Comments
iAUDIT - One of the most tragic consequences of L.A.’s homelessness crisis is the large number of street people with serious mental health problems. There is probably no one in Los Angeles who hasn’t encountered clearly disturbed people during the course of their daily routines. Some encounters are frightening, while some are merely distracting, but all are emblematic of a larger crisis. That so few of the unhoused receive needed mental health services makes the tragedy a man-made disaster.
The perception that many homeless people have mental health problems is supported by the actual numbers. According to LAHSA’s 2023 Point in Time count, about 55,155, (73 percent) of the 75,518 homeless people in L.A. County are unsheltered. Two professional, unbiased studies from the RAND Corporation and the California Policy Lab estimate between 54 percent and 78 percent, or an average of 66 percent, of the homeless have some type of mental health issue, equal to about 36,400 unsheltered people. Many have comorbidities with medical and substance abuse problems.
The L.A. County Department of Mental Health (DMH) and a host of nonprofit organizations are the lead agencies for providing mental services to the unhoused. Medical and mental health experts agree the most effective treatment model for people with mental illness is Full Service Partnerships (FSP’s), commonly called wraparound services. County DMH defines FSP’s as “doing whatever it takes” to provide focused services to people with serious mental illness. The County’s website says, “Adult FSP programs assist with housing, employment and education in addition to providing mental health services and integrated treatment for individuals who have a co-occurring mental health and substance abuse disorder”. The program’s website describes a robust system of interconnected services delivering treatment to those who most need it. The truth, however, is far different.
DMH provides field interventions through its in-house HOME (Homeless Outreach and Mobile Engagement) Team. According to HOME’s website, in 2021, the team provided services to 2,100 people, or about 5.7 percent of the estimated 36,400 people who need mental health assistance. Even at that low level of service, the website advises the public to “be patient” because it takes time to build trust and rapport with seriously mentally ill people. So, less than six percent of the homeless people who could benefit from an FSP program receive services to begin with. The HOME Team’s low contact rate is reflected in low FSP participation numbers. According to the Department of Mental Health’s Services Dashboard, just 2,049 people were admitted to FSP programs in fiscal year 2022-23, even as the homeless population grew.
Because of the inherently transient and mobile nature of the huge unsheltered population, providing consistent care is nearly impossible. Media stories abound of family members desperately trying to get care for their mentally ill loved ones, only to be told they have “personal agency” and can’t be forced into care, except in the most extreme cases. Meanwhile, outreach teams search for clients who move from place to place or disappear entirely.
Once in a shelter or housing, people fare little better than those on the streets. The L.A. County Homeless Initiative’s latest Quarterly Report shows that it enrolled 4,242 people who were in permanent supportive housing (PSH), in its Intensive Case Management System (ICMS) program (Appendix A, page 13). According to LAHSA’s latest PIT count, 22,540 people received permanent housing in 2022, (although the count notes there are an unknown number of repeat clients in that number). Assuming the same percentage of people with mental health needs (66%) placed in housing, there are about 14,876 people with mental issues in PSH, of whom 4,242, (28 percent) received intensive services.
Shelters are notorious for being poorly managed by their nonprofit administrators. Many, like a shelter operated by Los Angeles Family Housing Corporation (LAFH) in North Hollywood, is a center for drug use, crime, and violent behavior. Even the shelter’s clients don’t feel safe there. The North Hollywood shelter is not an outlier. The Venice Bridge Home is well-known for virtually non-stop violence and anti-social behavior. Many shelters and transitional housing sites are surrounded by tent encampments, where people transit from rooms to tents so they can continue the behaviors that often contributed to their homelessness.
On its website, LAFH claims it provides extensive mental health and counseling services to its sheltered clients. Its 2021 annual report, like most service provider publications, shows smiling, well-scrubbed clients in pristine settings. Anyone who has been in or near a shelter knows that is rarely the reality. People with serious mental illnesses cannot care for themselves, and many shelters, regardless of the operator, are little better than warehouses for the desperately ill.
Despite low service numbers and chaotic shelter and housing facilities, City and County leaders continue to follow the same failed pattern. Just last Wednesday, the City Council’s Homelessness and Housing Committee approved the construction of a new transitional shelter in the Pico-Midvale area. The Committee members assured concerned residents this shelter would be different from all the others, and managed safely, with a no-camping zone around the facility. Yet the chosen operator is LA Family Housing, the same organization that manages the North Hollywood shelter. And Katy Yaroslavsky, the District’s Councilmember, has consistently voted against anti-camping ordinances.
