Overview of the Public Mental Health System in Oregon
History of Public Mental Health in Oregon
See also A
short history of public
mental health system in Oregon
The Current Mental Health System
Mental Health Administration
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History of Public Mental Health in Oregon
Oregon's mental health system has been in existence
for more than 150 years. Oregon has historically been sensitive to the needs
of people with mental illness. In 1844, territorial lawmakers appropriated two
hundred dollars to defray the expense of caring for persons with mental illnesses.
The first hospital for persons with mental illness in the State was opened in
1861. The state maintained a contract with the
private facility until the Oregon State Hospital was
completed in 1883.
Unfortunately, part of that facility is still in use today.
Through the 1950s, Oregon, like most states in the nation, placed great
emphasis on treating people with mental illness in institutional settings.
The State hospital population peaked in the 1950s at over 5,000. By 1962, three
state hospitals, Oregon State Hospital in Salem, Eastern Oregon Hospital in
Pendleton, and Dammasch State Hospital in Portland, were in use. There was
little community care for adults.
In 1961, the Mental Health Division, hereafter referred to as the Division,
was established. During the 1960s, fueled by the national effort to begin treating
people with mental illness in communities and the Community Mental Health Centers
Act, Oregon began contracting with Community
Mental Health Programs.
In 1973, the Comprehensive Community Mental Health Program Act was passed.
The Act integrated the three state hospitals with community programs into a
regional system. In an effort to encourage counties to expand basic mental
health services and to develop alternatives to hospitalization, the Act also
granted one-to-one matching state funds to cover the cost for most services,
with up to 100% state funding for defined alternatives to state hospital care.
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Recent Developments
Through a flourish of initiatives in the late 1980s and early 1990s, Oregon's
public mental health system developed to its current capacity. The most notable
achievements, highlighted below, include the Oregon Health Plan, deinstitutionalization,
development of a system of care for children, and improved funding for all mental
health services.
The following chart demonstrates the evolution of Oregon's Medicaid-funded
health care system. Throughout the 1980s, an increasing amount of state General
Fund was used to leverage federal Medicaid dollars. This allowed for considerable
expansion of the public physical and mental health care systems. However, escalating
health care costs necessitated new strategies to provide cost effective and
appropriate public health care. The Oregon Health Plan was developed in the
late 1980s by Oregon lawmakers to provide a rational method for allocating
public resources for health care. The basic tenets of the plan were to devote
resources to services that had the greatest impact on the lives of consumers,
to develop an alternative incentive structure to promote cost effective and
appropriate service provision, and to provide coverage for all who needed it.
The Health Services Commission, comprised of physicians, service providers,
and consumers, was formed in 1989 and charged with prioritizing medical conditions
and associated treatments. Condition and treatment pairs are ranked according
to the state of medical technology, the effectiveness and cost of treatment,
public values, and advice from medical specialists and ethicists. In 1993,
Legislators provided for the integration of mental health conditions and treatments
into the prioritized list.
Beginning February 1994, Oregon's Medicaid Authority began contracting physical
health service delivery to managed care organizations and paying for services
on a prepaid, capitated basis. Administered in this manner, providers no
longer have the incentive to increase revenues by delivering costly and
inappropriate
services. At the same time, Medicaid eligibility criteria were expanded to
provide health care coverage to a larger proportion of the population. In
addition to the traditional Medicaid eligibility categories, all persons
with family
incomes below 100% of federal poverty level (FPL) and children under age
6 and pregnant women with family incomes below 133% FPL became eligible
for the
Oregon Health Plan. The 1997 Legislature increased the income limitation
for children and pregnant women to 170% of FPL and added children age 6
to 11 to
this group.
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In July 1995, mental health services were added to the Oregon Health
Plan benefit package for contractors providing coverage in 20 of Oregon's 36
counties. In January 1997, the Division released a Request for Proposals to
provide capitated mental health services on a statewide basis under the Oregon
Health Plan. As of July 1, 1997, the Oregon Health Plan will include an expanded
mental health benefit that will cover all Oregon Health Plan eligibles. Beginning
October 1997, services will be provided through managed mental health organizations
statewide.
Deinstitutionalization.
