Wednesday, September 18, 2019

Comments by Robert Nikkel, MSW

Showing 16 of 16 comments.

  • Stephen, I wasn’t sure if you wanted more information on the series of webinars but looking at more of your comments, I think you are asking for some beginning points of reform in your state hospital. I actually have something that might be of interest and would want to email it to you because it’s longer than works well in a comments section. If you’re interested, email me at [email protected]

    I think I recognize the dynamics you’re dealing with.

  • Stephen, could you give me an idea of what you’d like to see in your state hospital to move toward a “green” reform or revolution? I’d be happy to think with you about what the budget implications would be. Steve, i agree completely that part of the problem is what you’re pointing to–the waste on ineffective and destructive “treatments” for people who don’t need or want them.

  • I want to thank each person who commented. Every one added something important to the process (or I should say, processes) that would lead to major protections, up to and including the dismantling of the entire system that supports involuntary “treatment”–as Julie Greene points out, you don’t need just the elimination of forced interventions–it happens almost everywhere in direct and sometimes more subtle ways. I think some way of organizing efforts makes total sense and Andrews Mom provides a lot of background, ideas and experience in how to do this. This will require the engagement of a grassroots constituency. Some will work on the kinds of protections I (and several others) have outlined. I appreciated the additional ideas. And as I said, I would prefer to see every one of the 47 states retract their AOT laws. This will require both political and legal activities. I have read each and every comment several times now, and again, want to express my respect for and satisfaction with these thoughts. That was one of my hopes in writing this blog. I continue to believe that the article by Bob and Michael have written have laid a solid foundation for the arguments that can be made in situations where logic and evidence are needed.

  • I “attended” this ground rounds event by remote internet connection–so I was not able to participate in any discussion–though it would have been good thing to do. However, even if I had been there in person, I wouldn’t have been able to get any comments in. There was very little (if any, I just don’t recall) time for discussion. It’s a good point you’re making and one of these days, I’m going to try to get up there for one. I am having a meeting next week with one of the faculty members, someone I’ve known for quite a long time, and you can be sure I will be trying to get in my 2 cents worth (maybe even a Nikkel’s worth).

  • I left my position (actually, I was fired for raising questions about “integrated healthcare”) in 2008 before I had read anything by Bob Whitaker. So I would do things differently now–and almost certainly get fired much sooner. As it was, I did last almost 6 years, a long time for state mental health commissioners who usually last about 18 months–not much time to get much done. That’s one of the perspectives that I have–it’s very difficult to do reform in state systems. Frankly, abolishing the mental health system just isn’t going to happen if you understand even the first things about legislators. I realize by sharing what we collectively accomplished during my 6 years in leadership, I am just opening myself up to more criticism but this will at least answer your question. As I stated, I would do many things differently now. Please note that I was also the director of addiction services.

    Here goes:

    Increased services for people with addiction disorders – AMH is overseeing statewide implementation of $16 million in new funding for services for people with alcohol and drug abuse problems. Under the Intensive Treatment and Recovery Services Initiative, $10.4 million is directed at families whose children are in or at risk of being in the child welfare system due to parental substance abuse. Twenty-eight counties and tribes are participating in the evidence-based Strengthening Families Program, aimed at decreasing adolescent substance abuse and aggression through the promotion of better parenting and child-parent relationships.
    Children’s Mental Health System Change Initiative – More children are enrolled in managed care and receiving community mental health services as a result of AMH’s Children’s Mental Health System Change Initiative, which began in late 2005. The changes have increased supportive and wraparound services for kids and reduced lengths of stay in institutional care facilities. Families are more satisfied with coordination, participation, treatment, and outcomes. Treatment is linked to increased school attendance, a decline in school suspensions and expulsions, and decreased arrests.

    Problem Gambling Awareness Program – This AMH unit created an award-winning problem gambling awareness video featuring Oregon youth and distributed it and a facilitator guide to all Oregon middle schools. The unit sponsored a youth problem gambling prevalence study, one of the first in the nation to include parents and to report that young people are gambling online. The study indicated that parents need to learn more and advise their children against the online games, which start for free and then begin collecting money. The study indicated that 1.3 percent of Oregon adolescents are problem gamblers, and another 4.6 percent score as at-risk gamblers. Also a college problem gambling prevention and awareness initiative is taking hold on four major campuses – Portland State University, Oregon State University, University of Oregon and Oregon Health & Science University. And the program added an online (chat, instant message, email) component to the Oregon Problem Gambling Helpline to reach more youth.

