Mental Health Housing First
Preface
Learning from your mistakes makes you smart. Learning from other people’s mistakes makes you a genius.
Recently, Governors and other leaders in states such as California, New York, Oregon, and South Carolina are reversing course on homeless policies, addressing what has not worked over time. After his state spent over $20 Billion in 5 years, Governor Newsom recognized that to “reduce homelessness” things needed to change. Governors are boldly prioritizing mental health over Housing First (without a broad array of mental health services). In March of 2023, the Joint Legislative Audit Committee was tasked with conducting an audit on Public Funds related to Homelessness. They are inserting accountability and responsibility into the funding equation.
Athens and the state of Georgia have a unique opportunity to learn from mistakes made in states like California, New York, and avoid wasting millions without adequate mental health treatment. We have the unique opportunity to benchmark and learn from these states to save lives, reduce suffering, increase safety and security, extending to the UGA campus, and in Athens neighborhoods.
We side with these elected officials having the courage to tackle “reducing homelessness” by prioritizing mental health treatment housing coupled with the megabucks needed, changing the game and ultimately changing outcomes. Right now, the game in Athens is to sustain and expand the broad array of homeless services offered by the many existing providers. This means a continual influx of money (and homeless), keeping jobs in this industry afloat, and keeping service providers happily in business. Just this week, an Athens nonprofit website highlighted a note from Mayor Girtz to City Manager Blaine Williams outlining a “rush” concept to create permanent construction for the First Step Barber Encampment in the form of ‘tiny houses’ and ‘cottages’ on what would be newly acquired property/acres adjacent to Advantage Behavioral Health. Advantage already lacks the complete funding to build the 60 bed ‘mental health housing’ on-site. Why? Why isn’t Mayor Girtz and Manager Williams prioritizing the $5 million (available for their new ‘tiny home’ approach) toward needed funding for the 60 bed mental health housing on-site at Advantage? Be smart and learn from past policy mistakes.
The Barber encampment was not ‘the success’ the mayor and some commissioners report. As reported on the ACC ARP funding website, 40 individuals at the camp found permanent housing while we incurred $1,660,385.25 (total as reported to Treasury thru Q1 2023) over the course of 12 months, March 2022 - March 2023.. If “housing first” indeed was the goal, this suggests it cost tax payers $42,000 per person for just one year of permanent housing. Each month, 15-20 homeless individuals come and go from the camp - many with mental illness and substance abuse issues. Absolutely nothing has changed for them. Moreover, the city refuses to answer questions as to ‘how’ the camp can continue to operate since the nonprofit contract with the city was signed solely by the nonprofit CEO, who was sole principal when founded, and also registered agent of the nonprofit; a person who was expelled from the camp and as result, dissolved the nonprofit through the Secretary of State’s website. How can this nonprofit still exist? What is the potential liability of city government? Who holds liability insurance for this operation?
Nearly two years ago to the day, UGA Parents for Safety and Security was formed which eventually evolved into the nonprofit SafeD Athens Inc 501 c3. It’s inception was due to the Mayor casting the deciding vote on the Barber encampment, and it seemed to be under our noses, as UGA students were busily moving into housing before the Fall semester started. Here we are two years later and our crime blog on safedathens.org shows alarming homeless incidents multiple times a day. Two consultant assessments report Athens is a ‘hub for the homeless’. And today, the mayor moves towards another attempt to set up a sanctioned tiny village of sorts, spending millions without specifically addressing the root causes of mental illness and substance abuse. If this endeavor is to exclusively fund the Advantage Behavioral Health expansion, increasing the number of mental health treatment housing beds built, then one might argue the Mayor is on the right track.. Apparently, from the wording of his memo describing a camp replacement to include a ‘wet facility’ nonprofit and the Continuance of Care, that is not the case.
