Assembling a fairly scathing report after months of study, a City Club of Portland committee had some blistering words for the way Multnomah County doles out treatment to the mentally ill—accusing the county of muddy budgeting, poor communication both internally and with regional partners, and failing to properly assess whether its programs were actually working.

The report was issued after more than year of close work with county officials, who invited committee members to advisory discussions and shared hundreds of pages of documents and data. And, harshness aside, it's a fairly fascinating read (non-wonks may want to reach for a cuppa coffee) on a worthy subject, especially with politicians and others increasingly pointing the finger at mental health whenever a police officer shoots someone.

Needy individuals fall through the cracks, sometimes receiving no care or care at inappropriate levels and locales... Coordination among departments within Multnomah County that serve the mentally ill is poor. Financial resources (primarily Medicaid monies) flow through a multi-level system from the federal government, to the state, to the county, to those providing care in a system that is complex and opaque. It is impossible to distinguish direct costs for patient care from indirect costs for administration. Even worse, assessment of treatment outcomes is inadequate, so that the effectiveness of treatment cannot be ascertained.

Committee members did pay lip service to the fact that much of the county's funding is tied up by Salem and Washington, D.C. And they took pains, at one point, "to praise the the dedication and commitment of those who testified, including both service providers and county administrators."

But while county officials said they welcomed the review of their work on mental health, it's pretty clear they weren't happy with what emerged, especially in light of all the time they spent with committee members. County Chair Jeff Cogen's spokesman, David Austin, rather charitably called the report an "attempt" to study the problem and said committee members drew mistaken conclusions. For one, he says, the county has already begun reaching out to the state and other regional governments.

"Maybe the committee didn't understand the information. Maybe it was a short time frame," Austin told me. "We don't think we're perfect. like any public agency we're always looking for things to improve. But certainly, we're just puzzled at their tone and some of their erroneous conclusions."

Talking to the Portland Tribune, Jason Renaud of the Mental Health Association of Portland, wasn't as forgiving when it came to the county's argument: “The current county commission has shown no interest in mental health or addiction health issues. We’ve been down this track before and the political and management leadership—many of those persons interviewed for this report—betrayed that effort and failed to make the changes people wanted.”

Below is the full memo the county's mental health and addiction services office sent to the board of commissioners. City Club will vote next week on whether to endorse the report—not that the group's opinions carry as much weight as they once might have.

Date: March 30, 2011

To: Multnomah County Board of Commissioners

From: Kathy Tinkle, DCHS Director
Karl Brimner, MHASD Director

Re: Response to committee report from City Club of Portland

Earlier this week, we received a draft report from the City Club of Portland's committee entitled, "Improving the Delivery of Mental Health Services in Multnomah County." The report is the culmination of more than a year of extensive interviews and the exchange of numerous programmatic and budget documents.

We appreciate the City Club committee's attempt at analyzing the mental health care system, despite some inaccuracies in the report, and we welcome any opportunity to look at how we can improve things.

Budgets
Our Mental Health and Addictions Services Division (MHASD) staff and others in human services spent more than a year providing detailed information — including budgets, program offer details, fiscal information and other data — to the City Club committee. As a public agency, information about our services is always readily available and transparency about our systems is a priority. Having provided this information to the committee, we are perplexed by the tone of the report in this and the other sections.

Contracts
Currently, copies of all county contracts and procurements are available to the public through the county’s Purchasing Office. Oversight of purchasing functions is centralized for the county and separate from the departments. We work closely with central purchasing staff and are within all county procurement guidelines. Contract fiscal compliance is reviewed and monitored by the county’s Finance Department. Programmatic contract compliance is monitored and enforced by MHASD staff.

The City Club committee report appears to confuse “Partnership Purchasing Agreements” with standard county contracting. These agreements are very specialized contracts where partners contribute substantial funding to a system of care in addition to the public money provided by the county. The mental health system utilizes standard county contracts and is completely compliant with county rules for setting expectations in contracts.

Outcomes
Of the nine mental health outcomes measures listed on page 11 of the City Club committee report, we have prioritized our limited resources to measure those that give us the most meaningful and easily obtainable information, including monthly treatment access and referral data, treatment utilization data, cost by mental health level of care, authorizations for care and inpatient hospitalization data. It is appropriate to collect data about housing stabilization, employment and other non-clinical indicators of success. The county continues to look for cost-effective and streamlined means of collecting such data.

Please see the attached Verity Data Dashboard from the 2010 Verity Quality Report for the current outcomes measured for Oregon Health Plan (OHP) members. We are currently working with the state to streamline contracts for non-OHP-funded services and create clearer specific outcomes. We support the recommendation that resources should be allocated to collect and analyze data. However, direct services are our priority given our limited resources.

The report mentions the A Collaborative Outcomes Resource Network (ACORN) assessment tool and its appropriateness when considering a tool to pilot that measures patient satisfaction. The MHASD staff balanced the administrative burden to providers against the need for an appropriate system-wide outcomes tool. ACORN is a nationally recognized tool for outcome data collection that has been applied in many mental health systems.

ACORN offered the system the lowest administrative burden to the provider system while providing the best outcome data. In addition, we found that researchers from two prominent universities had studied this outcome tool for use with the Medicaid population and deemed it reliable for tracking outcomes. We have completed the pilot and we are currently in a Request for Proposals process to choose a tool to be used system wide. The county plans to continue using our Level of Care Utilization System (LOCUS) tool to assign levels of care.

Systems
We support the work of the Oregon Health Authority to redesign the provision of mental health services and are currently working across jurisdictions to streamline care and achieve what is known as the Triple Aim: improved quality, improved access and reduced costs. We are hopeful that Health Care Reform will achieve many of the goals as outlined in the City Club committee report recommendations. The county is working closely with the state, other counties and the fully capitated health plans to develop the new system.

Finally, we value and encourage public involvement in systems planning. Multiple opportunities for public participation and advising MHASD’s work include the following:
Adult Mental Health and Substance Abuse Advisory Council (AMHSAAC), Children’s Mental Health Services Advisory Council (CMHSAC), Wraparound Advisory Council, Quality Management Committee, Citizens Budget Advisory Committee (CBAC), DCHS-specific CBAC.