Introduction to Position Paper

10/15/2008

Eastern Oregon Human Services Consortium (EOHSC) is dedicated to helping our communities provide professional, quality and comprehensive care for the mentally ill.  Currently most communities in the EOHSC region are not able to adequately serve the mentally ill due to several critical issues.  The following “Position Paper” presents these issues and potential solutions. In order for our rural EOSHC communities to provide quality care we urge rapid action on these issues.    

In order of priority these are the areas that EOHSC has identified needing action:

1)  Acute Care Services
2)  Extended Care Services
3)  Community Care Services

The “Position Paper” that follows will detail both issues and solutions beginning with Acute Care in the Eastern Oregon region.  Once Blue Mountain Recovery Center (BMRC) eliminated their acute care status Eastern Oregon was left without an acute care facility, this has placed tremendous pressure on a system that was already having difficulty obtaining secure placements for clients that are dangerous to self or others.  The implications of this issue are extremely serious.  EOHSC outlines a temporary resolution that involves developing an operational process to “unplug” bottlenecks in the flow of clients and dedicating one position to the coordination of acute care placements in the region.  Ultimately to obtain a permanent fix, the region will need an acute care facility.

Extended Care services in the region are disjointed and inefficient.  Delays in referrals, lack of accurate communication, lack of familiarity with clients, cumbersome paperwork and distances are all contributing factors.  The performance of the extended care system directly affects the acute care system.  If the utilization of the region’s beds is not efficient, then the lack of available beds resonates throughout the entire care system.  EOHSC Member Counties, acting through their mental health organizations, Greater Oregon Behavioral Health Inc. (GOBHI) and Clackamas County for Oregon Health Plan and through EOHSC for persons who are indigent, are proposing an “at risk’ arrangement of extended care in the EOHSC region.  The EOHSC region desires to accept all of the Extended Care Management Unit’s (ECMU) current responsibilities for persons from the region or moving into the region via the state hospital system.

Community Care services at this time suffer from antiquated and partisan funding processes and overburdened providers and employees.  EOHSC outlines systematic changes that will integrate Acute, Extended and Community care in order for EOHSC to achieve the goal of quality “cradle to grave” services which will better serve Eastern Oregon residents.

Position Paper

The Providers of the Eastern Oregon Human Services Consortium (EOHSC) have been aware of the critical issues plaguing mental health services in the region for several years and have attempted to overcome these issues by being innovative and progressive in developing coordinated systems and processes to increase the efficacy of the system.  Former AMHD Administrator Bob Nikkel repeatedly assured us that the state will not leave the region without access to acute care services after Blue Mountain Recovery Center (BMRC) eliminates their acute care.  However, BMRC has eliminated its acute care and no reasonable replacement has been developed within the region.

The following letter from Dwight Dill, Director of the Center for Human Development, Inc. to Len Ray of Addictions and Mental Health Department (AMHD) addresses the concerns well.

09/08/2008

Len,                                                                                 

I am aware that the acute care workgroup continues to meet around the acute care needs across the state.  However, I am increasingly concerned about the serious lack of acute care resources in Eastern Oregon as well as statewide.  It seems the entire acute care system is in crisis and it is not a matter of if, but rather when, we are going to have some very dire outcomes as a result of this situation.

I was in a meeting Thursday morning with our local sheriff,
under-sheriff, District Attorney, Parole and Probation Director and one of our county commissioners to discuss this issue.  We are experiencing situations where individuals who are extremely psychotic and should not be in a jail setting are there as there are no other alternatives available.  We have provided support to the jail staff thorough our mental health resources but that support is woefully inadequate for the needs of some of these individuals. 

Our crisis staff spent hours calling acute care centers, on a daily
basis, in an attempt to locate a bed for the last individual who was in this situation.  Meanwhile, he continued to wreak havoc in the jail setting to the point that it was disrupting the entire milieu of the jail.

I have daily concerns that we are going to be faced with an individual who is highly suicidal or dangerous to others for whom there is not an available bed and is not willing to voluntarily stay in a respite setting.  I think one only need look at the recent events in Washington State to appreciate this concern.

