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← Recent meetings · September 2026

The record · Transcript

Council Session — 2026-09-09

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Wed, Sep 9, 2026 · meeting length 2 hr 25 min · council salary-time ≈ $1,852

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0 Good afternoon. It feels like we've been gone for so long. I am calling to order this work session of the Portland city council. This is a intended to help us in development of our state legislative agenda for the 2027 session. This work on a behavioral health advocacy strategy started during the agenda development process last year. So during the transition between council presidents, I asked councilor Pirtle-guiney to continue to help shepherd this work moving forward. So for this work session, I'd like to hand the gavel over to councilor Pirtle-guiney. I'll pass it to her to make some opening remarks.
1 Thank you, council president, and thank you for prioritizing the continuation of this work during the agenda, during our legislative agenda development process last year, a number of councilors voiced a strong interest in wanting to engage in and have some shared legislative goals related to the behavioral health system. Our guests today have been invited to help us dig into the regional behavioral health landscape, and what we would need as a community to have a functional continuum of care. Health care will be a major part of the presentation today. They are our local coordinated care organization, making sure that everyone in our community receives the care that they need. They will be joined by a number of other partners who we will introduce in just a few minutes. I name them though, here because they have been gracious enough to help engage in the planning for this work session and to share some of the work that they have been doing more broadly to provide context for us. My hope is that this discussion will help council to clarify where we think the city's efforts are most needed as we prepare for our state legislative priority setting work. I want to thank everybody who has joined us today and recognize that our guest speakers represent only a handful of the people who have contributed to the work that we're going to hear about and the work that's done in community. I'll also note that as you are listening to the presentation, if you have questions for groups that are not at the table, please ask them. We have representatives from our own city services, from the state, from community providers in the county who are all in the room with us to answer questions, even if they are not part of giving the specific presentation. I'll note that we're taking on this topic separately from the rest of our discussion about our legislative agenda, our state legislative agenda, I should say, because it is a somewhat new topic for this council to discuss. Together. We as a city don't provide behavioral health services, and we don't generally weigh in at this dais about what these systems should look like in our community. But we know collectively that the greatest challenges before us as a city are intricately tied to the shortcomings in our behavioral health system and the desperate need for investment in layers of care that don't functionally exist in our community today. We're doing this separately so that we can dig into these conversations a little bit more. But these conversations will then roll into the rest of our agenda setting process and the broader conversations we'll be having with the office of government relations over the next month. Last year, after we heard from a number of members of this body that you were interested in weighing in on this topic, I asked a few providers in our community to sit down with a few councilors who had been a part of expressing that interest, part of wanting to learn more. Providers who are often on different pages about what we need to prioritize moving forward. And I ask them to come up with a proposal for the city of what they think collectively would allow our behavioral health system to better provide services to members of our community. Something that this council could take on as a proposal to move forward in our state agenda. I want to thank the councilors who joined me in some of those conversations last year. I know not everybody was able to make each meeting, but the feedback that you provided helped to shape the proposals that we will be hearing. I hope this will be a useful presentation and beneficial conversation that helps give our folks at ogr, at the office of government relations a good sense of where and how this council is interested in engaging in the work, and how we might be able to come up with a city agenda to improve our behavioral health system across the region. With that, I want to turn it over to our director, sam chase, who will give us a full overview of the agenda, introduce our presenters and help lead us through this conversation. Thank you for being here, director chase.
2 Thank you so much. My name is sam chase, director for the office of government relations. And thank you, council president councilor Pirtle-guiney and council for your work on this and inviting us here today to do have this conversation. The. In short, the purpose is to really understand if we are on the right track, that we have an accurate understanding of what is intended to be achieved, and if we're going in the right direction, I would I would start with thanking you all, including the mayor and administrator and and staff of the city, for really leaning in on the process. As you know, there is not a policymaker or decision maker. We're really process people. And the, the, the city as a body has really leaned into doing the hard work internally before we're going and doing our advocacy externally with state government, federal government, tribes, local government, and more. And so that effort of really leaning in, doing that hard work, finding collective action, finding common ground, finding, getting as close to consensus as we can, and having a unified voice pays off in many dividends when we when we do that work. So really, we're we're sort of here on a new frontier now, which is to do this work and also do it in coordination and coalition with the county behavioral health partners, coordinated care organizations, and many others that are working in this space. Behavioral health is an area where the city has limited expertise and limited operational involvement involvement. But yet we've heard from many of you that the issues profoundly affect our core responsibilities. And as we are reluctant to engage in issues that aren't directly associated with city services, this is one where you've said, hey, there are so many services affected by this work that we have to take some bold action. Today. We seek to build a foundation for partnership, collaboration, and coordinated and coordinated state level advocacy. We're bringing forward leading behavioral health experts so that together, the city can help shape and join a focused coalition delivering urgent, unified and actionable recommendations. Before we transition to council discussion, our guest speakers will provide background on the behavioral health landscape, describe key system challenges, share findings from their recent work, and outline their proposed direction for state advocacy. And again, I want to I want to share that this is a a foundation, a foundational point for us to engage in this work going forward. And so as you're hearing those recommendations, those are the point in time that we are in right now as we're preparing for the 2020 1107 legislation, and there will be more work to do, more work to work out. We'll be coming back at the end of September for our first agenda setting work session with you, where we'll where we'll build on this work, and then we'll have yet another work session and hopefully an adopted legislative agenda in December. So with that, I will invite our panelists up to the dais, doctor joe hardman, health share of Oregon. They will do more introductions of themselves. Julie ibrahim, new narrative, james schroeder, cascadia behavioral health care director, rachael banks, Multnomah county health department, and stephanie howard, public safety service area area doctor hardman, please take it away.
3 Thank you, director chase. Good afternoon everybody. We have some slides to show here. All right. There we go. Hi, everybody. My name is joe hardman. I'm an internal medicine physician and the chief medical officer at health share of Oregon, which is the coordinated care organization that serves the majority of ohp members in our community here. I'm very excited to be here because today's discussion is focused on state policy and advocacy. I wanted to start off with a quick reminder of how responsibility is shared across the behavioral health system. So that's demonstrated in this somewhat busy slide here. The point of this busy slide is that behavioral health is not a single system run by a single organization. Obviously, federal and state governments set important codes and rules. Codes like ours administer the behavioral health benefits. Counties, of course, deliver very important care in terms of crisis care and additional services. And then there's this entire network of providers, hospitals and community organizations who all play an important role in delivering behavioral health care to our community. And because we all play a role, no single partner can solve these challenges alone. We really need to come together around a shared understanding of what the problem is, and then advocate collectively for how we think we we need to address it. So the state does have a particularly important role here, right? State policy, state funding, state capacity decisions all directly impact us and where the care how we can accomplish the care locally. But that really is the point of today's conversation to align around what we are seeing in the region and what we need to ask of the state. Rachel, did you want to add something about.
4 Sure. Happy to. On that last slide, you'll also see the role for the county. So I wanted to talk. For the record, my name is rachel banks. I'm the health department director for Multnomah county. And I wanted to just talk about a couple of the unique and distinct county roles in that you'll see in this diagram. So one is, under Oregon law, the counties are designated as the local mental health authority. So our board of county commissioners fulfills that role. And their role is for planning and oversight for behavioral health services that are offered in the region. The region, of course, including Portland, as well as Gresham and our other eastern cities, and then the community mental health program. That's the role that the department plays, and our role is to fulfill statutory requirements, obviously, under the direction of our board of county commissioners as the local mental health authority. Some of those statutory requirements include things like an assist, safety net services, oversight, planning, those sorts of things. And then we work with the board as a local mental health authority who's responsible for policy adoption, for funding, for statewide advocacy, for policy, and funding for statewide advocacy, and adopting a local plan that we submit to Oregon health authority, which basically talks about how we fulfill the statutory requirements. So thank you, joe, for allowing me to provide that background in the local mental health authority and the community mental health program.
5 Yeah. That's great. I mean, with that context in mind, I think we should look at the behavioral health spectrum that people are trying to work through, because that'll provide some additional helpful context, I think. So this slide is also busy, and I think that's because the adult behavioral health system is very busy. As an internist, I can tell you that this is far more complicated than the medical side of the equation. And patients and family members experience that come complexity every day. So the continuum here runs from prevention, outpatient treatment and housing on the right hand side of the slide, all the way up through residential treatment, crisis care, inpatient psychiatry, all the way to the Oregon state hospital on the left hand side for the most complex patients. The point with this slide is that this is a continuum. These aren't separate systems. They're all connected. And because they're connected when they're one part backs up, the rest of the continuum feels it. So for example, if a patient is admitted to an inpatient facility, they get stabilized. They don't meet inpatient care needs anymore. They then could step down to another level of care. But if that level of care doesn't exist, they end up staying in the inpatient setting and then taking up a bed from somebody who is having a crisis and needs that bed. Similarly, if community services aren't available, people end up cycling through the emergency department or shelters or even jail while they're waiting for access. So the point is that this is a full continuum. There are challenges throughout it, of course, but we're really focused today on the yellow circles there because those, according to our data, really represent the major bottlenecks in the system. And opportunities, therefore, to improve flow throughout it. So our focus today is pretty practical. What capacity and coordination are needed so people can reach the right level of care when they need it at the right time. They don't have to wait until it becomes a crisis to understand the bottleneck. On the left hand side of the slide, the Oregon state hospital, I think it helps to understand the legal framework in which we're operating here. So on the next slide, I should point out that I'm not a lawyer, I'm a doctor, and I'm going to try my best to share the legal landscape. This legal framework is something that we did not set and we don't really control. Back in 2003, the case established requirements for how quickly aid and assist patients should be admitted to the Oregon state hospital. Continued noncompliance then led to increased federal oversight, some tighter requirements, and then significant financial penalties. So the practical result of all this is that currently, the Oregon state hospital is now largely focused on the aid in assist patients, I would say, almost exclusively focused on the aid and assist patients. That is not a criticism. That's just what's happening today. That's what we're working within. So while the state hospital serves a really important role for our state and a very important.
6 Aid and assist, please one more time.
7 Aid and assist. These are folks who have mental health challenges who can't aid in assist in their own case. So state hospital, very important part of the continuum on the left side for the most complex patients, it doesn't solve all of our problems, right? We need a range of options for people who have different levels of need. And no single bed, especially the most expensive type, can meet every need of every patient, right? So we really need kind of that spectrum within the middle and some additional capacity, particularly in the middle of the continuum. And I will say that the legislature has actually made some pretty significant investments in that middle part, particularly for residential care. On the next slide, we share what those state investments have been. So through 2021 and 2025, the state has made some pretty significant investments across residential treatment, withdrawal management, supportive housing, as well as community based behavioral health services. Many of these beds and programs are actually still coming online, so we actually haven't seen the full impact of their, you know, the potential benefit. It's also important to remember that these are statewide investments. So not all of this capacity is actually built in the Portland metro region. But even if it were, bed types are not interchangeable. So a residential bed, a withdrawal management bed, a subacute bed, an inpatient psychiatric bed that serves a very specific purpose for a very specific type of patient with a specific problem. So yes, the state has made some very meaningful investments, but really, we haven't overcome decades of underinvestment, I would say, in behavioral health. And I'd also say that like, you know, we we need some more in the middle to help to make that challenge a little bit more concrete. I want to share with you some of the populations at the center of these pressures. And the next slide, I think, will be familiar to several of you, hopefully at health share. Over the last couple of years, we've really worked hard to identify a particularly complex group of patients whose behavioral health needs are really not being met by our current system. We call this our high acuity behavioral health cohort. It includes adult members of healthshare who have a stimulant use disorder and opioid use disorder, a diagnosis of psychosis, or an unintentional substance associated overdose. And you can see with those overlapping circles that a lot of these conditions overlap. For patients, this is meant to be an analytical definition, not a label for an individual. It really just helps us kind of identify where the system is struggling and where we really need to lean in. So this cohort represents 9% of our adult members, and yet it accounts for 29% of our total costs. And that's mainly through use of our emergency departments, admissions for medical conditions, admissions for psychiatric conditions, as well as behavioral health costs. So the point is not that this population is expensive. They tend to be. Yes, but we think that these costs are high because there are too few appropriate alternatives for them to meet their care needs. Right? So they their care ends up needing to be in a crisis setting because either that's all that we have or because their behavioral health condition hasn't been treated well enough. So it becomes a crisis. And I'd point out that these aren't just health care challenges, by the way. These challenges also impact our housing and homelessness systems as well. And that overlap has become increasingly obvious now that we're integrating our data. On the next slide, you can see when we link that health and housing data, the overlap here is very striking. More than half of the people served through shelter, supportive housing and street outreach have a high acuity behavioral health condition. So the takeaway here is also simple. Housing and behavioral health are not separate. They're not separate challenges. These are the same populations. We're serving the same people. So and you know, we all know this housing is foundational to good health, right? But housing alone can't replace psychiatric stabilization, medical management, effective treatments, care coordination and those sorts of things. So it's at the same time, behavioral health treatment is really difficult to sustain without a safe place to go or a safe place to live. So we need folks housed in the places that are safe in order to address their healthcare needs, right? It's it's both. And when those systems are not coordinated and working together seamlessly, people do end up kind of falling through the cracks, cycling through crisis settings, coming to the emergency department, ultimately struggling to remain housed. So fortunately, I'm joined here by a couple individuals with deep experience in this space. So I'm going to turn it over to julie ibrahim to describe how these gaps and system constraints show up in real life.
