed under debt after a period of rapid growth.

“The financial issues were very similar to the financial issues happening with Cascadia in that I don’t think the reporting of the finances were, I don’t want to say accurate, but not in enough detail to let the board know how bad finances were,” he said in a recent interview.

Ben Wood, a former Cascadia vice president, remembers being struck by how Cascadia’s Ford and Humphrey-Keever put a positive spin on the worsening financial situation at board meetings. He was equally struck by the lack of skepticism from the directors, leading him to start an unsuccessful effort to replace most board members.

“I’ve never seen a board as devoid of critical questions as that one,” Wood said. “Even if you accept the excuse of being misled, if you are not getting enough information, shame on you for not demanding it.”

It took a new finance manager to snap people to attention.

Chip Burczak came out of retirement after 25 years at Intel to take over as Cascadia’s chief financial officer in February. No one told him that his predecessor quit after less than a week on the job, he said. No one told him that the company was past due on a $2 million loan with no prospect of repaying it.

Burczak also discovered a bookkeeping error showing Cascadia was about $1 million more in the hole than it thought.

With the force of his brash personality and the financial time bomb he unloaded, Burczak made a lasting impression when he walked Cascadia, county and state officials through the financial morass.

This was the moment that everyone — Ford, the Cascadia CEO; Miya, the board chairman; and Brimner, the county mental health chief — said they realized the company was in danger.

Finally, the response was swift and decisive.

It took just weeks for Cascadia to oust its entire executive team, Ford and Humphrey-Keever included. The company’s bank, Capital Pacific, swept Cascadia’s cash accounts to pay back the overdue line of credit.

The county and state agreed to a $2.5 million emergency loan in May to keep Cascadia’s clinic doors open and employees paid. Almost immediately, county leaders began working with Cascadia to dismantle the company.

But the changeover has proven messy, with Cascadia and county leaders publicly deferring to one another while privately bickering about what to do. In the meantime, cash is running out again.

County officials said this week that Cascadia has enough money to carry it through the rest of the month but maybe not enough to cover August payroll. If that happens, Cascadia could receive another government bailout or declare bankruptcy.

On Tuesday, the chief financial officer quit.

“When I was hired, it was my intent to try and help improve a struggling organization,” Burczak said in his resignation letter. “However, it has become increasingly clear that for many reasons, Cascadia is unlikely to take the actions necessary to ensure the long-term viability of the company.”

From the Portland Business Journal, April 24, 2008

Leslie Ford is stepping down as Chief Executive of Cascadia Behavioral Healthcare Inc., Oregon’s largest provider of mental health and addictions treatment services.

Ford held the post for more than six years, and previously served for 13 years as the CEO of Network Behavioral Healthcare Inc., an agency that merged with Cascadia.

The Cascadia board of directors has appointed Derald Walker as the new CEO, effective immediately. Walker had served as a clinical vice president for Cascadia for less than one year.

Cascadia has recently struggled financially as it made major investments in new electronic business and billing systems, including a comprehensive, state of the art electronic medical records system, while continuing to provide client services in an environment with constantly changing reimbursement models. Cascadia, which employs more than 1,000 people, provides services in Multnomah, Clackamas, Washington, Marion and Lane counties.

Portland-based Cascadia in December was asked to repay $2.7 million in overpayments it received from Medicaid in the wake of a steep drop in Oregon Health Plan coverage. It is one of at least a half-dozen organizations that may need to repay Medicaid dollars due to overbilling.

Cascadia ended its last fiscal year with a budget of $56 million, and earnings of $250,000, after serving about 23,000 clients. It has virtually no cash reserves.

From The Oregonian, November 7, 2007 – not available online

As Joshua Shane Overstreet was booked into jail on a heroin count, the warning signs quickly added up.

The 18-year-old told jail staff that he had been diagnosed with suicidal depression. His mother, when contacted by telephone, warned that Overstreet was unstable, a danger to himself, and said he should stay in jail , records show.

Overstreet seemed such a risk to harm himself that a staff member recommended against the teen’s release even though the jail typically lets people with no previous criminal record go home right away.

“We did an override,” said spokesman Robb Freda-Cowie.

The mental health team at the Multnomah County Detention Center evaluated Overstreet, and he stayed the night in jail on a suicide watch.

