Multnomah mental health system at risk, audit says

Portland Tribune, November 20, 2019

County not connecting needy people with treatment programs they are eligible for, according to report

As Portlanders call out for better care for people facing homelessness, including those struggling with mental illness, a new audit has found that even with its funding shortages, Multnomah County could be doing more to connect mentally ill people with needed services.

READ – Ability to serve adults with serious and persistent mental illness is limited and at risk – 11 2019

The report is the latest in a long line of reports highlighting poor mental health care in Oregon’s most populous county. Multnomah is not enrolling all of the people eligible for state or county programs as it could or should be, and the county is not publicly discussing some of the choices being made, said the audit released by Multnomah County Auditor Jennifer McGuirk on Wednesday, Nov. 20. The report recommends county managers more aggressively and publicly advocate for needed services.

“What was concerning is just that … we were not seeing all those people being referred for enrollment” into programs that could help them, McGuirk said.

The audit notes that the state is under pressure to move people out of the Oregon State Hospital into county care thanks to a 2016 agreement to resolve a U.S. Department of Justice civil rights investigation into the state’s treatment of mentally ill people. But counties don’t have the resources available to cope with all of the people transferred.

The audit also comes eight months after the county fired David Hidalgo, the director of the county Mental Health and Addiction Services, as well as another top manager, Joan Rice. The county had placed the two on leave in August 2018 in connection with an investigation into how abuse complaints of patients at the Unity Center for Behavioral Health, a facility operated by Legacy Health that was set up with county and state funds, were handled or ignored.

That investigation, overseen by the Multnomah County District Attorney’s office, did not result in charges.

The new audit does not delve into Unity. But it does look at the county’s administration of the programs funded or mandated by the state. It found that “Currently, over half of people who are involved with the civil commitment system are not receiving the most intensive services the county offers.”

One program, called Choice Model, is supposed to coordinate care for people with serious or persistent mental illness, especially those who have been civilly committed because they are a danger to themselves or others. The audit found that more than half of those who’d been civilly committed in Multnomah were not enrolled in the program, in ways that appear to violate the state’s agreement with the county.

Another problem with Choice was the lack of “supported” housing, meaning connected with intensive treatment services. Marion County has 40% more supportive housing units, about 70 compared to 51, for a Choice program that is a third of the size of Multnomah’s.

The report adds that the county lost $1 million between 2016 and 2017 due to questionable management decisions that were not publicly discussed with the board even while seeking money to fill the resulting gap.

The county had been reserving Choice funds to use in future housing projects rather than on programs. Learning this, the state in 2016 cut funding, causing county mental health officials to go to the county’s elected Board of Commissioners for $280,000 in emergency funding in 2017. County officials told the board the need stemmed from cuts in the 2018 budget, rather than what actually happened. “The modification paperwork and presentation did not accurately describe the circumstances leading to the request,” the audit said.

“We would like to see greater transparency around the policy choices that are being made,” McGuirk said.

The county is reviewing the matter, according to Julie Sullivan-Springhetti, the county’s communications director.

The audit also looked at a second intensive treatment program, called Assertive Community Treatment, finding that it largely goes unmonitored by county staff. The county appears to not be placing eligible people in the program as aggressively as they could be.

County officials praised the report and said they will work on implementing its recommendations.

Audit Blasts Multnomah County’s Handling Of Millions Of Taxpayer Dollars For Mentally Ill

The Lund Report, November 20, 2019

Multnomah County has failed hundreds of patients who suffer from severe mental illness like schizophrenia or bipolar disorder by not providing them with taxpayer-funded services, a county audit said Wednesday.

The audit looked at three years of data through 2018 for two publicly funded programs that serve people who’ve been committed to the Oregon State Hospital or risk being committed and those who suffer from mental health problems that prevent them from managing on their own. It found that just over half of about 900 people who would have benefitted from a program intended to help them access mental health treatment or housing were not offered those services. It also found that only about one-fifth of people who would have benefitted from another program that offers an intense level of out-patient mental health treatment received those services.

The audit paints a picture of mismanagement of state and federal funds that are supposed to help some of society’s most vulnerable. It comes at a time of state focus on behavioral health care following failures in the past to provide treatment for many Medicaid patients, who account for one-fourth of the state’s population.

Multnomah County Auditor Jennifer McGuirk told The Lund Report she was surprised and disappointed by the findings. Both programs that the audit studied, Choice and ACT, or Assertive Community Treatment, have been shown to help mentally ill people function better in society.

“If something seems to be working well, I don’t understand why you wouldn’t offer it to more individuals,” McGuirk said.

The county’s director of mental health services, Ebony Clarke, said she welcomed the audit.

