Mental Health Association of Portland

Oregon's independent and impartial mental health advocate

Redesigning Multnomah County’s Mental Health System

Posted by CoffeeX3 on 25th May 2008

In 1999, in the wake of the shuttering of Garlington Center, several public deaths of people with mental illness, and a distressing countywide site review by the state mental health division, a wide-open, concerted, public conversation about Portland’s mental health system was launched by County Chair Beverly Stein.

The conversation became more complex as the County Mental Health Division was unable to provide basic data for an initial survey by a blue ribbon task force, chaired by Elsa Porter, a systems engineer. The media became alert.

Read – Mental Health Care Needs Overhaul, Panel Says, from The Oregonian, March 2000

Read – County Department Offers Mental Health Ideas, from The Oregonian, April 2000

Consumer and family members, invited into the discussion for the first time, insisted the system be overhauled, that the system be redesigned to suit the needs of people with mental illness instead of County bureaucrats and vendor agencies. Ed Blackburn from Central City Concern wrangled ten or more committees over the summer of 2000, with over 100 participants, to spell out how services should work.

Once services were redesigned, a third committee was formed, led initially by County Chair Diane Linn, to implement the changes to the mental health system. Large government contracts were at stake and both the direction and the leadership of this committee veered through the Spring and Summer of 2001. The final controversial solution, offered by proxy from the State mental health division and by the County was Cascadia.

Read – Mental Health HMO Proposed for Multnomah County, from The Oregonian, May 2001

Read – Radical Shrink, from Willamette Week, May 2001

Largely designed by Kim Burgess, now with Washington County, Peter Davidson, now with the State Mental Health Division, Cascadia offered a managed care proposal where risk for hospitalization would be shared with a single large provider. This potent incentive for change caused the immediate creation of psychiatric outreach teams, and a drop in hospitalization. The saved costs were to be invested in infrastructure and services.

Read – Turnaround Against Odds Earns Support, high praise from Bob Landauer, May 2003

Read – Give County Credit That Is Overdue, again from Bob Landauer, December 2003

In 2004 or 2005 Multnomah County, under Derald Walker, now Cascadia CEO, shifted the financial model of Cascadia from managed care to fee-for-service leaving Cascadia with no incentive to manage hospitalization risk, and the most service-needy clients. Acute care suffered and hospitalization began to increase. Public oversight was limited at this point – the community trusted a fix had been made.

Because no outcome data is made public by the County or Cascadia – anecdotal information is all we know. This inferior data about the quality and quantity of mental health services is scattered, but uniformly critical. From every perspective, system witnesses remark access is limited, treatment services are poor, ancillary services such as housing and employment assistance are limited, staff turnover is high and moral is low. Homeless shelters, jails, hospitals, and public health clinics are overflowing with people seeking services which should be readily available from County-funded mental health clinics.

Below is a mish mash and incomplete collection of useful documents from 1999 to 2003 from the redesign process. Bookmark this page – the documents will remain here as an archive.

Read – Network Behavioral Healthcare’s 1999 contract with Multnomah County. Note the added language requiring and defining consumer and family participation.

Read – Treatment of the Mentally Ill in the Criminal Justice System – written in August 2000 by Bill Toomey, probably for the Design Team Criminal Justice group. A nice snapshot of that moment.

Read – Options for Persons with Mental Illness in Multnomah County’s Criminal Justice System – probably from Summer of 2000.

Read – DCJ mental health resources, Summer 2000

Read – Overview of DCJ Case Management for Mentally Ill Offenders, October 2000

Read – the charge for the Design Team, Spring 2000

Read – the charge for the Persons With Mental Illness in the Criminal Justice System Work Group, Spring of 2000

Read – the charge for the Client Transportation Workgroup, Spring of 2000

Read – the charge for the Community-Based Intervention Services Workgroup, Spring of 2000

Read – the charge for the Transportation Group, Spring 2000

Read – the charge for the Inpatient Services Workgroup, Spring 2000

Read – the charge for the Data Collection Workgroup, Spring 2000

Read – the charge for the Crisis Workgroup, Spring 2000

Read – the charge for the Best Community Mental Health Services Model Workgroup, Spring 2000

Read – the minutes for the Best Community Mental Health Services Model Workgroup, July 13, 2000

Read – the minutes for the Best Community Mental Health Services Model Workgroup, August 10, 2000

Read – the minutes for the Best Community Mental Health Services Model Workgroup, September 14, 2000

Read – the charge for the Best Community Mental Health Services Model Workgroup, October, 2000

Read – Interdepartmental Communications Workgroup Minutes, October 24, 2000

Read – Mental Health Design Team Coordinating Team Agenda, September 11, 2000

Read – Mental Health Design Team Coordinating Team Agenda, September 26, 2000

Read – Mental Health Design Team Coordinating Team Agenda, October 2000

Read – Mental Health Design Team Coordinating Team Agenda, November 2000

Read – Memo from Design Team Child and Adolescent Work Group, Summary of Priorities for Work Group Recommendations, September 2000

Read – Summary of Recommendations from Design Team Child and Adolescent Work Group, October 2000

Read – Recommendations from Design Team Child and Adolescent Work Group, September 2000

Read – governance structure for community mental health system, 2000?

Read – Multnomah County Behavioral Heath Division policy manual, 2001

Read – Memo on Administrative Changes and Support, November 2000

Read – Report of the Alcohol and Drug Systems Workgroup, August 2000

Read – Proposal for the Atypical Anti-psychotic Medication Project, Spring 2000

Read – system description of the Case Management for Offenders with Mental Illness, Spring 2000

Read – Evaluating the Health Of Multnomah County’s Mental Health System, by Elinor Hall, MPH, May 2000

Read – Introduction: Recovery-Oriented Mental Services, by Ed Blackburn, Summer of 2000

Read – letter from Pat Cosgrove to Lolenzo Poe, one of the many reasons the CTC was closed, Summer 2000

Read – What Do I Want? (consumer / survivor focused mental health services), by Scott Snedecor, Summer of 2000

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New approaches lower mental health expenses

Posted by CoffeeX3 on 6th June 2004

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.

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Give county credit that is due

Posted by CoffeeX3 on 14th December 2003

By Robert Landauer – editorial columnist for The Oregonian, December 14, 2003. Not available elsewhere online.

The Multnomah County crisis line (503-988-4888) dispatched the county’s mobile crisis unit, Project Respond of Cascadia Behavioral Healthcare, to one of about 150 calls for mental -health assistance it receives weekly from the public and police. Julie Larson of the aid unit summarizes the case:

A Latina woman was hallucinating about rats. Spanish-speaking cultural specialists immediately began working with the family to ensure her safety and avoid hospitalizing her, if possible.

