Hundreds with serious mental illness not getting services, Multnomah County audit finds

Street Roots, November 29, 2019

The county’s mental health funding isn’t reaching half of the people who qualify, according to the report

More than half of adults who qualify for mental health services offered by Multnomah County aren’t getting them, according to an audit report released by the county auditor’s office last week.

READ – Audit Finds County Mental Health Programs Aren’t Reaching Everyone Who Needs Them, Portland Mercury 11 20 2019

One of the programs began in 2016 with a $2.5 million surplus closed its fiscal year in 2017 $650,000 over budget when it entered into what the report characterizes as an “unsustainable housing contract,” resulting in the closure of 18 units of supported housing and 13 units of room and board. The report also points to what the auditor’s office characterizes as an overall lack of transparency on the county’s part.

Multnomah County Mental Health and Addiction Services will close fiscal year 2019 with $1.4 million leftover, according to the audit, which has been earmarked for the new Behavioral Health Resource Center. That center, to be located at 333 SW Park Ave., will focus on services and treatment for people experiencing homelessness, addressing mental illness and substance abuse disorders.

“My initial kind of impression is that, first off, I absolutely agree with the auditor that for those who receive services from us the county’s intensive services are working. But I also agree with the auditor that there are too many people with serious and persistent mental illness who are not getting all the services and support that they need,” said Ebony Clarke, who was hired in March as the director of the county’s Mental Health and Addiction Services Division.

The audit focused on two programs – Choice and Assertive Community Treatment, or ACT – that serve adults with serious and persistent mental illness, defined under Oregon Administrative Rules as people with diagnoses that include schizophrenia, bipolar disorder and major depressive disorder that has lasted or is likely to last for more than a year, and need assistance with tasks like maintaining a home, finding or keeping a job or grocery shopping.

“We focus on these programs because they’re intensive services for people with serious mental health conditions, and they’re also programs that are really prioritized at the state level,” auditor Caroline Zavitkovski told Street Roots.

People with serious mental illness make up a small portion of the general population, and of those with mental health diagnoses generally. According to the National Institutes of Health, about 4.5% of adults in the U.S. have a serious mental illness, compared with 18.9% of American adults who have a mental health diagnosis of any kind. People in the former group have more serious outcomes, including a higher likelihood of institutionalization and a high likelihood of becoming homeless.

One program the audit examined, the Choice program, is a care coordination program for people with serious and persistent mental illness, intended to keep people from needing admission to the Oregon State Hospital and to help transition people in the state hospital or residential treatment to the least restrictive level of care possible.

According to the audit, between 2016 and 2018, 676 Multnomah County residents were civilly committed — but only 326 were enrolled in Choice.

The second program reviewed by the report, Assertive Community Treatment, is a team-based community model for people who are living independently but who need support in managing their lives and illnesses. Teams are typically led by a mental health provider such as a psychiatrist and include housing and job specialists, substance abuse counselors and peer support specialists – people with similar diagnoses or experiences who can offer support.

An even smaller percentage – just 19% ¬– of those eligible for ACT were enrolled in ACT programs.

Mental health advocates who spoke with Street Roots said the report underscores some things they’ve been calling attention to for years, but they were also critical of its narrow scope and the vagueness of its recommendations. Those recommendations include reporting to the county Board of Commissioners on funding priorities, obtaining written approvals from the state for plans to reserve state grant funding, and taking steps to ensure people who could benefit from services are identified.

Jason Renaud, co-founder of the Mental Health Association of Portland, said it’s interesting that so few people who are eligible for the Choice program are referred to it, but the scope of the report was so narrow and its recommendations so vague, he doubts it will have any meaningful results.

“There’s a big disconnect. And it’s just not clear from this audit or from the chair’s response what’s happening here,” Renaud said.

He also said some of the report’s most damning details aren’t placed in a meaningful context. For example, while many people who have been discharged from the Oregon State Hospital are technically eligible for ACT, Renaud said, they may not need it. The program is designed for people who are unlikely to attend traditional appointments – who need to be met where they’re at, sometimes literally on the streets.

“It really kind of dives into what happens when you have scarcity of services,” said Sarah Radcliffe, the managing attorney for Disability Rights Oregon’s Mental Health Rights Project. “The fallout that results from scarcity is that you have a lot of barriers to accessing those services – so not only is the capacity not sufficient to meet the need, but the system itself becomes really inaccessible. That’s kind of how providers and systems deal with scarcity, is by erecting barriers to accessing the services.”

ACT clients have to be referred, for example; it’s not something people can sign up for by going to a website or walking into a clinic. So they rely on gatekeepers to find out whether they’re eligible for services.

“The other thing that struck me was just the lack of outcome data,” Radcliffe said, especially when considering long-term outcomes.

The audit found that from 2016 to 2018, 40 patients went directly from the state hospital to motels or room-and-board situations – twice as many as those who went into supportive housing. Not only did the clients not get the care and support they needed in managing mental health issues, the cost to taxpayers was higher. And clients who were living in hotels were initially categorized as living independently.

“We just don’t have a good statewide system of looking at long-term health care outcomes for people with serious mental health concerns,” Radcliffe said. “And I think that’s a real gap, because we should be moving towards models that promote long-term stability and health. And how can you do that if the only thing you’re tracking is dollars spent and services provided?”

Radcliffe said adequate funding is the obvious answer, particularly for supportive housing that offers wraparound services for individuals with serious mental illness. She noted that Marion County has one-third the number of Choice clients versus Multnomah County, but has 70 units of supported housing reserved for them, versus Multnomah County, which has 51.

The response from the Mental Health Division included in the audit mentions three supported housing developments in progress – Central City Concern’s Division Street apartments, the Westwind Apartments in Old Town and the Joyce Hotel downtown – for a total of 179 units. County officials couldn’t say when those buildings are coming online; a 2018 report presented to Multnomah County said a total of 2,000 supported housing units is needed to address the current shortage.

“I’ve been studying mental health politics and policy for 30-plus years. I’ve never been clear about how this stuff works. It is always obscure,” Renaud said. “There’s no other part of medicine or science or public policy that is this bizarrely obscure – and not this in particular but mental health in general. They make it intentionally complicated which makes it impossible for accountability and the general public to know and support these funds.”