Reckoning with the homelessness crisis in The Dalles

Kenny LaPoint is the executive director of the Mid-Columbia Community Action Council, an organization that provides services to people experiencing homelessness in Wasco, Hood River and Sherman counties. MCCAC operates the only homeless shelter in Wasco County, a facility made up of 18 tiny homes in an industrial part of The Dalles, overlooking the Columbia River. It also conducts a federally mandated Point-in-Time count of people experiencing homelessness, and is in the process of acquiring a 54-room hotel to serve as transitional housing for families and clients with complex medical cases. This spring, MCCAC will break ground on a navigation center on the west side of The Dalles which will not only include shelter beds, but also office space for community agencies to provide wraparound services, including employment assistance. On Tuesday mornings, a mobile medical clinic operated by a non-profit medical center, One Community Health, visits the shelter to offer free medical services such as diabetes and cancer screenings.

We hear from LaPoint and Kathryn Perkins, a client experiencing homelessness who has lived in a tiny shelter home for six months. Middy Tilghman, a family nurse practitioner at One Community Health and the lead medical provider at the mobile medical clinic, shares with us the impact it’s having on improving health outcomes for unhoused patients.

This transcript was created by a computer and edited by a volunteer.

Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. We are going to spend the hour today at a homeless shelter in The Dalles, the only shelter in all of Wasco County. It’s on industrial land near the Columbia River, and it’s made up of 18 tiny homes. Later, we’ll talk to a resident at the shelter, and we’ll hear from the lead medical provider who works at a mobile clinic that serves patients at the shelter once a week.

We start with Kenny LaPoint. He is the executive director of the Mid-Columbia Community Action Council. They provide services to people experiencing homelessness in Wasco, Hood River, and Sherman counties. That includes running the shelter in The Dalles. We met up in a small office in an RV at the site. I had him give us a sense for where we were.

Kenny LaPoint: We’re in the port area of The Dalles, Oregon, on the waterfront, but it’s an industrial area that’s primarily used for the Growers Association. We have Google down here. There’s one restaurant nearby. But it’s really an industrial area, and we have our pallet shelter site down here.

Miller: The fact that this is not residential and not really commercial, did that make it easier to site the shelter here?

LaPoint: I think it was easier to sell the community on the idea of that, while our belief is that we should be integrating folks back into the community.

Miller: Are there services near here?

LaPoint: There’s not much in the way of services, which is why we bring them out here. We have transportation, medical, behavioral health, housing services, all come out to this site.

Miller: They exist naturally downtown, but you couldn’t easily put a shelter system like this downtown?

LaPoint: Well we’re working on doing something like that. We are working to get into a more residential-ish type location, a location that’s integrated into the community. But yeah, there’s no services down here. In fact, there wasn’t even infrastructure services down here when we first were here. There was no water and no sewer at this site. And so when we took over in January of 2021, when we had to clean out units, I had to truck in water in Arrowhead water jugs to clean the floors.

Miller: Wow. What do you do now?

LaPoint: Now we have water on the site. The city of The Dalles put in water and sewer to this site, so we have a shower and restroom trailer that is located on the site, and is served by that water and sewer. We did have electricity from when we first got here, but we didn’t have any water or sewer line.

Miller: How many people are living here right now?

LaPoint: Right now, we have about 30 people here.

Miller: Doubled up? Most of them are two to a pallet shelter?

LaPoint: Yeah, most of them are two to a shelter. We try and maximize the use of the units as best as possible, especially right now, as we have pretty cold temperatures and it’s supposed to get even colder in the next week.

Miller: How long do people spend in this shelter in general?

LaPoint: Our maximum stay is six months. When we first started operating this site, it was really supposed to be like a warming shelter that was only operated during the wintertime. But we advocated to get it to become year round immediately, and we were successful in doing so. We allow folks to stay here for six months, and they’re all required to be really working on a housing case management plan so we can transition them into a permanent situation before the six months is up.

Miller: What happens if someone can’t get housing in six months?

LaPoint: If someone can’t get housing in six months, typically they need to leave.

Miller: They do, there’s “no okay, you can stay?”

LaPoint: Yeah, there is no “okay, you can stay.” And that’s mainly because it’s a fair housing issue when we get down to it.

We have not had issues with that. Typically folks are transitioning out into permanent housing. Like I said, we bring housing services out to this site. So our housing team at Mid-Columbia Community actually comes out to the site every week and works with the shelter clients to get them placed into permanent housing. And since the beginning of this year, we’ve placed over 60 people into permanent housing from this site.