Family members attributed the woman’s disorder to a curse or spell. “We said it could be caused by other things also, and these pills could help.” The staff also reinforced things the family was doing with herbs and prayer and taught her husband techniques he might use to keep his wife calm. County and state workers developed a safety plan that kept the children in a familiar environment but out of range of any unpredictable behavior.

The mother had been discharged without support plans after previous two- to five-day hospitalizations. Once Project Respond became involved, a support plan was drafted, including instructions for family and support-group members to call for early help if specific behavioral indicators appear.

Crisis unit staff members’ visits to the family, originally three or four times a week, now are down to every other week, with phone calls in between.

Since Project Respond’s participation began almost six months ago, there have been no hospitalizations.
In 1999 and 2000, I sat through hearings of a citizen-led task force that was trying to figure out how to improve Multnomah County’s deteriorating mental -health system. Two anecdotes from those who testified have stayed with me.

One was from a woman who reported that her psychiatric-based hospitalizations and jailings rose from once or twice a year to once every two months as her social worker’s caseload rose to the point that he would visit her too rarely to see that she needed help to stop her unraveling.

The second was a complaint that the county’s lack of any Spanish-speaking mental -health professionals for almost 50,000 Latino county residents forced relatives to travel almost 300 miles to Burns to get culturally appropriate mental -health services in Spanish for family members.

A great deal has changed.

A county walk-in center at Southeast 43rd Avenue and Division Street is open full time to help prevent and to treat psychiatric emergencies. Project Respond’s 35 mental health caseworkers now include specialists with capabilities in 14 Asian languages, Spanish, Russian and Polish.

Also, Karifa D. Koroma, the crisis team’s criminal justice liaison, connects county jail inmates with mental illnesses to the services they need after release. Without that help, many would recycle back to jail more often, at $1,950 a month, than is avoidable.

Where is the evidence these and other changes make any difference?

The county’s premise is that the better its community-based supports are, the more they will shrink the need for costly acute-care hospital beds.

In one month, November 2001, mentally ill Multnomah County residents’ time in acute-care hospitals peaked at 3,485 patient bed-days. Since then, that bed-day tally has plummeted. As reforms have gained traction over the past 18 months, a chart showing mental -health bed days (at $700 per day) would look like a steep ski slope viewed from the top.

“We have achieved all-time lows in the past couple of months for residents who still have Oregon Health Plan benefits,” says Dr. Peter Davidson, medical director of county mental health and addiction services. Hospital-bed days per month for the last several months are in the low 300s — accomplished even as the county’s mental -health budget from Medicaid has been slashed by $10.5 million.

Let the record show that Multnomah County commissioners, especially Chairwoman Diane Linn and predecessor Beverly Stein, made politically risky changes and have produced amazing improvements to the delivery of mental health services.

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Diminished care, diminishing returns

Posted by CoffeeX3 on 27th July 2003

From the Oregonian, July 27, 2003

Cutting mental health services to patients such as Douglas Bean has cost Oregon more money than it is saving

Douglas Bean was a quiet success story for the psychiatrists and others who struggled to treat him. After more than 30 years in and out of state hospitals, he was finally living on his own. His frequent visits to a Portland mental health agency cost about $2,000 a year.

Then in February, as Oregon grappled to balance its budget, the state stopped paying for that care.

Bean quickly fell apart and wound up in the emergency room of a Portland hospital, which later admitted him to its psychiatric unit. His weeklong stay cost taxpayers more than $7,000.

In the past five months, Oregon has dramatically reduced its spending on mental health, saving the cash-strapped state $21 million. But state officials say those savings are already evaporating as people such as Bean deteriorate and require much more expensive care. Many have landed in hospital psychiatric units and emergency rooms, where a few hours of care can cost as much as six months of outpatient treatment.

Officials at the Department of Human Services say the mounting costs could outstrip even the short-term benefits of the cuts.

“I don’t know when we will hit the point of paying more than we’ve saved,” DHS Director Jean Thorne said. “But it’s possible it will happen.”

Community mental health officials said they believe Oregon has already reached that point.

“I would be amazed if the state has saved anything,” said Leslie Ford, CEO of Cascadia Behavioral Healthcare in Portland, where Bean was treated until February.

State officials said they do not yet have precise figures for how much has been paid in mental health-related emergency room visits and additional inpatient psychiatric care. Hospitals have up to six months to submit data and some are thought to be absorbing a substantial portion of the additional costs.

To Ford and her colleagues at Cascadia, the anecdotal evidence is clear.

There is the woman who couldn’t afford her new $15 weekly co-payment for medications. She quickly became psychotic and wound up in the hospital for five days at a cost of more than $800 a day.

Another woman, Ford said, who lost her medication and counseling tried to commit suicide by jumping off a bridge. Her care had cost less than $2,000 annually. Now, the state will pay intensive care and rehabilitation costs of at least 50 times that.

Oregon’s cuts to mental health services run counter to national research that shows reducing medications, housing and counseling only increases costs borne by the mental health and criminal justice systems.

“We knew it would happen,” Ford said. “I’m surprised it happened this fast. It’s an eloquent demonstration that if you don’t pay for prevention, you’re going to pay for emergency.”

In April, the state surveyed hospitals across Oregon to try to gauge the impact.

Of 16 hospitals that responded, 13 reported an increase in the number of people seeking emergency psychiatric care since the budget cuts took effect.

Providence Medical Center in Portland, for example, has seen a 14 percent increase. Oregon Health & Science University reported a 25 percent to 30 percent jump.

Smaller emergency rooms in Baker City, Cottage Grove, Heppner and Springfield reported only slight increases but said they expect more soon.

“It will be a bloody nightmare,” the state survey quoted a worker at McKenzie-Willamette Hospital in Springfield as saying. “Hospitals are not set up to take this increase. People are receiving very expensive work-ups.”

Battling an illness for decades

Bean’s case illustrates the problem.

Throughout his 20s, 30s and 40s, Bean was ordered in and out of psychiatric hospitals in California and Oregon more than a dozen times. Electro-shock treatments all but destroyed his memory. His disease, bipolar disorder, took everything else.

In 1988, after he slammed his car into another vehicle and injured himself and two others, a court ordered Bean to take his medications and participate in a publicly funded mental health program.

The care he received at Cascadia Behavioral Healthcare in Portland was simple but effective: help deciphering his electric bill. Help so he could remember to take his medications. An occasional reminder of what year it was.

The years passed, and Bean, now 60, never committed another crime or returned to the hospital. Last year, he moved into his own apartment after more than a decade in a state-paid group home.

Bean’s Social Security disability income of $865 a month makes him ineligible for the Oregon Health Plan, the state’s insurance program for low-income people whose coverage is required by federal Medicaid law.

To pay for his prescription drugs, Bean’s case manager, Genevieve Moore, tried to sign him up for the state’s Medically Needy Program. The benefit covered more than 9,000 Oregonians who did not qualify for the health plan but had unusually high medication expenses.

