A new report from Central City Concern highlights concerns around the “housing first” model the Homeless Services Department uses for prioritizing who gets housing. The nonprofit notes that affordable housing providers have faced a number of challenges that are unsustainable and is pushing to add another model to the mix: engaged social housing.
Andy Mendenhall is the CEO and president of Central City Concern. He joins us to share more on this report. Multnomah County Commissioner Shannon Singleton also joins us to share her response.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. Not long ago, one of the largest providers of services for people experiencing homelessness in the Portland area sounded a kind of alarm. Central City Concern says that the combination of cheap and potent drugs, the pandemic and high rents, along with an inadequate behavioral health system, have made the approach to housing unsustainable. They point to cycles of eviction, to staff burnout and crumbling financial models. So they’re calling for a new way to get people with the highest needs into housing. They call it Engaged Social Housing.
Not everybody is on board with this plan. In the second half of the show, we’ll talk with Multnomah County Commissioner Shannon Singleton, but Andy Mendenhall joins us first. He is a CEO and president of Central City Concern and the lead author of this proposal. Just last week, the new point-in-time count for people experiencing homelessness in the Portland metro region was released. It found a 61% increase in just two years. So I asked Mendenhall what went through his mind when he saw that number.
Andy Mendenhall: Dave, two things. First, I was really sad, and I was also not surprised. And the primary drivers for that really relate to, one, the human impact of people being affected by homelessness and, two, the reality that we continue to be behind in terms of our built strategy. There simply aren’t enough housing units to get folks placed in response to all of the different drivers that are creating that demand.
Miller: It’s one thing to say that that’s why we haven’t gotten better, but we’re getting so much worse in terms of the numbers, at a time when a lot of hard work, a lot of attention and a lot of public money is going in to try to solve this. So, why is it getting worse in that time?
Mendenhall: Indeed. Well, two things. The first is [that] we know we have a profoundly unmet need for behavioral health treatment among the population of individuals who are struggling with homelessness or are at risk of being homeless. And that’s something we can talk about in greater detail related to the Medicaid analysis that’s been done over the last couple of years. So we have a behavioral health system that is not meeting the needs of the population and that does represent a not insignificant portion of individuals who are experiencing homelessness.
And again, the second piece is simply, we need more housing resources than exist for people who are extremely low income and/or the subsidies to help those individuals be successful and avoid falling into homelessness.
Miller: I want to turn to your broader critique. As I understand it, the core of it is that the Housing First philosophy that has reigned supreme for a while now is not working right now for large numbers of people in Portland. So, let’s get some definitions first. What does Housing First mean?
Mendenhall: So Dave, Housing First is an approach to providing housing to people with severe pervasive mental illness and/or severe substance use disorders. And it is characterized by an approach that is appropriately low barrier, meaning there’s not a lot of hoops that folks have to jump through in order to be housed. And it also values client or individual choice in determining whether or not individuals engage in services that will help them stay healthy and/or help them be effective, healthy members of the community they’re living in.
Miller: In Oregon and around the country, a lot of service providers have talked about Housing First, not just as a housing strategy, but just as a more humane approach to addiction, to mental health challenges and to living on the street. Is there evidence that it does work to reduce substance use, to get people stably housed and to help them get various kinds of help that they do need in addition to housing? Is there evidence that it works?
Mendenhall: Absolutely, and we referenced that evidence in our paper. It’s important for listeners to recognize that Central City Concern is actually one of, if not the largest provider of low-barrier Housing First affordable housing in the state of Oregon. So we’ve been doing this for many, many years. And really, the premise of our paper is acknowledging that while a Housing First strategy works and we fundamentally support that, we need a functional behavioral health system of care to make a Housing First strategy and support a low-barrier affordable housing continuum across our region.
For us, as a housing provider, this paper is our clarion call that the unmet behavioral health needs of individuals, in particular with severe mental illness, needs to be elevated and identified. And we need leaders at the state to invest in the things that they know we need – and have received extensive consultation – in this region to help people that we are struggling to keep housed, get the services they need to empower a successful low-barrier Housing First strategy.
Miller: How long have you had this feeling that, while you still believe in Housing First, that it’s not working because of the behavioral health support system that we have?
