Central City Concern: Providing Comprehensive Services to Help People on the Path to Housing, Recovery, and Employment

The Portland metropolitan area, and Oregon overall, have seen one of the nation’s biggest jumps in the rate of homelessness over the past three years, with about 3,900 people in the Portland-area lacking shelter each night. Many have co-occurring mental health issues. The city also has a high rate of overdose-related deaths. In 2020, Oregon voters legalized possession of heroin, methamphetamine and other hard drugs, though a 2023 law sharply limits the quantity a person can legally possess. As in other parts of the United States, Oregon has a shortage of facilities for housing homeless people, particularly with supportive services, plus a shortage of inpatient and outpatient programs to provide substance use disorder (SUD) and mental health treatment.

Background

Central City Concern (CCC) was founded in 1979 as a small not-for-profit organization, originally called Burnside Consortium, mainly to provide housing for homeless people. It has greatly expanded its range of services since then. Now a federally qualified health center (FQHC), CCC offers 34 housing sites and 29 FQHC clinic programs located at 17 sites, with about 1,400 employees and an annual budget of $155 million.

"CCC currently serves a total of about 14,000 people a year," said Andrew Mendenhall, MD, who was named CCC’s president and CEO last year. It provides about 2,500 total housing units, including short-term and long-term. Some sites are designated alcohol- and drug-free (ADF) and others are not. Its residential drug withdrawal program served about 2,762 people last year, and its employment services program serves about 1,550 a year. In 2022, CCC provided primary and preventive care to 7,435 patients, and it treated 2,912 patients in need of mental health support. It treated 2,531 people through medications for addiction treatment (MAT), such as buprenorphine or similar medications.

According to Mendenhall, CCC offers both ADF and non-ADF housing to meet individual and community needs. The program offers a “housing choice” approach where clients can choose the kind of housing that makes sense for where they are at and their personal goals. In addition, some government grants require housing to be non-ADF. “We need to have housing that’s true ‘Housing First,’ where people who are actively using step in off the street and get an opportunity to see if they want to take the recovery pathway,” he said. “Our goal has been to engage people where they are, creating a safer environment for those who return to using and getting them back in recovery.”

Most of CCC’s funding comes from Medicare, Medicaid, the U.S. Department of Housing and Urban Development, and local jurisdictions, with some funding from charitable foundations.

Intervention

“We need to have housing that’s true ‘Housing First,’ where people who are actively using step in off the street and get an opportunity to see if they want to take the recovery pathway.”

Andrew Mendenhall, MD, President and CEO, Central City Concern

CCC follows a housing-first model, which seeks to quickly connect individuals and families experiencing homelessness to permanent housing without preconditions and barriers to entry, such as sobriety, treatment or service participation requirements. Core services include:

• Withdrawal management. "Many people enter CCC through the 55-bed Hooper Detoxication Stabilization Center (Hooper), a withdrawal management program," said Amanda Risser, MD, CCC’s senior medical director of SUD services. Hooper provides medical support for up to one week for patients seeking to withdraw from alcohol or drug use; it offers MAT, including buprenorphine and a long-acting injected form of that drug called Sublocade.
• Primary care. People also walk into CCC’s primary care clinics and receive same-day access to MAT, including buprenorphine or naloxone, a drug used to reverse opioid overdoses. CCC is providing MAT services to nearly 1,000 people at any given time. “We try hard to make it so there is no wrong door, that people can start somewhere, and we can support them in their next steps, whether it’s our withdrawal management program or residential services,” Risser said. “The idea is they can walk into an CCC health care site and get good support for whatever they need.”
• Outpatient SUD treatment. In recent years, CCC created an intensive outpatient SUD treatment program, the Blackburn Center — located away from the downtown Portland corridor where many people who use drugs congregate — with the goal of helping people in early recovery stay in treatment. Now the organization is planning to establish a residential treatment center. Mendenhall said that’s needed because fentanyl and other drugs now increasingly available on the streets are so powerful and reinforcing that outpatient treatment isn’t as successful as it used to be. “We’d much prefer broader access to residential treatment for a month or two for the 60 percent of folks who meet criteria for residential treatment when they arrive at our doorstep, then as a next step, they move to our supportive housing and outpatient treatment continuum,” Mendenhall said. “The newer drugs require longer periods to stabilize from.”
• Housing. CCC also offers a continuum of housing options, including supportive transitional and permanent housing. About half of CCC’s 2,500 units are for people with SUD who want to live in alcohol- and drug-free housing. The remaining half do not have any recovery requirements. MAT is allowed in both the alcohol- and drug-free housing and non-ADF housing. About one-third of CCC’s housing units are transitional in nature, with a high level of services and an average resident stay of 8-15 months. The remainder are permanent housing units with a range of supportive services, from lower to higher intensity. 

