Program Aims to Innovate to Improve Health, Lives of Portland Area’s Most Vulnerable
When a worker at the Multnomah County Tri-County Service Coordination program met with a client recently, the client, Tina, was having a meltdown.
Her boyfriend had just been incarcerated, and she’d been up all night, recalled Alison Goldstein, the program’s lead social worker. Tina was yelling profanities and throwing things at a security guard, “incredibly anxious and scared,” barely able to sit still.
Tina is young, pregnant, and has spent much of her life in the foster system. She’s homeless, uses methamphetamine, and has an intellectual disability: multiple life difficulties clinical workers sometimes call “tri-morbid,” a combination which studies have shown can lead to frequent, expensive ER visits. And efforts to reshape or replace the Affordable Care Act could jeopardize the Multnomah County program that’s helping Tina — not her real name, which is being withheld to protect her privacy.
Goldstein was there to help thanks to the Multnomah County Tri-County Service Coordination program, or TC911, which seeks to identify people like Tina — hard-to-find, struggling, and unlikely to take the steps on their own that would connect them with public support. She was identified via a monthly data dump from ambulance companies MetroWest and American Medical Response. Goldstein’s team searches for those in Multnomah, Clackamas and Washington counties who have had ten or more contacts with ambulances and fire in six months, then uses “sleuthing” to connect.
“We’re like the Nancy Drews of EMS,” Goldstein joked.
The program’s allows local agencies to overcome past cuts to street outreach paraprofessionals who worked with the tri-morbid population, Health Department Director Joanne Fuller said. Tuesday, May 9, Goldstein will present TC911 outcomes in Salem at the Oregon Health Authority’s “Innovation Cafe.”
TC911 saves lives and dollars, said Multnomah County spokeswoman Julie Sullivan-Springhetti. It helps people like Tina get healthcare and other forms of support — even when they face multiple barriers to accessing public programs.
Proponents call it innovative and effective, but 87 percent of its budget comes from Medicaid. Congress’ efforts to cut and rework Obamacare could defund TC911, Goldstein said. “We could certainly go away,” she said.
Yet cutting TC911 could cost taxpayers more than it saves. According to a summary provided by Multnomah County and based on a 2016 study by the Providence Center for Outcomes Research & Education, the program costs $1.16 million per year, but brings a return-on-investment of $3.6 million per year.
County Commissioner Sharon Meieran, who is an ER doctor, describes current proposed cuts at both the state and federal level as “both uncertain and scary.”
“It’s two bad things,” she said. “It looks like it’s bad, and it’s uncertain. That makes it even more important that we at the county level are providing services, and identify those gaps in interconnection so we have a comprehensive approach.”
TC911, Commissioner Meieran said, is “exceptionally valuable.”
The deaths of five people on the streets of Portland during a brutal winter triggered a storm of media coverage. The news hit home even for Oregonians who suffer from “compassion fatigue” thinking about these tough issues.
Unfortunately, new results from Clackamas County and Clark County, Wash., show significant increases in unsheltered homelessness, sure to lead to a corresponding increase in health problems linked to homelessness. The Portland-Multnomah County Continuum of Care homeless count is expected later this month.
At the March 3 executive committee meeting of A Home For Everyone, the city-county group, Multnomah County Health Department staff shared that there were 144 hypothermia-related emergency department visits this last winter — nearly three times the 53 from the winter before.
Health Department Director Joanne Fuller, who has seen these issues evolve during 28 years of service overseeing three county departments, discussed the term “tri-morbid” to describe homeless individuals whose multiple barriers often prevent them from accessing healthcare and social support.
Common usage conflates “morbidity” with death, but Fuller explained that tri-morbidity is “the intersection of all those challenges.” Typically, it’s three co-occurring conditions from a list that includes mental illness, addiction, homelessness, physical health problems or incarceration.
One person may have many problems, but a human being isn’t just a list of disorders, and real help is holistic in nature.
