Oregon's High-Priced Hospital of Hurt

24 Oct 2004

By Michelle Roberts

Oregon spends half of its annual $180 million budget for mental health on the Oregon State Hospital, an overcrowded, decrepit institution that serves less than 1 percent of patients who need psychiatric care.

The hospital -- only a mile from the Capitol -- is a hulking reminder of the state's failure to forge a modern approach to treating people with mental illnesses.

Study after study has recommended that Oregon scale back the hospital and invest in a network of community homes that would be both cheaper and more effective for patients.

But until now, mental health leaders and advocates have feared that if they pushed this approach, the hospital would close and, given the Legislature's consistent failure to adequately fund community mental health services, nothing would replace it. State officials also have been reluctant to risk a fight with the unions that represent the hospital's 1,150 employees.

As a result of this impasse, the state has spent millions of dollars renovating the 121-year-old hospital.

A significant shortage of group homes and other community-based services has forced hundreds of patients who could live in less restrictive surroundings to remain in the hospital, despite growing evidence that long-term institutionalization makes psychiatric patients sicker. Most patients who arrive at the hospital psychotic quickly stabilize with modern medications.

On Friday, Senate President Peter Courtney, D-Salem, said the hospital is in such dire straits, it's in danger of being shut down by federal authorities. He warned that the issue could no longer be avoided.

"The physical condition of our state hospital is merely a metaphor for the ramshackle state of our larger mental health system," Courtney wrote in a letter to fellow senators last week. "We must address this crisis, and we must do so before we adjourn the next legislative session."

Experts agree. "It's astounding that Oregon is operating such a massively large institution in the 21st century, and unthinkable that they are adding more wards," said Robert Bernstein, executive director of the Washington, D.C.-based David L. Bazelon Center for Mental Health Law, a leading advocacy group for people with mental disabilities.

"It runs counter to all that we know about people with mental illnesses, the treatments that really work and the ability of people to recover," Bernstein said.

Many states have shuttered or dramatically reduced the size of their mental hospitals, responding to federal policies that reward creation of community-based centers to treat the acutely ill.

State officials acknowledge that if they invested the Oregon State Hospital's $90 million annual budget into such projects, the state would receive a matching $90 million from the federal Medicaid program, allowing the state to help tens of thousands of Oregonians who now go untreated.

The hospital is the most expensive way to treat people with mental illnesses, costing taxpayers an average of $11,000 per patient per month.

In September, the hospital housed at least 130 patients who had been cleared to live in group homes or assisted living centers, which cost between $1,000 and $5,000 a month. Such patients are routinely held for an average six months after state hospital doctors approve them for release, hospital data show. Some wait more than a year.

Top state officials insist that Oregon's mental health system is on the verge of reform.

A 21-member task force, appointed a year ago by Gov. Ted Kulongoski, recently recommended examining the possibility of building a single forensics mental health facility for patients who can't be treated in the community.

In addition, state mental health leaders are working to create 80 community beds for forensics patients who are able to live outside the hospital.

However, even the governor's own task force questions whether its recommendations will be followed.

Bob Nikkel, who heads the Department of Human Services' mental health and addictions office, promised the task force updates on progress. "It is my intent to make things happen to the degree I have the ability," he said.

Advocates and lawmakers are disappointed that the task force failed to recommend shutting down the hospital.

They blame a lack of political will: To close the hospital now would be an indictment of state officials who, they say, have long recognized the need for change but will not risk upsetting the status quo.

State Sen. Avel Gordly, D-Portland, said the state needs to salvage the lives of state hospital patients rather than the careers of bureaucrats.

"It can't go on," she said. "Everything that happens there happens in our name -- and let's be real clear, what happens there is shameful."

Any attempt to do so will run into political reality: Hospital workers have much more clout than those they treat.

"There are a lot of jobs at stake," said Bob Joondeph, director of the Oregon Advocacy Center. "Why take on a group of public employee unions in something in which you're going to have to invest a whole lot more money upfront for a population that, frankly, the public's primary concern is their safety from these folks rather than the quality of their care?"

