Policy level meltdown

By Robert Landauer – editorial columnist for The Oregonian, part of the series – “Rescuing the mentally ill,” March 24, 2000. Not available elsewhere online.

The Oregonian has found no one during the last three months who can say reliably how much money is spent in Multnomah County on mental -health support”

Confused thought processes and bizarre, self-destructive behavior typify certain mental illnesses. That also describes the way public agencies in Multnomah County deliver services to residents with severe brain disorders.

City police, county jailers, the Oregon Health Plan, housing and development agencies, employment and vocational rehabilitation services, social workers, probation and parole officers, judges, Oregon Health Sciences University, Portland State University, hospitals, the crisis triage center, schools, alcohol and drug counselors, the education service district and many, many private contractors and charitable groups all deliver mental health services.

And they fail.

The reason is that they are fragments. They are not integrated and coordinated, so they fail to conduct successful recovery efforts for many of the 10,000-plus low-income county residents receiving public assistance to cope with their mental illnesses.

The extent of this organizational meltdown is frightening.

For example, The Oregonian has found no one during the last three months who can say reliably how much money is spent in Multnomah County on mental -health support, what share goes to administration vs. direct services and what the outcomes are for different types of patients and agencies.

Lacking information, agencies build budgets and operate independently. No one prioritizes to produce better human and financial value for the services clients need and taxpayers buy.

No coach designs overall strategy. No manager breaks bureaucratic barriers and forces interagency cooperation. Skilled and dedicated doctors, nurses, social workers and police end up dealing with the mentally ill one-on-one — but not as a disciplined team.

The early intervention and unbroken chain of care essential to keep the mentally ill healthy disintegrate under those conditions. So thousands of the mentally ill continue to relapse into crises that could have been prevented or eased.

What should be done? Here are some suggestions:

Link the fragments

The core challenge in Multnomah County is to link the service fragments into a mental -health system that is coordinated, responsive and accountable.

The county should start by reorganizing the entire administration of public mental -health services. With other local governments’ participation, it should centralize responsibility for all mental -health services in a permanent task force operating out of the Behavioral Health Division. That would, at least, eliminate multiple layers of administration, freeing resources to cut front-line workers’ huge caseloads.

Get a Medicaid waiver

To gain utmost flexibility and effectiveness, the county should seek a local waiver allowing it to apply Medicaid money to mental -health medical treatment and to related, critical support services. This specialized waiver within the waiver that the federal government granted the state to operate the Oregon Health Plan would recognize that patients need more than medication management to recover and thrive.

Merge bureaucratic empires

As a start and as a minimum, merge the county’s mental-health and alcohol/drug empires. It is self-defeating, wasteful and cruel to separate the treatment of patients with co-occurring mental disorders and addictions.

Seek intelligence, not just data

Build a data warehouse with a strong clinical base to support a shared information system. Mental -health systems cannot run well without accurate, timely, and complete information. When doctors, hospitals, housing agencies, vocational rehabilitation services, alcohol and drug counselors, police, judges, jailers and probation officers don’t share information, patients cannot get the coordinated care they need.

The mentally ill are not alone in being badly served by data systems that don’t talk with one another. Taxpayers are penalized, too, because the billing and clinical information is not now compressed and spin-dried to reveal which prevention and treatment programs are most cost-effective. This information allows us to make intelligent choices on how much, where and when to spend public resources.

Bluntly stated, a data system fails us unless it shows how much of what we do for the mentally ill makes a positive difference. Without that evidence, much current spending is wasted.

Only when the major tasks are done can other critical elements be properly integrated. Among them:

  • Year-round countywide mobile response teams must step in as early as possible when mental -health crises are signaled. This includes mental -health professionals who can respond to any brewing threat to landlord/tenant or employer/worker relationships.
  • Cooperating agencies must repair the delivery network’s neglect of racial and ethnic minorities’ special language and cultural needs. Spanish speakers, for example, are the county’s fastest-growing minority, yet a shameful inability to communicate with them in mental -health emergencies and in continuing care smothers minority clients’ chances of recovery.
  • Early assistance must move higher among local mental -health priorities. Programs such as Healthy Start, which provides two years of training and support to disadvantaged mothers, reduces child abuse and mental / behavioral disorders. Research increasingly demonstrates very favorable returns on selective early investments.
  • Computer technology, available at libraries, should be used to help families gain access to mental -health support services, now hidden in a bureaucratic jungle that many find impenetrable. Websites such as Family Care America (www.familycareamerica.com) could provide families with the most suitable resources in their ZIP codes.

Many Multnomah County residents who receive public services for mental illnesses can be rescued from the worst symptoms of their treatable brain disorders, and taxpayers can get better value for the support they extend.

That will happen only if all mental -health providers are harnessed to pull as a team and if they are given the information to make excellent choices.