Mental health treatment improving in Central Oregon

April 29, 2012, from

Telecare caused quite a stir in 2010 when it opened two residential homes in northeast Bend. Neighbors feared their property values would drop and worried that some residents of the mental health facilities might be dangerous. They later complained about residents’ tendency to smoke on neighborhood sidewalks.

The debate put a magnifying glass on the treatment of mental illness, which is delivered much differently in Central Oregon today than it was even a decade ago.

Before the 2005 opening of the Sage View Psychiatric Center near St. Charles Bend, anyone who experienced a psychiatric problem requiring help faced a long trek. Adequate care was available in the Willamette Valley and Pendleton, but not here.

Sage View administrator Molly Wells remembers very well what services looked like back then. “Before, we had two hold rooms on the fourth floor (of St. Charles Bend) and we had to send all of the clients to Pendleton or (Salem) or Portland.”

Mental health care has changed dramatically thanks largely to a 1999 U.S. Supreme Court decision, which coincided with local officials’ desire to create more options for the mentally ill and with the state’s push for deinstitutionalization.

As a result, Central Oregon today provides a greater spectrum of care for people struggling to cope with schizophrenia and other mental illnesses.

The 1999 Supreme Court case, commonly called the Olmstead decision, determined that it is discriminatory to keep the mentally ill in institutions if they can reasonably be placed in community settings instead.

According to a February 2011 memo from the Oregon Department of Human Services/Oregon Health Authority, “To achieve the intent of the Olmstead decision Oregon intends to move healthy people to independent housing that promotes recovery, resiliency, independence and wellness in a system that is consumer driven and assists people in obtaining ‘a key to their own door.’ ”

That means cutting the length of time people stay in the Oregon State Hospital in Salem and expanding “independent living environments” around the state.

A study completed in 2010 by Accumental Health, a nonprofit contracted by the state, found that about 60 percent of people in some form of mental health facility could be placed in less restrictive facilities or could conceivably live independently.

However, a 2010 state memo discussing the Oregon Health Authority’s plan to honor the Olmstead decision noted that Oregon’s system was “under stress because the state had relied on creating a facility-based approach to service delivery” reliant upon large hospitals. As a result, “the mental health system at present is meeting less than 50 percent of the need for public services for adults and children.”

The problem was evident in Central Oregon. Because the area lacked the necessary homes and community-based facilities, the mentally ill either remained in the state hospital much longer than necessary or were released to other areas of the state.

“We didn’t have nearly enough resources,” said Deschutes County Mental Health Director Scott Johnson. “I’d hear from a mom, ‘I’ve got a daughter (receiving care) in Medford and I want to bring her home,’ and we realized we needed to do more to keep people in our community.”

Bob Joondeph, president of the advocacy group Disability Rights Oregon, says it’s better to place the mentally ill in smaller facilities for several reasons.

“In a big state hospital there’s huge bureaucracy,” he said. “If you just look at our state hospital, there are all kinds of problems. . It is clinical, and supervision becomes more difficult with more and more wards and doctors. The tradition at the state hospital in Salem is that wards are these independent little fiefdoms, so there are difficulties (for patients) in transferring to different levels because of the politics within these institutions.”

Smaller facilities, he said, avoid many of those problems.

“They tend to be more relaxed environments,” he said. “The staff (relationship) to the patients is steadier and more direct, more long-term, and that’s good for folks.”

Joondeph said Oregon’s treatment model has long involved the transition of the mentally ill to smaller facilities as they recover. The model hasn’t worked perfectly, he said, but he believes the state is trying to revive it.

“For many years the system that was originally designed to be a step down became sclerotic,” Joondeph said. “It became clogged. And our mental health system is designed for people to move, and so once any part of the steps in movement become clogged, it backs up, and you end up with folks staying (too long).”

The state hospital, meanwhile, has had its share of problems. The hospital is famous for its role in the 1963 Ken Kesey novel and 1975 film “One Flew Over the Cuckoo’s Nest.” In 2008, the U.S. Department of Justice’s Civil Rights Division issued a critical report on problems at the hospital that violated patients’ rights. Among them, the report found the hospital wasn’t protecting its patients from harm, wasn’t providing proper assessments and mental health care, overused seclusion and restraints, and didn’t properly manage medication. The federal investigation into the hospital continues.

In 2010, Oregon began to implement the Adult Mental Health Initiative, which seeks to better use facilities already in place and to improve the coordination of care. The initiative aims to address a problem identified in a 2010 Oregon Health Authority memo: “Currently, too many Oregonians living with mental illness spend too much time in the wrong level of care and cannot access services that could help them become more independent.”

To combat the problem, the state decided to transfer responsibility for managing the residential services to local mental health organizations. The state’s large residential facilities “are less flexible and more costly than a community-based supportive housing system,” the memo states.

The Adult Mental Health Initiative provides funds directly to counties and other mental health organizations, allowing local government officials to determine — and pay for — the services their communities need. Deschutes County’s mental health department has used these funds for about a year to run its Assertive Community Treatment, or ACT, team. Each team member makes regular visits to a small number of people living independently or in supported housing, said Travis Sammon, the team’s supervisor. By making health checks, bringing medicine and ensuring the provision of needed services, team members help those dealing with mental illness live largely on their own.