8 Good afternoon, mayor and councilors. For the record, my name is julie ibrahim and I'm the ceo for new narrative. We are a nonprofit, 50 year old agency that provides comprehensive mental health treatment, psychiatric care, residential treatment, supported housing, transitional housing and peer support. And we serve 2000 folks in Multnomah and Washington county. So the the key takeaways from the data that joe shared earlier are that the lack of capacity for the high acuity, high acuity behavioral health cohort drives poor health outcomes, disproportionate health care spending with limited outcomes, gaps in the continuum, and gaps in coordination, challenges in the downstream, supported and affordable housing system, and community livability. Livability challenges. What this data describes is something we see every day as providers, people getting stuck and getting worse because the level of care they need isn't available when they need it. Someone may be ready to leave inpatient psychiatric setting, as joe said, but there is an appropriate place for them to go. They may no longer need hospital level care at all, but will still need more support than traditional housing or outpatient services can provide. To me, that points to two challenges capacity and coordination. We need a behavioral health continuum with capacity and coordination that centers on the client's recovery journey to ensure they're not falling through the gaps. That means we need multiple options for this complex population, including inpatient care, subacute and respite care, which we'll talk about later. Residential treatment transitional housing with behavioral health supports, tiered supported housing, outpatient treatment, peer services, and other community based supports. But having those services isn't enough. People also need to be able to move between them as their needs change. And it's not always linear movement, believe me. They need coordination that helps them stay connected to appropriate levels of aftercare and housing, supporting them through their recovery journey, whether they're moving forward or taking a step back for this population, success doesn't necessarily mean they no longer need support. In fact, some people may need significant support for most of their lives. A new narrative. We have clients that have been with us for years, stable, housed in the community because we have supported their recovery journey. Success can mean fewer crises and hospitalizations, fewer incarcerations, stable housing, trusting relationships, and living safely in the community where they have dignity and choice. So the question is, do we have a supportive continuum? And continuum is the key word here the right level of care at the right time, and can people actually get to it when the answer is no, people get stuck and they fall through the gaps and the pressure shows up throughout the system with significant human and economic impacts. Now, one of the places we see this most clearly is actually in the downstream part of the continuum, affordable and supportive housing. So with that, I'm going to turn it over to james to talk about cascadia's experience with this population in their housing portfolio.
9 Great. Thanks, julie. Hi. Good afternoon. I'm jim schroeder, ceo of cascadia health. Similar to julie and new narrative, we kind of have the spectrum of services at cascadia. So we do street and housing outreach. We operate project respond, which is a crisis response in Multnomah county all the way through with outpatient, lots of residential and then housing, including affordable and supportive housing. And my job today is to really highlight the challenges in the housing system. What joe mentioned is that a lot of folks are not getting the treatment that they need at the level that they need. And then what happens is we end up putting them in settings that aren't right for them. And oftentimes that's what's happening in housing. So we are getting folks in our housing services who have untreated need and high acuity. That's not a great match in those settings. That's not what they're not set up to support those things and stabilize. So what we end up seeing is that three and a half times more likely return to homelessness. I'm going to talk about that a little bit. But the other thing I wanted to highlight is just in the last month, just to make it really real, at cascadia, we've had one murder at one of our affordable housing units from someone getting shot and killed. We've had three staff assaulted, and this is all because of that acuity mismatch, because we're putting people into a setting that isn't right for them, that may not be ready for housing yet. And that's kind of the key takeaway is that we need to address that, stabilize that, and make sure that they're getting the treatment that they need, along with their housing and not just housing alone. So I'm going to give a couple of stories. But before I do that, I wanted to share because I took the time in preparing for this to meet with our housing outreach team. We have a lot of peer support providers on that team. What they shared with me, I actually hadn't thought about before, and that's being housed, can actually be a traumatizing experience if you've been on the streets for a while. If you think about it, it kind of makes sense. You've been living on the streets in a communal setting. You have a society, you've got people around you, and all of a sudden we put you into a single room apartment by yourself. So just that move on its own is enough to try to work through and get to a better place so that you can stay. But if you're coming in with untreated behavioral health and untreated substance use, that makes it almost impossible to then deal with those things that allow you to stay housed and not have that three and a half times more likely to return to homelessness. Most of that return to homelessness is because of evictions. Evictions are a failure, right? If we're in a housing system, our goal is to keep people in housing for the rest of their lives. It doesn't mean that we're going to pay for their housing for the rest of their lives, but we're going to try to give them the support they need to not get evicted and not dealing with that acuity and that untreated behavioral health and substance use is just setting us up to do that. The other thing that it does that I didn't think about a lot either until I really started spending more time at cascadia is it impacts everyone else around them as well. So think about it. We've all lived in an apartment at some point, right? We all hate the noisy neighbor upstairs, right? If you're dealing with untreated mental health, you are more likely to be depressed. You disturb people, right? You're going to cause noise, you're going to cause damage in your apartment. And those are all then reasons that you end up not being able to stay housed, not because you're a bad person, but because we haven't treated the things that are setting you up to then fail in that new system. And we're expecting you to socialize yourself to that while trying to deal with your substance use and behavioral health disorder. So that's just a, it's not a great setup, right, for doing that. So you can see why we're getting the outcome that we are without pairing those things together. And like julie mentioned, we'll talk a little bit later about a part of our continuum that is really under capacity, which is around the subacute and respite, which is really a readiness piece for then getting people ready for treatment. Housing. Et cetera. But two stories. So I asked the team for stories. I probably got like 25, so I had to try to find some. But one is alex. So it's a 47 year old male who has been housed, let's see, I think eight times they have been evicted eight times. And the primary reason that that keeps happening is because they're not getting the treatment for their behavioral health disorder. They have a lot of paranoia, which tends to make them not trusting and more violent. And so they tend to react when they're in that paranoid state by being aggressive to other residents or to staff, which then sets them up for being evicted. Unfortunately, you know, this is one of the folks that just recently punched one of our staff, did some other things, and is now being evicted and is going to go back on the streets, which is again, a failure. Tracy is a 36 year old female with severe substance use disorder. She's also been evicted six times because of her drug use. Her addiction just makes it very difficult for her to be a good neighbor. She tends to disrupt people. She can be violent. She's really destructive. She unfortunately chose to intentionally flood her apartment, which then not only impacted her, but it impacted the people below her as well as us at the organization, because then we have to repair all of that, and we've got units offline and all those things. I wanted to include a good story, though, is that we finally were able to get her into treatment, and she now has been housed for a period of time and is doing really well. And it just demonstrates that when we take the time to address that, we're going to get better outcomes and better use of our resources. Because right now, funneling people through housing with that mismatch of acuity isn't a great use of our resources. And so that was the, you know, my primary goal was to kind of highlight that. And that eviction isn't the outcome that we're after. But if we do a better job with some of the continuum pieces, but also just matching housing and services and treatment, we can do better and do better for our clients as well as the community.
10 Thank you so much. Now we're going to hear a little more about from the county and city around how some of this plays out locally.
11 Yeah. Thank you. So this plays out, as I mentioned earlier about the county's role as the community mental health program. The underfunding of the behavioral health system plays out across the continuum, particularly because we operate the crisis service, because we provide services to the uninsured and underinsured and really work across that, that system. And because the entire behavioral health system is underfunded and was not designed or has not been re envisioned to serve the sort of acuity and complexity of needs that we're seeing at this particular moment. So and I appreciate that for today, we're focusing in on a part of particular of, of the continuum with specific needs that my colleagues here have outlined really well. Ultimately, we want to ensure that we're able to be providing preventative services and the right interventions at the lowest level of acuity that we can. And as folks have said, the right care for the right people in the right time, in the right place, and ultimately the underfunding of this part of the system has, has created a situation where, as we've we've heard that it's not happening. Some of the outcomes and impacts that we see, as we've heard, obviously, evictions, folks not being able to stay in their housing because of the unmanaged symptoms. We see it in people not being able to gain or keep employment, and then all of the basic and social needs that that contributes to. We know that when people cannot reasonably access the higher level of care that they need or the lower level of care that they need when they need it, that there are real impacts to themselves, their health outcomes, and those around them, their families, their neighbors. As we've heard. And I think, you know, there's real impacts for the folks that are struggling that with a really challenging issue and are not getting the supports that they need. I think that's especially important because we know that 50% of people will not seek behavioral health services, perhaps at the time that they need it at a lower acuity because of stigma or negative impressions, societal impressions, beliefs, or stereotypes about them. And while they're experiencing one of the most complex health issues, then if you add to that the kind of internalized shame and blame that then people experience on top of all of the other pieces, and we see that that can lead people to hide their struggles until they become a crisis, until they can no longer hide them. And so I really just wanted to, to bring that piece in as well as, as part of our role is to be thinking about how do we both have the services that we need and ensure that those services are destigmatized and that folks want to access them, particularly where we can prevent crisis from, from escalating? So in short, as we've heard, both totally agree with the impacts that my colleagues have shared and the impacts throughout the system for the county, which basically is we see poor health outcomes, we see interventions at higher costs. We see people worsen, and ultimately we see more service delivery at the crisis or a higher acuity end, which is often less effective and more expensive and demeaning for folks. So with that, I'll turn it over to you, stephanie.
12 Thank you. Good afternoon councilors. My name is stephanie howard. She her pronouns and I'm the director of community safety programs for the city of Portland. I'm here to represent a little bit about the impacts to programs and services that these gaps have represented, and I'm very happy to be here today with our partners from the chat program, who you can see here, partners from Portland street response from pb's behavioral health unit, and other partners here that can answer more specific questions that you might have going forward. Oregon's behavioral health system gaps directly affect the city's core services, and put that in the category of captain obvious. Right. Staff across bureaus, including public works teams and public safety teams, have increasingly encountered individuals in crisis. City public safety systems are designed to address a moment of crisis. Currently, we can only offer temporary stability without transitional and longer term behavioral health support capacity, which is deeply needed. These system gaps are visible in our public safety programs, and yet we all are working very hard to strive for more options. The police bureau's behavioral health unit was established because so many calls for service involved a mental health component. The bu pairs officers with licensed clinicians who work proactively with individuals who have repeated or high risk contacts with police to try to break that cycle of crisis response. In 2025 alone, the bu received 775 referrals, and of those referrals, 37% were people who had been previously on a caseload. Meanwhile, the demands for Portland street response services continue to grow. As of August this year, psr has received nearly 14,000 calls for service, which is an increase of approximately 4000 more calls this year than the same time last year. Since the program began, Portland street response has received nearly 60,000 calls for service in just a few years. And over the last couple of years, especially, psr has been working to expand its staffing and its presence throughout Portland, all with the goals of providing care to portlanders, experiencing behavioral health crises and significantly reducing the call load on police, fire and emergency rooms. The chat program continues also to absorb medical and behavioral health related impacts. Since 2021, chat has responded to more than 17,000 medical and overdose related calls, including nearly 3000 repeat callers, with about 1100 individuals calling four or more times due to unmet behavioral health needs. Health share data shows that 65% of the known community members chat serves are in the high acuity behavioral health cohort, underscoring the intensity of that need. Chats overdose response units regularly encounter individuals cycling through crisis without access to sustained care, requiring repeated emergency responses from fire boec police, Portland street response and others. Since the 2024 fentanyl emergency declaration chats, buprenorphine program has reduced emergency department use by 80% among participants while connecting as many as possible to same day care and shelter and long term treatment. And these efforts can demonstrate that both the scale of the repeat caller impact and also how targeted interventions can reduce strain on city systems. The city's sheltering work has also evolved, and while not every unsheltered portlander has behavioral health needs, a significant portion of guests in city shelters do, and our providers report rising behavioral health acuity, driven in part by substances like fentanyl and p2p meth. To meet these needs, the city has established a recovery oriented shelter sites and wellness centers that. Alternative shelter sites that bring behavioral health services to the site, along alongside, excuse me, medical and dental care and case management options to move people with severe and persistent mental illness out of shelter into appropriate care and housing is extremely challenging. There are two. There are two few available options, which greatly inhibits the city's ability to provide more people with shelter and wraparound services. City bureaus are doing everything they can to respond to the need, but without accessible and sustainable varieties of treatment pathways, we all face the same challenge. People repeatedly cycle through emergency response systems, get short term stabilization and without longer term supports quickly decompensate, leading to yet another crisis call. This strain on city resources really cannot be overstated. We've worked hard to create programs with partners and to fill system gaps, often with only one time funding. But these really are just band-aids. Additional capacity and stabilization options are critically important to alleviating the pressure on portland's core services and achieving better outcomes for the people that desperately need our help. As you'll hear from everyone today. With that, I will pass it back to julie. Thank you.