The chart below demonstrates the shift from institutionalization towards a
continuum of intensive community placements, short-term acute psychiatric care,
and state hospital services when necessary. Since 1987, the number of adults
served in state hospitals has declined 9.8% annually. During 1995, Dammasch
State Hospital was closed and a 68-bed Oregon State Hospital-Portland campus
was established to enhance accessibility and coordination with local community
programs. In addition to budget savings, this also resulted in improved staffing
at the state hospitals.
Since 1987, the number of adults served in acute care units and intensive
community and residential programs has increased at an annual rate in excess
of 50%. This has assured stabilization of consumers nearer their homes with
less disruption in their lives.
The Extended Care Management Unit (ECMU), created in
1995, is responsible for individual placement approvals and service utilization
reviews for adults in need of extended mental health care. ECMU staff's efforts
to monitor and coordinate the intensive service system have been instrumental
in reducing the number of people requiring treatment in state hospitals, and
have allowed nearly 400 people to leave state hospitals. Since 1995, 62% of
those people have lived in the community without needing any form of emergency
hospitalization for psychiatric conditions. Only 80 people have returned to
state hospitals for extended stabilization and treatment. Of the 80, 38 returned
to the community.
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System of Care for Children. Historically,
Oregon's state and county mental health services were focused primarily on
the needs of adults. From 1987 to 1992, Oregon received funds through the federal
Child and Adolescent Service System Program (CASSP) to design and implement
a system of care for children with mental health treatment needs. The program
provided a set of values and principles, including early intervention, family
involvement, and minimal restriction of freedom, to guide system development.
Implementation of the federal Early and Periodic Screening Diagnosis and Treatment
Program (EPSDT) expanded mandate resulted in expanded funding for children's
mental health services. In fiscal year 1996-97, an estimated 28,000 children
received public mental health services compared to 10,239 in fiscal year 1987-88.
In addition to serving an increasing number of children, Oregon has
also modified services and added new components to the system of care. Mental
health services for children are currently provided in settings that were not
previously used or were under-utilized, including homes, schools, and other
community settings. In 1991, responsibility and funding for other state-funded
treatment services, such as day and residential treatment, were transferred
to the Division from the state's child welfare agency (formerly called Children's
Services Division, now named Children,
Adults and Families). For children needing intensive
treatment, a system of residential and community-based programs has been developed
and jointly managed between the division, Services for Children and Families, Oregon
Youth Authority, and the schools. The number of children served in such
programs has increased from 44 in fiscal year 1987-88 to 1,743 in fiscal year
1996-97, a 51% annual growth rate.
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Oregon completed a two year managed mental health care demonstration for 25%
of the state's population in July 1997. The Child and Adolescent Plan (CAP
Care) implemented in Multnomah County in April 1996 provided outpatient and
acute care for an additional 25% of the state's children under a 1915(b)
waiver. Like the Oregon Health Plan demonstration, CAP Care was also funded
on a prepaid capitation basis.
Expenditures for Public Mental Health Services.
As the following chart illustrates, growth in nominal expenditures for mental
health services has outpaced growth in numbers served, particularly for children.
While the number of children served in the public mental health system increased
at an annual rate of 11.8% from 1987 through 1997, expenditures for children's
rose 33.1%. As indicated earlier in the section, this is primarily the result
of both the EPSDT mandate and the expansion of intensive services for children
and adolescents in the custody of the state. Expenditures
for adult programs rose at an 8.0% annual rate, slightly greater than the 5.9%
annual growth in numbers served.
Resources have been shifted from state hospitals to community programs as a
result of deinstitutionalization. The proportion of dollars expended on adult
and children's community mental health services relative to state hospitals
was 71.3% in fiscal year 1996-97, compared to 37.2% in fiscal year 1987-88.
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The Current Mental Health System
Guiding Principles
Oregon's primary focus in developing the current system of care is to prevent
or reduce the impact of mental illness for all persons affected. Success depends
on empowering persons with serious mental illness and their families to achieve
the most meaningful lives in the most natural settings possible. To this end,
the Division strives to serve individuals in community-based programs that provide
as much freedom as possible. In addition, care is taken to assure continuity
between different settings and integration of essential supports. Finally, consumers
and family members are regarded as valuable sources of insight and direction
whose involvement is encouraged at every stage of decision-making from individual
treatment planning to
system development.