The program was scrapped Feb. 1 — around the same time the Psychiatric Security Review Board turned him out of its group home and stopped paying for Bean’s therapy because he’d successfully served his probation on the 1988 traffic charge.

When told he would no longer receive services, even Bean, who has trouble remembering what pocket he keeps his wallet in, knew what lay ahead.

“So what? I’ll just get manic and depressed and spend the rest of my life in the state hospital,” he told Moore. “That’s a great life.”

After Bean was cut from services, Moore tried to keep him on track, even though she wasn’t paid to do so. She got him signed up for seven different free prescription samples — a temporary measure in which drug companies give “scholarships” to some patients — and checked on him by phone on her own time.

But without regular reminders of when to take his pills, as well as the daily routine of going to see Moore and his friends, his fellow clients at Cascadia, Bean became psychotic. In late June, an apartment maintenance worker found him naked, crawling in his own filth and crying that the world was ending.

At least some of Bean’s recent and future hospital costs will be paid by Medicare, the federal health plan for older and disabled people. But for many low-income Oregonians now forced to seek mental health care in hospitals, the burden falls fully on the state.

Hospital officials say many of those flooding their emergency rooms are enrolled in Oregon Health Plan Standard, which provides a lesser benefit for the working poor who earn too much to qualify for full health plan benefits.

On March 1, lawmakers dropped mental health coverage from that plan, but hospitalizations and emergency room visits were still covered. In other words, they no longer could be treated on the less expensive outpatient basis.

“Hospital units are packed with people because it’s the only mental health benefit people have, and it’s indefinite,” said Dr. Peter Davidson, chief clinical officer for Multnomah County’s Mental Health & Addiction Services Division.

“The more they get hospitalized, the more the state pays. What this means is that the disenrollment didn’t save any money, which of course, we all predicted.”

Lawmakers also put an end to retroactive health plan enrollments. In the past, if an uninsured patient showed up in an emergency room and was eligible for the health plan, the hospital could recoup its costs. Now hospitals must absorb those bills, which are eventually shifted onto commercial insurers and their policyholders.

Even cuts that appeared to be minimal — such as health plan co-payments for prescriptions — have boomeranged.

Two months ago, a local pharmacy turned away a Cascadia client who couldn’t afford a $15 co-pay on her anti-psychotic prescriptions.

“She got frustrated, so she just went without for two weeks,” said Dr. John Bischof, medical director at Cascadia and the woman’s psychiatrist. The woman, who suffers from bipolar disorder, became psychotic and was hospitalized for five days.

When put back on her medications, the woman was “immediately clearer, better,” Bischof said.

“The state paid for that to the tune of $5,000, solely because the pharmacy, as their representative, could not collect a savings of maybe $15 on her prescriptions,” Bischof said.

“The shortsightedness of that is outrageous. Not to mention the impact on this woman’s life.”

Caregiver’s fears become reality

The bulk of the service cuts, which have led to what mental health officials call the imminent collapse of the system, was made quickly during the past five months by legislators intent on balancing the budget.

Mental health workers across the state have lobbied lawmakers throughout the current session to restore some of what has been lost, not only to stave off skyrocketing costs, but also to save lives.

In February, Cascadia’s Ford testified before lawmakers and predicted — correctly — that without care, Bean would wind up in the hospital. She did not name him. Bean subsequently agreed to allow The Oregonian to make his case public.

Ford also told lawmakers the story of a woman in her 40s who last year had repeatedly plunged a knife into her chest and, on another occasion, barreled her car into oncoming traffic.

The woman had responded well to medication and counseling, but without care, “she will likely have contact with the criminal justice system again,” Ford said. “And one episode of booking costs as much as an average year of outpatient treatment.”

As it turned out, Ford’s prediction was too optimistic — for both the woman and the state’s bottom line.

In April, only two months after the woman lost her services, she became despondent and jumped off a freeway bridge.

She survived, but taxpayers now will pay at least $100,000 for her six weeks in the hospital, including two weeks in intensive care, and the year she will spend at a rehabilitation center.

Davidson said he at least has some hope for Multnomah County clients. In May, voters there approved a temporary income tax increase that will soon help restore some of the lost services.

“We’re going to put a whole bunch of folks back into regular services to try to stem this tide,” he said.

But most counties, many of which have been patching together their crisis programs with dwindling reserve funds, predict the worst is yet to come.

“If we don’t get money soon, you’ll see the real crash in the emergency rooms in the next few months,” said Gina Firman, executive director of the Association of Oregon Community Mental Health Programs.

It is unclear whether any funding will be restored to the 2003-05 budget to mental health programs by lawmakers grappling to close a $1 billion gap.

After his hospitalization last month, Bean moved in with his daughter in Eugene.

His medication scholarships could run out at any time, and Moore said she is worried. Bean’s illness, she says, comes on like a series of fires, each one harder to douse than the last.

“If anything happens,” a Cascadia psychiatrist told Bean’s daughter last week. “Take him to the emergency room.”

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County may stop mental treatments

Posted by CoffeeX3 on 22nd February 2003

From The Oregonian – February 22, 2003, no longer online

Multnomah County notified the Oregon Department of Human Services on Friday that it is terminating its mental health outpatient contract under the Oregon Health Plan because of drastically cut state money.

The decision could mean the end of county-provided help to about 10,000 indigent adults and children on March 25.

County officials say they still hope to renegotiate terms to maintain some level of care. But they say they have been talking unsuccessfully with state employees for several months about modifying the agreement, which has been renewed on an annual basis since January 1998.

“So it’s gonna be really bad, or it’s not gonna happen,” said Peter Davidson, director of the county’s Mental Health & Addiction Services Division. “I’ve never heard of a big city mental health system taking cuts this fast.”

In a letter to Madeline Olson, assistant administrator of the state Office of Mental Health and Addiction Services, county Chairwoman Diane Linn said a series of three state budget cuts in effect Feb. 1 and March 1, plus an expected further reduction this spring make it impossible for the county to comply with the clinical and fiscal provisions of the contract.

Being under contract without enough money puts the county at risk for paying hospital expenses for needy people because they will have nowhere else to turn, and the county’s dwindling budget does not have the money, officials say.

“As long as we have responsibility for the system, we have responsibility for the outcome,” explained John Ball, county chief operations officer.

The contract includes funding for a myriad of services to help keep mentally disabled residents in crises out of hospital emergency rooms and jails. The care includes help through primary care providers and walk-in clinics.

Multnomah County is the only county that has given the state a termination notice or sought modification of this service contract, Olson said.

She said receiving the notice was not a shock, because of the discussions.

“We will continue with contingency plans,” she said, “and come to whatever resolution we can to assure services continue to be available to people covered by the Oregon Health Plan.”

