by Peter Davidson, MD, Multnomah County MHASD Chief Clinical Officer/Medical Director, December 2002

Recession:
First the bad news. No one can tell where the bottom is, there are too many variables in play, most of which are interdependent. But it is safe to say that we will emerge next spring even smaller than we are now. So far, cuts have been relatively evenly distributed between the various categories like county employees and contracts, administration, clinicians, addictions, and mental health.

We will attempt to maintain this balance, but of course some revenue streams are more categorical than others. The overarching principle of cut priorities is that we must attempt to preserve services which may not be able to be reconstituted once cut and/or which have life and death significance for the beneficiaries.

We will need to preserve the mental health crisis system including the Call Center, but it looks as though we may lose most or all of the Verity Plus programs and “special arrangement” services. We have already lost all County General funds in the adult mental health system contracts. It is not clear how much longer we will be able to maintain the panel of “non-participating” providers.

There are no plans to “out source” the county role as a way to cut costs. In fact, we may be able to bring in some contracted services as a way to maintain jobs. Stevie Bullock was been wonderful at this.

The End of the Adult versus Child Tension:
Child-centric thinking has given way to the System of Care set of values and it makes poor sense to treat the adults in a family in a manner entirely distinct from the child or children. Both the Children’s System of Care committee chaired by Commissioner Naito and the School Age Framework group have been highly critical of the series-of-projects approach to the mental health system for children and families.

Throughout the winter we will be bringing together the administration of key elements of the System of Care for families, in order to implement the recommendations of the aforementioned design groups. The Call Center will work directly with both the Children’s Care Coordinators and the work units like Member Services to create seamless transitions between the care of children and their families. We are working to get all of the major Primary Providers dually certified to treat both children and adults.

In the near future we will see work unit changes to get our systems more closely aligned with their clinical functions. We will see a natural distinction develop between the system of care for families at various stages of child development and that for “level one” adults, by which we mean those who, due to a severe mental disorder, are at risk for high level (multi-systemic) interventions and/or are a danger to self or others, etc.

What must be borne in mind, however, is that the mental health system can not be built as it has been, whereby we create a program that seems like a good idea and then we look for clients who are appropriate for the program. We have to adapt our programming to the actual presentations of anyone. There are “Level One” adults who are parents of school age children and there are level one children with no real family and everything in between. In the public sector, the paradoxical phrase “outliers are normal” is the best touchstone for program design.

We will need to upgrade our software systems so that the folks seen in our family programs can be tracked through the Raintree database and so that whole families can be kept intact in our data system in a manner similar to the system used by the State’s Department of Human Services.

With all of this said, we will continue to maintain a distinct boundary in the payment structures for the care of children versus adults. In most circumstances, we will braid funding and not blend, to ensure that services for families are not diminished to pay for the very expensive care of Level One adults.

In fact, the concern about children’s dollars being taken for adult services will be turned on its ear. There is a tremendous amount of “adult” system capacity which can be brought to the table for the care of families, the School Age framework and System of Care implementation in particular.

The Mobile Outreach for family crisis services, for example, can be brought to the School Age Framework as available to schools and other family serving agencies to do on-site mental health crisis work.

Conclusion:
Very difficult times are ahead as a result of the simultaneous arrival in these coming months of budget cuts in all of our revenue streams. But even if all the projected cuts on the lists we receive do happen, there will be around $60 million dollars in the mental health and addictions budget going into Fiscal Year 2003-04. That is a lot of services. More than ever they will need to be very efficient to be effective. People need what we do and we have to do it as well as we can.