But a Health Department employee at the jail later determined Overstreet was fit for release, allowing him to leave the jail last Friday. The Lake Oswego teenager died about an hour later, after plunging from the parking garage across the street from the jail .

On Tuesday, as Overstreet’s family were preparing for his funeral, officials at the county Health Department declined to provide an explanation or any information about the case, citing privacy rules.

“I’m a little concerned about the details of his release,” said Kevin Bermingham, an uncle speaking on behalf of the family. “We’re just trying to get a memorial service together and at least put that to rest and get some closure for the family. And then we’ll get into the minutia of what went wrong.”

As news of Overstreet’s death spread through mental health circles, officials lamented what they saw as another example of an overburdened jail system struggling to handle an influx of mentally ill people.

“They do the best they can, they’ve got a good staff, but they are swamped with people who should be in treatment rather than incarceration,” said Leslie Ford, chief executive officer of Cascadia, the largest nonprofit mental health care and addictions treatment provider in Oregon.

Ford said that cuts to the Oregon Health Plan and insufficient treatment space had the effect of pushing many mentally ill into the jails .

“This is a dramatic case because this young man was released and demonstrated so quickly that he was not ready to be on his own, but there are many much less dramatic cases that happen every day,” Ford said.

Even as the jail has cut space in recent years, the number of mentally ill people has increased, said Judy Shiprack, director of the county’s Local Public Safety Coordinating Council, which has studied mental illness in the criminal justice system. About 13 percent to 15 percent of inmates report to jail staffers that they have a mental illness, but the true number probably is much higher, she said.

“The sad fact is there is a lot of pressure to release mentally ill people to free up space in the jail ,” Shiprack said. “This is a sad result of that.”

Overstreet wound up in jail last Thursday after a tumultuous day. On Wednesday evening, Overstreet left the residential drug and alcohol treatment program where he had been staying and attending school, his mother told jail staff.

On Thursday afternoon, Portland police arrested Overstreet for using heroin in a downtown Starbucks restroom. They took Overstreet to the downtown jail .

At 10 p.m. Friday, police found him by the parking garage, dead of head, neck and back trauma.

Lee Brown, Overstreet’s former counselor at Lakeridge High School in Lake Oswego, said he can’t figure out what happened to the teenager. “I just feel a lot of shock and disbelief that this could happen to Josh, who had so much potential.”

Overstreet grew up in Eugene, where he attended Magnet Arts Elementary School, Jefferson Middle School and Churchill High School. In 2005, after his sophomore year, he moved up to Lake Oswego with his mother, Elizabeth, and began attending Lakeridge.

“I generally have 400 kids on my caseload, but Josh was a very memorable individual,” Brown said. “He was an exceptional student who took AP history and science and other classes, and he excelled across the board. He was very mature, and he could clearly see his path beyond high school.”

Despite the high marks, Overstreet had “attendance issues,” said Lake Oswego School District spokeswoman Nancy Duin. In March 2006, after about 100 days at Lakeridge, Overstreet, his mother and Brown decided that he would begin working toward his GED at Portland Community College.

There was no question that Josh –who came across as a serious, ambitious, “mainstream student” –would do just that, Brown said.

Yet by spring, a school district secretary noticed that he hadn’t actually been going to the college classes, Duin said.

Later he enrolled at the De Paul Alternative School, part of a youth residential alcohol and drug treatment program in Portland. An administrator declined to discuss Overstreet, citing privacy rules. Records indicate that he dropped out Thursday.

From The Portland Business Journal, February 5, 2006

Urgent-care patients from Portland get sent to facilities

Over a recent holiday weekend, three Portland-area patients needing emergency mental health care were sent out of town for help. One patient ended up in a Medford hospital; the other two went to Corvallis.

The reason: Not one Portland-area hospital with psychiatric units had beds for these acutely ill patients.

Unfortunately, such out-of-town transfers are routine, say area mental health workers and advocates.

Almost every week, hospital emergency rooms in the Portland area send psychiatric patients — people who are suicidal or hallucinating, for example — to hospitals in Salem, Eugene, Corvallis, Pendleton, Bend, Medford or Coos Bay.

“There aren’t enough psychiatric beds in the city to handle the amount of people needing them,” says Jean Dentinger, supervisor of the involuntary commitment program in the behavioral health division of Multnomah County’s Department of Community and Family Services.

“It’s an inefficient and expensive way to provide care,” she says with frustration. “It’s not good care for patients to sit in an emergency department in Medford. We don’t like it, they don’t like it and the hospitals receiving them aren’t happy either. But it’s the system we have.”