One of our County Commissioners, Nellie Bogue-Hibbert, is going to be taking this issue up with Senator David Nelson and Representative Greg Smith to raise the awareness of this issue to their level.

At Thursday morning's meeting, all participants were aware that this is a statewide issue and not just an issue unique to Union County.  They are very much interested in developing some regional strategies to address the problem but also know that resources will need to be brought to the table for any solution to be implemented.

My concern is that we need to recognize the seriousness of this issue and find some immediate solutions.  We are straining our community resources, especially our crisis staff, who are less and less willing to provide after hours coverage.  We are at a point where we are going to have staff resigning rather than being placed in a situation for which there is not an adequate solution.

We are very willing to be part of the solution to this issue but we also recognize that any solution will involve resources beyond those that are currently available to us.  

Thanks,

Dwight

Dwight Dill
Center For Human Development, Inc.
(541) 962-8845

 

EOHSC and its Providers have a vision, a vision of efficient and effective mental health treatment.  EOHSC is dedicated and determined to achieve this vision. This has been demonstrated by EOHSC’s willingness to “step-up” to the challenges by offering recommendations, being willing to be a “pilot” program and act on its recommendations.  EOSHC has an ability to communicate with their communities by being transparent, honest and respectful.  This has been demonstrated by several communities accepting placement of “hard to place” facilities.  EOHSC and its Providers have the leadership and the high level of professionalism required to meet the challenges of improving mental health services in the State of Oregon.  We intend to address this challenge by working with AMHD to develop a system which utilizes the unique strengths of the region and its communities to provide better care to our citizens.  At the same time these efforts will benefit the state by addressing the very real concerns of Olmstead and save the state from a federal lawsuit

Existing Barriers and Costs

Extended Care Services as currently operated by AMHD (identifying ready-to-place residents, completing the screening process, processing referral packets, determining Extended Care Management Unit eligibility) in EOHSC Region are outdated and inefficient.  The Extended Care Management Unit (ECMU) system that provides this service has not been able to keep pace with the workload and expanding number of community based facilities. While the hospital wait list continues to grow and lengths of stay continue to increase, treatment beds at the community level are not utilized in a timely fashion.  There are currently 118 of these types of beds in the communities of eastern Oregon.  The graph below illustrates the condition of the
current system.

Timeframe - Nov. 2007 to present

Both the Occupancy Rate and Referral Capacity have an optimal goal of 100 percent. The Occupancy Rate has increased from an average of approximately 90 percent to an average of 96%.  This increase is due to the increased efforts of EOHSC, but cannot increase to 100 percent without improving the referral system.  The Referral Capacity, which averages approximately 15 percent, could reach 100 percent by restructuring the referral process.  The Referral Capacity directly affects the Occupancy Rate: when the Referral Capacity reaches the 90 percent range Occupancy Rates will reach 100 percent. 

A critical flaw in the current system is lack of continued financial and clinical responsibility for persons in high levels of care.  Recovery is not encouraged if an organization is able to shift clinical and financial responsibility to the state without consequence and a citizen suffering from mental illness becomes disconnected from their community.  

Next Steps

The Eastern Oregon region has developed and will continue to develop specialized residential resources for those with long-term mental illness.  By the end of 2009 the region could have over 140 residential beds, some serving very specialized, high risk populations.  Blue Mountain Recovery Center (BMRC) as of October of 2006 lost its Federal Medicaid waiver, leaving the region with very limited acute care capacity.  Further, the state hospitals and the Extended Care Management Unit are working hard to reduce the wait list to comply with the Olmstead ruling and to meet the requirements of the Oregon Advocacy Center’s class action law suits.  If managed correctly, the region’s residential capacity can help provide a step down from or alternative to psychiatric hospitalization. With effective residential and patient discharge management, we could affect a reduction in hospitalizations and reduce hospital lengths of stay that will result in a significant reduction in average daily population (ADP) at BMRC 

EOHSC is committed to providing recovery oriented, community based treatment options to the state hospital system for both Acute and Extended Care Services. 