Mendenhall: We have seen this evolve, Dave, over the course of the last couple of years. And by that, let me be more specific: in the last five, five-and-a-half years in particular. The first challenge really occurred when our state lost access to serving individuals who were civilly committed for severe psychiatric illness at the Oregon State Hospital. And that rolled out in 2020 at the beginning of the pandemic.
If we think about the experience of an individual who needs society to step in and care for them because they’ve lost the ability to care for themselves, that’s the population segment, that group of people. In this region, there used to be 450 Medicaid recipients that were being served under civil commitment by the Oregon State Hospital. Imagine now, if you’re a homeless system and you are trying to help those individuals off the street, help those individuals in shelter or help those individuals into housing and stay housed, we don’t have the backstop of when those folks are not doing well to get them the treatment that they need.
Miller: So, what is happening right now? What does the failure of some part of Housing First look like in Portland to you right now?
Mendenhall: So, again, I appreciate the framing that you’ve offered on that. The way I see it is we have a behavioral health system that is failing to meet the needs of individuals who would otherwise be very well served by a low-barrier Housing First strategy. So, again, that failure actually looks like our lived experience on Saturday morning.
We have an affordable housing program that we operate in the downtown Portland area. And we had a housing client receiving a permanent supportive housing intervention. They’d been in that unit and in that program for the last 10 months. And that individual has been in an active methamphetamine-induced relapse and psychosis, and that individual has needed to be held, potentially civilly committed, but at a minimum stabilized psychiatrically. That individual, for the last five months, has been struggling and having a negative impact on that building that they lived in. And unfortunately, because of the conditions of their room associated with their unmanaged substance use disorder and their unmanaged psychosis, the pestilence, the hygiene issues led to that individual needing to be evicted. And that individual received their eviction notice and then set their room on fire.
So tragically, that individual who should have been served by a behavioral health system to meet their needs way further upstream, that individual has now taken close to 12 units offline, done about $300,000 of damage to that building, impacted their neighbors for months. It’s an example of the psychiatric system of care in this region not being able to meet the needs of that individual far upstream of when they unfortunately now are facing an eviction. They’re facing arson charges and will eventually get their needs met through the forensic system once they’ve been arrested – and that’s a tragedy.
Miller: This is a very dramatic but helpful recent example that we can talk about a little bit more. Did you have any choice, as Central City Concern, in whether or not to put this individual in housing? If some number of months ago, your folks had looked and said, “Based on this person’s needs, we think there’s a good chance that it’s not going to go well.” Could you have said, “No, we’re not going to take them in?”
Mendenhall: This individual was stable when they received their placement, as is the case with many people who are absolutely appropriately placed. There’s another group of individuals who are being prioritized and/or are underreporting the significance of their symptoms relative to the supply demand mismatch that exists out there. And I want to honor the work that our homeless services division’s partners are doing. They’re facing a really insurmountable task trying to equitably and ethically apply a very limited set of resources for literally thousands of people who have very high acuity at times and also have need.
So again, our treatise here, our paper, very much the primary platform is elevating the critical need for scaled investment in behavioral health resources for our region and our system.
Miller: Is that different from what we hear county level lawmakers, state lawmakers, the governor saying? I mean, isn’t everybody saying that they want the same thing? They want way more behavioral health treatment options of different kinds in the state of Oregon? I mean, I feel like if the diagnosis maybe is different at the edges, it does seem like everybody agrees on the prescription … or am I missing something?
Mendenhall: Indeed it is, Dave. The question becomes how much and how quickly. So, the Oregon Health Authority asked the public consulting group in 2023, and their report was formalized in 2024 to evaluate across the state what level and amount of residential behavioral treatment the state needed. And they came up with 3,000 units and close to 1,700 of those units were identified as being of need in the Metro area.
Our partners at Health Share of Oregon and Care Oregon, all of our county partners across the Metro region came together – a bunch of experts – and said we think that we probably need about 40% of what the public consulting group has said was needed or identified as needed to the Oregon Health Authority. And we also added some things. We added that we need some inpatient psychiatric beds – about 40 to 50 of those. We also need somewhere between 500 to 700 recovery housing beds.
So, not formal levels of behavioral health treatment, but strategies to have something in addition to low-barrier housing. And that’s again, a part of the dialogue here is it’s not one or the other, it’s absolutely both. And that’s where a lot of the political tension also sits. It’s not just Housing First or low-barrier housing – which is truly what Housing First has come to mean across the country – it’s really about the need for both low-barrier housing and then also some very focused structured housing that meets the needs of individuals who have a desire and or a need for a recovery pathway supported by behavioral health services.