A combination of funding cutbacks, steep cuts in the Oregon Health Plan, rising health care costs and an increasing number of uninsured Oregonians have all contributed to what has become a crisis-level shortage of beds for mental health patients in metropolitan Portland.

Since 2001, the metro area has lost nearly 200 psychiatric beds, beginning with the closures of Pacific Gateway Hospital in Southeast Portland and the Providence Crisis Triage Center. That same year, Oregon Health & Science University Hospital shut down two mental-health units.

Two years ago, Woodland Park Hospital in Northeast Portland closed its doors, eliminating another mental health unit.

Currently, about 150 beds are available at the six area hospitals that have psychiatric units, according to statistics from Dentinger’s office. All of them fill up on regular basis.

Patients who show up at emergency rooms for care wait hours or sometimes even a day or more for placement in a psychiatric unit.

“Psychiatric patients really clog up the emergency department,” says Sue Dietderich, administrative director of emergency services for Legacy Health System. Psychiatric patients, who can be a danger to themselves or others, need special attention and one-on-one observation, all of which strains emergency departments.

“It ties up a staff member, ties up a critical-care room and is a disservice to the patients themselves,” says Dietderich.

Kaiser Permanente, which currently does not operate a mental health unit, will relieve some of the pressure on emergency rooms in the summer of 2007 when it opens a 40-bed psychiatric unit in a new building now under construction next to its Sunnyside Medical Center in Clackamas.

“We looked at what we needed to do to take care of Kaiser patients and at our community obligation,” says Keith Griffin, assistant chief of Kaiser’s mental health department.

Like other hospital emergency rooms, the Kaiser mental health unit will admit anyone needing a bed, not just Kaiser members. “We’re all in the same dilemma,” Griffin says. “Everybody is having to make sure we help each other and stretch what we do have to the max.”

On the other hand, Physicians’ Hospital in Northeast Portland — the former Woodland Park Hospital which reopened under new ownership in 2004 and is still working to become financially stable — has dropped plans to add a mental-health unit to an urgent-care facility it is building this year.

“It wasn’t economically feasible to add mental health services,” says Bill Houston, the hospital’s chief executive officer. “It would have presented a degree of staffing requirements that would make it expensive to operate. Revenue reimbursement for mental health services is terrible. We would lose money, and we can’t afford to do that.”

Houston says he recognizes the community need for such services. But, he says, “the system is broken.”

What’s needed is a full psychiatric hospital to care for patients in need of urgent care, he says.

Such a facility would be useful for providing emergency care for mental illness, agrees Herb Ozer, director of operations for Providence Health System Behavioral Health Services. However, that’s not to say that Portland or Oregon needs a major psychiatric hospital for long-term care.

Mental health providers and advocates agree that residential treatment facilities and other community resources other than a hospital would provide better and more appropriate on-going care for psychiatric patients.

Ozer says that was the idea when Dammasch State Hospital closed in the mid-’90s.

“Closing Dammasch was a good thing,” he says. “Some were in Dammasch for years who could have lived in their community.”

But the state never provided enough money to establish services and facilities for people who otherwise would have been treated at Dammasch.

And there has never been adequate funding since then for comprehensive outpatient mental health care, Ozer says.

“So we end up having to hospitalize them,” Ozer says. “We can’t get patients into ambulances for cardiac care. Or they take up hospital beds, which are not set up to be safe for suicidal patients.”

Because reimbursements for mental health patients are low, hospitals end up absorbing the cost of their care or passing it on to insured patients in the form of higher insurance costs, he says.

Mental health workers agree the bed-shortage situation is dire and needs a broader solution than adding more beds.

“It’s important not to look at it as a bed crisis, but as a system crisis,” says Leslie Ford, director of Cascadia Behavioral Health Services, which provides mental health and addiction services, assessments, a 24-hour crisis team and other services for low-income clients.

“We need more case management, more crisis intervention, more affordable and supportive housing services,” she says.

Mental health workers and advocates are meeting regularly to find solutions. More funding from the Oregon Legislature is a priority.

A group of providers has formed the Oregon Psychiatric Inpatient Committee to urge state lawmakers to step up to the funding plate.

Metro-area hospital emergency department managers are meeting once a month to share problems, discuss solutions and look for ways to cooperate with each other, says Kathleen Ramey, director of emergency services for the Portland Providence Health System.

