The uncertainty of COVID-19 is impacting many of us, but for people working through severe mental health challenges, the trauma and triggers associated with the pandemic can be especially overwhelming. During National Health Center Week, we want to recognize the important work of our staff at Old Town Recovery Center, who show up every day to provide compassionate, trauma-informed care for individuals experiencing major mental illness.

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Central City Concern’s Old Town Recovery Center (OTRC) has been a mainstay provider for Portlanders experiencing severe mental illness for more than 20 years. The majority of clients experience both mental health and addiction challenges, some are homeless, and all have been impacted by many years of poverty.

For individuals with severe mental illness, it takes a dedicated, interdisciplinary team to work alongside clients and support their success. Through an integrated coordinated care model, patients receive physical and mental health care, medication from OTRC’s onsite pharmacy, and personalized case management tailored to their individual needs. While COVID-19 has brought trauma and triggers – from social isolation to uncertainty about the future – OTRC has maintained its team-based approach, keeping clients grounded in a community committed to helping them heal and meet their goals during these turbulent times.

In less than three days, clinicians made the switch to virtual visits by phone or video – something that hadn’t existed at Old Town Recovery Center before the pandemic. .

Care teams and clinicians are a key ingredient to OTRC’s integrated model. Before the pandemic, nearly all clients enrolled in OTRC’s Intensive Case Management (ICM) program came in to the building for in-person visits with a counselor, psychiatrist or other mental health professional. In order to limit exposure to COVID-19 for clients and staff, the ICM team acted swiftly to ensure clients remained well-connected and supported.

In less than three days, clinicians made the switch to virtual visits by phone or video – something that hadn’t existed at OTRC before the pandemic. More than 100 clients without access to technology received cell phones so they could stay in touch.

“The team is doing amazing things,” said Bob Kleinjan, OTRC Clinical Supervisor. “It’s been difficult, and everyone has adapted to really tough circumstances. The fact that people are still showing up and doing their best is truly impressive.”

For clients experiencing the most severe mental health challenges, staff are still providing care onsite, in the field and by phone. The Community Outreach Recovery Engagement (CORE) team serves patients with major mental illness who would otherwise likely cycle in and out of hospitals, shelters or institutions. Caseloads are small on the CORE team and relationships are close.

“We’re in their homes and we’re in the community,” said Sally Swain, program manager for OTRC’s CORE and Assertive Community Team. “We send our clients birthday cards; we know their pets’ and neighbors’ names. We’re a supportive presence in their lives.”

Staff are calling clients daily to check in, delivering medicine and food boxes, and meeting their needs. It just looks a little different – wearing masks and staying six feet apart. But the connection is still there.

Pharmacists also play an important role in OTRC’s coordinated care model, serving as the connective tissue between clients’ primary care and psychiatric care. During COVID-19, the pharmacy remains a busy hub for clients picking up prescriptions and consulting with the pharmacists. For individuals cycling in and out of hospitals or homelessness, keeping track of medications can be a challenge. Pharmacists use tools like bubble-packing all of a client’s medications in one place, encouraging proper dosage and timing for medication adherence.

One consistent anchor for clients before and during the pandemic has been the staff they see whenever they come in for an appointment or to pick up medication. Netta Holden supervises OTRC’s front desk and lobbies. She and her staff wear many hats – answering phone calls, connecting people to resources, de-escalating situations and triaging people in crisis. Now, Netta and her team also make sure clients are following physical distancing recommendations and properly wearing face coverings to reduce the spread of infection.

“I’ve grown up with a lot of our clients,” said Holden, who has been doing this work since the early 2000s. “Knowing where they came from, I love to see how far they’ve come.”

COVID-19 has been a true test for OTRC’s coordinated care model – which has proven effective for those we serve, despite the challenges.

“This experience has made it clear that our programs are adaptable,” said Swain. “Our staff are creative, and our clients are resilient.It's been tough, but we’re getting through it together.”

This year, National Health Center Week is shining a light on the impact of the COVID-19 on our health centers and our communities. Coronavirus has been particularly challenging for people struggling with substance use disorder and people in recovery. For our medical providers and recovery staff, creativity and innovation are more important than ever as we work to meet the needs of our clients and support their recovery.

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Oregon ranks nearly last in the country in access to addiction treatment. Waitlists for treatment can be months long, and treatment is virtually inaccessible in some rural counties. This is one reason why one to two Oregonians die of drug overdoses every day, sometimes while waiting to get treatment.

Substance use disorder is also a key driver of homelessness. At Central City Concern, our goal is to meet people where they are with treatment options that meet their needs. Our comprehensive approach provides critical primary care, housing and employment assistance to help people stay on the path to recovery.

 

Oregon ranks nearly last in the country in access to addiction treatment . . . One to two Oregonians die of drug overdoses every day, sometimes while waiting to get treatment.

 

The COVID-19 pandemic has brought with it a surge in substance use, acute withdrawal, relapse and overdose, as well as challenges for those currently in recovery. For CCC’s medical providers and recovery staff, creativity is more important than ever in meeting the needs of our clients and supporting their recovery.

Lauren Land is CCC’s Associate Medical Director of Primary Care at Old Town Clinic. She's also one of the pioneers of CCC’s Medically Managed Medication Supported Recovery Program, also known as M3. M3 is an office-based opioid treatment program helping those with an opioid use disorder through the use of prescribed buprenorphine (or Suboxone), used to help reduce harm from opioid addiction.

Office-based treatment is one tool in CCC’s toolbox of available substance use disorder programs. It's often a low-barrier window of opportunity for clients to receive recovery support while engaging with other services within CCC.

As a primary care provider, Land has the unique ability to engage across the spectrum of CCC recovery options, allowing her to support the whole person and address their physical, mental and social determinants of health (e.g. housing related issues, access to food, physical environment, etc.). CCC offers one of the most comprehensive arrays of recovery services in the region, including behavioral interventions and supports, medication management, supportive housing, acupuncture, harm reduction, mental health and culturally specific supports. These range from our Hooper Detoxification and Stabilization Center, CCC Recovery Center, and the Recuperative Care Program, to the Old Town Recovery Center, Imani and Letty Owings Center – to name a few.

Our goal is to meet patients wherever they are on their recovery journey.

“I’m so grateful to be able to offer these services to my patients,” said Land. “What makes CCC stand out is the fact that patients can engage with primary care, behavioral health and access our entire spectrum of services. We take a whole person approach, looking at all of the factors affecting a person’s physical and mental health.”

 

Our goal is to meet patients wherever they are on their recovery journey.

 

One of the cornerstones of recovery is human connection. For those in recovery, isolation is one of the biggest challenges of COVID-19 and can increase the urge to use. While in-person groups and one-on-one mentor sessions have been reduced, CCC has responded by providing tele-connections for clients – meetings with recovery mentors and support groups by phone and video. At the same time, CCC continues to offer a full array of onsite services, including medical visits and physically distanced recovery groups. We have a “no-barriers exist” philosophy.

CCC’s recovery staff often say that isolation is the opposite of recovery. That’s why CCC has made a concerted effort to ensure clients maintain connections with their support systems.

The COVID-19 pandemic has highlighted how many people in our communities have been living without proper care and stability. At CCC, we’ve stepped up quickly with a rapid response. We want Portlanders to know that help is available, and we're as steadfast as ever in our commitment to supporting people transitioning away from addiction struggles and homelessness.