She was released from prison a year ago and often failed to show for scheduled appointments with her parole/probation officer -- let alone for visits with her doctor.
“She had severe anxiety with making [medical] appointments and lots of complex medical issues and a long history with trauma,” said Ortiz, who works with the County’s Health Assessment and Treatment, or HAT, team. “She was so embarrassed of what her arms and legs looked like because of scars from intravenous drug use that she couldn’t put her socks on. I put her socks on for her.”
Ellen used drugs to manage pain for a condition that wasn’t fully diagnosed because of her reluctance to see a physician. She was hesitant to disclose her drug use because of the stigma associated with it, Ortiz said.
But her condition was only bound to get worse without a complete examination by a doctor.
“So, I built a relationship with her and started getting her to go to her appointments including meeting with her probation/parole officer,” Ortiz explains. “I physically accompanied her to her doctor's appointments. I prepped her before her appointments.”
After five months of consistent effort and follow-through, which included some missed appointments and some appointments that resulted in walking out, Ellen was finally diagnosed with rheumatoid arthritis. That official clinical diagnosis meant she could fill out the healthcare and Social Security paperwork she needed to establish consistent care and financial resources to gain independence and stability.
Today, Ortiz says, Ellen sees a fixed specialist physician for rheumatoid arthritis as well as a primary care provider -- giving up a life of mystery symptoms and piecemeal treatments.
“She’s not going to the Emergency Department anymore to get narcotics, which can cost on average $1,233 a visit,” Ortiz said. “We’ve gotten her to a point where she is managing pain with something that is not heroin and gotten her connected to pain management, primary care.”
It’s a success story that Ortiz -- a bicultural, bilingual community health worker with the HAT team -- likes to share as she explains the challenging work of connecting people leaving prisons and jails to the community-based support services and providers that can keep them from going back.
Multnomah County’s HAT team is a collaboration between the Department of Community Justice and the Health Department. It includes corrections counselors, parole and probation officers, dual-diagnosis evaluators through LifeWorks, and community health workers like Ortiz.
Staff work to set up clients with services such as food assistance benefits, while also helping them obtain vital records like identification cards, create living wills, stay focused on drug and alcohol treatment, obtain transportation services, and find housing for those who are eligible.
Collectively, HAT team members work to set clients up for long-term success by teaching them how to navigate the healthcare system and to advocate for themselves.
“A lot of these people grew up in a culture of not going to a doctor,” says Ortiz. “Many clients have dual-diagnosis (a combination of mental illness and drug abuse) and don’t have the skills to speak to providers or negotiate services, so I serve as a buffer.”
Ortiz, a self-described military brat, was born in Panama and raised by a Puerto Rican father and a Filipino mother. “I know what it’s like to be an outsider, to be a survivor and the need to adapt quickly,” she says.
For more than 20 years, she’s worked in public health, primarily serving the most medically underserved and marginalized populations. Alongside corrections professionals, she connects with those who’ve served time for criminal convictions. Many struggle with addiction and homelessness, and may not have anyone else but HAT team members for support.
“Often times, there is no one else there to support them, many times a natural consequence of their past criminal behavior or addiction,” Ortiz says. “So we deal with a lot of isolation and rejection.”
The HAT team boasts strong accomplishments. Since its launch in 2014:
- Hundreds of adults have been enrolled in the Oregon Health Plan.
- Hundreds of people have had behavioral health evaluations to determine the appropriate level of care.
- In the last 6 months, 201 referrals were made to the team for behavioral or medical services, 95 percent of those clients engaged in services with a Primary Care Provider.
- Up to 90 percent of clients use county health clinics.
But for every success story, there are equal or worse challenges.
“I’m dealing with a gap of time, where we’re dealing with, in some cases, people in need of medical assistance right away,” Ortiz says.
Department of Corrections nurses may contact Ortiz directly to set up coordinated care for clients upon their release from prison or jail. Parole and probation officers make referrals to the HAT team or call Ortiz directly to help respond to everything from migraines to antibiotic-resistant bacteria like MRSA.
When clients are released from the Department of Corrections, many of the services they relied on while incarcerated are no longer available. Some clients need dialysis or a new catheter as soon as the day after their release, but barriers keep them waiting.
One of Ortiz’s clients needs a colonoscopy. But he’s still waiting because he lacks regular access to a restroom, where he would be able to prepare for the procedure in a private, sanitary space.
“A lot of my clients can’t get the surgery they need because they aren’t surgery ready. They haven’t quit smoking, lost weight or they don’t have permanent housing -- there’s no place for them to prep.”
Ortiz has the autonomy and ability to make assessments on clients and determine what precise wraparound services are needed.
“And [I have] the ability to really hold their hand for a while,” she says. “Especially for those who have been incarcerated for a long time, or an elderly person released from DOC.”
Advocates say the team creates consistency among medical practitioners and clients alike, and has a positive influence on a challenging population’s health. HAT team members step in before an issue spirals out of control, and they can help reduce the recurrence of crime.
“It’s been hard to measure what we do because of the vast variety of activities,” said Susan Palmer, manager for the County Community Health Worker Program. “But I’m sure that people’s lives were shortened without these kind of services, or they end up back in jail because that’s where they get what they need.”
Ortiz is also trained to conduct assessments for Coordinated Housing Access waitlists. Coordinated Access, a federally required system adopted by the City of Portland and Multnomah County’s Joint Office of Homeless Services, works to provide a single point of entry for single adults and families who need services. The system assesses people based on vulnerability to provide streamlined and equitable access to shelter and housing.
Ellen was screened, waitlisted and recently placed in a permanent supportive housing unit in North Portland.
“This job requires compassion, resiliency, hope, tough love and lots of patience,” Ortiz says. “People deserve the dignity to own all of their own successes and challenges and to know that there are people who believe in them.”