THE ROCK REPORT: SLO County Health Leaders Focus on Housing to Treat Chronic Homelessness, Mental Illness

By ED OCHS

As undeniably complex as the issue of homelessness is nationally, what is needed to provide better homeless and mental health services in SLO County is clear: More of everything.

According to a February survey on homelessness and mental illness treatment in SLO County conducted by The ROCK, SLO County officials and professionals working to find pathways to solutions on a daily basis agree: More funding, more affordable housing and more treatment are badly needed to begin to make a serious dent in chronic homelessness shadowing the county.

They also unanimously concur that the Affordable Care Act will offer a huge boost for the chronically homeless in the county as more people become eligible and more services are offered, including mental health, under an expanded Medi-Cal program. (See separate article. Click here.)

More permanent housing for disabled

Last year’s Point-in-Time Count, conducted by the Homeless Services Oversight Council (HSOC), logged 2,186 homeless people in San Luis County in one 24-hour period in January 2013, and an estimated 3.497 people homeless over the course of a year. Of those, 29% were chronically homeless, with many more at risk, while 49% reported experiencing some form of mental illness, according to the count. Significantly, missing from the data, according to Homeless Services, are persons who do not access shelter, case management, or transitional or permanent housing assistance.

“These statistics demonstrate the need for more permanent, supportive housing for persons with disabilities as well as more treatment services,” responded Laurel Weir, Homeless Services Coordinator, Department of Social Services.

According to Weir, approximately 25 homeless patients per month are admitted to the County’s Psychiatric Health Facility (PHF), a short-term-stay, crisis facility for adults and youth who are admitted because they are a danger to themselves or others, have been found incompetent to stand trial, or who have been conserved. Over the past year, homeless persons constituted the overwhelming majority of persons admitted to the PHF under California Penal Code 1370 (incarcerated persons who have been found incompetent to stand trial).

Because of revised questions and an added provider in 2013, comparing 2013 homeless numbers to 2012 is inexact. Over all, though, Homeless Services reported a slight decrease in the number of new persons reporting mental health issues in 2012 (575 out of 1451 new “intakes” or 40%) versus 2013 (483 out of 1258 or 38%). But of clients whose first intake was in 2012, 257 were still being served by one or more Homeless Services programs in 2013. From July 1, 2012 to June 30, 2013, there were 137 homeless persons admitted to the PHF, approximately 16% of all PHF admissions.

“According to the federal Substance Abuse and Mental Health Services Administration, homelessness exacerbates mental illness,” Weir stated. “Therefore, housing is an important part of the treatment. In particular, the Housing First model has shown promise for moving chronically homeless individuals with severe and persistent mental illness off the street.

“As a first step towards increasing resources for people with severe mental illness, particularly those who have co-occurring substance abuse disorders and chronic health conditions, the County recently issued a Request for Proposals to serve 50 of the most vulnerable, chronically homeless persons.”

The RFP explains the program and Housing First model: “The ‘Housing First’ approach has emerged as a favored policy in addressing issues of homelessness. … ‘Housing First’ places people into permanent housing and then provides behavioral health treatment, case management, and other services needed to allow the clients to stabilize in place and to maintain their housing. The model does not require people to be well before putting them into housing, nor does it require clients to participate in any services other than case management as a condition of receiving housing. The ‘Housing First’ model is considered by HUD and other federal agencies to be a best practice for ending homelessness among those who have been chronically homeless, because use of this model consistently demonstrates a decreased use of emergency services, criminal justice resources, and many other public services.”

The RFP continues: “As part of a strategic planning effort in March of 2013, the Homeless Services Oversight Council (HSOC) identified ‘Housing First’ as a priority. To address this priority, HSOC voted in May of 2013 to join the 100,000 Homes Campaign, a national effort that emphasizes a ‘Housing First’ approach to housing highly vulnerable, chronically homeless individuals.”

Explained Weir: “Mental health treatment is not necessarily the first action that should be taken to get homeless persons with mental illness off the streets, nor are clients required to obtain treatment prior to being housed. Treatment often comes after the clients are housed.

“We are also looking at some additional opportunities to expand the number of permanent housing units in the Continuum of Care’s Supportive Housing Program, although whether or not funding is available for this will depend on the aftermath of the federal budget Sequestration.  Additionally, we have asked the agencies that run the existing Supportive Housing Program beds to agree to give priority to chronically homeless persons—who must have a disability, such as mental illness, to be considered chronically homeless—if units become available in their existing Supportive Housing Program.”

