On May 27 three organizations, the Mental Health Association of Portland, the Mental Health Association of Oregon and the National Alliance for Mental Illness of Multnomah County wrote to Joanne Fuller, Director of the Multnomah County Department of Human Services, and Karl Brimner, Director of Multnomah County’s Mental Health and Addiction Services Division.
Our letter in bold, and Karl’s replies in italics, are below.
As the leading mental health advocacy organizations in Multnomah County, we write with a goal of ensuring that the reorganization of county mental health services results in both the best possible care for persons living with mental illness and a new era of transparency, inclusion, and accountability begins for Multnomah County’s mental health division. To that end, we respectfully make the following requests:
Thank you all for your e-mail of May 27, 2008 and the points you have identified. My reply is in the order of the issues you raised in that e-mail. As you know, we are not pursuing reorganization of the mental health system at this time, but we are responding to the problems created by Cascadia’s financial instability. I hope that our strategies for resolution of the immediate issues will lead into others areas of improvement that can be addressed in the future.
Learn from history. Attempting to fix Multnomah County’s mental health system has crumpled the careers of many. Where the County is going, others have been before. We suggest leaders of the reorganization become as knowledgeable as possible about what’s occurred in the recent past by reviewing the following documents and talking with the following individuals:
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1. The original Cascadia proposal by Kim Burgess and Peter Davidson.
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2. The final report on redesigning Multnomah County’s mental health services by the Technical Assistance Collaborative from November of 2000.
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3. The chairpersons of the three committees of the redesign process, Elsa Porter of the Chair’s Task Force, Ed Blackburn of the Design Team, and Jim Gaynor and Diane Linn of the Implementation Committee. We also suggest talking with Kim Burgess who was the primary author of the Cascadia plan.
I appreciate your suggestion to review the documents from work accomplished in the past. We have all of these documents at our offices and have already begun our review. Since I arrived here two years ago, I have had an opportunity to talk with Kim Burgess and others about past efforts. After I have an opportunity review the documents I hope to talk with key members in the planning process.
Demonstrate transparency and inclusion. In the extended redesign process of 1999-2003, the Division agreed to pursue a policy of fiscal transparency and involve people who are using or who have recently used services provided by through the Division in all major policy decisions. Today, the need for transparency and inclusion has never been greater. We ask the Division to make good on this promise with the following first steps:
Demonstrate transparency and inclusion. We are in complete agreement that transparency and inclusion are cornerstones of good public policy. When Joanne Fuller took the position of Director for the Department of County Human Services it was one of the first items we implemented under her direction.
I think our management of the Cascadia situation has demonstrated our willingness to give and receive information from the community. Historically, the County has requested information that was not provided in a timely manner. We see this as an opportunity to change our contractual access to critical provider information. However, while the County can request information and set standards it cannot directly operate its contracted organizations.
1. Routinely include the three major state advocacy organizations and their local affiliates in communications, decision-making processes, and advisory councils:
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Disability Rights of Oregon (formerly Oregon Advocacy Center)
Mental Health America of Oregon and Mental Health Association of Portland
NAMI Oregon and NAMI Multnomah County
1. The Mental Health and Addiction Services Division (MHASD) has a number of consumer advisory venues including the following:
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The Adult Mental Health and Substance Abuse Advisory (AMHSA). AMSHA is co-chaired by a consumer and the advisory council must have a minimum of 51% consumers and family members.
The Children’s Mental Health System Advisory Council (CMHSAC). The co-chairs are family members with requirements similar to AMSHA for family membership.
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The Verity Quality Management Committee has consumer members as well.
2. Active contracts for all the treatment vendors should be made available online along with timelines for renewal.
2. Placing contracts on line is a concept we have considered for some time. As the County is redesigning its websites we hope to include this information on our website in the near future.
3. Audits and quarterly financial reports for all major treatment vendors must be made available online.
3. I would hope that we can post provider audits and/or financial reports but I want to talk with the County Attorney’s office for review.