    Housing – In 2005-07, AMH invested $6.15 million in residential development projects to transition people from institutional settings and homelessness, and to create housing for people with barriers to residential stability. The housing, valued at $55 million, includes 24 residential facilities/homes, four transitional housing programs and 14 supportive apartment complexes. Twenty-nine projects were initiated in 18 counties to house 363 people with serious mental illness, including housing for 287 people leaving psychiatric hospital facilities. There were seven projects in six counties to house 54 residents in recovery from alcoholism and drug addiction. Using these new residential programs and other community settings, 128 individuals were moved from state psychiatric hospitals to community settings.

    Evidence-based practices – Addictions and mental health treatment systems exceeded statutory requirements (ORS 182.525) for delivering evidence-based practices with at least 25 percent of the 2005-07 budget. AMH surveys indicate that 33 percent of mental health expenditures and 54 percent of addictions expenditures were for evidence based practices. There are more than 150 approved practices from which providers may choose. AMH is reviewing the fidelity of providers in delivering the approved practices. AMH staff and stakeholders developed procedures for evaluating and approving practices, contract language, fidelity monitoring, and readiness assessment. The system is scheduled to deliver evidence-based practices with at least 50 percent of the service expenditures in 2007-09.

    Dual Diagnosis Anonymous – Over 100 of these critical self-help groups have been established in the last two years, serving people with both mental health and addiction disorders. These peer-directed groups support people in recovery and foster their success in the community. Over 1,200 members are now actively participating in recovery from co-occurring disorders.

    Wellness Initiative –An AMH wellness committee is working with people who are recovering from mental illness to improve their health and longevity after a recent study indicated they often die much younger than others in the general population. They are working to improve health and wellness by sharing information on scientific research, literature, peer guidance, and successful practices among user groups. The committee is made up of those in recovery, DHS staff members, physicians, health and wellness professionals, and others.

    Jail Diversion programs – AMH is distributing $4 million authorized by the 2007 Legislature for jail diversion programs in all 36 counties. These programs are aimed at individuals charged with low-level crimes whose treatment needs are best met in a mental health setting rather than a county jail with fewer treatment resources. The programs involve intensive case management, which includes working with courts, parole and probation officials and others to ensure that treatment, housing and other client needs are being met.

    AMH supports drug treatment court services – Oregon’s 47 drug courts are helping to reduce drug use and re-arrests among people involved with drugs and the criminal justice system. And they save counties money on corrections costs. Drug court participants must go through a long-term, structured, supervised and coordinated multi-agency treatment program before they are eligible for “graduation.” AMH supports services that are essential to drug courts, such as outpatient and residential treatment for drug and alcohol addiction, detoxification, mental health treatment, and housing and peer services aimed at recovery.

    AMH funds early psychosis programs – In December 2007 AMH selected two organizations and three counties to receive $3.02 million to conduct early psychosis programs, which aim at helping young people who experience psychosis to stay on their normal developmental path with as little disability as possible. Oregon is the first state in the nation to expand availability of these life-saving invention programs beyond very limited pilot projects to half of the young people in Oregon experiencing their first major psychotic episode. The funding for programs serving approximately 200 young people is: Deschutes County, $535,993; Multnomah County, $1.15 million; Washington County, $843,599; Greater Oregon Behavioral Health, Inc. (for Clatsop, Columbia and Union counties), $410,561; and Mid-Columbia Center for Living, $180,169.

    Network for the Improvement of Addiction Treatment – Fifty Oregon treatment providers are participating in the Network for the Improvement of Addiction Treatment, or NAITX 2000 project. It is designed to help people with drug and alcohol addictions get into treatment, reduce the waiting time to start treatment, and increase the likelihood they will remain in treatment long enough to benefit. AMH is managing the federally financed research project, which is evaluated by the Oregon Health & Science University. The goal of the project is to gauge what technical assistance is most effective in helping treatment providers improve outcomes.

