A court-appointed outside expert has submitted recommendations for the Oregon State Hospital as the state-run psychiatric residential facility faces an onslaught of litigation and criticism for its failure to complete timely admissions of patients stuck in jail without treatment.
The wide-ranging recommendations represent a potential shakeup for the status quo in Oregon’s mental health system — and its impact would reach beyond the state hospital. One recommendation, significantly, calls for the state to start charging Oregon counties that decline to accept state hospital patients deemed fit for release to their communities.
That proposal underscores a key finding about Oregon State Hospital: plenty of patients no longer need hospital-level care and can be discharged to a lower level of care, such as community mental health programs or residential facilities. But counties and communities don’t accept them, often citing a lack of resources such as residential facilities.
Instead, they linger in the hospital, taking up bed space that otherwise could be used to admit patients who are being deprived of adequate treatment while waiting in jail.
“That is really one of the most crucial recommendations in the report,” said KC Lewis, managing attorney for Disability Rights Oregon’s Mental Health Rights Project, in an interview with The Lund Report. “If we don’t create an incentive, it’s just too easy to write them off and leave them there.”
Disability Rights Oregon sued Oregon over its failure to admit patients within seven days who need treatment so they can aid in their defense for pending criminal cases. A federal judge appointed the expert, psychiatrist Dr. Debra A. Pinals, to submit recommendations as Disability Rights Oregon and the Oregon Health Authority, which runs the state hospital, negotiate a potential resolution. Pinals is a clinical professor of psychiatry at Michigan State University and director of its Program in Law, Psychiatry and Ethics.
The two parties agreed to use the expert’s recommendations as a jumping off point for discussions. The expert will submit a report with additional recommendations in April.
The report said the Oregon Health Authority is seeking legislation that would allow the state to charge counties when patients are still in the hospital and no longer need hospital-level care. Full details were unclear Wednesday, though the report calls it “county financial risk sharing.”
Disability Rights Oregon supports that move, along with increased efforts for more engagement and accountability with counties for timely transitions out of the hospital, the report said.The concept appears to be in its early stages. It doesn’t appear on the Oregon Health Authority’s internal bill tracker, which lists nearly 50 bills and legislative concepts on the agency’s radar. The Lund Report obtained the tracker Tuesday through a public records request.
Lewis said he expects to see that legislation this short session, possibly as an amendment to another bill.
The Oregon Health Authority appreciates the collaborative work with Disability Rights Oregon and the expert to create solutions, said Aria Seligmann, a spokesperson for the agency, in an email. The authority has $123 million in infrastructure and investment grants and another $20 million for community services for people who need treatement to stand trial on criminal charges, Seligmann said. Those funds will "help alleviate the burdon on the hospital," Seligmann said.
Backlog of Delayed Discharges
The number of patients who no longer need hospital-level care but remain at the state hospital was greater than the patients on a waiting list in January, the report shows.
The hospital had 115 patients clinically approved for discharge as of Jan. 11, the report said. The delayed discharges comprise 16% of the hospital’s 706-bed capacity at its Salem and Junction City campuses.
The population of patients with delayed discharges is greater than the number of people waiting for admission: 93. As of Jan. 28, that group had been on the wait list for an average of 22.5 days. Time on the wait list ranged from three to 44 days.
Policymakers and advocates have long said Oregon needs a more robust community mental health system to help people before they reach the point where they enter Oregon State Hospital, which often happens only after a person enters the criminal justice system. In 2021, Oregon lawmakers appropriated nearly half a billion dollars to prop up the state’s behavioral health system, with money earmarked for more residential facilities, programs and incentives to expand the workforce. But the work to set those programs up and award funding to providers will take time.
The report targets the bottleneck, saying the sprawling system of counties, providers, local organizations, the court system and coordinated care organizations creates a “challenging process under the best of circumstances.”
“That said, as reported by nearly every group with whom I spoke, there are barriers at the county and community levels that warrant further scrutiny and attention in order to achieve compliance with admissions,” Pinals wrote in the report.
Meanwhile, Oregon Health Authority, Disability Rights Oregon and the outside expert continue to meet at least weekly, Lewis said.
Other recommendations include:
- A general refinement of discharge policies to increase efficiency and get patients out of the hospital sooner when they are ready to leave. This includes a look at barriers in communities that prevent their discharge.
- Continue to advocate for the additional staffing at Oregon State Hospital. Officials have requested lawmakers to approve a $33.5 million hiring plan that would add 359 positions to the hospital. Staffing shortages continue to plague the hospital, which has relied on Oregon National Guard troops for support.
- Develop a data infrastructure to monitor compliance, including a data dashboard to share and use for admission strategies. That would include the number of individuals waiting for admission from jail, whether to serve a sentence after being found guilty except for insanity or to get treatment before going to trial on charges. It would include average wait times and be broken down at the state and individual county level.
- Under that plan, the data system would have details about the patients ready for discharge, including information about the care they need and how long they no longer need hospital-level care.
Lewis, the attorney, said the recommendations represent a good start as the work continues in the months ahead.
“I think we are simultaneously very excited and cautiously optimistic,” he said. “Our hope is that these recommendations are going to make some progress.”
Lengthy Legal History
It’s the latest chapter in the Oregon State Hospital’s legal troubles that stem from lawsuits filed by advocates and people in the criminal justice system who languished in jail for months, even after judges ordered them sent to the hospital for treatment.
The report seeks solutions for two federal lawsuits that have been combined into one case. The Disability Rights Oregon case has been combined with a lawsuit filed in 2021 by Jarod Bowman and Joshawn Douglas-Simpson. They sued for failure to receive a timely admission after a Multnomah County judge ordered them sent there without “unreasonable delay” after they were found guilty except for insanity in criminal cases. After the order, Bowman spent nearly eight months in the Multnomah County Detention Center. Douglas-Simpson was there for nearly six months.
In June 2019, the court ordered the state to become compliant within 90 days and begin timely admissions of patients who need treatment before standing trial, called “aid and assist cases.”
Then COVID-19 hit. Oregon State Hospital asked and received more latitude due to the pandemic. Disability Rights Oregon appealed the ruling and the Ninth Circuit Court of Appeals granted their appeal, sending the case back to the district court judge. The state and advocacy group in December 2021 agreed to an interim settlement agreement, which includes working with the neutral expert.
I am glad to see this perspective highlighted. The dream of community-based care wil never be realized in Oregon until the NIMBYism that has stunted development of neighbrohood-based residential/step-down care is recognized and addressed head on.