There are at least two major factors contributing to the failure of mental health outreach in L.A. County. First, No Barrier Housing First does not require a commitment to behavioral change as a condition of long-term housing. Even if providers offered state of the art services, clients have no requirement to use them. The consequences have been detailed many times before, so there is no need reiterate them, except to point out the policy often results in a revolving door of mentally ill people moving in and out of (or being made to leave) housing.
The second factor grows from the first: Housing First’s emphasis on expensive and time-consuming construction has sapped funding from other services, including mental health. As a recent report from the United Way and RAND says, nonprofit homeless mental health program providers are underfunded, understaffed; and they are usually unaccountable as well. The report points out many providers cannot depend on public funding for their budgets, (most of which goes towards housing construction rather than services), hindering long-term program planning. A knock-on effect of unstable budgets is the inability to recruit and retain trained professional staff. The report says at least 50 percent of respondents reported wanting to expand professional services, including mental health.
The report also hints at the worst-kept secret in L.A.’s homelessness world; the lack of accountability among public and nonprofit providers. The report noted the median capacity of the shelters in the survey was 140 to 200 people, but the average daily population was 100. Despite claims of a dearth of beds, the problem is filling existing space as well as expanding capacity. Because services are often fragmented across a variety of providers, coordination is vital, especially for clients who need consistent mental health or substance abuse services. In theory, the County’s Homeless Management Information System (HMIS) is supposed to track clients and services, but survey respondents reported various problems with the system, including:
- It does not track client experience data, such as client satisfaction with referrals. It is difficult to hold an agency accountable for outcomes if nobody knows if the clients benefitted from the services they received.
- HMIS does not always facilitate data accuracy, due to data fields that do not enforce data integrity requirements like consistent terminology.
- A lack of standardized reporting quality, because frequent changes to the system’s data fields affect long-term data continuity.
- Respondents said the user interface isn’t intuitive. This is exacerbated by a lack of trained staff, meaning new users are on a constant learning. curve.
- Perhaps most seriously, HMIS does not allow consistent access to personal information across service providers. According to the report, this is to protect sensitive data, but it frustrates coordination. As demonstrated time and again by LAHSA simply “losing” people, the lack of coordination leads to serious gaps in providing effective services.
Like the storm surge that follows the wake of a major hurricane, the lack of homeless mental health services affects other areas of the community. It is easy to find media stories of random and unprovoked attacks—sometime fatal to the victims—committed by disturbed people. Although anecdotal, these stories fuel the common perception that most homeless people are potentially dangerous. Encounters between law enforcement and people experiencing a mental health crisis can end violently, and sometimes fatally, for the unhoused person. Even a nonviolent encounter with someone sprawled on the sidewalk, unwashed, clearly troubled and sometimes covered in their own filth, is traumatic for members of the public and dehumanizing for the homeless themselves.
The shortage of institutional care for the mentally ill homeless even affects the most vulnerable in our population—those in skilled nursing facilities. As described in heartbreaking detail by LAist, California’s lack of institutional mental care facilities has turned many nursing homes into de facto mental hospitals, where 8,000 California residents live in a facility where at least half of patients have a serious mental illness. Nursing home employees are among the lowest-paid and least trained in health care, and they are being overwhelmed by a tidal wave of mentally ill people, many placed directly from the streets into a care facility. Regular patients—those who need physical rehabilitation or constant supportive and palliative care—are living side by side with people experiencing a variety of serious mental illnesses from psychotic disorders to schizophrenia, or a combination of those and others, in an environment more akin to Bedlam than a recuperative facility.
There is plenty of blame to go around. We can blame the ACLU and advocates who insist everyone, even the most disturbed, has “personal agency” to decide how and if they need treatment. We can blame elected leaders for lacking the courage to confront the failure of Housing First’s addiction to construction (and developers’ money). We can blame state leadership going back to Reagan’s governorship, when funding was drained from public mental institutions, and never invested in community-level facilities as promised. We can blame the fragmented and unaccountable system perpetuated by the City, County, and service providers. We can blame ourselves for not expressing the outrage commensurate with the crisis. Perhaps the only innocent parties are the mentally ill homeless themselves, who are offered almost no options for treatment, even if they are cognizant enough to seek it. As long as the current system endures, it will only lead to heartbreak for the homeless, their families, and the community at large.
(Tim Campbell is a resident of Westchester who spent a career in the public service and managed a municipal performance audit program. He focuses on outcomes instead of process.)
