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

Oregon State Hospital by Jessica Floum.jpg

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.

You can reach Lynne Terry at [email protected].

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Multnomah County Mental Health prepares the Farm Team for the homeless sector. We’ve lived here for over thirty years, the county’s inability to launch and manage an effective, ethical, compassionate, and cost effective mental health system has been in the news since the day we arrived. (Remember when it was Diane Linn’s top priority?) All while the county receives more state mental health money per capita than other counties, and pours more local taxpayer dollars into its failed system than any other county. Time for major housecleaning of current staff, and bringing in an outsider to take over county mental health. 

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