A Crisis in Costs, Day 3: Economic change may alter construction plan

From the Salem Statesman Journal, May 25, 2010

Critics say money would be better spent providing services in community

Building two new mental hospitals to replace the Oregon State Hospital in Salem doesn’t make sense during the worst recession in generations, critics say.

The two-hospital plan grew out of a state-commissioned report issued in 2006 — before the economy tanked, spinning off double-digit unemployment, reduced tax revenue to pay for state government and looming budget deficits.

“When the study was done, those were fat times in the state economy,” said Robert Joondeph, executive director of Disability Rights Oregon, an advocacy group that monitors the hospital. “We’re looking at serious budget problems, so we have to figure out how to work smarter with the money we have.”

The latest projections are for a $2.5 billion gap between what the state will bring in during the 2011-13 budget period and how much it will cost to provide the current level of service.

Joondeph said the state can’t afford to spend more than $120 million annually to operate the hospital in Junction City.

“It doesn’t make sense now,” he said. “We have an upcoming budget cliff, and the state is on track to build yet another state mental hospital in Junction City, which it does not have the money to staff. And, by the state’s own studies, it has a community mental health budget that is woefully underfunded.”

In fact, state legislators haven’t heeded the advice of a state-commissioned report that set the stage for building two new psychiatric hospitals.

The State Hospital Master Plan Phase II Report (13.5 MB), issued in February 2006, recommended significant investment in community mental health services.

“Enhancing the breadth and depth of community-based services is a critical piece of the state hospital master plan,” the report said. It warned, “Without the enhanced community programming, demand for Oregon State Hospital beds will substantially exceed projections of size and cost.”

State mental health officials and advocates agree that funding continues to be lacking for services designed to help mentally ill Oregonians before they become acutely ill and require hospitalization.

But they disagree about whether the Junction City hospital should be shelved.

“I think all of us in DHS are aware that there are a number of people who have started to question whether or not the Junction City hospital should be built,” said Richard Harris, director of the state Addictions and Mental Health Division of the Department of Human Services. “Right now, I would say there’s nothing in our work plan that tells us that we should do anything differently.”

Without the Junction City facility, the state would face a severe shortage of mental hospital beds, said Senate President Peter Courtney, D-Salem.

“It simply won’t work,” he said. “We’re not going to stockpile people at the Oregon State Hospital. We can’t do it. We’d get in serious trouble.”

Both hospital projects are moving forward, said Linda Hammond, hospital replacement administrator for the state.

“I’ve still got the same marching orders I’ve always had, to build facilities in Salem and Junction City,” she said.

Services ‘way behind’

Advocates say that postponing or canceling the Junction City project would free up a big chunk of state general fund money to expand an array of thinly supported community services, such as early intervention and prevention, supported employment and education, affordable and safe housing options, jail diversion programs, wellness programs, medication management, case management and more.

“The money and vision needs to be redirected to evidence-based, outcome-driven integrated treatment on demand in the communities,” said Jason Renaud of the Mental Health Association of Portland. “This is a promise which has gone undelivered for, well, generations, and the result has been a migration of persons sentenced to the hospital who often lose hope, community connections and remain ill.”

Harris agreed that community mental health has been slighted.

“Our investment in the community side is way behind what it needs to be,” he said. “That’s a problem. You can’t solve all the mental health problems in the state of Oregon with a state hospital.”

“My plea would be for the Legislature to seriously look at the community services work group report, which said that there needed to be an equal investment in community-based services if you wanted to adequately serve the needs of people with mental illness in a way to keep them out of the state hospital,” Harris said.

Courtney said hospital reforms remain his top priority. He favors incremental improvements in the community side.

“I can’t take care of all fronts at once,” he said. “We want to do the community right, but I can’t just sacrifice one for the other.”

Motivation to build

The existing state hospital consists of dozens of buildings, all built between 1883 and 1955. The crumbling facility reportedly is the oldest state-run psychiatric facility on the West Coast still being used for patient care.

The state’s drive to build two new hospitals was spurred by a series of critical reports, documenting sweeping defects in hospital conditions.