13 So the challenge is this individuals with complex high acuity behavioral health conditions need some combination of what you see on this continuum, particularly in the step-down psychiatric care box. They need yes. Diversion and early prevention. Sometimes inpatient psychiatric care almost always though step down psychiatric care. And that can include things like traditional behavioral health housing or I'm sorry, transitional behavioral health housing, psychiatric respite and or subacute care. It will always include outpatient care, I guarantee it and case management, and ultimately supported housing with some higher tier supports. And I'm going to talk about that in a minute. Without access to this continuum, this population, as you've heard, enters the system in crisis, landing in emergency rooms, jails or straight or straight to affordable housing without supports, which risks their housing retention and doesn't give them the recovery support they need. So, as joe said, when one part of the behavioral health continuum doesn't have enough capacity, the impact ripples throughout the continuum. If someone can't move out of inpatient psychiatric care because the appropriate next level is not available, the bed remains occupied. This backs up inpatient care. Inpatient shortages put pressure on emergency departments and without appropriate community based options, people cycle right back into crisis. That's why we need a supported flow through the continuum. The answer isn't simply more of the expensive and restrictive levels of care. We need the right capacity and a variety of capacity throughout the continuum, and that includes subacute care, psychiatric respite, residential treatment, transitional transitional behavioral health housing, high acuity, tiered supporting housing, supportive housing, and strong community based services. Now, these options can often stabilize people and community with a significantly lower cost. And let me tell you a story to illustrate that new narrative operates supported housing building on 13th and clay. It's 47 units. Mayor. You toured it the other day. It's considered supportive housing, but it's it's a much higher tier of support. It's 24 over seven staffing, usually at least double staffing. We provide provide clinical support. Their case management, we provide some meals and some medical support. We've had folks that have lived there for years stably. But the other day there was a young man. He was diagnosed with schizophrenia. He got very agitated. He got very angry. He was threatening staff, threatening other residents. He claimed he had a gun. The staff him. Normally in a traditional supportive housing situation, crisis response would have been called. The police would have been called. But that staff is very experienced and knows this participant very well and and speaks and works with him every day. So they were able to de-escalate them with their clinical skills. They were able to determine that he didn't have a weapon. They got him a meal and got him back into his room. And there was there was not another incident after that. Bridgeview operates at about $50,000 per bed per year. That is a bargain compared to hospitalization. But capacity alone isn't enough. We also have to ask who is helping the person move through the continuum. There is good care coordination happening today. The gap is that the coordination doesn't always follow the individual from one setting to another through their entire recovery journey. That's something we're exploring with the psychiatric hospital to housing pilot that's being run by metro in Multnomah county right now, and I'm co-chair of that along with andy mendenhall. How do we make sure that the person, rather than the program, remains at the center of the transition and doesn't drop through the cracks? So I think the path forward is this, yes, we build the capacity we're missing, but we also improve the connections between what we already have and invest where the data tells us that we'll have the greatest impact. Healthshare commissioned this capacity. Modeling and providers across the region have supported it. There is broad agreement that it points us in the right direction, especially when public resources are constrained. I'm sure you will agree that we should be very strategic about where that next dollar goes to fill in the continuum gaps with the most cost effective options. The goal is the right care at the right time in the right setting. I'll turn it back to joe to walk through what the modeling says.
14 All right. We're now at the proposal that we're hoping to gain your support. I think it's important that you know that this proposal, by the way, is data driven. It isn't just our opinions. Healthshare worked with the analysts from OHSU business intelligence unit. These were the folks under peter graven that did the predictive modeling for the state. So it's a very smart group of folks at OHSU who helped us create a computer simulation of that continuum in our region. And the really cool thing about this simulation, by the way, is it's dynamic reflecting the changes in our current environment. So for example, those beds that are coming online as a result of the state's investments, those are built into this simulation. The unfortunate recent closure of 55 inpatient psychiatric beds in our communities. That's also built into the simulation. So we are able to take this computer simulation and start testing things like if we add this number of beds, what happens to ed boarding and inpatient boarding if we add this type of bed, if we make this policy change, what actually will be the most helpful? So we tested various scenarios and arrived at several priorities, which we then, as julie said, reviewed with dozens of local providers and system partners to just really get aligned around what we think will be helpful. So the model points to four priorities. And these are all linked one. Preserve inpatient psychiatric capacity and backfill the recent closures. Those 55 beds that are coming offline two. Add approximately 50 psychiatric respite beds and 50 subacute beds. Three create sustainable reimbursement rate for inpatient psychiatry. And that's given some of the financial challenges in the recent closures that we've seen. And four, remove barriers that make capacity building harder to, you know, to actually operate. So I want to point out here that this is not a menu of options that we're suggesting we pick and choose from. These pieces all work together. We need the right mix of capacity as well as the system changes, in order to help people move through the system and receive the care that they need at the appropriate level. You might have some questions. We've talked a lot about subacute and respite beds, and I think james can give a little bit definition, some context of what those actually mean.
15 Yeah. Thanks, joe. So cascadia has been operating two respite sites for a number of years for a total of 16 beds. Traditionally, respite is. A low, you know, like low care model. It's more peer engagement, engaging people and getting them ready for where they're going to be going next. So we might do some med management, case management, things like that. But it's a it's a fairly lower touch model. Subacute, however, is a higher touch model, but it's lower than hospitalization. So the best example I have is sadly a physical health one because that's I'm a physical health provider. But if you imagine that you're getting iv antibiotics for an infection, like a bone infection, that drags on for a really long time, but you're kind of risk area is only for a few days. Once that risk area is done, you don't need to be in the hospital anymore. You could be managed at a lower setting to have those iv antibiotics if that setting exists. This is the same for behavioral health. There's a lot that needs to happen in the inpatient setting, but once you've gotten to that point, we can move them into a subacute setting, which is lower cost, and then opens up care, you know, for for those beds to be utilized for someone who needs that level of care. So this recommendation is because we need something that's lower cost, but also it's missing in our continuum. So the uses for these, if you think about it, is, as stephanie was saying earlier, if you have somebody in crisis, these could be a setting where that could actually work to, to stabilize them, right. And get them ready. This could be somewhere that people go when they're done with their hospital stay and can go to a lower care. But it's also a place where, like julie's example, we could send someone who's in our housing to one of these sites to go for a week, stabilize and go back, which then prevents the eviction and further violence and other things happening. So they have a really important role in our continuum. We just haven't built it out as much here in Portland. There's a lot of other cities and states that have.
16 All right. So I think we'll close by coming back to our goal here. Goal is, as we all know, we want our region to have a behavioral health continuum where people can get to the right level of care at the right time when they need it, and not fall through the cracks and not waiting until it becomes a crisis. I was also thinking of a sort of medical example as an internist. You know, if I see a patient in my clinic who's got chest pain, I get him or her right in for a cardiac catheterization, diagnose the lesion, stent it. I don't wait until there's a heart attack, right? That just doesn't make any sense. And we want to apply that same kind of logic to the behavioral health network, right? Like we don't want to wait until these become crises. We need this kind of middle part of the continuum. Yes, crisis care is important because it will happen and it will continue to happen. So you will see part of our recommendation is building out our inpatient capacity that's sorely needed and supporting it with additional funding. But it's that kind of middle part that we're really focused on here today, because we just don't have that in our current system. We know that no single investment is going to solve all the problems, but we do feel like this recommendation does address a lot of the critical gaps that we're all experiencing daily. So I think I'll turn it back to director chase.
17 Thank you. And I think so. I'll just briefly share legislative landscape. You've you've heard me on this. You're probably going to hear us on this. Again, there are really significant challenges with this legislative session. There are impacts from the federal legislation in h.r. One. There are growing wildfire costs, drought costs, transportation issues of significance, a number of preemptive issues we're concerned about. This is just to say that even in that scenario, we see this as. And we're going to be pushing to be, you know, disciplined and focused and defensive in in not losing, keeping our eye off that ball. And this will help us with that at a minimum. But there are a significant number of investments and resources that are part of this that, you know, we may not have the ability to get that all in one session, but we want to put forward the best foot, feet we can and, and continue to build on that over time. And so this is a long term strategy to get this fundamental system change, demonstrating to legislators, the governor's office and oha that we understand how these systems affect our our communities. So with that, I want to open it up for questions and discussion. And I and I want to have this question on the table, which is also for you. Does the approach presented today align with the direction you intended for our behavioral health advocacy moving forward?
18 Thank you, sam, and thank you all for bringing together not just the five of you, but your colleagues, especially the other organizations who are providing services on the ground daily in our community. I know there are a lot of other groups that were a part of this. Colleagues. I think the question that director chase just asked is the right question. Before we jump into that, I do want to note that I had a few people ping me during the presentation to say, can we get the numbers that weren't on the slides? So, director howard, I think you had a fair amount of data, and then the specific bed counts in the proposal that you have before us. I just want to make sure I have those down correctly. This is a proposal to backfill 55 beds that came offline this year. Add 50 subacute beds, 50 respite beds, and then address the reimbursement rates and a few policy pieces, both at the city and the state that you did detail in the slide. But those 55, 50 and 50 numbers, is that correct?
19 That's correct.
20 Okay.
21 So we can share that and we'll work to try to compile some of that information, more detailed information and share. And we'll have some opportunity to bring back more thinking at the end of the month at the next work session.
22 Great. And I think what we're aiming for today is to provide feedback on the proposal before us. And to the question, director chase asked whether this is right direction or not, and then if it is, we can ask the folks at the table to develop a little more specifics for us. I'd note that we heard that this is a data driven approach. This is about where we can spend dollars to get the the greatest impact. And that was part of what I heard from a few counselors as we went into these conversations, is what is actually going to free up the system and give us the greatest impact. So thank you all for focusing on that. We have a couple of folks in the queue and colleagues, I'll note we do have a fair amount of time, but probably a lot to say, and we'll probably have some longer answers to some of our questions. So I'll keep an eye on the time. But for now, let's jump into a discussion. Councilor Zimmerman, go right ahead.