4. The budget and budget calendar for the Division should be made available online.
4. The County’s budget and budget calendar are posted at the following web site. MHASD’s budget is available there at http://www2.co.multnomah.or.us/Public/EntryPoint?ch=f00e74726f41e010VgnVCM1000003bc614acRCRD
5. Require non-profit vendors who are treatment providers to have a minimum of 25% of their Board members persons who are in recovery from mental illness or addiction and family members.
5. You suggest that the County require that non-profit vendor boards contain a minimum of 25% consumers. This item raises questions as to the scope of the County’s ability to place requirements on our providers. However, I have seen similar requirements successfully applied in other states where I have worked. I will refer this question to the County Attorney to make sure that we can make that request.
6. The County should hire three or more consumer and family advocates, housed in the same office to provide support for each other. These advocates would have three distinct roles: one, speak for people with mental illness who cannot speak for themselves; two, provide technical support to persons with mental illness and their friends and family members who are members of county advisory councils and treatment vendor boards of directors; and three, to identify and train prospective advocates for future positions on councils or boards.
6. We support the concept of paid consumer and family advocates. MHASD purchases the following through contracts.
- NAMI of Multnomah County for 2 full time positions to support and provide access for parents of high needs children.
- Oregon Family Support Network for two half-time positions to enhance consumer voice and representation in consumer mental health issues.
In addition, we have plans for the following consumer positions.
- Three paid consumer positions are included in the operating budget of the sub-acute facility.
- MHASD has submitted a program offer to the Board for one consumer position in the MHASD office.
Collect and share data about services to show progress. We suggest basic system outcome measures such as types of services provided, costs of services, quality of life, race, sex and age be collected from all treatment vendors and openly shared online.
Collect and share data. MHASD currently collects a considerable amount of data concerning member progress from our vendors, much of it in the areas you address. Like my previous comments concerning the website redesign, we will look to include this data when our site is able to support it.
Ensure access to and availability of effective treatment services. The most crucial focus of any design of mental health services is effective outcomes that are desired for persons living with serious mental illness and quick access to services.
Ensure access and availability of effective treatment services. Almost all of our contract language now includes a requirement for the use of evidence-based practices (EBP’s). Our RFP’s require that methods to measure outcomes and EBP’s be included in responses.
For our Medicaid-funded members, access and availability of care is specified by regulation. Persons with no insurance or other forms of coverage present our greatest challenge. Multnomah County currently contributes County General Funds to support treatment of indigent persons. While Multnomah County’s contribution is, by far, the largest in the state, services will remain limited for indigent persons in the foreseeable future.
Establish recovery-oriented outcomes, and the measures used to gauge progress, should be developed collaboratively with persons who live with mental illness, family members, legal advocates, providers, and state and local agencies.
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Multnomah County requires the inclusion of recovery-based programming in all of its RFP’s and contracts. We have a considerable number of progress measurements that we would be happy to share with you.
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Develop clear standards of eligibility for services and priority populations that are consistent with Oregon Revised Statutes in collaboration with persons who live with mental illness, family members, legal advocates, providers, safety net clinics, and state and local agencies.
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Eligibility standards in all of our federal and state-funded programs are strictly regulated. Those regulations might benefit from a collaborative process but that would have to occur at a state and/or federal level. Multnomah County would not be at liberty to change eligibility without their explicit agreement.
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County General Funds expended for indigent persons are reserved for individuals who are experiencing the most severe symptoms of mental illness. An authorization for care from the County must be acquired in advance of service if a provider expects to be reimbursed for care.
In closing I would also like to mention that the (County) Mental Health & Addiction Services Division will soon begin developing its Strategic Plan. I had hoped that this process would be further along but, as you might imagine, the Cascadia event has been time consuming and has slowed this process down. I am looking forward to continuing the process once we are beyond the most critical aspects of Cascadia’s situation. I will look forward to working with you and others once we are able to renew development of this plan.
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Thanks Karl!
I notice that the letter to the County suggests “a minimum of 25% of [provider] Board members [should be] persons who are in recovery from mental illness or addiction and family members.” The County mistranslates this to “non-profit vendor boards contain a minimum of 25% consumers.” These are different things. Many people in recovery from mental illness or addictions are not consumers. They may be former consumers, or they may be people who decided not to seek professional services and hence never were consumers. In the case of family members, they may have never themselves personally experienced mental illness or addictions, and therefore never were consumers, yet their family experience is a valuable asset. The County should be re-directed back to the original language.