SafeD Athens is all about data and solutions. Below we outline what California, New York, South Carolina are all doing - the solution - mental health treatment housing and accountability. Athens and the state of GA, let’s learn from other cities’ and states’ expensive lessons. We deserve ambitious plans like theirs. CA is spending billions on reversing failed policies. Let’s be bold and invest in transformative mental health and substance abuse services in our municipalities and through out the state of Georgia, in a decentralized way. If we don’t, we will rue the day we must build-back those mental institutions viewed as inhumane incarceration. For the sake of community mental health and safety, the status quo is not viable. Clean safe streets IS a primary function of all levels of government.
States Start to See Need for Mental Health Housing; Invest in Decentralized Mental Health Housing and Services
UCSF recently published a lengthy study after interviewing hundreds of homeless individuals in California. Simultaneous to this publication, Governor Newsom outlined his new strategy to tackle the real issues driving unsheltered homelessness - Mental Illness and Substance Abuse. His strategy aligns with the following findings from the UCSF study, realizing that to reduce the number of homeless individuals unsheltered on the streets of California, mental health and substance abuse must ‘first’ be tackled and ‘mental health treatment housing’ provided, with courts offering mechanisms to order treatment for those with severe pervasive mental health illness (SPMI) and chronic substance abuse. To ignore pervasive mental health illness and drug abuse histories of homeless individuals is inhumane. Large states like California are realizing that ‘housing’ alone will not reduce the number of homeless on the streets and to say otherwise is disingenuous.
Directly from the UCSF June Homeless Report Executive Summary.
“Participants reported high lifetime rates of mental health and substance use challenges. The majority (82%) reported a period in their life where they experienced a serious mental health condition. More than one quarter (27%) had been hospitalized for a mental health condition; 56% of these hospitalizations occurred prior to the first instance of homelessness. Nearly two thirds (65%) reported having had a period in their life in which they regularly used illicit drugs. Almost two thirds (62%) reported having had a period in their life with heavy drinking (defined as drinking at least three times a week to get drunk, or heavy intermittent drinking). More than half (57%) who ever had regular use of illicit drugs or regular heavy alcohol use had ever received treatment.”
Calmatters concluded from this same report - “A recent study from UC San Francisco found that two-thirds of homeless individuals experience mental health conditions”
What is Governor Newsom in California doing?
California 2024 Bond Initiative
“Governor Newsom has proposed a 2024 ballot initiative to improve how California treats mental illness, substance abuse, and homelessness: A bond to build state-of-the-art mental health treatment residential settings in the community to house Californians with mental illness and substance use disorders and to create housing for homeless veterans, and modernize the Mental Health Services Act to require at least $1 billion every year for behavioral health housing and care.”
This ballot initiative will provide for thousands of new community behavioral health beds in state-of-the-art residential settings to house Californians with mental illness and substance use disorders, which could serve over 10,000 people every year in residential-style settings that have on-site services – not in institutions of the past, but locations where people can truly heal. It will allow MHSA funds to serve people with substance use disorders. It will also Include new accountability and oversight measures for counties to improve performance.
California CARE Court 2022
In addition to creating sustainable mental health housing funds, Governor Newsom also introduced the CARE Court in 2022 through CA SB1336.
“The CARE process is an upstream diversion to prevent more restrictive conservatorships or incarceration; this is based on evidence which demonstrates that many people can stabilize, begin healing, and exit homelessness in less restrictive, community-based care settings. With advances in treatment models, new longer-acting antipsychotic treatments, and the right clinical team and housing, participants who have historically suffered tremendously on the streets or during avoidable incarceration can be successfully stabilized and supported in the community.”
Governor Newsom, “Sadly, the status quo provides support only after a criminal justice intervention or conservatorship. CARE Court is a paradigm shift, providing a new pathway for seriously ill individuals before they end up cycling through prison, emergency rooms, or homeless encampments.”
What is Governor Hochul in New York doing?
Governor Hochul of New York is also realizing the need of mental health housing among the homeless and proposes budgeting $1 Billion in funding to tackle pervasive needs. Governor Hochul calls it a “public safety crisis".