“That’s what we hope, too,” Linn said. “We’re hoping it doesn’t affect anyone,” but people will be feeling the result of human services cuts and the failure of Ballot Measure 28 to restore some cuts.

“Anybody who thought everything was gonna work out OK . . . this is the kind of fallout” on the way.

Davidson thinks that without change, the current money climate with the state will “basically end the adult mental health system in four months.”

The proposed Oregon Health Plan budget “has very little money, if any, for the adult mental health system,” he said.

The county has received $33 million annually in federal Medicaid money under the Oregon Health Plan contract for adult and children outpatient services. Davidson said the budget for adult Medicaid eligible outpatient services at the start of this county fiscal year, July 1, 2002, was $23 million. Federal, state and county cuts this year have reduced that by $11.5 million, including $5.7 million in state cuts in the past five weeks.

The contract is administered through a county program called Verity, which in turn contracts with 60 subcontractors. The largest is Cascadia Behavioral Healthcare, which just announced plans to lay off 180 employees this month and close 10 sites by mid-March. The next largest are Oregon Health & Science University and the Morrison Center.

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Seeking solutions state and counties study a tiny fraction of deaths of patients in Oregon’s mental health system

Posted by CoffeeX3 on 31st December 2002

From The Oregonian, December 31, 2002 – not available online

For more than a decade, Oregon has relied on county mental health agencies to investigate themselves when a mentally ill patient dies under their care.

The result: County officials have faulted their own conduct in only two of 247 deaths during the past 3-1/2 years.

State records show that in nearly 50 of those cases, county officials performed a cursory inquiry in which they did not interview the families of the people who died or the mental health workers responsible for their treatment.

Officials at Oregon’s Department of Human Services acknowledged in interviews that their system for tracking patient deaths is inadequate and that their records included a number of cases that should have been more closely examined. They said they had assigned only one person to review the countys’ reports of deaths and had neither the staff nor the budget for more in-depth investigations.

Shown The Oregonian’s analysis of his own agency’s files, Bob Nikkel, community services manager for the DHS Office of Mental Health & Addiction Services, said the statistics were “not a surprise” and reflected the state’s longstanding failure to track deaths in county mental health agencies.

“Aside from whether people are whitewashing certain aspects of the investigations, when you do these things on an absolute shoestring you’re asking for problems,” he said of the death reports counties send to his department.

Several officials suggested patients’ groups go to court to force tighter scrutiny of county mental health agencies.

“Someone should sue us,” said Kevin Moynahan, regional protective services coordinator for the DHS Office of Investigations and Training.

Moynahan and his supervisor, Eva Kutas, said a lawsuit had prompted the state to assign four workers to review death and abuse cases involving developmentally disabled people, even though they number 15,000 statewide, compared to the 66,000 Oregonians with mental illness who are under state care.

“I read all the stuff that comes in, and I’m thinking, ‘This is just wrong,’ ” said Karla Kerstner, the lone state worker reviewing mental health death reports. “But our hands are tied. We don’t have the people, the budget or the law on our side. And it’s sad for the people who’ve been hurt and all the potential victims out there.”

Among the mental health deaths the state did not question:

* Amelia Scott, a 44-year-old schizophrenic homeless woman, who died “suddenly and unexpectedly” inside the psychiatric unit of a Portland hospital. The only explanation the hospital could offer was that she stopped breathing. State and county officials never asked why.

* A 38-year-old man in Baker County who committed suicide. In explaining why the county chose not to investigate the case, a supervisor wrote that the man’s suicide note “exonerated others for his suicide choice.”

* Norrine Sharkey, 52, who visited a Linn County mental health office, where she admitted drinking alcohol with her medications. Both her therapist and the doctor asked for the pills, but she refused, promising to flush them down the toilet. She was found dead the next day from an overdose. The state closed the case after a phoned-in account from the county.

The counties play a crucial role in Oregon’s mental health system. Almost $300 million a year in state and federal money to help the mentally ill is distributed to 33 county agencies. They in turn hire mental health workers and psychiatrists, or contract the work out to companies or local nonprofits.

It is up to state officials in Salem to make sure the money is well spent and that patients are properly cared for.

Counties were not even required to report deaths until 1991. That year, the Legislature passed a law that ordered mental health agencies to file a report on patients who die “by anything other than accidental or natural means.” The law gives counties 45 days to investigate whether “abuse” played any role in the deaths.

Under pressure from county officials, lawmakers drafting the statute drew an important distinction: Abuse was defined only as deliberate or “willful” acts to harm a patient. Neglect or serious errors by mental health workers were not covered.

In the nearly four years for which records were available to examine, nearly 100 Oregonians have died after significant lapses by county agencies, state records show. None was defined as “abuse.”

Only five cases were subsequently examined by DHS, which has broad authority to look at how the counties are spending their mental health dollars. Experts say patient deaths are one crucial warning sign of potential problems with the work of a county or its contractors.

DHS officials said they investigate deaths when they perceive something unusual in the county reports.

The DHS investigator who handles death cases has no authority to shut down a county mental health agency. If serious flaws are found, the matter is referred to another part of DHS, which licenses mental health agencies. None of the deaths of mentally ill patients in the past 3-1/2 years has prompted the state to strip a county’s authority to provide care.

Some patient deaths are never even reported to the counties. Dr. Peter Davidson, head of Multnomah County’s mental health department, said that in 2000 when he took over the agency, he discovered 20 unreported deaths in a 15-month period in one facility under contract with the county.

Davidson said he called the state and said, ” ‘You’ve got a company here pretending that it’s taking care of people in order to keep its cash flow going. You have to close them to admissions because they are killing people.’ ”

Davidson said the state workers “got a little upset with me,” but briefly looked into it and said they couldn’t find problems because the program kept no documentation.

“They would never allow this in surgical practice,” he said. “But in psychiatric practice, a lack of record keeping is considered prima facie evidence of competency?”

The company was bought by Cascadia Behavioral Healthcare, the largest mental health provider in Multnomah County, and now provides services under that name. Mark Schorr, a Cascadia spokesman, said, “Clearly having 20 unreported deaths, in fact, any unreported deaths, is unacceptable,” but he could not say how it had happened because the former program officials no longer work for the agency.


Amelia Scott, a 44-year-old homeless woman with schizophrenia and no known family, was placed in the “quiet room” of the psychiatric unit at Legacy Good Samaritan Hospital and Medical Center in Portland on April 13. Twenty minutes later, she was dead.

No one ever bothered to find out why.

A hospital doctor conducted a “provisional autopsy” that found Scott had died of “cardiorespiratory failure, etiology not determined.” In other words, she stopped breathing for unknown reasons. The medical examiner did not take the case after being told that Scott had died of natural causes, records and interviews show.

Another stone unturned: Toxicology tests ordered upon Scott’s admission were canceled after her death, DHS records show.

