Karl Brimner Responds to Advocates

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:

    1. The original Cascadia proposal by Kim Burgess and Peter Davidson.
    2. The final report on redesigning Multnomah County’s mental health services by the Technical Assistance Collaborative from November of 2000.
    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:

    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:

    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.

    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.
    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.
    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.
    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.
    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.


Thanks Karl!