One man’s experience emerging from homelessness reveals the challenges California faces as it ramps up permanent supportive housing.
As the number of homeless Californians grows, the state is spending unprecedented dollars to build tens of thousands of homes for people living in shelters, vehicles and encampments.
CalMatters detailed the experience of Fernando Maya, a chronically homeless man who left the streets of Los Angeles in 2020 and landed in one of these new units.
A year and a half later, Maya remains in permanent supportive housing, a model that combines ongoing housing support with in-house services, such as social workers and addictions counsellors. But he encountered personal and systemic obstacles that nearly pushed him back to the underpass where he once lived.
The researchers, advocates, and managers who run the systems aim to help Maya come to terms with her struggle to transition inside is common. At the same time, Maya’s experience reveals a number of problems the state faces in rapidly developing permanent supportive housing.
Here are five key challenges, along with potential solutions:
1. Understaffing and turnover
What’s the problem: Experts say understaffing and staff turnover affect permanent supportive housing, due to burnout, low wages, lack of training for challenging work, and few job opportunities. career progression. The number of cases in permanent supportive housing often far exceeds federal recommendations.
Working with burnt-out, transient staff can break trust, hampering a person’s recovery from homelessness, said Suzanne Wenzel, a professor at the University of Southern California who studies health and homelessness. “Because of the way one had to survive on the streets,” Wenzel said, “confidence is not a very abundant commodity.”
What are the solutions : State officials and researchers agreed that solutions must combine a variety of long-term strategies, including more recruitment of behavioral health workers, more training opportunities, and more funding to deliver better wages and benefits.
What does the state do: The state has been trying to develop the behavioral health and medical workforce for years. It has a five-year, $60 million plan to grow the mental health workforce and offers scholarships to students in health care and adjacent fields, including occupational therapists and social workers, in exchange for working. in underserved communities for a year. To boost those efforts, Governor Gavin Newsom proposed this month to spend $1 billion over three years to increase the number of community health workers, social workers, psychiatrists and addiction counselors.
2. Processing remains compartmentalized
What’s the problem: People who are chronically homeless often face complex and interrelated health issues, ranging from physical conditions to serious mental illnesses and substance use disorders. As homeless services increasingly take a collaborative approach, experts said treatment remains siloed. Patients often navigate multiple healthcare systems, with providers dealing with their issues in isolation and not coordinating with each other, even when working in the same building.
What are the solutions : In a study of permanent supportive housing programs in Los Angeles, Wenzel’s research team found that staff struggled to coordinate and communicate with contracted service providers. The researchers recommended that permanent supportive housing programs consider hiring or training internal staff to provide certain services rather than contracting with external providers.
What does the state do: The state is pushing for greater top-down healthcare collaboration. Since 2016, 25 programs have been launched across the state to pilot the “whole person care” model, which emphasizes the coordinated treatment of people with complex health conditions and encourages providers to collaborate. Soon, California will launch the next step: CalAIM, a statewide Medi-Cal upgrade for the most needy patients. CalAIM will cover non-traditional services, such as a personal care coordinator, food and housing assistance, and sobering up centers.
3. Beyond Medication Management
What’s the problem: Government-funded mental health services often begin and end with medication management. But people recovering from homelessness also need intensive counseling and opportunities that help them find purpose and a sense of belonging, said Dr. Jonathan Sherin, a neuroscientist who heads the department of mental health at Los Angeles.
“We really need to think of models where we incorporate all aspects of the human condition into healing,” Sherin said.
What are the solutions : One such setting is a community mental health system started in Trieste, Italy in the 1960s and 1970s. There, treatment focuses on holistic well-being, emphasizing community development and professional training. Sherin also believes that people living in permanent supportive housing could benefit from better access to occupational therapists, who help people learn the skills needed for daily life and work.
Sherin hopes to demonstrate that the Trieste model can work in California. In 2019, he proposed a pilot program in Hollywood that would reform how providers treat patients, track their outcomes and bill for services. Instead of focusing on illness, mental health providers would focus on helping patients improve their physical health, achieve housing stability, and find love, belonging, and purpose. Approved for 2020 but stalled by the pandemic, the pilot remains in the planning phase.
What does the state do: While recent public funding rounds for permanent supportive housing for people with serious mental illness specify that projects must provide mental health care and encourage them to provide employment services, there is no is no further guidance on mental health strategy.
4. Allow people to move
What’s the problem: The Housing First philosophy emphasizes consumer choice, meaning that formerly homeless people choose where they live and what services they receive. Researchers and officials said this means residents should be able to move out if their original apartment is not suitable for them. In practice, homeless agencies and housing providers do not always prioritize moving as they try to get other people off the streets.
What are the solutions : One solution comes from a permanent supportive housing program for the most frequent chronic users of emergency rooms, prisons and acute mental health facilities in Santa Clara County. According to Abode Services, the Bay Area’s permanent supportive housing provider, they have kept several units vacant throughout the year, so people can move out if needed. A multi-year study found that participants stayed housed 93% of the time and 70% had moved at least once.
What does the state do: The state requires permanent supportive housing programs to submit regular reports showing they are complying with Housing First policies, which are supposed to include the possibility of transfers.
5. Track why people are returning to homelessness
What’s the problem: The US homelessness services system is divided into local jurisdictions, known as continuums of care, which receive federal funding to address homelessness. However, their data systems don’t always keep track of who is returning to homelessness and why, making it difficult to understand why interventions aren’t working.
What are the solutions : Built for Zero, an initiative of national nonprofit Community Solutions, is partnering with local governments to redesign homelessness data systems around shared goals of reducing homelessness and collaborating between homeless service providers. Co-director Jake Maguire said a robust data system allows local governments to detect low housing retention rates and then drill into individual experiences to determine what’s not working.
What does the state do: California is trying to strengthen local government accountability. The latest round of local homelessness relief requires counties to establish action plans, including tracking and reducing the number of permanent residents returning to homelessness.
Dr. Mark Ghaly, secretary of state for health and human services, said he hopes the state’s new homelessness data dashboard can aggregate data on housing retention , allowing the state to study the impacts of permanent supportive housing programs.
“Housing alone, we won’t be surprised, won’t be enough,” said Ghaly, who co-chairs the California Interagency Council on Homelessness. “But when you enrich it with sophisticated, intelligent, available clinical services, does it help someone become safe and self-sufficient?”
This article is part of the California Division project, a collaboration between newsrooms examining income inequality and economic survival in California.