The system of care for children is based upon the Child and Adolescent
Service System Program (CASSP) principles and places emphasis upon providing
services in normative, more familiar settings than mental health clinics, such
as schools, homes, and other outreach programs. Substantial emphasis is placed
upon service coordination and integration of services across multiple systems
including education, health, juvenile justice, and child welfare service providers.
Coordination and service integration across these social service components
has increased the capacity of local service providers to maintain children
in less restrictive community based settings. Capitation funding for the Oregon
Health Plan and Multnomah CapCare program described below also allow for blended
funding and flexible funding to improve overall service delivery.
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Population to Receive Available Services
Traditionally, adults have been prioritized for publicly funded mental health
services based on risk of hospitalization and/or posing a hazard to the health
and safety of themselves or others. Oregon, like other states, has been required
under federal law to provide Medicaid-covered services to eligible children assessed
with a condition by an EPSDT screen. Prioritization for non-Medicaid resources,
if available, is based on risk factors associated
with a psychiatric disorder.
Oregon's Medicaid managed care demonstration, allowed through a Federal
waiver of part 1115 of Title XIX of the social Security Act, entitled the "Oregon
Health Plan", has changed how this client population is determined in two important
ways. First, eligibility for Medicaid has traditionally been restricted to
people who met eligibility for other welfare programs and then only for a subset
with average family incomes around 58% of Federal Poverty Level.
The Oregon Health Plan established expanded criteria for Medicaid eligibility,
beyond the requirement for categorical eligibility and resulting in coverage
for all persons whose income falls at or below the federal poverty level. Second,
for the Medicaid population, eligibility for mental health services is no longer
determined by risk factors. The Oregon Health Plan Medicaid benefit package
integrates health services for dental, chemical dependency, mental and physical
conditions. Coverage is based on a prioritized list of integrated condition/treatment
pairs. Assessments needed to diagnose a condition are always covered. Thus,
an individual with an approved condition can receive appropriate mental health
treatment, including educational and preventative programs, before the condition
deteriorates to a critical stage.
Not all individuals requiring public mental health services will meet
Medicaid eligibility criteria. Services continue to be made available to persons
not eligible for the Oregon Health Plan according to statutorily defined risk
criteria. In addition, various federal grants, local funds, and private insurance
payments provide additional sources of revenue for Community Mental Health
Programs to serve people who have not been identified as having serious mental
illness.
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Array of Services
Outpatient Services. Regardless of funding
mechanism, clients are provided with an array of outpatient services, including
assessment and evaluation, individual and group therapy, medication management,
case management, and daily support and skills training. A range of services is
available for clients experiencing psychiatric conditions including 24-hour crisis
assistance, community-based respite care, and sub-acute psychiatric care. A promising
feature of the Oregon Health Plan is the flexibility providers have to develop
individualized treatment and intervention strategies. Allowable treatments for
covered mental health conditions include both traditional treatments and alternative
services suggested by contractors, allowing for less costly, more effective service
delivery when appropriate.
Intensive Services for
Adults. In addition to the services outlined above, Oregon maintains a comprehensive
system of intensive community-based, residential, and inpatient programs for
clients requiring extended treatment and supervision. As of June 1997, 264 extended
care placements located in secure residential, foster care, and supported-living
programs were available for adults. An additional 126 placements were maintained
in nursing homes or other facilities funded jointly with the State Senior and
Disabled Services Division for clients requiring nursing care and added psychiatric
treatment. A statewide system of regional acute care units provides 109 beds
for short-term inpatient psychiatric services. For adults in need of long-term,
secure treatment, 188 state hospital beds are available in two state psychiatric
hospitals.
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Intensive Services for
Children. A variety of intensive service options are available to children
and adolescents. Psychiatric Day Treatment (DARTS) programs provide 384 placements
for children and adolescents who cannot attend regular school programs due to
a mental or emotional condition. Therapeutic Foster and Proctor Care, and Therapeutic
Group Home services offer approximately 50 additional placements of community-based
treatment as an alternative to psychiatric residential and hospital levels of
care.
