Prescription for Better Health: A Home

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A year ago, Tammy Bell, 42, was sleeping in her car on the streets of Los Angeles, trying to manage nerve damage and seizures from a car accident, along with depression and post-traumatic stress disorder. She had nowhere to cook, bathe, or go to the bathroom. At night, she worried someone would break into her car and assault her. She felt hopeless.

“I couldn’t get an apartment. I couldn’t afford it,” said Bell, who had been homeless on and off since she was a troubled teenager, when her parents kicked her out of their home. “Mentally it was very, very depressing. It was very hard, very stressful.” Today, Bell lives in a spacious and light-filled one-bedroom apartment in the Watts neighborhood of Los Angeles that was leased to her by the nonprofit affordable housing developer Linc Housing. It has new furniture, ample space for Bell’s clothes and toiletries, and a roomy bathroom. On her living room wall she proudly displays her graduation cap and banner from a ceremony celebrating her completion of a medical assistant program in June. On her bed sit books for her ongoing studies in nursing.

“This is a whole 360 compared to what I’m used to,” said Bell as she showed off her new place. “This has given me a second chance at life.”

Marking 10 Years of Success

Bell is one of almost 20,000 formerly unhoused residents currently benefiting from a groundbreaking program run by the Los Angeles County Department of Health Services (DHS), now marking its 10th year. Called Housing for Health, the program rests on a fundamental principal: improve the health of people experiencing homelessness by giving them a place to live along with the support they need to stay housed. It’s known as a “Housing First” policy, which connects people to housing without requiring that they first resolve other issues, such as mental health or substance use disorder. Housing for Health targets the people like Bell, who had complex medical and behavioral health conditions that traditional systems are not structured to effectively care for. And the conundrum is that the longer people remain unhoused, the more complex their health needs become, requiring increasingly intensive services to ultimately move them into permanent housing.

Launched in 2012, Housing for Health is one of the nation’s largest local government programs that prioritizes housing people experiencing homelessness on a “Housing First” basis. The program oversees a continuum of care, starting with outreach and health care provided to people living on the streets. Teams work to move people into interim and, ultimately, permanent housing. Once clients are housed, case workers support and link them to health and other services to address their underlying physical and behavioral health conditions and help them achieve their goals, such as education and job training. Housing for Health is also a rarity in that it’s run by a health department rather than a housing organization. It now serves as a model for communities nationwide and helped to lay the groundwork for key programs in the massive Medi-Cal transformation known as CalAIM (California Advancing and Innovating Medi-Cal).

Once a Dream, Now a Community Standard

Housing for Health’s methods “are standards of practice now, but they weren’t in those days,” said John Maceri, chief executive officer of The People Concern, a nonprofit housing and service provider that was a pioneer of the Housing First model. The organization has been a partner with the county on this initiative since it began. “We believe that housing is the most stabilizing factor in a person’s life,” Maceri said. “Then you wrap the services around people. That’s when they’re often willing and able to accept treatment.”

Housing for Health was the brainchild of Mitch Katz, MD, former director of the Los Angeles County Health Agency and now president and CEO of New York City’s municipal health system. Katz viewed housing as a necessary “prescription” for stabilizing the health of people experiencing homelessness, many of whom were churning through the county’s hospitals, emergency departments, and jails at huge public expense. Katz and the program’s first director, Marc Trotz, launched Housing for Health to fill that prescription, basing it on a similar but much smaller project the pair had overseen at the San Francisco Department of Public Health.

When Katz arrived in Los Angeles in 2011, DHS operated a handful of small projects focused on people experiencing homelessness who were frequent users of the health care system. Altogether, these programs served about 225 people. Katz’s goal was much more ambitious: create 10,000 housing units and the wraparound services to support their occupants.

“It was so, so exciting,” said Leepi Shimkhada, who worked in the special programs department and is now the program’s deputy director. “We had been doing this work for most of our careers before coming to DHS. Now we can do this at scale for the county of Los Angeles, and we can make a huge impact.”

Flexible Pool of Money

Trying to build 10,000 units would be too expensive and slow, Trotz decided. Federal housing vouchers were in limited supply and inaccessible to many people experiencing homelessness because they came with a lot of restrictions. Housing for Health needed its own flexible pool of money to subsidize client rents. Arguing that housing chronically ill people living on the streets would ultimately save money for taxpayers, Katz convinced Los Angeles County supervisors to contribute $14 million in seed funding. The Conrad N. Hilton Foundation added $4 million to launch what would be known as the Flexible Housing Subsidy Pool. Housing for Health hired a nonprofit agency, Brilliant Corners, to administer the subsidies and to develop and manage the program’s housing portfolio, including contracts with landlords.