Despite such sketchy information, a mental health worker urged the state to close the case. Even though Scott died “suddenly and unexpectedly,” wrote Iris Kern, a protective services investigator for the Multnomah County mental health department, “It is my impression that there is no allegation that the treatment given to Scott by any mental health providers contributed to her death.”

The state agreed, and on May 1 filed away Kern’s 1-1/2-page report, one of the few pieces of obtainable proof that Scott ever lived.

It wasn’t until The Oregonian questioned how abuse could be ruled out based on so little information that state officials conceded that Scott’s case might have deserved a closer look. “You’re right,” said Kerstner, the state employee who handles all abuse and death reports within the mental health system. “It’s unclear from that why she died.”

Kern did not return calls for comment. Davidson, the Multnomah County mental health director, said his employees have to rely on the records hospitals provide, which frequently are incomplete, but allowed that “if this had been an important person, this wouldn’t have happened.”

Hospital officials declined to comment, saying medical privacy laws do not allow them to do more than confirm the time and date Scott died.

Asked what became of Scott’s body, a hospital spokeswoman would speak only in general terms about policy governing such matters: The unclaimed bodies of indigent people are disposed of by the crematorium with the lowest bid.

The death of Elise John, a 28-year-old woman suffering from schizophrenia, illustrates one reason Oregon’s counties are reluctant to look too closely at patient deaths: The cases sometimes involve hospitals that are the only providers of crucially needed psychiatric beds in a county.

John, an heiress to the Miller brewing fortune in Milwaukee, was involuntarily hospitalized after a suicide attempt in March 1999. She spent two weeks at Good Samaritan Hospital in Portland, mostly under her covers or cowering near the nurses’ station, hiding from an imagined killer. State records show she talked openly about hanging herself, tried to swallow a comb and ate soap.

Nonetheless, John’s psychiatrist released her on an evening pass, alone, to buy clothing for herself on March 26, 1999. John bought a rope, waited until dark and hanged herself from the Morrison Bridge.

Three days later, the state closed the case after a county investigator filed a report saying the death did not result from “abuse,” meaning it did not involve a deliberate act of wrongdoing.

Another county worker, Greg Monaco, the investigator who had petitioned a court to send John to the hospital, said he “discovered errors” in the investigative report of her suicide and challenged why she had been released.

“When I pointed out the errors to my superiors, I was stonewalled and worse,” he said in a letter to an advocacy agency. “The reaction I received convinced me that the county administrators at that time were more interested in denying complicity and protecting their relationship with the hospital involved than they were in honestly evaluating the preventable circumstances that led to Ms. John’s death. No one at either the county or state level seemed willing to look at this tragedy. It wasn’t worth their time.”

After Monaco’s complaint, another county worker revised the findings of the county’s report to the state to “inconclusive.” The state did not investigate further.

The agency Monaco wrote to later determined that the county’s inquiry into John’s suicide “lacked thoroughness and independence.”

“The county should not be investigating itself or its business partners, the hospitals,” Monaco later wrote in a letter to the advocacy agency.

Davidson, hired to reform the system in which Monaco works, said he has placed a much higher emphasis on getting to the bottom of why county mental health patients die.

But the potential conflict of interest that arises when counties investigate possible wrongdoing at hospitals or other contractors remains, not only in Multnomah County but throughout the state. In at least three cases The Oregonian examined, the state closed the files after case managers and therapists had investigated the deaths of their own clients.

A bill to provide independent oversight of investigations of care in county mental health agencies failed during the past legislative session. Advocates say they will try again next session.

“There needs to be an independent watchdog to keep everyone honest,” Monaco said in an interview by e-mail, “to ensure that the very necessary checks and balances are in place.”

Inconsistent practices

The Oregonian’s review of death reports by counties found a hodgepodge of procedures.

Some county workers routinely closed cases with no greater effort than clipping a client’s obituary and mailing it to the state. Other reports were written so unprofessionally they were either illegible or rife with misspellings. One investigator noted, “Due to suicide, (alleged victim) was not interviewed.”

An analysis of the records shows that of the 247 deaths collected in state files, 46 were closed with an obituary or brief account phoned in to DHS. Asked about the case in which a Baker County worker relied on a man’s suicide note to justify not investigating, Nikkel, the DHS official, rolled his eyes and said, “The obvious appearance is that it’s grasping for anything that would exonerate” the county.

Ninety-three death cases were given a cursory examination by county officials and were closed because they did not meet the state’s definition of abuse. In 98 additional deaths, counties looked more closely but still could find no fault with their actions or those of their contractors. Eight deaths, they found, were “inconclusive.” Only twice did county workers determine abuse had led to a client’s death.

DHS has been slow to build a system for dealing with the county reports, which began trickling into its offices after the law was passed in 1991. Before 1999, the reports were stuffed into a cardboard box and reviewed by a DHS worker allowed to devote only a quarter of her work week to the task, officials said.

That year, DHS transferred the job to its Office of Investigations and Training and hired Kerstner full time to serve as the gatekeeper to the reports.

Since then, the state has examined five deaths, a slight improvement from what it did before.

The state is well aware of the lack of accountability. Last year, DHS conducted focus groups and interviews in more than a dozen counties to try to gauge the law’s progress. The agency found that county mental health directors often placed the job of investigating death and abuse cases on the shoulders of already overworked case managers. The comments of those workers, published 11 months ago in a 30-page report, painted a picture of a system with little oversight.

One mental health worker said: “Sometimes we investigate and sometimes we don’t, depending on our workloads.”

Said another: “Our mental health program director has thrown away critical incident reports rather than assign them to be investigated because they don’t generate any program funding. He just doesn’t see them as a priority unless they are a politically sensitive case.”

Yet another: “We’re not funded to do this job, and we don’t have the money to train clinicians to become something they don’t want to be and never went to school to become.”

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Free to Die

Posted by CoffeeX3 on 30th December 2002

From The Oregonian, December 30, 2002 – not available elsewhere online

In the past three decades Oregon has made it much harder to send mentally ill people to institutions against their will. Today, those laws prevent some of the most severely ill Oregonians from getting the treatment they need.

An investigation by The Oregonian has found that at least 28 people have died in the past 3-1/2 years in the state after doctors, county mental health workers and other officials unsuccessfully sought to send them to psychiatric hospitals without their permission. The problem is almost certainly more widespread. The Oregonian studied only those whose deaths were documented in Department of Human Services records.

Judges, doctors and mental health workers say the laws intended to protect patients often work against them.

“I have had a number of cases in which I very much felt the people should be hospitalized,” said Multnomah County Circuit Judge Lewis Lawrence, who hears more involuntary hospitalization cases than any judge in the state. “But they weren’t committable under the law. And I felt terrible because I knew I was sending them to an unknown, perhaps horrific, fate.”

