Portland First Responders Aided by Homelessness Outreach Team

The Oregonian, Portland, Ore.

As the sun began to set, Chelsea Swift and Amanda Smith pulled their white van up near a man tucked between some bushes on the side of a busy street. He was grumbling and yelling at passing cars. He grasped a handful of toys and a flashlight as he held a conversation that only he could understand.

Swift and Smith work for Crisis Assistance Helping Out On The Streets – most commonly called CAHOOTS – a 48-person program that provides medical and behavioral health services as an official third arm of Eugene’s public safety system. It’s become the national model that many cities are trying to emulate. But few have.

Portland joined that list this year when the City Council dedicated $500,000 to figure out how to adapt CAHOOTS to a larger urban area. The city’s working group is expected to put a proposal before the council in November.

The idea was spurred by an editorial from Street Roots, the Portland nonprofit newspaper focused on problems faced by people living in poverty. Editor Kaia Sand called for an alternative method for helping homeless people who are in mental health or drug-related distress. The editorial drew from an investigation by The Oregonian/OregonLive that found 52% of all arrests in the city were of homeless people -- the vast majority of those for low-level crimes.

Those are exactly the kinds of arrests CAHOOTS is trying to deter.

Swift and Smith left the man alone after unsuccessfully trying to cajole him into a ride to a place to chill out, away from the concerned -- and sometimes fearful -- public eye.

Even interactions like that one -- that seem to go nowhere -- are important, they say. Now they are aware of him and a little bit about his mental state. If they get three more calls that night, each time they will build more of a relationship. Maybe on the fourth, they say, they’ll be able to help him access services he might need -- a place to sleep, food or a ride to the pharmacy to pick up medicine.

And maybe the next time, he’ll call them for help as many people do when their phone is out of minutes and can only dial 911. That’s why Swift is willing to work within a system that is so closely tied to law enforcement.

“If they have one number, we want to be part of what that number calls,” Swift said. “If we want to keep the scope of our work, we want to be part of that system.”

She thinks that by addressing those issues with CAHOOTS, she can help the man avoid becoming more aggressive in the future and interacting with police, who have more limited options: jail or the hospital.

Eugene garners attention

On one of the first chilly September nights this year, Swift drove the darkening streets of Eugene like a veteran cab driver. She’s worked the night shift for three years and is used to navigating the city and its highways, running after vague descriptions of people in distress -- sometimes from hours-old calls.

But it was a wrong turn that brought her to Linc, a middle-aged man lying on a grassy median that separated a residential neighborhood’s sidewalk from the street. Three women sat on the sidewalk nearby.

One of the women said she’d called for a CAHOOTS response, but the dispatcher told her it would take too long and opted for a paramedic. That frustrates Swift. CAHOOTS is sent when 911 dispatchers recognize the person in crisis may respond better to a civilian than police.

Some people ask for CAHOOTS specifically, a growing habit the program wants to encourage.

Early on, the relationship between CAHOOTS and the city’s other first responders was more adversarial. The program sprouted from a group of radical hippies who began helping people in drug crisis who needed a place to sleep for the night. Eventually they shifted, aiming to be “in cahoots” with police when they turned their grassroots approach into a program that city officials chose to fund over hiring more police.

But over the last 10 years, CAHOOTS staff have invested more time building relationships with police and dispatch workers by being open to receiving feedback as much as giving it. While some officers embrace the program more than others, the first responder and broader Eugene-Springfield community has come to see CAHOOTS as an equal resource.

That night, the fire crews were happy to have Smith already taking Linc’s vitals by the time their two engines pulled up.

Linc was an alcoholic, he said, and wanted to walk to the hospital to enter a detox program. He had been denied over the phone, but in the past, he had found that he could get in this way. Problem was, he’d overshot the hospital and was in too bad of shape to keep walking.

Swift said Linc’s was a typical call. It’s also the kind of call that she is glad to respond to instead of police or even the fire department, which likely would have taken Linc to the nearest hospital. There, he would rack up a medical bill before being released to go home after he sobered up -- or maybe he actually would get into a detoxification center.

Instead, Swift and Smith helped him to the van, which is set up with a few seats bolted to the wall and a wide space on the floor, where Linc lay down.

As the sun set, they drove him to the Buckley Detoxification Center. The nurses there recognized the van and its occupants and helped Linc check in for the night.

While Portland has more beds for people in Linc’s situation, Eugene is more limited. A homeless couple with a toddler who called Swift and Smith to ask where they could sleep safely for the night ended up with no options other than to walk the streets to stay awake.

Eugene has one shelter and it only had room for the mother and child, but the father said his post-traumatic stress syndrome acts up when he is separated from them and could become violent and end up in jail.

CAHOOTS answers a variety of calls in addition to drugs and mental health. They even notify families when a loved one dies on the street and provide grief support.

Program Manager Tim Black said it’s an approach that has shown measurable impact over the past 30 years. He estimates CAHOOTS saves $7 million annually in medical costs because the people they help would otherwise end up in emergency rooms.

Today, the lean operation deploys two vans with two workers each who log about 110 hours daily in staggered shifts. Combined, they field about 20% of calls that come in to 911 and the non-emergency line.