Miller: What does it take for people to get into this site to begin with?

LaPoint: They really just have to come complete an intake form. Again, they have to be willing to work on a housing case management plan. There’s not much that is required of them to get in. They have to be willing to comply with the few rules we have, which is can’t use drugs on the site, can’t drink on the site, can’t have weapons or be fighting on the site. Pretty basic safety rules to ensure the safety of the folks who live here, our staff and the surrounding community as well.

Miller: What other current shelter options are there for people experiencing homelessness in Wasco County as a whole?

LaPoint: There are none.

Miller: None, in all of Wasco County. And we’re in the largest city in it. But there are no other shelter options?

LaPoint: No, there are no other shelter options in Wasco County.

This shelter is really designed to serve individuals, so we do not serve children under the age of 18 here, we utilize hotel vouchers to place families with children, also those fleeing domestic violence or those with a complex medical condition where they would be better suited to be in a a really contained hotel room where the healthcare system could come in and provide some sort of ongoing care for them.

Miller: But that’s a voucher system to go into regular hotel rooms or motel rooms as opposed to a set aside location that is a shelter.

LaPoint: That’s correct.

Miller: Can you give us a sense for the numbers, as you know them, in terms of people experiencing homelessness in Wasco County? Am I right that the last point in time count was about a year ago?

LaPoint: Last point in time count was done in January of this year, and in Wasco County there were 194 people that identified as experiencing homelessness.

Miller: We’ve talked about these numbers a lot over the years in different counties and I’ve come to think that they’re sort of helpful and sort of not. It’s one night, it’s who you can find. But it also seems like there can be something valuable about comparing these numbers over time. So what do the trends tell you about both numbers, and demographic groups of people experiencing homelessness?

LaPoint: I think one of the big things is doing an apples to apples comparison year over year. That wasn’t really anything that was being done here historically. We feel like in 2022 we did a good job of doing the count, and we really hope in 2023 we’re able to see better trends.

We partnered with a couple culturally specific organizations to ensure that the Latinx community and the Native community were counted, which are highly represented in the region. We have a large agricultural community, alot, a lot of native fishing villages here. And historically those communities were not counted well. And so in the numbers, you saw significant increases in the number of people who are experiencing homelessness that represented those demographics in the most recent count.

Miller: So if I understand you correctly, you’re implying that it may not be that there has been a huge increase in those populations from 2020 to 2022, but you’re just doing a better job at counting them? That’s your best guess?

LaPoint: That is my best guess right now. Again, by doing an apples to apples comparison in 2023, using the same strategy to conduct the count, I think we’ll have a better idea of any trends that exist amongst those populations.

What we did do in 2022 is we partnered with culturally specific organizations to go out and count those communities, to make sure that they are represented. That’s what we did different this year.

Miller: Every person who’s here or is experiencing homelessness somewhere else has their own story, obviously. But what do you see as the most common reasons now in Wasco County for people to become homeless?

LaPoint: Housing is really tough here, just like the rest of the state. We’re very development constrained in our region, due to the national scenic area that we live in. There’s not a ton of land to develop on. A lot of folks have been pushed out of Hood River County and end up in Wasco County as sort of a bedroom community.

Miller: Is the same thing happening now in The Dalles? People getting pushed from Hood River to The Dalles, and then being pushed out of The Dalles?

LaPoint: Definitely. And it’s not just lower income households, it’s moderate income households as well. We have staff that live in other parts of the region, Goldendale for instance, which is not very close to here, because they can’t afford to live in Wasco County. So we’re seeing a lot of folks get pushed out.

I do believe that folks are experiencing homelessness for longer, and behavioral health conditions are impacting their ability to be stabilized.

Miller: When you say behavioral health, I immediately think about drug use. What role do drugs, and I’m thinking particularly about meth and opioids and fentanyl, play in homelessness as far as you’re seeing it here?

LaPoint: What I say is really only anecdotal, but I think the sort of new era of meth and the increased use of fentanyl is having a significant impact, particularly on those who remain unsheltered. So not folks who are here, but folks who are continuing to live outside. I think it’s creating a situation where they’re unable to make the right decisions to go into shelter because that environment is scary when it comes to somebody who is addicted to drugs, and they’re unwilling to come into shelters like this because of that situation. So we’re definitely seeing that play a role, and that is probably the biggest community issue that our elected officials deal with on a day to day basis.