“I absolutely agree with the auditor that for those who receive services, the services are working,” Clark told The Lund Report. “I also recognize that there are still too many people who suffer from severe and persistent mental illness who are not getting adequate services and support.”

She said the audit has her full attention.

The audit discovered that county officials have managed the mental health program in a roller coaster fashion: alternating between underspending, overspending, and then underspending again. At the moment, the county has squirreled away $1.4 million in state funds it received from the state for mental health clients. The county said it planned to use that money for so-called supportive housing which includes mental health services. But it didn’t ask the state until recently if it approved that decision to sock the money away, the audit shows.

To date, the county still has no new housing for Choice clients — people who’ve been committed to the state hospital or risk commitment. One housing project fell through. County managers said they will now dedicate some of that surplus money for the Behavioral Health Resource Center planned for downtown Portland, which will offer transitional housing to people with behavioral health issues and connect them with treatment.

Multnomah County only has 51 units of supported housing for Choice clients compared with 70 in Marion County, which has one-third as many clients.

The audit found that Multnomah County appears to have applied stricter enrollment criteria for the Choice program than other counties, for example by waiting to offer care until patients had been civilly committed and sent to the state hospital in Salem while some other counties didn’t require state hospitalization.

It’s not clear why Multnomah County was more restrictive. The program is managed by Neal Rotman, senior manager of the community mental health program. Rotman formerly worked under David Hidalgo, who was forced out following a state investigation of abuse, neglect and violence at the Unity Center for Behavioral Health in Portland. The county was recently cleared of any criminal wrongdoing in its handling of complaints at Unity.

Clark, the county’s mental health director, declined to comment on whether she plans any staff changes.

“Over the last year, we’ve gone through significant transition and turnover and we’re struggling to provide services for more and more people while our state funding remains flat,” Clarke said.

As the county’s new mental health director, she said the audit helps focus her priorities on the need for more transparency in how the county spends state money and a need to widen access to services.

The audit said the decision by Choice program managers not to enroll clients who qualified for services appears to have contradicted a county agreement with the state.

“Anyone who was referred to, or at risk of being referred to, the state hospital should have been enrolled in Choice,” the audit says.

And not using allocated money put the county at risk of seeing those funds shrink in the future, McGuirk said.

“If you have unspent funds, you should treat them like they are one-time-only funds and not as if they’re ongoing expenses,” McGuirk said.

In fiscal year 2018, a year after the county not only spent all of the state funds for the Choice program but also had to carve $650,000 out of the general fund to make ends meet, it was forced to close 18 units of supported housing and 13 units of room and board because of a lack of money.

The Choice program is funded by state taxpayer dollars while ACT is a Medicaid program, paid for by federal and state dollars. In the most recent biennium, the state paid the county just over $5 million for the Choice program. ACT teams, which include psychiatric nurses and social workers and 24/7 support, cost about $18,500 per person per year, paid for by federal and state Medicaid dollars.

Even when patients received help, they didn’t always get the kind of help the program is designed to provide. The audit found that between 2016 through 2018, 40 patients went directly from the state hospital to motels or room and board situations — twice as many as those who benefited from supportive housing. Those housed in motels did not get the kind of mental health support the others received, the cost of their housing was expensive and it often failed the clients.

The average length of stay in a motel or a room and board unit was seven months. Some of the clients moved into residential housing but one-quarter ended up being admitted to local hospitals, further eating up state funds.

The audit offers a dim view of the future for the county’s patients with severe mental health problems, predicting that state funding will remain flat.

“Demand for the services and programs highlighted in this report appears to outstrip the supply, and that’s unlikely to change,” the audit said. “As the urban center for the state, Multnomah County seems to end up with a higher proportion of people needing intensive services.”

The calls on county staff to monitor the outcomes of clients in mental health programs more closely, regularly report to the Board of Commissioners on priorities and development of new housing, identify clients who qualify for services and share data with other county agencies

“There is clearly a need to be more transparent in terms of their expenditures because what they’re doing is not sustainable,” McGuirk said.

In Multnomah County, mental health services are increasingly scarce
Oregonian, November 21, 2019

Caught between stagnant funding, an insurance maze and an affordable housing crisis, Multnomah County is struggling to deliver its mental health services to the people that need it the most.

That’s according to an audit released Wednesday from the Multnomah County Auditor’s Office. The county’s ability to deliver its services is “limited and faces imminent risks,” the audit states.

It found the county is serving less than half of the people who could benefit from the county’s most intensive mental health services, while demand for services grows. And access to county programs is further limited by housing costs and a small supply of residential treatment facilities and local supported housing programs, all of which have long waitlists.

“People who should be getting it, aren’t getting it,” staff auditor Mark Ulanowicz said. “It’s a big issue and it cuts across so many things that are going on in the community right now.”