Three types of residential psychiatric treatment services are available
in JCAHO-accredited treatment facilities: 47 placements for assessment and
brief treatment, 58 "step-down" beds for children discharged from psychiatric
care, and 167 placements for residential psychiatric treatment services. Access
to non-emergency inpatient care in psychiatric residential treatment facilities
accredited by the Joint Commission on the Accreditation of Healthcare Organizations
requires approval from a statewide Certificate of Need for Services Committee.
Certificate of Need for Services (CONS) screening procedures require that a
child's need for psychiatric residential treatment be determined by a psychiatrist
prior to admission. This process assures that admissions are made according
to the treatment needs of referred children and assures that less restrictive
levels of care have proven ineffective or are inappropriate to meet these needs.
The Certificate of Need for Services process preserves high level treatment
options for those children who are most in need of these services and prevents
inappropriate placements for other children.
Residential Medicaid (RES-MED) programs provide mental health services
in State Office for Services to Children and Families (SCF) and Oregon Youth
Authority (OYA) contracted programs. The mental health services are co-funded
and managed by these agencies. Placements numbered 207 as of June 1997. Treatment
is directed by an individualized treatment plan, which is regularly evaluated
and adjusted for effectiveness. Staff deliver mental health treatment focused
on symptoms, behavior, feelings and perceptions the child presents in the treatment/living
milieu. Treatment includes regularly scheduled curriculum-based group therapy,
group and individual skills training, and individual and family therapy. Most
RES-MED programs provide on site education for enrolled children.
Psychiatric inpatient services are available in local acute care units for
children in crisis. Sixty beds were available as of June 1997. Services include
psychiatric assessment, diagnostic testing, medication administration and stabilization.
The Child and Adolescent Treatment Program, located within Oregon State Hospital,
provides 60 beds of extended inpatient care for children suffering from severe
functional impairment. This program is JCAHO accredited and children's treatment
is financed through federal Medicaid reimbursement to the state. Families are
encouraged to participate in their child's hospital treatment and aftercare
planning.
The Psychiatric Security Review Board (PSRB) maintains
jurisdiction for individuals adjudicated "Guilty Except for Insanity". The
PSRB reports to the Governor and has successfully utilized a variety of resources
to manage people under its jurisdiction. In 1996 none of the people under the
jurisdiction of the PSRB re-offended. The Division, in close coordination with
the PSRB, provides mental health services to such individuals. Besides State
Hospital services, the Division provides assessment of persons for the PSRB
and court to determine whether treatment in the community is appropriate, determination
of the supervision requirements of each placement, and treatment for persons
conditionally released into the community. Community treatment includes evaluation,
supervision, case management, psychotherapy, and medication management.
Access to Services
The Oregon Health Plan Mental Health Benefit. The comprehensive
nature of the benefit package available to Oregon Health Plan enrollees is expected
to improve access to mental health treatment for a significant proportion of Oregonians
afflicted with mental illness. Contractors that demonstrate integration and coordination
of necessary physical and mental health care and social support services are given
preference in the selection process. Enrollees will also be able to access mental
health treatment at earlier stages given that individuals are no longer required
to be at risk of hospitalization or a safety hazard in order to receive priority
for services.
Oregon lawmakers have expanded Medicaid eligibility criteria twice since
the Plan's inception, increasing the number of Oregonians eligible for Medicaid
approximately 80%. As of July 1, 1997, all persons whose income falls below
federal poverty level (FPL), pregnant women and age-12-and-under children with
family incomes below 170 percent of FPL, and some full-time college students
will be eligible for the Oregon Health Plan in addition to persons meeting
traditional Medicaid criteria.
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Access for Persons Residing in Remote
Regions. Access to mental health services in rural areas of the state is
comparable to that in urban areas. In addition to local programs, all persons
have access to appropriate statewide resources such as acute psychiatric hospitalization,
state hospital programs, and intensive community and residential programs.