Miller: Then what near term solution do you see? It seems like you’re saying that, to some extent, this site has been a success. People come here, and five dozen people this year have been able to go into some version of permanent housing through here. But there’s a lot of people who, because of meth and fentanyl, don’t even want to come here in the first place. So what options do you see for them?

LaPoint: We see options here for them. They can come here as long as they’re willing to work with the behavioral health provider that provides substance use counseling, and mental health counseling. So the Center for Living, a strong partner of ours, is our behavioral health provider for the region. They’re here every day, providing services. We see that as an opportunity. But again, we have to hold the line when it comes to safety. Because we’re not just taking care of that one individual, we’re taking care of 30 people, plus our staff and the neighbors here. So holding the line when it comes to behaviors is really critical, I believe, to the success that we have had. And it has resulted in some folks stepping up, and being able to overcome issues that they’ve had in the past, whether it’s behavioral health or substance use issues, or just behavioral issues. They’ve been able to overcome those things because we’ve held the line.

I like to say that what we do different is that we believe people can be better. We, I think, instill that hope into them, where they may have not had that belief in themselves or hope for the future in the past. And I think that’s something we’re able to impart to people.

Miller: It’s interesting the way you’re putting that, because that seems like the positive version, that sort of carrot version of the dynamic you’re describing. But it also seems like the flip side is a kind of stick, that you need to abide by these rules if you’re going to stay here, and that if I hear you right, that abiding by those rules can actually be beneficial in and of itself. You’re forcing people to make better choices for their own lives.

LaPoint: Definitely. And it can be really tough when you come from an environment that has no structure or rules to it. It’s kind of harsh to refer to it as these rules, or it can be referred to as barriers too. But I think often when we say we want to remove barriers for people, we create barriers for others.

Miller: What do you mean by that?

LaPoint: If we were to say you could actively use drugs on our site, we would potentially cause a barrier for somebody who is maybe trying to overcome years of drug abuse. And that may be a barrier for that person. And we don’t want to create barriers for others by removing barriers for some. We want to make sure that this community is safe for the clients, it’s safe for the staff, it’s safe for the neighbors. Our mission at our agency is to build a better future for our community. That’s our entire community, not just one population of people.

Miller: Have you started to see the effects of increased funding from Measure 110?

LaPoint: We have not seen the effects yet. We’re starting to see those dollars roll out slowly, and we believe there’s going to be impacts on our community related to those funds, but it has been slow going.

Miller: Because at this point where it’s two years past, when voters decriminalized all drugs in the state, and not two years past money starting to flow in, but it’s been enough time that I would have hoped that you would start to see something at this point. You’re saying you haven’t really seen it?

LaPoint: We’ve heard of things that are coming, that are happening. It’s just not impacting people on the ground at this point in time.

Miller I’m curious about your vantage point here. You’ve, in the past, worked Deschutes County, you worked at the state level. We’re coming from Multnomah County obviously, which is less conservative politically than Wasco County. But even in Multnomah County, there’s been a shift that we’ve seen. A lot of people are becoming more frustrated and fed up because of two things at once: a lot of unsanctioned camping, and a fear of crime, and the perceived connections between those two. That’s led to a kind of rightward shift in Portland politics as far as I can tell. Wasco County was already more conservative. How is homelessness impacting the politics in this county?

LaPoint: I said before, I think it’s the number one issue that elected officials are dealing with. I think if you talk to our county commissioners, our city councilors, the mayor, they would say this is the one thing that constituents contact them about pretty frequently.

Miller: Even though, as I’ve been driving around, homelessness hasn’t seemed particularly visible here, certainly coming from Portland where it’s inescapable visually. Nevertheless, here, it’s still the number one issue?

LaPoint: Yeah, I believe it still is a pretty strong issue. The visible homelessness is what people refer to most often with elected officials. Most folks in the community actually don’t even know we have this facility, and they don’t know that we’re having great success with working with people who are experiencing homelessness, and they don’t know that the couple handfuls of people that are living unsheltered do not represent the entire homeless community that is out there.

Miller: Do you want more people to know about this place? Or do you feel like if they did, then they would figure out reasons to not like it?

LaPoint: I think people will figure out reasons to not like it. But we have been highlighting the successes that we have had here. Like I said, we’re planning to relocate this facility into a more central location, and people are going to see what we’re doing. They’re going to be able to see the impacts that we’re having on people. I don’t think they know that there are a lot of people that now live in permanent housing that have been reintegrated into the community because there are services like this being provided to folks.

Miller: In the time we have left, I am curious about your plans for the future. What is in the works in Wasco County as new approaches to homelessness?

