New Residents’ increased needs and history of prolonged periods of outside living create new challenges and decisions about balancing the desire to serve with the ability to support safely.
Macdonald Residence has served Medicaid-eligible adults who need help with daily living tasks for over 25 years. While our mission has always been to support whole-person health, including behavioral health, the number and severity of the support needed has increased dramatically with our new state contract in mid-2023.
Because our facility is now at the highest acuity level in Multnomah County, we serve folks with the most needs and who are the hardest to place. Today, all incoming Residents require not only direct support with daily tasks but also have a history of behavioral health issues that have caused disruptions in their access to care—like substance abuse, verbal aggression, or prolonged houselessness.
Over the last year and a half, we’ve invested in a behavioral health department to better support our Residents and staff. Sam, our Behavioral Health Director, discusses the effects of the shift to higher acuity and the adjustments they’ve made to maintain high-quality care.
Q: How has the type of Residents you serve changed over the last year and a half?
Sam: We used to get people who had maybe lived independently and now needed a little bit more help or were coming from other facilities. Now, the majority of Resident applications are people who are houseless and have been for many years. Ultimately, the behaviors that we’re seeing have definitely increased. A lot of times, people think that once someone is housed, that’s it. But it actually can be a really challenging transition.
Q: Why is serving Residents with extended periods of houselessness more difficult?
Sam: People with a long history of houselessness often feel really hemmed in by four walls. They can find it really difficult to shake the substance use and addiction issues, get along in a communal setting, or just let staff know where they’re going.
It’s been much more work for staff. And there really isn’t a roadmap because there’s not a lot of training about how to help someone transition into housing after having been houseless for a long time . Houselessness is such a big issue here and all over the country, and we’re part of the solution. We’re an organization with boots on the ground, making an impact in downtown Portland.
Q: Is there specific support you provide to those transitioning from living on the streets?
Sam: Often, it’s connecting people to resources like mental health counseling, psychiatric prescribing, or recovery groups. Or it’s sitting down with people and making a relapse prevention plan or working through grounding exercises and mindfulness techniques. We also provide in-house groups on verbal de-escalation, smoking cessation, and Seeking Safety, an evidence-based therapy treatment for trauma, PTSD, and substance misuse.
For all of our incoming Residents, we build Behavior Support Plans that outline a Resident’s specific behavioral health challenges, strategies for staff to help prevent that behavior, and steps if it occurs. Ultimately, I’m here to help people with behavioral health challenges and help them maintain housing.
Q: These sound like great resources, but they also require a ton of staff time and support. How do you balance incoming Residents and ongoing needs?
Sam: Of course, you want to help people who have been houseless and have had many struggles in life. But we also have to think about the other 53 people who live here and the staff.
With every applicant, we have to consider: Can we really safely support that person and retain our staff? We haven’t always gotten it right. But we’re working to hone our process so we’re getting people who can be successful here.
Q: What are you excited about for the future?
Sam: We’ll be expanding the Behavioral Health Department this winter, and I’m really looking forward to it. Currently, we’re so strapped for time that we don’t get to spend enough time one-on-one with people. This expansion will help reduce incidents and staff frustration—it’ll make a big difference.