Miller: You’ve argued recently that your own sustainability is at risk. What do you mean?
Mendenhall: At Central City Concern, for us, the damages related to unmanaged behavioral health acuity. And again, it’s not a critique of the model, it’s a critique of the unmet needs and the scale of behavioral health resources that are needed out in our community to meet the needs of folks quickly and timely when they’re not doing well. Those folks, when their behaviors are out of control, out of management, and folks are empowered under the Housing First model to decline service engagement, even if they lack the capacity to truly make decisions on their own behalf, that’s when we experience not only the harm to our physical facilities, but our staff see the moral injury of our clients becoming more ill. Other clients experience what it looks like for individuals to have unmanaged hoarding behavior or quite frankly, to be engaged in antisocial behaviors or have problems with hygiene and cleanliness.
So for us, that really hits both our bottom line in terms of insurance costs, labor costs, added security costs for our environments. It also contributes to unpaid rent. So for us at CCC, and for many other housing providers and shelter providers in the region, this imbalance related to unmanaged behavioral health acuity is impacting our staff, is impacting our other clients and it’s impacting our bottom line, to the tune of many millions of dollars a year. CCC had an increase in our insurance premium cost, partially market driven, but a lot by our own claims history of over 500% over the last six years.
Miller: It seems to me that there is a scary imbalance between the emergency you’re talking about right now and the medium- to long-term solutions of a much more robust behavioral health treatment system that is not going to happen overnight. There are a lot of efforts to beef it up, but whatever is gonna happen is going to take some number of years to really fully implement. So, what do you see in the near term as humane, reasonable solutions?
Mendenhall: I agree with your concerns, Dave, very much. Humane, reasonable considerations look like preserving the existing approach to low-barrier housing for 70% to 80% of the individuals that are currently being placed within our system. There’s good evidence that that’s working very well. There’s retention at 12 months ...
Miller: Let me just make sure I understand the math here. Sorry to interrupt, but does that mean that more like 20% of the people you’re serving, those are the ones who you’re really talking about here as causing the majority of the problems?
Mendenhall: That’s exactly right. It’s important to not stigmatize those individuals but just acknowledge that 10% to 20% of the folks that we’re serving are having an outsized negative impact on the community. And it’s their unmet needs and or their ability to choose to not be engaged in services that’s driving a lot of that complication.
Miller: OK, so to go back to what you’re saying – 70% to 80% can keep going, they’re being served, they’re not causing major problems. They’re not living on the street right now. They’re doing better and getting their lives together, partly based on your help or other nonprofits or service providers.
What about the other 20%? If the idea is that they could, under the current model, find some unit in one of your buildings or somebody else’s, they could also maybe burn it down or cause all kinds of other problems. Are you saying that they should then stay on the street, not long term and not because that’s your preference, but because it makes a less unsustainable system in the near term?
Mendenhall: Not at all. I appreciate the direction of your question, Dave, very much, but we are not proposing that those individuals stay on the street in any way, shape or form. We just are proposing that those individuals receive a housing benefit that’s assertively connected with limited but necessary behavioral health resources. And that’s really divining the original spirit of the Housing First model.
If we really look back, Housing First, as envisioned and developed and researched by Dr. Sam Tsemberis, was anchored very much in a robust behavioral health system of care and services at all levels. Meaning when people needed to be psychiatrically hospitalized, they could be. So for 10% to 20% of the folks that we are serving, we would like to see those individuals served in a long-term transitional model that is assertively engaged, meaning we’ve got really robust behavioral health resources.
While we are, to your earlier point, waiting for the psychiatric hospital beds that we need, waiting for the workforce of behavioral health to come up to scale, we have to make better use of limited resources. And sometimes that could mean bringing people out of a stabilizing environment like a psychiatric hospital or bringing them out of a residential treatment facility and giving those individuals priority placement over an individual who needs to stabilize first in one of those environments. It’s really about flow and better stewardship of limited resources while we are continuing to focus on, what I like to say, numerators and denominators; the number of folks that we know have a need that are getting engaged in services and the number of folks that we know have a need but aren’t getting engaged in services, and really clearly performing against both parts of that equation.