“You have to address all of it together, you can’t just think about one thread of that,” Fuller explained. “They can be compounding. When people are dealing with all of that together, it can be more impactful than if they just were dealing with substance abuse and mental illness. That’s why I don’t talk about it as dual diagnosis, because it doesn’t acknowledge the impact of the other issues.”
Goldstein said TC911 social workers reach out to ER and EMS staff in order to get “real-time alerts” on hard-to-reach clients who’ve just come in to a hospital or clinic. Then they go meet them.
“We say, ‘Hey Joe, what’s been going on? Are you eating? Do you have a doctor? Do you need help with transportation? Are you lonely? Do you need help with meds?’” If Joe doesn’t have a sleeping bag or tent, or if he needs a little help with transportation or food, TC911 staff have access to “flex funds” to buy stuff.
How many homeless people are “tri-morbid”? Answers can be elusive, but studies suggest it’s a significant percentage: 26 percent of homeless adults live with serious mental illness and 46 percent live with severe mental illness and/or substance use disorders, according to the National Alliance on Mental Illness.
About one in three TC911 clients are unstably housed, according to a program summary provided by the county. “It’s closer to one in two” in Multnomah County, Goldstein said.
Other TC911 statistics about clients:
- Three of four have a significant physical health diagnosis
- Three of four have a mental health diagnosis
- One in two are substance using
- They have 40 times higher rates of ER visits than the average Medicaid member.
“If you were to look at my wait list right now, if we get someone who has just a physical health condition, it’s incredibly rare,” Goldstein said, adding that TC911 is considering adding a nurse to help understand complex medical situations. “Most of the time there’s at least two things going on, if not three or four. So these are the most vulnerable, the most burdened.”
This ability to work across system silosis crucial, Commissioner Meieran said, noting that her experience as an ER doctor has shown her “services that are operating within their own universes and not aware of one another.”
“We see a lot of where those connections that should be there in our system fail, and those collaborations that should occur fail,” Commissioner Meieran said, “and people end up in the ER, which is the least effective and most expensive place to deal with that.”
Part of what makes TC911 successful in the face of overwhelming challenges is that caseloads are small. Each of the program’s six social workers has about 15 clients, and seeks to connect or reconnect them to available support systems during a six-month period, Goldstein said.
“We call ourselves Janes of All Trades,” Goldstein said. “We are masters of nothing — we can’t be. We do a lot of medical, but we are not medical providers. We assist people with housing, but we are not housing workers. We work with DD folks, but we are not developmental disability workers.”
What TC911 workers actually do, Goldstein said, is based in addressing the most pressing needs first and can be as simple as buying a client lunch, or a tent. Goldstein brought Tina a cup of water to drink.
Or it can be as complicated as finding a bed at a residential treatment center, a hard-to-find option which Goldstein joked “requires star alignment.”
Goldstein shared the story of an alcoholic man TC911 helped get into residential treatment. These days, he walks by his former “street family” every single day to get outpatient services.
“In a year this guy goes from being on the street, probably having over 100 ER visits in the last year, to physically he looks like a different person, he put weight on, he’s eating, he’s not drinking, and he feels like he has meaning in his life,” Goldstein said. “Who doesn’t want that?”
Of course, for some TC911 clients, like Tina, there are no easy answers.
Goldstein says her pregnancy and recent meth use made Tina a “rule out” for the Unity Center, so with no other options, she got Tina a cab to a local hospital ER. Then she got a call that Tina hopped out after traveling ten blocks.
“She was agreeable, until she wasn’t,” Goldstein said. “When that person says ‘I’m ready for treatment,’ our systems aren’t designed to provide access in that moment.”
Still, Tina’s connection to TC911 may yet prove a lifeline amidst stormy waters.
The Lund Report’s educational arm, the Oregon Health Forum, will host a discussion of how counties are tackling community mental health problems, with a panel that includes Fuller, as well as other experts on the topic, on May 31. Tickets are limited and are selling fast.
This story was first published on the Lund Report.
