Addictions and Mental Health Division (AMH)

1. Addictions and Mental Health Division (AMH) Addictions & Mental Health Delivery Systems in OregonByRichard Harris, Assistant DirectorApril 2010

2. AMH Mission Assisting Oregonians to become independent, healthy and safe by: • Preventing and reducing the negative effects of alcohol, other drugs, gambling addiction, and mental health disorders and • Promoting recovery and resiliency through culturally competent, integrated, evidence-based practice, treatments of addictions, mental illness, and emotional disorders. • AMH provides leadership, manages information, builds competencies, creates linkages, guides public policy, promotes high clinical and administrative standards, and develops and manages resources to accomplish its goals.

3. AMH administration, programs and services goals • to promote in prevention, early intervention, treatment services, housing and supports for individuals, families, and communities; • to substantially increase the availability and quality of individualized, integrated culturally competent home and community-based services for children, youth, and adults. • to substantially increase the availability, utilization and quality of individualized, integrated, culturally competent home and community-based services for children, youth, and adults; • to invest in prevention, early intervention, treatment services, housing, and supports for individual, families, and communities; • to ensure an effective system of care for children, youth, and adults and their families through a statewide system of quality improvement, performance management, outcomes, and accountability; • to ensure meaningful involvement by individuals and family members who have experienced the public addictions and mental health system in all aspects of the system of care including: developing and implementing policy, financing, local and regional managed care and provider systems, and case level decision making; • to ensure sound clinical services and supports that are integrated, comprehensive, and culturally competent with the intensity and duration needed to promote recovery, resiliency, independence and wellness; and • to operate an administrative infrastructure that accomplishes the mission and goals of AMH in an efficient and effective manner.

4. Oregon Health Authority Division of Medical Assistance Programs Addictions and Mental Health Division State Hospitals Fully Capitated Health Plans County Mental Health Authority State Hospitals Portland/Salem Blue Mountain Recovery Center Community-Based Alcohol and Drug and Mental Health Programs AMH Treatment and Recovery System Mental Health Organizations

5. AMH key responsibilities • Single state authority for Addictions and for Mental Health • Planning and Policy Development • Funding and development of prevention, early intervention and treatment programs for people at risk of developing or with addiction and/or mental health disorders • Contracting for state addiction, gambling and mental health programs • Developing appropriate treatment facilities and housing with supports for individuals in the community • Maintaining custody of persons civilly or criminally committed by courts to the state for care and treatment of mental illness • Licensing and certifying prevention and treatment programs • Oversight for the two state psychiatric hospitals

6. Populations Served • Children and Adolescents with severe emotional disorders • Adults with severe and persistence mental illness • Adolescents with serious addiction disorders • Adults with mid to late stage addiction disorders • These people frequently: • have co-occurring disorders • are unemployed • are arrested and jailed • are uninsured • are disconnected from their families

7. Substance Abuse and Mental Illness Prevalence in Oregon • Substance Abuse and Dependence prevalence in Oregon is estimated by using information from the National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA). • 9% of adolescents ages 12-17 need substance abuse treatment; • 20% of adults ages 18-25 need substance abuse treatment; • 6% of adults ages 26+ need substance abuse treatment. • Estimates for Severe Mental Illness (SMI) among adults and Severe Emotional Disorders (SED) among adults and adolescents/children are derived from national epidemiological studies. Based on this information SAMHSA publishes prevalence information for each state. The main factors for adults are age, gender, and urbanicity. For adolescents/children, the main factor is poverty level. • 12% of children and adolescents are in need of mental health services; • 5% of adults are in need of mental health services.

8. Number of those in need versus number served

9. Health Disparities for Behavioral Health • Drugs and alcohol impact people across many socio-demographic factors. There is information that suggests a greater impact on specific communities. • Based on data available from Oregon Vital Statistics, Native Americans show a much higher rate of alcohol induced deaths, while African-Americans show a much higher rate of drug induced deaths.

10. Health Disparities for Behavioral Health Utilizing individuals who have participated in Oregon public behavioral health system, it is easy to see that people with substance Abuse and mental health issues die sooner than The general population. Often people with mental illness have higher rates of physical illness than the general population. The chart to the left compares the Rate of selected diseases/illness among people with severe mental illness in intensive residential treatment and the general Medicaid population.