Only about 10% of CAHOOTS responses require help from other public safety agencies. Black said the key is that his team works with public safety, but isn’t beholden to them. That allows them to respond with different tools -- and a different mindset.

“The type of response that an officer is going to have is completely different than the response we would have,” Black said.

CAHOOTS has become the frontline defense for the area’s homeless, even though it was never meant to provide homelessness outreach. But the calls they respond to coincide with the area’s population of people who struggle to be able to pay rent.

Now, about 60% of all the people CAHOOTS work with are homeless.

Likewise, officials say the majority of calls to Portland’s 911 system are about homelessness. And when police receive a call, they say they are obligated to check it out.

Data shows many of those interactions end in arrest, creating a disproportionate number of homeless people in jail or cited for low-level crimes. Advocates say that doesn’t need to be the case.

Sand, the Street Roots executive director, said she proposed the street response idea after a series of articles in local media made it clear the current system isn’t working. She also heard from homeless Portlanders who said interactions with law enforcement made it harder to find housing and other employment.

City Commissioner Jo Ann Hardesty is leading the charge to create a CAHOOTS-style program, and is in the early stages of deciding who would be involved and in what capacity. Part of that work has been to collect data from people living on the street.

“Getting the right first responder to the right incident means we need to talk to the people who will interact with these first responders,” she said.

Representatives from nonprofits, advocacy groups, public safety agencies and various bureaus meet regularly to iron out other issues.

Robert King, who is Mayor Ted Wheeler’s public safety policy adviser, also helps lead the planning and is focused on defining what a pilot project might tackle with the first infusion of cash.

He sketched out a two-person walking beat with a distinct boundary, such as the downtown core or a section of Southeast or North Portland. The street responders would work like CAHOOTS, but only for calls about unwanted people or welfare checks – calls that might be low priority for police on a busy night.

The street responders would also plug into the police radio channels, so they could head for scenes where they’d be helpful. Or be called directly by police and fire officials. They would likely be stationed within the fire department or be contracted to do the work, King said.

“It’s going to be a bit of a learning curve for the street response folks and for council and for the community,” King said.

Portland isn’t alone. Olympia, Wash., hired Eugene’s former police chief and this year, became one of the first cities to adopt the CAHOOTS model.

The new chief insisted Olympia would benefit from the program, so city officials worked with residents, community leaders and business owners to create the Crisis Response Unit. It is housed within the police department and responds when asked by police, fire or social service agencies.

About two-thirds of their calls are self-initiated: They see someone charging into traffic and intervene. City data also showed that the unit showed up at the same place as police in at least half of the first six months’ worth of calls.

Washington’s labor laws block emergency medical technicians from working in the unit, so instead two mental health workers patrol the streets. The first team was deployed in April.

Portland’s Bureau of Emergency Communications, which houses the 911 call center, is already used to weighing various options when considering how to respond to Oregonians in need.

In 2011, the U.S. Department of Justice stipulated that Portland needed to fix how officers handled interactions between mentally ill people and police. As part of the settlement, the Multnomah County health department agreed to take on some calls from suicidal people with its federally mandated crisis line.

The line is staffed by mental health counselors with advanced degrees. Neal Rotman, who heads the county’s mental health programs, said it only made sense to divert similar calls from 911.

Of the more than 80,000 calls the crisis line handles a year, about 500 are diverted from 911.

County officials have also tried to reduce the number of calls that must be diverted. They posted advertisements on buses and elsewhere hoping to provide an alternative to calling 911 for mental health issues. Rotman also met with business groups and others to urge them against calling police on the person who appears to be homeless and yelling outside their door.

His staff has access to a vast database of health records. They can see whether a caller was put on a psychiatric hold recently after being picked up by police or if they were seen at a hospital for similar behavior over the past two years. If a caller is on Medicaid, their case manager will be notified, allowing the crisis center to alert a familiar face to check in on the caller within hours.

In some cases, the contracted mobile mental health intervention team Project Respond is sent out immediately. Otherwise, a county clinician or other mental health worker is supposed to follow up within 24 hours.

Rotman said that many callers prefer to deal with someone who is not in uniform.

“In many cases, people will engage because it’s not the police,” he said, “because they don’t have that fear.”

The diversion was a change for dispatchers. They had to learn to evaluate who would be best served by a crisis counselor and who needed a police officer.

Lisa St. Helen, who runs Portland’s 911 center, said that the policy has been tweaked as dispatchers ran into gray areas. No other city had tried this strategy, she said, so it was challenging to figure out how to keep a caller on the line as they were transferred. City officials also had to consider liability when telling a suicidal caller to hold on the line.

Now, the guideline is whether someone is in immediate danger -- standing on the bridge -- or whether they are still in the phase of talking about stepping on to the bridge. Dispatchers might ask if there is a gun in the house, and if so, where. Is it loaded? Is it unloaded but ammunition is on the table?

Police, who sometimes face life-or-death situations without the training to talk someone off the ledge, saw the benefit of shifting that burden elsewhere.

Providing more options to the people handling calls makes sense to St. Helen.

“911 is ever evolving and change is a part of the process,” she said. “When you find there is a better way to respond or handle calls, we have to make those changes.”