"Cuckoo's Nest" revisited Thirty years ago, the Oregon State Hospital molded the nation's image of institutionalization when it became the setting for the movie "One Flew Over the Cuckoo's Nest."

A look behind hospital walls shows that many of the conditions depicted in the film still exist.

The J Building, named for its shape, borders a blocklong stretch of Center Street. Except for two disjointed wards at either end, much of the building is uninhabitable.

On one empty ward, lead paint curls from the walls. Asbestos frost floats in the air. On a recent day, a dead rat lay rotting in an oversized trap on the day-room floor.

One ward over, where patients live, conditions aren't much better. Aging pipes emit cloudy water. Strange smells float from vents. Asbestos floor tiles, when chipped, are treated as hazardous material. Raw sewage occasionally leaks through the ceilings of patient rooms.

The hospital, built in 1883, is one of the oldest, most dilapidated state mental institutions in the United States. In fact, a 1988 report urged lawmakers to demolish the J Building because of health and safety dangers.

But two years ago, after another 14 years of decay, state officials did the opposite, pouring nearly $1 million into a corner of the crumbling structure to make room for more patients. Another ward was added last month.

"When it comes to opening new wards, this is the kind of space we have left," said Maynard Hammer, a deputy superintendent, as he stood last summer in a vacant corridor inside the J Building, kicking chunks of plaster that had dropped from above. "We're not talking about what's best for patients. We're only talking about having a place to put them."

The J Building isn't the hospital's only structural liability. The 1988 report also warned that the outside walls of the newest building on the 148-acre campus, the five-story 50 Building erected in the 1950s, were at risk of crumbling.

The top floor of the 50 Building, which houses locked forensics wards, was vacant for years because faulty plumbing could not deliver water high enough. A $4 million renovation was completed in the 1990s to secure the walls and fix the plumbing, but doors throughout the structure, including those on elevators, often refuse to open and close.

A year ago, a group of patients was so desperate to document living conditions that they sneaked a disposable camera into the hospital. Their pictures showed steel beds crammed into dirty, crowded rooms, filthy toilets, torn furniture, broken sinks, and portable bathrooms in the outdoor yard overflowing with urine and feces.

More than 100 patients in the 50 Building asked for a state investigation.

A 2003 report by the Oregon Health Services Health Care Licensure and Certification Section stated that the hospital had broken several state rules. Each of the building's seven wards exceeded capacity by two to 12 patients. Ward 50 I, which ideally would hold no more than 30 patients, held 43.

Toll of thin staffing Administrators estimate that the hospital is 30 percent to 40 percent understaffed. It houses 760 patients and has 1,150 staff members -- one of the lowest patient-to-staff ratios in the nation, Courtney said. A comparable facility in Washington state employs 1,900 staff for roughly the same number of patients.

Seven physician and 40 to 50 nurse positions stand vacant. Openings for more than 40 psychiatric aides -- employees who do the bulk of direct care -- go unfilled because many qualified professionals are unwilling to accept low salaries and what Courtney called "awful working conditions."

State records show the hospital relies on overtime, both mandated and voluntary, to fill shifts.

According to a recent audit by the Department of Administrative Services, the hospital could save more than $1 million every two years if administrators filled staff vacancies instead of habitually using overtime.

Records examined by The Oregonian reveal the dangers of thin staffing. Two years ago, hospital administrators sent a memo "reminding people that it was not OK to sleep on the job," state records show.

However, the state documented four subsequent cases in which employees fell asleep when they were supposed to be watching dangerous or suicidal patients.

An examination of state documents further shows that patients were beaten, kicked, humiliated and tormented by staff in more than 50 substantiated incidents of abuse within the past 3-1/2 years.

In case after case, staff demeaned patients, calling them names, such as "retarded" and "zombies." Some patients sat in dirty diapers for hours because workers were too busy to change them.

