What We Found
The Behavioral Health Services (Division) has implemented 9 recommendations from our 2019 audit of the county’s community mental health program, with 1 in process and 1 not implemented.
What the Statuses Mean
- Implemented – Auditee has fully implemented, or auditee has resolved the issue to meet the recommendation’s intent.
- In Process – Auditee has started implementation.
- Not Implemented – Auditee has not implemented, or does not intend to implement.
Why We Did This Evaluation
The Auditor’s Office follows up on audit recommendations to support county government’s accountability. This evaluation focused on all 11 of the recommendations from the 2019 audit.
Status of Recommendations
Recommendation 1: Publicly report to the Board of County Commissioners on Choice program funding prioritization decisions, the status of state funding, and progress in developing new housing resources.
a. Present at least once during each state biennium in a board briefing or board meeting.
b. Explain tradeoffs in funding decisions considering possible areas of investment, such as:
- Developing new supported transitional housing
- Enrolling more Choice clients (and consequently potentially hiring more Exceptional Needs Care Coordinators)
- Adding peer support services to the Choice program
- Purchasing additional non-Medicaid assertive community treatment (ACT) slots
- Contributing to the new Behavioral Health Resource Center
Auditor’s note: The Health Department and Behavioral Health Division presented to the Board of County Commissioners on the Choice program during the previous state biennium in January of 2020. The current biennium ends on June 30, 2023.
Recommendation 2: In the future, do not underspend state grant funding unless there is a written commitment from the state that the county can keep the funding in future years, and only spend reserved funding on one-time use, not ongoing expenses.
Auditor’s note: In the two years since the audit, the program has not underspent its state grant funding to a significant amount – less than $5,000 in 2020 and 2021 combined. Moreover, the state contract manager confirmed that the county is allowed to carryover unspent grant funds for use in future years.
Recommendation 3: Analyze and publicly report on options for addressing ACT accessibility such as:
- Advocating with Health Share for additional ACT capacity,
- Breaking up ACT services so some can be billed to non-Medicaid insurers,
- And/or developing alternatives to ACT services that could provide intensive treatment but be billable to non-Medicaid insurance and with fewer fidelity constraints.
Auditor’s note: Choice managers monitor ACT capacity and statistics. ACT capacity is currently limited by ACT team staffing shortages, rather than funding. Private insurance coverage of ACT is evolving – with at least one private insurance carrier now covering ACT.
Recommendation 5: Develop a process for regularly monitoring commitment services data, to ensure that those who could be eligible for Choice and ACT are identified.
Auditor’s note: The Behavioral Health unit created a process by which the involuntary commitment program refers individuals to be evaluated for the Choice program. Hospital staff as well as others can also refer individuals to Choice and ACT. Finally, the Choice program created a process to manage and track all referrals.
Recommendation 6: Advocate with the Board of County Commissioners, the Joint Office of Homeless Services, regional partners, and the State of Oregon to increase the number of dedicated supported housing units for people with serious and persistent mental illness.
Auditor’s note: The Division told us they had engaged with partners such as the Joint Office of Homeless Services to increase supported housing capacity.
Recommendation 7: Review data collection processes and make adjustments to improve the availability of information to assess program outcomes for Choice and ACT.
a. Including changing the “independent living” categories into more categories and conducting satisfaction surveys.
Auditor’s note: Choice program staff made strides in improving data collection and quality – for example, better capturing the living situation of Choice clients. Changes like these improve program staff members’ ability to measure outcomes for clients.
Recommendation 8: Develop a process to capture ACT outcome data that is sent to the state, for monitoring and evaluation purposes.
Auditor’s note: The Choice program works with the Oregon Center of Excellence for Assertive Community Treatment to obtain ACT outcome data.
Recommendation 9: Set up data sharing processes and agreements with other county entities (such as, the Sheriff’s Office, the Joint Office of Homeless Services, and the Intellectual and Developmental Disabilities Services Division), to share data for program evaluation purposes.
Auditor’s note: The Choice program has access to data from the Multnomah County Sheriff’s Office and the Joint Office of Homeless Services as well as data on emergency room visits, crisis calls, and some medical claims. Since the 2019 audit, the Division lost access to enrollment and claims data for some Medicaid clients. HealthShare has these data and had denied access.
Recommendation 11: Allocate staff for ACT contract management (as applicable after CCO 2.0).
Auditor’s note: The Behavioral Health Division allocated a contract specialist and a Senior Manager to administer the ACT contracts for the 42 ACT slots the division manages in the Choice program. CCOs manage the contracts for the remaining ACT slots.
Recommendation 10: Develop a process to routinely measure outcomes for Choice and ACT, including identifying racial disparities in outcomes.
Auditor’s note: The Division reported making progress in building reports from their electronic health record system. They are now moving toward a more sophisticated use of these data to report on program outcomes.
Recommendation 4: Update county Choice policies to ensure that the policy language is aligned with the contract with the state; to clarify Choice enrollment criteria, particularly related to people who are civilly committed but do not go to the State Hospital; and clarify criteria for exiting someone from Choice.
Auditor’s note: This recommendation was not implemented. Multnomah County Choice Program Policy is mostly consistent with the language in the state funding agreement with one notable exception. The state contract says that individuals who, due to severe and persistent mental illness, meet a number of criteria shall be offered Choice services. County policy says these same individuals may be offered Choice services – making the county policy more restrictive than the state agreement calls for.
Division management told us the state has not questioned the program policy language. Moreover, they said that the contract language has not changed since the advent of CCO 2.0 that brought with it alternative intensive care coordination programs that are more appropriate for some people who would otherwise be enrolled in Choice. Offering Choice to these individuals wouldn’t provide additional benefit and would simply add more to existing Choice caseloads.
Objectives, Scope, & Methodology
The objectives of this evaluation were to determine the status of recommendations from the 2019 audit of mental health services. Auditors evaluated the status of recommendations based on interviews, documentation, and other available evidence.
Updating the Status of a Recommendation
During each audit our office conducts, we develop recommendations intended to improve government operations, particularly with regard to effectiveness, transparency, accountability, and equity. Our goal for evaluating the status of recommendations is to help ensure management implements these recommendations for improvement.
We recognize that after we publish an evaluation on the status of recommendations, management may fully implement a recommendation that we reported was in process or not implemented. Management can then provide evidence to the Auditor demonstrating why the recommendation’s status should be changed in the Auditor’s future reporting. The final decision on whether to change any recommendation’s status rests with the Auditor.
Mark Ulanowicz, CIA, Principal Management Auditor