Mental Health Association of Portland

By Maxine Bernstein, The Oregonian, May 4, 2013

After her son died, Carol Slaney found help at the CATC.

Carol Slaney woke up Jan. 31 to find her 26-year-old son dead beside her bed from an accidental drug overdose. She grabbed a .45-caliber revolver and disappeared, hiding in an abandoned house behind her Southeast Portland apartment.

“I just sat in that house, spinning the gun, planning my death,” Slaney said. “He was my world.”

Worried family members called police to check on her. As officers shined flashlights into the windows of her apartment, Slaney watched through the window of the derelict home nearby.

Slaney, who suffers from depression and post-traumatic stress disorder, had been placed on mental health holds before, a self-described frequent flyer at hospital emergency rooms. She didn’t want to return there, so she remained hidden from police.

On her fourth day alone, Slaney desperately called her case manager and pleaded, “I need to go to CATC.”

Peer support counselor Ashleigh Brenton

“In my darkest time, they just took my hand and walked with me,” Slaney, 49, said this week, as she sat inside the Multnomah County’s Crisis and Assessment and Treatment Center. “This place is personal and genuine. CATC is probably my savior.”

The 16-bed secure center opened in June 2011 off Northeast Grand Avenue to considerable fanfare by city, county and state officials. They touted it as a much-needed alternative to jail and hospital emergency rooms for people suffering a mental health crisis. Portland’s City Council resolution called the investment “a very high priority.”

But nearly two years later, Mayor Charlie Hales has recommended cutting the city’s annual $634,000 share of funding for the center, based on reports from Portland police that they haven’t found it useful.

CATC Administrator Dan Clune

Some veteran patrol officers dedicated to crisis intervention work say they didn’t know the center existed. The Police Bureau hasn’t encouraged officers to bring people they encounter there, largely because it doesn’t allow for drop-offs.

“It’s a valuable service,” said Lt. Cliff Bacigalupi, who is supervising the creation of a new police crisis intervention team. “It just wasn’t a good fit for us.”

Center managers, though, point to statistics that show while Portland police aren’t taking people directly to the center, many of the people they encounter are ending up there for treatment anyway.

To date, the center has treated 1,300 people. Of those, 942 patients came from emergency departments, where police likely took them initially, county officials said. Another 358 came from community referrals through social service agencies and the county jail. Of those referrals, 82 came from Project Respond staffers, who police regularly call out to mental health emergencies.

Peer support counselor Akil Stigler

“We discovered the police have been using it indirectly,” said Jeff Cogen, Multnomah County chairman. “But it doesn’t have to happen that way.”

The center, on the second floor of the David P. Hooper Sobering Center, serves adults 18 or older who live in Multnomah County and have serious mental illness. They must be indigent or have insurance coverage through Oregon Health Plan-Health Share.

The locked floor with 16 rooms resembles a wing of a hospital, yet with a lounge area decorated with patients’ artwork, an outdoor patio with picnic tables and a kitchen. It’s the only short-term crisis center of its kind in the county.

Patients stay from four to 14 days, until their symptoms stabilize. They must have a diagnosed mental illness, be referred from either a community care provider, an emergency room or acute hospital unit. They also must have stable medical vital signs on arrival. Upon discharge, they leave with a plan for follow-up treatment.

A patient room at the CATC.

Mental health clinicians, psychiatrists, nurses and peer support specialists are on staff 24 hours, seven days a week.

If the Portland City Council approves the mayor’s proposed cut, the county-run center expects to reduce its beds to 11 and serve about 200 fewer people a year. The city and county had agreed in 2010 to each pay 20 percent, or $634,000, of the center’s $3.5 million operating costs. The state picks up the rest.

Police say the center simply isn’t practical for patrol officers. In a March 2012 report, they said they can’t take people straight there and that the center doesn’t accept patients who are a danger to themselves or others, combative or assaultive, high on drugs or drunk. Instead, the report said, police end up arresting people in crisis and taking them to jail or driving them to local emergency rooms.

READ – Police Bureau report on CATC, March 2012

Outside patio at the CATC.

The Police Bureau’s position baffles center administrators, particularly when federal investigators have demanded Portland police improve their encounters with people suffering from mental illness.

The county also has a dedicated line for police to call when dealing with mental health emergencies and the staff can refer them to the crisis center. But police have rarely used it.

Center managers said police can request workers from the nonprofit Project Respond to assess people in the field and refer them to the center for treatment when appropriate.

Project Respond tries to use the center as much as possible, said the agency’s director, Jay Auslander. “It allows some folks to avoid going to the ER, or helps shorten their hospital visits,” he said.

Staff meeting at shift change.

Center managers estimate that it takes an average of 15 to 30 minutes to admit a person, often a far cry from the lengthy wait police find at hospital ERs.

They also dispute that the police claim that the center doesn’t treat people who are a danger to themselves or others.

“We take those folks all the time,” said Kevin McChesney, the regional director for Telecare, which contracts with the county to operate the center. In fact, he said, most patients are considered a danger to themselves or others.

Center workers just want to make sure police have disarmed the people so they’re not an immediate threat, he said.

Artwork on the wall was done by a former patient.

“We can certainly take people police pluck off a bridge who are suicidal,” McChesney added. But he acknowledged: “We’re not so certain about the person swinging an ax.”

It appears from his discussions with police, McChesney said, that they want a drop-off treatment center that accepts people without a referral, similar to the county-sponsored Crisis Triage Center that operated at Providence Medical Center until its closure in 2003.

“It seems to me they want an all or nothing solution. There needs to be a cooperative effort with police and so far that hasn’t occurred,” he said. “I think there are additional avenues where police can use this. There really hasn’t been a great dialogue about that, and I would welcome that.”

Police Capt. Sara Westbrook said most of the people officers place on mental health holds require a higher level of security and care than the patients accepted at the center. It just isn’t a good option for police, she said.

The mayor said the city is working to seal an agreement with the U.S. Department of Justice for police reforms on how to help people with mental illness.

“If it’s the county center or another resource, the bottom line is helping people who the police encounter,” Hales said by email. “… We’re actively engaged with a wide array of parties to determine the type of resources that would be of greatest practical assistance to our officers on the street.”

Slaney has been admitted to the crisis center at least five different times. She’s gotten to know the staff, many of whom had met her son, Jonathan, during his visits with her. He died from methadone and methamphetamine toxicity.

“Sometimes I get weak and fall astray and return here,” she said. “I didn’t think anyone could ever understand. I didn’t see no hope. But the staff here reminded me that I needed to honor my son’s memory. Regardless of my mental illness, you’re made to feel special here.”

Slaney recently packed up her son’s clothes and donated them to the crisis center.

“They don’t get enough credit for who they are and what they’re about,” she said. “I just knew where I was, and what they’ve done for me.”

