From The Lund Report, October 12, 2009

A building boom may be good for capacity but it threatens to supplant community mental health options

As private mental health hospitals spring up across the state to compete with a new Oregon State Hospital building under construction, community mental health providers are crying out for their own funding.

Leaders at the highest levels in the state’s mental health system acknowledge the strange universe that funds hospitals for the mentally ill while allowing out-patient preventative care to whither.

Given the recent crisis and patchwork reformulation of the state’s largest mental health provider, the current situation is even more surreal. In the wake of Cascadia Behavioral Healthcare’s collapse last year, providers hoped that a better community-treatment system would emerge from the ashes, but so far, they lament no framework has proven viable to replace it.

Most insiders aren’t especially surprised that community mental healthcare got the short shrift once again.

“Community mental health has never been adequately resourced in Oregon,” says Mary Claire Buckley, executive director of the state’s Psychiatric Security Review Board.

Convicted criminals who successfully assert the insanity defense are placed under the review board’s jurisdiction, yet Buckley worries more and more about what prevents patients from entering the criminal justice system in the first place. “The more resources you have in the community, the better the whole system, and that’s what I’m concerned about,” she says.

Concern is especially high throughout Oregon’s mental health field due to a January 2010 ballot referendum that would renege $733 million in state taxes designated for upkeep of social services post-recession. Gina Nikkel, the Association of Community Mental Health Programs executive director, argues that the mental health care situation had reached dire proportions long before the economic downturn.

“If that ballot measure at the end of January goes south for us, we’ll be looking at cutting 30 percent of services, and we already don’t have funding that’s even close to adequate,” Nikkel says.

That said, critics of insufficient allocation to community mental health wouldn’t want community funding to come at the expense of acute care centers such as the state hospital.

Buckley, whose board manages forensic patients’ entry into and exit from the state hospital, has always tried to keep lengths of stay to a minimum. The facility was originally built in the 19th century and is best known as the filming location for the Academy Award-winning version of Ken Kesey’s One Flew Over the Cuckoo’s Nest. “A replacement of the current hospital is long overdue,” she says.

However, Buckley and other administrators lack many alternatives to the state hospital, which has operated at more than 100 percent of capacity in recent years. The last biennium budgeted $373 a day per patient, which quickly adds up over $100 million when the hospital keeps more than 800 patients year-round.

“It’s not the chicken or the egg, we need all levels of care,” Nikkel says. “You have to fund it all.”

She sees a dangerous proposition in such an uneven funding environment. “You can’t shift all the money to the front end and let the back end fail or vice-versa,” she says.

Yet now the main hope of community mental health care advocates lies in the unlikeliest of places, the hospital system itself. Once a new Salem building is completed in 2011, Roy Orr, superintendent of the Oregon State Hospital, sees an opportunity for his staff to administer non-ward-based services that have traditionally been solely in the community realm.

“Historically the state hospital hasn’t been strong enough on treatment in general, but more specifically, we’ve lacked the staff to provide the intensity of treatment that our residents deserve,” Orr says.

The shortage of services has not been unique to the state hospital. Richard Harris, Addictions and Mental Health Division director of the Oregon Department of Human Services, figures that only half of the vulnerable population has any access to care.

“Sub-acute capacity needs to be increased in communities,” Harris says. “The goal for all mental health services should be to get people self-sufficient.”

Orr has agreed to this goal in principle and claims it’s already playing out in practice at the state hospital. He points to “treatment malls,” designed toward socialization, in which his staff has already begun participating off-site.

“We can’t just take the old contents of the state hospital and dump it in the new one,” he says.

As to why the funding for building wasn’t spread out among more community facilities, Orr says, “That decision was frankly made before my arrival, and I didn’t second-guess that.

“Our critical point of articulation with community providers, whether out-patient or acute, is that we provide a safety net,” he adds. “What we really try to do is work as closely as we can with AMH and through them work with all the community providers.”

Advocates aren’t so sure the system can support itself effectively. Buckley emphasizes the importance of preventative care to support the acute-care facilities.

“DHS has been doing a good job creatively getting people back in the community, but there is only so much they can do with the current funding situation,” she says. “Hopefully what that building’s going to bring is a whole new treatment model, but we’re spending all these millions on the state hospital, and that’s only a small piece of the process.”

OUR COMMENT – As for the question of who approved the development of two new “hospitals” when the preponderance of evidence shows the greatest need for funding is in the community was entirely in the hands of politicians – and not clinicians or medical administrators. The Mental Health Association of Portland is on record in opposition to these new facilities from the moment they were proposed.

This misappropriation of funds toward hospital-which-are-prisons and away from community mental health clinics – and those who know better and are not speaking up – is a grave betrayal of persons with severe and persistent mental illness for future generations. These buildings, and the staffs who occupy them, have a determined life of their own, which is proven dangerous to their inmates.

Don’t be fooled by the public relations machine in Salem – the new Oregon State Hospitals are a $600 million dollar boondoggle our children and grandchildren will loath us for permitting.