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  • 26 Nov 2014

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Cinching up the safety net

Regional psychiatric center might offer crisis relief to police, ERs

Photo Credit: TRIBUNE PHOTO: JAIME VALDEZ - Portland police officers regularly transport people in psychiatric crisis to hospital emergency departments. A proposed new facility would relieve them of that duty. Here, Portland police officers Jonathan Richardson, left, and Brad Yakots check in with a homeless man in Old Town.Chris Farentinos and Cindy Scherba think they might have the solution to one of the city’s most vexing problems: finding a place for people experiencing psychiatric emergencies to go or be taken to by police. If they’re right, they could improve care for thousands of Portland residents going through crises and satisfy a lot of key political players at the same time.

Police say they are desperate for a place they can take the steadily increasing number of people they encounter who are suicidal, homicidal or unable to cope with daily living because of mental health crises.

Mental health advocacy organizations say the establishment of such a place is the single most important line item in the city’s settlement with the U.S. Department of Justice over police treatment of the mentally ill.

The city’s hospitals want a drop-off center, too, because police currently take their mental health emergency cases to hospital emergency departments. The emergency departments fill up with costly psychiatric patients who sometimes wait around for days because the hospitals are short of psychiatric beds.

Dr. Farentinos, director of behavioral health at Legacy Health, and Scherba, Oregon Health & Science University’s director of behavioral health, have been quietly holding talks across Multnomah County to build support for a facility they are calling the psychiatric hospital and regional psychiatric emergency service. The key to solving what has been such an intractable problem? Billing, apparently.

“We know that to improve mental health care for psychiatric patients we need to look at how we can decriminalize the mental health treatment we provide,” Scherba says.

The proposed new facility even has a designated, already-constructed site that currently houses the Portland campus of the Oregon State Hospital in the Lloyd District. The state is vacating the former Holladay Park Hospital and transferring its functions to a new state psychiatric hospital being built in Junction City.

Scherba and Farentinos are pitching a place where people experiencing mental health emergencies can find sanctuary while being observed. That’s how John George Psychiatric Hospital in Alameda County, Calif., works and that’s the idea, called the Alameda Model, that Scherba and Farentinos want to adopt here in Portland.

At John George, about eight in 10 of the patients in crisis brought in by police or who walk in on their own end up leaving the facility in under 24 hours. Psychiatric staff assess them within 15 minutes of arrival and can get them started on medication if needed. Then, most of their time is spent under observation in an open room with recliners where they basically calm down with few restraints. For those acting out of control who need to be separated from the rest, there are rarely used seclusion rooms.

But here’s the key. John George’s model requires psychiatric staff 24 hours a day, seven days a week. That’s expensive. Historically, health insurers don’t pay for time when patients are just kept under observation. John George worked a deal with insurers in California to establish a billing code for observation that the insurers would pay, recognizing it probably would cost less than the emergency department bills they pay for those same patients.

Farentinos says such a facility would bring mental health care up to the standards in effect for other types of medical care.

“Think of a stroke center or a trauma center,” she says. “This is a center for behavioral health care.”

Portland police say they’re on board with the idea, though the facility wouldn’t technically be the drop-off center they prefer. Instead, following the Alameda Model, police officers who detain somebody experiencing a mental health crisis would call for an ambulance. Paramedics would take over from there, transporting the individual to the psychiatric emergency center unless the patient also needed medical attention that could only be delivered at a hospital emergency department.

“At the end of the day, that would be a huge asset for police,” says Lt. Cliff Vadigalupi, who heads the Portland police behavioral health unit.

The current practice of police taking people in crisis to emergency departments is a horrible way to start the treatment process, Scherba says.

“You go in the back of a police car, you’re handcuffed, and you’re taken to the emergency department. When we look at mental health, we look at trauma recovery, and we try to minimize trauma to patients,” Scherba says. “For any individual who is suffering, you want as humanistic a treatment as you can have.”

The trauma often continues at the hospital. Emergency departments are not equipped for people in psychiatric crises, Scherba says, and most don’t even have a psychiatrist on duty. Which leaves patients in crisis and police officers waiting around.

Photo Credit: TRIBUNE PHOTO: JAIME VALDEZ - Dr. Lyle Jobe meets with a patient at the Multnomah County Crisis Assessment and Treatment Center on Northeast Grand Avenue. The center was intended as a drop-off center for police, but it is not used that way.

