The mental health care transition in Klamath County

From the Klamath Herald and News, September 1, 2013

Though from the outside the process seemed sudden, boiling into a difficult situation within weeks, the county commissioners had an inkling of the direction they were headed before they sent a letter to the Oregon Health Authority on June 14 saying the county wanted out of the mental health care arena.

“I think from a strategy perspective it was bubbling under the surface,” said Klamath County Commission Chairman Dennis Linthicum.

He compared it to a cup of coffee in the microwave.

“You’re watching it because you’re afraid it’s going to boil over. It looks fine, and then it pops a big one and you’ve got a mess inside your microwave,” he said. “But all the while it was heating up just like you were expecting — and then it made a mess.”

That mess is what came to light in July. On July 19, the commissioners sent a letter to the state saying it faced an “imminent emergency situation” because employees were leaving the department and there weren’t enough staff to keep services going. The county asked for immediate transfer of the department.

On July 23, the commissioners sent another letter, this time saying the mental health department was canceling all outpatient appointments and would need to send residents at Phoenix Place out of the area — unless the state stepped in.

That is when the cup of coffee that is the mental health department boiled over.

“So in your eyes you’re thinking it just exploded,” Linthicum said, “and the truth is it was moving in that direction all along.”

Why did the mental heath care transition happen so fast?

When the Herald and News asked that question to Stan Gilbert, executive director of Klamath Youth Development Center, the nonprofit that took over Klamath County’s mental health care on Aug. 1, he was not quick to answer.

He paused for almost 20 seconds, considering what he would say.

“I think the truth is the county found out it could not sustain their mental health department operations given the financial realities,” he said.

Realities like Jefferson Behavioral Health, the once five-county mental health provider Klamath County contracted out to, closing shop. It closed when the other four counties — Coos, Curry, Jackson and Josephine — moved to the new Oregon-driven coordinated care organization model and no longer needed Jefferson Behavioral Health.

The Oregon Health Authority also changed its funding model from capitated — a set price per month regardless of the procedures done — to a fee for service — paying only for what services are provided. The county admitted it couldn’t keep its mental health program afloat with that kind of funding. That was the No. 1 reason given in letters to the Oregon Health Authority for transferring the mental health department.

“There was a lot of, to be frank, there was a lot of financial waste and inefficiency in the old state model for delivering public health care,” Gilbert said. “The state saw that and took aggressive action to try and change it. When it became clear to the county they probably couldn’t be financially viable without dramatic change, I think they saw this as the best way for them.”

County Commissioners see the change coming

Like Linthicum’s boiling coffee cup analogy, the other commissioners said they saw the change coming before they took action to shut down the county’s mental health department.

“We didn’t really have a choice. It wasn’t that sudden. We knew it was heading that direction,” said commissioner Tom Mallams. “I’ll be honest with you. The way this all ended up is the way I thought it was going to end up six months ago. It was no surprise to me.”

“I think it was in the back of our minds before July,” commissioner Jim Bellet said. “Back in June we wrote a letter to the state and told them that we did not think we could provide the service anymore. We needed the state to help us make a transition.”

Linthicum was asked: was the transition planned before June?

“Your comment ‘planned ahead of time,’ was this a negotiating tactic? The answer is no,” Linthicum said.

When asked if he knew the county was going to abandon mental health before the commissioners sent their letters to the Oregon Health Authority, Gilbert said no.

“I knew things were not good with the county mental health department,” Gilbert said. “There were signs of instability. Those of us that were trying to create a coordinated care organization, we could see the county mental health department was struggling. That was pretty clear.”

Blaming the Oregon Health Authority for inaction

After the commissioners’ letter on July 23, representatives from the Oregon Health Authority came to Klamath County the next day to hold meetings and take care of business. Gilbert signed a contract between Klamath Youth Development Center and the state. The county, the state and KYDC formed a plan to keep Phoenix Place residents at home. KYDC organized to help patients transfer from the county’s outpatient mental health department to KYDC’s. On July 31, KYDC and the county signed a lease for the nonprofit to take over Phoenix Place. On Aug. 1, KYDC officially took over mental health care in Klamath County.

The time from the commissioners’ “immediate” letter to when KYDC took over was only 14 days. Commissioners blamed the Oregon Health Authority for not stepping in sooner.

“It was difficult to get the state to act,” Linthicum said. “The state was leaning in that direction, but it had no impetus, no reason to swing at this pitch, this time, until we made it an absolute necessity. ‘Look, you guys are going to have to hit the ball here and then we can start running the bases.’ But until you hit the ball, we’re going to stand here and nobody’s ever going to move around the field.”

Linthicum said he would have supported a longer, smoother transition, but again lays the blame firmly at the feet of the Oregon Health Authority.

“Ninety or 120 days would have been a beautiful transition for OHA to have helped us with instead of just passing the keys in the parking lot at midnight,” Linthicum said.

When asked if it he believed it was the Oregon Health Authority’s job to facilitate the transition, Linthicum said: