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By
Robert Landauer

Any darn-fool manager can make an agency look good when taxes flood in like high tide at full moon. When the tax tide ebbs, though, it takes brains, skill and grit to perform like a star.

As one who has often flayed Multnomah County's mental-health programs, I have to confess: The county's delivery of care to poor mentally ill residents is a virtuoso turnaround performance in our deep recession.

Let's set the scene: The news here for several years reported uncoordinated mental-health services, impossibly large caseloads, a controversial closing of the crisis triage center and a plague of suicides among mental-health clients. The county jail was the Portland area's largest mental-illness treatment center. Services were cruelly fragmented. They weren't a system because the gears of interrelated health, mental health, courts, jail, housing, employment, alcohol/drug and Social Security components didn't mesh.

Bev Stein, county chairwoman four years ago, launched a study that triggered an extensive reform process. Diane Linn, her successor as county chairwoman, staked her political reputation on carrying on with a large but unsettling reorganization despite budget woes.

Begin with a few numbers: About 70,000 low-income county residents were eligible until recently for the Oregon Health Plan; 13,000 received mental health services. State budget cuts have ended 20,000 people's eligibility. The county has had to cut its mental-health patient load down to about 9,000 people. Some patients' mental illnesses flare up several times a year, so the 9,000 patients account for a caseload of 2,600 mental-health interactions with the county each month.

Next, recognize that early help stops most mental disturbances before they become public as well as personal crises: jailings and hospitalizations; loss of jobs, housing and benefits; drug/alcohol abuse; personal isolation; and criminal victimization.

Now, accept as auditor-certified truth that treating mental-illness upheavals early is hugely less expensive and far kinder than coping with late-stage crises in hospitals and jails, then trying to build secure support systems for patients leaving confinement.

So, what has changed?

The total days per month that the county's low-income mentally ill patients are in acute-care hospital beds is the indicator of choice. The better the community-based supports, the more surely early interventions will shrink the need for hospital care.

In April 2002, the county paid for 805 mental-health hospital days. The total climbed to 919 hospital days in May and peaked at 1,054 in June. At an average $700 a day, the peak-month bill was $737,800 -- close to $9 million a year if that trend weren't reversed.

But as reforms have gained traction over the past year, a chart showing mental-health bed days looks like a fairly steep ski slope viewed from the top. Bed days have fallen almost steadily, to 445, or $311,500, in March. That is almost 60 percent less than the peak-month bill -- money that more usefully can be shifted to prevention.

Some heavyweight new or expanded services aiding this about-face are the 24-hour crisis line offering brief counseling and information about where to go for help; a 24-hour crisis walk-in clinic and a child and family after-hours walk-in clinic; and Project Respond, which has become a countywide culturally competent child/family/adult mobile outreach service.

One of the most striking advances is that county workers now know where every mental-health patient is hospitalized and begin coordinating supportive, stabilizing services for them right away. This is progress that few of us in 2000 thought possible this soon.

"For the first time, I feel like we have a system worth fighting for," says Commissioner Lisa Naito, a hard worker on mental-health issues in the county's criminal justice system.

But it is a fact, not a threat, that the county can't maintain programs and extend reforms that keep mentally ill people out of hospitals and jails unless voters support Measure 26-48 in the May 20 mail election.

"For us dealing with mental health, Measure 26-48 is about saving money," says Linn, the county chair.

Our votes ought to reward the county for its effective and compassionate mental-health turnaround.

© 2003 Oregonian Publishing Co. All rights reserved. Used with permission of The Oregonian.