To help alleviate the bed shortage problem at its hospitals, Legacy Health System hired a psychiatrist to examine mentally ill patients who show up in the emergency room, says Legacy’s Dietderich.

“She makes the rounds daily at Emanuel and Good Samaritan hospitals and at some Legacy clinics,” Dietderich says. “We need four of her!”

The Oregon Psychiatric Association also has taken on the bed-shortage issue, says Portland psychiatrist Dr. Thomas Dodson, the group’s president-elect. The problem will be a major topic of discussion at the association’s access-to-care summit in April.

“We know what’s necessary for comprehensive mental health system,” Dodson says. “The problem is to get funding for it and to work with local communities to make that happen.”

From the Oregonian, December 29, 2005

Donita Diamata, director of consumer affairs for Cascadia Behavioral Healthcare, is managing two thorny problems.

For one, she’s mediating between an upset advocacy group of 14 Cascadia clients, whom she helped organize, and the person they are unhappy with, who happens to be her boss.

At the same time, she says later, her obsessive-compulsive disorder has kicked in, and images of herself flipping over the conference table and scattering papers and people flash unbidden through her mind.

Diamata sits calmly, arms crossed.

Her job, oddly enough, includes organizing and directing dissent within Oregon’s largest mental health care provider for poor adults and children. She also has to make sure the complaining stays constructive, or it could threaten another important role: sounding board and real-world adviser when Cascadia’s leaders make plans that affect clients.

The advocacy group feels blindsided. They look at Cascadia’s planned changes for client drop-in centers, long low-key respites from a stressful world, as a “sneak attack.” Diamata’s boss listens, admits mistakes, but sharply warns the group about personal attacks on Cascadia staff.

To beat back the flashing pictures, Diamata runs through the U.S. presidents’ names in alphabetical order in her head, one of her favorite tricks. Then she delivers a trenchant commentary, reminding group members that they persuaded Cascadia to postpone the decision because of their objections. “I feel very good about the outcome of this,” she concludes. “I was kind of rooting you on. But I didn’t know if you were going to organize or you were going to lie down.”

At age 40, Diamata is one of the highest-level managers in Oregon’s mental health system with an openly acknowledged mental illness. That puts her at the front of a decades-old civil rights movement to give people with mental illnesses more control over their medications, their jobs and their lives.

Her journey has included hospitalizations, psychotic breaks, prescription-drug-induced blackouts, a stint on welfare and a job-endangering nine-month leave of absence just two years ago while she battled depression.

It also has included 13 years of activism on behalf of people with mental illnesses, multiyear stretches of being highly productive and medication free, a passion for geography and international travel, a 330-page manuscript for a love story –and a growing devotion to crystal-clear candor.

“The more honest we are, the more open, the less stigma there’s going to be,” Diamata says. “It’s sort of like the gay-rights movement. Everybody knew they were out there, but nobody wanted to address it.”

Two years ago, the President’s New Freedom Commission on Mental Health issued a report sharply critical of the nation’s mental health care system, echoing long-standing concerns of mental health activists.

Ideally, the commission said, the system’s focus would be working with individual clients on holistic treatment plans that help them better participate in society. Instead, it’s more focused on cookie-cutter diagnosis and treating symptoms, including a heavy reliance on drugs.

Among the commission’s findings:

• Up to 7 percent of U.S. adults have a serious mental illness in any given year, but only a third are employed.
• People with serious mental illnesses are the largest group on Social Security’s supplemental income rolls.
• More than two-thirds of people with both serious mental illnesses and college degrees earn less than $10 an hour.

That bleak picture stems, in part, from social stigmas, the commission says. Employers fear people with mental illnesses, even though studies indicate a tiny fraction have violent tendencies. And employers can overestimate the hassle factor. They often think of people with mental illnesses as constantly sick and unreliable, though most have periodic and often widely spaced episodes.

People with mental illnesses can also “give in and give up,” Diamata says. Doctors and therapists often discourage patients from working, she and other activists say. And the mental health system fosters a reliance on drugs over self-determination, activists contend, the quick fix over the hard work of balancing medication with good nutrition, therapy and healthy relationships.

That insight sparked the mental health consumer movement, which traces its beginnings to 1970 and the formation in Portland of the “Insane Liberation Front.” The front, like the movement it helped spawn, began with an anti-psychiatry bent, seeing medications as harmful and mental illnesses as figments of the medical establishment’s imagination.