“Supportive employment services are the most cost-effective intervention, contributing to positive housing stability, health and wellness, and recovery engagement outcomes.“

Andrew Mendenhall, MD, President and CEO, Central City Concern

• Employment services. In addition, CCC provides a continuum of employment services, including the Community Volunteer Corp, the Employment Access Center, and Central City Staffing. These programs offer volunteer activities that build confidence and job skills, training and mentorship through temporary social service jobs, and individualized employment assistance. “Having employment is the most important factor in helping people find and stay in permanent housing,” Mendenhall said. “Supportive employment services are the most cost-effective intervention, contributing to positive housing stability, health and wellness, and recovery engagement outcomes.”
• Harm reduction. Harm reduction is part of CCC’s program for clients with SUD. Faced with a big increase in residents dying of drug overdoses in CCC housing in 2021, CCC launched a Zero OD Initiative in January 2022. That involved supporting residents with naloxone, training them in use of the overdose-reversal drug, and referring them to drug treatment. CCC now distributes 300-400 doses per month of Naloxone within its housing facilities.
• Street outreach. CCC operates several street outreach teams. The teams aim to offer connection and bridge support to more traditional, ongoing services. They provide resource navigation — including health care, naloxone, shelter, Medicaid enrollment — and varying levels of ongoing case management support.
• Mobile medical service. CCC will soon start a mobile medical service to make medical care more accessible for people who have become disconnected from care. The team plans to offer MAT and primary care stabilization services, such as identifying and immediately treating urgent health needs (e.g., elevated blood sugar, high blood pressure), with an aim to build connections that lead to patients eventually receiving care at the primary care clinics for ongoing care. The mobile medical service will focus outreach on temporary shelter sites, sanctioned encampments of homeless people, and safe-rest villages around Portland.

Implementation

Key players in providing CCC’s supportive housing services are peer mentors and peer case managers. About 75 percent of them are former CCC clients who help residents with day-to-day issues such as paying rent, performing activities of daily living, staying on medications, and seeing their doctor. CCC employs about 75 peer counselors and more than 100 peer case managers. Peer case managers help clients primarily in housing and employment services.

“Folks with SUD need support to stay in recovery, and folks with severe mental illness need a supportive team to help them get back to the right direction,” Mendenhall said. “These are social, not medical, interventions that take place in the housing milieu. They have a profound human impact on clients, and also drive health care outcomes.”

“My past experience as a client made it easier to help my clients navigate our organization. It’s pretty cool.”

Lisa Greenfield, Peer Case Manager, Central City Concern housing site

Lisa Greenfield first got involved with CCC about seven years ago when she walked into the Hooper detox center to stop her substance use. After failing twice and returning to homelessness, she entered CCC’s outpatient drug treatment program, which offered supportive housing. Participating in the program’s counseling groups and working with peer mentors led to her doing volunteer work through CCC’s Employment Access Center and its Community Volunteer Corps. “I had to build a routine, have consistency, show up regularly, and be on time, which were work ethic skills I didn’t have,” she recalled.

Under the guidance of an employment specialist, Greenfield started working as a fill-in janitor at one of CCC’s housing sites. Meanwhile, she received care at a CCC primary care clinic and stabilized her physical and mental health. She worked her way up, first becoming a peer mentor in 2018, helping CCC clients access treatment, appointments, and other resources. In 2019, she became a peer case manager for clients at one of CCC’s housing sites, helping them handle personal crises and teaching them life skills, such as how to manage their personal budgets and clean their room. “That changed everything for me,” Greenfield said. “My past experience as a client made it easier to help my clients navigate our organization. It’s pretty cool.”

Impact

"Nearly 75 percent of residents in CCC housing enter through the Hooper Detox Stabilization Center. Of those, about 42 percent successfully complete an exit to stable housing," Mendenhall said. "That, however, is down from about 65 percent successfully transitioning to stable housing prior to the COVID-19 pandemic." Mendenhall and Risser attributed the decline to the greater street availability and use of fentanyl and methamphetamine, and reduced access to clinical services due to area workforce shortages. “Fentanyl is really cheap, tiny amounts are incredibly potent, and it’s a lot harder to get off of than heroin,” Risser said. “Pretty quickly you are dependent and have a big tolerance. A lot of new users are homeless and struggling.”

