L.A. Ramps Up New Model to Tackle Homelessness

Every day for the past 10 years, Dr. Paul Gregerson has confronted the same daunting task. As chief medical officer at the largest health clinic in downtown L.A.’s Skid Row, a neighborhood he describes as “the homeless capital of the United States,” Dr. Gregerson is responsible for coordinating care for many of the thousands of homeless who are living in dire straits on the crowded, chaotic streets surrounding his clinic.

“This happens to be the place where the sickest people end up,” he said.

For first-time visitors touring the infamous 10-block patch just east of downtown’s high-rises, as journalists in the 2013 National Health Journalism Fellowship did last week, it can feel like a post-apocalyptic tumble down the rabbit hole. Block after block, the sidewalks bulge with homeless encampments. Clusters of residents guard their tattered shelters and shopping carts filled with their few possessions. Drugs flow freely and mental illness sets the tone. Most of those living on the street struggle with multiple chronic diseases and disabilities; HIV rates are among the highest in the country, and TB is a pervasive threat in a densely occupied zone where an estimated 5,000 to 15,000 homeless live. Staying alive is a daily battle here.

But as Gregerson and others working to change the lives of L.A.’s homeless are quick to tell you, it doesn’t have to be this way. The city is taking a cue from metro areas such as San Francisco and New York in gradually implementing a “Housing First” approach to homelessness, a program that takes some of the sickest, worst-off people living on the streets and puts them into permanent housing. They’re also provided with medical, mental-health and substance-abuse support. (The slideshow below is of the 2013 National Health Journalism Fellowship's visit to Skid Row. To see the captions, watch in Full Screen mode and click on Show Info in the top right corner.)

[video:http://www.flickr.com/photos/health_fellowships/sets/72157634696316269/…]

The ultimate success of the new approach remains to be seen Los Angeles is famously sprawled, and an estimated 50,000 to 75,000 homeless people call the county home. But city officials and advocates working in Skid Row and elsewhere are optimistic they can move many of Skid Row’s most vulnerable residents into respectable housing and keep them there.

Boulevards of broken lives

Dr. Gregersen sees thousands of homeless pass through his doors every year at the Center for Community Health, run by the John Wesley Community Health Institute, where a host of agencies collaborate to treat mental and physical health problems and provide social services to homeless people. Patterns quickly emerge, and Gregersen offered a thumbnail sketch of the typical Skid Row male: He grew up in South Central without a father, had a mother who was mentally ill and emotionally unavailable, was abused as a child, dropped out of school, and generally had no social support. Turning to gangs, the young man started abusing drugs and eventually washed up on the streets of downtown, where drugs are rampant and free meals abound.

Among the women, who make up one-third of the population, typical stories include broken homes, battered women and sexual abuse. Traumatic childhoods are the norm here, and African Americans are overrepresented – about 70 percent of those living on Skid Row are black.

“These people really do have post-traumatic stress disorder,” Dr. Gregersen said. “Every one of them will tell you a story of something that happened to them 15 or 20 years ago that either involved some type of abuse or something that they just haven’t been able to deal with ever since. For a lot of them it’s the root of their mental illness and the reason for the drug addiction.”

Gregersen estimates about 60 percent of the residents have mental health disorders, and another 60 percent are addicted or have a history of addiction. Schizophrenia and bipolar disorder are the most common mental health problems, often with a PTSD component. Gregersen says his clinic’s HIV rate – about 4 to 5 percent – is the highest in the country.

With patient profiles like these, the clinic’s primary care doctors spend much of their time doing social services, behavioral health and substance-abuse work.

“They don’t understand until they’ve been here awhile that patients are not going to focus on their diabetes, hypertension, asthma and physical complaints until they’ve solved some of the other issues – mental health, substance abuse, and things like that,” Gregersen said.

But the newest strategy these days is to get those living on the streets into permanent housing with support services and then tackle their problems.

“The most important thing we do is try to get them into permanent supportive housing,” Gregersen said.

L.A. adopts ‘Housing First’ approach

One way L.A. has tried to get a handle on homelessness in recent years is not just by looking at what’s worked elsewhere and but also importing the talent behind it. Before he came to L.A., Marc Trotz, who now serves as director of Housing for Health for the Los Angeles County Department of Health Services, was instrumental in changing how San Francisco approaches homelessness.

In the late-1990s, Trotz began touring San Francisco General Hospital and talking to health providers to better understand where and how the system was failing the homeless. The more he learned, the more convinced he became that the city could begin to house homeless right from the start, before they underwent treatment, even the really difficult cases. Trotz and others began rallying support for the new approach.