Miller: When you say “assertively engaged,” do you mean that, in a sense, if you want housing, we’re going to compel you to get some kinds of behavioral health services, mental health treatment or substance use disorder treatment? That’s part of the deal. You can’t refuse it. You have to get this help.
Mendenhall: Again, the short answer is yes. Compel can happen in a variety of different ways. It can sound very non-compassionate. What I would say is that what we’ve observed in our community is compassionate neglect, empowering people who truly lack the capacity to make decisions in their own best interest. For those folks, that’s when we absolutely need to step in. And stepping in may not be … Again, compelled – there’s a slippery slope there about compel versus force, right? What we know, however, is that when you have a treatment team that is capable of showing up every day and capable of helping individuals who are on that margin of can they truly make a good decision or not, most of the time those folks are going to say yes. But what we are lacking in our community are the hundreds of people that are needed to go out and literally connect with folks on a day-to-day basis.
Miller: But that goes back to the earlier question about time. We’re not gonna have those hundreds of folks tomorrow.
So the urgent question remains, what does happen tomorrow? Can you give us an example of what you’d like to see in the coming weeks? Because I feel like it does seem like we’re going towards a more robust – I hope this is true – behavioral health system in the coming years. But what would you like to see in the coming weeks that would be different from what you’ve seen in the last few weeks?
Mendenhall: We would like to see more management of individuals who are leaving environments where they are stabilized. Examples would be our local psychiatric inpatient settings, our local residential substance use disorder treatment settings. We’d like to see a rebalancing of individuals leaving those environments, be connected with a housing benefit and connected with a behavioral health resource in the community.
Miller: As opposed to what?
Mendenhall: As opposed to taking the same number of individuals who have yet to stabilize, who ideally would be served tomorrow or the next day in that open hospital bed that is now created, by ensuring that everyone leaving an inpatient psychiatric hospital bed or a residential substance use disorder treatment is at least being considered for placement in a housing unit, in proportion to the broader population need.
Miller: What’s standing in the way of that?
Mendenhall: Two things. The first thing relates to how individuals are being assessed for housing placement. Now, there is some very positive work that is changing around the Metro region. And I want to commend each of our county partners, both behavioral health and housing continuum of care partners, for engaging in – and this has been sponsored by Lynn Petersen and folks at Metro – cross-sector case conferencing. And this is the first time in our region when behavioral health providers, county behavioral health folks and county housing continuum of care folks are working together on a case-by-case basis to ensure that there is a – this is the population health word – segmental approach, meaning understand what the needs of an individual are and do a better job of lining up the housing and behavioral health resources.
So, cross-sector case conferencing is a movement in the right direction. We need to do more of that. We need to do more of that quickly. And we need to therefore commit to having that be 10% to 20% of the available housing resources being dedicated in that fashion. And that’s part of that reworking of prioritization across different population types.
Miller: I know that you’ve gotten a fair number of other service providers, prominent ones, that have signed on and said we support the analysis by some of the folks at Central City Concern, county folks and others, we want you to pay attention to this. What do you see as the most helpful pushback or criticism that you’ve gotten in the last two months since you put this out? What have you heard that has made you say, “Yeah, that’s actually, that’s a good point. I hadn’t considered that?”
Mendenhall: So there is universal acceptance that our region needs more behavioral health resources at scale. The edge work on this is really related to the prioritization work that goes on with respect to who deserves to get housing and who needs to wait. And the tension space that has existed has really related to what I would call a mischaracterization of Housing First as housing first only or a low barrier. Also, it’s important to know that there are many hundreds of individuals that are seeking a recovery journey whose needs are not being met and those individuals have been deprioritized historically.
So, some folks would say that that does not accurately characterize the prioritization and placement aspects, but we really just need to look at where the resources have been invested. And it makes perfect sense to me that our regional county continuum of care and our housing development strategy has simply aligned, purely aligned with the federal HUD policy over the last 15 to 20 years – which is predominantly focused, almost exclusively focused, on Housing First as truly just low barrier housing – and has deprioritized the need.
CCC is a big operator. We operate some of the largest transitional recovery housing and alcohol and drug-free permanent housing portfolios in the state. Again, there’s tension between those two spaces.
Miller: But am I right that just last week the federal government announced a major overhaul of their biggest homeless services program fund or something – close to $4 billion? So what is that change at the federal level going to mean for everything you’re talking about?
