The number of people in Oregon who are accused of crimes but cannot understand the charges against them due to psychosis has increased to what one state official called “record levels” this fall, and is throwing a wrench into efforts to reduce the waitlist at the Oregon State Hospital.
Patrick Allen, the outgoing director of the Oregon Health Authority, told lawmakers the wait list is “going in the wrong direction.”
His remarks, accompanied by data showing a marked increase in monthly cases of people deemed too mentally ill to aid and assist in their own defense, came during a hearing of the House Interim Committee on Behavioral Health last week. This fall, there have been 20 more aid and assist patients entering the system each month than public officials had expected.
Oregon has been sued over the length of time people who should be at the state hospital spend in jail, without access to treatment, while they wait for admission. Prior court cases have held that people held in jail who need 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 waitlist has 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 discharge people faster.
A court order issued on August 29 capped stays at the psychiatric hospital at 90 days for people accused of misdemeanors and one year for people accused of felonies.
The court also ordered the hospital to stop admitting patients who are civilly committed — when someone not accused of any crime is forced into psychiatric treatment — with an exception only for people who are deemed dangerous to others. Civil commitment happens to about 500 people a year and now there is no room for those people at the state’s one public psychiatric hospital.
The health authority started implementing the new plan in September and has been essentially meeting its targets for speeding up discharges. Yet the number of people waiting for admission has grown, from 86 people in September to 104 people in November.
If things were going according to plan, the state hospital waitlist 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 assist” orders in September, 95 new people with “aid and assist” orders in October, and 95 new people with “aid and assist” orders in November.
Should the Oregon State Hospital Expand?
At the hearing last week, Committee chair 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 far too many people wind up at the state hospital because they become involved with law enforcement, which makes treatment and recovery from addiction or mental illness more challenging. The state needs more community mental health resources to get upstream of the problem, Allen said.
“What are we missing? It’s probably pieces of every part of the system at the community level, to keep that from turning into a law enforcement engagement,” he said.
Allen also endorsed a more controversial idea: Expanding the capacity of the Oregon State Hospital.
“Nobody wants to hear this, but we probably need more state hospital beds as well,” he said, echoing a similar call this week from Portland Mayor Ted Wheeler. Wheeler said it is time to lower the bar for civil commitments in Oregon, which he acknowledged would require expanding mental health services in the state.
Expanding the state hospital system may be a tough sell for legislators because federal Medicaid dollars don’t pay for any of the 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 growing the capacity of the two existing Oregon State Hospital campuses, one in Junction City and one in Salem. “Where it is, 100 beds here, 10 beds in 10 places, I have no opinion on that, but that is 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, Oregon’s county mental health programs will soon be responsible for dozens more people with mental illness that respond poorly to treatment - patients the counties may end up sending to motels, lacking a better option, according to testimony during the hearing.
Legislators heard about the lack of appropriate community placements for the sickest patients and chronic short staffing in behavioral health programs from a psychiatrist working at the hospital, a union representative, and a county behavioral health director.
The Mosman order is rooted in best practices 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 Program in Psychiatry, Law, and Ethics at the University of Michigan.
But throughout the hearing, people working in Oregon’s mental health system challenged 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’s psychiatric hospital.
Tom Crawford, a policy advisor for SEIU Local 503, said he was speaking on behalf of the staff at the hospital who are union members and wanted to provide feedback on the Mosman decision anonymously. Patients who reach their time limit are getting discharged to homeless shelters or to the streets, and are ending up re-arrested and back at the hospital.
Crawford said staff at the hospital disagree that 90 days is an adequate length of time to stabilize most patients facing misdemeanor charges.
For some patients it takes 30 days to detox, he said, and then 4 to 6 weeks for psychiatric medication to start working.
“That’s their 90 days and then they are back there out on the street,” Crawford said. “This is not an environment where patients can heal.”
Crawford also said the Mosman decision has impacted the safety of patients and staff.
In recent years, short staffing has created a serious safety problem at the hospital, with the number of workers’ compensation injury claims rising from 152 in 2019 to 263 in 2021.
According to Crawford, the Mosman decision is further undermining safety by creating rapid turnover and insufficient time to stabilize the patients.
“We are looking at a recipe for further injuries,” he said.
What should we do about Frank?
Data shared earlier in the hearing showed that about 70 percent of “aid and assist” patients at the hospital are discharged because they have successfully completed their treatment or are found to be unlikely to ever regain competency before the time limits go into effect, while 30 percent are discharged only because they have reached the time limit for their stay.
Dr. Amit Bhavan, a psychiatrist who works at the Oregon State Hospital, said county mental health departments do not have the resources to manage the people he is discharging due to the Mosman decision, often the sickest patients with symptoms that do not respond well to treatment.
Bhavan said that day, he had discharged a patient back to Jackson county on an expired “aid and assist” order. The county had no capacity to offer treatment or services to a person with that patient’s degree of difficult symptoms.
“The best they could offer the patient was a stay in the local motel,” he said.
He will soon face a similar situation with patients returning to Josephine and Washington County without any ability to get community services there.
“It is a factor in the high rate of recidivism we are currently seeing,” Bhavan said.
Julie Doge, Interim Behavioral Health Director at Multnomah County, also described the difficulty finding community placements for the individuals discharged under the Mosman order.
Doge shared the story of a patient she referred to by the pseudonym “Frank,” who has spent most of his adult life in secure residential facilities. Frank was recently sent to the Oregon State Hospital on an aid and assist order after he assaulted a resident and staff member at the secure facility he’d been living in.
Doge said the county received a notice that Frank would be timing out of his stay at the Oregon State Hospital in 30 days.
“That means Frank is not stable,” Doge said, “and we need to begin finding a place for him to go.”
The county may not have the legal jurisdiction to compel Frank into treatment. And the only facility in Multnomah County that can use seclusion and restraint and involuntarily administer medication has criminal charges pending against Frank.
“We’ll do our best, even so, because not doing so leaves Frank unable to care for himself and a safety threat to our community,” Doge said.
Doge said there’s a gap between the funding legislators have been historically willing to provide to 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, she said.
At least 128 people currently at the hospital are due to be released to the community without having been restored to competency, Doge said.
She urged legislators to look at staffing recommendations and best practices for those patients and to use that to guide county mental health funding.