Hundreds of people with serious mental illnesses in Multnomah County aren't being enrolled in treatment programs they qualify for, according to a new county audit.

“Multnomah County’s ability to serve adults with serious and persistent mental illness is limited and faces imminent risks,” reads the audit, which was released by the Multnomah County Auditor's Office on Wednesday. “Currently, over half of people who are involved with the civil commitment system are not receiving the most intensive services the county offers.”

The bulk of the audit is devoted to the Choice Model Program, a state-funded program meant to help keep people who have a "serious and persistent" mental illness out of the state mental hospital and enrolled in treatment programs in their own community. If patients have to be held in the Oregon State Hospital, the Choice program works to connect them with the "least restrictive level of care" possible.

The majority of Choice clients are referred to the program after they are civilly committed—a process where a judge rules that a person is danger to themselves or others and must be committed to a mental hospital for at least 180 days.

The audit finds that, between 2016 and 2018, 676 Multnomah County residents were civilly committed—but only 326 people were enrolled in Choice.

In other Oregon counties, being civilly committed would usually be enough to be accepted into the Choice program. But in Multnomah County, the audit finds, there aren’t enough resources to serve this entire population. That means Choice program is mostly limited to people in the most restrictive scenario—those being held in the Oregon State Hospital.

“Multnomah County already serves a huge number of people, so that may be a driving factor on keeping a narrow criteria [like only allowing OSH patients access to Choice], just so that their caseloads don’t explode,” says Caroline Zavitkovski, an auditor who worked on the report. “But those are the tradeoffs that are faced.”

County auditors found a similar lack of resources for clients enrolled in Assertive Community Treatment (ACT). The state- and Medicaid-funded program provides services for individuals with serious and persistent mental illness who are living independently, "but are not able to manage significant aspects of their daily lives, such as consistently taking medication, on their own,” according to the audit.

The audit found that only 19 percent of people potentially eligible for ACT between 2016 and 2018 were enrolled in the program.

For clients who do qualify and are enrolled in Choice, their options for housing and care remain limited. There are 26 residential treatment facilities in Multnomah County for people with persistent mental illnesses, but they don’t always have open availability.

“Program staff told us that residential waiting lists in the county are usually closed and when they do open up, are open only for minutes or seconds at a time, due to high demand,” the audit notes. “Once on a waiting list, clients still have to be screened, accepted, and wait for an opening.”

Multnomah County also operates supportive housing, or housing paired with social services aimed at ensuring a resident’s long-term success. ACT and Choice clients are theoretically eligible for this type of housing—but they can face bureaucratic barriers, according to Multnomah County Auditor Jennifer McGuirk.

“Let’s say they’re homeless, and they want to get into these new housing developments we’re building,” McGuirk told the Mercury. “For a lot of them, they would have to meet the federal definition of homelessness—and if you’re coming out of the state hospital, that’s considered a residence, so you can’t get into one of those slots.”

McGuirk’s team found that even tracking outcomes for Choice and ACT clients was a challenge, because the county has one overarching category given to people enrolled in those programs—“independent living”—that covers a broad range of living situations.

“This category could include an independent apartment, room and board, a motel, living with family, being homeless, or living in a shelter,” the audit reads. “Without being able to disaggregate further, this category is clearly problematic for assessing outcomes.”

McGuirk said that vagueness “makes it harder to adjust for individuals, so you don’t even know what your baseline is, or what you would expect” from the programs.

Many of the problems mentioned in the audit seem to be caused by problems that are oft-identified and well-understood in Multnomah County: a lack of adequate state funding for social services, and an impacted housing market. But one issue points to an irresponsible use of funds at the county level.

In fiscal year 2016, the county’s Choice program had a $2.5 million surplus. Zavitkovski said the responsible way for an agency to spend a surplus is to “only use it for a one-time expense, because if you use it for something ongoing, you’ll run out.”

Instead of doing that, the Mental Health and Addiction Services Division chose to spend its extra money on an ongoing “expensive [housing] contract" says Zavitkovski. When that surplus ran out the next year, and the state decreased its funding for Choice, the county had to cancel the contract, resulting in a net loss of housing units for Choice clients.

In 2019, the county is again saving surplus Choice funds—this time, it’s $1.4 million for transitional housing at its new Behavioral Health Resource Center. McGuirk said this use of funds is a more appropriate use of the surplus, but that “there are tradeoffs.”

“Maybe they’re not able to help someone with their immediate needs if they’re doing that,” she said.

“The program needs to be more transparent with the [Board of County Commissioners] and the community” McGuirk added, “about how they choose to use the funds they get from the state.”