An early Federal Community Mental Health Center Construction Grant was
awarded to rural Eastern Oregon counties to develop an integrated community
mental health service delivery system. The consortium of eastern counties has
evolved over time. A new quasi-public benefit corporation, the Greater Oregon
Behavioral Healthcare, Inc. (GOBHI), recently emerged to purchase and manage
mental health care in rural Oregon counties under the Oregon Health Plan mental
health demonstration. Through the pooling of resources, the fifteen counties
that comprise GOBHI are able to provide mental health services across an area
that makes up more than half of the landmass of the state. GOHBI's base of
coverage will expand to include at least two rural counties in western Oregon
as a result of the Oregon Health Plan expansion.
In an effort to better serve rural children, Treatment Foster Care was
developed in 1992-93 through a joint funding initiative with the State Office
for Services to Children and Families. Considered the least restrictive of
the residential treatment options for children in child welfare custody, Treatment
Foster Care provided by trained foster parents, employed and supervised by
the local Community Mental Health Program is a particularly viable treatment
option for children in rural counties. Of the thirteen Treatment Foster Care
contracts awarded, eight are in rural communities.
While individuals in rural areas have access to services through manage
care organizations and community mental health providers, access to some services,
notably psychiatric evaluation, extended care and acute care, requires travelling
long distances to reach the nearest provider. One solution has been the development
of psychiatric evaluations delivered via teleconference. A majority of Oregon's
rural counties have received federal designation as mental health professional
shortage areas. This designation appears to be helpful in recruiting psychiatrists
for areas that lack coverage by physicians without regard to specialty. Organizations
in these counties are eligible to apply for repayment of student loans on behalf
of a newly recruited psychiatrist, increasing the likelihood that that a full
range of services can be developed.
Medicaid Authorization Specialists (MAS) authorize
services for all children who receive more than 15 hours of Medicaid reimbursable
services per month or who receive mental health treatment services from more
than one provider. The MAS develop plans of care that prescribe necessary services,
including medical, dental, protective services, and housing and identifies
the providers responsible for providing them. They facilitate entry into higher
levels of care for those children who need more intensive services than outpatient
treatment or who require authorizations for extended stays greater than seven
days in local hospitals. The Medicaid Authorization Specialists also facilitate
access to statewide resources such as residential treatment or the Oregon State
Hospital. These functions will become the responsibility of the Mental Health
Organizations under the Oregon Health Plan.
Access for Persons Who Are Homeless. Access
to available services is most problematic for the homeless. The Federal Plan
to Break the Cycle of Homelessness was authorized under presidential authority
in 1993. A survey conducted by the federal department
of Housing and Urban Development (HUD) in that same year indicated that
federal, state, and local planners consistently rated mental health treatment
needs among their highest priorities in planning for services to people who
are homeless.
Since 1988, the State has received Federal McKinney Mental Health Services
for Homeless (MHSH) Block Grant funds, currently titled Projects to Aid in
the Transition from Homelessness (PATH), to establish specialized services
in the two counties with significant homeless populations: Marion and Multnomah.
Both counties provide outreach services to engage those individuals who are
seriously mentally ill and who use emergency shelters or live outdoors. Once
engaged, other services may include intensive case management, medication stabilization
and management, referral for primary health care problems, transitional and
supported housing options, dual diagnosis services and treatment, money management,
referral for job training and/or education, and linkage to ongoing community
mental health services.
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The Division supports a number of programs that provide housing opportunities
to homeless persons with mental illness: (1) the Housing Authority of Portland's
Shelter Plus Care program providing rent subsidies combined with support services;
(2) Northwest Human Services' Safe Haven program for five persons from Marion
County who are transitioning from homelessness to permanent housing; (3) Lane
County's Safe Haven program for 12 persons who are transitioning from homelessness
to permanent housing; and (4) Mental Health Services West's "Royal Palm" program
that provides a dormitory and single rooms for 45 of the most persistently
homeless persons with mental illness in downtown Portland.
In Oregon, the majority of children and adolescents who are homeless
reside in the Portland metropolitan area. A limited array of services are available
through a small number of private nonprofit social service agencies including
Portland Impact, Human Solutions, Outside-In, and the Green House youth shelter.
These agencies provide housing, case management and related social services,
and operate a drop-in center and youth shelters for runaways and street youth.
