Interview with Rachel Solotaroff, MD, MCR, FACP, Penobscot Community Health Care’s (PCHC) new
Executive Clinical Director of Behavioral Medicine and Community Wellness. Dr. Solotaroff joins PCHC
having previously served as the President and CEO of Central City Concern in Portland, Oregon, an
agency providing healthcare, housing, and employment services.
(responses have been edited for brevity)
What led you to move from Portland, Oregon, to Maine?
I’m one of those people who is “from away” but always wished I was from Maine. I grew up in Minneapolis and spent summers on Swan’s Island. By the time I was about eight, I thought, “Oh, that’s where I’m going to live,” but after college in New England and med school in New Hampshire… life happens. I met my husband, who lived and worked in Portland, Oregon. Although I didn’t love Portland, OR, I became involved with this incredible organization, Central City Concern, in 2006. Years passed, and with COVID, I had a reckoning, that perhaps I could move back to Maine. So i spent a year or two just talking to people [in Maine]…, and of the places was Penobscot Community Health Care. It’s a highly regarded organization, that I’d already known of. And, unsurprisingly, the issues of substance use disorder and housing and social isolation, which are profound in an urban homeless community in Portland, Oregon, are equally if not more prevalent here in Maine. My hope is that I could be of service in some way here in Maine.
Of your many accomplishments, what are you most proud of?
[As President and CEO of Central City Concern, Dr. Solotaroff oversaw an agency that provides housing, health care, and employment to over 15,000 individuals and grew net assets from $86 million to $123 million in her first three years as CEO. During this time, she oversaw the creation of the Blackburn Center, a $55 million facility that provides integrated primary and behavioral health care, supportive housing, respite care, and employment services as a model to end homelessness. She also implemented key diversity, equity, and inclusion initiatives and launched the agency’s first Equity Steering Committee].
So, this is a little bit of a story, but we opened a site on the eastern side of Portland, Oregon, an area of high poverty with not a lot of services. My predecessor, my boss and mentor, a fellow named Ed Blackburn, recognized that after the Affordable Care Act was passed, there’s going to be a lot more money in our hospital systems and a lot of people going to be covered by insurance with Medicaid expansion.
He brought all the hospital executives in Portland together, plus our Medicaid managed care payer. And he said, “What if we pooled those dollars, your community benefit dollars, so we could have a collective impact investment in housing and services for people experiencing homelessness?” and, frankly, for your own workforce because people couldn’t afford to live in Portland anymore. And it worked!
He got a commitment for 22 million dollars, which our organization leveraged through low-income housing tax credits and new market tax credits and a capital campaign to about 90 million dollars.
We opened 400 new housing units and a large integrated healthcare clinic with housing on the east side of Portland, a flagship project called the Blackburn Center. It opened two years after I became the CEO (after serving as Chief Medical Officer when the development was happening).
The first thing my board chair said to me was, “The Blackburn Center cannot fail. The eyes of the country are on you, and don’t fail.” It was a bit intimidating. So, we just were very deliberate about it. We spent a lot of time talking to the neighborhood in East Portland, enlisting staff and clients in the clinical model and design, and are still working on bumps and things to work out.
Under one roof, we have 60 beds of medical respite care, 110 units of transitional housing, and another 50 or 60 units of permanent housing. And then the first two floors are an integrated health center with a full range of services, including substance use disorders, mental health, and primary care with employment services embedded within it.
I remember our first patient who walked in: homeless, with terrible trauma and PTSD, in active withdrawal from opioids, and just within two hours, we induced onto buprenorphine. She was filling out an application to get into housing. She’d had her thyroid medication refilled. She also deliberated: “I don’t want to talk to an employment specialist, yet, but sign me up.” And the best thing was that she said, “And you’re all so nice.”
I think the other thing [I’m proud of] is our work on equity — not financial equity, but racial equity and anti-racism in the organization. Central City Concern has a long history of providing culturally specific services, but we expanded that while I was the CEO. We looked at everything from culturally specific re-entry programs to broadening our services for monolingual, monocultural, Latino adults and kids, to expanding Afrocentric services, in particular. It was how the community defined it. The key was working with staff to say “How do you want to see these programs grow? How do you want to see this organization change? What are policies that don’t express the values of anti-racism? What ways do we do things in terms of decision-making that could be more inclusive?”
I don’t take credit for that work. I had wonderful partners and mentors with a long legacy, and it’s work that will take generations to unbuild structural and institutional racism. It is hard work, but we tried to be both honest and substantive. The goal was to make a difference. As my colleague Freda Ceaser, our Chief Equity Officer, would always say to me: “Show your receipts.”
How might you apply your experiences and learning to Maine?
I don’t want to be presumptuous…but here are a couple of thoughts. Just as there’s diversity in approaches to how to treat substance use disorders, and there’s evidence for all of them, the same applies to housing. There is recovery housing, formally called alcohol drug-free community housing, where one of the conditions of being in the housing is that you’re engaged in a program of recovery. While there is right to remedy, there is no substances use in the housing.
On the other side, there’s permanent supportive housing; often which is a low barrier and has a housing first approach. In this model, there’s no precondition for treatment or sobriety or engagement in any services.
What I learned at Central City Concern is this idea of housing choice. There is no one right way to provide housing, especially for people with substance use disorders. You match the housing to the circumstance of the individual. This concept and access to Housing Choice might be helpful in Maine. I’m just getting to know a little bit better and better understand what different housing models we have here and what ones need to grow or at what scale. The next step is to think about how to link the healthcare intervention with the housing intervention.
