Outgoing health authority director suggests Oregon needs to expand state psychiatric hospital

The number of people in Oregon who are accused of crimes but are unable to understand the charges against them because of psychosis has risen to what one state official called “record levels” this fall, and is hampering efforts to reduce the list of waits at the Oregon State Hospital.

Patrick Allen, the outgoing director of the Oregon Health Authority, told lawmakers that the waiting list is “heading in the wrong direction.”

His comments, accompanied by data showing a sharp increase in monthly cases of people deemed too mentally ill to help and to help in their own defense, came during a House Behavioral Health Interim Committee hearing last week. . This fall, there have been 20 more aid and assistance patients entering the system each month than public officials expected.

Oregon has been sued for the time people who should be in the state hospital spend in jail, without access to treatment, while they await admission. Previous court cases have held that incarcerated persons in need of treatment for mental illness have a constitutional right to be admitted to the Oregon State Hospital within 7 days. And this year, at least one person on the waiting list died in jail.

In September, health authority officials agreed to increase turnover and speed up admissions to try to settle the lawsuit. To do that, they have to enlist people faster.

A court order issued on August 29 limited stays in the psychiatric hospital to 90 days for people charged with misdemeanors and one year for people charged with felonies.

The court also ordered the hospital to stop admitting patients who are civilly committed, when someone who is not charged with a crime is forced into psychiatric treatment, with an exception only for people who are considered dangerous to others. Civil commitment happens to about 500 people a year and now there is no room for those people in the state’s only public psychiatric hospital.

The health authority began implementing the new plan in September and has essentially been meeting its targets to speed up discharges. However, the number of people waiting for admission has increased, from 86 people in September to 104 people in November.

If things had gone as planned, the state hospital’s waiting list would have been cut in half by the end of November and essentially eliminated by February.

Instead, there were 85 new people with “aid and assistance” orders in September, 95 new people with “aid and assistance” orders in October, and 95 new people with “aid and assistance” orders in November.

Should Oregon State Hospital expand?

At last week’s hearing, the committee chairman, Rep. Rob Nosse, asked Allen, “If you could wave a magic wand, what would you do to make this situation better?”

“More of everything,” Allen said.

Allen said too many people end up in the state hospital because they get involved with the police, making treatment and recovery from addiction or mental illness more challenging. The state needs more community mental health resources to overcome the problem, Allen said.

“What are we missing? They are probably parts of every part of the system at the community level, to prevent that from becoming a law enforcement engagement,” he said.

Allen also backed a more controversial idea: expanding the capacity of the Oregon State Hospital.

“No one wants to hear this, but we probably need more state hospital beds as well,” he said, echoing a similar call this week from Ted Wheeler, Mayor of Portland. Wheeler said it’s time to lower the bar on civil commitments in Oregon, which he acknowledged would require expanding mental health services in the state.

Expanding the state hospital system may be a hard sell for lawmakers because federal Medicaid dollars don’t pay for any treatment there, due to a longstanding federal law that prohibits states from spending Medicaid dollars on people in institutions.

Allen said the key is adding capacity to provide a “hospital level of care” and not necessarily increasing the capacity of Oregon State Hospital’s two existing campuses, one in Junction City and one in Salem. “Where it is, 100 beds here, 10 beds in 10 places, I don’t have an opinion on that, but that’s part of what needs to be looked at,” Allen said.

Oregon State Hospital “Not an environment where people can be cured”

As a result of Mosman’s decision, Oregon county mental health programs will soon be responsible for dozens more mentally ill people who respond poorly to treatment — patients counties may end up sending to motels, with no better option, according to testimony during the hearing.

Lawmakers heard from a psychiatrist who works at the hospital, a union representative and a county behavioral health director about the lack of appropriate community placements for the sickest patients and chronic understaffing in behavioral health programs.

The Mosman order is based on best practice in forensic psychiatry and how long most patients benefit from a hospital level of care. An independent expert, Debrah Pinals, recommended the 90-day and one-year limits. Pinals is a clinical professor of psychiatry and director of the Psychiatry, Law, and Ethics Program at the University of Michigan.

But during the hearing, people who work in Oregon’s mental health system questioned whether those time limits are appropriate for patients. They said the time limits contribute to recidivism and are worsening an unsafe environment at the state mental hospital.

Tom Crawford, policy adviser for SEIU Local 503, said he was speaking on behalf of hospital staff who are members of the union and wanted to provide comment on Mosman’s decision anonymously. Patients who reach their time limit are released to homeless shelters or on the streets, ending up re-arrested and back at the hospital.

Crawford said hospital staff disagree that 90 days is an adequate amount of time to stabilize most patients facing misdemeanor charges.

It takes some patients 30 days to detox, he said, and then 4 to 6 weeks for the psychiatric medication to start working.

“That’s their 90 days and then they’re back on the street,” Crawford said. “This is not an environment in which patients can be cured.”

Crawford also said Mosman’s decision has affected the safety of patients and staff.

In recent years, understaffing has created a serious safety problem at the hospital, with the number of claims for workers’ compensation injuries rising from 152 in 2019 to 263 in 2021.

According to Crawford, Mosman’s decision is further undermining safety by creating rapid turnover and insufficient time to stabilize patients.

“We are looking for a recipe for more injuries,” he said.

What should we do with Frank?

Data shared earlier at the hearing showed that around 70 per cent of “help and assist” patients at the hospital are discharged because they successfully completed their treatment or are found unlikely to ever regain competence before before the time limits take effect, while 30 percent are discharged just because they have reached the time limit on their stay.

Dr. Amit Bhavan, a psychiatrist who works at Oregon State Hospital, said county mental health departments don’t have the resources to handle the people they are releasing because of Mosman’s decision, often the sickest patients with symptoms that do not respond well to treatment.

Bhavan said he had released a patient back to Jackson County on an expired “aid and assist” order that day. The county did not have the capacity to provide treatment or services to a person with that patient’s degree of difficult symptoms.

“The best they could offer the patient was a stay at the local motel,” he said.

You will soon be faced with a similar situation with patients returning to Josephine and Washington County without any possibility of obtaining community services there.

“It’s a factor in the high recidivism rate we’re currently seeing,” Bhavan said.

Julie Doge, Acting Director of Behavioral Health in Multnomah County, also described the difficulty in finding community placements for people released under Mosman’s order.

Doge shared the story of a patient he referred to by the pseudonym “Frank” who has spent most of his adult life in secure residential facilities. Frank was recently sent to Oregon State Hospital on an aid and assist order after he assaulted a resident and staff member at the secure facility where he had been living.

Doge said the county received notice that Frank would be completing his stay at Oregon State Hospital in 30 days.

“That means Frank is not stable,” Doge said, “and we need to start finding a place for him to go.”

The county may not have the legal jurisdiction to compel Frank to receive treatment. And the only facility in Multnomah County that can use seclusion and restraint and administer medication involuntarily has criminal charges pending against Frank.

“We will do everything we can, even so, because if we don’t, Frank won’t be able to take care of himself and will be a threat to the safety of our community,” Doge said.

Doge said there is a gap between the funding that lawmakers have historically been willing to provide for community mental health services and the actual cost of caring for the sickest patients like Frank.

They need “a familiar place that feels like home” with the flexibility to get higher levels of care, he said.

At least 128 people currently in the hospital need to be released into the community without competency restored, Doge said.

He urged lawmakers to seek staffing recommendations and best practices for those patients and use that to guide county mental health funding.