Mental health in crisis

From The Portland Business Journal, September 16, 2001

The area’s mental health care system is in a state of disrepair, but county officials have created a stop-gap plan

Anyone involved in the local mental health system as a client, provider, administrator or family member has been familiar with the litany of faults and failures of the system for years.

But it took a one-two punch–closure of Sellwood’s Pacific Gateway Hospital, where a Mexican national died this spring, and the subsequent collapse of Multnomah County’s Crisis Triage Center–to point out the grave structural defects in the system to the rest of us.

Critics say problems in the health care system can be traced to 1998, when the county switched from fee-for-service contracts to managed care. Additional system stresses include the expansion of mental health services covered under the Oregon Health Plan and cost controls placed on nonprofits that deliver mental health care services in the community.

Residents of Multnomah County access mental health care at a rate twice the state’s per capita average. The average cost of an acute care bed in area hospitals was $422.50 through June of 2001. But new per-diem rates negotiated with local hospitals bring that cost up to almost $700 a day.

“It’s keeping me awake at night,” admitted Diane Linn, Multnomah county commissioner chair. “We’ve really been struggling with this.”

The problems attending the grim statistics are large and complicated, involving various agencies, each with its own bureaucracy; a difficult and expensive client base with which to work; and a virtually nonexistent data collection system.

Add in the larger social issues, such as the lack of affordable housing, the stigma still attached to mental illness and ambivalence toward the poor and homeless, and it’s clear there are no easy answers.

The county spends almost 20 percent of its mental health care budget on hospitalizing mentally ill patients because cheaper and more effective care alternatives have been cut.

Linn believes the system is failing in its responsibility to its most vulnerable citizens.

“If you look at it from the perspective of the person who needs to use this system, it’s awful,” she said.

The closure of Crisis Triage Center–the centralized care center for Multnomah County–has further complicated the situation. The CTC opened in 1997 as a state-of-the-art psychiatric triage facility, located at Providence Portland Medical Center. It served everyone from private clients to Oregon Health Plan enrollees in psychological crisis.

The CTC contract with Multnomah County expired June 30, and talks to renew it broke down over escalating costs. The closure of the CTC on Aug. 1 left emergency personnel with no designated place to take area residents in psychiatric crisis.

The closure of Pacific Gateway Hospital, following the death of Jose Victor Santos Mejia Poot this spring, further added to the gap.

The county has redesigned a system that would redirect dollars from acute care facilities like emergency rooms and hospital beds to neighborhood clinical services and outreach professional services.

The county’s “gap” plan establishes four walk-in, no-appointment clinics and mobile crisis teams to replace the failed Crisis Triage Center.

It also calls for adding a secure evaluation facility to replace the 66-bed psychiatric ward at Pacific Gateway in the near future. The gap plan addresses the first 90 days of the newly redesigned county system. Phase two, which should be adopted this month, covers days 91 through 365.

The improvements can’t come too quickly for emergency services that end up with seriously mentally ill clients in their care while an overcrowded system tries to find a place for them for longer-term care.

“Now officers must go to the nearest emergency room and wait,” said Ed Riddell, head of the Portland Police Bureaus’ Crisis Intervention Team. “And the wait is often four hours or more.”

Riddell points out that officers waiting in emergency rooms with mental health patients is awkward and keeps them from doing police work.

Three of four walk-in clinics opened Aug. 1, and another one in downtown Portland is expected to open in September. Clinics offer services in a more welcoming, less anxiety-producing environment, said Jim Hlava, program director of rehabilitation services at Network Behavioral HealthCare Inc., which operates the walk-in clinics.

“There are other existing programs here,” he explained. “We have peer counseling. We have a meals program. Some of the clients who walk in here are homeless and they haven’t had a bath or a shower in awhile. We’ve got a shower and that helps bring down someone’s anxiety or agitation. If you’re feeling a little bit better about yourself you’re not as angry and agitated.”

That’s the approach favored by Barry Kast, an administrator with the State of Oregon Health Services, which includes mental health.

“The key to a successful mental health program is that you’re combining a health program with other services, such as income support, housing, employment,” he said.

Adding to the county’s troubles with the redesign is the discovery of a $4.7 million revenue shortfall.

Estimates of county reimbursement through the Oregon Health Plan were both too high in the number of clients served and the reimbursement per client the state would provide.

To get clinics and mobile teams up and running, the county plan calls for dipping into the existing mental health care reserves for a one-time bailout of $1.72 million.

“We’re pretty much shoulder to shoulder with chair Diane Linn, and her staff,” Kast said. “She has quite courageously taken on what has been a decade or two of struggling to find the right system for the county. It’s a very difficult problem.”

Though the contribution per patient has dropped, according to Kast, the state has allocated an additional $1.5 million to help meet the extra costs, on top of the money already earmarked for Multnomah County health services.

“I have to tell you that I think the general community still struggles with the whole issue as a great big terrible, frustrating, tragic mystery,” said Linn. “There is a terrible stigma attached to mental illness, and that complicates the problem.”

In addition to walk-in clinics, the plan calls for a county-run crisis phone service, to attach mobile outreach crisis teams to each clinic, as well as a contract for a new secure evaluation facility to replace Pacific Gateway.

The plan calls for a centralized mental health care administration, the installation of a data system, provider contracts increasing the accountability for outcomes and incentives to avoid acute hospital care.

“We as a community have the responsibility to manage this,” Linn said. “For me that is very close to home.”