Editor’s note: Throughout 2023, OPB is taking a deep look at the biggest social and economic challenges facing Oregon today – their origins, their impacts and possible solutions. We start this week by looking at the gaping holes in the state’s mental health system, including the lack of services and beds to help children showing signs of mental illness or distress.
PROBLEM: There are not enough beds - or therapists - in the state for children with the most intense needs.
Many teens experience depression and anxiety and might go through a brief period of crisis, like a bad break-up or an episode of bullying. The pandemic turned up the volume on all of those problems, worsening already long wait lists for child and adolescent therapists.
The state must shore up services to keep these real, but manageable, problems from becoming critical. Increasing school counseling services, running the 988 youth line and investing in the behavioral health workforce are all likely to help.
But a subset of young people face much more serious headwinds and need much more help. These are kids and teens who are growing up while dealing with profound pain and stress: Homelessness, a serious mental illness, a developmental disability, experiences of abuse and neglect or some combination of all of it.
And kids are falling through some of the worst gaps in Oregon’s mental health care system. Those gaps were created in the past 20 years, in part, by the state’s efforts to save money and increase the efficiency of the Medicaid program.
Since 2003, the state has lost more than 200 residential beds as facilities that used to work with youth have closed, said Dr. Ajit Jetmalani, who directs the division of child psychiatry at OHSU and is a consultant to the Oregon Health Authority. Statewide, just four programs remain that serve youth with the most acute mental health needs: Trillium Family Services and Albertina Kerr in Portland, and Looking Glass and Jasper Mountain in Lane County.
“Everybody else has left the field,” Jetmalani said.
Before 2003, the state health authority had contracted directly with companies to make sure youth mental health beds were available whether or not they were in use.
“That allowed for a stability of staffing and predictability of services” Jetmalani said.
Now, facilities have to negotiate separate payment contracts with 15 different Coordinated Care Agencies, groups that administer the Oregon Health Plan and reimburse providers, with a focus on preventative care and containing costs for the state. Those contracts generally mean facilities are only paid if their beds are in use.
That may sound like a good cost-saving strategy. But Jetmalani likens it to only paying firefighters while they’re out fighting a fire. The unpredictable funding has made it much harder for the industry to pay fair wages and retain quality, experienced staff and that means that at times, when the number of youth in crisis is high, the state runs out of places for them to go.
There are now 100-150 residential beds available statewide for youth with acute psychiatric needs, according to Jetmalani. “And our estimated need is 240,” he said.
PROMISING STRATEGY: Staffing and expanding residential treatment facilities for youth could give Oregon the baseline number of beds and professionals needed to serve our children in crisis. Simultaneously, bringing more services into homes for kids who need urgent, but less acute care, will allow more young patients to stay with their families during treatment.
To avoid losing any more beds and to add capacity in its remaining residential treatment programs, the state needs to stabilize funding. Jetmalani believes OHA and private insurers should be paying a base rate to maintain some minimum number of staffed beds year-round, in addition to facilities billing Medicaid for the services they provide.
And though having sufficient residential beds is critical, Dr. Robin Henderson, the chief executive for behavioral health for the Providence health system in Oregon, says the state’s focus should be on supporting family caregivers to keep children in their homes if at all possible.
“The longer they stay in a facility outside their home, the less likely they are to ever go home,” said Henderson, who started her career more than 30 years ago working in the secure child and adolescent treatment unit at the Oregon State Hospital.
Oregon has some models for doing this. The nonprofit Youth Villages runs a program called Intercept for kids up to age 18 who have emotional or behavioral problems or who are at risk of entering foster care.
Andrew Grover, the executive director of Youth Villages, says it’s easy as a parent to be overwhelmed by the needs of a child who is suicidal or aggressive. Parents may feel like the only way to keep their family safe is to go to the emergency room or call the police.
“The problem is that it only resolves the crisis for that particular moment,” he said of using emergency services. “We can find a safe place for a day; we can de-escalate the aggression for a few hours.”
Instead of focusing on moments of crisis, Intercept staff focus on the long term. They work on making home a safe place and on teaching families how to communicate with their kids and how to build a network of supportive adults and peers around a struggling child.
Safety planning is the first step. For a child having thoughts of suicide, that could mean bringing lockboxes to secure any unsafe items in the home, installing a door alarm, and making a supervision plan with family members, teachers, and friends. The team helps the child identify things that might trigger them to feel badly - and makes a list of steps they can take, like playing music or talking to a friend, to help themselves manage their emotions.
And then there’s a lot of counseling.
“We see these families at least three times a week face to face,” Grover said. Staff also provide 24/7 crisis intervention. Therapists in the program carry no more than five families at any given time so they can provide that level of support. “That enables them to work at that level of intensity,” Grover said.
About 80 percent of the children who’ve been through the Intercept program are still living with their families a year later, according to Grover. Intercept typically enrolls around 200 families a year through referrals from doctors, teachers and child welfare workers.
At any given time, there are 60 to 70 families on a waitlist. The program could grow if Grover could hire more staff, but the intensity of the work and the demanding schedule have made it difficult to fill positions. “Like everyone, we’re having challenges getting enough people to do this work,” Grover said.
In 2020, Oregon made a big structural change that could unlock a lot more funding for programs like Intercept. It began formally recognizing this type of in-home care as a treatment for mental illness that qualifies for Medicaid reimbursement. The official name is “Intensive In-Home Behavioral Health Treatment.”
Private insurance plans, however, do not typically recognize and cover in-home treatment for behavioral health, meaning Intercept only works with kids on the Oregon Health Plan.
Grover says the commercial insurance world tends to consider just two levels of care when it comes to behavioral health: outpatient services, where a person meets with their therapist at a doctors office for a few hours each week, and hospitalization. Commercial insurance companies need to re-think that standard and start recognizing other treatment options for youth, “if we’re talking about getting this to every kid who needs it,” Grover said.
If you or someone you know is struggling with mental illness or addiction, you can call the free and confidential treatment referral line (1-800-662-HELP) or visit findtreatment.gov to find providers in your area who treat children.
Up next: Wednesday, we’ll examine another missing link in Oregon’s mental health system: Addiction is rising, but there are nowhere near enough programs to help Oregonians seeking recovery.