"Honestly, the care we provide is of low quality," said Jon Sears, a mental health specialist who gives group and individual therapy at the hospital. "I say that with reservation because we have so many people who are trying so hard. But with so many things against us . . . we're in a situation where all we do is triage, over and over."

"They're warehousing us" Psychiatric research has long shown that people with mental illnesses can recover -- a notion unfathomed when the country's first "insane asylums" were erected in the 1800s.

Today, mental health experts widely accept research that shows that, with supports such as medication, housing and meaningful human interaction, most people, even those with serious mental illnesses, can lead productive lives outside of institutions.

In fact, long-term isolation from family and community can slow, even thwart, their recovery.

"What's happening in Oregon is a throwback to a time in which patients were treated in a way we no longer believe is appropriate," said Dr. Paul Fink, professor of psychiatry at Temple University School of Medicine and past president of the American Psychiatric Association.

Patients at the hospital put it more bluntly.

"They're warehousing us," said Richard I. Laing, a 64-year-old patient who has been hospitalized since 2002. "We get here and there's no treatment. There's no interaction. Just a bunch of people sitting in a room getting on each other's nerves."

Exhausted ward staff often must break up fistfights on the tense, cramped wards. Injuries against staff are up nearly 40 percent this year, to 200 incidents, Sears said. Patients often go months without seeing psychiatrists, languishing instead of moving forward with therapy.

Some patients arrive at the hospital under civil commitment, meaning a judge has determined they are so ill they are either a danger to themselves or others, or they are unable to survive on their own. Others are forensics patients under the jurisdiction of the Oregon Psychiatric Security Review Board, which monitors people who plead guilty, except for insanity, to crimes that range from misdemeanors to murder. Only a very small number have committed heinous crimes. Most, say their therapists, are accused of offenses that never would have occurred had the patient had medications and services in the community.

In December 2000, the federally funded Oregon Advocacy Center, which monitors rights for people with disabilities, filed a class-action lawsuit against DHS and the hospital, alleging that the agency failed to provide adequate community-based mental health services, resulting in "unnecessary segregation" of state hospital patients.

Earlier this year, the state agreed to settle the suit brought on behalf of more than 100 patients who had been held in the hospital for months and years longer than necessary. Under the settlement, the state must create 75 community-based mental-health slots by next summer and spend $1.5 million for other outside services for hard-to-place patients.

But the problem is far from solved.

The settlement, although a major victory for patients under civil commitment, did not affect forensics patients, who are similarly stranded in the hospital.

According to records examined by The Oregonian, 86 forensics patients last month were deemed ready for discharge by doctors but couldn't leave the hospital because of a lack of alternatives outside. The psychiatric security board, which gives final approval to discharges, won't grant them until beds are available in the community. And those beds don't yet exist.

This year, the board is expected to take on 140 new cases, more than double the number four years ago.

Most forensics patients are not inherently dangerous and can live safely and productively if given proper community support. While some will always need treatment in a secure setting, they represent only a fraction of the total state hospital population, said Joondeph, of the Oregon Advocacy Center, which successfully fought to close Dammasch State Hospital, another psychiatric institution, in the mid-1990s.

He said the state would benefit by creating small, acute-care facilities that serve people with special mental health needs. If kept smaller than 16 beds, such facilities would be eligible for the Medicaid match, effectively doubling the state's investment in mental health care.

The Oregon State Hospital is funded completely by general state funds. A 1965 congressional act excluded nearly all payments to state psychiatric hospitals from Medicaid because the federal government did not want to take over what, historically, had been a state responsibility. Congress also wanted to provide an incentive for states to build systems of community mental health centers to replace psychiatric hospitals.

"The hospital shouldn't exist," Joondeph said. "The science of mental health treatment has advanced so much that we're operating under a very old model that's becoming harder and harder to justify."

© 2004 Oregonian Publishing Co. All rights reserved. Used with permission of The Oregonian.