Caption: this is a chart our Hollywood Top 14 committee created in 2016 to document the multiple ways in which a person would be dropped from the mental health continuum of beds back to the street. None of these beds appear in the Coordinated Entry System.
We are in the midst of a full-blown humanitarian crisis. This is not “homelessness” as we knew it in the first decade of the 21st century. This is far bigger and more complicated. There is a growing awareness of the need to centralize data collection and to deploy resources in a more strategic manner to address the lives of people deteriorating on our streets. This is a good move. However, would the paradigm shift if we let the driver be the need for beds, in addition to housing units?
The federally-mandated Coordinated Entry System (CES) requires an inventory of housing units with supportive services and a list of eligible people sorted by acuity scores. The challenge is, in the face of our acute housing shortage, there are more people on the CES list than there are housing units.
Each day, there are un-housed people with mental illness, physical health challenges and substance abuse showing up at the front doors of hospitals, living on our street corners, or languishing in jail. It begs the question: would it make sense to evaluate the inventory of all treatment beds available, not just those attached to a front door key? The gap between the human needs identified and the available beds might shine a light on where we need to focus our attention to stem this tide of human suffering.
Granted, we aspire that all people experiencing homelessness will achieve the level of stabilization and independence that supports their ability to move into an apartment or a supportive housing unit when they are ready. But in our society, we have allowed a relatively small cohort of people to become very, very, very sick. (I would posit that this is less than two percent of our county’s homeless population.) For some, there is a need for sustained treatment and care first.
As our government officials begin to look at consolidating decisions about moving people off the street, all available beds need to be taken into consideration – public, private, medical, acute psychiatric and sub-acute psychiatric, substance abuse treatment, sober living, transitional shelter, family reunification, emergency shelter, board and care etc. These systems need to talk to each other, because in the life of a person experiencing homelessness, it is possible that one might find themselves encountering each of these beds.
Though I have not fully formulated this thesis, I am going to take the leap to publish this on my blog in the hopes that some may step forward to help me make sense of this. Or – challenge my assertion!
I start with an excellent report that was issued by the LA County Department of Mental Health on October 28, 2019, Report on Addressing the Shortage of Mental Health Beds. This has received very little public attention. I found one media mention of it and it was in LAist. My sense is that this is enormously complicated system to wade into because of the challenges associated with how Medicare and Medicaid works and the insufficiency of public funds to site and operate these various facilities.
The report documents that there is a severe shortage of beds to serve people with mental health challenges – from minor to severe. It is getting worse. It doesn’t take a rocket scientist to look at this data and see that there is a correlation between the steady decline of psychiatric treatment beds and the increase in people wandering our streets in need of treatment, or filling our county jail.
The report was a response to a 1/22/19 motion from the LA County Board of Supervisors which, in essence, asked DMH to provide a plan for the creation of more mental health beds in the county. The motion provides an extremely concise description of our problem.
- The number of state hospital beds in this state has declined from 37,500 in 1959 to 6,078 in 2019. (That is an 84% drop despite an 158% increase in state population.)
- Apart county or state resources, private mental health hospitals continue to close. The number of hospitals has declined from 181 in 1995 to 144 in 2016. That represented a loss of 2,651 beds.
The LACBOS motion also describes that the minimum number of recommended beds to meet public needs is pegged at 50 public mental health beds per 100,000 population. Los Angeles County has 22.7 beds and the state of CA has 17 beds per 100,000 population!
With the motion in hand, DMH set to work. In the executive summary to their report, the department describes a “continuum of care” in which beds at every step of the way need to be increased. The report provides a key observation, that should factor into the overall “command post” conversations we are having in this state about “holistic system planning” and centralizing decisions about how to get people off the street and keep them off the street:
“The availability of mental health hospital beds depends upon both the capacity of hospital beds in the system and the quality of services delivered. Higher quality services are more likely to promote client recovery and reduce the risk of readmission, which can reduce future demand for hospital beds and services and alleviate bed shortages. (page 7)”
Here is what I am wondering. I think about the cases of people we’ve been following in Hollywood, and I see where the lack of psychiatric treatment beds at different steps along the process contribute to someone becoming homeless again and again.
I accompanied Douglas Walker from The Center recently, who was visiting Mr H. at a local Hollywood hospital. Walker has made heroic efforts to help this man, who is limited to a wheelchair, find a stable place to live. Mr. H had been living in filth in front of the Home Depot on Sunset Blvd and was taken to the hospital by paramedics. Clearly the hospital staff was challenged because there were precious few discharge options for him, being homeless, mentally ill and physically disabled. He ultimately was discharged to a skilled nursing facility in Hollywood, but for some reason, his insurance would not cover the necessary physical therapy and rehabilitation. Bored in this environment with no treatment plan to keep him engaged, he wheeled himself out and is homeless again. The cycle will continue. Because of HIPPA, we don’t know for how many years he has experienced this cycle, but absent a serious intervention, it appears he will die on the street.
A similar recent story is unfolding this week. Douglas Walker noticed a woman whistling and screaming at the corner of Ardmore and Clinton in East Hollywood in the morning when he dropped off his car for service. When he returned at the end of the day, she was in the same place, screaming still. He engaged with her and found her very confused, thinking it was 2019 and unable to state clearly where she was from. When she mentioned that she had previously fallen and hit her head, Walker called 911 and the paramedic transported her to a local hospital. Two hours later, she was discharged as she was found to be “oriented and able to ambulate independently.” The picture depicts where he found her two days later, lying outside the hospital, hungry and dehydrated. This tragic story reinforces my point that something other than a CES is required to triage people into treatment beds where they can be cared for in a true recovery mode.[As a sidenote, if we had had this comprehensive inventory of all available beds, above and beyond what CES keeps track of, perhaps we would’ve seen the early warning signs that we were losing our precious board and care beds at an alarming rate, starting about five years ago.]
There is much more in the DMH report that is worth sharing. What is heartening is that our county board of supervisors is taking this seriously, and our mental health department is working to identify a way to bring 500 more beds into the county system over the next two years, as per an October 2019 motion.
I would assert that this needs to be on the radar of all policymakers involved with identifying the resources available to provide alternatives to people experiencing homelessness. Is it time for something more all-encompassing than the traditional Coordinated Entry System to meet the human needs on the street?