EOHSC works with local hospitals and AMHD to develop secure sub-acute capacity. Lifeways, Inc. is in the process of getting up to six (6) beds located at McNary Place in Umatilla approved to provide secure, sub-acute services.  These resources and the “system” presented in this report are only short term alternatives to BMRC.

Ultimately, an Acute Care Facility needs to be developed
in the EOHSC region.

Please refer to the update at the end of the paper.

The Eastern Oregon region has a high interest in developing an ability to effectively manage our residential and state hospital capacity.  The following are basic components of a regional system that could reduce ADP at the state hospital and maximize the use of our residential capacity in Eastern Oregon:

• Provide timely access to acute care
• Reduce the amount of time our citizens spend in acute care
• Help reduce the wait list and maximize the use or our regional residential capacity
• Eligibility determination should occur while people are at the lowest appropriate level of care rather than delaying them in acute care while ECMU Eligibility is determined.

 
We envision a system that would integrate portions of the current state hospital discharge and the majority of the current ECMU functions into our regional residential coordination services.  This function will be achieved by developing a Regional Utilization Team (RUT), this team will be comprised of three (3) FTE positions (1.5 of these positions are currently in place).  The positions will be as follows:

• Regional Extended Care Coordinator
• Regional Acute Care Coordinator
• Regional Case Management Coordinator

Regional Extended Care Coordinator (RECC): The Regional Extended Care Coordinator would work with the hospital treatment team and community to ensure timely discharges and help facilitate residential placements.  This position would free up existing hospital discharge staff and assist communities to affect timely patient discharges.  The position would also identify and refer hospital patients eligible for ECMU placements using the most current ECMU criteria and process to the ECMU unit in Salem. This position would be granted authorization from the ECMU manager to place consumers meeting the ECMU criteria into open ECMU beds within the identified operational area of the Eastern Oregon Region. Utilization management would include identifying current and pending residential vacancies, informing the region and the ECMU manager (related to ECMU sites only) as to the type of residential beds available, assisting with referrals and the placement process, developing wait lists and reviewing all residents to determine when full benefit as been reached from the placement and recommending an appropriate alternate placement and discharge plan.

Regional Acute Care Coordinator (RACC):  The Regional Acute Care Coordinator will promote timely acute hospital admissions by establishing excellent working relationships with all Psychiatric facilities and Providers.  This position will also develop a comprehensive inventory of all acute care and respite/crisis beds within the state of Oregon.  This inventory will include all relative information (LOC, Staffing, Specialized Services, etc) of each facility necessary for accurate, effective and appropriate placements.  The utilization status of all beds will be maintained in “real time”, insuring that the Regional Acute Care Coordinator can coordinate placement in the shortest amount of time possible.  This will be accomplished through utilization of state supported HOSCAP (Hospital Capacity and Diversion Tracking Software) on the HAN (Health Alert Network) as well as personal contact with hospitals on a daily basis to maintain personal relationships.  Person to person relationships continue to be a key element of successful systemic change and if there is a surge demand due to a major disaster event these communications would be essential.  The RACC will be responsible for providing shift supervisor updates status on bed vacancies through web based technology.  This position will have the knowledge and ability to advise and/or assist the crisis worker through the commitment process and the hospital system. Having first hand knowledge of the bed availability and services provided in both hospitals and crisis/respite facilities the RACC will help relieve the tremendous amount of pressure that both the Providers and Consumers encounter when attempting to access the acute care system.  

Regional Residential Specialist (RRS):  Residential case management would include completing the necessary paperwork to ensure service payments, setting board and room rates, preparing providers for state reviews and offering technical assistance on a variety of facility and residential support issues.

Regional Utilization Team works as one, with open communication within the team and comprehensive knowledge of one another’s duties. 

EOHSC strongly supports efforts of AMHD to remedy the bifurcated system of funding responsibility with development of the Co-management Plan and efforts to better define County of Responsiveness for acute care as well as civil commitment.  However, for such plans to be successful, they must be monitored and enforced.  This is currently not happening.  We believe the best long term solution to the problem will be an adjustment to capitation rates paid through MHO’s to accommodate responsibility for long term care.  Only through maintenance of the system in a managed care environment will we be able to bring accountability to both the system and expedite recovery for our citizens.  As that happens, MHO’s may choose to establish a common risk pool to address the needs of individuals whose residency is not easily determined because of years of life in ‘the system.”

