The Oregon Legislature must soon decide to fund or not to fund the construction of a state mental hospital proposed to be sited south of Junction City. That decision will determine the focus of treatment for Oregon’s mentally ill population for years to come.
A decision to fund the hospital construction will commit the state to over $100 million in construction costs and an annual budget of over $48 million (174 beds at $280,000 per bed per year). This huge expenditure will drastically curtail funding for the development and operation of community-based services; community-based residential facilities, community mental health clinics and out-patient care centers and community-based crisis care facilities. Funding the hospital construction and operation will put all our mental health care dollars in one basket — and, in my opinion, it’s the wrong basket.
Every “stakeholder” group engaged in this debate has publicly and vehemently opposed the hospital’s construction. Every patient’s advocacy group has opposed it. Every mental-health professional organization has opposed it. The governor-appointed State Hospital Advisory Committee has opposed it and sent a very strong letter of opposition to all state legislators. The U.S. Department of Health and Human Services has expressed its opposition to large facility/locked ward care with its “wallet.” Community-based treatment facilities and services receive a 50 to 60 percent federal subsidy; locked ward facilities such as the proposed Junction City hospital receive no federal subsidy. The Junction City proposal is both “wrong-headed” and hugely expensive.
The guiding principle of mental-health care and placement is “the least restrictive appropriate treatment placement.” Lock-ward placement is the most restrictive placement on the continuum of services for the mentally ill. The funding of the J.C. hospital will represent commitment to funding that extreme level of treatment at a direct “opportunity loss” cost to all other placement and treatment options. Oregon, especially in these difficult economic times, simply cannot fund this facility and develop and support other, less restrictive treatment options.
Even the proponents of the hospital construction acknowledge that we do, indeed, need to move toward community-based facilities, programs and services; but, they claim the increased commitment to locked-ward treatment is a necessary step toward those programs. This argument is akin to suggesting the best way to drive from Eugene to Portland is to first travel to Medford — rather than taking us closer to that goal of community-based mental health treatment, the hospital’s construction takes us much further away from that goal.
The debate centers on “forensic” patients, individuals who have committed crimes, but are adjudicated “mentally ill” and send to the hospital rather than being processed further into the criminal justice/penal system.
Based on August 2011 data, 40 percent of Oregon’s forensic patients were committed for crimes which were not Measure 11 felonies. Were these individuals not judged mentally ill and, instead, had been convicted of such crimes, they would have been sentenced to either very short periods of incarceration or placed on probation. Most of these patients could be treated in community-based facilities at a much lower cost (about 14 percent of the cost of hospital placement), receive more appropriate treatment, more readily transition back into the community while, importantly, presenting no risk to other patients, staff or the community.
Additionally, locked-ward mental hospitals across the country, including Oregon, have an increasing population of geropsychiatric patients; older patients, many of them quite elderly and infirm, who could be placed in community-based facilities with absolutely no risk to anyone. We’re both violating the mandate for “least restrictive appropriate treatment placement” and wasting tens of millions of tax dollars with these locked-ward placements — or, if you will, “misplacements.”
The simplest and most economic approach to forensic patient care is to provide proactive support; care, treatment and supervision before they commit the crime leading to their hospital placement; i.e. help them avoid becoming forensic patients.
Most (virtually all) forensic placements have long histories of mental illness. They are individuals living in our communities who are receiving maintenance levels of psychotropic medications to treat, primarily, schizophrenia and bi-polar disorder. They function quite well in the community so long as they maintain that therapeutic level of medication. However, nearly all psychotropic drugs have rather unpleasant side-effects: nausea, headaches, muscle and joint pain, stomach and digestive problems and, often, impotence and loss of libido. The problems arise when individuals taking these medications decide to “self-UNmedicate”; to, on their own, reduce or terminate their medications. Most of the incidents leading to forensic placement occur when such patients are “off their meds” and in the throes of a psychotic episode.
We need community resources to help these individuals continue their medication at an appropriate level: We need out-patient support groups and individual therapy and counseling support. We need out-patient clinics with physicians and psychiatrists to help adjust medicines and doses to minimize side-effects and, when needed, nurse-practitioners to supervise court-ordered medication dosing. We need community-based residential facilities with a continuum of security levels to house patients. We need community crisis centers for temporary secure placement to provide short-term detention, observation and evaluation and, as often needed, to facilitate the re-establishment of therapeutic levels of medication
We need legislative support for these services which patient advocates, professionals in the field, and the State Hospital Advisory Board endorse. The termination of the J.C. hospital project and redirecting of funding toward these proactive community-based programs and facilities is the first important step to providing that needed support.