 
Leaders of the House and Senate have boosted support for the EASA program, which assists youth after a psychotic break. Gov. John Kitzhaber has earmarked a $1.8 million increase for the program, while the dramatic increase envisioned by Sen. Peter Courtney awaits a funding source.

If left improperly treated, someone suffering from psychosis can have a bleak life ahead of them: years of drifting in and out of the medical system or the prison system. A psychotic break can often set up a person for a life on the margins living off meager disability payments.

The Early Assessment and Support Alliance aims at changing that. By working with teens and young adults during the first year of a psychotic break, the program can help guide clients toward accepting and managing their condition, helping them to stay out of the hospital, out of prison and in school while removing environmental barriers that may be exacerbating their disorder.

“Our goal is to provide support to people as early as possible,” said Tamara Sale, the program coordinator at the Mid-Valley Behavioral Health Network in Salem. “It’s not easy for families to find the help that they need. Half of people who call us have no signs of psychosis, but they do need some kind of help.”

Sale said clients are treated in an evidence-based but holistic fashion, tailored to the individual’s needs. A number of people who have gone through the program are not only staying out of taxpayer-funded institutions but working toward college degrees. Program coordinators also work to stay in touch with clients after they finish the two-year intervention.

“It’s really about helping people gain some context,” for their condition, Sale said. “Our goal is to avoid them ever going to the hospital again.”

The program served 600 families between 2008 and 2011, but it’s still not funded statewide. Three Western Oregon counties that recently joined the program — Clackamas, Lane and Douglas — were funded by one-time private grants.

In a state with millions of dollars in unmet mental health funding needs, House Speaker Tina Kotek, D-Portland, pointed to EASA as a high priority.

“She’s called that out as a successful program, and the kinds of programs we ought to be funding,” said her spokesman, Jared Mason-Gere.

Senate President Peter Courtney, D-Salem, specifically mentioned the EASA program when he called for a “game-changing” increased mental health investment of $331 million at the start of the legislative session. Added revenue in the governor’s proposed budget would boost EASA, but the money that Courtney suggested would allow for a greater expansion.

“We need services that can intervene and make a difference in someone’s life before they wind up in the Oregon State Hospital or one of our prisons,” according to an earlier press release from Courtney. “More than half of the adults with mental illness are slipping through the cracks.”

Courtney’s proposal is roughly six times what Gov. Kitzhaber submitted in his 2013-2015 budget to legislative leaders, while funding for Courtney’s proposals was unclear.

“The governor strongly supports Senator Courtney’s mental health initiative and appreciates his leadership for taking on an important issue that’s been neglected for too long,” said Tim Raphael, the governor’s spokesman. “The governor stands ready to help in anyway possible.”

While Kitzhaber’s proposals could come from the general fund, Courtney’s “game-changing” investment would require a new revenue source — and bipartisan approval of two-thirds of the Legislature or a direct vote of the people.

At the press conference, Courtney cited raising the beer and wine taxes as one possible revenue source, but said he was open to other ideas. Courtney’s spokesman Robin Maxey told The Lund Report this week that there have been discussions with players behind the scenes, but nothing he was ready to make public.

“We have to do something,” said Rep. Jim Thompson, R-Dallas, who’s the ranking Republican on the House Health Committee. But he hadn’t been privy to any discussions over funding sources and was noncommittal to raising revenues. “New taxes — those are always so popular with the people.”

The governor’s budget predicts that the Medicaid expansion in 2014 — thanks to the Affordable Care Act — will save Oregon roughly $44 million for what’s currently spent from the general fund on indigent mental healthcare because those people will eventually come onto the Oregon Health Plan.

But instead of cutting that money from the general fund or allocating it elsewhere, Kitzhaber has proposed rolling the dollars back into state community mental health programs, and adding another $12 million.

The governor’s budget also includes $1.8 million for the EASA program from the general fund, which Sale said would allow the program to become statewide. All the EASA sites do receive some support from the state’s 15 coordinated care organizations, but those sites require more revenue to remain sustainable, she said.

Chris Bouneff, the executive director of the National Alliance on Mental Illness of Oregon, said it was encouraging to see Kitzhaber increase mental health funding after several years of flat funding, but the system still was not properly funded as well as it should be.

“You have a mental health system that is stretched to the limit,” Bouneff said. “We have some programs that we know work, they’re just not widely available.” He also stressed the serious need for housing for people with mental illnesses.

EASA started in Salem in 2001 and has since expanded to 19 counties around Oregon. But it’s still not available in much of Eastern Oregon or two of the state’s largest cities, Medford and Corvallis. Once funding becomes available, Sale said they had agencies ready to go east of the Cascades and in Benton County.

Although the CCOs are tasked with integrating mental and physical health services, Bouneff said it’s too early to credit much success to them, other than diverting some patients from the emergency rooms.

“I think it’s overly optimistic to expect the CCOs to have much impact in the first year on mental illness,” he said. “The CCOs came into existence before we had any plans … If they work as intended, there’s a lot of potential.”

State officials are taking public input about how Oregon Health Plan reforms are going, including written, Internet and in-person testimony, culminating in a Dec. 11 public meeting.

Starting in August, the Oregon Health Authority that oversees the state’s low-income health care system has shifted members into coordinated care organizations, essentially locally based health plans set up to manage spending while melding physical, mental and dental health. Today, about 90 percent of the Oregon Health Plan’s roughly 600,000 members are in a CCO.

There have been issues, such as complaints that some CCOs have excluded naturopathic doctors from serving Oregon Health Plan members, and whether dental care is being integrated quickly enough.

The Oregon Health Policy Board, which oversees the authority, meets Dec. from 1 to 4:45 p.m in the Multnomah County Commissioners’ meeting room 501 Southeast Hawthorne Boulevard Portland. Satellite locations for viewing and participation will be set up in La Grande, Medford, Eugene, Bend and Tillamook. For more details and the full agenda, including public testimony times, see the meeting’s web page.

Panels of providers and others will discuss how things are going. There will also be a webinar allowing people to register and comment online during the meeting.

Written comments must be submitted by Dec. 7. Emails should be sent to ohpb.info@state.or.us with a subject line of “Health System Transformation Feedback. Letters can be sent by mail to the Oregon Health Policy Board at 500 Summer St. NE. Salem, OR 97301.

State officials have intervened once again, sending in another mediator, while residents continue circulating petitions, asking the Oregon Health Authority to re-open the bidding process and allow a new coordinated care organization to emerge. But that won’t happen while the mediation process continues, according to Patty Wentz, spokesperson.

Two issues still separate county officials and Cascade Health Alliance, the physician-hospital owned group that’s attempting to become the CCO – the control of mental health services and representation on Cascade’s for-profit board of directors.

As the local mental health authority, the county is responsible for such services and has the ultimate contracting authority, but Cascade prefers to establish its own provider network.