Mendenhall: So, the first thing that it’s important for listeners to remember, Dave, is that the reframe away from Housing First, in no way, shape or form reflects the value that Housing First and low-barrier housing is having currently for many marginalized individuals. So the federal policy is going to have a really significant negative impact on hundreds of thousands of individuals nationwide who are benefiting absolutely from the existing paradigm. And that’s going to create a rebalancing pressure and stress for every housing continuum across the region.
In addition, the approach the federal government has taken is very rapid. Each housing continuum of care – there are 3,003 across the United States – have to get their applications formally submitted, literally over the next 45 days. That’s an unprecedented and rapid shift that will result ultimately in harm to individuals. That’s the first take home.
The second take home is that it is useful for there to be a focus on transitional and recovery housing because it will reflect a rebalancing that is long overdue. In the political sphere, the concept here is around self-sufficiency. Self-sufficiency is absolutely possible for many folks. And we also have to recognize that the social safety net around our country is really struggling for survival. Housing and Urban Development strategic changes in the recovery space are going to be positive but are going to have a net negative impact for people that are currently benefiting from the existing system.
Miller: Your paper came out at a time when the city, under the direction of the mayor, is pursuing its own major strategy, which is focused neither on long-term housing, nor on support services. That’s not traditionally the city’s role. It’s worth saying that.
So that part may not be surprising, but obviously, the mayor’s big focus is a big increase in emergency overnight shelter beds. How does that fit into what you’re talking about?
Mendenhall: Absolutely. One of the most important things is to acknowledge that our region has had some of the highest, if not the highest per-capita unsheltered homelessness rates in the United States. And at Central City Concern, we absolutely agree that people need the opportunity to get out of the weather, get dry, and be in a more sanitary and safe space. The challenge has been that rapid expansion also needs to have wraparound services provided as well.
That rapid expansion strategy also is concentrating a lot of unmanaged clinical acuity in small spaces. So, it’s creating pressure for those individuals. It’s also creating pressure for the service system at large that needs to continue to scale during a time of really significant funding cutback.
Miller: So those are some pretty serious concerns you just outlined. I mean, do you support this plan?
Mendenhall: We do, absolutely. Central City Concern very much supports the mayor’s plan. We always have. We recognize as well that these opportunities for individuals to be inside for even just the evening also create the opportunity for folks to become service connected, for folks to ensure that their paperwork’s being filled out, they’re getting some care navigation. And we recognize, as well, the tension that the mayor’s plan has created with respect to the limited funding and the rebalancing that’s been needed.
Miller: Finally, we’re going to be talking to the county after we talk to you. What do you most want the county to do right now? Obviously, it’s a county that is in charge of behavioral health to a great extent in counties all across the state – that’s one of their big roles. But for Multnomah County in particular, what do you want to see?
Mendenhall: We would love to see Multnomah County continue to do 80% of what they’ve been doing. They’ve been doing a really difficult job very, very well. For the other 20% of the clients that we know need a very specific strategic approach to meeting the needs, their behavioral health and their housing needs simultaneously, we’d like to see a continuation of the work, a scale of the work in cross-sector case conferencing. We’d like to see a very specific population health strategy for folks with substance use disorder, for folks with severe pervasive mental illness, and for folks who are aging with medical complexity and also experiencing homelessness. We’d like to see those segments very clearly defined.
Some of that work is in its infancy, and so we’re very optimistic regarding those strategies. We also understand, as well, the financial pressures that the county is really trying to struggle with right now at a time when there is a very significant pressure. And I’ll say it bluntly, there’s a war on poor people taking place right now through the Medicaid system, through the SNAP system, through profound changes in Housing and Urban Development strategy. At the same time, we also honor and acknowledge that we need to do better with the existing resources that we have today.
Miller: Andy Mendenhall, thanks very much.
Mendenhall: Thank you, Dave.
Miller: Andy Mendenhall is a CEO and president of Central City Concern.
We’re going to get another perspective on this proposal right now. Shannon Singleton is a member of the Multnomah County Commission. She’s a former executive director of the homeless services nonprofit JOIN. She also spent three years advising former Oregon Governor Kate Brown on housing and equity. Welcome back to the show.
Shannon Singleton: Thank you so much, Dave. It’s good to be here.
Miller: I want to start with the same question that I asked Andy Mendenhall. What went through your mind when you saw the 61% increase in homelessness in the tri-county area in just the last two years?