23 Thank you. Chair. Not really sure what your role is here, but okay, counselor. Thank you. So, you know, it was some year and a half ago when I kind of dramatically when we had our joint county and city meeting said, I think the county and the city should go get every tv news camera, take our legislative agenda, get in front of them and rip it up and say, we need a mental health hospital, north campus that is not accessible to the judicial system. Part of that was bombastic to get attention, but part of it was also, I think it's still the most critical thing that is facing the community. Every topic, frankly. To an extent that we've discussed in this city, where it's been a challenge in this dais is actually related to this everything we're spending money on, every argument we've had about right choice, wrong choice, right amount. It's related to this. And so I recognize that a new state hospital north campus is not perhaps the solution. But I am so grateful that the ball has been rolling. Now, this is my at least fourth engagement with a few of you at the dais on this. And so my invitation to counselors is I spent ten years at Multnomah county. I know director banks fairly well. I know some other folks in the audience fairly well, and yet I still each time learn something new. So I'm glad that we ended on some definitions, because if you don't know what psych respite ed and assist subacute. If you do, you know what boarding is. If you don't know what boarding is, please ask because that helps us. You will get when you understand how the system is not something moving through a snake right now. It is the rat sitting at the back of the snake's throat, just chilling, not paying rent and it's never going to move. Not in our current system. We have the most broken system in the country. Other states aren't this bad. It doesn't have to be this bad. We are not the mental health authority, but we have a bigger microphone than anybody else. And that is why I'm so happy that we are having this briefing and this plan. With that, there was a presentation, and we have one of the directors from the homeless services or the director here, but there was a presentation at the soc a few months ago that had some pretty different numbers. And I think the reason they were quite different is maybe they were state wide numbers in terms of secure residential treatment, secure acute respite, etc. But it was not 5050. We were into the hundreds. And so I'm really encouraging that if there's an annex to this, that we get that annex, because I actually think we got to go big. I'm not interested in any mediocrity, frankly, on this topic. I think it should be the most important topic for the governor all the way down to the freshman legislator in this next session. So I'd like to ask for 285, which I think that was the number of the most severe beds. And if we got 100, okay. But we got to ask big. So I'd like to see where we can get that presentation. I'm not on the housing committee anymore, colleagues, so I don't get to report back on the soc meeting often. But I'll just tell you, in the last year of experience and the data that has been presented to us, I've come to a conclusion at this point that I'm comfortable sharing in a lot of venues at this point, your SHS dollars are obscuring the state's responsibility for mental health care and addictions. To an extent, we are spending what I think are poverty dollars on medical issues and not people who are in poverty because they have medical issues. Not I'm not, I'm just just be basic about it. We don't have to. What if this. We are pretty good with rent assistance, evictions, prevention, things like that. But we are using a lot of our money on people who, if the state had been doing its job, the feds and state and the county have been doing this job all the way through our our mission with shsi think would be better. And I say that collectively, our. I'm not really pinning this on any one place. I just think that this is really important is that the soc and experience and data in the last year and a half of serving on that, it's very clear to me that we're spending dollars in areas I think are actually directly related to the state's mental health and addictions responsibility. I really want to uplift james wright, the story about some people who aren't ready for housing. We've turned the corner a couple of years ago where providers, housing providers are now willing to say, yes, we've been taking some clients, and what's going on now is actually really harmful to the other residents in that building. The example that one of the providers, who we all know has told me is like when john floods his unit because he doesn't know how to live independently. And john lives on floor 12. I got 12 new homeless people because all of them are now homeless. That's what we're talking about. And so I'm so glad we're saying that because I think ten years ago, if you'd said not everybody's ready for housing, your nonprofit would have been canceled, you would have been fired from your thing and Multnomah county would have taken you out in the back and beat you. But that's over. That phase is over, and it's over because it got so bad. And that is a really important opportunity for us that I'm excited about. And I want us to go big here, because when I said the billion dollars for mental health hospital north, it was because in my head, my calculation is if I went to every Oregonian and said, I need you to hang on one extra year on the pothole that you're about, let's not put $1 billion in the transportation fund, because we can guarantee that we're going to take care of the folks you encounter who are just not able to take care of themselves. I actually think every Oregonian would have said yes if they had faith in the system. That's the calculation that I'm talking about in terms of what do we give up? But I, I invite you all to please ask specific questions in this. Councilor. Pirtle-guiney and the president and I and others have been trying to put something together that is a reasonable and sam, a reasonable ask going forward. You know, it's. I think it's I think it has been challenging sometimes in a in a in a society, somebody has to talk about the toughest things that we do because there are a lot of people in our community who cannot or won't be able to take care of themselves. Like nobody wants to talk about committing a person, right? It's, it's our worst case. But actually the worst case is saying that we shouldn't address them at all. Right? Because what we're talking about is people that can't take care of themselves. And I don't want this principle of autonomy to allow us to dive further into societal neglect. And I think we really went that direction for a long time in collective oregon's history right now. And we see it every single day in old town. We see it every single day in most parts of our city, and that type of neglect is killing people. So if I'm feeling passionate about if you're hearing that, it's because I'm inviting, I hope, I hope, I hope that this council can tell sam and his team, we have a lot of priorities, but actually, we need you to go lift up anybody else who wants to do mental health work. We want to go hard. We want to go heavy and we're not. And please notice who's not here today. These folks showed up, right. Not everybody's in this. There's a hell of a lot of people in this in this community who are in this work, and they only want to participate if it balances their budget or if they make money on it. That's not the case for everybody. So appreciate you all taking the time. And I know you've put a lot of work into this, and I appreciate it. And I really hope we can get those numbers from the soc, because I think that rounds it out for the actual number that we're talking about. And I'll stop there.
24 Thank you, councilor Council president Dunphy.
25 Thank you. I, I want to echo a lot of what councilor Zimmerman said. I think that this is the challenge of our time. This is 50 years in the making. This is, you know, the state of Oregon got in trouble in how we were using the state hospital and how we were assessed, you know, what the state's role was in helping with mental health before I was born. And we have never built the capacity that we were promised in our local community level, mental health system. And honest to god, if you go back and read some of the transcripts from when they were discussing the bottle bill back in the 70s, there are legitimately testimony that says that this will actually absolve our responsibility for building mental health, because this is a funding source for the homeless. That actually was said on the record. We never stepped up to the challenge, and the state has never stepped up to the challenge. And I was in this building about eight years ago when council or then commissioner Nick fish started the conversation around permanent supportive housing. It was 2018, 2018 when we started talking about psh. And that's kind of crazy to me that like, I didn't know what it meant. And I was working on housing policy for many years before that. And we're not meaningfully further along and actually solving the problem. I do, however, believe that we have two opportunities before us right now that we've never had before. The first is that this government, the city of portland's government, has never been in a position to be able to be strategic partners with our partners in Multnomah county. In this way, I think that the old commission form of government meant we had five cowboys who were always running in different directions of whatever they had, and we can actually be strategic and recognize who's actually on first. And the reality is that the county is the seat of public health, and the city has attempted to recreate many of the processes that have historically been the county's. And I think we all recognize that it's time to stop doing that. We should stop replicating things. The other reality is that the state legislature has a lot of bad choices ahead of them. They are going to have budget cuts, and we're not going to get almost any of the. There's nothing fun that's going to come out of Salem this year. And I think it is incumbent upon us that if if we know that if we send a wish list of 100 different items and they're all going to get rejected, or we have an opportunity to coordinate with our regional governmental partners and speak with the same voice and say, this is the issue. If you are going to do one thing, state legislature, this is the thing that you do for the Portland metro region. I'm really eager to see that, and I think we're really on the right track towards informing what that state legislative agenda should look like. And I look forward to going down to Salem and advocating to get this. We need our resources. We need the state to treat this seriously. This is a crisis. This is not a casual thing. And as councilor Zimmerman said, other cities have figured this out. Other states have figured this out. No one solved it. But they're certainly doing better than we're doing. And I think this city council is ready to be serious and strategic and go a mile wide and an inch deep rather than the opposite. So thank you for the presentation. Thank you for the work that you all have been doing for your careers. All of this is really hard, and thank you for helping us find what that next step is. And we will be back to ask what the next step is after that and what the next step is after that. We need experts. No one on this dais is an expert. We need you all and we will make the decisions. So thank you all for everything you're doing for our community, and I look forward to being supportive of tackling this as a region. Thank you.
26 Thank you. Council president, vice president Clark.
27 Thank you. Can you hear me? Okay.
28 We can.
29 Yes.
30 Great. I just want to thank everybody for an excellent presentation because some of the terminology is new to me. I probably need to study it and hear it again, maybe a couple more times. But I've been aware of this problem since I ran for the city council. One of the first people I met with was doctor andy mendenhall at central city concern, who was sharing some of this information for me. For me, I really didn't have the mental infrastructure to absorb it all, but I knew there was a problem, the acuity level being very high. And as my colleagues have said, there are so many people who will never be able, maybe never be able to take care of themselves that we have to deal with. I also learned about this when I was on the board of the Oregon providence health system, where the emergency room became the place where so many people went, and they would sort of joke about their frequent fliers, that there were people who continually came in and out of the emergency room who really need to be in a facility and have have some sort of support services. And so I think I agree with everything that my two colleagues before me have said. And I know we were been joking a lot in some ways about getting an annex of the state hospital in Portland. But I understand that from this presentation today, it's much more complex than that. I don't understand why we're so bad, exactly how we got here. But my real question is, you know, what is the reasonable ask when you when you take the recommendations that we've just heard and you put a price tag on them, what what really are we talking about? And where were those? Where will those dollars flow? Now, I know that's down the line as we refine our legislative proposal, but I agree that we need to go big. I agree with councilman Zimmerman, and I agree with stephanie howard that this is connected to so many other issues that we wrestle with and that cost us. But I I'm just wondering now how big is big and what what do we go in with? And maybe this is premature, but and maybe the committee or the panelists are not ready to answer that question. But that's going to be on my mind is just how how much do we ask for and where does it go? Thank you.
31 Yeah. Thanks so much for your comments and your question. I mean, I think the purpose of this work session was really to agree on the what and to get alignment around that without going into a lot of the details of the how much it is, we do know that inpatient beds cost about one and a half to $2 million each. On the flip side, we know that subacute and respite beds are probably more on the order of about $500,000 each. So that gives you a little bit of a sense of scale in terms of like how much the total package would be. But again, we are also recommending that we come out and have 248 beds all at once, right? Like it would be like a gradual build up. And, you know, and we need to obviously get some more details. This was really an initial conversation and just to kind of get aligned around what we're talking about and whether or not you could support that, but we're happy to come back and work with director chase on further details.
32 And I might.
33 Just jump. Thank you.
34 Yeah. Jump in to just a little further on that. The process here is to start this foundation, identify that these are the this is the right path forward and then start to tier some of the the potential areas and levels of support that. What is that ultimate need? What is that high number that go big need? What is political viability during this legislative session? To be strategically smart about what we can achieve and, and making sure at a very minimum, that we are ready to play as much defense and be as ready to be on call and doing our work when questions come up. But over the, the the next work session, end of September and October and November, and then again another work session in December. We plan to be processing this along with you as, as I hope it's come to be understood that we really try to work collaboratively and informatively with all of you as we're going through that process. So this is this is sort of a key milestone in that process of getting those specifics down, having some dialog with our Portland delegation and, and leadership in the legislature to see how we can position and move this forward in the most effective way.
35 Thank you, sam, and thank you to doctor hartman for actually beginning to put some numbers on things that helps with our perspective. So thank you all.
36 Thank you. Council vice president councilor Novick.
37 Thank you councilor. I really appreciate the presentation. I agree with councilor Zimmerman and president Dunphy on how high a priority this is. I just wanted to state a few things that I've heard that relate, which maybe are obvious, but I think are worth saying and worth getting your confirmation that they're true. One is, the one thing I've heard is that a major factor in the acuity of our behavioral crisis now is that fentanyl and the new kinds of meth do greater damage to people's minds than heroin did earlier forms of meth. And that drives up the acuity of the situation that we're dealing with. Is that true? That is true. Okay. The other thing I wanted to follow up on the impact on the housing system, james. And again, maybe these go without saying, but I've heard that the financial cost of destructive behavior by people with unmet needs, both repair costs, increase insurance costs or in some cases, threatening the financial viability of the housing providers themselves.
38 That is also true. The one comment that I would make to that is the key one to hone in on is the insurance piece, because we've all had to go from we used to have like $10,000 deductibles. In fact, we still have a contract with the state that requires that we don't have a deductible. More than 5000. Most of us are now in the 100, $150,000 deductible range, and that's per incident. So we're essentially self-insuring and affordable housing and wasn't set up to self-fund for those types of incidents. So it is a big thing.