A significant wing of the movement still feels that way. Other advocates just want patients to have more control over treatment and medications, which they say have helped thousands cope with life.

Those different factions converge periodically for an alternatives conference.

“People are really passionate, and a lot of them have been harmed by the system,” Diamata says. “But you get us all together and we’re not violent. There’s 500, 600, 700 people, and we’re pretty civilized. We’re eating with knives and forks.”

In 1992, Diamata didn’t know a thing about the consumer movement. She had been hospitalized multiple times. She lived on welfare. And she had applied for disability, thinking she couldn’t hold down a job. “I could easily have made a career out of being a mental patient,” she says.

She moved with her parents and four brothers and sisters to Portland when she was 13, later graduating from Franklin High School. She was hospitalized for the first time at 21.

Diamata had moved out of her parents’ house, had a job raising money for charity door-to-door, and was studying at Portland Community College. The stress of all those changes, doctors told her, triggered depression and a severe obsessive-compulsive episode.

She would obsess about eating, and get too thin. She’d make long lists of numbers that she would count and recount. She downed medication. But the side effects caused all sorts of problems. Her hands would shake so badly she couldn’t draw or paint, activities she turned to as therapy in down times.

Diamata also has Tourette’s syndrome, which causes involuntary movements or tics. More recently, she has been diagnosed with bipolar disorder, marked by periods of depression and mania.

In 1992, she spotted a help-wanted ad for Mind Empowered, a drop-in center where people with mental illnesses could unwind, share stories and support one another. It turned out to be next door to her apartment near Southeast Belmont Street.

Mind Empowered actually wanted workers with mental illnesses –the interview was the first time Diamata discussed her illnesses openly with a prospective employer. It was also the first time she heard of the consumer movement, which her interviewer had to define for her.

“When I started working at Mind Empowered , I was a walking pharmacy,” Diamata says. ” I was taking at least seven or eight kinds of medications, and I expected them to fix everything. I’d drink. I wouldn’t eat right or take care of myself. With the medication, I didn’t have to have any responsibility over my own actions.”

Diamata weaned herself off prescription drugs over the next six years as she helped run the drop-in center at Mind Empowered . In 1997, as the center ran out of money, Diamata shopped it around to Multnomah County’s various mental health providers. Only one bit: Network, Cascadia’s precursor.

Network chief Leslie Ford hired Diamata to help start a consumer run drop-in center within the agency. Today, the Renaissance center still operates at Cascadia’s clinic on Southeast Division Street and 43rd Avenue, along with four other Cascadia drop-in centers.

It didn’t go smoothly at first, Diamata says. The center, staffed by people with mental illnesses, was relegated to the night shift, while a traditional program operated during the day.

She and other center workers had to enter through the back door, then meticulously clean and rearrange furniture so it looked like they’d never been there, Diamata says. “The idea was that no one would ever see us.”

Ford, now chief executive of Cascadia, oversees five large mental health clinics and 767 housing units for people with severe mental illnesses. Attitudes toward clients still need work within the agency –”It’s unbelievable, but there had been kind of a classism approach,” Ford says, with some workers considering themselves above the clients. Diamata has helped change that, she says.

John Shatokin, 57, sits on the Cascadia client advocacy council. Recently, he and other clients met with Ford to air concerns. “Donita gets us in the door with the people making the decisions,” says Shatokin, who has been diagnosed with clinical depression. “Without her, I think it’d be, ‘This is the way it is, folks, and that’s it.’ ”

Bob Nikkel, who heads Oregon’s Office of Mental Health and Addiction Services, has been the target of much of the lobbying organized by Diamata and has known her for 10 years. “She’s very straightforward, but she doesn’t jump on the table and pound her shoe,” Nikkel says. “She just has incredible credibility. People gravitate to her, so she can kind of work behind the scenes.”

Diamata is helping create a network of consumer advocacy groups, which write letters to politicians and bureaucrats and speak up at legislative hearings. She also preaches a gospel of self-determination with Cascadia’s clients, meeting them in groups and one-on-one. She’s helped develop a guidebook to help clients control their lives, and she’s working on another for building a career.

Diamata’s goal is to get people with mental illnesses involved in changing the system. By that yardstick, she says, her work is further along than it’s ever been.