The Housing for Health team set about convincing many future partners that the plan would work. They visited social workers in county hospitals and persuaded them to refer clients. They met with permanent supportive housing developers and private landlords with a reassuring message: Housing for Health clients also receive intensive case management to help ensure they were good tenants and make sure the full cost of rent was covered. Typically, housing developers cobble together a variety of funding streams to pay for all this, Trotz said in an interview. They built partnerships with community-based organizations to provide case management and other services for the clients.

“All sorts of small- and large-scale landlords were interested,” Trotz said. “By the time I left in 2018, we were housing 200 people every month, month in and month out, in a whole variety of housing sites.”

A Model for the Nation

Ten years later, Housing for Health has a $600 million budget, nearly 400 staffers, and more than 100 community-based partners providing housing, case management, and other wraparound services. These include on-call support from county teams specializing in mental health, nursing, and benefits advocacy. The program and its partners house about 18,000 people in permanent supportive housing and 2,500 people in interim housing at any one time — far surpassing Katz’s original goal of helping 10,000.

On average, nine out of 10 people in permanent housing remain housed after one year, a success rate Shimkhada attributes to the wraparound services and the program’s philosophy of doing “whatever it takes for as long as it takes” to get and keep people housed — even people so traumatized from being chronically unsheltered that they adopt unhealthy survival habits.

“Once someone’s in our system of care, they’re in it. We’re going to hold onto them.“

—Sarah Mahin, director, Housing for Health

These commitments include a willingness to rehouse a client several times if necessary to find the right fit for them, and allowing funding flexibility to ensure the client has what they need to succeed, including furnishings or utility deposits. An essential component is having a case manager who works to understand and build an individualized support plan, said Suny Lay Chang, president and chief operating officer at Linc Housing.

“You can’t just put people in a building,” she said. “If you want the highest level of effectiveness, you want to give them services, you want to give them someone who can really be a dedicated advocate for them, who is familiar with the system and understands how to navigate it and when to pull in additional resources.”

Seventy Outreach Teams

Housing for Health operates 70 outreach teams who interact with unhoused people all over the county, building trust — a crucial first step to eventually connect people to housing. The program also oversees a homelessness prevention unit and a fleet of mobile clinics that provide primary and urgent care to people living in encampments. Housing for Health manages data collection and offers technical support to its contracted partners.

A major source of funding to power this massive growth is Measure H, a quarter-cent sales tax passed by voters in 2017. Another source of funding is other county departments, cities, and government entities that pay Housing for Health to care for their clients. Housing for Health also leverages federal housing subsidies and continuum of care funding, said Sarah Mahin, the director of Housing for Health.

Despite the growing complexity of its funding sources, Housing for Health has created a streamlined system for its contractors, which is a key to its success, Mahin said. Standardized contracts, simple reporting requirements, and a commitment to covering the full cost of their work means partners spend less time on paperwork and more time serving clients, she said. This makes things easier for the people being served, she said.

No Time Limits

“Once someone’s in our system of care, they’re in it,” she said. “We’re going to hold onto them and we’re not going to say, ‘Oh, you’re not eligible because of this time limit.’”

Housing for Health has not solved Los Angeles’ persistent homelessness crisis, in part because of the staggering number of people who become homeless each year. In 2020, the Los Angeles Homeless Services Authority reported that for every 207 people who exited homelessness every day across Los Angeles County, about 227 more fell into homelessness. Program administrators and contractors said the resources available still fall short of what’s needed to address the full scale of the housing crisis and ensure that homelessness is a rare and brief experience. Much more must be done to address the underlying causes of homelessness, such as high housing costs, low wages, systemic inequalities, and social determinants of health, they said.

For Trotz, however, Housing for Health exemplifies what can be accomplished if people are determined, are willing to find ways around bureaucratic hurdles, and will think outside the box.

“The importance in my mind of the program was to show that if you had ambitious goals and you didn’t go with all of the orthodoxy, it can be done,” he said. “It showed that if you got people together who were willing to work this way, you could help a lot of people quickly.”

“You Must Not Quit”

Bell, who has now been housed for almost a year, said having her own apartment means she can focus on future goals and taking care of her health instead of worrying about her safety and basic needs. She no longer has seizures. Her depression is under control. In January she will graduate from a nursing assistant program, and she plans to continue her studies to become a registered nurse. Her dream is to run her own nursing company.

Every day, before she heads out, Bell reads a poem by John Greenleaf Whittier posted on the inside of her front door. It reminds her of the hardships she’s overcome and inspires her to keep moving forward.

“Stick to the fight when you’re hardest hit,” the poem reads. “It’s when things seem worst that you must not quit.”

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