    Promoting Medicaid Funded Peer Delivered Services: The Addictions and Mental Health Services Division (AMH) recognizes the indisputable value of peer delivered services in transforming a mental health service delivery system that is based on the recovery model. AMH will work with consumers/survivors and stakeholders to develop strategies to increase the use and availability of peer delivered services. The largest funding source for community-based mental health services in Oregon is Medicaid.
    AMH Cultural Competency Plan: The purpose is to establish cultural competence standards, values, and policy requirements for AMH and all organizations and agencies that receive grant funds from, or that are under contract with AMH, including county social services organizations and their vendors or contractors, managed care organizations and their provider networks, and community-based organizations. It is the intent that this will serve as a planning document to assist AMH, County Governments, and provider networks to develop and implement an individualized cultural competence plan as addressed in each County’s bi-annual implementation plan, with its goal to enhance treatment outcomes for all patients.
    Mental Health Emergency Preparedness Response Plan: The Division has completed a comprehensive emergency preparedness plan in collaboration with other key stakeholders in state and local government.
    Negotiation of Co-Management Plan: The Division negotiated into county intergovernmental agreements for the first time a section which makes counties ultimately responsible financially for any patient deemed ready to discharge who is not placed in the community in a timely manner. This is a major step forward in working out details of how Oregon can be consistent with the Supreme Court’s Olmstead decision.
    OSH Census: The Division and community partners, both county and non-profit, have worked diligently to increase the number of placements available for persons ready to leave the state hospitals and have decreased significantly the number of persons who are civilly committed and also decreased the number of beds needed in the state hospital for longer-term civil commitment stays.
    Miranda B Settlement: The Division was able to reach a settlement on the Oregon Advocacy Center’s Miranda B lawsuit by agreeing to create a significant number of new placements in the community. Community resistance has made complete fulfillment of all goals difficult but Division staff and county/community programs have worked diligently and in good faith to create hundreds of new places for persons leaving the state hospitals to continue their recovery in the community.
    EOPC Name Change: The Division worked with 2005 Legislature to change name of EOPC to BMRC (Blue Mountain Recovery Center) following receipt of a petition signed by an overwhelming majority of patients at the state facility in Pendleton. This reflects a considerable transformation of thinking about how people in state hospitals are viewed and treated in their movement toward a real life in the community and recovery.
    Reduced use of Seclusion and Restraint in state hospitals and local acute care units. Data has clearly indicated a consistent and long term decline in the use of seclusion and restraint in the most highly restrictive levels of care for adults.
    Created PAITS (Post Acute Intermediate Treatment Service): PAITS is a mix of rehabilitation services designed for adults who have received acute psychiatric care services in a local hospital and who have been approved for Long-Term Psychiatric Care.

    Children’s Mental Health:
    • Closed state hospital units for children and adolescents and opened successful community programs as alternatives.
    o Secure Children’s Inpatient Program & Secure Adolescent Inpatient Facility
    • Children’s System Change Initiative – outcomes data has shown a significant decline in out-of-home and other residential treatment for the most challenged children and adolescents in Oregon.
    • Children’s Medical Director – this position was established for the first time rather than the adult-focused Medical Director positions in the past. The AMH Medical Director has proposed a Position Description which will allow for a shared position with Children, Adults, Family Division as a model for future development and current integrated work between the two Divisions.
    • Developed plan to increase percentage of MH assessments for children placed in out-of-home care under CAF in order to provide better services and to meet a federal requirement that has long been neglected.

    Adult Mental Health
    • Governor’s Mental Health Task Force Report prepared and issued in 2003
    • Implemented the 20-hour Personal Care option as a way to avoid major cuts in 2003 and begin supporting peers delivering support services.
    • Jail Diversion Projects implemented in all counties following the 2007 Legislature’s approval.
    • Established a consumer/survivor council; codified in statute by 2007 Legislature
    • SB 267 implementation is on track to achieve the 75% required funding levels for 2009-11.
    • Expanded Secure Residential Treatment Facilities to 21
    • Resolved 15 Acute Care issues in summer of 2008
    • Enforced Umatilla County intergovernmental agreement by revoking the certificate of approval in 2005 and re-contracting to Lifeways.
    • Community Services workgroup provided a framework for “front end” and “back end” services in order to make the OSH replacement facilities work.
    • Olmstead Plan has been completed in 2008; will be modified as needed in next year.
    • Supported Employment pilot projects have served as national and state models for this evidence-based and recovery service.
    • Agreed on MHS 20 allocation formula (Kessler) with counties to achieve an equitable distribution of non Medicaid State General Funds for adult and crisis services.
    • Returning Veterans Workgroup is scheduled to initiate review of needs.
    • Wellness Initiative established to reduce the years of lost life expectancy for adults with major mental illness, perhaps the single greatest health disparity at this time in all of Oregon and around the country.
    • Dual Diagnosis Anonymous – 300 gps/week and growing
    • NAMI – Report Care Top 10 with 40th per capita funding

    Transition Age Youth
    • Established EAST and first state to extend to ½ state
    • New position for Transition Age Youth
    • 1st statewide Transition Age Youth conference in country in summer 2008

    Children’s A&D
    • Re-established Prevention Manager position and hired national expert
    • Adopted Risk & Protective Factors as framework for focused prevention services
    • Established list of EBPs
    • Children’s Intensive Treatment Program with CAF implemented statewide in 2007-08/
    • Developed Policy Option Package of $12 million investment in prevention
    • Suicide prevention services have been developed in close collaboration with Public Health Division and Oregon Partnership

    Adult Addictions
    • Established EBPs and met 2007-09 goal of 50% in 2005-07
    • Developed Community Addiction Plan with Governor’s Council
    • Elevated visibility of addictions by restructuring and renaming AMH and creating Addiction Manager position
    • Led implementation of NIATx and SBIRT treatment improvement initiatives
    • Established co-occurring specialist position and issued first Dual Diagnosis Directory with 122 programs statewide