11. Select Substance Abuse Services Outcomes Adults • 40% of the children of parents in Intensive Treatment Recovery Services have been reunited with their parent(s) –as of January 2010 • 78% of adults who complete substance abuse services are employed. • Across all substance abuse services monthly income increased on average $30/month. This represents an increase of $1,080,000 per month across all people discharged from services. • Only 7% of substance abuse clients referred by criminal justice sources were arrested during treatment. Adolescents • Among adolescents completing substance abuse service: • 94.5% improved academic performance • 94.9% improved school attendance • 95.5% improved school behavior • Only 14% of substance abuse clients referred by juvenile justice sources were arrested during treatment

12. Select Mental Health Services Outcomes Adults • 54% of adults arrested in the 12 months prior to treatment where not arrested in the 12 months after treatment started • 54% of adults needing better housing at the start of treatment improved their housing stability during treatment • Over 50% of adults report feeling more social connection, improved daily functioning, and general outcomes as a result of treatment Children/Adolescents • 30% of youth improved attendance at school as a result of mental health services • 60% of youth demonstrate improved functioning with parents, sibling, and peers • 56% of youth arrested in the 12 months prior to treatment where not arrested in the 12 months after treatment started

13. Incident YLD Rates per 1,000 Population by Age and Broad Disease Grouping, Victoria 1996 • Mental illness and substance use disorders account for 60% of the non-fatal burden of disease among young people aged 15-34 (Public Health Group 2005) • 75% of mental health problems occur before the age of 25 (Kessler et al 2005) • 14% of young people aged 12-17, and 27% of young people aged 18-24 experience a mental health problem in any 12 month period (Sawyer et al 2000, Andrews et al1999)

14. Adult Mental Health Outpatient and Residential: Budget vs. Served

15. Early Assessment and Support Alliance (EASA) & Early Assessment and Support Team (EAST) 40% of the participants in the EAST program were hospitalized in the three months prior to beginning service. Three months into the programs hospitalizations are reduced to 10% of the participants and continue to decrease over time. At the same time the percent of participants working or in school shows continuous improvement

16. Recovery focus • AMH promotes resilience and recovery for people of all ages who experience or are at risk for substance use and/or psychiatric disorders. The division promotes a recovery-oriented system of care. • This is accomplished by re-aligning policy, programs and services, and financing strategies to support a recovery model. • Recovery, a process of healing and transformation leading to a meaningful life in the community, must be the common outcome of services. • The concept of resilience applies to all ages, but particularly to youth and young adults experiencing the first symptoms of a mental health or addiction disorder. AMH provides leadership and support for innovative systems and strategies designed to keep young people at home, in school and out of trouble. • For addiction recovery this typically means achieving sustained, long-term abstinence, re-establishing positive social relationships, and involvement in a faith-based or secular recovery community. For mental health recovery this includes self-directed management of daily activities and assuming a meaningful role in the community of choice with or without the aid of medications. • There are many paths to recovery. Managing addiction and mental health recovery involves individualized person-centered strategies including access to a network of community-based services and supports.

17. Evidence-based practices • Oregon Revised Statues (ORS) 182.515 and 182.525 define requirements for evidence-based practices • Goal of the Statue • To increase the percentage of public funds spent on EBPs in treatment and intervention programs or services intended to • Reduce the propensity of a person to commit crimes (due to alcohol and drug abuse) • Improve the mental health of a person with the result of reducing the likelihood that person will commit a crime or need emergency mental health services. • Current Status: • Total Prevention practices: 106 • Total Mental Health treatment practices: 47 • Total Substance Abuse treatment practices: 37 • Using evidence-based practices with community, stake holders and providers since 2002 • Tribal Best Practices • The Nine Tribes have developed criteria and a process for determining EBPs for services provided to their members • Results to Date • 2008 survey results indicated 54 % of funds in 2009-07 used to treat behavioral health disorders were spent on approved EBPs

18. Blue Mountain Recovery Center • 60 bed state psychiatric hospital in Pendleton • Provides services to adults who are civilly committed or are being treated until they are able to aid and assist in their defense for a crime committed while experiencing a serious episode of mental illness. • The hospital is certified by the Centers for Medicare and Medicaid • Budget Authority 2009-11 • $25,034,185 126 positions

19. Oregon State Hospital (OSH) • Oregon State Hospital (OSH), with campuses in Salem and Portland, is the state’s primary state-run psychiatric facility for adults. • The State Hospital delivers psychiatric and medical care to patients through two programs: • Forensic Psychiatric Services for patients who are judged guilty except for insanity. The forensic program includes 369 hospital beds and 36 transitional cottage beds. • Psychiatric Recovery Services for patients who are civilly committed. The PRS program has 144 beds in Salem and 92 in Portland. • The hospital is accredited by The Joint Commission and certified by the Centers for Medicare and Medicaid. • Budget Authority • The OSH budget for 2009 – 2011 is $323,587,123

20. Oregon State Hospital-Continuous Improvement Plan • In response to November 2006 U.S. DOJ CRIPA review of OSH, OSH leadership developed a continuous improvement plan (CIP) to increase the level of active treatment. • The need to improve the amount and quality of treatment and the safety for patients and staff are the core of the CIP. • OSH added staff to implement the CIP with support of February 2008 Supplemental Legislative Session and in the 2009 Session. • OSH staff, consultants and leadership are developing and implementing a new service delivery model that will improve the quality and amount of treatment. This model drove the design of the new hospital. • The model is recovery focused and relies on a central treatment environment that provides a more normal distinction between patient’s living areas and where they work on recovery.