“We can take people who have been in residential care for years, and what we’re able to do with the ACT team is put them in their own apartments,” Sammon said. “Some of them are 50 years old, and it’s the first time they’re on their own.”

ACT team members look for indications that their clients are struggling to manage their apartments and keep themselves clean and well-fed. They track police calls and visits by their clients to the emergency room.

Using local residential treatment homes, meanwhile, can prevent hospitalization for people in a downward spiral, said Sammon, though “sometimes it takes a while — a week or a month or three months.”

To Sammon, who worked in a state hospital before coming to Deschutes County, keeping the mentally ill in their home communities is vital.

“Being in a state hospital — it’s not very helpful to a lot of people to be in that situation,” he said. “It’s a very unappealing environment to help those who are not the illest of the ill. The units have people who are very psychotic, violent, aggressive. And that’s the last place you want to be if you’re trying to get help and recover.”

Sammon said the ACT team is cheaper, too. According to Oregon State Hospital spokeswoman Rebeka Gipson-King, the average cost for a patient to stay in the state hospital is $21,875 a month, or $262,500 each year.

“I can house a person for $6,000 for a full year,” Sammon said.

Much of this money is used to subsidize rent and provide housing vouchers for people who often receive less than $700 per month in Social Security Disability Insurance.

In 2010, nine people from Deschutes County were admitted for state hospitalization. In 2011, four were.

“I believe this is a direct result of having increased residential beds, which allowed us to divert a number of individuals instead of sending them to the state hospital,” Sammon wrote in an email.

The average length of hospitalization dropped as well over the same period. In 2010, locals committed to the state hospital typically spent 94 days there. In 2011, those stays lasted only 65 days.

Although the area has seen an uptick in the number and variety of placements available for people who are struggling with mental illness, many say there is a need for even more.

“We want lots of options. The state as a whole, they’ve made past development of structured residences more of a priority to meet the need,” said Kevin McChesney, who oversees Telecare’s Oregon operations. “Because of the budget we’re only serving 40 to 45 percent of people, so there’s a huge unmet need. We need those RTFs (residential treatment facilities) and RTHs (residential treatment homes), because people are backing up in the secure facilities. It’s a real need.”

In 1999, HousingWorks Director Cyndy Cook took her first step into supported housing for the mentally ill.

A pair of Deschutes County case managers showed up at her door that year and told her they couldn’t treat clients who didn’t have places to live.

“They were in crappy old motels,” she said. “Some were living in camps.”

Spurred by their pitch, Cook toured the Willamette Valley, talked to developers and mental health departments and checked out housing.

“I said, ‘We should be doing this, and we can do this better.’ ”

In 2000, HousingWorks opened Emma’s Place, an apartment community in which people with severe and persistent mental illness can live for as long as necessary. HousingWorks is also responsible for Horizon House, a two-year transitional housing facility in Bend, which opened in 2005; Prairie House, an apartment complex for people with mental illness in Prineville, which opened in 2006; and Barbara’s Place, an apartment complex in southwest Redmond for chronically homeless people with severe mental illness, which opened in 2010.

In 2010, Telecare Corp., in conjunction with the state, opened two five-bed residential treatment homes in northeast Bend. Those homes allow residents to come and go as they please, but provide structured times for eating meals and taking medicines and receiving various types of therapy.

“If you’re in a larger facility like the state hospital, you get three meals a day and housekeeping and all these things that make it so you’re at camp,” Joondeph said. “You go and all these things are taken care of. It’s not like living in the community.”

Months later, the Alameda, Calif., company opened a secure residential treatment facility on Poe Sholes Road in Bend. The locked facility has 16 beds and two staff members for every five residents. It also features a variety of oversight levels. Some residents earn the right to go out into the community on hours long passes. Others remain locked up, including some who are always in a staff member’s line of sight.

The goal at the secure facility, which opened in January 2011, is to help residents develop skills. Some, for instance, can earn a food handler’s card and work in the facility’s dining area and, eventually, a restaurant. Others work on hygiene and other coping skills like housekeeping.

“We try to get them to identify their hopes and dreams, then try to give them activities to move toward that,” said Emilie Dauch, the facility’s director. “If you’ve been institutionalized a long time, your hope has died to some extent. . Even the idea of an open kitchen can be a new thing.”

The region also has several adult foster homes to serve people with mental health issues.

Given the availability of many treatment options, a mentally ill person could conceivably suffer a psychotic episode and receive treatment without ever leaving Bend: starting at the emergency room or Sage View, moving through local facilities, and eventually returning to an apartment or family home. Those who present a danger to themselves or others can still go to a state hospital for help, as can those with significant needs. They return to the area when they feel better.

“We want people to move to lower levels of care, with more responsibility,” Johnson said. “If they deteriorate, they can move back up to a higher level. That continuum of care should go both ways.”

Ultimately, the local expansion of mental health treatment reduces the likelihood that Central Oregonians will end up in the state hospital. In addition to reducing treatment costs, this can prevent disruptions for patients, who would have to head to Portland, Salem or Pendleton for treatment, Sammon said. Such upheavals can force the mentally ill into a frustrating cycle: rebuilding lives that are already fragile.