“In a period of a few years, we housed like 550 people in these master-leased single-room occupancy buildings,” said Trotz, who previously served as San Francisco’s director of housing and urban health. “And guess what – the buildings didn’t burn down, we had some of the most complicated folks on our streets and in our hospitals [now] in housing, and people were getting better.”

Before, the hurdles homeless residents were being asked to jump over – mental health counseling, sobering up, successfully navigating transitional housing – on the road to permanent housing proved difficult to clear while still being homeless, explained Mitch Katz, former director of San Francisco’s Department of Public Health and current director of Los Angeles County’s Department of Health Services.

“Achieving sobriety is very hard under the best of circumstances,” Katz said. “Imagine trying to achieve it while living under a freeway.”

“From that came the idea of Direct Access to Housing,” Katz continued. “Just house the person: they’re homeless. They’re medically ill, they’re never going to get well living on the street. First house them and deal with their substance abuse and mental illness. Not surprisingly, it turns out to be much more successful and less expensive.”

The ambitions for the program in Los Angeles, like the city itself, are huge. According to Trotz, Katz has “been running around saying, ‘Well, if we did 1,500 units in San Francisco, I by default just add 10 times to everything.’”

Is 15,000 units doable in L.A.? Trotz isn’t sure if they can pull it off, but the effort is underway. Building homeless housing and providing ongoing support services is not cheap, but Trotz and others insist the alternatives are far more mostly.

“A day in the hospital costs a minimum of $1,500,” Trotz said. “We can buy a month of housing for someone for that in supportive housing.”

One of the early fruits of the city’s Housing for Health program is a newly renovated 15-unit apartment building in south Los Angeles. Formerly homeless residents such as Willie Jordan are just moving in.

“I’m happy that I’m here,” said Jordan, as he gave journalists a tour of his one-bedroom apartment, furnished with sturdy new furniture, wood floors and an accessible bathroom that accommodates his wheelchair. “I wish more people could be here in a place like this.”

Unlike San Francisco’s reliance on high-rise single-room occupancy (S.R.O.) hotels to refurbish for the homeless, L.A. is building a mix of units ranging from single-family homes to duplexes and small apartment buildings. Residents, who pay 30 percent of their income in rent, are referred directly from the city’s health system.

“We’re actually reaching down to the clinical level to say these folks are most at risk, and, if we can house the next 56 people in this network of units, this is who we want to house,” Trotz said.

Developers reimagine housing for homeless

One wouldn’t expect housing for the formerly homeless to be a prime space for innovative design and architecture, but the Skid Row Housing Trust has disrupted old assumptions about what homeless housing should look like with award-winning developments such as its mixed-use Star Apartments project. When complete, it will feature 102 downtown apartments made out of prefabricated modules designed by Michael Maltzan Architecture.

Mike Alvidrez, executive director of the Skid Row Housing Trust, said his nonprofit began to move toward a Housing First model in 2003 after concluding too many homeless were falling through the cracks in the old paradigm, where you earned your way to permanent subsidized housing and support services.

Beginning with the 86-unit St. George Hotel, the Trust began building satellite medical and mental health clinics into their housing developments. Alvidrez said the city had demolished many of downtown’s S.R.O. hotels in previous decades, prompting the Trust to turn to take on new construction after exhausting the supply of existing S.R.O.s to renovate. Many of the developer’s new projects, several designed by Maltzan, combine striking aesthetics with on-site amenities such as community gardens, bicycle clubs, pet-rescue programs, even yoga classes.

“We began to put as many of those services in the buildings as we could,” said Alvidrez. “It’s amazing what people gravitate towards, all of which we hope will help them establish positive social relationships with other residents and further facilitate the creation of community within buildings but also across buildings.”

As a result, Alvidrez said, some of the formerly homeless living in these communities have stabilized and taken up volunteer work, reaching out to those now caught in the same cycles – addiction and illness, shelters, transitional housing, failed treatments – they were fortunate enough to escape. Sometimes the most persuasive voice in getting someone to come in off the streets is one who has successfully made the journey and lived to tell about it.

Starting with a roof and four walls isn’t traditional “health care,” but it just might be more effective than starting from the other direction.

A steady place to live can break the cycle of what Gregerson calls “the revolving door where people end up in the emergency room, back on the street, they go through transitional housing, then they get arrested, they go to jail, they get out of jail, they go come back into a transitional housing program.”

“People have realized that if you house people first, you eliminate a lot of the problems,” said Gregerson.