Swinging doors at the state hospital

From The Oregonian, May 2, 2011

Lawmakers must carefully balance patient care, taxpayer cost and public safety

It’s clear that some patients spend too long in the Oregon State Hospital, where a year of care and confinement costs $200,000. It is less clear why that’s so, and what the Legislature should do about it.

There’s a rush on in Salem to lay blame for the lengthy hospital stays and extraordinary costs onto the Psychiatric Security Review Board, which decides when a forensics patient — someone who has pleaded guilty except for insanity to a crime — is ready for release from the hospital to less-restrictive community facilities.

It’s true that the PSRB has a long history of erring on the side of confinement. That’s what Oregonians apparently wanted when they established the pioneering PSRB in 1978, and wrote into law that the board’s primary responsibility was to protect public safety. It’s done that. Over the past three decades fewer than 2 percent of conditionally released patients committed new crimes. That’s a remarkable figure, but it’s come at a high cost to patients and taxpayers.

It’s also contributed to a damaging kink in Oregon’s mental health system, with patients stacking up at the overcrowded and expensive hospital, while little or no care is available to many other persons with mental illness. The crowded conditions and lengthy stays are part of an ongoing federal civil rights investigation of the hospital.

Given all this, it’s appropriate that lawmakers are debating legislation that would reduce the number of patients sent to the hospital, and, in theory at least, shorten the length of stay for some of those who are hospitalized.

We’re strongly in favor of Senate Bill 3100, which would reduce the number of patients coming in the hospital’s front door. It would require an evaluation by a state-certified psychologist or psychiatrist before a person could successfully plead guilty except for insanity. It would also exclude from the hospital persons who plead guilty except for insanity to misdemeanor crimes.

Senate Bill 420 is a more complex, difficult question. That bill proposes to take the responsibility for deciding when a hospital patient is ready for release away from the PSRB and give it to the Oregon Health Authority. Supporters, including patients and advocates for those with mental illness, strongly support the bill, arguing that decisions about the fitness of patients for release belong with physicians and the health authority.

That makes sense. But SB420 may have less impact than many people expect. In recent years, as scrutiny on the state hospital has grown, the PSRB has been more accommodating about moving people out of the hospital. In fact, it’s hard to find many recent cases in which state hospital physicians have recommended a patient’s release, and a community facility were ready and willing to accept that patient, and yet the PSRB denied the release.

Shifting responsibility for release decisions from the PSRB to the health authority will not magically open up more community beds for patients prepared for release from the hospital. We’re not opposed to the shift, but if the Legislature makes this change, it should be done with clear eyes. In the end, the only way to move people more quickly from the state hospital is to ensure that they have a place to go, one that provides an appropriate level of care and protects the public safety.