21. Centralized Treatment • OSH is committed to a continued shift to a centralized recovery model. Centralized treatment is a move away from the traditional ward-based treatment model. • Since 2007 – 4 Treatment Malls have been established providing services to over 500 patients. • Portland – Serving all patients on the Portland Campus • Forensic – Serving more than 300 criminally committed patients • Gero – Serving approximately 25 civilly committed patients • Transition – Serving nearly 100 patients nearing discharge

22. OSH Staffing November 2007-09 Base Staffing Level 1,290 2008 Continuous Improvement Plan Special Appropriation s 216 2009-2011 Base Staffing Level (includes administrative Reduction of 12 positions) 1,494 2009-2011 Policy Option Package Appropriation 527 Total Authorized Staffing Level – July 2011 2,021

23. OSH Hiring OSH Hiring of Nurses and Physicians November 2006 March 2010 Change Physicians 31 43 +39% RNs 158 231 +46%

24. Recent Improvements at OSH • Construction of a new hospital continues – Phase I, including 124 patient beds, is scheduled for completion in the 4th Quarter of 2010 • Electronic Medical Record (Avatar) is in development – Implementation is scheduled for early 2011 • Advisory Board formed in October 2009 • Weekly Continuing Medical Education provided by OHSU via videoconferencing to Salem and Portland campuses • Metabolic Clinic established to improve the physical health status of patients at risk for diabetes, high blood pressure and other conditions • 28% decrease in aggression between patients in the 4th quarter of 2009 as compared to the 4th quarter of 2008 • 37% decrease in aggression from patients to staff the 4th quarter of 2009 as compared to the 4th quarter of 2008

25. Challenges in the current system • Oregonians do not have sufficient access to publicly funded addictions and mental health treatment due to lack of funds • The funding of mental health services is weighted toward institutions and facility-based services to the detriment of supportive, flexible services in the community • Caseload and mandated services often are driven by the legal system • Providers struggle with low reimbursement rates and the inability to provide competitive wages • The stigma associated with addictions and mental illness: • Prevent people from accessing services early • Hamper the state’s ability to return people to their community • The mental health and addictions payment and management systems are overly complicated

26. Strategic Planning 2009-11 Initiatives • 1915(i) Medicaid Home and Community Based State Plan Amendment • Alcohol and Drug Policy Commission • Blue Mountain Recovery Center: The Future • Impaired Health Professionals: Implement Statutory Requirements • Integrated Services & Management Demonstration • Integrated Services and Supports Rule Implementation • MH Adults Residential Utilization Analysis • Peer Delivered Services • Strategic Prevention Framework • The Criminal Justice Door to the Mental Health System • Wellness • Young Adults in Transition

27. Transformation Initiatives 2010 • 01 – Transitioning People to Least Restrictive Level of Care • 03 – OSH Process Improvement • 04 – OSH Quality Improvements • 08 – AMH Central Office Process Improvements • 09 – Lean Daily Management System Rollout • 010 – Vacancy Exceptions In Mental Health Residential Programs • 011 – NIATx Expansion – A&D Treatment Quality Improvement • 012 – Adult Mental Health Initiative • 013 – Supportive Housing • 014 – Community-Based Gero-Psychiatric Programming Cross-Organization Initiative • 0X9 – Children’s Wrap Around

28. Oregon Web Infrastructure for Treatment Services (OWITS) • Oregon needs a new data system for its behavioral health system that works efficiently with its providers and allows them to coordinate better with each other and other health providers. OWITS will be piloted this summer and will help AMH achieve this vision. • OWITS is a web-based, shared source electronic behavioral health record that would be available to all substance abuse and mental health programs providing publicly funded services in Oregon. • OWITS is designed to meet the growing need to capture client treatment data and satisfy mandatory federal and state government reporting requirements for the planning, administration, and monitoring of Substance Abuse and Mental Health Treatment Programs. • OWITS is a clinical and administrative tool to help providers deliver mental health and substance abuse services effectively and efficiently. • OWITS would facilitate cooperation and collaboration among treatment providers by enabling the sharing of client treatment information via the web in a statutorily compliant manner. • DHS received $3.9M in total funds for the Medicaid Health Information Technology Plan a portion of which will focus specifically on broadening the availability of electronic health records for behavioral health providers. • $8.58 million was received for a State Public/Private Health Information Exchange from the Office of the National Coordinator. AMH will work to utilize this structure to facilitate the exchange of electronic behavioral health information.

29. 2009-11 Legislatively Adopted Budget

30. Oregon Mental Health and Addictions Services Provider • Addiction Services Providers • 177 AMH funded unique treatment providers deliver the following number of programs • 10 detoxification programs • 54 residential programs • 261 outpatient programs • Mental Health Services Providers • 33 Community Mental Health Programs • 100 Community Mental Health Program Subcontractors (outpatient)  • 5 AMH Contracted Mental Health Programs (outpatient) • 56 Certified Private Mental Health Programs (outpatient) • 73 Adult Residential Treatment Facilities  • 31 Adult Residential Treatment Homes  • 172 Adult Foster Homes  • 10 Child/Adolescent Psychiatric Residential Treatment Programs • 20 Child/Adolescent Psychiatric Day Treatment Programs