Once a year or so, members of the Mental Health Association of Portland issue recommendations on how service providers can improve the quality of life for people with addiction and mental illness. This year we consider Multnomah County. 

Next Best Steps for Multnomah County 

For people with lived experience of mental illness and addiction, and for those who love them and care for their welfare, the list of Multnomah County’s deficits is long and has been long for a long time. There’s no simple repair to the deficits, no replicable model from another comparable county to install, no instant fix. But there are solutions which will take time, effort, and the willingness by County leadership to change. And change starts – and stops – at the top. 

Here are the next best steps for Multnomah County – to improve services, to reduce risk, to rebuild the workforce, and to repair confidence that something can be done. 

Priorities, Plans & Integration

The County Chair should create and disseminate a statement of priorities for the County, listing reducing the impact of addiction and mental illness as a top priority. To put that priority into action, the Behavioral Health Division needs to step up with a clear and coherent plan of service which includes administrative and skills integration with other agencies within the County which also provide services for people with mental illness or addiction, such as DHS, the jail, Aging, Courts, Public Health – even Animal Services. 

Informed Advocacy & Representation

The Chair should designate a member of their staff to be comprehensively knowledgeable about how the service system for people with mental illness and addiction works. This person should be supported to:

• Speak on behalf of the Chair to the Commission, the media, and to the public
• Actively participate in public and private meetings where policy is determined
• Provide neutral-perspective subject briefings as requested by internal and external stakeholders
• Provide evidence and supporting data of planned outcomes in an annual report
• Identify and propose changes to County and contract services which under-perform

Director Recruitment

Designate a Board Commissioner or authoritative community member to lead a national executive search for an experienced, knowledgeable Director of the Behavioral Health Division capable of fully addressing the deficits at hand. This national search should begin with a review of the job description and salary in partnership with Clackamas and Washington County healthcare leadership. Example – clinical licensure is irrelevant to this position, a barrier to strong applicants, and should be removed from the job description. 

Leadership with Lived Experience
The foremost quality for the Behavioral Health Division Director should be their own recovery from mental illness or addiction. Recovery should be a prerequisite for employment. Recovery should be both trusted and valued as an experiential quality not unlike an advanced degree or long duration of employment. When a leader has equal personal experience as those being helped, trust and respect can be quickly built and maintained. 

Recruitment & Revitalization

While a search is underway for a permanent Division Director, county executives should prepare to quickly execute a national search for a permanent Medical Director and Operations Director of the Behavioral Health Division; a search to be led by the new Division Director. These are complex positions with subtle responsibilities which would be well suited for a person with direct prior experience from a comparable county elsewhere in the country. 

The workforce which provides services and support for people with mental illness and addiction has been badly damaged and is in need of immediate repair. The Division Director can make Multnomah County an attractive and comparative employer by working with its labor associations and state professional associations to identify incentives, remove barriers to hiring, design scholarships and past tuition support, and identify valued or in crisis staff for immediate support. The Behavioral Health Division needs to look beyond its borders to recruit new staff and should improve recruitment and hiring incentives to meet county DEI goals and Division recovery goals. 

Transparent Reporting & Outcome Accountability

In an annual public report, the County Chair’s designee should create a clear explanation of the roles, responsibilities, and relationships between the County, the City, JOHS, the State – ODHS, OSH, ODOJ, OHA, OYA, ODE, DOC, Health Share Oregon, CareOregon, Comagin, neighboring counties, local hospitals, various for-profit and non-profit companies, and consultants which provide services for people with mental illness and addiction. This report should contain links to all intergovernmental agreements and important contracts which define the mental illness service system. 

The report should include a set of distinct outcomes which the County will fund to occur. Examples may be a finite number of OP treatment episodes, amount contributed to JOHS, number of psychiatric clinicians available to inmates, number of secure residential beds funded, number of persons still sober 30 days after discharge from treatment, number of people accepted for treatment in sub-acute detox. 