But, she adds, this is also her toughest time of year.

Since she was a child, Diamata’s moods have turned with the weather. Her birthday falls in October, and it was on the morning of her 8th birthday when she felt the first sure touch of mental illness, a depression that blew in unsuspected.

“I remember that day –as an 8-year-old –thinking how I had wasted my life and hadn’t accomplished anything,” Diamata says. “This was not a family of high achievers; there was no pressure to be a genius. It came from inside me.”

She had been a notably fearless kid, a leader. Then she started to obsess about not stepping on cracks. She counted her paces to and fro, set on specific numbers. She became certain that parked cars were going to back up and crush her.

Today, it’s hard to detect she has any health problems. She’s high energy, her friends and relatives say, but controlled. She’s a wisecracker, opinionated, a deft conversationalist.

The uninvited images are her most common symptom, sometimes arriving midconversation. But the “tells” are subtle to outsiders –she breaks eye contact or looks down at the table or a sheet of paper while she runs through her mental routines to control them. She’s also accustomed to that battle. “It makes for a really active brain,” she says.

Diamata’s parents, much of her family and several close friends live nearby to provide support. But even when she’s having a lot of trouble, it can be hard to tell, says her younger sister, Dion Plamondon. It’s not always clear where her personality ends and illness begins.

“She’s just this powerhouse –if she wants to get something done it will get done, forget about sleeping and eating,” Plamondon says. “That can be good and bad. It crosses over into obsession really easily. But that’s just her. That’s always been her way.”

In fall 2003, Diamata had been off medication for five years, and her symptoms were under control. Then cuts to the Oregon Health Plan came down. She had to help lay people off. A colleague committed suicide. For Diamata, a familiar pattern began.

She describes it this way: A dialogue starts in her head, usually when she’s trying to go to sleep at night. She doesn’t like what her life has become. The future is bleak.

Apathy sets in, but she can’t sit still because stress boosts the Tourette’s, too, so she’s bouncing off the walls. Her reasoning ability drops. Then the compulsive disorder flares. She counts everything, each action follows a strict routine. The obsessions help shield her from her dark thoughts, but they also isolate her from friends, family –and work. “I became ridiculously stubborn,” Diamata says. “I’m just daring them to fire me.”

Diamata left work in September 2003, briefly returned in December, then left again until July 2004. In between, she got booted out of an eating disorder program after she tried to organize a revolt, insisting the clients should be running the show. She went back on Haldol, an antipsychotic, and ended up in an emergency room, her muscles frozen, unable to talk or signal the nurses calling her name.

When she returned home, she had a psychotic break she blames on the drugs, going from coherence to mumbling nonsense in one evening while a friend watched in alarm. Her friend took her back to the hospital.

She returned to work for a few months, but last year, shortly before Diamata’s 39th birthday, the depression hit again. By early December, she packed her bags full of prescription medications and planned to check into a motel to take them all that night. Then she paused, looked back at her house and saw it was dirty. She started cleaning and ended up working through the night.

The obsessive-compulsive disorder “kind of saved my life,” she realized later.

This time, she made a plan to work from home with the OK from her boss, Paul Potter. Ever conscious of numbers, she challenged herself to write a book in 39 days. She worked on Cascadia business during the day, then wrote much of the night despite the incessant tics of Tourette’s. “Everyone thought I was crazy,” Diamata says. “They thought I was writing gibberish.”

In 36 days, she had her novel, “Turning Stones,” a story about an isolated woman who finds her love in the spirit world.

She was back in the office in January.

It’s another managers meeting at Cascadia, and the acronyms fly. They talk of floating FTEs, budget cycles, staff reductions, the everyday chaos that follows fickle government funding. Cascadia manages more than 1,300 employees in four counties.

Diamata mostly observes, but chimes in when someone mentions that half of Cascadia’s walk-in patients don’t return after their first interview. “Why is it they don’t come back?” she asks.

Her question sparks an unscheduled 10-minute discussion, with answers ranging from cramped waiting areas to lost funding for long-term individual therapy.

The exchange illustrates the importance of Diamata being in the room, Potter says later.

“Donita keeps our feet to the fire,” says Potter, Cascadia’s vice president of clinical services. “If we have three options in front of us, and one is going to do less harm to clients than the other two, that’s where she becomes invaluable.”