“When the HSOC held discussions last year about the Psychiatric Health Facility, it noted that some of the homeless persons being discharged from the PHF were sent to the homeless shelter because of a lack of suitable housing options. The Housing First program and the expansion of permanent, supportive housing would be a first step in helping homeless persons with mental illness to move out of the shelters and off the streets and into more appropriate housing with the supportive help they need to keep them stabilized in housing.

“To be clear, these would be only first steps. In order to fully serve all the homeless persons with mental illness, we would need to significantly increase both our housing and supportive services for this population. We will continue to pursue additional federal and state funding to expand resources needed.”

Finding funding is a full-time, never-ending pursuit for providers, particularly when new funds for new programs can’t keep up with federal cuts that undermine existing programs.

“Recent federal cuts have made our efforts more challenging.” Weir noted. “In particular, the federal Budget Sequestration has put one of our permanent, supportive housing programs at risk of losing its federal funding. Also, a change in the major federal homeless assistance program that funds some of the case management services provided to homeless persons placed into permanent housing has limited the amount of time that case management services may be provided to six months. When someone with a severe and persistent mental illness is placed into permanent housing, they will often continue to need services well beyond six months.

“Cuts to the federal Housing Choice Voucher program have reduced the number of housing subsidies available to place people into permanent housing. Also, cuts at the state level have reduced funding available to build supportive housing for extremely low-income persons with disabilities.”

Limited number of mental health providers

Replied Grace McIntosh, Deputy Director of the Community Action Partnership of San Luis Obispo (CAPSLO): “While some of our programs see relatively few individuals with mental health issues, other programs, such as Homeless Services, see a larger number. Since mental illness is a major contributing factor to homelessness it would make sense that mentally ill individuals remain in our homeless program for longer periods of time and are more challenging to place into permanent housing. The numbers have remained fairly steady as many individuals are in services for a number of years.”

The need for more funding extends beyond the areas of mental health and housing, McIntosh points out.

“I think most non-profit providers and the county would agree that there is a need for more funding, not only in the area of mental health services, but drug and alcohol services and affordable housing as well. Funding for mental health services for children is an area that needs to be increased as some of our programs are seeing a larger number of younger children presenting behaviors that challenge their ability to be successful in preschool and school.”

McIntosh is among several county officials and professionals who believe Medi-Cal will help more homeless receive care. (See separate article.)

Explained McIntosh: “With expanded Medi-Cal now including mental health services, there will be the opportunity for qualifying individuals to receive these services. I think there may be difficulties with access given the limited number of providers in the county. The issue of a limited number of mental health providers is not only in our county—it is a national issue that I believe is going to need to be addressed in the very near future. Funding is always an issue that providers struggle with. In addition to public dollars most non-profit agencies also look to the community for support.”

A little togetherness is helping providers deal with funding issues. Forming a network allows them to continue to provide essential services, individually and collectively, which benefits clients and community.

“Given the obvious funding gaps, service providers countywide are partnering as best they can to meet the needs of the mentally ill,” McIntosh stated.

“The SAFE program is one concrete example of non-profit service providers, schools and county departments working together to provide preventive and therapeutic services to children and their families. Transitions-Mental Health is partnering with County Mental Health in providing outreach to mentally ill homeless individuals to try to get them into services. ECHO is completing the expansion of their overnight shelter to meet the increase in the numbers of homeless individuals and families in the north county coming for services.”

Lack of funding, lack of advocacy for children

“The final judgment in the lawsuit known as ‘Katie A.’ resulted in some additional resources,” responded Lee Collins, Director of the County Department of Social Services and Child Welfare Services (CWS). CWS is not a provider of care. “We are a broker for care, referring children and advocating on their behalf,” Collins explained.

“Now some additional therapists have been added, some additional contracts have been let—primarily to Family Care Network, the organization that is our most trusted provider of services—and we expect to see a gradual, incremental increase in services. We fund a great deal of mental health services out of our own funding, because we decided that we could not let children languish without care until we’d won the battle on their behalf.”

“We funded the Kinship Center’s expansion into San Luis Obispo County, an organization that primarily serves relatives who are taking care of children. (Think grandmothers, taking care of grandchildren who have been removed from their parents, for example.)  We paid for it ourselves and have done so for many years now. We pay for a host of ‘wraparound’ services provided by the Family Care Network, including therapeutic services provided by their staff.