Commission Chair Dennis Linthicum is willing to sign an agreement with GOBHI, a mental health group in 17 rural counties, but its CEO, Kevin Campbell, has been unsuccessful in reaching agreement with Cascade. “It could be a boost if they could be brought to the table,” Linthicum said.

For the time being, he’s not ruling anything out. “Right now everyone’s back at the negotiating table. If we can clean up those areas of hesitancy, we’d be more likely to sign an agreement. But if the public doesn’t have the ability to help direct those interests, it becomes problematic. Because of our statutory authority, this lands directly on the county’s shoulders.”

Neither Linthicum nor Bill Guest, CEO and president of Cascade, was willing to discuss details about the negotiations. “We’re not under a cloak of silence but would like to play our cards as close to the vest as possible,” Linthicum said. “I’m looking forward to seeing what the mediation process bears, and am hoping for results amenable to both sides.”

Cascade, which has been struggling to get the go-ahead as a CCO, is now saddled with a financial penalty imposed by the Oregon Health Authority and receiving 1 percent less in reimbursement, Guest said.

“We’re hoping the CCO can happen as soon as possible, and we’re going to abide by the original agreement with the county not to discuss the issues outside the mediation process” Guest said. “We’re working in a positive manner toward resolution with a state-appointed mediator.”

In earlier article about this situation, The Lund Report inadvertently said that Guest refused to comment on the situation. Instead, he had not responded by press time because of the Thanksgiving holiday.

Cascade, with 10,000 members, is managed by a nine-person board of directors – three primary care physicians, three specialists and three representatives from Skyline Hospital, and owned by its physicians and the hospital. The company also runs a Medicare Advantage Plan, known as Atrio, with 12,000 members.

“I really hope we have good news very shortly, and that the mediator is able to conclude the process successfully. It’s the first time we’ve been involved in the mediation process in our history,” Guest added.

It’s also premature, he said, to discuss the details about Cascade’s intention to integrate mental health care. “We’ve put together contracts with providers, and the first step is to do a memorandum of understanding with the county mental health authority.”

Earlier, GOBHI was rebuffed by Cascade after trying to buy into the company, according to Kevin Campbell, CEO. “It’s unfortunate that Cascade has a design plan in mind that is highly privatized and doesn’t see value in GOBHI being involved in the future. We’d like to be part of the solution, not the problem,” he said. “We’ve had tremendous success getting people out of the state hospital and into long-term care and community living.”

Campbell believes it’s beneficial for rural counties to join together and help move the system forward with a critical mass, rather than small counties going in different directions. “We’re willing to work with all providers if we get a chance to move forward,” he said.

He’s also interested in having a minority voice on Cascade’s board. “At the end of the day, decisions have to be made about whether to put money into public health or other preventive initiatives or pay dividends to shareholders.”

Campbell also questioned why Cascade intends to split adult and children’s services into two programs. “That’s a mystery to me. You don’t spend a million dollars on children just to have them go into the adult program and be ignored and end up in prison. You need to wrap services around so people know the services are there, whether they’re 18, 25 or 55.”

No matter what transpires, GOBHI is likely to become the go-between for mental health services until new contracts are in place since the county’s relationship with Jefferson Behavioral Health’s ends in January, Linthicum said.

Jefferson Behavioral Health is evaluating its future role, said its chief operating officer, Bob Furlough. “We’re continuing to work with our board of directors to identify what activities we’ll be involved with.” Currently his organization has contracts with the state for acute care indigent services and developmental disabilities services.

There’s a very high preponderance of people on the Oregon Health Plan who have a mental health or substance abuse problem, according to Mary Monnat, president and CEO of LifeWorks NW. In the Portland metropolitan area, such problems affect 70 percent of that population.

Now that coordinated care organizations are under way, it’s not only important for people to receive better coverage, but mental health professionals also need to connect their patients with primary care physicians, said Monnat, who serves on the board of Health Share of Oregon (formerly known as the Tri-County Medicaid Collaborative).

“We were very concerned about the people we were seeing,” said Monnat, who initiated a partnership with Virginia Garcia Memorial Health Clinic to provide such services.

Working with that clinic and Providence Health & Services, her agency began analyzing claims data to identify the highest users of emergency services, and help people find a medical home.

Once they realized that people were visiting emergency rooms because they were unable to get time off work during the day, Virginia Garcia extended its clinic hours to accommodate evening visits.

The clinic has also assembled healthcare teams that respond to patients’ needs so that a mental health provider can screen for depression or substance abuse as part of a primary care visit.

“We really need to provide culturally diverse care,” said Monnat, since racial and ethnic minorities tend to be overrepresented in the Oregon Health Plan.

When the coordinated care organizations were formed, “there was a big concern that mental health would be left behind” said Ed Blackburn, executive director of the Central City Concern who’s also on the board of Health Share. “So far I have not found that to be true.”

Blackburn has firsthand experience bridging the gap between mental health and physical health services at Central City Concern, which started out as a substance abuse treatment facility, but gradually expanded into those other areas.

“We find that people with lower level mental health diagnoses, we can treat effectively through integrated primary care,” Blackburn said. “A coordinated care model for people with mental illness that includes primary care and social services intervention helps across diagnoses on the mental health side.”

Monnat is optimistic about how coordinate care organizations can make a difference in peoples’ lives. “If you keep the patient, the consumer, at the center of all this, that’s what grounds me,” she said. “I’m working hard to keep that front and center.”

By Joseph D. Bloom, MD – Dean Emeritus at the School of Medicine and a Professor Emeritus in the Department of Psychiatry at Oregon Health and Science University.
From - Conundrums and Controversies in Mental Health and Illness • Winter 2010

In 1848 Dorothea Dix, the famous 19th century advocate for the indigent mentally ill, appealed to the United States Congress to support the set- aside of a very large tract of land that was to be used for the “Relief and Support of the Indigent Curable and Incurable Insane.” She stated:

It will be said by a few, perhaps that each State should establish and sustain its own institutions; that it is not obligatory upon the general government to legislate for maintenance of State charities…. But may it not be demonstrated as the soundest policy of the federal government to assist in the accomplishment of great moral obligations, by diminishing and arresting wide-spread miseries which mar the face of society; and weaken the strength of communities?

The proposed legislation, the “12,225,000 Acre Act,” did pass the Congress, but was vetoed by President Franklin Pierce, who stated in his 1854 veto statement:

I have been compelled…to overcome the reluctance with which I dissent from the conclusions of the two Houses of Congress…. If Congress has power to make provision for the indigent insane…the whole field of public beneficence is thrown open to the care and culture of the Federal Government.