The Americans with Disabilities Act mandates reasonable accommodations at work for people with mental illnesses. At Cascadia, that includes hiring flexible shift workers who step in when colleagues need time off for health reasons. Potter allows Diamata to work flexible hours at home to better manage her illnesses.

“The reality is the job still has to get done,” Potter says. That’s gotten tougher in the past decade as the trend has moved away from make-work jobs for people with mental illnesses, things like stuffing plastic eggs for gumball machines, to more meaningful work.

But the switch isn’t easy, even within the mental health field. Diamata forfeited leadership of the Renaissance drop-in center because of her long absence in 2003. Big hospital bills and the loss of pay forced her to sell her house. She’s working to regain the same level of trust with her colleagues and responsibility she had before her episodes resurfaced.

She knows a lot rides on getting through this year’s stormy weather without missing too much work.

Her strategy includes eating better, being more honest with family and friends about her moods, and closely monitoring her thoughts before they spiral out of control. She’s off medication again but has a nurse practitioner lined up if the early warning signs return.

Asked whether she regrets her mental illnesses, Diamata is quiet for a moment.

Relationships have ended because she’s hard to live with, she says. She’s unpredictable, at times unreliable. Her life can be chaotic.

But her relationships have become more stable as she’s grown older. Her mania has contributed to her productivity. And some of her most powerful art and writing has emerged when she was struggling most with depression.

“People always use the word ‘suffering’ for mental illness,” Diamata says. “Suffering can be there. But even at the times you’re having symptoms, it’s not all about that.”

From The Portland Business Journal, June 27, 2005

ASAP Treatment Services, a Portland agency offering substance abuse therapy, will become a set of specialized services within Cascadia Behavioral Healthcare, the agencies announced.

Termed a merger, the deal will be final July 1. The combined agencies will take the name Cascadia.

“Joining together with ASAP advances Cascadia’s mission of creating hope and opportunity for people affected by mental illness and addictions in a way not possible before this merger,” said Cascadia President and CEO Leslie Ford.

ASAP will widen Cascadia’s current offerings to the community, adding on-site child care services; specialized and culturally specific recovery programs for gay, lesbian, bisexual and transgendered people; treatment services for domestic violence offenders; and intensive residential treatment programs for men and women at the Columbia River Correctional Institute in Portland and the Coffee Creek Correction Facility in Wilsonville.

Cascadia, with a fiscal year 2006 budget of more than $48.4 million and a current staff of over 1,100, provides an array of mental health and addictions treatment and housing services, and cares for 20,000 clients annually in Oregon. With the addition of ASAP’s programs, Cascadia will have about 1,160 employees, and will provide services to residents of Clackamas, Marion, Multnomah, and Washington counties.

With the merger, Cascadia — Oregon’s largest provider of mental health and addictions treatment and supportive housing services — will provide services at nearly 70 locations.

From The Portland Business Journal, June 6, 2004

Four years ago, Multnomah County’s mental health care system, like so many of its patients, was in crisis.

People struggling with severe but manageable mental illnesses were unnecessarily hospitalized at great expense.

Lack of adequate emergency services and poor coordination among Portland-area mental health agencies led to expensive, inefficient and sometimes tragic outcomes, such as the 2001 shooting death of a Mexican immigrant at Pacific Gateway, the now-closed psychiatric hospital.

That same year, the county’s Crisis Triage Center closed due to escalating costs, cutting off a crucial emergency service for patients suffering from acute mental illnesses.

To deal with these and other mounting problems, county and mental health leaders began three years ago to revamp the way adult mental health services were delivered.

They created a system that now includes a 24-hour mobile response unit, 24-hour walk-in clinics, and teams of mental health and social workers who design out-of-hospital treatment plans for mentally ill clients.

The redesign still is in progress, but it has brought some dramatic results particularly in reducing hospitalizations of adult mentally ill patients, say officials of Portland-based Cascadia Behavioral Healthcare, the largest of about a dozen mental health organizations that contract with the county to provide mental health services.

“We have cut unnecessary hospitalizations in half, thanks to increased hours, outreach and more intensive services,” says Mark Schorr, director of communications and staff development for the agency, which performs services worth $38 million a year.

“This has been vital, not only because of the state financial crunch, but also because two hospitals with psychiatric beds [Pacific Gateway and Woodland Park] were closed in the past few years.”