39 Thank you. Another thing I've heard is that we've all heard complaints about vacancies and affordable housing, and I've heard that one factor in the number of vacancies is that when you have people engaging in behavior that's disruptive to their neighbors, there's people who simply leave. Is that really is that really a factor?
40 I don't think that we've had people just leave. I would say the destructive piece is that we then have to spend a lot of time and money repairing after someone leaves, which then creates vacancy right? During that time period.
41 Okay.
42 So slightly different. We I haven't heard where we've had folks had to leave because they're, I mean, they might have to go to a different site, etc. But the bigger issue around vacancy is really that turnover, because sometimes we have to do the entire unit over again, which is expensive.
43 But okay. So you don't think that it's prevalent of there's people in places where they're just dealing with neighbors they can't deal with and they go somewhere else.
44 Oh, sure. I mean, that's an issue. I don't think that that's causing vacancy, however. Okay. Because we have folks waiting to, to come in. So I don't think that's a vacancy issue. That definitely is a, you know, sustainability issue, right? For those folks having to move around and not be stable, but it's not driving vacancy, okay, from a like units going unfilled.
45 Okay. And it's, it's a churn issue. Okay.
46 May I add something to that? Sometimes the vacancies are because of coordinated entry, because that process can sometimes take a long time. They're eventually filled. But I know that some providers, including us, where we have units that are with coordinated entry, we usually are running at about an 80% occupancy, whereas buildings that are not under coordinated entry, I can fill like almost 100% all the time.
47 Can you please explain exactly what coordinated entry means?
48 So it's, it's a counting process. And there's a process like that in Multnomah county and Washington county where if you're if you're homeless, you need to go through the coordinated entry process. They assess what your needs are, and then they try to pair you with a housing provider. And then then you might go on a waiting list. There's a lot of, you know, there's forms you've got to fill out. There's a, there's a bureaucratic, bureaucratic process that you have to go to the, the idea of coordinated entry is, is wonderful, a clearinghouse for everybody to go to, to find someplace to live. The administration of it can sometimes lead to, to vacancies.
49 The last thing I wanted to say, and this is probably something we can't do anything about, is that the reverend sarah fisher, who some of you know, made a comment to me a couple of weeks ago that it worries her when people use the phrase behavioral health, because when people hear behavior, they think that, well, you have a choice, you can just change your behavior. And she was saying that people on fentanyl, fentanyl takes away people in particular, takes away people's choice. So I don't know if we should just talk always about mental health and addiction or if there's another phrase, but that kind of stuck with me. Thank you.
50 Thank you, counselor colleagues, I am going to give the mayor an opportunity to ask some questions or provide some remarks. This is the point in the queue at which he messaged me and said, hey, can I join the queue as well? And frankly, our, our state legislative agenda is something that is approved both by the council and by our executive. So I think it's important to make sure that your voice is a part of this conversation, and that all 13 of us are on the same page here.
51 Yeah. Thank you. And that's really what I wanted to talk to you, is just a commitment from the executive with these council colleagues to work lockstep. Whatever we choose. I'm going to be following your lead on this very significant issue because, you know, we've been dealing with homelessness in a robust way and then housing. But at the end of the day, when we drive to work, ride the bus or take transit, we all see our neighbor suffering and we see them on the street. We see them at night, we see them in transit, and we haven't been able to come up with a concerted effort. How are we going to care for our neighbors that we're leaving behind? And it's anecdotal as well. So, julie, thank you for allowing me to view your facility and new narrative. It's an extraordinary success in my eyes. As far as subacute, you're able to stabilize and maintain. And james, you mentioned that is, is that when you go to the doctor in a crisis, you stabilize and then there's oftentimes a long path to that recovery, whatever it may be. I went down to the Oregon state hospital a month ago to tour, because that's where our individuals, through aid and assist are primarily going. Right now, 90% of our state hospital is aid and assist, 10% are our civilly committed. A decade ago it was reverse. And so you see, we're using our state hospital as a carceral system now. And when I talk to the director and the deputy, and they state that a significant, a very large, significant of the people who are being admitted were already seen, stabilized, were released and are being readmitted again, because we don't have a new narrative to address and stabilize the drugs because fortunately, with behavioral health, a large majority can be stabilized with med management. But then we're losing the management. As we release somebody to the streets, they go off med, and then they're being seen by stephanie's team. Our public safety support and or in our our housing, affordable housing. It's not a proper match. So been working closely with evan, been working closely with sam. And our overall commitment is to work with council to come up and speak with one voice as we go down to the legislature to recognize that this is a meaningful and material impact in Portland. And so with Multnomah county here and such, we're going to really lean in on our side of the table, work with your side of the table to really partner through this, because this is the next big issue we need to do well at or do less poorly at. Thank you.
52 Try to aim for. Do well. Councilor Green, thank you for letting me take a quick pause there in the the order we have on our screens and go right ahead.
53 Thank you so much. Councilor. Pirtle-guiney. Thanks for those words, mr. Mayor. When I'm asked about how to deal with this problem from constituents or at town halls or even at campaign events, the the response I have to give is it's it's a scale of a problem that's larger than the city of Portland. Like, we do not have the resources in the city of Portland to address this with a magic wand. And that's an unsatisfactory answer to give. But it's the truth. And I usually say, to solve this problem, we have to go to the root of the problem. And we have to think in systems. We have to think about what is broken in our system, and recognize that this is a multi-jurisdictional problem that requires multi-jurisdictional resources. And so I'm, I'm always going to be in support of an evidence based approach that thinks about the system. What I what I want to make sure that we're doing when we put together our agenda is we're centering the care of the people being treated in that system. And I have to say, and I don't I don't suggest that this is what's being proposed here, but because I do get cornered by a certain type of person to say, you know, we should just lock them up. You know, let's just let's just commit everyone because I think some people are desperate and that's what comes out of their mouth. But because I know that that's an an impulse in this community, I want to make sure that we are not saying that's what we want to do too. I, I have an interest in making sure that the people that we're trying to serve and treat never see the inside of a jail cell. I have an interest in making sure that if there is a warrant served or, you know, an contact with the with the Portland police bureau that they go to diversion and then they move through this system and they get treated for the thing and avoid the criminal justice system. So that's my interest. And I'm going to support an approach that finds the resources to build the system that can treat people. And so I just want to make sure that that's what we're doing here. I think that's what we're doing here. We've got some policy choices that we'll have to make as a city about where we interact in that that will come down the road after we've figured out whether or not we can get some support from the state of Oregon to figure this out. But but I but this is certainly something that costs a lot of money. But if we solve the problem, we'll take care of some people and we'll move forward. So I'm open to this conversation, but I just needed to lay out my caveats and concerns because, you know, mr. Schroeder, that's your name, right? Thank you. You said something that that I'm keenly I'm thinking about every single day, which is the, the connection to the, the sort of affordable housing system. And I think one of the turns of phrases I've used in the past is that we're using, we're using the affordable housing system as a backstop against a failing and insufficient mental health and addiction system. Or, you know, I'm going to be I like sarah fisher a lot. So I'm going to be very careful on the behavioral health piece. But I think that's true. And and so I'm not an expert in this part of it. And so I'm, I'm placing some faith here. But, but but knowing that my, my, my interest is always to make sure people are housed and have the possibility of being housed at all hours of the day and treated for what they need to be treated for and not expose the criminal justice system. So that's, that's where I'm at on this. And I think, I think I think many of my colleagues would share that, that approach. Thanks.
54 Councilor was that a question you wanted answered by the folks at the table? I want to make sure we get you in.
55 Sure. But also, I'm also known for pontificating and sort of putting my my preferences out. But if anyone wants to respond to that, I.
56 Think the proposal we have is in line with what you're saying, but I'd love to have a couple of the providers maybe weigh in on that. And I don't know if it's worth talking a little bit about what the approach at new narrative is, I think, is that a respite care level facility, is that technically what level?
57 No, it's got quite a history.
58 Okay. And we don't need to get into the full history. I'll be speaking a little bit to how this fits in with what you heard from the council.
59 What what it is, is it's technically permanent supportive housing. And people are on a lease. But what we have done is this particular program to get in, you have to have been diagnosed with mental health issue and you have to have been homeless or at risk of homelessness. Those are the two criteria, and that's it. We have cobbled together funding over the years. It's not s.h.s funding per se. We've cobbled together many sources of funding over the years, but what we've found with this particular population and the population that joe has described, that those are the folks that that live at bridgeview. What what we found they need is they need 24 over seven staffing. They need help with with food access, they need medical care. And I'm not talking about full primary care. We have a nurse that comes in, we help them with their medications. We have a counselor that comes in every week. We have case managers. And then of course, we have our just our residential staff that are there to interact with them, support them, make sure they're okay, check on them in their rooms, that kind of thing. And what we're calling this is informally peer support, permanent supportive housing plus or what the what oca hcs is now calling tiered supportive housing. And there is an effort at ohc s to try and actually put put a proposal in front of the legislature next year to support capacity building for this higher tier, permanent supportive model. We we are doing that at bridgeview. I believe central city concern has a program that's very much like it, but it is very, very effective in reducing hospitalizations and incarcerations and stabilizing people. And they have community there because the the team there interacts with them as community.
60 Thank you for that. I mean, that helps clarify that this is just an enhanced version of permanent supportive housing.
61 Yeah. Very enhanced.
62 I think I'll wrap by basically saying that for me, it's not the cost. I don't think the cost is negotiable. I think that we are already paying the costs by not having the system. And and so I'm just interested in the design, the program design and whether it's evidence based or not. And from what I'm seeing, it feels like it's in line with that. Unless there's anything I'm not seeing. But I agree earlier, I think the case was made that this is the work of our time and the resources are in our community. If we have the political will to get them, I think that we should be building the resources for people to to have access to the care they deserve. So sam, I'm I'm supportive of that.
63 Thank you.
64 Thank you. Councilor councilor Ryan.
65 Yes, thank you. First. Thank you panel. There was some very refreshing truth being spoken this afternoon. I think in this room we've come a long way. And being more honest about these issues, I said a lot of the things that I'm hearing in 2020, and I wasn't very popular in the political arena for that. And so I just want to acknowledge that denials, the one of the biggest factors, I think, in why this state got here, and I think it's really important that we continue to do like anyone in recovery must do to stay sober. And that's to tell the truth. My experience also is with the language behavioral health is that a lot of people don't realize that's the big box. And underneath it is mental health and and then also substance abuse or addictions. And then I see people race too quickly to mental health and treat addictions as a lesser issue to discuss. I think it makes more people uncomfortable for some reason. So I just want to put that out there. This, I think, is for you, rachel. Thank you for being here. By the way, six years ago, when I was first elected, like the first official meeting, because the mayor at that time put me as a dotted line person from the city to work with the joint office, now called the office of homeless services. And about halfway through the meeting, I put my hand up. Everyone was on zoom there at that time, and I said, where are the behavioral health and mental health specialist at the county? And the chair at that time looked at me like I was asking a really silly question, and that said everything to me on why we were in this situation that we were in. Where was that integration with what is obviously through my own lived experience, from friends to a brother to a nephew who ended up chronically homeless. And the biggest factor was their mental health and substance abuse issues. They both are capable of working and doing, being stable in housing, if in fact they weren't an active drug addict medicating their mental health through that means. So thank you for lifting that and not shaming that, but actually just naming it as a factor. So I come to this with a lot of lived experience. I also so I want to ask you then, rachel, are they integrated in 2026 since they weren't in 2020 and 2021, and even going into 2022 to feel like the system at the county with behavioral health, mental health and homeless services, are actually integrated and working together as a team.
66 Yeah, thank you for that question. I think we've done we've come a long way and there's more to do. So there are you know, I'm here with my colleagues in the homelessness response system. We have our homelessness response action plan and some governance around bringing in behavioral health folks. Also my colleagues that that work across the housing system, behavioral health colleagues. And but where I think we have more to do is really building a population health approach to behavioral health. And that population health approach looks at systems, it looks at, you know, data and bringing in assessment and epidemiology, as we've seen here and, and uses levers like policy and whatnot. So a couple of the things that we're working on, one of the things that have been added is additional assessment and capacity, kind of those sort of positions that are connectors and conveners. Because as has been said, this is a complicated system and it's going to take all of us and it's an issue of our time. And we're going to be. You may have remembered working. We have in on the in the public health system, we have a public health officer that works across systems, that brings together hospital systems in all of that. And we're going to be hiring behavioral health officer to do just that, acknowledging that that has been a gap and a missing link in the behavioral health system. That person's role is going to be obviously working with our behavioral health programs and colleagues, but also connecting across our other areas, whether that's our housing area, our libraries, our, you know, various human services arms, because the folks that we're seeing are interacting also with all those systems. So that level is really around putting the, the folks at the center, us getting more coordinated in the various areas. And then the third thing that the behavioral health officer will do is be working with decision makers, policy makers, and, and having these sort of conversations as well, and really bringing that behavioral health science to the system level conversation.