I readily…acknowledge the duty incumbent on us all…to provide for those who, in the mysterious order of Providence, are subject to want and to disease of body or mind but I cannot find any authority in the Constitution that makes the Federal Government the great almoner of public charity throughout the United States. To do so would, in my judgement, be contrary to the letter and spirit of the Constitution…and be prejudicial rather than beneficial to the noble office of charity.2

For most of our country’s history, the federal government followed the position taken by President Pierce and avoided major responsibility for the public mental health system or for that matter, now, for a national health system. In fact, the only time the federal government assumed a significant role in the care of the mentally ill was between the end of World War II and the election of Ronald Reagan in 1980. This era began with great optimism and ended with all the seeds of the current crisis in mental health care clearly apparent as the forces that were unleashed began to unfold.

Shown above is the exercise yard at the Oregon State Insane Asylum in about 1905. (Photo no. OSH0023, Oregon State Hospital Records, OSA)

Prior to and after the election of President Reagan, the states had the major responsibility for the care of the seriously and chronically mentally ill. The earlier state era was characterized by the large state mental hospital, while the current state era is characterized by the criminalization of the mentally ill. In order to describe the current condition, I will use the public mental health system in the State of Oregon as a case study. Oregon is chosen because of my 30-year experience with the public mental health system in this particular state. I believe and hope to illustrate that Oregon’s problems in the delivery of public mental health services are very similar to those that exist in most states.

The Federal Era in Mental Health Services

The linchpin of the federal era was John F. Kennedy’s 1963 Presidential Message on Mental Illness and Mental Retardation. President Kennedy described the failures of the past and looked forward to a new direction for the country. He stated:

Most importantly the institutions that housed such large numbers of mentally ill individuals were slated to be closed. Hospitalization, if needed, was to take place either in the community mental health center’s inpatient service or in the developing psychiatric inpatient services in local community general hospitals.

Unfortunately, in retrospect, and for a variety of reasons, the community mental health center movement was a conceptual success, but an actual failure. Not enough centers were funded. For those that were, the funding formula in the federal legislation was based on a decreasing federal match with state funds, and many states did not pick up the costs. In addition, the centers themselves were accused of not focusing sufficient resources toward the problems of the chronically mentally ill.

President Jimmy Carter attempted to refocus the federal program on the problems of the chronically mentally ill. He came to the presidency with a strong commitment to mental health services which he and President Kennedy’s concern was translated into a bill that was introduced into Congress one month before his death,4 enacted soon after, and signed by President Johnson. The passage of this legislation created the community mental health center movement.

I began my psychiatric residency in that same year, 1963, and experienced the community mental health center movement on a personal level. The movement was conceptually elegant. Each state was governed by a mandatory state mental health plan that divided the state into designated catchment areas. Each area was assigned a priority score for the development of a community mental health center responsible for the mental health care for the catchment area population. It was anticipated that catchment areas might differ as to the characteristics of their distinct populations. Using the developing methods of psychiatric epidemiology, the goal was to measure the amount and types of mental illness in the particular population and then tailor services to the particular needs of that population.

Each mental health center was to have inpatient, outpatient and partial hospitalization services, a 24-hour walk-in service for immediate care, along with a branch of consultation and education designed to strengthen the mental health fabric of the community.  Local administrative control and accountability were part of the CMHC governance and, of course, there was the promise of adequate funding.

Most importantly the institutions that housed such large numbers of mentally ill individuals were slated to be closed. Hospitalization, if needed, was to take place either in the community mental health center’s inpatient service or in the developing psychiatric inpatient services in local community general hospitals.

Unfortunately, in retrospect, and for a variety of reasons, the community mental health center movement was a conceptual success, but an actual failure. Not enough centers were funded. For those that were, the funding formula in the federal legislation was based on a decreasing federal match with state funds, and many states did not pick up the costs. In addition, the centers themselves were accused of not focusing sufficient resources toward the problems of the chronically mentally ill.

President Jimmy Carter attempted to refocus the federal program on the problems of the chronically mentally ill. He came to the presidency with a strong commitment to mental health services which he and his wife helped to strengthen in the State of Georgia.

As president, in 1979, he delivered a message on mental health which:

….establishes a new partnership between the federal government and the states in the planning and provision of mental health services. It seeks to assure that the chronically mentally ill no longer face the cruel alternative of unnecessary institutionalization or inadequate care in the community.5

In his message President Carter noted that although 700 community mental health centers had been built, serving some 3 million patients annually, the majority of the country’s population were not served by federally funded community mental health centers. During the same time period what actually did occur was the accelerated discharge of the state hospital patients into local communities. This came about for many reasons including the advances made in psychiatric drug treatment, and the great pressure coming from the legal and patient rights community driven in part by reforms in civil commitment laws.6 The results, as is evident, from President Carter’s words, were large numbers of chronically mentally ill individuals in the community, many who were faced with inadequate community level care.

To put President Carter’s words in perspective, in 1955 there were 558,239 state and county psychiatric beds in the United States.7 When he took office in 1976 there were 222,202 beds in the country, and when he left office in 1980 there were 156,713 beds.8 (For reference later in this paper, in 2005 there were 52,539 beds in what was left of state and county hospitals for the mentally ill.9) This was the time that the terms “deinstitutionalization,”10 “the homeless mentally ill,”11 and “the chronic mental patient in the community” first appeared in the mental health literature,12 and we first began to be concerned with the mentally ill as they became a significant population within the nation’s jails and prisons.13

The federal era ended with the election of President Reagan. He ended support for federally funded community mental health centers and instead funded block grants to the states to be used within general guidelines to support state services. However, it is important to note that since that time federal support of mental health programs has remained in the form of financial support to individuals and states through the Medicare and Medicaid programs. In essence federal leadership and national policy were replaced by financial support for individuals.

The New State Era in Mental Health Services: Oregon — A Case Example

Is the public mental health system in Oregon representative of the services provided in other states?

There are several studies that compare states on various indices related to mental health care. In 2006 the National Alliance for the Mentally Ill (NAMI) compared state mental health systems using a detailed quality index that rated programs along ten defined criteria14 ranging from comprehensive services and support, to access to acute and long-term care treat- ment, to adequate funding. These criteria were adopted to support recovery oriented treatment models which most public mental health programs support today.15

Five states received a grade of B with the highest scoring states being Connecticut and Ohio. Seventeen states received a C, 19 a D, and 8 were awarded an F. Oregon received a C+, while South Carolina received a B-. NAMI identified that the most urgent need in both of these states was “funding.” South Carolina was ranked 32nd in per capita funding for mental health while Oregon ranked 40th. NAMI gave the country as a whole a national grade of D.

In 2008, the Treatment Advocacy Center issued an online report that evaluated the adequacy of the number of state and county hospital beds in each state using a scale developed by an expert panel organized by the survey’s authors.16 In 2005, there were 17 public hospital beds per 100,000 in the U.S. population. The expert panel determined that 50 beds per 100,000 was the minimum number needed to provide adequate service. Eleven states, including South Carolina (10.6 beds per 100,000) were determined to have a “critical bed shortage” in public beds, while Oregon was listed with 20 other states as one category better in the “severe bed shortage” range, with 19.2 beds per 100,000. Only one state, Mississippi, at 49.7 beds per 100,000 was at the minimum number determined by the expert panel. From these two surveys at least, Oregon does not appear to be an outlier.

