'Holding on by a thread'
Jackson County Mental Health therapists are warning that disruptions to the local mental health system could lead to spikes in homelessness, unemployment, domestic violence, child abuse, crime, addiction, hospitalizations and suicides.
"A lot of clients are really holding on by a thread," says Jackson County Mental Health counselor Raelle Kaia.
She sent a letter to Gov. Kate Brown asking for intervention in the dispute between Jackson County Mental Health and AllCare Health, which are in negotiations over a planned transition of AllCare's Oregon Health Plan patients from county services to other mental health providers.
AllCare, a coordinated care organization, says the county was not able to see enough patients, and waiting times for appointments were too long. AllCare says it could not meet state quality and access requirements by relying on the county alone — and was in danger of losing funding from the state for mental health care.
Jackson County says AllCare is understating the number of patients seen, and an offer made to the county to continue providing services was unacceptably low.
Jackson County had been receiving $13 million per year from AllCare for mental health services and was offered $8 million. AllCare says it planned to use the $5 million difference to provide an array of additional mental health services and boost the number of providers in other settings, such as schools and doctors' offices where people are already going.
County Administrator Danny Jordan countered with an offer of $1 million per month for services, plus $750,000 per year for crisis services — an offer that would have totaled $12.75 million annually. He wanted the agreement to continue through December 2018, according to a letter from Jordan to AllCare obtained by the Mail Tribune.
Regardless of who is providing services, AllCare has no plans to cut spending and instead plans to invest $14.5 million on mental health care in the county this year, says AllCare Vice President of Government Relations and Health Policy Josh Balloch.
With the current contract set to end March 31, the county and AllCare remain in negotiations about a potential 90-day extension, Jordan said this week.
Jackson Care Connect, the other coordinated care organization serving OHP patients in the county, already decided to transition away from most county mental health services over an 18-month period that started this winter. It also cited a need for increased access to services in a variety of settings.
County mental health workers and community providers with county contracts to provide care served 2,903 AllCare clients and 3,409 Jackson Care Connect clients in 2016, according to county data.
The county could lay off 200 workers — 180 in mental health — because of the loss of the Jackson Care Connect and AllCare contracts, according to county officials.
With so much uncertainty, Jordan says the county already has lost more than 70 workers.
"Our ability to enter into an extension with AllCare is being compromised. Our staff is leaving," he says.
Mental health workers in danger of losing their jobs are speaking out against the proposed AllCare transition. They also say Jackson Care Connect has had to slow the rate of its transition because it can't handle the client load.
On the front lines
County therapists say clients have to work up the courage to seek mental health treatment, and when they do, forming a trusting relationship with a therapist takes time.
"They often have trust issues because of abuse," Kaia says. "For them to build up trust in the relationship is key for them."
She says people with milder forms of mental health issues, such as anxiety, have a hard time applying for a job, securing housing or taking the next step in their education if they don't have support and encouragement.
Those with more difficult issues can struggle to remain sober, regulate their emotions and maintain hope. They may become vulnerable to abusive people in their lives, or become abusive themselves. If they lose their ability to pay the rent or keep a job, they can spiral down into addiction, which can lead to criminal activity, Kaia says.
People with severe, persistent mental illness, such as schizophrenia, require consistent care and medication to remain stable and to guard against symptoms such as delusions and hallucinations, she says.
Linda Eppler, an AllCare client who has been seeing the same county therapist for a year, says it took a few months for her therapist to persuade her to go through a behavioral therapy program that helped her reverse her negative thinking and control her emotions.
"It took a lot of commitment, but I was committed. Trust was my biggest issue. I said, 'I can't live like this, not trusting people,' " says Eppler, who suffered physical and sexual abuse in her past. "I didn't trust anybody, because no one was there to protect me."
Eppler says her therapist is leaving her job with the county and going to work for Options of Southern Oregon, a nonprofit mental health provider. She plans to keep seeing her therapist through Options.
"She's a really awesome counselor. I was worried about having another counselor. I was not going to go," Eppler says.
Previously in Lane County, Eppler says she went through six or seven different counselors.
"Every time I got used to one, they would switch me to another one," she says.
Anne Beaufort, who is relatively new to the mental health field, says working for the county on the adult outpatient team has opened her eyes to the severe problems many of her clients face. She says many are in poverty.
"They are struggling to have hope. They are struggling to have the courage to apply for a job. They are struggling to get out of abuse and addiction so they don't have to live in their truck or under the freeway," she says. "When you sit down with them and look them in the eye, it's different than just passing them on the street. It's a much different picture when you get to know them and hear their stories."
Beaufort says many are at the level of just trying to survive. She says mental health care is a critical service for a very needy population.
"How these people fare affects all of Jackson County," she says.
Amy Pearson, another therapist with Jackson County Mental Health, says she is worried people will slip through the cracks during the transition.