One great example is when people are leaving withdrawal management. In my view, if a person to homelessness, the system has failed that person. Once on the street, it is likely they are going to return to use quickly, which is dangerous.
So, it’s important to have concerted pathways by which people go from withdrawal management to recovery housing. You have services in the recovery housing; peer support, employment services, and connections to the treatment and health care team.
That pathway accelerates people’s ability to move on, graduate from treatment, get permanent housing and sustainable employment. With that model, in one unit of recovery housing, you can end homelessness for one or two people a year because you’ve knitted together the steps, and each intervention is leveraging the one before it. That kind of stuff makes me super excited.
Tackling homelessness can be overwhelming. But the key to making it not overwhelming is to use a population health lens and a population approach. To try to accomplish everything for everyone is hard. But if you say, “Hey, we have X many people with serious mental illness coming out of the state hospital. And what’s our pathway for that?”
Or, we have X many people in the reentry community, X many people coming out of withdrawal management substance use. You start to construct pathways based on a specific population, one by one. And each time you do, you see success, and then you build on those successes…I think that makes it seem more doable. It’s just breaking the problem down into its component parts.
How might we expand MOUD?
I think, in the state of Oregon, I believe we are much further behind Maine in terms of how to think about this issue on a statewide basis and ways to engage rural communities through technical assistance and support. There is so much amazing work here in terms of learning collaboratives and grant opportunities.
Also, from what I’ve seen, MaineCare is terrific. They listen to what the community is asking for and take action. And their customer service is great (at least every time I’ve called!).
Other examples of great access to care are the Opioid Health Home expansion, removal of PAs when needed, and lots of really good clinical guidelines. Right now, in an overdose crisis, a prescription for MOUD is our absolute, single best tool for preventing overdose. The expansion and access to MOUD is indispensable and the ground floor of our overdose response.
Then what’s the next step after that? I think that’s where we need to be focusing next. In terms of recovery (not overdose prevention), a prescription I write pales in comparison to when somebody gets into safe and supportive housing, or when someone connects with peer support, or when that person gains employment (if that’s what they want). These are all vital components of recovery.
Here in Maine, the low barrier to access to MOUD as an overdose prevention strategy is brilliant. Then we have to start thinking about, okay, how are we now improving people’s quality of life and wellbeing? And that’s where all those other things come into play.
In your previous work, what were the challenges, and how did you move forward?
First, there can be a lot of analysis paralysis that stops forward progress. I’ll be transparent and say I saw that often in Oregon. I think being able to be thoughtful and inclusive but ultimately decisive and action-oriented is critical. Every hour or week you spend having more meetings, deliberating more, or trying to please everybody, is another week that you’re not advancing your goals of helping somebody with substance use, getting them out of homelessness, or helping with supportive employment.
So, I think there’s something around gathering good evidence, gathering good input, and then being decisive and intentional in action that I think was a challenge.
Second, funding for supported employment has always been and continues to be a challenge. Employment services are the most cost-effective intervention we have to end homelessness. $4,000 a year, often coupled with some rent support, vastly increases chances of somebody maintaining employment, maintaining housing, and not needing further assistance in the future.
I don’t know why, but employment services have always been that step-cousin that get less attention, yet it are such a valuable resource. It’s so helpful in reducing substance use or eliminating substance use, improving the quality of life for that person and the community. It addresses recovery and harm reduction. The basic idea is that anyone who wants to work, can work. They can obtain competitive employment and get some follow-along support. For the investment, there are just so many leverageable benefits.
What do you think are your first steps here in Maine?
Well, I’m just getting to know all the different sites at PCHC, what resources and support they need, where there is great practice that should be spread, et cetera. But, very soon, we will be figuring out (back to this idea of pathways) what a pretty seamless pathway looks like for somebody seeking care for a substance use disorder, and how to take a population health approach to that.
For instance, how do we connect someone who may be coming out of withdrawal management seamlessly into the right level of service and what they want? Perhaps they want to be in a bridge clinic, a low barrier service, for a while, or maybe they want to be in a structured program, or perhaps they need a lot of support for co-occurring mental health issues, or advanced medical issues.
Then you have to layer in the issue of geography. Can we offer the same array of services in different geographic areas, as the catchment area at PCHC is quite large? I believe we need to have different levels of care in each geographic region, but the specifics may look different, depending on the differing needs of people coming in.
Next, how are we connected to other substance use disorder services in the community, whether it’s withdrawal management or a reentry program? And then the next step from that is starting to think about housing. What’s available for housing resources? You can’t just build a lot of housing out of thin air. Still, there are tried and true ways of integrating substance use disorder services with housing, whether it’s low barrier housing or recovery housing.
Finally, there is always the question of racial equity, and providing culturally specific services. I have always felt my job is to partner with community-based organizations and culturally specific organizations to see how we can be of help. Often, that catalyzes more change and supports more people than starting your own services, especially in a large organization.
Is there anything that you would like to add?
Part of the reason I also wanted to come to Maine is that I think there’s incredible work that happens here. It’s groundbreaking and visionary how we feel about responding to and preventing substance use disorder as a state. It is heartwarming and inspiring. I’m certainly not the person from the outside who has all the answers. I just want to be of service to the visionary work here.
I believe Maine undersells its exceptionalism. On my second day of work, I went to the Governor’s Opioid Summit, which blew my mind. Things like that don’t happen everywhere, or easily.
There is also a wide range of work happening, which has support across the state and at the federal level. And there is a willingness to act decisively, to take action and move things forward, that, to me, is stunning. I just want to express gratitude to be able to be here and help in some capacity.