As part of its harm reduction program, CCC launched a zero-overdose initiative in January 2022, and that has helped. In the fiscal year 2021-2022, 17 residents died of overdoses. After the program started, that dropped to 7 overdose deaths in fiscal year 2022-2023, despite an increase in non-fatal overdose events from 39 to 61. “We can’t get our hands on enough Naloxone,” Mendenhall said. “We give it out every day in our primary care clinics and street outreach services. We also provide safer-use supplies in a limited fashion to engage folks and reduce the probability of eviction. We don’t provide syringes because of FQHC funding restrictions.”

“Individuals come into housing who either are not interested in treatment, or we don’t have the ability to get them timely access to services. The default pathway is eviction, which is anathema to a homeless services agency.”

Andrew Mendenhall, MD, President and CEO, Central City Concern

Overall, Mendenhall said about half the people who enter CCC’s low-barrier “stabilization” housing get engaged in drug treatment, while the other half return to the street or a shelter without entering treatment. He acknowledged that housing people safely under the Housing First model has become more challenging with the increased acuity of mental illness and untreated SUD in recent years. “Individuals come into housing who either are not interested in treatment, or we don’t have the ability to get them timely access to services,” he said. “The default pathway is eviction, which is anathema to a homeless services agency.”

“CCC supports the philosophy of Housing First, but it can’t be housing only,” Mendenhall said. “There has to be a continuum of care that’s sufficient to meet the needs of people who return to using drugs, or who stop taking their medications and regress.”

Insights

The following are key program lessons.

• It’s important to work closely with local public agencies and payers to influence policy and funding, in order to develop a consensus-driven model for tackling homelessness, SUD, and mental health care. “The big challenge is how the money gets spent, who’s in charge, and having a coordinated strategy,” Mendenhall said. “We are seeing more political will and collaboration to align around strategy, informed by good population health data. That is reassuring but feels long overdue.”

“It’s part of our secret sauce — having people with the lived experience of SUD, mental illness, or both, working with the people receiving services. It helps mitigate stigma and fear for new clients, and it’s extremely effective.”

Amanda Risser, MD, Senior Medical Director of SUD Services, Central City Concern

• Employing peers with lived experience is invaluable. “It’s part of our secret sauce — having people with the lived experience of SUD, mental illness, or both, working with the people receiving services,” Mendenhall said. “It helps mitigate stigma and fear for new clients, and it’s extremely effective.” Risser said peer mentors and peer case managers help her by spotting things that she doesn’t necessarily see. “They’ll notice patterns of behavior and hear things from patients that can be incredibly meaningful in making changes and improvements in what we’re doing,” she said. “Patients have someone who can connect with their stories. And it’s inspiring for me to work with so many folks in recovery. It gives us all a little bit of hopefulness and delight.”
• Training your own workforce may be necessary given the workforce shortage. There is a serious shortage of drug and alcohol counselors, health professionals with master’s degree-level training, and qualified mental health assistants. That’s been exacerbated by the clients’ greater level of behavioral health acuity, staff not feeling physically safe, wage competition from well-funded hospital systems, and staff feelings of moral injury due to the shortage of housing resources, residential treatment, and psychiatric providers. “We are developing ways to internally train folks who have the capacity and interest to work in our organization,” Risser said. “We’ve also made the decision to have competitive wages, robust recruiting, and try hard to make it a good program that people want to stay with.”
• Finding organized ways to have staff support each other is essential. Staffers often feel overwhelmed by the magnitude of the problems their clients face, the challenges of helping them on the road to recovery, and the high rate of relapse into SUD and homelessness. “The idea of community care rather than self-care was an ah-hah moment for me,” Greenfield said. “That’s the most important thing, us supporting one another and having that connection with one another. If someone had a difficult day, it may be going on a walk or break together, providing space for a conversation like, ‘What can we do to help you through this.’ We do staff events like going out and playing frisbee golf. It’s celebrating each other’s successes that’s been really beneficial.”

Acknowledgments

 Thanks to Dr. Andrew Mendenhall, Dr. Amanda Risser, and Lisa Greenfield for helping to inform this profile.

*Author Harris Meyer is a freelance journalist who has been writing about health care delivery and policy since 1986.