State-hired consultants deemed the hospital obsolete and unsafe in 2005. They warned that the massive J Building could collapse in an earthquake.

Courtney’s determination to build modern new facilities started when he toured the decrepit facility in late 2004.

“I am well aware of the concerns of the advocates, but I had to get new facilities,” he said. “I’m sorry, I couldn’t just say we won’t move on building new facilities until we have the community thing taken care of. I didn’t have that option.”

More pressure for hospital reforms came in January 2008, when the U.S. Department of Justice put state leaders on notice that sweeping improvements must occur in patient care and hospital conditions or the state would face a federal lawsuit that could place the institution under federal court control.

The feds haven’t sued, but the threat still looms.

Courtney expects federal scrutiny to drag on for years.

“They’re just going to hover, so to speak, and watch and watch and watch,” he said. “I think we’re going to have to live with that indefinitely.”

Advocates who oppose the Junction City hospital point to persistent problems at the existing hospital as another reason not to build two new hospitals.

October’s death of a patient, Moises Perez, heightened their concerns about adequate treatment and patient safety. Perez, 42, was found dead in his hospital bed Oct. 17. An autopsy determined that he died from coronary artery disease.

Investigators reported that Perez’s caregivers failed to properly treat his chronic medical conditions, failed to prepare a meaningful treatment plan for him, failed to update his medical chart and failed to return calls from his family in the last weeks of his life.

“The fact that they can’t get the Oregon State Hospital right is not encouraging,” said Chris Bouneff, executive director of NAMI Oregon, a chapter of the National Alliance of Mental Illness. “They have no business building a second hospital.”

Overcrowding taboo

At the hospital in Salem, patients are packed into overcrowded treatment units and cramped bedrooms. Some bedrooms have five or more patients.

The design for the new hospital in Salem calls for patients to occupy single-person and two-person rooms.

Overcrowding won’t be allowed, hospital planners said.

“You’re going to be licensed at 620 beds, and I cannot see any exception in this process,” Hammond said. “There’s nowhere to put anybody else.”

State-hired work crews are erecting the first sections of the new hospital in Salem. Building is occurring south of Center Street NE, on the existing hospital campus.

The 620-bed facility, described as “world class” by state officials, is scheduled to open in phases, starting this summer with the kitchen, warehouse and vocational rehabilitation facilities. The first patient-occupied areas are scheduled to open in November or December, and the facility is scheduled to become fully operational by late 2011.

The 360-bed Junction City facility is earmarked for construction on state prison land — about 50 miles south of Salem. Work is due to begin next year, and the hospital is supposed to open in 2013.

Budgeted costs for building the two new psychiatric hospitals are $458 million.

As approved by the Legislature, state financing for constructing the facilities will come through the sale of certificates of participation, or COPs. COPs commonly are used in Oregon to pay for new public buildings. COPs are sold to investors whose interest income is exempt from state and federal taxes.

Unlike construction costs, operational costs would draw on the state’s general-fund budget, which pays for a wide range of programs and services, including schools, prisons and social services.

Mentally ill in jails

Spending vast sums of money for two new hospitals and keeping the community mental health system on a back burner means that many mentally ill Oregonians won’t receive the help they need, advocates said.

In the past decade, county jails and state prisons increasingly have become warehouses for mentally ill inmates. The statistics:

    -Of the 540 criminal defendants booked into county jails each day, at least 20 percent of them have a serious mental illness, jail surveys show.

    -Nearly half of the prisoners in Oregon’s 14,000-inmate state prison system are mentally ill, according to the Department of Corrections.

    -About three-fourths of the patients housed at the state hospital were committed by criminal courts. They are housed in the hospital’s crowded forensic psychiatric program.

Advocates described the 450-patient forensic program as part prison, part hospital, part warehouse.

Patients deemed ready for discharge often languish at the hospital because of a shortage of community beds. Too often, released patients cycle back to the mental institution or land in jail because they don’t get enough support on the outside.

“The way to measure the success of a hospital is when patients get well, leave and don’t come back,” Renaud said. “But at OSH, too many patients never leave, and too often they leave for situations which are unsustainable. And then they come back, which benefits no one but the OSH staff, vendors and construction companies.”