Service System Mapping & Funding Transparency

The report should include an integrated, reasonable, graphical map of the existing service system for people with mental illness, addiction, those who are homeless, and who are entering and exiting county programs, such as jail, parole, and probation, etc. for system navigators – not system users. That map may be large, or multi-level, or require study, or routine updates – but it needs to exist. 

The report should list how funding is collected and spent on services for people with mental illness and addiction, whether the spending is by the state, the county, the CCO, or other entities

The Division should provide comprehensive and regular in-person training for Medicaid – eligible agencies on fast-tracking Medicaid applications and coding for the 1115 Medicaid waiver. 

Navigation & Crisis Case Management

As an impartial voice of public health and welfare, the county should expand its Crisis Hotline to include short-term phone-only navigation services, including a case management database to allow callers to make repeated calls for additional information without having to repeat all the facts from prior calls. The goal of navigation and case management should be to engage or re-engage people with appropriate treatment or medical services. 

Much of the need for person-to-person navigation could be relieved if basic information about how to access services were available on the County’s website. Example – it’s completely obscure how to access emergency shelter services without making a series of telephone calls or accessing additional websites. Does the County website provide an answer? No. Does JOHS? No. Does 211.org? No. 

Jail & Court Support

Services for addiction and mental illness in Multnomah county are an ineffective sieve into the criminal justice system. The majority of people arrested in Portland are homeless. Hundreds of those arrested each month are so disordered their lawyers must ask for them to be restored to competency prior to a hearing. The vast majority of these people have not committed violent crimes. Four suicides in jail in the past year. The jail is the state’s foremost dispenser of psychiatric medication. Sheriff’s deputies desperately need training to recognize illness and manage it, corrections health staff need administrative and managerial support to meet the need, and the forensic team from the Behavioral Health Division needs to be rebuilt from the ground up.

Foremost, Multnomah County needs additional secure beds outside of jail for people who are grievously ill and need medical and psychological treatment, or who cannot aid their own attorney in their own defense. This week Judge Nan Waller will see dozens of people eligible for conditional release – and there is nowhere for them to go. She can’t do her job until the County develops new resources. 

Further, the county knows it can interrupt the path to jail, or to a psychiatric emergency requiring hospitalization, by providing respite housing and peer services. There was a good start in the creation of the Behavioral Health Resource Center, but because of mismanagement in the first weeks of opening the BHRC day center is only available to a fraction of those its design budget planned for it to serve. We need respite housing managed by peers, and we need additional drop-in centers. 

Recovery Housing

Most, almost all, public housing in Multnomah County is wet housing, meaning there is no intervention by management if a tenant uses drugs or alcohol in the building. This is a threat to people in early recovery from addiction or alcoholism, and to people with mental illness who need peace and quiet. Many people in early recovery and who are serious about it, decline wet housing when it’s offered as the only option. There are many models of extremely successful Recovery Housing, and housing which has used the Oregon Alcohol and Drug Free Community law, to endorse and implement. Most people in Recovery Housing can pay rent – reducing the long-term capital costs substantially. The County should use its facilities department to aggressively invest in Recovery Housing, especially in using a master lease for houses and large apartments to acquire 500+ units per year until the need is met. More information about Recovery Housing is available at the Oregon Association of Recovery Residences.

This is not an exhaustive list of what the County should do with urgency. All of these recommendations can be further explained, evidence can be provided, expertise can be acquired locally and nationally. None of these steps are outrageous, or experimental, or controversial. None are expensive and most will save the county money immediately and over time. All will increase the respect of BHD employees, staff in adjacent county departments, in allied external agencies, from clients and their families, from the media, from the state and other local governments. Regained respect will retain good employees and attract better ones. 

 

Learn more about the Mental Health Association of Portland by visiting the website at www.mentalhealthportland.org or ask a question by email to info@mentalhealthportland.org