Outgoing health authority director suggests Oregon should expand state psychiatric hospital

The number of people in Oregon accused of crimes but unable to understand the charges against them due to psychosis rose to what one state official called “record levels” this fall, throwing a wrench in efforts to reduce the list with waiting at Oregon State Hospital.

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

His remarks, accompanied by data showing a significant increase in monthly cases of people deemed too mentally ill to help and assist in their own defense, came during a hearing of the Interim Committee on Behavioral Health last week. This fall, there were 20 more AID patients entering the system each month than state officials expected.

Patrick Allen, the outgoing director of the Oregon Health Authority, told lawmakers that Oregon’s public hospital waiting list is “going in the wrong direction.”

Christina Wentz-Graf / OPB

Oregon is being sued over the time people who should be in the state hospital spend in jail, without access to treatment, while they wait to be admitted. Previous court cases have held that people held in jail who need treatment for mental illness have a constitutional right to be admitted to an Oregon state hospital within 7 days. And this year, at least one person on the waiting list has died in prison.

In September, health officials agreed to increase turnover and speed up admissions to try to settle the lawsuit. To do this, they need to release people faster.

A court order issued Aug. 29 limits mental hospital stays to 90 days for people charged with felonies and one year for people charged with misdemeanors.

The court also ordered the hospital to stop accepting patients who are civilly committed — where someone not charged with any crime is forced into psychiatric treatment — except for people deemed dangerous to others . Civil commitment happens to about 500 people a year, and now there is no room for these people in the only state psychiatric hospital.

Health authorities began implementing the new plan in September and are essentially meeting their goals of speeding up discharges. However, the number of people waiting for admission increased from 86 people in September to 104 people in November.

If things went according to plan, the state hospital’s waiting list would be 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?

During last week’s hearing, committee chairman Rep. Rob Noss asked Allen, “If you could wave a magic wand, what would you do to improve this situation?”

“More than anything,” Allen said.

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

“What are we missing? It’s probably parts of every part of the system at the community level so that it doesn’t become a law enforcement commitment,” he said.

Allen also supported a more controversial idea: expanding Oregon State Hospital capacity.

An Ariel shot of the Oregon State Hospital complex shows a long, rounded driveway and an old-fashioned red brick building with a white dome

Oregon public hospital’s waiting list grows longer despite controversial release plan designed to make more room for incoming patients

Courtesy of Oregon State Hospital

“Nobody wants to hear this, but we probably need more public hospital beds, too,” he said, echoing a similar call this week from Portland Mayor Ted Wheeler. Wheeler said it’s time to lower the bar for civil commitment in Oregon, which he acknowledged will require expanding mental health services in the state.

Expanding the state’s hospital system could be a tough deal for lawmakers because federal Medicaid dollars don’t pay for any treatment there because of a long-standing federal law that bars states from spending Medicaid dollars on people in institutions.

Allen said the key is adding capacity to provide “hospital-level care,” not necessarily increasing capacity at 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 heal’

As a result of the Mosman decision, county mental health programs in Oregon will soon be responsible for dozens more people with mental illnesses who don’t respond well to treatment — patients the counties may end up sending to motels with no better option. according to testimony during the hearing.

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

Mossman’s order is rooted in best practices in forensic psychiatry and how long most patients benefit from hospital-level care. An independent expert, Debra 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 working in Oregon’s mental health system disputed whether those terms were appropriate for patients. They said the terms contributed to recidivism and worsened the unsafe environment at the state mental hospital.

Tom Crawford, policy counsel for SEIU Local 503, said he was speaking on behalf of unionized hospital staff and wanted to provide feedback on Mosman’s decision anonymously. Patients who reach their term are discharged to homeless shelters or the streets and end up being arrested again and back to the hospital.

Crawford said hospital staff disagreed that 90 days was a sufficient amount of time to stabilize most patients facing felony charges.

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

“It’s their 90 days and then they’re back on the street,” Crawford said. “This is not an environment where patients can be treated.”

Crawford also said Mosman’s decision affected patient and staff safety.

In recent years, staff shortages have created a serious safety problem at the hospital, with the number of workers’ compensation claims increasing from 152 in 2019 to 263 in 2021.

According to Crawford, Mossman’s decision further undermines safety by creating a rush shift and insufficient time to stabilize patients.

“We’re looking for a recipe for new injuries,” he said.

What shall we do with Frank?

Figures shared earlier at the hearing showed that about 70 percent of the hospital’s “aid and assistance” patients were discharged because they had successfully completed treatment or were found to be unlikely to ever regain competency before time limits to take effect, while 30% were discharged only because they reached the stay limit.

Dr. Amit Bhavan, a psychiatrist who works at Oregon State Hospital, said county mental health departments don’t have the resources to manage the people he releases because of the Mosman decision, often the sickest patients with symptoms who don’t respond well of treatment.

Bhavan said the other day that he discharged a patient back to Jackson County with an expired “aid and assistance” order. The county did not have the capacity to offer treatment or services to a person with the patient’s level of severe symptoms.

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

He will soon face a similar situation with patients returning to Josephine and Washington County without any opportunity to receive community services there.

“is a factor in the high recidivism rate we’re seeing right now,” Bhavan said.

Julie Dodge, Multnomah County’s interim director of behavioral health, also described the difficulty of finding community housing for individuals released under Mossman’s order.

Dodge shared the story of a patient she nicknamed “Frank” who had spent most of his adult life in assisted living facilities. Frank was recently sent to Oregon State Hospital on an order to render aid after assaulting a resident and staff member at the secure facility where he lived.

Dodge said the county has received notice that Frank will be up at the Oregon State Hospital in 30 days.

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

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

“However, we will do everything we can because if we don’t Frank can’t take care of himself and is a threat to the safety of our community,” Dodge said.

Dodge said there’s a gap between the funding lawmakers have historically been willing to give to public 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 receive higher levels of care, she said.

At least 128 people currently in the hospital are to be released into the community without being reinstated, Dodge said.

She urged lawmakers to look at staffing recommendations and best practices for these patients and use them to guide the county’s mental health funding.

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