Oregon’s Programs

As in most states Oregon traditionally funded its state hospitals with general fund dollars while community funding is based on a “state-county partnership” written into law in 1973. Community programs are administered at the local level by county health and/or mental health departments.

This partnership was altered in the decade between 1993-2003 when the Oregon Health Plan was most prominent. Since 2003 the Oregon Health Plan (OHP) has been in decline,17 but some of the mechanisms that were set in place for the OHP, which included the establishment of specific insurance products and some mental health carve outs, remain in place.

Oregon’s State Hospitals

My colleagues and I recently examined the inpatient bed situation in Oregon in both state and private hospitals18 and found that for the most part Oregon’s psychiatric hospitals are full to capacity. In addition, the state is, in essence, running a forensic inpatient system for those who enter the hospital under the state’s civil commitment or criminal justice standards, those who are incompetent to stand trial, and those who enter under the jurisdiction of the Psychiatric Security Review Board.19 We found in another study20 that over the past 20 years civil emergency holds have increased as the population of the state has increased, while actual civil commitments have diminished by 50 percent. The state hospitals now predominantly serve the civil commitment court (24% of the state hospital population) and the criminal courts (63% of the state hospital population). The state hospitals contribute minimally to the general welfare of the non-court adjudicated Oregonian. In the same study (cited above) we found that over the last decade the number of general hospital psychiatric beds had significantly decreased in Oregon, and this decrease mirrors the national situation. It is extremely important to note that there is, in essence, no room for the voluntary patient in either state or the community hospital beds.

In addition to the issues related to those who are served at the state hospitals, Oregon’s major state hospital, the Oregon State Hospital (OSH), is operating under very heavy strain. Oregon is one of the oldest western states and OSH is one of the oldest state hospitals in the west. It was originally built in 1883 and most of its “newer” buildings are close to 50 years old. To understand the current pressures affecting OSH, it is helpful to understand three recent lawsuits and one threatened lawsuit.

The first suit,21 heard in the Federal District Court for the District of Oregon22 and decided in favor of the plaintiffs in 2002, sought to compel the State of Oregon to provide more expeditious treatment for criminal defendants who had been found incompetent to stand trial and who were languishing in Oregon jails waiting for beds at the Oregon State Hospital. The plaintiffs, presented data that showed that seriously mentally ill individuals were held in jails under very poor circumstances, for abnormally long periods of time, awaiting evaluation or treatment beds at the state hospital. Data was presented on 105 individuals who had been found incompetent to stand trial of criminal charges. These individuals spent an average of 32 days in jail waiting for a bed. Forty-eight were held for more than 30 days and nine were held for more than 60 days. Only 19 were transported to the hospital in fewer than seven days. The judge’s final order stated that admissions to the state hospital “must be done in a timely manner, and completed not later than seven days after the issuance of an order determining a criminal defendant to be unfit to proceed to trial because of mental incapacities.”

The second law suit, settled in 2003, was a class action suit23 brought against Oregon’s two state hospitals, contending that the defendants failed “to develop the array of community-based mental health services needed to meet the special needs of a group of patients, causing them to remain unnecessarily institutionalized in Oregon state hospitals.” This case was Oregon’s response to the 1999 United States Supreme Court decision in Olmstead v. L.C.24 in which the Court held that states were required to provide community based treatment when treatment professionals had determined that these placements were justified. The Oregon case was concluded with a settlement agreement which applied to “civilly committed adults in Oregon state hospitals” and “who had not been discharged within 90 days of the ready-to-place determination of their Treatment Team.” The state agreed to develop additional community based facilities and resources to accommodate members of the class.

The third law suit, Harmon v. Fickle,25 finalized in 2006, alleged that the State failed to provide adequate numbers of professional and direct care staff at the state hospital; failed to provide adequate and “meaningful” treatment; had violated multiple plaintiffs’ rights to privacy; and failed to protect patients from harm. The settlement agreement stated that the state would take “all necessary steps within their control” to increase the staff patient ratio by both hiring more staff and by reducing the state hospital population by developing secure residential treatment options in the community. The state legislature made funds available to achieve these goals, but to date neither goal has been reached. The hospital has been unable to hire sufficient staff, mainly nursing and psychiatric staff, and attempts to contract for more community secure residential placements especially for those hospitalized from the criminal courts have met severe resistance in several of Oregon’s communities.

These problems at the Oregon State Hospital led to a 2006 Department of Justice investigation under the authority of the Civil Rights of Institutionalized Persons Act (CRIPA).26 In January of 2008 the Justice Department issued its findings, a stinging critique of the hospital.27 The CRIPA investigators found that the hospital failed to protect patients from patient to patient assault, and from the physical dangers inherent in the aged facilities themselves. There was a heavy emphasis in the report on the problem of inadequate nursing care. In addition the report faulted aspects of psychiatric and psychological practices including lack of adequate assessments, medication management, and overuse of seclusion and restraint, with additional weakness found in discharge planning.

The 2007 Oregon Legislature responded to the CRIPA investigation with a significant financial commitment to build two new state hospitals with a total of 1100 beds. The numbers of professional staff needed for these hospitals was not actively debated,and the need is only now beginning to become apparent to state leaders within the executive and legislative branches. The question of how to find the requisite numbers of nurses and physicians is yet to be addressed along with the sticker shock that will no doubt accompany this discussion.

Oregon’s Community Mental Health Programs

The situation is not much better with regard to Oregon’s community mental health programs. These programs serve predominantly three categories of clients: those who remain as OHP beneficiaries, those who receive traditional Medicare and Medicaid benefits, and those with no coverage of any sort (the medically indigent). There is limited funding with limited treatment options available for the medically indigent.

Cascadia Behavioral Health, a not-for-profit private agency, operated on contracts with state and local governments and on fee-for-service revenue. The program provided mental health services to 20,000 clients in five of Oregon’s largest counties, particularly in Portland, the state’s largest city, and at its height had a budget of some $60 million per year.

The Cascadia story provides an instructive lesson in regard to the problems inherent in community mental health programs in this state. What it says is that these programs operate very close to the margin. In essence, they are grossly under-funded by both state and county governments. If they are not extremely well managed, they will run into trouble, as was the case with Cascadia Behavioral Health. State and county officials responsible for oversight were not sufficiently aware of the problems because too little attention was paid to program evaluation and oversight.