Jamie, you’re right, there’s an important meaning switch in the language here, but I would give Karl the benefit of the doubt. It would be a great challenge to recruit 3 – 5 individuals actively using county services to vendor boards. This could be at full effect over 100 new active volunteer board members. Today these people aren’t available and the infrastructure to make this next step (if this is where we want to go to assure community oversight) needs to be built in parallel; the county would need to alter their contract language, 2. the vendors would need to alter their bylaws and recruit, nominate, elect new board members, 3. the “consumer” community would need to support and empower these individuals. At minimum this would be a several year project, but the result might actually be a person-centered service system.
There are good local models of nonprofits who have recognized the value of these sorts of board members and added them voluntarily. Executives and board presidents will argue this policy would actually injure the organization because “consumer” board members would not bring the same level of affluence, professional skills or social network. This is unarguably true, so a further burden is placed both on the County to remain a constant revenue source and on non-consumer board members to carry a heavier load. There are people who are affluent, skilled and have social networks who are also in some sort of recovery, but they will battle both stigma and professional inhibitions and are usually poor recruits for treatment vendor boards.
Yes to all of this… I totally agree with you! I just worry that if we do see some shift, it could miss out on some of the potential, by equating “consumer” with “persons who are in recovery from mental illness or addiction and family members.” Although I have my own mental health issues, I am mostly in this as a family member. My son has struggled for more than a decade with mental health and addictions issues, and I have come to realize that a far better path for him, and a far less expensive path for taxpayers, would have been for someone to serve as my coach as I intensively case managed him. I generally see that as my role as a dad anyway; it’s just that i don’t always know what to do! As he worked to find sobriety (7+ years clean and sober now!!!) I made all sorts of time wasting mistakes because I didn’t know how to be the best advocate for him. Years later I find out that there were resources for us but I didn’t know about them. He still has severe MH issues, but he is not a consumer… he is in self-treatment with my help. I’m not saying it’s the best plan, I’m just saying it IS the plan. And it’s HIS plan. He’s not a consumer and I’m not a consumer, but we both have advice that could promote recovery and save taxpayers money. Also, I am not affluent, but I do have professional skills and social network connections. This may be true for other family members. I’m not volunteering for this right now either; I have my hands full. I just hope as we make progressive changes we don’t start by putting ourselves into artificial boxes. Thank you!!
Below are some salient points on funding for consumer-run drop in centers, as identified by the National Mental Health Consumer Self-Help Clearinghouse.
Cascadia closed the drop-in centers. But it’s known that drop-in centers are the most cost effective use of funds as a preventive form of care. They help people so much that the rate of hospitalizations goes down, and hospitalization is a lot more expensive than drop in centers. Does anyone have comparison figures? Many people living with (and recovering from) mental illness love going to a good one (esp. if it has a pool table and ping pong). The New Mezz Connection downtown was on the road to becoming consumer-owned, but was subsequently taken over by Cascadia, who fired all the consumers and advocates who had been working there for at least two years.
Marian
Consumer-Run Drop-In Centers
http://www.mhselfhelp.org/
Technical Assistance
The following is an excerpt published by the National Mental Health Consumers’ Self-Help Clearinghouse
Consumer control
Some mental health providers offer services that are called “drop-in centers” but are not consumer-controlled. In reality, this other type of service is very similar to any traditional mental health service that is planned and controlled by mental health professionals. Although these services can provide a supportive environment, consumer-run drop-in centers offer many other advantages.
One advantage is empowerment. Sue Mader, a consumer who is one of the founders of The Gathering Place in Green Bay, Wisconsin, says that consumer-run drop-in centers “empower people a lot more than professional services can. There is more peer support here. There are no labels like ‘client’ or ‘professional’—we are all equals.” The absence of a wall between “consumer” and “provider” makes consumers realize that they have the power to make their own decisions.