67 Okay. That was helpful to hear. It does sound like you've been in many meetings trying to help put that together. And I, I trust you on that. I also was, I also wanted to make sure I lifted what I also heard from you, james, the whole issue of when someone's in chronic homelessness, suffering from untreated mental health, behavioral health, and taking someone like that in the housing first model and putting them into an sro single occupancy unit without any support systems, I couldn't think of anything that could be worse for an addict that's in early stages of recovery, and I've seen this with multiple loved ones because we all we all know it's about going from isolation to connection and whether we want to approve of what that connection is like out in the street. They have connection and community. So that was the main reason I was able to lobby and get a five zero vote here to build safe rest villages and get the county to support it. I was struck that it was odd that after the passage of ships we could not use money for that. I still to this day don't understand that. I think a lot of people that voted for funding the taxpayers of voters assumed that there would be services for behavioral health and mental health. But it was really clear to me that that wasn't what the lobby wanted. And so I hope that we're continuing to wake up to reality and, and see how the the blurriness of all of that. So when we built the safe rest villages, mayor, that was a part of that continuum. And for the first six months when we were actually funding it and we had services, that's where we were getting the best results. We were having people move out of the safe rest villages when 6 to 9 months was needed, at least that much time to get acclimated, to build your resilience, to build your agency, to get to a place where you're working a treatment program, where you're getting workforce aligned in your life, that then you would have the possibility of being successful in housing. And so we've had fits and starts with building a continuum, but we haven't had the political will to stick with it. So we've had those fits and starts, and then someone else gets elected and new things start and that gets blown up. And so it's like, we need a clear game plan about what that continuum is. And when people are running for office, please work with them to understand the complexity of that continuum. We should all be on the same page here. No one likes, you know, googling where oregon's at and mental health and behavioral health and always seen us either one, 2 or 3 on the bottom. We'd like to be. I never thought I'd like to be more like utah. Like they seem to always be at the top of the list and some other states. So where is it that that we keep getting in our own way? Like what is it with the lobby, the different lobbies where they, you know, like rats just eating each other up when we should be on the same page. If success is to take people from co-dependence on services, co-dependence on drugs, co-dependence on chat services, because they're, they're basically in an er place on the ground. When are we going to move to a more stabilized continuum? What's that going to take? And when is Salem going to be able to have that conversation? And it doesn't matter what side of the aisle you're on, you should be excited about moving people from that dependance to that independence sense. This stat of the majority of people who are homeless are men ages 24 to 55, who aren't physically disabled, and they've been taken out of our workforce. And instead they're dependent on our government resources. This is such an economic deprivation to our state and to our city. So are there those kind of conversations where you can make the economic argument down in
68 Salem that this is killing us economically.
69 Well, I would jump in here because I want to. Those comments underscore a lot of important issues around this work. And so we have this incredibly large, complex system for what we call our calling behavioral health care, but, you know, may appropriately be termed with different nomenclature. But I, I, I think that that issue and there are many issues to be resolved and refined and developed and put forward to have a comprehensive system. And we saw the continuum and some of those pieces, the the place where we are feels like a good start, which is to say, these are the the most fundamental priorities that we can be more narrowly focused on that will have major impacts to having the system work better. That is also an entree to be bringing forward those other understandings about the economics, the, the of the cost, the cost issues, and all of those that many of the council have brought up. So that in and I think your message here to this group is helpful in that we can continue to develop that messaging, that communication, how we're talking about this work and bringing folks along. And this is really the the, the furthest, I think this region has come along around a unified behavioral health. There are challenges. City and county are working on a lot of different issues here. They're incredibly aligned. Right. And, and the health providers are incredibly aligned around this in a way that has not been seen, I don't think, on these issues in the region. And I think that's a real entree strategically to being able to inspire and, and, and bring other electeds along and, and, and other communities along to really start more comprehensively addressing these issues.
70 I hope so, because if we really care about the people suffering on the street and not being right about our plans from 10 to 20 years ago, but actually dealing with the reality of today, I think we could get there. And I do think the economic equation hasn't been used enough to answer your question. So that would be one the other one to make that case. And also I think it's all about on ramps to stability, which is why I'm deeply disappointed that we didn't continue to fund the safe rest villages that were getting results. Instead, we've defunded them and we need more on ramps. So when you mentioned the transition housing that works, my last thing that I'll do too is, is bring up two more points. One is, is there anyone on the panel that's in? If you want to admit it, is it dealing with lived experience in recovery? Are we going to hear from people today that are in lived experience, meaning they are in treatment, they are stable, they're in recovery, if you will, because I think the peer to peer services are essential. I don't know one recovering addict. Key word recovering who remains in recovery unless they're active daily. That's why they say one day at a time, connecting with other recovering addicts or helping those that are suffering. So lifting the peer to peer services is authentic. It's inexpensive and it works. So are they at the table?
71 I mean, from healthcare's perspective, I would say we have a number of interventions for folks who are in our high acuity behavioral health cohort. And most of those programs do have peers who have been dealing with issues themselves. Right. And they do become a really critical piece to engaging patients because they understand where they're coming from. I think your question around, do we have peers actually helping us advise like our next steps, I think is a really good one and a great suggestion. We definitely have them involved in our interventions at the patient level, but what you're suggesting is kind of a level up, which I think is a really great suggestion.
72 I appreciate you acknowledging that. I, I again, I just haven't seen any results unless there's people with lived experience active in a leadership role in this type of work. I'm no offense, but like the people that I know that are in recovery, they stay sober, if you will, because of those relationships, not with phds and people that are credentialed. So I think we need to know our level of engagement. And I think we too often in government don't lift what works on the ground. So I just really hope that you push for more peer to peer work, and also that we really do build more on ramps. And I, I want to believe you that you think that the city and the county are more aligned than ever. Maybe. Rachel, you said that I look forward to that day because I often say that we should be merged. And it's on both public safety and when it comes to this type of work, we get in our way and we waste time fits and starts of, oh, shelters are the number one priority. Two years ago, shelters or services. Now they're off the table and we're starting to already see those impacts on the ground. And so I think it's really important for us to stop moving the goalposts, but actually be comfortable with how messy and challenging this work is, learn from the mistakes, get back up and do it better. This isn't linear work. It's messy. And you guys know that. I want to end by acknowledging the first responders. I have so much respect for you. The chats here. I think street responses back there when I do the ride alongs and I experience what you go through, this goes for the police and fire as well. It must be difficult to constantly care for the same people over and over again, because you're all they've got. And where do you take someone? And so we as a government, the state of Oregon and the city of Portland, the county Multnomah, we've just failed miserably to find those places that our first responders can take someone to. And I just hope that we can continue to know that we need to respect their work enough to allow them to actually see it through, because it's pretty demoralizing when you go on a ride along with fire and they say, yes, that's the same person. We've had to move from the doorstop five times this week, and it doesn't feel that good to go home and say, what did you do today? I moved the same poor soul from the same doorstop five times this week. That's not that's not what we want to be. We want to know that there's somewhere to take them, and we can start really being a part of that continuum that you talk about. So keep keep hammering on us. We need obviously to stay focused on reality here. Thanks.
73 Thank you, councilor. Colleagues. Right now we have four more people left in the queue. And if we actually truly only have four more people left in the queue, we are going to power through and try to give folks a little bit of their afternoon back because we've had a lot of time. So consider this an invitation that if you are planning to speak and are not in the queue, get yourself there. So I know whether we need to take a break and give everybody a bit of time, or if we can power through because we only have a few people left. Councilor Smith, go right ahead.
74 Thank you. Thank you for bringing this forward. This is very important work. And I just want to say I appreciate all the intricacies of, you know, offering housing and supportive services with that. I was there in 2018 at Multnomah county, and that was kind of a novel thing, adding services to, to housing. And it was it was much more expensive and for sure, but in many ways it was much more effective. So I just wanted to say that I support this. You don't get any pushback from me. I also wanted to find out if you all participated. Sam, in the pre-session this week at ledge days, were there any bills that you put forward this week?
75 We don't have any bills. Our staff are down there. Although evan had came up for the work session here, but the staff are down there and working, you know, with legislators, but there's no bills being introduced. Okay. At this time.
76 What are we talking to folks about during ledge days this week?
77 We're really learning to understand what the priorities are that are moving forward and get a sense of where the legislature is intending to go on a majority of our issues. I mean, certainly learning what we can about what might be in the pipeline around some of these big issues that we've been talking about. Yeah, you know, ci hub, you know, automated vehicles, transportation issues. What are the costs, you know, associated with the more greater than expected wildfire season drought? You know, so there's a lot of really learning that is part of that process. And then sharing generally what, you know, the city's. You know, sort of overarching priorities are that we, we, we carry over just as general talking points from our, our, our regular agenda. That is still our 2026 legislative agenda.
78 So when will we be getting our overall priority list? When will you come forward to us with a list of other things in addition to the supportive housing?
79 Thank you. We so we've done the issue sheet kind of collection and many have participated in that. And that's from folks throughout the city and council. We are now. This is one step in the process for this particular issue. And then late September, we have a work session where my goal is to bring you a draft. That is a starting point that says, we think there's consensus within the city around these items. So let's start to to, you know, make sure we're on the right path.
80 That's going to be September what?
81 September 28th?
82 September 28th. Okay, perfect. I will cut my comments short. Thank you. You're speaking to the choir with me. I support this and certainly pushing this as a part of the city's priority is something that I don't have a problem with.