LaPoint: We have a couple pretty big projects going on. We’re building a multi agency navigation center. A shelter will be located on the navigation center site, and then we will have a building that will house about seven different agencies, with also other agencies coming in on a regular basis to provide services. But we believe if we can sort of provide this one stop shop in rural Oregon, it will create better access for folks who are experiencing homelessness or housing instability or just poverty generally. It’ll just be better access to services. There’s a lot of land in our three county service territory, which is Hood River, Wasco, and Sherman counties. It’s a long way to travel. We feel like if we can create one place that people have to go, it’ll just be easier for them to access services.

Miller: And that’ll be right downtown?

LaPoint: That project is going in sort of on the west side of town, within the urban growth growth boundary on the west side of town. We’re very fortunate that a community member donated 2.6 acres of land to us for this project.

Miller: I understand you’re also acquiring a hotel. What are the plans for that?

LaPoint: We were a recipient of Project Turnkey 2.0 funds, which is funded through the Oregon Community Foundation. The funds came from the Oregon Legislature. We’re in contract on a 54 room hotel here in The Dalles. Undisclosed location at this point in time due to the nature of the business, but we are planning to utilize that facility. I mentioned families with children cannot be served in our shelter site here. This will bring family shelter units to our area, so we’re not anymore having to put folks into other hotel rooms. That will give us an opportunity to wrap services into that site as well. We’re also planning to have some other additional transitional shelter units in that same site, so it’ll increase our shelter capacity pretty significantly in the region. It will probably act a little bit more like transitional housing for folks. But there’s not really a ton of difference between that and what’s going on here.

Miller: Kenny LaPoint, thanks very much.

LaPoint: Thanks for having me.

Miller: Kenny LaPoint is the executive director of Mid-Columbia Community Action Council, the nonprofit that provides services to people experiencing homelessness in Wasco, Hood River and Sherman counties.

[Kenny LaPoint] introduced us to one of the residents there, Kathryn Perkins. She brought me inside the small prefab room where she’s been living with her Dachshund/Pomeranian mix.

Do you mind showing me your home here?

Kathryn Perkins: No, I don’t mind at all.

Dog (Monster): Bark, bark!

Perkins: Knock it off!

Miller: Maybe you should introduce me to your dog first.

Perkins: Okay, this is Monster. Monster, be good, be good, be a good boy.

Miller: How long have you had Monster?

Perkins: Well, I inherited Monster from a friend that passed away. He’s a good service dog. He’s protective.

Miller: Yeah.

Perkins: Come on in.

Dog (Monster): Bark bark bark!

Perkins: Stop, stop!

Miller: He doesn’t like visitors that much?

Perkins: No, he’s just not familiar with you.

Miller: I’m Dave, Monster.

[Laughing]

How important is it to you that you can have a dog here?

Perkins: It’s very important. I worry about him more than anybody. When I first came here he wasn’t here with me, and it was really hard. I worry about him more than I worry about myself. Like I said, I inherited him. His owner passed away and I didn’t want him to feel as though he was being abandoned again.

Miller: His owner had been here?

Perkins: No she hadn’t been here. But she was a friend of mine, a very close friend. And she had cancer and passed away. And of course Monster, I’ve been around him since he was born. And so of course he came to me. But when I first came here I didn’t bring him with me because I wasn’t sure what the setup was gonna be. And it was really tough. I worried about him constantly. I just didn’t want him to feel like he was being abandoned again, when he was staying with friends of mine until I could get him here.

Anyway, he’s adjusted well. It’s hard because it’s very small.

Miller: Can you describe where we are right now?

Perkins: Yeah, we’re in my room. There’s two beds, and there’s shelves above each bed, and in-between against the wall.

Miller: We have about 8ft by 8ft, how big is this?

Perkins: I would say 10x10 maybe. I don’t know, I’m not really good at measurements actually.

Miller: Yeah I think that sounds about right yeah, 10x10. So room for two beds and a narrow passageway between and then and some shelving.

Perkins: Right. And it gets snug with two people, but it’s workable, definitely. It takes a little bit of adjustment and working around each other when we get dressed or things like that.

Miller: Your roommate was a stranger before you moved here?

Perkins: Yeah, I hadn’t met her before.

Miller: How’s it going?

Perkins: It’s going great! I was so lucky because there have been issues with other roommates. Sometimes people just don’t mix. They try to match people up pretty good. They get to know one person when somebody comes in. They try to make it a good fit. It really works out. They’ll put somebody in a different room, or they’ll just move it around if it doesn’t work.