Meanwhile, the county has squirrelled away portions of its state funding for mental health services since 2016 with the intent to create more of the much-needed supportive housing. But that hasn’t yet happened — in fact, the county has lost some supportive housing that was costing it too much, the audit shows. In 2018, a contract dissolution resulted in the closure of 18 supported housing units and 13 housing units where mentally ill clients waiting to get into treatment programs could get county-provided housing and meals, according to the audit.

“Are we going to try and put our money into these treatment programs or are we going to try and develop supportive housing? Because we need both. And we have a fixed amount of money,” Ulanowicz said.

The auditors called for a marked increase in transparency from Multnomah County Mental Health and Addiction Services Division. They recommended the agency report funding decisions and policy in public meetings of the Multnomah County Commission at least once every two years.

The auditors sent the county 11 recommendations in total, including to improve data collection and better analyze its program’s effects on clients.

The Mental Health Division responded that it would implement the auditor’s recommendations.

The auditors examined two of the county’s most intensive mental health and care coordination services for adults with what they term “serious and persistent mental illness.”

“We started narrowing in on the folks who were probably the most vulnerable,” Ulanowicz said.

Serious and persistent mental illness includes schizophrenia, bipolar disorder and major depressive disorder, according to the audit. And it can lead to something called civil commitment, a mandate to undergo treatment decided by the state legal system.

In a civil commitment, a judge can order an individual to receive mental health treatment or go to a psychiatric hospital for up to 180 days. Before a person is civilly committed, they are often put on short “involuntary holds” at hospitals.

In Oregon, the bar for state-ordered commitment is high — one must be imminently dangerous to themselves or others or unable to take care of basic personal needs in a way that poses a serious risk.

The auditors examined records for Multnomah residents involved in the civil commitment process or at risk of commitment between 2016 and 2018, focusing on two key programs for the population: Choice Model Program and Assertive Community Treatment. Choice is an intensive care coordination service, while assertive treatment is an intensive team-based treatment model, auditor Jennifer McGurik said.

“They are intensive services that are really being prioritized at the state level, which then affects the county,” staff auditor Caroline Zavitkovski said.

The auditors found that while Multnomah County serves about 650 Choice clients at any time — the most per capita among Oregon counties — the county has opted to use narrow criteria to determine who qualifies, which means many who could qualify aren’t offered the services.

The services can be offered to anyone at risk of going to the state hospital, but Multnomah County has generally only offered them to people who do go. That leaves “significant unmet need,” the audit found.

Structural issues in Multnomah county may exacerbate that problem. Multnomah County has most of the state’s large psychiatric hospitals, and anyone who is homeless in the county with a last known address older than 60 days becomes the county’s responsibility, the audit notes.

Other systemic issues trickle down to affect the county, according to the audit. Capacity at the state psychiatric hospital is limited. Partly as a result, the state has pressured the county to take on more responsibility, prioritizing community treatment services while the state decreases the availability of institutionalized care.

“So even someone who might have been admitted to the state hospital a year or two ago — no luck. There’s no room there now,” Ulanowicz said. “And so, if that is the bar [for enrollment in an intensive community mental health program], it probably isn’t really appropriate anymore.”

Once a person is ready to leave the state hospital, they often need to transition to residential treatment or supported housing. But in Multnomah County, those situations are in low supply. There are only 51 supported housing units for people served by the Choice program. By comparison, in Marion County, where the equivalent population is only one-third as large, there are about 70.

Clients leaving the state hospital are sometimes placed in expensive temporary housing situations, like at a motel or a “room and board” home that doesn’t provide treatment.

And the county often does not track what happens those clients next. The audit found that data was missing for a third of moves, and for those that it did track, over a quarter ended up in a local hospital.

But the program that could fill that gap in supported housing – Assertive Community Treatment — also doesn’t have enough capacity to meet the need. It is covered by the Oregon Health Plan, costs $18,500 per year per person and is documented to stabilize or improve outcomes for most participants, according to the audit.

But only about 20% of Multnomah residents who had been civilly committed from 2016 to 2018 were enrolled in the program, according to the audit. It’s seldom available to people not on the Oregon Health Plan, the state’s version of Medicaid.

“The bottom line is there’s a significant number of people who are not in Medicaid who need services that somebody else has to pay for,” Ulanowicz said. “And private insurance (and) Medicare does not pay for those services. So that’s a — talk about that gap,” Mark Ulanowicz said.

And the county isn’t receiving all the funding that it could, Zavitkovski said. That’s because the state makes some of its funding for the Choice program contingent on achieving certain outcomes.

“Multnomah County has not been able to meet those measures for the past several years,” she said.

Ulanowicz said the county isn’t likely to get that incentivized funding anytime soon. So, funding for the programs has remained flat, which means it pays for less service over time due to inflation, Ulanowicz said.