The painful life and tragic death of Mary Boos, a Portland woman with paranoid schizophrenia, is one such case.

Mental health workers, her parents and two court psychiatrists agreed that Boos, 40, was in grave danger and should be hospitalized. A judge, not Lawrence, refused, saying her case didn’t meet Oregon’s standard, under which a person must be a danger to herself, others or unable to provide for her basic personal needs. The Oregon Court of Appeals has told judges not to force patients into treatment unless they are unable to “survive in the near future.”

Boos lived 10 more months. But without treatment, she sank so deeply into her delusions that she would not leave her apartment. She would not eat the food her parents faithfully and frantically set outside the door no law could make her open. Her decomposing remains were found almost a year later on Oct. 20, 1997. The medical examiner ruled she died of “natural causes probably related to schizophrenia.” In other words, she starved to death.

Oregon lawmakers have been reluctant to touch the politically charged issue. In response to Boos’ death, they did add some provisions making it easier to hospitalize chronically mentally ill people. But because the process is so restrictive, judges and mental health officials acknowledge that the additional criteria rarely are used.

The laws in Oregon and other states were drafted as part of a nationwide reform in the 1960s spawned by revelations that thousands of Americans had been locked away against their will in barbaric, state-run psychiatric hospitals.

The reforms closed many of the hospitals and made it much harder for doctors or state officials to hospitalize, or “commit,” people without their consent. Reformers envisioned a benevolent system in which patients would have the deciding voice in determining their course of treatment. Studies in the past three decades have shown that this approach ignores the medical reality that severely ill people are sometimes too sick to recognize they need help.

“Nearly 30 years ago civil libertarians forced a national agenda that has made it virtually impossible to treat a large number of people with severe psychiatric disorders,” said Dr. E. Fuller Torrey, author of two books calling deinstitutionalization a “failed social experiment.”

Torrey said Oregon has been particularly reluctant to use civil commitment because of its tradition ” of independent living and not wanting government to interfere.”

As outraged as many people were by Boos’ death, which was openly discussed by her family, others said it was her right to decide and, ultimately, to die.

“As a society, we have set a very high bar,” Lawrence said. “We’re saying this is someone’s freedom. Who are we to try to control eccentricity if it’s not causing immediate harm?”

Even supporters of forced hospitalization in extreme cases do not want a return to the dehumanizing conditions depicted in “One Flew Over the Cuckoo’s Nest,” a movie filmed at Oregon State Hospital.

“Institutional care is really grim,” said Dr. Peter Davidson, head of Multnomah County’s mental health department. “We don’t have to force treatment on people all the time. We don’t have to ignore them, either.”

Illness creeps in

Mary Boos was raised on a maple-canopied block in Portland’s Laurelhurst neighborhood. A faded snapshot shows a toddler with blunt-cut bangs in a crisp cotton dress wedged and grinning between her two sisters.

At Laurelhurst Elementary School, Boos was curious and quick. At Grant High School, energetic and popular. By her sophomore year at the University of Oregon, she was sullen and withdrawn.

Boos managed to graduate with a bachelor’s degree in recreational therapy but couldn’t keep a job. A position as a nursing home activities director ended after three months when she was unable to follow through on basic tasks.

Many schizophrenics experience a sudden split with reality. The illness crept up on Boos so quietly that her family was left for years to wonder what was wrong.

When her parents, Carol and Richard Boos, finally persuaded her to confide in them, Boos couldn’t stop. During an eight-hour rant, she told them that the FBI and CIA were engaged in a conspiracy against her.

The Booses used their insurance to try to get her help, but their daughter wouldn’t go. Studies show that about half the people with schizophrenia or bipolar disorder are afflicted with a little understood symptom of the illness: lack of insight. That is, the disease impairs the part of the brain that enables them to evaluate themselves. In her mind, Boos didn’t need mental health treatment — she needed protection from the government operatives who were stalking her.

By the late 1980s, Boos’ parents put her up in a Northeast Portland apartment, which she decorated with an artist’s eye and yards of white linen. But before long, Boos was too paranoid to venture out.

The Booses thought their daughter needed to be hospitalized, so they turned to the public system. There, a mental health worker gave this advice: Stop supporting her. She’ll be evicted, act out violently and be hospitalized.

The worker knew that without Boos’ permission, the state could not intervene until she was a danger to herself or others. If she could be provoked into a violent outburst, chances were good that authorities would initiate the civil commitment process.

The Booses didn’t understand why they had to abandon their child to help her, but they went with the plan.

Eviction notices soon fluttered on Boos’ long-unopened door. But when a Multnomah County sheriff’s deputy came to remove her, she did not erupt. Instead, she collected her belongings, placed them on the porch and walked away in silence.

She was gone for a week. The Booses canvassed parks with her photo. Late one night, they heard a scraping sound on their patio. It was their daughter, disheveled and delusional, pulling up a chair to sleep.

Boos moved in with her parents but tumbled deeper into illness. She emerged from her room only to sneak unopened cans of food upstairs, checking them for tampering because she feared neighbors were poisoning them.

Carol Boos, confronting her worst fear, bought a book about schizophrenia and read it in secret. She once forgot and left it on a table.

“I do not have schizophrenia!” Boos screamed when she saw it.

The Booses called the public mental health system again. Weeks passed before a case manager visited their home.

On the day of the appointment, Boos came downstairs, fully dressed for the first time in weeks.

“The caseworker’s going to be here,” Carol Boos remembers telling her daughter.

“Not for me,” Boos said and walked out the door.

Hospitalized in South Carolina

As her parents frantically looked for her, Boos crisscrossed the country for 11 months in 1989 and 1990, searching for clues about why the government was after her.

She lived on the kindness of strangers. Passers-by slipped coins into her hands. Truck-stop waitresses tucked sandwiches in her pockets. But mental health officials in at least five states did nothing.

In Washington, a Pierce County sheriff’s deputy called Western Washington Mental Hospital when Boos showed up, talking of conspiracy. A hospital worker “talked to her for a while and said, ‘Well, nice meeting you, Mary,’ and left,” the deputy later told the Booses.

From there, Boos hitchhiked to Washington, D.C., and parked herself in the lobby of the Pentagon, records show, rambling that she’d been drugged as a child and in college.

“They told me they had nothing,” Boos later wrote in a letter to family. “But a Pentagon official said there was something too confidential for me to know.”

From there, Boos took a bus to New Jersey to find a lawyer who could force the Pentagon to cooperate. Social services workers there gave Boos a bus ticket to New York, a tactic social scientists have dubbed “Greyhound therapy.”

Boos slept on the steps of a Roman Catholic Church in New York City, where nuns fed her and helped her secure welfare benefits. But she wandered the streets delusional and afraid. After several months, Boos handed her welfare check to a bus ticket agent and asked, “How far will this take me?”

