An Authority. A Plan. A Program

April 10, 2019

You could be forgiven for failing to immediately grasp the structure of mental health oversight in Oregon. It’s an eye-crossing web of authority.

Commissioner Sharon Meieran spent a year looking at the structure of mental health care in Multnomah County — and she still thinks she could understand it better, she told fellow Commissioners on Tuesday the first in a series of briefings on their power to preside over public health and mental health.

Ebony Clarke, Director of the Mental Health and Addition Services Division, explains the county's role as the Local Mental Health Authority

“It’s like spaghetti,” she said.

Tuesday's briefing on the County’s role in mental health care was a first for the current Board — made up of Chair Deborah Kafoury and four first-term Commissioners.

The Board serves not only as a state-designated Local Public Health Authority, but also as a Local Mental Health Authority. In that role, it determines the need for local mental health services and adopts a comprehensive local plan for how the services will be provided. It manages the mental health crisis system, community-based specialized services, and coordinates care for children and adults entering or transitioning from the Oregon State Hospital or residential care.

How it works

The State grants each county the power to coordinate its own mental health care system, and designates each county’s board of commissioners as the Local Mental Health Authority.

That Authority must assess its county’s need for programs and services, adopt a plan for administering those services, and oversee a program to deliver those services.

Each Authority identifies how it will operate its Community Mental Health Program. Some counties, such as Josephine and Clackamas counties, have outsourced mental health to a private contractor. Other counties may cooperate on a regional program, or opt to create their own programs. Multnomah County designated its Mental Health and Addiction Services Division, in the Health Department, to oversee its Community Mental Health Program.

When funds are limited, state law requires a Program prioritize services for:

  1. People at immediate risk of hospitalization because of mental illness.

  2. People who are least capable of getting help from the private sector, because of the nature of their mental illness, geography or income.

  3. People who are experiencing mental illness now but are unlikely to need hospitalization in the future.

Ebony Clarke, director of Multnomah County’s Mental Health and Addiction Services Division, identified additional priorities during Tuesday’s briefing. The County’s Program prioritizes services that address the needs of people with chronic mental illness, youth at risk of being removed from their homes, older adults and people of color.

Each Program must have a Mental Health Advisory Committee. In Multnomah County, it’s called the Adult Mental Health and Substance Abuse Advisory Council.

Commissioner Sharon Meieran says oversight of regional mental healthcare can be hard to untangle.

And that advisory body provides input on a Program’s Local Mental Health Services Plan, which describes how the Local Mental Health Authority will ensure the delivery of clinically appropriate services based on community needs.

In Multnomah County, contracted community organizations provide most of the mental health and addiction services supported through the Community Mental Health Program. The County retains direct service for state-mandated crisis services, referred to locally as the Multnomah County Mental Health Call Center.

How it’s funded

Multnomah County’s Community Mental Health Program cost about $45 million last year, with half funded  through state and federal agencies. Federal Medicaid dollars fund the majority of crisis services, while the state pays for most residential treatment.

State and federal funding usually can’t be used to reimburse services for people who are uninsured or underinsured, or for culturally specific services. So the County established the Multnomah Treatment Fund to care for individuals at risk of hospitalization or incarceration because of symptoms of mental illness. The County’s general fund pays for that program.

Neal Rotman, interim deputy director of the Mental Health and Addiction Services Division, said the County tries to stretch the reach of its resources by supporting programs that give clients a chance to gain a foothold and stabilize. The Division hopes to build a mental health resource center for people who are homeless and experiencing mental illness, with peer-support services, shelter beds and transitional housing. Even after a significant investment in property and renovations, such a program would save costs long-term, Rotman said.

What needs fixing

Clarke, the Division’s Director,  told the Board that a lack of both services funding and affordable housing loom as the biggest challenges for the Community Mental Health Program.

“We have access and coverage issues,” she said. “In order to sustain recovery, you need to be able to meet basic needs.” And there just isn’t enough affordable housing or supportive housing for people recovering from mental illness or addiction. The County is currently working with the City of Portland to add 2,000 units of supportive housing by 2028.

A poorly paid workforce and poorly funded system are equally threatening, she said.  

“Our workforce is one of the lowest-paid, and they struggle to find affordable housing based on the wages they make,” Clarke said.

She asked the Board to lobby the state government  for parity in reimbursement rates, ensuring providers won’t lose money when treating substance abuse disorders. Currently they make less on average than mental health providers, even though state law suggests substance abuse and mental illness should be treated the same.

“To effectively address these issues requires not only continued funding,” Clarke said, “but increased partnership with the Oregon Health Authority and at the local level.”