Singleton: Yeah, I think part of it for me around the increase has been one that we’re collecting better data. I think when we went to the by-name list process, that’s where we started to see a difference in how our count showed up compared to some of our other neighboring counties. So some of it is, I think, that increase in us actually counting appropriately the number of folks who are outside. It’s much less of a point-in-time count and much more of a by-name list count.
Miller: Let me make sure before you go on, but I want to hear the rest of it … Are you saying that it may not reflect a 61% increase in the total number from two years ago, but a better count? So maybe there were more people two years ago who weren’t counted?
Singleton: Correct.
Miller: OK, but do you also think there has been an increase?
Singleton: Yes, I also think there has been an increase. The county’s data dashboard now shows the inflow into homelessness, as well as the outflow. And I think you can see from that, even though we might be housing about 1,000 folks a month, almost 1,400 become homeless. So we know that more people are falling into homelessness than we’re able to get out of the system every month.
Miller: You’ve been working on housing in Portland since 2007 and in a variety of different ways – in the nonprofit community and in government now. You started the Salvation Army back in 2007.
Singleton: Yes.
Miller: Have the drivers of homelessness changed in that time, in nearly 20 years?
Singleton: I don’t think that the drivers have changed. I think that the length of time that folks are outside has continued to increase. We used to have a shorter length of time homeless, which meant then we had less people who were experiencing chronic homelessness. And I think the longer you’re outside, the higher acuity we start to see. So that is the shift that I really feel when I’m out walking around and talking to folks who are outside, even in this capacity.
Miller: Maybe this is an obvious point, but why does it get harder to house people the longer they’ve been unhoused?
Singleton: There’s a couple of factors. One can be that there’s exacerbated behavioral health conditions. I can tell you from my personal experience of being homeless, the shame and guilt that comes with that led me to drink a lot more heavily than I ever did before. So I think addictions also increase when you’re struggling outside. And when those complications come in, it’s harder to engage in a housing process. But I also think the longer you’re outside, the harder it is to remember how to be inside and be in that space.
One example I’ll give you is I had a client who it took about three months for me to get her to sleep on her bed in a shelter and not on the floor. And for me, we had to then celebrate that success of being on the bed. Then that then translates into an apartment. Now, how do we get her into an apartment where she’s not just treating it like a shelter bed? So some of those skill sets start to deteriorate, right? And what looks like protection and survival on the street looks like inappropriate behavior in an apartment.
So having to detangle that with people and really spend some time with them on how to be a good neighbor, how to be a good tenant, I think are critical components.
Miller: To go back to that point-in-time increase … I take your point that part of this could be that we’re looking at a more accurate count, but you said we’re also looking at an increase in the rate of new people becoming homeless. But as I mentioned to Andy Mendenhall, this comes at a time when so much public money, public attention and public work is going to address this. And a lot of public frustration as well, if people are looking at all these taxes that they’re paying and the work that they see being done. So what do you say to those people who say, “Wait, what are you doing?”
Singleton: I think one data point that is really important to bring into this conversation is that for every five people who need an extremely low-income apartment, we have one apartment for those five people. We have a deficit of almost 19,000 apartments for folks who are what we call zero to 30% income. So that’s a low income, single family or a senior on disability.
Part of the idea with the supportive housing services measure was we’ll be able to pay for supportive services and have people in apartments they can afford. It came on the back end of the housing bonds. So there was intentionality there that frankly never came to fruition. We should be spending less on rent assistance and more on services, and right now, we’re having to spend a lot of rent assistance and services. So it hasn’t actually shown up that we can leverage these two different resources.
If we have enough apartments that folks can afford, I really think we could have a system where we are able to pay for the support service, behavioral health, frankly, employment training, all sorts of things that would support people once they’re inside.
Miller: So I want to turn directly to the proposal that’s the reason for this hour and then what we heard about from Andy Mendenhall before the break. We can get into some of the specific details, but I’m curious, first, your big-picture take. What’s your response to this overall idea?
Singleton: I really appreciate that Andy talked about how many people are successful, and I think that’s really critical …
Miller: He said 80%.
Singleton: Yeah, we’re at 84% retention when it comes to our permanent supportive housing. It doesn’t mean I would love for us to be an A-student on that, right? We’re above the national average, but I think we could do better. So I do think there is a bit of us actually assessing what is provided in permanent supportive housing.