The Booses didn’t learn what had become of her until a family in Columbia, S.C., called police late one night in May 1990 to report that a psychotic woman was wandering their property.

They called the highest mental health officials in Oregon and South Carolina. Both states told them Boos was not an imminent danger to herself and could not be involuntarily committed.

“The law doesn’t mean just an immediate danger of going without a meal,” said Lawrence, the Multnomah County judge. “It means immediate danger of serious bodily harm or death. That is such a subjective area . . . . People who are on the streets and who are in need of fairly substantial medical care are still not committable because they’re not going to become seriously ill at any appreciable time in the near future.”

Kay McCrary, a mental health worker who learned about Boos through a family organization that tracks missing mentally ill people, thought otherwise.

She petitioned a South Carolina court without her boss’s permission. “I know that sometimes a person has to do the right thing,” she wrote to the Booses in 1991. “So, the next Mary Boos who comes homeless to Columbia won’t be left to their symptoms, deserted by the mental health system.”

Boos spent the next five weeks at the Bryan Psychiatric Hospital in Columbia. She would have been sent straight back to Oregon, but none of the state’s psychiatric hospitals had an open bed.

Boos was outraged when she was placed in a straitjacket and medicated against her will with Haldol, a highly potent antipsychotic drug with harsh side effects. But in less than two weeks, her psychosis dissipated.

She was diagnosed with paranoid schizophrenia and attended classes about the illness.

Boos began a new life.

“Getting here, in the hospital under medication, is what it took to free me from the thoughts and thinking I had,” she wrote her family. “It really was all my illness’ fault because now I can see how irrational I was. I’m determined to beat this illness as best as I possibly can.”

Brief respite, then lost
The brief hospital stay made it possible for Boos to function on her own for three years.

Back in Oregon in the summer of 1990, she faithfully took her medication and met with her Multnomah County mental health case manager.

Once too afraid to venture outside her apartment, she mingled with friends and family and joined a new church. She talked openly about her illness, sometimes even joking about it.

Boos’ improvement illustrates what reformers had in mind when they closed state-run mental hospitals: Although chronically ill patients might need occasional hospitalization, they would not have to be sent away for life.

But mentally ill people need structure and support to remain stable. At the same time civil libertarians made it difficult to treat those who refuse it, lawmakers, advocacy groups and mental health officials say the state abdicated its responsibility for the mentally ill, slashing budgets and cutting the very services that can keep them from ever needing involuntary care.Because of her parents, Boos had more help than most. It still wasn’t enough.

As with many patients, the side effects of Haldol — lethargy, blurred vision and involuntary facial movements — made it difficult for Boos to hold down anything but a menial job. Her parents remember her offense at being given a position “sorting screws” at a day treatment program.

But when Boos got her own job at a foster home for the developmentally disabled, she was so confused that on the third day she showed up at 8 p.m. instead of 8 a.m. and never returned.

Another problem: Boos, always a svelte beauty, had gained at least 60 pounds, another dangerous but common side effect of the drug.

In early 1993, Boos asked her Multnomah County psychiatrist to change her medication to Moban, a less potent antipsychotic medication that was less likely to cause weight gain and seizures.

It failed to control her illness.

A few months later, Boos was convinced that God had healed her and that she no longer needed medication. By October, she would talk to her parents only through her apartment window, which she had decorated with crosses.

Neighbors heard her chanting night and day. She stopped paying her rent.

Afraid she would run away if they again forced treatment, on Dec. 18, 1993, the Booses wrote a letter to the director of their daughter’s mental health agency, begging for help. “In her way, she has given us all plenty of warning. Now we must take action,” they wrote.

In Oregon the process to involuntarily commit someone can begin when two people sign a paper saying someone is a danger to herself. The Boos’ persuaded their daughter’s caseworker to sign such a document, and that allowed Boos to be temporarily hospitalized until a judge could determine whether she needed more long-term treatment.

A judge sent Boos to Adventist Medical Center on Jan. 26, 1994. She was released in slightly better condition after just two weeks of medication. But doctors did not change the medication to what had worked in the past, allowing her to stay on the less-potent Moban.

Boos soon slipped back into darkness. She kept no food in her apartment. She wore the same clothes day after day. She didn’t recognize her sisters.

When her parents came to her door, she smiled, took her father’s hand and said, “Dead.” She then took her mother’s hand and said, “Dead.”

This time the Booses petitioned the court on their own. They said the case manager had never checked on Boos after her release from the hospital nine months before.

After a petition, such cases are first assessed by county investigators, who interview the patient. Boos was hostile when the investigator came to her door. She demanded to see the paperwork, grabbed it from his hand and refused to return it. The investigator noted that Boos shouted at the voices in her head to, “Shut up! Shut up!” Asked whether she had taken her medications, she said, “Poison is your war.”

The investigator agreed that Boos was a danger to herself. Sheriff’s deputies pulled her kicking and screaming from her apartment. She told them they were from Satan.

At a hearing on Dec. 22, 1996, two psychiatrists recommended Boos for treatment, saying she was incoherent.

Boos’ court-appointed lawyer argued what she was paid by the state to argue: Boos might be a danger to herself, but not an imminent danger. The judge agreed and released Boos. She left the courtroom wearing nothing but a flimsy hospital gown.

When her father learned that her lawyer planned to put Boos on a bus to her apartment, he slipped $20 to a court official and said, “At least put her in a cab.”

They never saw her again.

Ten months passed. Boos sat inside her apartment and chanted.

The Booses wanted to pound the door down, but were told they could be arrested if they did. They left groceries at Boos’ door but had no idea whether she ate them or threw them away.

The county mental health agency charged with her care never sought her out, records show. When a mental health provider finally visited her apartment, Boos told him to go away. The agency complied and took her off the rolls. Under law, the agency could not force her to accept services. And it would not be paid for unproductive visits.

Mary Boos was found dead on Oct. 20, 1997.

State mental health officials at the highest levels sent their condolences to the Booses with a promise that they would investigate the circumstances of their daughter’s death. More than five years later, the Booses haven’t heard back.

A family friend, Eugene Minnard, lobbied legislators to dramatically change the laws. But the bills never made it out of committee.

Only after their daughter’s death were the Booses allowed to go into her apartment. They were horrified at what they saw.

The place was void of food or personal items but for some heirloom dishes Boos had ritualistically laid on the floor. Her curtains hung in tatters, and her bed was shredded, soiled and propped up on one corner by telephone books.

In the years since, the Booses have campaigned for changes in Oregon’s involuntary hospitalization laws, so far to no avail. They take small comfort in letters their daughter sent them from a psychiatric hospital in South Carolina, thanking them for never abandoning her to her illness.

“I really can’t thank you enough for that,” Mary Boos wrote. “I just hope I could do the same for you if you needed.”