“Still,” Collins added, “the available resources are woefully inadequate. There is a lack of funding—State, Federal and Local—but there also is a lack of advocacy on behalf of these children. They are seen as just one more ‘constituent’ group in need, among many. We see it differently, of course, because we see the pain endured by these children and by their family members.”

Most significantly, more people are eligible and more services will be offered under the Affordable Care Act, including mental health.

“We believe that the Affordable Care Act will be instrumental in expanding access to Mental Health services. (See separate article.)

Collins sees the need to establish an “intensive residential treatment center for children. Not a group home, and certainly not the PHF, but we do need a place where children can be hospitalized and treated in a safe environment.” Combining with Santa Barbara or another county on a regional facility might make it more economically viable.

“And we have to find a way to serve children who are not in CWS or Probation, rather than trying to convince those parents—as has been reported repeatedly—that they should ‘give up’ their children to the CWS system as the only means of getting care…”

He believes the mental health services gap will narrow when the width and breadth of the community comes to the full realization that the problem must become a priority, and a solution is possible.

“Our community—including advocates, the Board of Supervisors, school administrators, policy makers, media—must become aware of the extent of the issue, and of the deleterious effects that untreated mental health conditions can have on the children but also on the community at large. Untreated mental health issues can lead to increased incarceration, drug and alcohol addiction, unplanned pregnancy, domestic violence and the continuation of a cycle of abuse. We need to illustrate the issue in real terms that make sense to the average citizen who will want ‘something to be done.’ Then we have to show that funding really is available, whether through Medi-Cal or private insurance, or from cost avoidance in other systems, to effect a real solution.”

Keeping pace with the growth in needs

Jeff Hamm, Director, County Health Agency, and Anne Robin, Behavioral Health Administrator, County Health Agency, won’t characterize the status of mental health care in the county as a crisis, rather part of a nationwide increase in demand for services.

“We don’t believe there is a crisis. There are rising demands for mental health services statewide, even nationwide, as more people become aware of the benefit of mental health services and the stigma related to seeking these services has reduced. Approximately 1 in 4 adults will have need for mental health services during their lifetime; development of the capacity necessary to provide access to services has not kept pace with the growth in needs.

“Unfortunately, during the recent recession, capacity has remained static or has been reduced. There is reason to be optimistic about the immediate future, however. The Medi-Cal expansion component of federal health care reform (Affordable Care Act) will allow previously ineligible persons (primarily childless adults) to become eligible, and the expanded scope of benefits will be of tremendous help to those with mild to moderate levels of mental illness.

“The Affordable Care Act has increased funding for all levels of mental health services. In the past, only individuals with serious mental health needs have had access to care under Medi-Cal. Now there are additional levels of care available (individual and group psychotherapy, psychiatric consultation) for all Medi-Cal eligible individuals. This will allow the County services to focus more closely on those individuals and families who have the most serious illness and need for rehabilitative services. The ‘primary level of care’ for mental health services, for those individuals with mild to moderate illness, may also prevent individuals from becoming more seriously impacted by their symptoms.

“Not all homeless individuals have serious mental illness. Many do have trauma, anxiety, depression, and substance use disorders. Housing First models provide a safe place to assist individuals to deal with whatever their service needs may be. Shelters are simply a starting place; more permanent supportive housing are a much better solution to the problems of homelessness. Whatever the other challenges a homeless individual may face, the insecurity of day to day life on the streets creates an enormous barrier to recovery/wellness/health.

“The Affordable Care Act is expected to have a tremendous positive effect on bridging the gap between demand and supply. The coming months and years will shed light on the extent to which the problem has been substantively reduced.”

Creating more truly affordable housing

Increased attention of the unwanted variety was drawn to the Central Coast late last year, causing quite a stir in influential circles, when the annual homeless assessment report ranked SLO County third worst in the nation with 90% of the county’s homeless unsheltered.

This resulted in Jerry Rioux of SLO County Housing Trust Fund authoring some recommendations on how to remedy the situation, such as allowing greater flexibility with existing housing to open up more alternative housing opportunities. Rioux agrees with the Housing First concept.

“Individuals who are homeless will be better able to deal will their other challenges if they first have sufficient food and a roof over their heads,” he noted.

The Homeless Services Oversight Council (HSOC) recently adopted his recommendations to directly address the basic needs of “food and roof” as the best step forward out of homelessness.

The motion encourages the County and every city in the county to include various programs/policies in the Housing Elements of their General Plans. The state requires that they all update their Housing Elements by June 30, 2014.

Before his motion was approved by the HSOC, Rioux explained why it was needed.