Consequences

President Carter stated in 1979 that “unnecessary institutionalization” has given way to “inadequate community care.” He was correct, and in retrospect the dynamics were clear, resulting from the rapid reduction in the number of inpatients; closure of beds; increased vigilance, legal and otherwise, at the front door blocking easy access to the remaining beds; decreasing federal responsibility for the community mental health center movement; and the inability or unwillingness of states to assume the necessary financial burden to adequately fund hospital and community programs. All of these factors have produced the current situation with the most negative result being the large-scale criminalization of the mentally ill.

“Unnecessary institutionalization” has been replaced in many places by unavailable institutionalization. This situation is highlighted by the Oregon data, and nationally by the Treatment Advocacy Center,28 the National Association of State Mental Health Program Directors,29 the American Medical Association and the American College of Emergency Physicians,30 President George W. Bush’s New Freedom Commission,31 and a recent commentary in the American Journal of Psychiatry.32

This situation in Oregon and across the U.S. leads to an inevitable pathway to the nation’s jails and the prisons.33 In a recent commentary in the Journal of the American Medical Association, H. Richard Lamb and Linda Weinberger,34 citing evidence from the National Commission on Correctional Health Care, reported that in 2006 there were “at least” 341,000 incarcerated persons with severe mental illness in the United States, representing approximately 15% of incarcerated individuals in that year.

Bernard Harcourt contributed an added dimension to the discussion of mental hospital institutionalization in the United States by analyzing aggregate data from mental hospitals and jails and prisons in the years 1928-2000.35 He noted that hospitalization rates peaked in 1955 and declined rapidly after that date reaching the low levels cited in this paper (deinstitutionalization) and also noted that since the early 1980s the country is in an expanding period of criminal incarceration (the “incarceration revolution”). By combining data from both mental hospitals and the jails and prisons, Harcourt found that the current combined level of institutionalization had not yet reached the aggregate levels that existed in 1955. He also noted an inverse relationship between decreasing total institutionalization and the national homicide rate. Harcourt argues for further investigation to look for precise explanation for this finding.36

From the criminal justice system perspective, the current era is characterized as an “incarceration revolution,” while from the mental health perspective the era of deinstitutionalization has given way to the era of the criminalization of the mentally ill. The public mental hospitals now have the lowest number of beds in decades, and over the last decade we have been losing community hospitals beds, even as our population continues to increase.37

Are There Any Solutions?

Here it is appropriate to briefly discuss the question of national policy and the political process. First and foremost, there needs to be a national mental health plan, a consensus plan that is actively supported by the federal government.

We haven’t had clear national mental health policy since the administrations of Presidents Kennedy, Johnson, and Carter. There was some hope of positive movement early in the presidency of George W. Bush when in 2002 he appointed the New Freedom Commission on Mental Health charged with studying the mental health service system and making recommendations for improvements in the system.38 The president set out five Principles to guide the Commission, one of which, however, stated that:

The Commission shall follow the principles of Federalism, and ensure that its recommendations promote innovation, flexibility, and accountability at all levels of government and respect the constitutional role of the States and Indian tribes.

Reminiscent of President Pierce, this statement meant that President Bush was not interested in the development of national policy that would govern approaches in each state. That said, the Commission did make a serious effort to comprehensively describe the state of the country’s mental health service system, including its current deficits, and developed six goals for improving the system. The Commission also recognized the work of promising programs from various parts of the county. But, in keeping with the spirit of the new federalism, little comprehensive federal policy changes were recommended and little attempt was made that would bind the country to another major and unified approach that would address the current problems and look to a better future.

In addition, at the political level, recent decades of American politics have fueled the incarceration revolution. In many areas of political life, politicians have used fear and sensationalism as pathways to election.

Data is certainly not king in the public arenas. Incarceration is far cheaper when compared to mental hospitalization, and in every political race in this country the pledge of “no new taxes” has become an effective route to electoral success. And further, the police, courts, and jails and prisons remain the last resort, governed by laws which make it very difficult to pass the buck, as states have done in mental health care. The buck stops inside the doors of the jails and prisons. A rational conclusion would be that we probably do not have the political will to move into a new era of revitalization of the public mental health programs. If, however, there was a chance to move away from the “incarceration revolution” and attempt to rebuild the public mental health programs, we would be wise to look to the past for some guidance as there were many excellent program models that were developed that might serve as guides to future systems.

We have already noted the innovative program models embodied in the federally funded Community Mental Health Center (CMHC) of the 1960s and 1970s, which were based on the principles of public health psychiatry.39 In addition, there certainly is a need for a concerted effort to rebuild and expand psychiatric inpatient capacity. This is not a call for the reconstruction of the total institutions of the past, but for an adequate number of psychiatric beds in our communities to provide the necessary inpatient evaluation, treatment, and stabilization services that form the backbone of modern acute psychiatric services. Additionally, communities need an adequate number of public sector beds in acute care facilities to provide the necessary backup to criminal justice system detainees with severe mental illnesses. In 1960, Portia Bell Hume and Edward Rudin40 described the funding received by the state of California’s mental health program from the federal government via the Hill Burton Act and from the state’s Short Doyle Act. Both of these well-known laws were designed to encourage the development of general hospital psychiatric units. We are greatly in need of similar commitments now at both the state and federal levels.41

Included with the need for a revitalization of inpatient mental health services is the re-development of functional civil commitment laws. In years past civil commitment was the diversion method of choice for removing individuals from the criminal justice system and transferring them to the mental health system. Civil commitment provided hospitalization for individuals suffering severe psychiatric decompensation, before their behaviors brought them into contact with the criminal justice system. For those already in the criminal justice system and charged with minor crimes, civil commitment provided the major route for diversion into the mental health system. A constructive alternative to current civil commitment laws was developed by the American Psychiatric Association in the early 1980s. This model statute was never implemented among the states,42 but it is time to review it again as it contained many forward-thinking approaches to civil commitment.

It is important to note that currently, and only in a few communities, mentally ill individuals charged with crimes may be diverted from jail by the developing system of mental health courts.43 These methods, although promising and somewhat effective, do not take mentally ill persons out of the criminal justice system, thus leaving them vulnerable to the heightened stigma associated with such involvement.

In closing, although this article has focused a great deal of attention on inpatient care, it is important to conclude by acknowledging that it is the outpatient, residential, and occupational components of a mental health program that really comprise the core of services. All inpatient treatment are only in the service of a rapid reintegration of individuals into their communities, and into as productive situations as they are capable of achieving. Great strides have been made in these areas, but these advances cannot be realized without adequate support. Perhaps this will ultimately come from national mental health parity legislation. Perhaps adequate or even excellent out- patient care will come ultimately from a functional national health insurance program, or perhaps from a separate national mental health policy, but it must come as the central focus of a comprehensive mental health program if the national mental health plan is to be successful.

Note

This article was presented at the Fifteenth Annual Thomas A. Pitts Memorial Lectureship in Medical Ethics, Medical University of South Carolina, Charleston, SC.