Advocates sponsored a bill in the 1997 Legislature to address the problems
of homeless adolescents. The bill, which would have directed additional resources
toward this population as a delinquency prevention measure, did not pass.
The remaining counties in the State also serve homeless persons with
serious mental illness, largely through their crisis services. Specific services
provided include limited outreach, psychiatric and physical health stabilization,
emergency and short-term housing, assistance with entitlements, and linkage
to ongoing community mental health services.
Screenings Delivered in Non-Mental Health Settings.
Identifying that an individual suffers from mental illness is paramount to connecting
them with necessary services. Mental health screening programs for adults are
delivered in a variety of settings, including nursing facilities, correctional
facilities, and as part of the precommitment process. Medicaid eligible children
receive a mental health developmental assessment as part of the EPSDT screening
process and as part of the Oregon Health Plan focus on prevention and early
intervention. Also, in preparing children's individualized education plans required
through the Individuals with Disabilities Education Act (IDEA), children can
receive mental health assessments to determine whether they have serious emotional
or neurobiological impairments which would affect their ability to learn.
Access for Minorities. The Division has
worked to promote access to culturally appropriate and responsive services.
The Division routinely requires Community Mental Health Programs to address
cultural factors in organizational planning. To improve access to appropriate
services, the Division has developed Administrative Rules, which require that
cultural factors be included as one of the domains of comprehensive clinical
assessments for all persons enrolled in state-funded mental health treatment
services. Further, Mental Health Organizations and other Medicaid providers
are required to provide appropriate translation services for adults, children,
and families who require them.
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Adequate Linkages Between Services, Programs,
and Agencies
Mental health services are most effective when delivered in concert with other
social supports, including housing and income assistance, health care, and vocational
and educational programs. The Division is committed to developing the linkages
necessary to give persons with mental illness the opportunity for independent
and meaningful lives.
The Oregon Health Plan. Oregon Health
Plan contractors are required to establish linkages with support services,
including established Community Mental Health Programs, for services that are
not covered by the capitation payment. Thus, enrollment in an Oregon Health
Plan managed care organization will serve as a single access point for all
necessary social services available to persons eligible for Medicaid, more
than half a million individuals in fiscal year 1996-97.
Housing Issues. The Division provides technical
assistance to local agencies in the development of housing resources, financing
packages, and applications for federal Department of Housing and Urban Development
(HUD) awards. In addition, since 1989, the Division has awarded small grants
used to leverage funds to complete financial packages and develop housing for
persons with mental illness. As of July 1997, a total of $2,077,485 has been
awarded to 80 housing projects throughout Oregon to create or preserve housing,
accompanied by various levels of support, for 982 persons with psychiatric disabilities.
This program has taken on increased importance as the Portland Metropolitan
Area has become the second least affordable housing market in the nation.
Children in State Custody.
Children in the care, custody and supervision of the State's Services to Children
and Families Division comprise more than half of children receiving mental health
treatment services. The Division has Interagency Agreements to co-finance and
co-manage much of the out-of-home treatment services provided to these children.
Children in the Juvenile Justice System.
Historically, youth in the juvenile justice system have experienced difficulty
gaining access to mental health treatment services. In 1995, the State Legislature
established the Oregon Youth Authority, which has responsibility for incarceration
of and services for adjudicated youth. In establishing the Oregon Youth Authority,
approximately 50% of the child welfare-contracted mental health treatment beds
in Oregon were transferred from the State Office for Services to Children and
Families to the Oregon Youth Authority. As a result, these beds are now designated
for serving youth that are involved in the juvenile justice system. The Division
and the Oregon Youth Authority are working in close collaboration to expand
the system of care and to further develop appropriate mental health treatment
resources for adjudicated youth.
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The Division Maintains State Hospital
and Community Mental Health Program Linkage Agreements to assure effective
case management of persons treated in and discharged from state hospitals. Similar
agreements are in effect between regional acute care units and Community Mental
Health Programs. These agreements will require greater involvement in screening,
admission, treatment, discharge planning, and aftercare on the part of Community
Mental Health Programs.
Persons in the Extended Care System. The Division's
Extended Care Management Unit manages placements in state hospitals, acute care
units, and extended care placements. The ECMU is also responsible for coordinating
transition between settings and from extended care to lower levels of care (case
management and supported-living programs).