“I prepared the motion because I am concerned that it will be impossible to make much progress placing people who are homeless—for any reason—into housing unless we create more truly affordable housing throughout the county. I strongly believe that we need more small apartment units, granny flats, rooming and boarding houses, group homes, mobile homes, etc. The motion encourages County and cities to facilitate these types of housing.”

Embracing the ‘village’ philosophy of treatment

The County contracts with Transitions-Mental Health Association to runs its Full Service Partnership Homeless Outreach Team that conducts outreach and screening of homeless persons with mental illness. The team has helped to house 27 individuals with severe and persistent mental illness since January 1, 2013.

Transitions staff—Jill Bolster-White, Executive Director, Transitions-Mental Health Association, San Luis Obispo; Barry Johnson, Division Director–Rehabilitation and Advocacy Programs; Jessica Arnott, Outreach and Education Program Manager; Henry Herrera, Family Services Program Manager; and Shannon McOuat, Marketing and Outreach Coordinator—responded to The ROCK survey as a “village.”

“The term ‘crisis’ may be more extreme than what we are facing currently,” they stated, “but there is certainly a need for a greater spotlight on mental health in our community, and there are some critical gaps that, if filled, would help people get the help they need in a timely way.“

Transitions staff believes that cost-effective preventative and early-intervention services can help avoid the high price tag of chronic mental illness in the future—frequent crisis hospitalizations, incarcerations, broken families, homelessness.

“Housing is a significant problem for many members of the community; but people who are mentally ill and poor are more likely to become homeless than those without a mental illness. For that reason, housing that is safe, affordable and located close to services is paramount to successful recovery from mental illness. When a person is experiencing a mental health crisis, there needs to be a solid system in place to help the person as quickly and effectively as possible, and that is not always the case locally.”

They also expressed the need for “a more warm and welcoming mental health services system, starting with the Psychiatric Health Facility (PHF), which is an institutional and clinical setting. The PHF needs to be a place of refuge and safety for people who are experiencing one of the most devastating times in their lives.”

Transitions’ work as an independent outpatient facility has helped the County narrow the gap by providing the focused treatment that often isn’t available anywhere else.

“Non-profits such as Transitions-Mental Health Association can and do work well with county mental health services, private therapists and family practice doctors. The saying ‘it takes a village’ is truly applicable to community mental health; we must include the family, the school, the employer, friends and our entire community to help anyone who struggles with mental illness.

“Services such as family support groups to help caregivers and families; Wellness Centers that provide support and education about living with mental illness; employment for people who want to work but have been prevented from working due to their illness; SLO Hotline that offers a human voice 24 hours a day; outreach services for those who are homeless and suffer from untreated mental illness—can all provide a basic safety net of services for people here in San Luis Obispo County.

“In many ways, we are well on our way to accomplishing this already. We still have leaps and bounds to go, but we are able to provide a variety of services and programs that can help those in our community who otherwise might not receive services from the county.”

Long waiting lists for subsidized housing

Pearl Munak, President of Transitional Food & Shelter in Paso Robles, works with the physically disabled. Some homeless have both mental and physical disabilities. Munak believes more resources are needed to place against the problem, including building shelters and offering subsidized housing for mentally ill homeless.

“There is not nearly enough subsidized housing in our county for those who need it,” Munak stated. “That is why we are third in the nation in unsheltered homeless. People go to a shelter and caseworkers can’t get them into permanent subsidized housing. The County is supposedly pursuing a Housing First strategy, to get people into housing and then solve their problems, not try to solve their problems before they can get into housing.”

“Subsidized housing is either for families or for seniors. Some senior housing is for seniors-only, some also take disabled. But there are no subsidized apartment complexes devoted exclusively to disabled…”

“Transitions-Mental Health Association provides some transitional housing for homeless, where people can stay for up to two years and have a caseworker working with them. At the end of that time, they should be able to get into permanent housing. However, they have a very long waiting list, about a year. This program also takes persons with physical disabilities. It needs to be expanded and funds are needed to expand it.

“We could pass another proposition to add a surtax on another 1% of high income, or tax highest incomes more.”

Munak recently received a grant check from Paso Robles Wine Country Alliance Foundation for $4,500, to be used for sheltering physically disabled homeless from Paso Robles.

“We serve the whole county,” Munak remarked, “but the Alliance has a program of grants to charities serving Paso Robles, so we will use this grant for our Roblans only. The Alliance raises funds through the Wine Festival Futures Auction and the Wine Country ebay Auction, featuring lots donated by winery, hospitality and associate Alliance members.”