Financial costs add up

The cost of Portland’s current model is incalculable, for both patients and hospitals. According to Legacy, last year its six emergency departments handled about 10,000 patient visits for mental health issues. Daily, according to Legacy, dozens of mental health patients are kept in emergency departments overnight, often for many nights, because there are no available psychiatric beds. And Legacy emergency department staff are reporting an increase in violent behaviors among mental health patients. Similar conditions have been documented at other hospitals.

Farentinos and Scherba have been lobbying county and city players for support of their idea, but the most important targets of their lobbying may be insurers and coordinated care organizations who will have to pay bills for hourly observation at the proposed facility.

“Nobody has yet signed and said, ‘Yes, we will pay you,’ but everybody is saying this is very good because it avoids unnecessary in-patient hospitalizations, and it helps patients return to the community faster,” Farentinos says.

Which isn’t to say everybody is on board. The city needs a drop-off center for the police, but it also needs a separate place for people in crisis who walk in on their own, says Jason Renaud, spokesman for the Mental Health Association of Portland. The city’s previous incarnation of a mental health drop-off center was the Providence Crisis Triage facility, which closed in 2002.

That facility served the needs of police, Renaud says, because they came through a separate entrance and never had to wait to drop people off. But Renaud says people who walked in on their own, who often were suffering less acute symptoms — who weren’t in handcuffs and not acting violently — often had to wait 10 to 15 hours in waiting rooms.

Renaud says a drop-off center and a walk-in center are “the only good things for us (in the city’s settlement agreement with the Department of Justice). The rest of the stuff benefits police officers and police administrators and the city’s risk management officers.”

Wishes are far from reality

City officials say the DOJ agreement does not require the establishment of a drop-off center and that they consider its listing in the settlement as “aspirational.” Renaud says he’s pretty sure that means the city isn’t going to spend the money to help build out the Holladay Park facility.

“Good things for people with mental illness are expensive and complicated, and the city is going to do whatever they can do to get out from under these things,” Renaud says.

A drop-off center for police and a walk-in center for the public are only one piece of an incredibly complex local mental health puzzle that needs major repair, says Chris Bouneff, executive director of the Oregon chapter of the National Alliance on Mental Illness.

“I understand the excitement behind this,” Bouneff says. “But I’m always careful when we talk about building something large.”

Bouneff says that unless Portland and Multnomah County provide more community-based mental health services such as transitional housing and intensive outpatient treatment, psychiatric patients are going to cycle back in to whatever is available, whether it be an emergency department or Legacy’s proposed facility. In which case, money — and Legacy officials aren’t yet saying how much a psychiatric emergency center would cost — would be wasted on building out the Holladay Park site.

Bouneff would prefer that each of the county’s emergency departments take to heart some of the lessons of the Alameda Model. He’d like them to provide more round-the-clock psychiatric staff and possibly even develop small psychiatric observation rooms of their own, as well as forge better ties with community mental health resources so the patients don’t cycle back.

“Our emergency rooms are set up for medical trauma, and no one has given thought to how we can change our emergency rooms to be more accommodating of people in mental health crisis,” he says.

Possibly, Bouneff says, the new psychiatric emergency center could serve the unintended purpose of shaking up the city’s emergency departments.

“If they’re able to do the living room piece, that certainly will be a benefit to the region,” Bouneff says. “And it could have an influence on other hospitals and how they operate their emergency departments.”

Bouneff has one other concern about the Alameda Model and its claim that eight of 10 patients return home stabilized after less than a day at the facility. There’s no data, he says, indicating what happens to those eight of 10 in the long run. Maybe many of them needed a psychiatric hospital bed, or to be placed in another facility.

“The research only shows that 80 percent go home or don’t need hospitalization,” Bouneff says. “You don’t know if that’s a good outcome, not being hospitalized.”

Photo Credit: TRIBUNE FILE PHOTO: JAIME VALDEZ - The break room at Oregon Health & Science University often is used by police as they wait around, sometimes for hours, for emergency department staff to relieve them of people they have brought in suffering psychiatric crises. Here, OHSU public safety officer Sam Habibi uses the room.

Cops rarely use existing facility

Last week, Portland police officer Brad Yakots took a call from dispatch — a man who claimed to be high on mushrooms, clearly agitated, possibly suicidal, who said he wanted to jump in front of a MAX train. Yakots hurried to the scene and found the man, William, on the sidewalk in front of a homeless shelter.

Yakots, a member of the police enhanced crisis team, with a relaxed manner and a penchant for easy conversation, says he addressed William by his first name and asked if he was still having homicidal or suicidal thoughts. William said he was.

Yakots asked how he could help. William said he needed his psychiatric medications refilled but he didn’t want to be taken anywhere in an ambulance.