Miller: So how long have you been here?

Perkins: I have been here almost six months. I’m getting towards the end of my stay.

And I have prospects. I have two right now. So, let’s cross your fingers that everything works out. I should know within a couple of days. I’m hoping, hoping, hoping.

Miller: I want to come back to that. But if you don’t mind, we can go back to the past. How is it that you ended up here?

Perkins: Well it’s kind of a long story. I never thought of course I’d be in this position.

Miller: You never thought you’d be homeless.

Perkins: No, not in a million years. I raised two daughters alone as a single parent, always worked. But unfortunately I was a bartender for 20 some years, doesn’t have much of a retirement, and it’s a low wage but you make a lot of money in tips. And then I quit bartending when my oldest daughter hit high school, and she was very involved in sports and I didn’t want to miss anything. So then I went to working in a restaurant.

Miller: Monster is about to steal your cookies, by the way.

Perkins: He wouldn’t eat them. He thinks he would but he wouldn’t [Laughing].

But anyway, I worked in a restaurant a friend of mine owned, which turned out to be a great job because I was off at two, home when my kids got home from school. I’ve always been able to pay my way at least. Things weren’t great, but I had a car, we drove. I ended up having to sell my car.

I had two elderly women that I had known throughout the years. The first one that I took care of, it was me and another man, we both rented rooms from her, and that’s how she subsidized her income. We took turns running her to appointments and that kind of thing. That ended up being off and on for 10 years.

And then I had a stroke. and that’s when everything changed. Once I had a stroke, I was in the hospital for quite some time. Went through rehabilitation for six weeks, was released from rehabilitation, and went back to where I grew up, my hometown, which is Glenwood, Washington.

Miller: Across the river.

Perkins: Across the river. It’s not far actually as a crow flies. But anyway, I went back there and a good friend of mine from school and lifelong friend took me in to help me, because I couldn’t be alone. And so I had to go through a process of rehabilitation in that sense, and learning to navigate a house and all that.

And then from there, I rented a home. It was a studio apartment, an artist’s studio in Glenwood I loved. But unfortunately, the people I rented from there had their issues and she developed cancer and passed away, and they just didn’t need an extra person around. And that was totally understandable.

So I went back to where I was taking care of this elderly woman. And then a very good friend of mine, elderly woman that my daughter calls grandma, ended up having some really serious health issues. And because Nadine, the lady I had taken care of, had somebody there with her too, I went to Mary’s place. I was just there for her, I rented a room from her.

Miller: But you were also there to help out a little bit, in a kind of subsidized way.

Perkins: Right, exactly. Unfortunately, she passed away. And that’s when everything kind of fell apart. Her house was in a reverse mortgage, and we had to get out within a month. And it was in the winter, she died on Halloween. So it was right when the bad weather started to hit. Thank God for my children, they paid to put me up in the Shilo hotel.

And from there, I did not have any options. My oldest daughter lives in Dallas, Texas, and my youngest daughter was pregnant at the time and living in Vancouver with her husband. But they were just starting out, I wasn’t wanting to be a burden to them. But they did, they banded together and put me up in the hotel, because I had Monster. And from there I stayed in that hotel for probably three weeks, maybe, somewhere around there.

And another group of my friends, one of the girls had cleaned for this family that rented rooms to people in Hood River. They hadn’t for a while and they didn’t plan on doing it again. But because I was in a dire situation they did let me come in and rent a room. And that’s where I was until I came here. And that situation, they weren’t planning on it being long term, and I wasn’t. It’s hard to find housing. I have a limited income. I think I live on about almost $900.

Miller: From Social Security, or disability?

Perkins: I get half and half, because I never built up enough social security basically, I guess. I’m really not quite sure. I get two different amounts of money and they’re about the same, about $900. And that’s total income. Try to find a place on $900 when rent, for just a single bedroom or studio is 1200 and on up. Trying to find a place on that kind of income, it has to be a subsidized situation. And that’s why I am here, trying to get that going. And it has. I haven’t received my voucher for HUD, but I have one of the places that is just based on your income.

Miller: Where do you think you’d be if you couldn’t be in the shelter?

Perkins: It’s scary to think but I don’t know. I hate to think, but it’s quite possible I would be on the streets, and that scares me to death to think of that. I’ve always been able to manage having my own homes and all of that. The rents are just astronomical anymore. And in my situation, I have to live close to shopping. And that makes it even more expensive. The closer you are to all that, the more expensive it gets.

Miller: When you say you have to live close to shopping, why is that?