83 Thank you. Councilor councilor Avalos.
84 Thank you all for being here and sharing your expertise and also just being honest about what we're facing and what things that we need to grapple with as policymakers. I have a couple of thoughts and a couple of questions. I'm trying to organize them in a cohesive way, but if they're jumbled, then that's that's what you're getting. So first I'll say that, you know, it's clear that Oregon has tried to make some investments in the infrastructure, but it's obviously not enough. The investments do matter, but we're still not really seeing investments that are completing the continuum of care. And so that's something that's top of mind for me. And I'm also particularly interested in the relationship between behavioral health housing and the criminal legal system. You know, as your memo notes, the most of the public inpatient psychiatric care in Oregon is largely tied to people who are involved with the criminal legal system. And I know that our homeless community is experiencing a lot of health issues, not just mental health, health issues. So that includes behavioral health, but also a lot of them are involved in the criminal legal system. And it's hard for me to not clearly see those connections. Right. And as a counselor who represents communities that have historically experienced both divestment or disinvestment and overpolicing, I just don't want us to solve our behavioral health crises with creating another pathway into the criminal legal system. So that's where I'm coming from. You know, I also want to make sure that we're talking about housing as a fundamental part of behavioral health care. Last night I was at the parkrose heights association of neighbors, and they asked me directly, does this council care about housing first? Do you care about getting people into housing? And I hadn't I hadn't had anyone ask me that directly in a minute. And so it was good to kind of talk that out and, you know, just hear how they were experiencing it. And, you know, their perspective essentially is like, we've got to get people housing so that they can solve these issues. I also very strongly believe in that. And so I think we need to continue to have that conversation. What I told them essentially was like, because they were like, does no one care about housing first? I was like, well, I do, right? And there are definitely people who I know share those values, but it is mixed in our region. And I think those those changes in those policy differences definitely are stalling some of these joint efforts on deciding where to put limited resources, right? Where is going to get the most bang for our buck. And so, yeah, I just want to name that as an ongoing thing that we need to talk about and be honest about. Also wanted to say that I've heard a couple of times I hear this, and I've also heard today a couple of times, just this concept of like the people who are always going to need help from their government. And I do understand where those talking points are coming from. I get that they are, you know, because of gestures that everything right. Plus, you know, as you mentioned, the as it relates to the newer drugs on our streets, just their strength and incapacitating nature is just really making it difficult to get people into recovery. But I just want to pause on that and just say, I think it's really important that we keep in perspective, that it is absolutely the job of government to help people and be there, have services for folks. I have a 21 year old cousin who has severe behavioral and mental health issues, and she's always going to need her government, but that's why we pay taxes. That is what it's for. And so I just don't want folks that hear those talking points to feel like we're saying that everyone that needs assistance is a burden. I think that's really unfair. I think there are a lot of communities that, you know, have disabilities and other barriers that their government is supposed to be there for them. So I just want to caution my colleagues when we talk about that, that we keep that in perspective, because I've definitely heard feedback from folks that feel like, well, I, I deserve to have care. I deserve to exist and receive resources too. And I don't want the conversation, the very legitimate conversation about the increased strain on our resources and how more people are needing help. I don't want that to cloud and feel like everyone that needs help is a burden, and your government is supposed to be there for you, actually. And that's what we're trying to solve for and make sure that it can reach all of the people that it's supposed to serve. Because part of the issue is that we're not reaching everybody because the resources are just stretched too thin. So I just wanted to name that because I don't want folks to hear our words and think that we mean that, you know, that they don't deserve that care. I've also done ride alongs with chat and psr, and one of the things that really stuck out to me most is that people are relying on these really expensive emergency response systems for basic health care needs. On the chat ride along, we were assisting a man who, helping him get his medicines, checking in on him, right? Like calling, following up and all of that's great. I'm glad that that's available to them. But in a system that is fully functioning, that's a caregiver, right? That is medicaid helping to support in those in those scenarios, especially when we talk about our senior population. And let's not forget, our growing homeless population is mostly seniors. And so we have to connect these dots as we're talking about what the solutions are. And, you know, that brings me to, you know, for the state, it's like, if we know that these are solutions, why are we cutting medicaid? Why are we cutting health care? Why are we cutting eviction prevention? There's so many obvious tools that research shows is the best method, and the state is just slashing it left and right. We all know that they are under pressure. We are government officials. We know that budgets are tight, but it just feels like for us that are having to deal with it downstream feels like the state is not doing their part to put into those broader systems, because it has to come from them. We we don't fund those broader systems. The state does. So I think that's my message to the state. And as we're shaping, you know what? We're going to go down to Salem and say, here's what we need you to advocate for. I mean, I think everyone agrees with that, right? But I think it's important to just name and be real clear that the state is gutting these larger systems that are feeding into these smaller ones that we're having to deal with on the city level. And so all of that being said, you know, I guess my a couple of questions that I have. You know, if somebody has if someone can only access the highest level of psychiatric care only after being involved in the criminal legal system, I guess, how are we what is what is our thinking about how we're preventing the criminalization of people whose primary need is health care? Like what are how are we balancing those needs and seeing that in the system and trying to solve for that?
85 Well, I will say one of the things that and a number of the areas that you kind of flagged is. But, you know, nobody should have. I think what we've heard from this city in a resounding way is nobody should have to go to jail to get mental health care. And so that's, you know, a, a driver around really trying to create space that is accessible other than, you know, going back to that legal analysis and why there's this logjam where all the space is getting consumed for folks who, who have to go that route to get the care. So I that is on the minds of, of this work. And I think part of the, the driver behind this, and I certainly welcome any any added comments to that, but I also and I guess I'll also just touch first on your observation around the housing continuum and the importance of making sure that the state. You know, that that is more than just a Portland issue. The state needs to be part of delivering on that. And that, I think has a lot of important, you know, overlaps with this work. And that is something that I would like to continue to, you know, I welcome the discussion and dialog from you and others on council to help get through kind of how do we message and move that forward in a comprehensive way with our agenda as we're doing that agenda work? But I do open it up. If there's any other comments to, to some of the or to the question.
86 I guess.
87 Let me add one more layer to it before you keep answering. Also, I would love to know if we have data on how many portlanders, I guess Oregonians, but portlanders are cycling between the hospitals and the shelters and the jails and the emergency departments. Like are we able to track when people are kind of flowing through these systems and essentially they're kind of going in and out these doors, but they're not going into a permanent door where they're stable. So do we have are we collecting data on that? Go ahead.
88 Do you want answer the data question or or. Well, maybe before that, because I do think healthcare has done some great work in terms of folks who are cycling in between multiple systems. But I do think the proposal that's in front of you helps in a couple ways. And I agree from the criminal legal system that that is not the best place that we want folks to be getting any sort of health care and behavioral health care in particular. It's one of the things that we do in the health department is operate corrections, health. And, you know, that includes mental health and addictions and behavioral health care and all of those things. But I think we and we do a great job, and I agree with you that people deserve that service from their government, but I think we'd all agree that's not where we want people to be getting that care, having more resources in the community, I think, helps and to address some of the behavioral health needs before they become a criminal sort of piece. I mean, I'll just share a story. I have a family member, a parent who has not in the state, but in the been it's it's exact issue, a trespassing charge based on unmet behavioral health needs, waited three years to get on the list for housing and then wasn't able to keep it or manage the pieces and didn't have the behavioral health supports, ended up in jail, ended up in the state hospital just to get the treatment. That basically was like, no, you can go back to jail because now you can aid and assist in your own defense, all for something that could have been prevented from having those behavioral health supports in there. So I think having just in general kind of community level interventions like this do help to prevent folks from getting to that level. You know, so those are some thoughts on, on that. And I just, I really appreciate your comments.
89 Can can I speak to that too? It's also intervening before they commit a crime.
90 Exactly.
91 So what I've noticed and I live downtown, so I live among a lot of homeless folks. And but I'm also working on this hospital to housing pilot. So sometimes folks from the street are going to the er. That's their first encounter with the system. And so what our pilot is trying to do is work with those discharged folks at the hospital. We find out what's their issue. They get stabilized to some extent. The hospital then the, the, the transition team, the coordination team figures out, okay, where is the next best place for them to go to match housing and behavioral health care? So they're not going back out onto the street and stealing something or, or getting in a fight or something like that. They're being carried into a, into a recovery journey, right? And it takes, it takes coordination, not just capacity. And, you know, some, yes, we need more capacity throughout the system, but let's utilize the capacity we have even better with better coordination. That's what this pilot is about. And we hope to have some some recommendations by the by the early later fall. But so far it's working. We're we're holding supporting those people through that continuum. So they're not dropping into system based behaviors.
92 I came up, if I may just add one thing, because rachel said something that is really, really important to understand. The aid and assist population is not getting treatment for mental health or drug treatment. They are getting stabilized only to the point that they can then return and address their criminal case. That is not the same thing as getting stabilized, so that you could step down into community care, or the kind of sustainable care that prevents the next crisis. And I think it's a really, really important point that not everybody always understands. And so in my my former life as a public defender, that is a really, really critical piece. So these are not two avenues of health care. There's one avenue that is actual health care. And that's, I think, the system that we're talking about today. And then there's the system that just makes sure that you have enough stabilization to help your lawyer defend you in court in a criminal case.
93 Okay.
94 I really appreciate your comments as well. So thank you. And I also appreciate that you asked about data, because I think we all share a desire to do this in a data informed way. And. Councilor Ryan, I really appreciated your question about how separate these systems are. And the data for these systems are also very separate, right? We have healthcare data on one side and we have data on another side, and then there's correction data on a third side. But we've done as healthcare. We've worked with our county partners in Multnomah, Washington and Clackamas county to actually do data sharing agreements so we can start actually looking at the data collectively. And this out of this has sprung some of these interesting pilots, like the psychiatric hospital housing pilot. We also are doing this case conferencing pilot, where we actually bring housing providers and health care providers around a virtual table and discuss difficult cases and how we can help. And it's actually led to amazing insights. It's on a case by case basis. So we need to figure out a way to scale it and make it a little bit more efficient. But I mean, these are the things that data can give us. So we are starting to look we have a good data set from Multnomah county, and we're looking at psh in particular, and we're able to start seeing what types of patients are exiting permanent supportive housing to homelessness. Again, none of us want that. That's an unsuccessful exit. Well, what are some features associated with that patient population or that member population? Stimulant use disorders high on the list and they're not taking medications. Okay. I mean, that may be obvious, but now we have the data pointing in that direction. Now we can design clinical interventions or collective interventions with our housing and health care colleagues to say, okay, how can we address that problem? So we are just stepping into that space to kind of start doing things in a data informed way. But the first step was actually just getting the data and making sure these two systems that are actually talking to each other. And so that's been the first step.
95 Thank you. I have a comment, but it makes me a little emotional. You know, I just think about, you know, a couple of months ago, my house caught fire. And I've been thinking a lot about the person who accidentally burned my house. And it's all this, you guys, it's these systems. I've been going through the process, you know, as like, a victim of a fire and. I'm more sad for him because I was working with the da and, you know, it's just like, it just breaks my heart because. We deserve better systems for our community. And just watching him bounce back and forth and back and forth. And I have to be informed of all of this as somebody who's dealing with the fire. And it just just really hurts. And so it makes me emotional, but I say it because I think it's important that people see that intersection and it's really nuanced and it's complicated, and people want people to be supported. And obviously, I don't want my house to be on fire, but I just, I just think about him a lot because when we talk about this, like, this is exactly what happened, you know, he didn't have the ability to take care of himself, bounced him around. And he's he's out there. He's still out there suffering. And so I just it's vulnerable to say that. But I tell you that because I think it's really important that we remember the heart of it here. We talk about people like they're just numbers. There's a real impact. And I had to feel that really personally and watch that. And it just this is what this is, what I'm striving for is like, how do I help people like him? So I just wanted to share that personal moment because I hope we just keep keep grounded on how we do better for people like vachon. Thank you.
96 Thanks.
97 Councilor. Councilor. Koyama Lane.
98 Thank you.
99 And thank you, councilor Avalos for your questions and comments. I want to be clear that I believe that everyone deserves housing, and I, I think it was commissioner, Multnomah county commissioner Shannon singleton who had said housing first, like no one ever said it was housing only, like it's housing first. And then people also need support. And since we also kind of touched on this idea of thinking about language, I want to push a little bit for us to think about saying that there are people who are not ready for housing, because while there are people who, you know, have been living on the streets and are going to need access to information and support, skill building and support to stay housed, they can still be ready for housing. We all know people with mental health, substance use challenges who are firmly housed, and I don't think housing is just a privilege to be earned with certain types of behavior. So I wanted to be clear about that. And I think it's especially important to think about how we're talking about this and being mindful, because we're also talking about an area that we know is also an economic justice issue, as well as a racial justice issue with disparate rates based on race and ethnicity. And I also wanted to thank all of you for being here today. And I wanted to follow up on some of director banks's comments related to population health approaches, which I believe is part of a larger public health approach. And I would just love to hear a little bit more about the systems approach that public health brings to these challenges that we're talking about, that look holistically at how we solve some of these challenges, especially from a racial justice lens. And I'm wondering if you can share what the health department is working on from this perspective.
100 Oh, I love that question. And I also know that you all talked about maybe getting out early and not needing a break. So let me try to calibrate. And then with an offer to talk much more about it. But I think some of the things that a public health approach brings to any issue is that it starts with the systems it fundamentally looks to get upstream, it looks to prevent issues. And so and I think what you see here, that even though folks may not consider themselves public health practitioners, the things that that are public health core capabilities are data assessment and epidemiology are getting beyond, getting beyond and getting in between systems. You've heard a lot about. We need connections and coordination. That's inherently a public health approach where you're looking at what are the systems and what's driving people to the systems, and how can we better have folks move with it within that, to a health outcomes piece, it's looking at where are your populations of folks that are having the highest challenges in interacting with multiple systems? So I think looking at, for example, in this situation, the high acuity behavioral health cohort, as we called it a number of years ago, is one of those approaches. And the additional kind of piece around equity is a fundamental public health capability with many other things. So we know on that, as you mentioned, there are differences by race and ethnicity. There's also differences by life expectancy. We are seeing years and years and decades of years lost, preventable deaths with this population, for example, with the high acuity, behavioral health or other for a variety of reasons, including we've talked a bit about overdose. So I think the things that the public health or population health approach bring are a focus on policy, using those big levers to impact big decisions, getting in between systems. The what I've seen is that the behavioral health system is really built around silos, as many are, and we have phenomenal expertise in these kind of or cylinders of excellence. Right. And what everyone is saying is this continuum that's needed, and being able to have more capacity to, in this case, we're talking about step up or step down from care. But I would also add, those are the people that's shifting the approach to. As you mentioned, we need connectors that follow the people, not just connectors that are in each of the system. So it's conveners, it's connectors, it's those sort of things that sometimes are a little bit harder to understand than a direct service practitioner. But that's what I think is, is a gap. This helps us to get there a bit. And I think we, as I mentioned, we have more work to do.