I’ve also worked at Cascadia Healthcare, for example, and my permanent supportive housing program at JOIN looked like case management and trying to connect people with outpatient services. My permanent supportive housing at Cascadia looked like mental health clinicians as part of your case management team. And because they’re not all alike, I think we have really different outcomes from each model.
There is a piece that I agree with him on assessing people on the front end and really truly understanding their full behavioral health care needs so that we’re doing better matching. But I do think that we have not actually made permanent supportive housing or anywhere close to fidelity of Housing First. That’s where I want to spend our time. I’ve asked for an assessment of permanent supportive housing so that I can understand what types of services are being provided in each program, and do we need to increase behavioral health staffing capacity in those programs to increase our retention.
So I think we’re both coming at the same problem, but our solutions look a little bit different.
Miller: I’m not sure I totally understand what it is when you say fidelity. So what you’re saying you’re not sure that you’re doing correctly right now, or not sure that you’re doing in terms of the highest standards?
Singleton: With Housing First, one, there is no lack of engagement. There isn’t a way you get to tell me that you’re not going to meet with me. There’s a weekly check-in with a case manager that happens. I don’t think we have the staffing capacity that we do that to fidelity. It also includes having on the team behavioral health providers, whether that’s a mental health clinician and/or somebody who’s doing addiction services. Some of our programs have that, but they tend to be the programs that are part of the behavioral health care system. Our homeless services providers are not a part of the behavioral health care system and therefore don’t necessarily have that support staff. That’s a big missing piece of how you do Housing First that Multnomah County has not done.
Miller: But maybe I misunderstood the way Housing First works and what it means, but I thought that housing is not contingent on engaging with services, that the point is you don’t have to have a negative drug screening. You don’t have to say, “Yes, I will engage with this behavioral health support” in order to get housing. Am I wrong?
Singleton: You’re not wrong, but you do have to engage with your housing case manager. So there is …
Miller: OK. But the housing case manager is different from a behavioral health specialist, who can say, “Let me help you with this untreated mental illness or the serious and potentially disruptive substance use disorder.”
Singleton: Yes, and with a housing case manager who’s engaging you and having access to that care team, you have the ability to bring people in. The person may not fully engage, but they’re a part of their care team and regularly could be checking in. That’s the piece that we’re missing. And I think Andy talks about it as ACT teams in the paper which is the highest level of fidelity to the model. We also, locally, have a model that we use that is that choice, but there is an addictions provider, a community health worker to help you navigate, and a behavioral health, mental health provider.
So while it isn’t, “You’re going to sit down and do a therapeutic intervention with me all the time,” that person is still coming to do home visits and able to see and assess things in a different way.
Miller: So one of the points that Mendenhall made, the basic one as I hear it, is that if somebody right now … And it’s worth reiterating here – we’re talking about a relatively small percentage of the total population that’s being served, but as he said, even if it’s, say, 14%, 15%, it’s a population that can cause real problems for the system as a whole. But he says if someone has severe pervasive, untreated mental illness or substance use disorder that makes their behavior really disruptive to other people, right now, it does not make sense to put them in housing with no services.
Do you agree with that basic point? We can talk about what you do after that, but I’m curious if you agree with his diagnosis there.
Singleton: I think that that’s where it comes back to. I agree, but my agreement is it’s not a fidelity model of Housing First ...
Miller: And he says, fine, it’s fidelity for 84%. And then for this other part, things have gotten bad enough in Portland that we need a new model.
Singleton: I don’t think it’s a new model and I think that’s maybe where there’s a differentiation. What they’re talking about is what Housing First should be. The difference in what I’m hearing from them and what I read in the paper is that they want us to reprioritize some of the housing vouchers to folks exiting inpatient treatment, whether that’s addictions or mental health care. The difference there is that is an assessment piece that I do think is worth us talking about, but I don’t think it means that PSH or Housing First isn’t working.
I do think some of those folks, like the person he mentioned who was fine for five months and then decompensated, I don’t think we were doing Housing First or fidelity with that person. There’s no reason that it should have been five months of decompensation. The idea that there isn’t a place, a crisis center or a crisis service for folks when they decompensate is not new. This is something that’s been being talked about in this state for a very long time. And I do think we’re missing the ability for somebody to step up in care and the ability for them to step down and care.