Another advantage is a comfortable environment. Jim Prather, a consumer working at a drop-in center in Massillon, Ohio, compares his center favorably to a nearby one run by a mental health agency. “We are a lot less rigid. We have an easier atmosphere, and this contributes to a happier environment. The less structure, the less policing, the better.” This leads to a situation in which the members generally respect the rules and the staff rarely must intervene.
Consumer-run drop-in centers also may offer greater cultural competence and sensitivity than traditional mental health services. A consumer-run drop-in center will be more successful if its staff and volunteers represent the diversity of the community in which it is located.
Even consumer-run drop-in centers can begin to seem more like traditional mental health services if care is not taken to allow the consumers who use the center to continue to have input. When the staff—even if they are consumers—make all the important decisions, then a drop-in center is not truly consumer-run.
Donita Diamata, who founded Da Vinci Place in Portland, Oregon, says, “We have monthly membership meetings where the members set all of the rules and plan all of the activities. The staff will help them implement everything they enact as long as it’s ethical, legal, and financially possible.”
Diamata’s comments capture the essence of consumer-control: it is not enough simply to hire a consumer to run a drop-in center. Instead, consumer-run drop-in centers encourage as many consumers as possible—either as paid staff or volunteers—to get involved in every aspect of operations. In this way, the program meets the needs of its participants. For more information
about ensuring meaningful consumer involvement, consult the Clearinghouse Technical Assistance Guide Consumer-run Businesses and Services.
Funding
A significant majority of drop-in centers obtain their funding in the form of federal block grants that are administered (or “passed through”) by state or local mental health authorities. Therefore, the best way to start looking for funding is by contacting your local and state mental health authorities, which are listed in the blue pages section of your phone book.
When you contact your local and state mental health agencies, ask questions so that you can learn who is responsible for funding programs. You also might want to inquire whether the state mental health agency has an office of consumer affairs (many do.)
You should not limit yourself to the “proper channels” when seeking funding. If the local or state agencies are hesitant to fund consumer-run drop-in centers, you might need to work harder.
Maria Mar says that consumer advocates in Sonoma County, California, “had to buck the mental health system and get funding allocated by the county Board of Supervisors. We convinced them that it would be a wise expenditure and that the mental health director was on our side.”
Finding enough money to run a drop-in center will take hard work, but consumer groups are finding new ways other than relying on an annual budget from the county or state. In Oregon, a managed care organization (MCO) handles the state’s mental health services for people eligible for Medicaid. Donita Diamata’s Portland drop-in center bills the MCO for services to consumers.
“We let people get comfortable with our services before we ask them for insurance information.
We made a commitment to serve everyone, and we do not deny services to people whose insurance we cannot bill.”
Other drop-in centers have found ways to supplement the funding they receive from the county or state. As one director put it, “You can’t run your programs on what the state gives you.” A
primary way of supplementing government funding is seeking the donation of “in-kind” goods and services from local agencies. Some drop-in centers receive accounting services, computers, office supplies, phones, etc., from local agencies such as Mental Health Associations (MHAs) or NAMI chapters.
Some drop-in centers hold bake sales, craft shows, car washes, and other fundraising events.
Others even have full-time businesses such as thrift shops to raise money for funding the drop-in center’s activities. John Farmer reports that one Pennsylvania drop-in center has a great
fundraiser: the center’s consumers offer free coffee at a highway rest stop. People make donations and can also pick up information about consumer-run services.
More and more drop-in centers have begun to seek supplemental funding from private foundations. If you have access to the Internet (or can get to a library with Internet access), you can find many foundations that will give small grants to social service organizations such as drop-in centers. You can also join the local United Way agency. For more information about
using the Internet to seek funding, consult the Clearinghouse publication Advocacy and Recovery Using the Internet. To help you increase your chances of obtaining funding, the Clearinghouse also offers a publication titled The Art and Science of Writing Proposals That Win.
Where to establish a drop-in center
If you are starting a drop-in center, careful attention to your site can be a major factor in your center’s success. The type of building you choose, as well as its location, are both critical.
Additionally, many consumer groups find that they must work hard to convince neighbors that the drop-in center will be a benefit to the community. Often, neighbors have preconceived notions of mental illness that make them resist a new drop-in center.
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