Perkins: Well because I’m disabled. I have a hard time getting around. I don’t drive.

Miller: You need to be able to walk.

Perkins: Right now, we have the shopping center that’s probably from probably a mile away. And I take the bus. So I have to be somewhere where the bus is, and able to take me around. And unfortunately, it just costs more the closer you live to all of that.

Miller: What options do you have right now? You said at the beginning that you’re hoping that in a couple of days for some news. And the clock is ticking, because as we heard from Kenny in an earlier conversation, you have six months, and he said you can’t stay.

Perkins: Well you can stay, but you’ve got to have something going. They’re not going to just boot you out. Like I said, if this didn’t work out I have another option. They’re not gonna just boot you. But they want to know that you’re working towards something, and that something is in the works.

Miller: And you said something seems to be in the works for you right now?

Perkins: Right, yeah. I have the option of a place in White Salmon, that’s preferably where I wanted to go back to. It’s not like I have a lot of friends there, everybody’s kinda moved on, but that’s where I have lived for a long time and I’m familiar with, and I’m just hoping that works out.

Miller: You said earlier that you never thought you’d be homeless. How has being homeless changed your understanding of what this means?

Perkins: Tremendously. I just had in my head what it meant to be homeless, when you drive down the freeway and you see homeless camps or just homeless people. I, in my head, did not know what to expect when I came here. What do I bring? What things can I afford to have stolen? There was just all these thoughts going on in my head.

This is a little different here, and I’m probably very lucky. There’s programs for all different types of people really. But this program here is to give you a step up. They want people to work the program, they want you to get on those lists. They want to make sure that you’ve filled up all the paperwork, and they’ll help you if you need help doing that, they’re there to help you. It’s just there to give you that boost. Sometimes you feel when you’re homeless, you feel like you’re worthless. And that’s a really hard thing to deal with. I was always a working member of society, and then all of a sudden I’m not. I’ve had some bad times. I don’t even know really how to explain it any better. I just never imagined.

But then you realize there are degrees of homeless people. There are some that just can’t handle the structure of this. And then there are those people that just need that help. Here, quite a few people that are here work. It’s not that they don’t have jobs, it’s once again just being able to afford a place to live, and to be able to afford that electricity, and all the deposits it takes, and food, and all those things. And to be able to just feel like you’re a member of society again. It’s just hard.

And it causes a lot of issues in your head. It does. After years and years, or months even for me, it messes with you a little bit. Makes you just start feeling like you’re worthless, you’re just not worth it anymore. If you’ve already got issues that it just plays on all that. And this program has really helped to make me not feel that way. I was feeling that way for a long time, and it’s boosted me back up again.

Miller: Thank you for showing us your home and giving us some of your time. I appreciate it.

Perkins: Well, my pleasure really. I hope that this brings awareness to what it means to be homeless. There’s so many different things about it. And I met some very cool people here. I really have. People that I hope that I never lose contact with.

It’s been good. It’s actually a very good experience for me. Even though it’s not a great experience, it’s a good experience. I don’t know if that makes sense.

Miller: I think it does. Catherine Perkins, thank you.

Perkins: You bet.

Miller: Monster, thanks for being here. See ya later.

[Laughing]

Dog (Monster): Bark, bark bark!

Miller: That’s Kathryn Perkins and her dog, Monster. They live in the homeless shelter made up of tiny houses in The Dalles.

We’re spending the hour today at a homeless shelter in The Dalles. It’s made up of 18 tiny houses on pallets. Each house had room for two residents. Once a week, a mobile health clinic stops by the shelter to provide free medical services like checkups, testing and referrals. It’s run by One Community Health, a nonprofit community and migrant worker health center. Middy Tilghman is a family nurse practitioner and the lead medical director for the clinic. He brought us inside and gave us a tour.

Middy Tilghman: So, we’re starting here in our exam room. Patients usually start in our little lobby, but since we’re standing in the exam room, let’s start here.

This is a pretty standard exam room. We’ve got blood pressure stuff, stuff to check your eyes and your ears temperatures. And then we sort of start looking around the nooks and crannies, we’ve got a lot of stuff hidden. In the exam room, we have all the braces you could want, thumb braces, arm braces, elbow, shoulder stuff. We have a fancy portable ultrasound machine that allows us to get a quick glimpse into someone and see what’s going on. And we also have stuff that we can take outside the vehicle. Our vehicle isn’t accessible by wheelchair, so if we need to get outside we have the same things but they’re portable. We also have a baby scale for little tiny adorable babies (and non adorable babies).

