Multnomah County Commissioner Dr. Sharon Meieran became a mental health advocate after working in emergency rooms. During shifts as a physician, she saw patients languishing in scrubs with nowhere else to go. She saw homeless patients and people addicted to opioids cycle in and out of the hospital.
Meieran saw an epidemic.
Mental health problems in Oregon have only increased since Meieran started working as a doctor almost a decade ago, she said. More people are experiencing crises, and they’re often in even worse condition than they were in the past.
As commissioner, she is focused on mental health issues in the county. She also wants to see improvements statewide. She pressed the Oregon Health Authority to hire a behavioral health director, which it just did after a months-long search that broke down at one point.
She says that position is sorely needed to improve mental health care in Oregon, which has the widest prevalence of mental health patients nationwide and poor access to care, according to surveys.
Meieran recently discussed this and other issues with The Lund Report. mental health challenges The interview below has been edited for brevity and clarity.
What are some of the issues you saw that made you want to run for office?
There are a lot of issues. Working on the front line in the emergency department, we’re often the canary in the coal mine on a lot of the social issues. We’re the first ones to see it. With regards to mental health issues, it really was that increasing acuity and the increasing number of people coming in with mental health crises.
So often they seem to fall through various cracks in the system. People end up in the least effective, most expensive, most traumatic place to deal with whatever these underlying issues are.
In the ER, we’re used to taking action and treating people or at least getting people to a place they can be treated once they’re stabilized. This is just such trauma for people to keep them in this chaotic environment. We just watch people suffer. That’s how I got involved in advocacy areas.
How did we get to this point?
A lot of it ties to deinstitutionalization. This goes back to the 1960s. There was this idea that mental institutions at that time were horrible, horrible places and people would get terrible treatment. There was a move away from wanting to institutionalize people and have them get treatment in the community, which absolutely makes sense. But they didn’t put the resources into the communities.
It’s not just that (people) aren’t in institutions and getting that care. They’re really not getting any care. This has worsened over time. There is nowhere for people to go.
What about the Unity Center?
I was involved with conversations and discussion about the Unity Center since its inception and before, and I went and visited the hospital in Alameda County, (Calif.) on which it was based. At a center like that, you have the experts on hand. In most emergency departments, we don’t have psychiatrists waiting to see people. We don’t have psychiatric nurse practitioners. We don’t have social workers focused just on psychiatric care. At Unity, the idea is those people are right there. As soon as someone comes in the door, their issues are addressed. Treatment can be initiated -- the right kind of treatment. Therapy can be instituted. What was shown in California, where the model started, was people could be turned around, their condition could be stabilized, and they could be discharged, often in less than 24 hours.
So instead of languishing in the emergency department, they could be treated or stabilized and discharged, ideally with a connection to something in the community. They were able to decrease the need for hospitalization by 75 percent.
The idea with Unity was to implement that kind of system in the metro region.
How has or has it not done that?
Some of the issues that Unity experienced, (they) probably anticipated because in implementing this totally new model, there’s going to be some culture shifts between people used to doing it a different way. There are going to be miscommunications and misunderstandings. People have expectations that it’s going to solve world peace and world hunger. It can’t do that. It’s a small role, an essential one, but a small role in a much larger puzzle.
In California, when they first opened, there was a significant increase in assaults, but 15 years down the road, they have essentially zero incidents of violence, assault, constraint, those kinds of things. That’s great, but we’re definitely not there. I believe there were some missteps in how Unity was implemented. I’m hopeful that corrective action is being taken, and that as we move forward that those issues can be addressed.
In terms of the sheer volume and number of people, that’s still a huge concern. The model is built on the idea that people can be turned around and then discharged, or that they can be admitted to inpatient for a short period of time and then be discharged. But because of this increasing number of people being seen, that higher acuity, it’s not necessarily the case.
The big issue is we don’t have anywhere for people from Unity to go.
Taking a step back and looking at mental health care in Oregon, what should and can be done now?
One of the most important things that need to happen that should have happened years ago, that is critically urgent now, is we need behavioral health leadership at the state level. There’s not been a behavioral health director at the Oregon Health Authority for years. The prior Oregon Health Authority director dismantled the mental health and addictions department in general, so there has been a vacuum of leadership. Without that, it’s hard to imagine having a vision and moving forward in a meaningful way.
Are there any other immediate things that should be done to address the behavioral health need?
One of the most urgent issues that we need to address in the system (is) addressing the crisis with our aid-and-assist population. That deals with the intersectionality of our mental health system and our criminal justice system. That is huge. So often we see people that cycle through homelessness, into the criminal justice system, into the ERs and then back out on the streets. That’s the trifecta. We need to stop that cycle.
One of the biggest issues is people with a low-level misdemeanor, nonviolent crimes are brought into jail, and then they’re deemed not able to “aid and assist” in their own defense in whatever case they have. When that happens, this person who may have just had a minor trespass case or didn’t show up for their hearing on a minor trespass case and has mental illness are suddenly shipped down to the Oregon State Hospital, where they can be for 30, 60 or more days to be “restored to competency,” at which point they’re shipped back to their local jurisdiction and either serve out whatever sentence it is or released.
The Oregon State Hospital costs $1,300 a day for someone to be. Jail is about $100 to $200. This is a completely ineffective mechanism to deal with whatever this underlying issue is. We are wasting millions, tens of millions, hundreds of millions of dollars sending people to the Oregon State Hospital who could be restored to competency in the local jurisdiction for much less money.
