December 4, 2019

More than half of people in Multnomah County who are involved in the civil commitment system are not receiving the most intensive services for people with serious and persistent mental illness that the County can offer. 

For those people who do receive intensive services, the services work as intended. But the demand for services is not being met, and the division’s decision to reserve funds for future program needs, potentially constrains access to the services.

Auditor Jennifer McGuirk, right, and Principal Auditor Caroline Zavitkovski briefed the Board on a review of mental health programs.

Those were among the conclusions reached when Multnomah County Auditor’s Office this week presented findings to the Board of Commissioners from an audit of services for adults with serious and persistent mental illness. The audit focused on Assertive Community Treatment (ACT) and Choice care coordination — programs created to support people with serious and persistent mental illness. Both are managed by the County’s Mental Health and Addiction Services Division.

Choice is funded by the State of Oregon and run by County mental health programs, which provides care coordination to clients exiting and entering the state hospital and residential treatment. ACT is funded by Medicaid and run by contractors outpatient treatment provided by contractors, intensive, covered by Medicaid.

Among their findings: 

  • More than a third of clients in ACT and a quarter of Choice clients experienced at least one negative outcome during the 2016-2018 review period, such as being civilly committed or booked into jail; and higher proportion of people of color were involuntarily held than white clients.

  • Choice targets people who have been civilly committed, yet fewer than half of those civilly committed between 2016 and 2018 were enrolled in Multnomah County.

  • The Choice program reserved $1.4 million for future projects that could have been spent on direct services to eligible clients in immediate need.

  • Choice clients exiting the State Hospital were not always able to go directly to residential care or supportive housing in the County.

County Auditor Jennifer McGuirk said the Division’s inability to immediately place people in appropriate housing was largely out of its control. 

The state’s goals for Choice, are “based on the faulty assumption that countries can place individuals leaving the state hospital in residential treatment or supportive housing,” she said. “It’s a great idea but we don’t have that stock of supportive housing. And state hasn’t made residential treatment available in the amount we need.”

Among the recommendations, the Division should:

  • Publicly report to the Board of Commissioners on funding status and decisions and progress in developing housing resources.

  • Fully spend all state grant money unless there is a written commitment from the State that the county can keep funding for a future purpose.

  • Advocate with local and state lawmakers for more dedicated supported housing for people with serious and persistent mental illness.

Chair Deborah Kafoury thanked Auditor McGuirk and Principal Auditor Caroline Zavitkovski for their work and vowed to adopt many of the recommendations.

“This audit is a window into this whole funding system that has to be innovative to serve people with increasingly complex needs, but is operating in a state budget system that isn’t flexible, is often inconsistent and in the case of Choice program is woefully underfunded,” she said. 

Kafoury said she has a plan on her desk of how to spend down the surplus of Choice funds, a reserve resulting from two events: a transitional housing project which would have used Choice money fell through, and Family Care closed, shifting their Choice clients and dollars to Multnomah County.

“We’re committed to spending Choice funds on Choice clients,” she said Tuesday. “We’ll bring forward some ideas of what to do by the end of the year.”

Commissioner Sharon Meieran praised the Auditor’s Office for focusing on those programs that serve clients with the highest needs. “Looking at mental health in general is really challenging,” she said. “This illustrates the complexities of the system as a whole.”

Meieran expressed concern about the failure to spend down money for Choice. 

“I’m concerned about the processes in the past in terms of lack of transparency, if we have $1.4 million we’re not spending. My default would be to say, ‘spend down this money,’ but at least let’s have a conversation about it. I do feel it’s important to bring decisions before the board so we have an opportunity to be part of those decisions.”