References

1.    B. E. Harcourt, “From the Asylum to the Prison: Rethinking the Incarceration Revolution,” Texas Law Review 84 (2006): 1751-1786.
2.   H.  A. Foley and S. S. Sharfstein, Madness and Government: Who Cares for the Mentally Ill (Washington, D.C.: American Psychiatric Press, 1983).
3.    J. F. Kennedy, “Message From the President of the United States Relative to Mental Illness and Mental Retardation,” The White House, February 5, 1963.
4.    Public Law 88-164, 88th Congress, S. 1576, October 31, 1963.
5.    J. Carter, “Message from the President of the United States Transmitting Legislation to Improve the Provision of Mental Health Services…Throughout the United States” (Washington, D.C., U.S. Government Printing Office, 39-011-0, 1979).
6.   A.  A. Stone, Mental Health and Law: A System in Transition (Rockville: NIMH, 1975).
7.    See Carter, supra note 5.
8.   E.  F. Torrey, K. Entsminger, J. Geller, J. Stanley, and D. J. Jaffe, “The Shortage of Public Hospital Beds for Mentally Ill Persons,” available at <http://www.treatmentadvocacycenter.org/Reportbedshortage.htm> (last visited September 6, 2010).
9.    Id.
10.   E.  L. Bassuk and S. Gerson, “Deinstitutionalization and Mental Health Services,” Scientific American 238, no. 2 (1978): 46-53.
11.   H.  R. Lamb, ed., The Homeless Mentally Ill: A Task Force Report of the American Psychiatric Association (Washington, D.C.: American Psychiatric Association, 1984).
12.   J.  A. Talbott, ed., The Chronic Mental Patient: Problems, Solutions, and Recommendations for a Public Policy (Washington, D.C.: American Psychiatric Association, 1978).
13.   J.  D. Bloom, L. Faulkner, J. H. Shore, and J. L. Rogers, “The Young Adult Chronic Patient and the Legal System: A Systems Analysis,” New Directions for Mental Health Services 19 (1983):37-50.
14.    NAMI, “Grading the States, A Report on America’s Health Care System for a Quality Mental Health System: A Vision of Recovery,” available at <http://www.nami.org/Content/NavigationMenu/Grading_the_States/> (last visited April 30, 2006).
15.   W.  A. Anthony, “A Recovery-Oriented Service System: Setting Some System Level Standards,” Psychiatric Rehabilitation Journal 24 (2000): 159-168.
16.    See Torrey et al., supra note 8.
17.    J. Oberlander, “Heath Reform Interrupted: The Unraveling of the Oregon Health Plan,” Health Affairs 26, no. 2 (2007): 96-105.
18.    J. D. Bloom, B. K. Krishnan, and C. Lockey, “The Majority of Inpatient Psychiatric Bed Should Not Be Appropriated by the Forensic System,” Journal of the American Academy of Psychiatry and the Law 36, no. 4 (2008): 438-442.
19.   J. D. Bloom and M. H. Williams, Management and Treatment of Insanity Acquittees, A Model for the 1990s (Washington, D.C.: American Psychiatric Press, 1994).
20.     J. D. Bloom, “Civil Commitment is Disappearing in Oregon,” Journal American Academy of Psychiatry and Law 34, no. 4 (2006): 534-537.
21.    OAC, et al. v. Mink et al: Findings of Fact and Conclusions of Law, U.S. District Court for the District of Oregon, Case No. 02-003-00339-PA, May 9, 2002.
22.     Miranda et al v. Kulongoski, et al., Settlement Agreement, United District Court for the District of Oregon, Case No. CV00-1753- HU, December 18, 2003.
23.     Id.
24.     Olmstead v. L.C., 527 U.S. 581, 1999
25.    Harmon v. Fickle, Settlement Agreement, Case No. 05-1855-BR, United States District Court for the District of Oregon, April 17, 2006.
26.     Civil Rights of Institutionalized Persons Act (CRIPA), 42 U.S.C.C$ 1997.
27.    Report, CRIPA Investigation of the Oregon State Hospital, available at <http://www.oregon.gov/DHS/mentalhealth/osh/cripa06review/2-cripa-report.pdf> (last visited September 19, 2010).
28.     See Torrey, supra note 8.
29.    National Association of State Mental Health Program Directors, “The Crisis in Acute Psychiatric Care,” Report of a Focus Group Meeting, National Association of State Mental Health Program Directors, Washington, D.C., 2006.
30.     American Medical Association House of Delegates, American College of Emergency Physicians, Resolution 714 and 716, 2007.
31.    Subcommittee on Acute Care, Background Paper, New Free-
dom Commission, (Washington, D.C., DHHS Publication No.
SMA-04-3876, 2004).
32.    B . Liptzin, G. L. Gottlieb, and P. Summergrad, “The Future of Psychiatric Services in General Hospitals,” American Journal of Psychiatry 33, 10 (2007): 1498-1472.
33.     H. R. Lamb and L. E. Weinberger, “The Shift of Psychiatric Inpatient Care From Hospitals to Jails and Prisons,” Journal of the American Academy of Psychiatry and Law 33, no. 4 (2005): 529-534.
34.     H. R. Lamb and L. E. Weinberger, “Mental Health Courts as a Way to Provide Treatment to Violent Persons With Severe Mental Illness,” JAMA 300, no. 6 (2008): 722-724.
35.    See Harcourt, supra note 1.
36.     d.I
37.    See Bloom and Williams, supra note 19.
38.    President’s New Freedom Commission on Mental Health, available at <http://www.mentalhealthcommission.gov> (last visited September 24, 2010).
39.   G  . Caplan, Principles of Preventive Psychiatry (New York: Basic Books, 1964).
40.   P . B. Hume and E. Rudin, “Psychiatric Inpatient Services in General Hospitals,” California Medicine 93 (1960): 200-207.
41.    See Liptzin, Gottlieb, and Summergrad, supra note 32; see Torey et al., supra note 8.
42.     American Psychiatric Association, “Guidelines for Legislation on the Psychiatric Hospitalization of Adults,” American Journal of Psychiatry 140, no. 5 (1983): 672-679.
43.   M  . N. Schaefer and J. D. Bloom, “The Use of the Insanity Defense as a Jail Diversion Mechanism for Mentally Ill Persons Charged With Misdemeanors,” Journal of the American Academy of Psychiatry and the Law 33, no. 1 (2005): 79-84; P. A. Griffin, H. J. Steadman, and J. D. Petrilla, “The Use of Criminal Charges and Sanctions in Mental Health Courts,” Psychiatric Services 53 (2002): 1285-1289.

By Amanda Waldroupe, for The Lund Report, March 30, 2012

The Non-Traditional Health Workers Subcommittee, which has been designing standards for community health workers in Oregon, believes it’s important to continue its work to oversee the development of that work force. It intends to ask the Oregon Health Policy Board for permission to become a formal advisory body.