Seniors. The Division co-finances and co-manages
services to seniors with mental illness who require 24-hour care in Adult Foster
Homes and specialized Enhanced Care Facilities.
Persons in Correctional Facilities.
The 1995 Legislature gave the State Department of Corrections responsibility
for developing and providing a full range of mental health services for inmates
in correctional facilities. The Division's Mental Health Corrections Program
retains quality assurance responsibility, conducting reviews and providing technical
assistance to insure adequate and appropriate service delivery.
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Stakeholder Participation in Policy-Making and
Oversight
Planning and Management Advisory Council. The Division
provides administrative resources and staff to the Mental Health Planning and
Management Advisory Council (PAMAC). The Council consists of representatives
from consumers, family advocacy organizations, State hospitals, State agencies,
Community Mental Health Programs, and provider organizations and serves as a
forum for stakeholders to make recommendations on major policy changes and initiatives.
Equal representation is maintained
for both adults and children.
Regional Planning Councils. The
Division maintains six regional planning councils. Representatives from acute
care units, mental health administration, community providers, and advocacy
organizations give direction to both inpatient and community-based services
related to each of the local acute care facilities.
Director of Consumer Advocacy. The
Division has historically provided accommodations and administrative resources
for a statewide Director of Consumer Advocacy, a full-time position funded
through a CMHS Service System Improvement Grant to serve as an independent
advocate for consumer issues. Outstationed in the Division, the Director has
been intimately involved in state policy development and decision-making. As
discussed under Requirement 1 of the adult plan, the status of this position
will change during the coming fiscal year.
Oregon Family Support Council. The
Division participates in the Oregon Family Support Council. The Council provides
assistance in the development of family support policy for all of the agencies
in the Department of Human Resources. Family members will comprise at least
50% of the Council membership. Policy makers, advocates, and service provider
representatives are also included among the Council membership.
State Target Planning and Consultation
Committee. The Division participates as a member of the State Office
for Services to Children and Families Target Planning and Consultation Committee.
It is the responsibility of this committee to approve and fund individualized
treatment plans for children in state custody who would otherwise be placed
out of state or in the state hospital for treatment.
Oregon Health Plan. Oregon Health
Plan managed care organizations are required to maintain consumer, advocate,
and family member involvement in monitoring and quality assurance processes
for managed behavioral health services.
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Quality of Services
Training. The Division sponsors and coordinates
a variety of educational workshops, conferences, and training programs. Events
are held in a variety of formats, including on-site programs throughout the state,
closed circuit and satellite broadcasts, and videotape distribution. The Division
administers recertification workshops for Professional Assault Response Training
(PART) Trainers. The Division sponsors training for professionals in the Oregon
Youth Authority, Juvenile court system, and local agencies to provide mental
health screenings. Training is provided for commitment investigators and law
enforcement personnel to insure compliance with statutory requirements and appropriate
police response to persons
in crisis.
Quality Assurance. The Office of Mental Health
Services' Quality Assurance Unit is responsible for licensing Residential Care
Facilities and Adult Foster Homes serving persons with mental illness. Additionally,
certification programs are administered for Community Mental Health Programs
and sub-contracted providers, Day Treatment and JCAHO-accredited residential
programs for children, acute care units, privately-funded non-inpatient mental
health providers, and providers utilizing hold rooms. Unit staff conduct site
reviews of community programs and acute care facilities to insure compliance
with contract conditions and state regulations.
Oregon Health Plan contractors are required to develop comprehensive
quality assurance plans. A Mental Health Organization's plan provides for the
systematic collection of utilization, performance, and outcome data. This information
is compared to established performance standards for access to services, quality
of care, education, outreach, preventative care, and coordination of available
social services. The plan describes how findings are communicated to all stakeholders,
including practitioners, enrollees and family members, and Division staff.
A quality assurance committee representing all stakeholders is authorized to
identify and implement changes in the delivery of services.
Abuse and Critical Incident Reporting. Under
Oregon Statute and associated Administrative Rules, private or public officials
must report potential instances of abuse of an adult with mental illness to
the Division. The Quality Assurance Unit is responsible for logging reports
of abuse, monitoring the progress of investigations and when necessary, conducting
investigations and writing reports.