So looking more long-term, in terms of addressing behavioral health in Oregon, what should the long-term vision be?
Let me get back to short-term really quickly because I think there are some short-term solutions. The short-term solutions aren’t the big picture solutions where we’re doing systems transformation, but they are key elements of the system which clearly need addressing. There are missing links in our system of care. Some of these are just best practices, very evidence-based. We need peer-driven resource centers in the community. This can prevent people from going to ERs, prevent people from going to jails, get people on the right path. These are the things we can look at opening at least in the short or medium term.
Are these different or the same as the peer respite centers that are being discussed at the Legislature right now?
They can be related. It’s not a single model. Different jurisdictions could do it differently. It would be definitely related to that. It could have transitional housing. It could be workforce training. There could be many different ways, but a peer-based respite center.
Other things we should be doing immediately is addressing our workforce. Often the people who do this work on the frontline are the most underpaid, overworked, under-benefited people doing the hardest work. They themselves are often traumatized. They’re often not able to afford rent. They can be living in their cars. They can be suffering from some of the same things that their clients are suffering from.
We need to be paying them a living wage. Unless we do that, we’re going to have tremendous turnover, tremendous burnout, which is not good for the system. It’s not good for the people being served or the people doing the service.
One thing we’re looking at doing right now at the state Legislature, which Multnomah County and I are avidly supporting, is increasing the reimbursement rate for providers of substance use disorder services. Right now, you get reimbursed a certain amount for physical health conditions. You get reimbursed a certain amount for mental health conditions. Then way, way down is the reimbursement rate for serving people with substance use disorders.
The incentive to serve that population or to even combine that population with the service for mental health is minimal to nonexistent. People do this work because they have a passion, because they love it, but it is incredibly poorly reimbursed.
If we are able to bring the reimbursement rate up to parity with mental health reimbursement rates, that itself can help jumpstart the system and get some more resources out there to the workforce who really needs it.
Let’s talk long term.
Long-term, one of them is there is not a consistent vision of what mental health care should be. Behavioral health leadership at the state level could help identify that. We’re working on that at the county level. You need a vision to get somewhere rather than just doing things the same way. We need to address that intersectionality with the criminal justice system and our mental health system.
The biggest (issue) hits you in the face no matter who you talk to about the barriers to mental health care: housing. We need deeply affordable housing with wrap-around services available, also known as permanent supportive housing. Unless people have a place they can be to access their services, they won’t access the services.
Can you describe what some of those services are?
A place where they can get medication. A place where they can have a social worker check on them. A place where they can get therapy. A place where they may be able to engage with peers. If they have a substance use disorder, a place where they can get their medication-assisted treatment or go see their counselor. Those types of services.
Any other long-term goals you wanted to address?
The workforce issue is a long-term thing. We need to really engage culturally specific providers and workers to be able to serve diverse populations in our communities. That will entail ongoing training. It’s a long term, but that’s something that could and should start today.
What do people feel the system is providing?
Not very much. They feel there aren’t programs. Even when those programs exist, people feel they don’t exist. Even when they do exist and people know they exist, they feel like you need a secret code to be able to access them. You need to be able to ask the specific question to enter the door to speak the password to get into the service. They perceive the services how I perceive them as an emergency physician. (They see that) there are tremendous cracks, lack of coordination between services, systems and sectors and no one talks to anyone else. That perception came out very loud and clear. The other biggie was that there’s no overarching vision and shared understanding of what our mental health system should be. That’s big.
Right now, we have a system where we invest in the same programs over and over, but toward what? We need to take a step back and look at that. That is what we at the county are doing.
We’re also doing a deeper dive into how mental health systems are funded. That’s a huge issue at the state level, federal level and at the county level. It’s like a black box, opaque, impossibly complex system. Until you know (how) the money drives what services are provided and where you can make some changes, you’re never going to be able to address that complexity. I want someone to be able to explain (how money flows through the mental health system) to me and have me understand without resorting to 1-0 different white boards with hundreds of different arrows. I need to understand it functionally as a system, and, to date, I haven’t had anyone able to do that.
What’s happening with behavioral health initiatives around the state?
This is a lot of the frustration that people, including myself, have felt with a number of the processes that have been ongoing with regard to advocacy around behavioral health. Anyone who has been involved in this work in the system for any length of time, has been party to multiple task forces, and committees and coalitions and groups, to address the same issues. We have a pretty good understanding of what the problems are. What we don’t have is direction and leadership to point us toward solutions. It is extremely frustrating.
People lost faith and trust in the system.
What needs to be done to rebuild that trust?
That is the key question. I think it can be done. The first step is you need a strong behavioral health director at the Oregon Health Authority who people trust, who has subject matter expertise, who has worked in the system, who deeply understands it and over time that can bring people together and have these conversations one more time. I think there also are different levels within the Oregon Health Authority within that department where there’s a lot of turnover or a lack of subject matter expertise (and) a perceived lack of responsiveness sometimes to requests.
You need to be immediately responsive. You need to have a critical mass of that workforce in the Oregon Health Authority department who will be proactive and responsive to the people doing the work in the counties. That can begin to rebuild a lot of trust. Communication and accountability, I think are where it’s at.
Have a tip about mental health? Contact Jessica Floum at [email protected].