The exam room is really just a standard exam room except we have different stuff hidden in the closets. We can do pap smears and all that kind of stuff as well, and any sort of checks people need. I think that’s about it for the exam room.

Now going into our hallway, which is you know, this is just a converted RV, so it’s a single straight shot. We have an area where we can do some lab testing. For us, lab testing is two types. We can do all the tests you can do in a clinic, the rapid tests, we call them point of care tests. So that’s like flu, COVID, lead for kids, we can do a couple types of blood sugar checks. We can do rapid urine checks, all sorts of things like that I’m forgetting. And then we can take urine samples for certain things and take them back to the lab and get tested. We could do skin biopsies or pap smears, strep cultures and STI testing, and send it all back to the lab. We can’t draw blood right now because it’s kind of hard to transport. You gotta treat it just right.

You’ll see in the hallway we have some little fridges and freezers scattered around. Those are for vaccines. Mostly we carry on like the basic vaccines you might want, that’s like tetanus or COVID or flu and that kind of stuff. And then we have for kids, we can carry around a whole flight of vaccines. If we had kids scheduled and someone said I got a four year old and they need to catch up on the following vaccines, or we look in the registry and see what they need, we can always bring those out for our main clinics. So every morning we start at our main clinic and they support us.

Miller: What’s the overall idea behind this RV?

Tilghman: The overall idea behind this RV is that we live in a big rural area and it’s really hard for some of our community members to get to care. That’s true anywhere. That’s especially true in where we live. The idea is that we take the care to them. We’re trying to help those patients that we know are out there who are interested in medical care or aren’t quite sure and they need a little more information. Reduce some of the barriers to care, we say. So on this RV, this mobile medical clinic, we have a specialist who does insurance, for example. We have people come in and they’re like “well I think I need something that’s medical, but I’m not sure about my insurance status.” And then we say “come talk to this guy, he’s an expert. And if he can’t answer the question, he’s connected to super experts.” So the idea is that we’re going out and connecting people with care to reduce barriers.

Miller: Where do you go? We’re talking on Tuesday morning and this is the pallet shelter in The Dalles. Where else do you go?

Tilghman: We have a weekly schedule. So every Tuesday morning we’re here. One of the big things about providing care to people who are trying to help them engage in medical care is being really sort of regular and consistent. It’s really hard when you’re moving around and people can’t rely on you as a resource. So having a reliable connection is very important.

Our schedule is Tuesday mornings in the pallet housing, Tuesday afternoons at St Vincent de Paul, which is a warming shelter and soup kitchen in The Dalles that also helps the homeless community. And then on Mondays, we work with the Native American community at some of their in lieu and treaty fishing sites. Wednesdays we’re in the town of Cascade Locks, and then Thursday this team is off. Friday we work with the farm working community.

Miller: Where would people get medical care, the people who you’re used to seeing. If you don’t provide it, where would they be getting it?

Tilghman: Well, that’s a big question and sort of a big concern for our larger community. How people access the medical system affects all of us. A lot of our community members would come to our main clinics, but sometimes they can’t because of transportation. Sometimes they can’t because they don’t quite know the systems here, they’re new to town or new to the area. And then also there’s a fair number of people for whom they can’t access anything until they access the emergency room, and that’s where they go. The emergency rooms here are incredible, and obviously through COVID and everything else, have been incredibly taxed and working just incredible overtime to meet the community need. And so having these primary care, what we call urgent care needs, something like even stitches, we can do on this mobile medical unit. Being able to meet those needs and reduce people’s need to go to the emergency room, or even get into a regular clinic, where right now it’s even hard to get an appointment, is really incredibly helpful.

Miller: Can you chart it? Has this mobile clinic led to a decrease in emergency department usage?

Tilghman: That’s a great question, and we are charting that. I don’t have a formal answer for you yet. We have a researcher working on it, who hopefully by next summer should have some really good answers. But I can tell you nationally when they study these things, it’s pretty well documented that by reaching out to community members who don’t have a great connection to the health care system or are interested in a connection to the health care system but can’t do it for certain reasons, you drive down emergency room visits. And that’s really important for the patients because they get better care, they get what they need instead of going to the emergency room, where emergency rooms are incredible at helping you if you have an acute problem but they can’t always do the things that follow chronic diseases. So you get better patient care. But also, if you get put in an emergency room, and they’re all these people waiting for non-emergent issues and you have an emergency, it’s kind of gumming up the works. And so it affects our whole community.

