Central City Concern: Providing Comprehensive Services to Help People on the Path to Housing, Recovery, and Employment
September 28, 2023 Harris Meyer*
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 .
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 .
“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:
“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
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.”
"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.”
The following are key program lessons.
“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
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.
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