Implementing these acute and extended care options/alternatives is imperative to the EOHSC region.  The failure of AMHD to develop resources has resulted in stressing the entire system and straining local relationships because people have been spending hours in local hospital emergency rooms while crisis workers are attempting to arrange placement and transportation to resources far outside the region.  These situations are never good for the consumer, the CMHP, or the Local Hospital and it is extremely critical that they are avoided.

Roles of Community Mental Health Programs in Eastern Oregon

Mental Health Programs are committed to the planning, management and operation of a system of local services.  People who need services including mental health, developmental disabilities and alcohol/drug treatment are best served when services are provided locally.  ORS430.630 clearly states that the Board of County Commissioners or the County Court of each County is the local statutory authority.

HB3024 also amends ORS430.640 to read The Department of Human Services, in carrying out the legislative policy declared in ORS430.610, subject to the availability of funds shall: “(a) Assist Oregon counties and groups of Oregon counties in the establishment and financing of Community Mental Health and Developmental Disabilities programs operated or contracted for by one or more counties.”

Further ORS430.610 (4) states, "the state of Oregon shall encourage, aid, and financially assist its County governments through county administered Community Mental Health, Alcohol and Drug and Developmental Disabilities programs.”

Eastern Oregon counties have a long history of cooperation and innovation.  Notable results of these collaborative efforts include:

• 1971 the county mental health centers of the Eastern Oregon formed the nation’s first rural Comprehensive Community Mental Health Center under the 1963 Community Mental Health Center Act.
• 1987, the county juvenile justice departments of the Region organized under ORS 190 as the Central and Eastern Oregon Juvenile Justice Consortium (CEOJCC). Shortly after organization, Juvenile Court Resources, Incorporated (JCRI), a not for profit corporation, was established by CEOJCC.
• 1988, the counties of Eastern Oregon formally organized the Eastern Oregon Human Services Consortium (EOHSC) as an ORS190 organization that is made up of 13 Eastern Oregon counties.
• 1994, the EOHSC Board of Directors formed Greater Oregon Behavioral Health, Incorporated (GOBHI).  GOHBI is a Private, Not for Profit Managed Care Company, organized as a Member Managed Public Benefit Corporation (501 C (4)). 

EOSHC has a long history of playing an innovative and creative role in the management of both local and regional mental health services.  This governance vehicle has allowed Eastern Oregon counties to maintain a leadership role in the provision of effective and efficient services to our citizens.  

In summary, Oregon is crying out for leadership.  Where better to turn for it than to the region of the state, which has accomplished the most with the least for the longest.  We are losing a disproportionate amount of federal funding each time the general fund budget is reduced in Salem because our region is poorer than the statewide average.  Our citizens can no longer be held hostage by the systemic gridlock that has developed in this state.  Our citizens deserve the opportunity to invest in more accountable government and any new or increased taxes need to be aimed at the bottom of the delivery system, the county and its communities, rather than at the top.

The final element is for EOHSC, GOBHI, and Clackamas MHO to assist in transferring residents of the state hospital systems and funding from the state to the counties, including broad latitude to determine rates and service levels to be delivered by providers outside the current institutional setting.  We request that all ECMU functions be performed by regional staff for our citizens and for facilities located in our region. Commitment of funds may be an issue but we could be provided a cap and only if exceeded would we need state approval.