To say nothing of the cost. Emergency room visits are very thorough for acute problems, but that means they’re really, really expensive. And that’s a real drain on resources when you live in a small rural community and the hospital is working really hard just to survive.

Miller: What’s an average stint like for you here? As you know, you come here Tuesday mornings. What’s it normally like?

Tilghman: One of the fun things about doing medicine in general, and certainly about doing community outreach style medicine, is that every day is pretty different. Certain populations, certain groups of our community have rhythms. So when I come here on Tuesday morning, there are some of the regular gang I see. What’s really nice about this is you create the connection that welcomes people to health care. So they may not need anything from me today, but we chat, we check in, “did you get your thing at the pharmacy?” “Yes, I got it.” Great, move on.

I’ll have some regular patients, and then some new patients. The nice part about this kind of transitional housing is that people come in, and then hopefully they get connected to housing and resources and move on. We try to see the regulars, take care of everybody, but also see some of the new gang.

Miller: So you do get to know some people though over time?

Tilghman: Absolutely. And this is a community of people. And I mean that both in the sense that The Dalles is a community that we all live in together, but also homeless and marginalized communities that we work with, they’re also community too. They check in on each other. I certainly sometimes get internal referrals from the homeless community, they’re like “hey, have you seen so and so? You need to go check on them, they’re not doing the way they should be.” And that’s always both wonderfully warm that everyone’s looking out for each other, but also concerning because when they’re concerned about someone, I’m definitely concerned about them.

Miller: What do you see as the holes in the system right now? It seems like the idea of this clinic is to fill one problem, or a series of them, in various parts of Wasco County. What’s missing?

Tilghman: I think there are a lot of things missing, but also a lot of people working to solve those problems. And I think that’s the challenge. Everyone wants the singular bullet, they want this mobile medical unit to fix all the community’s problems. They want the emergency room to fix all the community’s problems. And the truth of the matter is you have to create a network of things, so that every resource is being used the way it should be, which is more efficient and more effective for all of us, everyone who lives here.

The barriers to care are a lot. And if you’re coming from a community that maybe doesn’t speak English primarily or doesn’t have easy transportation, in a rural setting, that’s really a big hurdle to get out the door. So consolidating these resources, especially for our houseless community, having the pallet housing means you can bring resources here and immediately connect with people. And that’s really powerful. You have to have a coalition of people working together to create a strong network that supports the community. And when they’re consolidated in a single place, then it’s really easy to access for both our organizations and for the patients. And that’s the best situation.

Miller: Where does the funding for this clinic come from?

Tilghman: The big challenge with one of these mobile medical or any outreach medicine is the funding, because we don’t see the same volume of patients that a clinic would see. So my colleagues who are working really hard in the clinic right now, they’re seeing more patients than I see in a day, most days. The funding is at this point largely grant and insurance based. The challenge is to paint the picture that, in a larger setting, this unit is saving the system a lot of money. Now, the system isn’t always cohesive in communicating about who should pay for what, but mobile medical units have been shown nationally, and we suspect this one will be shown, to in fact save our community lots of money.

Miller: But you have to change on some level the financial system of “how many people are you seeing,” and that’s the most important metric. You have to change that to actually prove the worth to the bean counters?

Tilghman: Yeah. And I think there’s actually some really interesting initiatives in Oregon, and this is a little bit out of my specialty, to change the way insurance is paid. So you’re not sort of just paid to see one patient, you get $1 kind of thing. It’s saying “if you’re in charge of this community, let’s see how many times you can take care of them, or how many times you can reduce the number of emergency visits every 12 months, or reduce the number of times they don’t get their medications because of a pharmacy medical connect snafu.” And those are pretty powerful. I think those sound like really boring things to most people. Most of my family doesn’t want to talk about health insurance. But it actually makes a massive difference in what we can do and what people can do.

Miller: Why were you personally drawn to this version of medicine?

Tilghman: This is something I really like to do, and something I’ve always liked to do. I think it’s important, and I think it’s something that I enjoy. Not everyone can enjoy this kind of work, in the same way surgeons love being surgeons and I can’t enjoy that kind of work. So one of the beautiful things that someone taught me in health care was that there’s a provider and a role for everybody. You don’t have to do everything, but you have to do your part. And I think this unit is an important part of that web, and so that’s sort of my role, and a role I’m very lucky to have.

Miller: Middy Tilghman, thanks very much.

Tilghman: Thanks so much.

Miller: Middy Tilghman is a family nurse practitioner and the lead medical provider for the clinic.

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