Remarkably, according to Yakots, William said, “I don’t want to charge the county money. I’ll ride in your police car.” Which is precisely what he did. Yakots took William to Legacy Emanuel’s emergency department, pressing a button on his hand-held computer to alert Legacy staff that he was there the moment he arrived.

For the next hour and a half, Yakots remained at Legacy’s emergency department waiting room, most of the time sitting beside William, trying to keep the conversation light. Once a psychiatrist became available and signed the paperwork transferring William’s care, Yakots returned to his patrol, noting that he had spent an hour and a half waiting at the hospital. He felt lucky. The majority of Yakots’ mental health cases are involuntary, someone acting out a psychosis who needs to be brought to an emergency department in handcuffs. With those cases, Yakots says he’s typically

sitting around the waiting room up to three hours.

As a member of the police crisis team, Yakots has received special training to help him deal with people experiencing psychiatric emergencies. But a lot of patrol officers, he says, anxious to get to other calls, will immediately call for an ambulance for people like William. Depending on just how many mushrooms William ingested, or how close he might be to an overdose, that call might make sense. But sometimes, Yakots says, officers make the call because those two or three hours is more time off patrol than they want to spend.

A proposed Holladay Park psychiatric emergency hospital could be just what police officers want — a certain and simple system for them to hand off people in psychiatric crisis. But some mental health advocates caution that just three years ago, Multnomah County opened a Crisis Assessment and Treatment Center on Northeast Grand Avenue that was supposed to provide police just such an option. Ironically, Yakots says he’s never used what is commonly called the subacute center, and has never been told to consider it.

The crisis center cost $4.5 million to build and more than $3 million a year to operate. It was called, “the one puzzle piece that’s missing,” by a Multnomah County spokesman when it opened in 2011. That hasn’t turned out to be the case.

Sometime after the opening of the 16-bed crisis center, police determined the facility wasn’t for them. Police officials say it doesn’t handle the acute cases — many involving people who suffer from mental illness and also have abused drugs — that make up the majority of people they pick up in crisis. In addition, its 16 beds often are full. County officials say there’s a special crisis-line number police can call to streamline the admissions process and that they could take some people in crisis there.

“What I’ve heard from police is they need a pathway that’s consistent on a regular basis, that is not a yes or no,” says David Hidalgo, director of Multnomah County Mental Health and Addiction Services. “The police need the path of least resistance. An emergency department cannot say no.”

Unlike emergency departments, the crisis center is staffed 24/7 by physicians and nurses with psychiatric training. It is based on a recovery model not unlike the sanctuary model proposed for the Legacy psychiatric hospital. It is usually pretty close to full with people who need what is called subacute care. Average length of stay is seven days, and when patents leave they have something they don’t generally get at hospital emergency departments — plans for future care.

“What we’re really good at is making sure people are hooked up with after-care services,” says Kevin McChesney, regional operations director for Telecare Corp., which operates the crisis center on a contract with Multnomah County.

McChesney says that police could bring even suicidal cases to the crisis center, but not those who are acting out of control and might pose a danger to others. Though the facility has seclusion rooms, McChesney says they’ve never been used. Ironically, 87 percent of the patients at the crisis center arrive after having been taken to hospital emergency departments — an extra step that might have been avoidable.

Telecare also runs subacute facilities in Alameda County, Calif., which is home to John George Psychiatric Hospital, the model on which a proposed Portland psychiatric emergency center would be based. McChesney sounds a cautionary note on the way the John George operates. John George is great at stabilizing people in mental health crisis, he says, but it isn’t about continuum of care.

“They say, ‘We’re not too concerned about the back end here,’” McChesney says. “Here’s your BART pass, and you need to follow up with your physician or clinic or wherever else you get your outpatient care.”

Which means, McChesney says, “We don’t know how many people are circling back.”

Dr. Chris Farentinos, in charge of plans for a psychiatric emergency hospital, says that if the Legacy facility becomes operational it will include a discharge plan much more detailed than the “call this number from home” that emergency departments generally provide mental health patients.

Farentinos, director of behavioral health at Legacy Systems, and Cindy Scherba, director of behavioral health at Oregon Health & Science University, are dreaming big. Their current prospectus says the Legacy facility would take mental health patients from other area emergency departments as well as from police and would include a connected 101-bed inpatient acute psychiatric hospital. Those beds would replace psychiatric beds currently provided at local hospitals.

The proposed facility also would serve walk-in clients. Farentinos and Scherba say that within two years either their facility will become a reality or one more failed attempt to address a critical health care need in the Portland area.

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