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Guest column
David A. Pollack, M.D.

Oregon has a long tradition of progressive social and health policy, including its approaches to mental health and addiction services. However, in recent years, economic and other factors have combined to impede or even reverse some of the progress that had been achieved in prior decades. Oregon’s mental health policy leaders believe that increased public attention, an improving economy, and appropriate political support can lead to a turnaround: a transformation of our system into one that is more effective, efficient, safe, and responsive to the needs of the persons we serve.

Most of the publicly funded services for persons with mental health and substance use disorders are managed by the State Department of Human Services and its Office of Mental Health and Addiction Services (OMHAS). OMHAS has embarked on a number of initiatives, which, taken as a whole, constitute the key elements of this system transformation. The main aspects of that transformation are reflected in the visionary description of what we want our service system to be: Recovery-Oriented, Evidence-Based, and Culturally Competent.

Recovery-Oriented Services

Recovery is a concept that incorporates the notion that persons with severe and persistent mental illnesses or substance use disorders can achieve a level of improvement that will allow them to live productive and meaningful lives. To achieve this, our service system must pay more attention to a wide variety of issues that will allow these individuals and their families to have more choice, autonomy, dignity, and hope.  Much of this emphasis has been stimulated and supported by the active involvement of behavioral health consumers in their own care, in the care of others, and in the development and oversight of policies and programs. 

System transformation initiatives related to recovery include efforts to put the patient in a position to choose the direction and manner of treatment services.  This also means making treatment settings, especially hospital and residential programs, safer and more aware of and sensitive to the psychologically traumatic experiences that many patients have experienced in their lives.  This includes the consequences of involuntary or coercive aspects of prior treatment in the mental health system.  Many treatment facilities have made great strides towards reducing the use of force, especially seclusion or physical restraint.  Recovery also includes educating patients about their illnesses and providing them the skills and encouragement to be more active and effective participants in their own care and to achieve independent lives in the community.

Evidence-Based Practice

Evidence-Based practice in mental health and addiction services is based on the premise that scientific findings that demonstrate effectiveness will lead to better clinical outcomes and lower overall costs (both costs of care and the broader societal costs associated with social services or lost productivity when people are ill, disabled, or involved in the criminal justice system).  There are many established evidence-based condition-specific treatments (such as medications, counseling, or skills training for specific conditions) or broader service system approaches (such as methods of case finding, assessment, case management, or patient eduction) that are not necessarily linked to a specific illness or condition. 

Oregon’s legislature passed a landmark bill in 2003 that requires the state to use public funds for evidence-based mental health and addiction services.  This has led to a major shift in how OMHAS and its clinical partners in community, residential, and hospital programs define and demonstrate how they provide care for persons with mental health or substance use disorders.  The OMHAS website has extensive information on how this initiative is proceeding. 

The Evidence-Based Practice Initiative includes efforts to provide more rational and effective counseling, medication, and psychosocial rehabilitative treatments for a wide variety of conditions, such as psychotic disorders, methamphetamine or opiate dependence, and the effects of child abuse.  It also involves efforts to transform the delivery system in scientifically valid ways to improve quality of care, examples of which include the use of information systems to effectively monitor patient clinical activities and outcomes, the integration of behavioral health into primary care settings, and the use of effective screening instruments and treatment guidelines to assist clinicians in making appropriate decisions in working with their patients.

Culturally Competent Services

Cultural competence may sound simple, but it involves a very complicated array of issues and approaches that involve making health care services more consistent and compatible with the ethnic, religious, racial, gender, and other defining characteristics that contribute to a person’s self- and world-view.  Cultural factors are critical to effective assessment and treatment of mental health and substance use disorders.  Achieving effective cultural competence throughout the mental health and addiction service system requires concerted efforts to recruit, train, and retain persons from diverse backgrounds.

A Diverse and Competent Workforce

For these cultural diversity reasons, as well as the need to promote the recovery and evidence-based concepts described above, the state and its clinical and academic partners have begun an ambitious intitiative to improve the behavioral health workforce.  This effort involves participants from all parts of the system, including graduate and undergraduate academic training programs, the business community (especially the employers of behavioral health providers in community-based, residential, and hospital settings), consumers and advocates for persons with mental health and substance use disorders, and policy experts from state and local government and the private sector.  Over the next five years these stakeholders intend to collaborate to dramatically increase the numbers and retention of motivated, diverse, and well-trained staff in our transforming behavioral health service system.

Is it possible?

The challenge, of course, is money. Is it feasible to proceed with such broad system transformation ideas when the state’s budget is so limited? And given this, how can (should) we prioritize among the various elements of system transformation when these elements are in the end so interdependent and all play a role in the successful transformation of the system?

Author Bio

Dr. Pollack is a psychiatrist and Professor of Psychiatry and Public Health and Preventive Medicine at Oregon Health and Science University.  He was the Medical Director for the Oregon Office of Mental Health and Addiction Services from 2002-2006.

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Join the dialogue here

Aug 24, 2006 9:49:30 AM
Jim Holman says

"The challenge, of course, is money. Is it feasible to proceed with such broad system transformation ideas when the state’s budget is so limited?"

Do we know what the price tag on these various programs would be? Some of these should end up being less expensive -- evidence-based treatment, for example. Also, there is definetly a cost when people are disabled from mental illness or addiction, so anything that would reduce such disability would be a savings. Considering the totality of costs, it may be that better programs would actually prove to be cheaper than the status quo. I know that in the business world, improvments in quality often reduce, rather than increase cost.

Aug 25, 2006 10:30:20 AM
Teresa Goodell,RN,PhD says

The writer above is surely correct about the advantages of evidence-based practice. I'd like to add that ongoing prevention programs that keep people with mental illness out of crisis should likewise reduce costs. When many insurers are not covering mental health treatment, it is no surprise that many individuals with mental illness relapse and cannot contribute optimally to society.

I think a paradigm shift is needed: we tend to wait for a disaster to take action, but maintenance of well-being in all chronic illness, not just mental health problems, is what is needed.

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