“There’s a lot more work to do,” said Carol Cheney, the subcommittee’s facilitator and equity manager in the Oregon Health Authority’s Office of Equity and Inclusion.

View Full Size     (Benjamin Brink / The Oregonian)

Meghan Caughey works on a sumi-e piece (Japanese for black ink painting) in her studio apartment, with her dog, Ananda.

Last year, the subcommittee began developing training and education standards for community health workers, and make recommendations to the Policy Board about how the work force should be incorporated into Coordinated Care Organizations (CCOs). The CCOs are part of a major overhaul to the Oregon Health Plan’s delivery system, and are expected to integrate physical and mental healthcare for 650,000 Oregon Health Plan patients in August.

The subcommittee is also proposing that its name be changed, and has recommended that it be called the “Community Health Worker-Peer Workforce Advisory Committee.” The subcommittee feels that its current name — which uses the phrase “non-traditional” — runs counter to its mission to help community health workers become part of the mainstream healthcare system.

“We recognize the irony of this name,” Cheney said.

It’s unclear which office within the Oregon Health Authority will oversee the subcommittee’s work. There was tentative consensus that the Office of Equity and Inclusion was the appropriate office, but the authority’s Addictions and Mental Health Division and the Public Health Division were also suggested when the subcommittee met on Wednesday.

A draft charter that was circulated during Wednesday’s meeting describes the advisory committee’s responsibility as advising CCOs “on the role and utilization of community health workers, personal wellness specialists, and personal health navigators” in the healthcare delivery system.

One of the main priorities identified during the meeting was educating CCOs about the role of community health workers so they are not overlooked by physicians and other traditional providers.

“I fear that out of ignorance, potentialities will be overlooked,” said Meghan Caughey, Senior Director of Peer and Wellness Services for Cascadia Behavioral Healthcare.

The subcommittee also wants to make certain that the current community health workers be grandfathered in, exempting them from the training and certification requirements the subcommittee has recommended for future community health workers (which include 80 hours of training).

Community health workers who now have at least five years of work experience or completed training within the last two years would be grandfathered in, according to the subcommittee. That action “assures availability of recently trained or experienced [non-traditional healthcare workers] for CCOs,” the subcommittee recommended.

Cheney said the advisory board would also continue developing the curriculum and training requirements. “This is a work in progress,” she said, adding that the requirements may change as CCOs and the role of community health workers evolve in the next few years.

Kris Anderson, director of the Oregon Family Support Network’s training and curriculum development, hopes that one topic would continue being discussed — more clearly defining the roles of community health workers, peer support specialists and personal navigators in a CCO.

“We’ve never really clearly defined what those roles are,” Anderson said, recognizing that the timeline to have CCOs operational means that “things are moving so fast.”

If those roles aren’t defined early in the process, they may never be delineated, she said.

Although some of those roles were outlined when the subcommittee made its presentation to the Policy Board in January, said Anderson, “they were very ambiguous.”

“They’re very broad,” agreed Cheney.

Among the roles of community health workers are being an advocate for patients, providing case management support, doing outreach to patients’ homes, and helping patients adopt a healthier lifestyle.

Jennifer Valentine, executive director of the Area Health Education Center in Bend, worries that a more detailed description could hamper CCO’s in determining the best way to use community health workers.

“If we defined [the roles] too tightly, we don’t give that experimentation enough opportunity,” she said.

In order for the advisory board to become a formal body, it needs approval from the Policy Board. Approaching the board is expected to be one topic discussed when Cheney and other members of the subcommittee make a presentation before the Oregon Health Care Workforce Committee on April 4.

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By Amanda Waldroupe, for The Lund Report, March 24, 2012

The effort, initially funded by a 2006 grant, is now being extended to Coordinated Care Organizations in southern Oregon

A quick, 15-minute appointment with a mental health counselor to talk about the effects of stress and anxiety when a person has an ulcer is radically different than a traditional hour long appointment with a counselor. But providers in southern Oregon are discovering that such appointments, which integrate mental healthcare in the same primary care setting, go a long way toward improving a patient’s health.

For the last three years, a licensed clinical social worker has been seeing patients at the Harvard Medical Park primary care office under a joint arrangement between Douglas County Independent Practice Association, the managed care plan providing care to Oregon Health Plan patients in Douglas County, and ADAPT, a Roseburg-based nonprofit offering substance abuse and mental health services.

Last year, a similar model got under way in Coos County by Doctors of the Oregon Coast South, which also contracts with ADAPT.

Both managed care plans, which are intent on becoming Coordinated Care Organizations (CCOs) in southern Oregon, are working with ADAPT to bolster the integration between mental and physical health.

John Gardin (from ADAPT website)

“It’s obvious that this [type of integration] is the mandate of desire relative to CCOs,” said John Gardin, ADAPT’s chief clinical officer and research director.

In August, CCOs are expected to replace the state’s managed care organizations, and integrate the physical, mental and dental healthcare for the 650,000 people on the Oregon Health Plan and emphasize preventive care, decrease hospital utilization and reduce costs.

In the clinics run by these two managed care plans, social workers work directly with primary care physicians to integrate physical and mental healthcare. When a physician believes a patient might have a mental health or chemical dependency problem, they’re referred directly to a social worker, who sees them for brief fifteen minute appointments.

“Typically, embedding mental health and substance abuse counselors in primary care has occurred in umbrella systems like Kaiser, HMOs, and federally qualified health centers,” Gardin said. “It’s very rare to have this kind of service in a private practice.”

Although rare, such a concept is becoming increasingly common elsewhere in Oregon. Central Oregon embeds mental health workers in primary care clinics, as well as the Old Town Clinic run by Central City Concern and other Portland-area nonprofits that serve vulnerable patients.

In 2006, after receiving a three-year $375,000 grant from the Health Resources and Health Management Administration, ADAPT began embedding licensed clinical social workers in a primary care clinic.

Within three years, that social worker saw 2,000 patients, half of which were Oregon Health Plan patients. Of that group, 15 percent saw the social worker more than five times, and their utilization including hospital visits decreased by 30 percent.

The short appointments patients had with the social worker were designed to target specific mental health problems that had exacerbated their physical health issues. “It’s just effective to give some basic tools, skills, training and development about what you can do,” Gardin said. “It’s way more practical.”

That way, there’s a higher probability of a patient seeing a mental health provider at the same clinic rather than being referred elsewhere. “Referrals just don’t work,” Gardin said. “They just won’t go.”

Physicians have responded positively to the program. “They can hand off problems for which they’re not well-equipped or well-trained to do,” Gardin said. “They can do what they went to medical school to do.”

However, integrating mental and physical healthcare does require a certain amount of flexibility by providers, Gardin said. “The medical environment is a very different environment from the counseling environment. The model is dependent on the physicians understanding that the social worker is there to help.”

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