    General
    • Initiated Hispanic Mental Health Workgroup to begin in Fall 2008
    • Brought MH budget in balance without need for other Division assistance
    • OAR simplification plan established
    • Performance outcomes data sheets & expansion to six program areas and six outcome measures
    • Morbidity/Mortality study completed in 2007 by Program Evaluation Unit consistent findings with about 9 other statewide studies
    • Research collaboration with PSU, OHSU (SB 267, etc.)
    • AMH forwarded 80 Policy Options Packages (POPs) for a needs-based budget to be considered by the Governor
    • Switched General Funds to Medicaid in order to avoid dismantling MH system in 2003

    State Hospitals

    • Reduced LOS by 30%
    • Master Plan completed and is on schedule and within budget
    • Worked with Oregonian editorial Board in Pulitzer Prize winning series on OSH
    • Transformed state hospital union adversarial relationship to collaboration
    • OHSU collaboration – created contract for improving MD services at Oregon State Hospital
    • Planning for new approach to state hospital recovery model to treatment mall
    • Established state hospital CFO position
    • Peer Bridgers project approved
    • First state hospital in the nation to implement Supported Education (over 100 patients enrolled)
    • Regained Joint Commission and CMS certification
    • Created Continuous Improvement Plan, retained 2 national experts to consult and lead culture change
    • Gained legislative approval for 211 new staff
    • Completed Psychiatric Nurse Workforce Development Plan
    • Resolved Harmon v. Fickle lawsuit
    • Developed DDA groups in State Hospital
    • State established “Ready for Discharge” criteria

  • BPDTransformation, B.A.
    Thank you for your comments and your catching the edit of a word missing. I’ll contact MIA and see if we can get if fixed. And yes, none of the points I made are new–but if you and others find them succinct and clear, then I’ve done something useful. I chose to use the term “best and brightest” for 2 reasons–the 150 people in the room are indeed highly educated and virtually all quite successful in their fields–especially so in this crowd of film-makers, attorneys and mental health professionals. The other reason is that I think at some point we have to find ways of communicating without maligning those who are not yet at a place where they really see what unbiased research and alternatives (btw, which I hope we can stop using the word “alternatives” because they become the norm) show. Otherwise, we continue to preach to our choir, which is good in the sense that we need the support of other like-minded people, but ultimately we need to draw all the others in.

  • madmom, thank you for your comments. There was an opportunity for countering opinions to be offered. One psychologist in particular raised virtually all of the points I’m making in this blog. He and I suggested that a future institute create a forum where respectful debate occur between those of us who see things differently than the standard cultural view be allowed to discuss issues–without personalizing and attacks. I do see private philanthropy playing a role–as they do with the Foundation for Excellence in Mental Health Care by funding the significant alternatives like Hearing Voices Network and adaptations of the Open Dialog in places like Framingham and soon in Atlanta, Georgia. I see cracks of light but we need to nurture them and find more philanthropists willing to help illuminate services and supports that will make a positive difference which then government and private insurance will see fit to support with the literally billions of dollars they have.

  • I agree completely with your assessment of both the risks of withdrawal from long-term use of neuroleptics (it’s more than a euphemism to call them “antipsychotics”). If we could get the “technology” of helping people reduce and as often as possible get them off completely, the system would save money in the long-term. Budgets that run from year to year don’t help with this equation. I’m concerned too that this is all getting lost in the shuffle toward integrating physical health and mental health and addictions and dental care–and it should be forefront. Public policy can be a tough nut to crack for the enlightened.

  • Eileen, I share your concerns about not using early psychosis intervention programs as a way to over-identify young adults who may or may not have major mental health challenges. I’m not confident at all that we know how to predict who will have these problems and who won’t. We do need to build in careful screening for alcohol and drug use or dependence because these can mimic just about any mental health issue–and of course, can cause some just as mental health challenges often lead young adults to using alcohol/drugs as ways of coping. The early invention approaches I’m familiar with do not use these approaches to funnel people into involuntary treatment or hospitalization, rather they try to prevent these. And you make a critical set of points about getting access to stable housing, decent jobs, support for education, recreation, dental health and on and on. One of the things that concerns me a great deal is all the big talk about integrated healthcare systems. While access to high quality healthcare is badly needed, it is being implemented without consideration of the risks of psychiatric medications, both short- and long-term with alternatives to the traditional arsenal of involuntary, authoritarian “care.” And how many primary care physicians know anything about recovery? Here screening is a real risk. For example, in Oregon, the highly touted healthcare reform is supposed to increase the screenings for depression and will almost certainly lead to even more use of ant-depressants. We have our work cut out for us.