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Free to Die Man Falls Through System’s Cracks to His Death

Posted by CoffeeX3 on 30th December 2002

From The Oregonian, December 30, 2002

In the end, all Randy Wike could find to love about life was his 3-year-old son and Ice House beer — he drank a case a day to mute the symptoms of a mental illness that had debilitated him since he was a teenager.

By age 30, it no longer mattered what had come first — the depression or the addiction. Wike had lost his job, home and Shay, the child he adored. The man who had once dreamed of becoming a chef found his meals in trash cans and stole six packs to wash them down.

Wike’s joyless existence passed mostly unnoticed until last summer, when he was twice subdued by police officers while attempting to jump off the Fremont Bridge in downtown Portland. On his second suicide attempt, a photographer for The Oregonian snapped photos of a police officer nearly plunging to his own death trying to save Wike, photos that were later published on the front page of the newspaper.

Multnomah County mental health workers examined Wike after both incidents and concluded that he was only suicidal when drunk and did not require their intervention. After he sobered up, they sent him back to the streets, where he returned to the bottle. On July 20, Wike again climbed atop the bridge. Again police officers tried to talk him down. This time, he wobbled for a moment and then fell off the span, plunging 205 feet to his death.

The mental health agencies in Oregon’s 36 counties treat about 66,000 patients a year. The state estimates that more than 12,000 additional mentally ill Oregonians need treatment. Some are turned away. Others are unable to navigate a system whose rules are opaque even to those who administer them. Advocates believe the number of untreated Oregonians is significantly higher.

Dr. Peter Davidson, the head of Multnomah County’s mental health department, acknowledged that Wike’s two suicide attempts should have prompted officials to treat him. Wike, he said, needed psychiatric therapy and help getting back on his feet.

Instead, Davidson said, “we didn’t maintain any contact with him at all.”

All of Wike’s dealings with the county, he said, arose from “his own cries for help. Not by anybody following through with him saying, ‘You don’t have to live like this. Let me help get you an apartment. Let me stay with you for a while.’

“My opinion why he’s dead is he was left to take care of himself,” Davidson said. “He was left to access the system after already showing that he couldn’t.”

Years of depression

Wike’s depression dated to his childhood, said his mother, Lynn Andre. When Wike was a boy, he would sleep all day, unable to drag himself to school. His first suicide attempt came shortly after he dropped out of high school in Hawaii his freshman year. Wike drank antifreeze and spent a couple of weeks in a Portland psychiatric hospital, his friends and family remember.

Years passed. Wike sought treatment several times but never had the money to stick with it.

In 1999, Angie Walton, the mother of Wike’s child, kicked him out of their Portland apartment, even though she said she still loved him. Until he straightened up, went to counseling and stopped drinking, she remembers telling him, he couldn’t be around their son.

Wike was mostly homeless after that, and his family was in no position to help. Both his mother and his sister were living in their cars.

By his 30th birthday in January, Wike had notched four drunken driving arrests, two relationships ending in restraining orders and a felony warrant in another state.

Wike took to the roads, traveling the country in search of work as a landscaper. He lived on a friend’s couch in Seattle and tried to become a music promoter, taping together fliers for a group called The Loungefly Band. In May, he hitchhiked to North Carolina to apply for a job with a circus. When he didn’t get it, records show, he was briefly hospitalized for depression and put on the antidepressant Prozac.

But Wike had lost his identification, so he couldn’t apply for public medical benefits to stay on the medication.

By June of this year, he was back in Portland. He slept in the woods. Panhandled for change. Ate out of garbage cans. Stole beer. Got drunk. Day after day.

On June 23, Wike was picked up in Northwest Portland by CHIERS social workers, drivers of the sobriety van familiar to people downtown, and taken to the Hooper Detoxification center in Northeast Portland.

Records show he was kicked out less than two hours later with $1.60 in his pocket “for being uncooperative with staff.” Hours after that, police were called to the top deck of the Fremont Bridge, where a tearful, drunken Wike said he was depressed, hadn’t seen his son and hadn’t taken his medication in two weeks. Officers talked him down and took him to the hospital where he was held temporarily while officials weighed whether to force him to stay for additional treatment.

Under state law, a county investigator is supposed to recommend a hearing before a judge if a person likely has a mental disorder and is dangerous to himself, others or is unable to care for his basic personal needs.

“He does have risk factors, but at this time does not meet commitment criteria,” a Multnomah County investigator wrote after determining that Wike was probably mentally ill. By law, a patient is released if he is willing to get treatment. Wike agreed to stay in the hospital for six days.

He was released on July 2 with a short supply of medications, records show.

Within four days, the cycle started over.

On July 6, police arrested Wike for trespassing when he crawled onto a Portland Fire Bureau boat to sleep. When police asked him what he was doing, Wike said in slurred speech, “I’m sorry, sir.” He was cited for trespassing and attempted theft: He’d taken a tarp off another boat to use as a blanket.

Police hauled Wike back to detox. He was discharged 4-1/2 hours later to what records called “the streets” with $4.96 and a bus pass. Less than two hours later, he was back up on the bridge.

This time, an officer nearly tumbled off the bridge trying to save Wike, a terrifying image captured by the photographer for The Oregonian.

Wike was taken to a hospital and again held for evaluation of his illness. A different county investigator, aware that this was Wike’s second time on the bridge in as many weeks, noted in her report that he smelled bad, but she did not try to call his family and friends, or read available police reports, despite agency rules requiring her to. Without that crucial information, the investigator determined that he was neither mentally ill nor an “imminent danger” to himself.

The hospital offered Wike voluntary admission anyway, but he declined. He couldn’t afford it. Wike had only $22, including $20 given to him by the police officer who had pulled him off the bridge.

The hospital and the county investigator jointly worked out a plan for Wike’s release. It consisted of directions to a social service agency where he could apply for a new identification card. They also gave him separate directions and a bus pass so he could travel to a mental health agency for counseling and free samples of one of the antidepressants they knew he was taking. Only one of those medications, Prozac, was available for free.

Wike never made it to either agency. His friends say he was too busy trying to survive.

Beers and goodbyes

The mother of his child spent her rent money to cremate Wike.

In August, his family and a half-dozen friends gathered at a Portland park to mourn his death.

They didn’t have enough money for a funeral, but they wanted to do something Wike would have appreciated.

They tossed a Frisbee, grilled burgers and blasted Ozzy Osbourne’s “Mama, I’m Coming Home.” Someone cracked open a bottle of Ice House beer and stuck the top in the ground “for Randy.”

His sister cried. His buddies let 30 white balloons swirl into the sky, one for every year Wike lived. And a 3-year-old noticed a photo, propped up on a picnic table and surrounded with plastic flowers.

“That’s my daddy!” Shay said, too young to understand his father was dead. “That’s him! That’s him!”

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