Miller: Well, maybe then this is where the issue comes down to timing, because you both agree that it would be a much better world and it would be a much better region if there were a more robust system of behavioral health for everybody. But we don’t have that right now.
So then the question is, what do we do … as I asked him, what do we do in the coming weeks? It would be great if there were a better system for people in dire need. But if that’s not going to be much more robust tomorrow, how do you prioritize housing?
Singleton: I think, for me, I would shift it to how do we start? There’s been this sentiment that homeless services shouldn’t pay for behavioral health care. And I appreciate the sentiment behind it, but it’s unrealistic. I do think we have to talk about, do we need to use some of our local dollars or SHS dollars to pay for people to provide behavioral health services and be doing home visits? The tricky piece is, until somebody’s fully enrolled in Medicaid, they can’t bill for them. So there is no way to pay for that staff if we don’t use local dollars to pay for it. I think that’s the shift that we have to make, to say how do we get back to fidelity of Housing First, pay for behavioral health staff? And when people get enrolled and they can bill Medicaid, great, but until then we have to be willing to pay for those staff.
Miller: Does that mean less money going to housing and more local taxpayer money going to behavioral health care services? You too, then, are talking about a very big shift.
Singleton: It’s a shift I think that we have to make because, again, I do believe that Housing First works, if we do it appropriately. Because that’s the missing piece that we have, then we have to be willing to say we need to make a shift in how we’re spending dollars.
I think, overall, we’re having to look at our whole system and think about where we have to make shifts. I’ve been very vocal about it as we have these decreasing funds, we’re overleveraged on shelter. I also don’t want a system where people are just warehoused in shelters. So, I think we have to take this opportunity to look at what we want our system to look like and where we have to prioritize funding to do that? So some of it may be for behavioral health care.
I think the other piece we’re missing is there are folks who got housed with permanent supportive housing, that there is no step down for them. They’re still poor, but they’re navigating outpatient treatment services and support services in a way that they can do on their own, but because we don’t have a place for them to step down to and have a rent subsidy, we’re taking up a voucher with services that somebody else needs. So I think we have to look at both ends of the spectrum, figure out how to right-size and make sure there’s flow through the whole system.
Miller: In the example you were saying earlier, you’re saying we should think about spending local money for people before they get on OHP, before they get Medicaid to pay for behavioral health support. But we’re talking at a time when we’re about to see what I think [is] the single biggest hit to Medicaid in our country’s history. What is that going to mean – the gigantic erosion of money, billions of dollars in Oregon and around the country for Medicaid, which is already the biggest payer for behavioral health care in the country?
Singleton: I will say there’s one shift. So a lot of folks already have OHP, but you have to complete what can sometimes take two to three hours of a behavioral health assessment before you are then able to bill for behavioral health services. So this isn’t getting new people on the rolls, it’s getting them eligible to actually bill for those services.
Miller: But am I right that in the coming years, even if they go through those hoops, there’s going to be way more hoops, which will lead to fewer people who effectively get health care from this program?
Singleton: Yes, absolutely. And I don’t think we’re best leveraging folks who might be eligible now and will continue to be eligible. So we’re not leveraging to the best of our ability the existing Medicaid dollars.
Miller: But what do you think these cuts are going to mean for everything we’re talking about?
Singleton: The cuts are going to be drastic for everything we’re talking about. I think just looking at the HUD continuum of care program and that shift, we’re talking about thousands of people that are in jeopardy of losing housing. Some of them have been in housing since 2004 on these voucher programs. And it’s not something that locally we can backfill. It’s not possible for us to backfill everything. I think you’ve seen at the county that we’ve been doing nothing but, frankly, budget modifications based on federal or state reductions.
So we’re going to continue, I think, to try to do the best we can to be a safety net, but there’s definitely folks who are going to either lose housing or we’ve got to figure out how to shift our resources to realign and make sure more folks don’t become homeless.
Miller: Does anything give you hope right now?
Singleton: Gosh, what gives me hope right now? I think I’m seeing people really come together and want to problem solve in a way that is about the whole system. I think that there’s hope. Some of the hope that I’ve seen has more to do with ICE activity in my district, and seeing my community really show up for each other, and in a way that is about how we support and make sure people know we have their back and they feel safe. But it’s hard to find hope right now.
Miller: Shannon Singleton, thanks very much.
Singleton: Thank you.
Miller: Shannon Singleton is a member of the Multnomah County Commission.
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