Oregon Administrative Rules. The body of Oregon
Administrative Rules (OARs) governs all services and activities administered
by State agencies. The Division continually reviews and updates rules regarding
the delivery of mental health services to reflect state-of-the-art practices
and insure consistency with federal regulations. In fiscal year 1996-97,
the Division adopted revisions for children's community treatment services.
Work continued on rule revisions pertaining to Residential Care Facilities
and the commitment process.
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Mental Health Administration
Organization (July 1, 1997)
Public mental health services are administered within Oregon's Department of
Human Resources (DHR) by the Division. Two State-operated psychiatric institutions,
Oregon State Hospital and Eastern Oregon Psychiatric Center, report directly
to the Division Administrator. Capitated services to Medicaid eligibles are administered
through contracts between the Division and managed care organizations. All other
non-capitated services are administered through Intergovernmental Agreements
and direct contracts between the Division and service providers for intensive
treatment services (JCAHO and Residential Medicaid programs, etc.), community
hospitals for acute psychiatric care, and county governments for community outpatient
and residential programs.
The Division is required by Oregon Revised Statute 430.640 to establish
a contractual relationship with each county to assure the provision of community
mental health services. State funds are allocated to counties using a "block
grant" approach. This method of allocation provides the greatest flexibility
for counties in managing resources to best meet the needs of consumers. Although
there are no requirements placed on counties by the State to serve minimum
numbers of people, contracts issued by the Division stipulate that counties
are financially responsible for the cost of State Hospital care after a person
is determined ready for discharge. This assures that support services will
be made available quickly to the people as they prepare to leave the hospital
and also provides a framework for counties to develop mental health systems
designed to prevent hospitalization.
In state fiscal year 1996-97, the public mental health system was in
transition. In twenty "demonstration" counties, provision of Medicaid-covered
outpatient and acute inpatient services were contracted through managed care
organizations under the Oregon Health Plan. Approximately 28% of Medicaid-eligible
public mental health clients received services in these counties. In addition,
Medicaid-eligible children in Multnomah County received services through CapCare,
a managed care initiative funded on a prepaid capitation basis through a 1915b
waiver. An additional 25% of child and adolescent mental health recipients
received services through CapCare. Medicaid mental health services in the remaining
counties were contracted through Intergovernmental Agreements with counties
and direct contracts and reimbursed on a fee-for-service basis. For individuals
not eligible for Medicaid, Community Mental Health Programs continued to deliver
mental health services prioritized according to statutorily mandated criteria
based on risk of hospitalization and dangerousness.
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Management Information Systems
Data on persons with psychiatric and emotional disorders and the services they
receive are collected and stored in three primary databases. The Medicaid Management
Information System (MMIS) provides information on the Medicaid-eligible population
and billable services delivered. With the transition to managed care for Medicaid
services, the type of information collected is changing from billing-related
data to encounter data. The Client Process Monitoring System (CPMS) contains
records for services delivered in community programs and intensive treatment
programs. The Oregon Patient/ Resident Care System (OP/RCS) is the information
management database for all publicly-funded psychiatric inpatient care delivered
in state hospitals and acute care units and serves as the primary resource for
tracking individuals who have been civilly committed. Each system contains client
level identifiers unique within the system. DHR's Office of Information Services
maintains inter-system references that allow analysts to track and summarize
service utilization and population demographics at the client level, regardless
of the type
of service received.
Additional information is collected by the Division. Outcome and performance
measure data are gathered through consumer satisfaction surveys. This information
is used to: 1) provide feedback to those who are affected by Division performance
measures; 2) identify areas in need of improvement or attention; 3) track improvement
in the well-being of people served with public funds; 4) recognize those programs
which are doing well; and 5) communicate results to the Legislature, Governor,
Department contractors, and the public.
The Division maintains detailed population estimates. This information
is used to derive estimates of prevalence for serious mental illness in adults
and serious emotional disturbance in children. Racial, age, and geographic
distributions are compared to those of the client population to identify potential
variations in access and appropriateness of services across groups.
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