"My biggest concern is that people in treatment now have overcome incredible obstacles to engage in treatment," she says. "What I'm hearing is they are just not going to do it again. Multiple people are saying, 'I don't want to go to a new building. I don't want to meet a new receptionist. I don't want a new therapist.' It's changing their entire treatment venue."
Pearson says she fears more strain on hospital emergency rooms, the local hospital psychiatric unit, law enforcement and addiction treatment providers.
"Eventually if there are comparable treatment services, things may normalize," she says. "But the way the transition is playing out, there's no way there will not be major gaps. I'm concerned lives will be lost."
Jackson County officials say Jackson Care Connect is already having trouble with its transition of mental health patients to other providers, including ColumbiaCare.
Jackson Care Connect has asked for a slowdown in the number of patient transfers, according to Jackson County Mental Health Division Manager Stacy Brubaker and Jackson County Health and Human Services Director Mark Orndoff.
"They think we are sending the worst of the worst, but we sent them the most stable," Brubaker says. "Their feedback was, 'Are they all going to be like this? Because we can't handle these people.' "
The original target was to transfer 150 county clients per month, Orndoff says.
The updated transition plan calls for transferring 95 clients in March, 103 in April, 109 in May, 67 in June, 83 in July, 61 in August, 134 in September, 119 in October and up to 164 in November and December combined.
Asked whether Jackson Care Connect's new providers are able to handle the caseload, Chief Executive Officer Jennifer Lind says, "We have been working really, really closely with the county leadership and staff and new providers in our network around planning for and ensuring safe transitions for our members."
She says the most critical piece in the transition is respectful, ongoing relationships among all the organizations involved.
"It's too early to speak about lessons learned. We're closely watching what happens elsewhere in the community," Lind says.
Lack of access
Therapists say Jackson County has worked aggressively to recruit employees to the area and hire more people amidst a nationwide shortage of mental health workers.
Passage of the 2010 Affordable Care Act increased coverage of mental health care and made more people eligible for government-subsidized health insurance. But the resulting spike in people seeking mental health care highlighted the country's inadequate mental health care system.
"Everyone in the state has an access issue," says Brubaker.
However, AllCare says Jackson County was lagging behind other counties in Southern Oregon when it came to providing enough services.
In 2015, 9.8 percent of OHP patients received mental health care, compared to 11.4 percent in Josephine County, 11.5 percent in Curry County, 11.7 percent in Douglas County and 12.7 percent in Klamath County, says Balloch, the AllCare representative.
AllCare says Jackson County ranked 33rd out of 36 Oregon counties in 2015 when it came to OHP patient utilization of mental health services.
Brubaker acknowledges that AllCare's clients often had to wait in line behind Jackson Care Connect's clients, who typically had been enrolled in OHP before the Affordable Care Act coverage expansion and had more severe mental and physical health problems.
"Some of the individuals with AllCare had longer periods before they got into services because of the acuity of the needs of others," she says.
But with Jackson Care Connect transferring its patients away from county services, Brubaker says the county was poised to provide more care to AllCare patients.
"We could have had same-day services in many cases," she says.
According to AllCare, wait times exceeded 40 days.
The late Sen. Alan Bates, a physician, criticized Jackson County wait times in 2016, saying his patients waited six to eight weeks or more to get appointments. He said Josephine County services, which are provided by the nonprofit Options of Southern Oregon, were more accessible, prompting some patients to move to Grants Pass for care.
AllCare and Jackson County have major disagreements over the amount of mental health services the county is providing.
AllCare says the county was spending only 30 to 55 percent of the money it received on direct patient care — which is tracked as encounters.
The county contends it spent 68 percent of the money on encounters during the July 2015 through June 2016 fiscal year. It says the number increased to 78.5 percent from July 2016 to January of this year.
Balloch says the county did show some improvement, but disputes the county's numbers. He says the county has been told for years about access problems.
"Though there was improvement in the number of services provided in 2016, there were still significant access issues and it still was underperforming compared to the other two counties, Josephine and Curry, where AllCare has services," he says.
Brubaker says the official state encounter data is not capturing all the services Jackson County gives through contracted mental health providers in the community.
County officials say money not spent on direct patient care is used to fund indirect services that improve people's health and well-being. For example, the county helps fund Compass House, a clubhouse in downtown Medford where people with mental illness can gather to socialize, get employment support and learn a variety of skills, from cooking to gardening.
County officials say Jackson County Mental Health, like other county departments and divisions, also pays for its share of administrative support, including human resources, legal services and information technology. Those overhead costs are 17 percent of the mental health budget, according to budget figures.
Like the county, AllCare also spends money on indirect services to improve overall health.
Balloch says in 2015 AllCare donated $3.8 million to dozens of local groups, including Compass House, ACCESS for its mobile food pantry, Kid Time! for its early-learning programs, La Clinica and Hearts with a Mission, which serves homeless youth.
AllCare CCO is paying approximately 9 percent of its revenue for administrative services to its affiliate AllCare Management Services, according to state data.
Balloch says that amount includes the donations AllCare makes to improve overall health that can't be billed as medical services.