101 Thank you. And I look forward to speaking more with you about this and want to be clear that I support this overall and just want to make sure that I'm also naming that that public health approach, the population health approach is also important, an important part of the conversation and finding solutions. Thank you.
102 Thank you, councilor Councilor Zimmerman.
103 Thanks. I just wanted to commend councilor Avalos. I think he brought up some important points about how this weaves together. And and actually toward the end there with with cuomo councilor Koyama Lane, too. I don't think that you know, anything about this is is anti housing. First, I want to be really clear with what we're seeing. What we're talking about is a group of folks who have a responsibility, who are saying, in order to do this, well, we need this other tool. And that is these increased beds and and things like housing first, one of the reasons why we haven't quite gotten it right in our state, in our community, is that we have major aspects of it that people don't have access to. And so to answer the question of like, how do we get upstream so that somebody doesn't ever engage in the criminal justice system? It's these beds. How do we make sure that the beds that we do have are treating people at the highest efficiency, if you will? That's not having the state hospital filled with aid and assist. Where to? Stephanie howard's point, no one's getting actually mental health care. They're getting like a band aid on a gaping chest wound, right? Just enough to walk somewhere else so that we want our mental health hospital. Who has the deep responsibility to deal with the most difficult stuff, to be able to do that and not be truly a warehousing, right? That that is what we've kind of moved to since the is it the mosman decision? Am I getting that right? Right. We've kind of moved that direction. And so we've got that that needs to happen, but we've got to figure out the rest of the system. So I'm seeing that happen. And I think that this I think these can be complementary to all the values we've seen come up on here. I want to I want to raise my one greatest area of concern. And most of my time in government, a department will come to me or to the person I worked for when I was at Multnomah county and say, hey, we need this thing to be better at our job, right? Whether it be planning, zoning, police work, fire work, etc. The health department has done that historically on a lot of topics. But on this topic, historically, I have my greatest concern actually with Multnomah county's health department and with the Oregon health authority, from a kind of almost a bureaucratic perspective about moving a little bit more aggressively in, there are some folks who we need to advocate for a bigger option, a more. Well, first off, you know, we've we've improved the commitment laws in this last session that not everything is always going to be community based. Like, there are some folks where because I agree wholeheartedly with councilor Avalos, some folks who. Government. We are, we are supposed to be that backstop. I'm in it. I am said that I'm always going to be there. I, I worry because in my time at Multnomah county, no public health. Excuse me, no health department director, employee, anybody ever came and said more than I'll just say some a little bit around the edges. Right. And it was a lot more about people who just with a few more supports, they're going to be successful. We spent a lot of time in that conversation. We spent no time in the most severe. And that's where my worry is at and giving. Given the 15 or so 17 years or whatever, I've got experience between the two. I know the revolving door between oha and co, and in a lot of ways that we've tried things out in multidose that oha can do it when it comes to like public health, things like kids and cigarettes and tobacco, right? So I'm raising that because I want to get proven wrong, right? I'm raising that because I also think that we have this opportunity here where I'm, I think that oha and co probably weren't going to do this or bring this to us on our own. And I'm seeing others up here. I'm seeing providers who have been coming out of the woodwork asking for a different perspective at those. Two are two largest health agencies in the state government, local government. So that's my ask. I want to be wrong as hell in a couple of years. But bureaucracy, what is it? It's like the stick in the mud thing. And this is one of those areas I have a lot of concern that Multnomah county has got some of the old cobwebs of that aren't that are not prepared for the moment. And I and I, we need I think we could have been further ahead of this years ago, maybe. But for some of that bureaucratic cement that existed between the two agencies. And so I'm asking for for us to oil it up, get things moving, except that we're going to have to make tough decisions. And if all the different perspectives that got shared and I and I've had this conversation with several county commissioners of this type of thing, and if we can be successful with all levels of the higher acuity stuff, makes our community based system a hell of a lot more successful because right people, right place and the throughput, that throughput. Maybe a few years ago, I didn't understand the importance of it. I think I'm understanding the importance of it, largely because some of your testimonies in our meetings over the last couple of years. But that throughput is important. So we need we need oha and we need more co health to be the leaders on this as the largest agencies. And I think where those two agencies go, the state can be the state broader other 35 counties can be successful as well. But please prove me wrong.
104 All right. So I didn't walk in here today thinking that I was going to say, I look forward to coming back and and proving me wrong. Councilor Zimmerman but you all heard it. No, I appreciate it. And I think that, you know, a couple of thoughts. One is that I would say this is a different conversation as recognizing that we don't have systems built for. We didn't they were underfunded, as I mentioned before, but we don't have systems built for the now. We've got to do new things. We've got to be thinking about, you know, behavioral health differently and, and working with partners and convening because there's so many different systems. And, you know, and I think then also just acknowledging that folks whose job it is to provide care to people just want to keep doing it. Right. And because they, they know that that that's a value. And so we'll continue to hold that value. We'll continue to have folks that want to see people in suffering and wrap other supports around. And I think we also know that we need system changes, and we need to be doing something differently to get the outcomes that we want to see. And, and, you know, change the trajectory.
105 So thank you.
106 Invite me back so I can prove you wrong. And I'm, I know we're all in it together, right? I think that's what's really powerful about this. And hopefully what folks are seeing is, is different and a mark of kind of a different way of moving forward.
107 Thank you. And last point to the chair and president. I just there was a moment about how do we do things cost effectively. And that was said a while ago. And councilor Green kind of alluded to like cost isn't maybe the driver for me. And I would just want to say, I also highlighted that as like, I am okay with the proposal that it's too damn expensive to fund because at least then I know where we need to get to. And so cost effective versus effective. I think the word I care more about on this topic is effective, but I don't want to start from a only a cost perspective or cost effective perspective. I should reframe that somehow. But I just want to convey that because I, I recognize that challenge that is every nonprofit, every health care system. That is always the challenge of what's. But we've gone so far in the other direction of spending money that isn't really intended for certain clients and patients in ways that I almost feel like there's a washing of a reset to know like what is effective and then going into how to then what is achievable in the short term, but also what's achievable in the long term, because I don't think this is a one session, two session or three session thing. I think we are I hope we are in a decade plus of building out a system so that we are not 50 out of 50. That's where that's where my passion is at here.
108 Thank you. Councilor councilor Kanal last in the queue.
109 Thanks. I have a question for director chase. Do you feel like you have what you need from us coming out of this?
110 I feel like I've been able to capture a lot of the kind of perspective and feel of counsel for this. A lot of the issues around how we're communicating it, messaging it, integrating it with the housing agenda and that work. I feel like I've got a really great sort of a foundation to be able to come back and, and continue this dialog with you in work session and beyond. And I, and I, I welcome and expect to have dialog and conversation with you in various ways. You know, we'll, you'll see us having our typical kind of briefing availabilities. You're going to see more of us than I always say than you did during budget season. You know, it's going to start picking up where you see us a lot again. And so, so yes, I feel like this is been a very insightful, enlightening kind of discussion. I really appreciate the way council has leaned in over the last year really on this issue to help sort of give us some guidance around where to land. It feels to me like we're landing in a place that council is collectively saying, yes, we want to continue and and do this work. And there there are a lot of nuances and ways that we want to make sure we get it right and that we're, we're, we're big and bold and looking at long term problem solving and also recognizing short term challenges. But I feel like this has been. You know, very welcome conversation. You know, I have so much appreciation for the alignment that is here with this body that is not fully representative of all of the folks that are united on the on, on this issue. So so the short answer is yes.
111 Great.
112 You know, sometimes in executive sessions, it's like people count how many times, how many different people are saying they agree. So I wanted to make sure I said I agree. I also wanted to really just highlight and uplift a couple things that are related to this medicaid reimbursement for the behavioral health work. I noticed we have folks from psr in chat here. That's really vital. And I know you don't just advocate to the legislature, but to the government. And so the oha could do a lot more there. I really appreciate what councilor Greene was saying. And as this relates to data collection, that we are paying the costs, when we don't pay the costs up front, we pay them in other ways. So I appreciate that as well. And I have very similar experiences on my my ride alongs, obviously same district to to councilor Ryan. And when I was with fire and went out on an overdose call and was told by the folks I was with that this was the third time they'd seen this guy that day in 24 hour shift. And I'm near the end of it, but still, right. That's that's a particularly egregious type of situation. So I, I look forward to, to getting to a place where we're giving people what they need, when they need it and not the bare minimum necessary after the fact. And thank you. Thanks. Thank you.
113 Thank you, councilor Colleagues, that exhausts the. Q I want to thank everybody who participated in the conversation and our guests who are here today and who brought this proposal forward for us and everybody who you worked with to put together these ideas and get to a place of agreement amongst providers, perhaps not all, but many providers. That allows us to have an entry point into this conversation in a place where we might be able to advocate together as a community. I also want to give a big thank you to our government relations team, director chase. Your team has spent a lot of time behind the scenes helping to corral this group and get us a proposal that we could consider today, and that work that is not the the direct lobbying, but is the behind the scenes helping to coordinate and plan and get us the proposal often goes unnoticed. So thank you to your team for putting this together for us.
114 Thank you.
115 I heard a lot of agreement today. And so I just want to restate a few things that I hope you're taking from this conversation. All of you. We want to go bigger and go bolder. If there is a need to do that and perhaps have an ask that we know we can't achieve just in one year, we want to make sure that we are building toward a system where you don't have to go to jail to get care. And the proposal that we have before us, we hope, helps to move us in that direction. And if not, we want to make sure we have something that does. There were questions about clarities on the level of care and making sure that this isn't just institutionalization by another name. So a little bit of clarity there as we move forward to make sure folks have confidence in the proposal will be helpful. Similarly, we want you to be clear about costs, not just the cost of these beds, but the cost of not having these beds, the costs to our housing system, our health care system, insurance costs in our affordable for our affordable housing providers evictions. And the way that that throws people into stability and make sure that as we bring this forward to advocate on, we're armed with that data and that information, and we need you to be in alignment with us if we are going to take this leap and say this service that we don't provide is a high priority, we need to make sure we have you all asking for the same thing and not a bifurcated group of asks from providers across the system and colleagues. As we move forward, let's keep in mind that we are not seeking to open a new book of business for the city. We're not seeking to direct the system or be a pass through for funds, but we heard loud and clear today that we can ensure that this system is meeting the needs we see in our community every day. If we're advocating for funding for the specific parts of the system which are desperately underfunded and underserviced right now. We can only do that, though, if we stay committed and focused to this being a high priority in our legislative agenda. So as we meet later this month to talk about the rest of our agenda, I hope that we continue to be as all in as I've heard folks being today. I think our conversation today has given ogr a sense of what we could collectively support. Sam, I heard your overview there. Thank you. And as we continue to meet, we'll be able to talk about what role this plays in our legislative agenda. Just as a note, there ogr will be back in late September to talk about the broader state legislative agenda. Council president, I look forward to you getting to run that meeting and not me. But at that point, we'll get to revisit how this is a part of our broader work. In the meantime, if you have questions, I know director chase, you have said you are open to more discussion around this topic. If folks have thoughts or ideas after we leave here today, and I hope that everyone gets their questions answered. If they haven't been yet, I'll look forward to seeing that data from director howard to make sure that we all have the background on what the city is doing right now. With that, I am going to turn it back over to director chase for a brief closing and then to the council president to close us out today. Thank you all for being a part of this work and walking this journey together.
116 Yeah, I just thank again the panel and council. I think we've we've we've got a game plan to sort of keep moving on this. And so I'm enthusiastic about it and feeling very hopeful.
117 Ditto.
118 We're adjourned.
119 Thank you.
120 Thanks.
121 All right.