Our ultimate goal is to create a cradle to grave delivery system for citizens of each county.  This effort will be implemented by integrating services those services in which the county currently has an interest.  Specifically, those services are Mental Health, Alcohol and Drugs, Developmental Disabilities, Public Health, Local Commissions on Children and Families, and Senior and Disability Services. This strategy will be best implemented by establishing shared risk pools and utilization of Medicaid Match.  Administrative and Quality Assurance/Quality Improvement responsibility should be shared between the state and the region

While the future of mental health in Oregon will be community based we recognize that there will be an on-going need for facilities based treatment of persons with the most devastating disabilities.  An example of a population most in need of these services is Oregon’s rapidly growing population of persons with severe and persistent mental illness who are also finding themselves addicted to methamphetamines.  We believe that development of specialized treatment facilities can divert persons from the state hospital and provide treatment options to many persons who are currently being sent to jail.  A recent step in this development of services was accomplished with approval of four beds in a new detox center being constructed by Eastern Oregon Alcohol Foundation to be managed by Lifeways.  These beds will provide a resource currently lacking in the region and will help fill the gap left by loss of BMRC as our primary acute care resource.  We are extremely concerned that the OSH Master Plan recommends the development of only 7 of 419 community based beds to be developed east of the Cascades.  It is essential to recognize that Eastern Oregon has and always will need residential capacity in excess of regional need in order to make the treatment within the region economically feasible.  In other words, there is not enough local demand for specialized services to support the cost of professionals or facilities to provide those services.  Therefore persons from outside the region must be served to provide the critical mass to make the cost affordable.  This relationship has proven to be a win-win for both the state and several rural communities in Eastern Oregon.  Establishing treatment programs have supported local economic development efforts and provided a portion of the financial support needed to bring additional professionals to the community.  Consumers have enjoyed a much higher quality of life and community acceptance has been remarkable.  It is important to note that the majority of residential projects developed within the region are owned and operated by the local community mental health program.

Systemic Improvements

Suggested improvements to the public mental health system include the following:

• The current system for delivering mental health, alcohol and drug, and developmental disabilities services is not a partnership between counties and the state.  This remains true in spite of these services being included under the purview of County’s as the Local Mental Health Authority.  Contracts for county run services are reduced while state run services are protected in spite of the fact that contracted services are often times more efficient and produce better outcomes.  These actions severely threaten the viability of a locally managed system while shifting an unaffordable burden to local law enforcement, emergency services, and jails. 
• Institute strategies such as revenue sharing or Oregon Options, which will spread the resources among communities and make the system more accountable at the local level.
  
  
• Allow counties to match existing resources with federal dollars to continue community-based services to needy Oregonians. 
  
  Examples of these funds are as follows:
• Local client fees for services
• Payments from insurance companies
• Commission on Children and Families funds
• Juvenile Department contracted treatment services
• Local philanthropic organizations contribution to community programs
• Facilities rental fees
• Other non-federal funds which may be unique to any given County
• Recognizing that local matching funds are being used to maintain or increase federal dollars and are back filling for state general fund reductions by giving more control to counties.
• Measure state budget cuts by county impacted as well as agency.  Inform counties of the amount being cut from state general fund and the resulting loss of federal match.  This would allow us to know how much local money it would take to maintain current funding levels.
• Reward positive outcomes with bureaucratic relief. There are currently eight different Client Process Monitoring System (CPMS) Forms to be completed on an individual client depending upon treatment program or service.
  
  
• Allow true co-management of the system to best meet the needs of consumers and the efficient use of money.  Financially reward counties, which exceed predetermined benchmarks.
• Restructure the funding streams for services provided and reduce documentation requirements enabling Clinicians and Case Managers to have manageable case loads.  By being creative and achieving this recommendation the entire system would reap the benefits of; reduced employee turn-over, reduced stress, increased quality of service, reduction in hospitalizations, increase in qualified employees, improved management of resources, etc.

Achieving the Goal

In order to achieve our goal of providing community based services as an alternative to hospitalization; it is important to continue developing facilities, expand the role of our existing Regional Adult Residential Services Program as outlined above, and it is crucial to continue acquiring and supporting the clinical expertise and professional networking capacity necessary to meet the needs of persons with increasingly complex psychiatric treatment needs at the local level.  In development of these programs it is important to address the needs of the increasing number of persons with severe and persistent mental illness who are currently incarcerated in the corrections system.  Development of local continuums of services which allow diversion from the corrections system for these individuals must be supported.  All of these objectives are strongly supported in the OSH Master Plan. 

Update

February 20, 2009