By PATRICIA CORRIGAN
Getting help or navigating a health care system can be difficult for individuals with substance use disorders or chronic mental illness, especially those who are homeless. In Oregon that's where Better Outcomes thru Bridges comes in.
Johanna Deeb, an outreach specialist with Providence Health & Services' Better Outcomes thru Bridges program, hands out hygiene supplies at a partner event in Clackamas County, Oregon, where unsheltered people are able to do their laundry.
The program started in Portland and is known colloquially as BOB. It knits together Providence Health & Services programs and outreach with community-based resources to provide practical assistance and a way forward for some of the most vulnerable patients in the region. The health system, part of Providence St. Joseph Health, has expanded the Better Outcomes thru Bridges model to all its markets in Oregon.
The 18-member Better Outcomes thru Bridges team includes a licensed clinical social worker, bachelor-level outreach workers and certified peer support specialists, many of whom have experienced homelessness and are in recovery from a substance dependency.
Staff coordinate access to and between primary and specialty care providers treating Better Outcomes thru Bridges patients at Providence facilities and link clients to mental health care and substance dependency treatment offered by community-based providers.
The Better Outcomes thru Bridges staff stay in contact with their patients for the long haul, providing case management and connecting the unsheltered to service providers that can help transition them into stable housing. In addition to mental health support, partner agencies assist with transportation, food and other necessities.
Big tent
Becky Wilkinson, the manager of Better Outcomes, says the program's community partnerships with schools and with agencies active in community mental health, public health and housing number in the hundreds, "and we're always looking for ways to be more creative, to bridge any gaps and extend our reach."
Wilkinson
Many patients find their way to the Better Outcomes program through the outreach workers who meet them in emergency departments in six of Providence Oregon's eight hospitals, in the system's inpatient behavioral health and medical units and in outpatient clinics. The program takes referrals from shelters and first responders.
To raise awareness, Better Outcomes staffs booths at select locations, including a shower and laundry facility for unsheltered people run by a rural Oregon nonprofit.
Better Outcomes staff make follow-up patient welfare calls from their posts at Providence's regional behavioral health call center in Portland. Some program staff are posted in Providence primary care and specialty clinics.
The program sends outreach specialists into elementary, middle and high schools to mount a crisis response in a rural district that previously had a high rate of youth suicide and little to no behavioral health support. The outreach workers function as case managers, helping students access mental health and other services including food assistance.
Last year, the program touched about 8,600 people throughout Oregon with contacts through Providence facilities, street and camp outreach, behavioral health emergency response and school programs.
Street cred
Wilkinson shares the story of one patient, a homeless man hospitalized about 18 months ago for treatment of a systemic infection acquired through intravenous drug use. He detoxed during his hospital stay and DJ Alex, a peer support specialist, arranged for the patient to stay with a family member when he left the hospital. She accompanied him to 12-step meetings and checked in on him regularly to support him in his recovery.
Alex
Wilkinson says the man came back to the hospital to thank his caregivers and tell them about his new job and his repaired relationship with his children.
Alex thought the man could be a good support to another of her hospitalized patients who struggled with substance dependency. The two men met and discovered through conversation that they had known each other while both were living on the streets. The former patient looked so healthy that the hospitalized man hadn't recognized him.
"Seeing how good his friend looked and felt after being clean for over one and a half years gave that patient the courage to want to do the same thing," Wilkinson says, adding the man is working on his recovery.
Better Outcomes thru Bridges staffers Tammy Wilkins, left, Jon Sherman, center, and a student intern deliver food, tents, hygiene items and other donated supplies to people living outside.
Alex has been a peer support specialist on the Better Outcomes team for about two years. Previously, she worked as an alcohol and drug counselor. Before that, she did prison time.
"I've got tattoos all over, I'm real loud and I'm real matter-of-fact," she says. "When I walk into the hospital room of someone admitted for medical issues that stem from drug use, I tell them I have a criminal background, and that after living as a drain on society, I got the opportunity to go to prison. Yes, it was an opportunity. I got cleaned up there, got my head on straight, and decided when I got out, I'd do something different."
As Catholic Health World went to press last month, Alex was about to receive a master's degree in human services, and she had just celebrated 10 years of sobriety. "After all the destruction earlier in my life, I give back now, and I love my job," she says.
When Alex meets with patients, her goal is to build a relationship with them. "I see if I can help with housing, food, clothing or any resources I can connect them with, including mental health services, a primary care physician, a phone or a bus pass. When they are discharged, I follow them until they don't need me anymore."
A 'we' problem
Not every patient who might benefit from participating in the Better Outcomes program is open to changing their life. "That's OK too," Alex says. "We meet people where they are. If someone is happy living in a tent, I ask if they need resources for a needle exchange or extra blankets or food. I plant the seed that help is available, and whether they take it is on them. Either way, we've got to help each other. This is a 'we' problem."
Since the program's founding in 2016, emergency department use rates have decreased by 45% for individuals who engage with Better Outcomes' outreach specialists.
Early in the pandemic, before counties set up "COVID motels," the team rented motel rooms and provided food, clothing, medications and support for the COVID-positive homeless population in Portland. Its school outreach specialists delivered food and other essentials to low-income students in rural Yamhill County. Better Outcomes operates an ongoing motel program for homeless families and adults who need a safe place to stay in Yamhill County.
It's personal
Team members have provided de-escalation training to some partners, including staff of a warming shelter, tiny home villages staff and several community action agencies.
Other recent projects include:
- A grant helped provide monthly on-site services with LoveOne Community events in Clackamas County, where more than 1,000 people received hot meals, hygiene supplies, tents, tarps, socks and warm clothing.
- Street outreach workers provided food, supplies and clothing in summer and winter for about 700 people who live outside throughout Oregon.
- Working with Providence's property management and real estate department, program team members offered housing alternatives including stays in the system's tiny home village, and support and supplies to individuals living outdoors on Providence properties.
- Team members have active partnerships with three additional tiny home villages sponsored by churches, working on-site each week at Agape Village and Beacon Village in Portland and Peace Trail Village in Newberg.
- A grant has provided funding to run a motel shelter project this year in Yamhill County.
Looking ahead, Better Outcomes has applied for a grant that would allow it to expand the outreach and peer support program to additional specialty behavioral health clinics throughout Oregon.
"This program means everything to me," Wilkinson says. "As somebody with my own mental health issues, I can relate to the feeling of being alone, and I never want anyone to feel like that. It's so important to me to do this work."
Click here to see a video of Better Outcomes thru Bridges.