Peter Davidson, medical director of the county’s mental health and addiction system and its clinical services coordinator, says the redesigned system has reduced the amount the county spends to hospitalize patients covered by the Oregon Health Plan — the state-sponsored safety net for low-income residents lacking health insurance — from $9 million three years ago to “well under $4 million” this year.

Some of the reduction is due to cuts in the health plan itself and the number of patients it covers.

“But [the cuts] weren’t nearly enough to account for the size of the reduction — they played only a small part,” says Davidson, who led the county’s redesign efforts when he was hired three years ago as medical director of its mental health division.

Under the redesign, Cascadia has managed to cut the number of days its Oregon Health Plan clients spend in the hospital from 678 in September 2002 to 291 last month, according to agency data.

Considering that hospitalization costs about $800 a day per patient, fewer hospital stays mean more money for out-of-hospital care, says Leslie Ford, Cascadia’s chief executive officer.

“For every month that we lowered inpatient utilization another piece, we were able to share in some of the savings and build up our outpatient system,” she says. “The more we build that up, the less we need to default into acute care [hospitalization].”

Adding to increased efficiency, Davidson says, is a mental health call center operated by the county that includes a crisis line where people can call during emergencies.

The center also has $9,000 that can be used to fix short-term problems, such as paying for transportation or medications for someone in crisis.

“We are building the details of the system project by project,” Davidson says.

Cascadia serves 80 percent of adults on the Oregon Health Plan who need mental health services. It responds to the bulk of the county’s emergency calls through Project Respond, a 24-hour mobile outreach program based at Cascadia’s largest facility at Southeast 43rd Avenue and Division Street.

Cascadia’s staff numbers around 1,000 and it operates about 60 sites in Multnomah, Washington and Marion counties

Besides mobile response teams, Cascadia’s programs include treatment, counseling, housing and job-seeking programs for people with severe and persistent mental illness.

Cascadia formed in January 2002, just as the county was embarking on its redesign program, with the merger of three independent mental health agencies — Unity Inc., Mount Hood Mental Health and Network Behavioral HealthCare. The merger was independent of the county’s redesign efforts, but Cascadia soon became the county’s major contractor for mental health services.

Cascadia primarily serves adults. Other agencies, such as Morrison Center and Trillium Family Services, work with children struggling with mental illnesses.

Trillium — formed in 1998 with the merger of Parry Center for Children and Waverly Children’s Home in Portland and the Children’s Farm Home in Corvallis — has redesigned its programs in ways that are similar to the county’s revamped system.

Trillium changed its funding model from traditional fee-for-service contracts to a more flexible system that allows children to receive an array of services, said Trillium President Kim Scott.

“We treat about 18 percent more children through flexible funding,” Scott said. “Outcomes are better, families are better supported and the services are more lower-cost.”

Trillium’s services include providing case managers and therapists to work in teams with parents, teachers and others who are acquainted with the children.

“Our goal is to help guide the child from high-end care back to the community,” Scott said.

Mental health services provided by the county and its contracted agencies get most of their funding from government sources — federal, state and the county’s own general fund. Not surprisingly, state and county budget shortfalls have presented hurdles in the county’s mental health redesign efforts.

The mental health division has had to absorb Oregon Health Plan cutbacks during the last two years, reducing the number of adults who receive services.

The income tax surcharge approved last year by Multnomah County voters gave the Mental Health Division $11 million to restore critical-care services that were on the chopping block, according to Davidson.

But adults with persistent, though not acute, mental illnesses have been dropped from the plan, leaving more adults without insurance for mental health care.

For instance, health plan cuts forced Cascadia to drop 2,500 cases since February 2003, from 8,500 to 6,000.

The agency saw a corresponding, 88 percent increase in the number of people seeking crisis services after the cuts, says Cascadia CEO Ford.

“That’s why so many cases are out in the street,” says Ford. “A lot of [mentally ill people] do not have insurance.

“As a state, we will have to deal with the issue of the uninsured because if you treat them in high-end services, like emergency rooms and hospital stays, it is less effective and far more expensive.”

Despite the cutbacks, county officials will continue to work for more cost efficiencies in the mental health care system, Davidson says.

Among the goals: continue to improve services for mentally ill adults, including finding solutions for homeless and other mentally ill people who are walking the city’s streets; combine programs that treat mental illness with those that treat alcohol and drug addiction; beef up systems for children and families.

“We’re in the earliest stages of finding out what works,” Davidson says.