Multnomah County exists to deliver essential services that protect life, health, and stability. Its responsibilities are among the most serious in local government: mental health and addiction treatment, homelessness prevention and response, public health, human services, community safety.

When County government works well, lives are saved. Crises are prevented. Families stabilize. Communities thrive.

When County government doesn’t work well, people fall into crisis, are harmed, and die. Families and communities suffer. 

Today, none of the County’s systems are working as they should. 

Multnomah County spends $4 billion each year, including hundreds of millions annually on homeless services alone. Yet unsheltered homelessness has more than tripled over the past five years. Mental illness and addiction remain largely untreated. Public trust has eroded. Hundreds of people are dying on our streets each year.

These are not isolated failures. They are symptoms of a deeper operational breakdown - a systems failure of County government itself.

• Money is dispersed across departments and can’t be tracked. 

• Authority is diffuse and fragmented without clear chain of command. 

• Budgets are based on history and inertia rather than strategy and results. 

• Management turnover is near constant. 

• The County Chair holds sweeping power with few checks and balances, and no accountability other than an election every four years. 

• Hundreds of millions of dollars have quietly disappeared into myriad overlapping programs with no end data to prove that anyone receiving County services moves from crisis to stability.

If we want different results, we must change how the County itself operates. This requires a fundamental reset - grounded in local expertise, informed by high-performing counties across the country, and built on concrete operational plans with measurable outcomes and aligned budgets.

As a former County Commissioner and an emergency and street medicine physician, I have seen the County’s dysfunction from both inside government and on the front lines. After leaving office, I began documenting what a functional county would require. That work evolved into this comprehensive turnaround plan.

The plan was informed by frontline providers, people impacted by County services, local experts, and community leaders I have worked and engaged with over years, along with best practices from successful counties across the country. It will continue to evolve based on expert and community input. 

The comprehensive plan offers a blueprint for transformation resting on four principles:

• Organizing for impact

• Measuring what matters

• Budgeting for results

• Accounting for every dollar

The Homeless Services Turnaround Plan is included as a detailed example because it is emblematic of the County’s structural weaknesses - fragmented authority, unclear accountability, misaligned budgets, and outcome measures that track activity rather than results. The same problems exist across behavioral health, public safety, human services, animal services, and other County functions. 

Outcomes can be significantly improved by extrapolating the approach outlined for homeless services to departments countywide. 

But fixing the foundation of the County requires more than improving programs, streamlining departments, and better administration. It requires restructuring governance, budgeting, contracting, and performance management, and embedding accountability and continuous improvement into the institution itself.

Within one year, the County will:

• Establish a clear chain of command and functionally integrated operational structure

• Implement a real-time, validated baseline of need across departments

• Align budgets with meaningful measurable outcomes

• Publish transparent performance dashboards that measure what matters

• Identify and redirect funding from ineffective programs

Within two years, the County will have:

• A functioning homelessness-to-housing continuum with verified placement and retention outcomes

• Reduced returns to crisis systems such as shelters, emergency rooms, and jails

• A culture of accountability embedded across departments

• A durable structural foundation capable of sustaining results independent of political cycles and fluctuations in funding

By performing an operational reset focusing on what’s truly ailing the County, Multnomah County will save lives, improve health, housing and wellbeing, strengthen community, rebuild public trust, and restore the region’s economic vitality. Not by spending more, but by doing its core work well.

See details of the plan for operational steps, governance reforms, budgeting and contracting changes, and meaningful performance standards.