This “transformative plan” will Increase Capacity for Inpatient Psychiatric Treatment by 1,000 Beds and Add 3,500 Housing Units Serving Individuals with Mental Illness. Governor Calls for Systemic Accountability for Mental Health Admissions and Discharges; Dramatic Expansion of Outpatient Services and Insurance Coverage.
Governor Hochul, “We have underinvested in mental health care for so long, and allowed the situation to become so dire, that it has become a public safety crisis, as well. This proposal marks a monumental shift to make sure no one falls through the cracks and to finally and fully meet the mental health needs of all New Yorkers."
How do these initiatives align with Georgia? And Athens-Clarke County?
The same drivers of homelessness in California and New York also exist in Georgia and Athens-Clarke County. We are not immune to the need for mental health housing, understanding that this need has grown organically since the defunding of psychiatric hospitals years ago across the country, coupled with failed federal “housing first” policies (see our previous article).
Mental Illness and Substance Abuse in ACC
What do the Athens-Clarke County point-in-time numbers tell us (if anything) about mental health and substance abuse needs? The 2023 Homeless Point-in-Time Count, conducted through the Department of Housing and Community Development, reported 177 unsheltered homeless individuals (indicating an increase from last year and includes individuals from the sanctioned camp), with a slight reduction in sheltered homeless. But, it is important to note that the July 2021 PIT count conducted just prior to opening the sanctioned homeless camp was roughly 155 unsheltered individuals which is in-line with the 2023 count. Those with mental illness or substance abuse were not identified within these 155 individuals. With an upgrade to the Athens Homeless Coalition website and release of the 2023 PIT count, these 2021 findings are no longer available on-line. Why? Also, in the ACC released 2023 PIT count report, the mental illness and substance abuse totals were absent. Why? The Athens Homeless Coalition and other experts are first to point out that absolute numbers are unreliable, undercount, only represent a snapshot in time, and are useful only for analyzing trends as a measure of success. Note: Our own data showed (October of 2022) that at any time of day one could randomly count 80 unsheltered homeless on the streets of Athens on our specified route (not including camp visits sanctioned or otherwise). So, is the number of homeless increasing or decreasing in Athens-Clarke County? And, how does mental health and substance abuse play a role?
According to ACC, the number of homeless individuals is increasing, as they point to the trending increase starting in 2015. It could also be said the number of homeless have decreased since 2005. Are these numbers driven by events or by changing count methodology? This is why we choose to use the number of ACCPD homeless calls per day to monitor trends although these data only go back to 2018. Also, the number of enrolled homeless into HMIS would be nice, but not all are entered (voluntary) and uncompleted follow-ups for exiting HMIS leads to insufficient data. Based on the following chart, is homelessness going up or going down? And, how does mental health and substance abuse factor into the sheltered and unsheltered populations?
Sheltered + Unsheltered in Athens-Clarke County by year as reported to the HUD Exchange. Jan 2021 unsheltered counts were not obtained due to Covid-19. The July 2021 number of 155 unsheltered was used to compute a total for 2021. The July data is available through the Athens Homeless Coalition.
Graph depicts only ACC ‘Unsheltered’ Homeless numbers as reported to the HUD Exchange. Percent of total ‘unsheltered’ was used to normalize data for comparison of mental illness and substance abuse over time. Note, no data exists for 2021 as only the total number of unsheltered homeless in July 2021 was reported. No data existed in 2021 for Mental Illness, Substance Abuse, or Chronic. Although Substance Abuse is showing a negative trend and Mental Health is showing a positive trend, as reported, the coefficients of determination for linear trends of the relative percents is very low, suggesting no significant trend can be established in any data.
In the January 2023 PIT Report to the HUD Exchange, 48% of Unsheltered Homeless were reported with a Serious Mental Illness. 40% of Unsheltered Homeless were reported with a Substance Use Disorder. Given incomplete overlap between mental illness and substance abuse, it is safe to say that over half of the unsheltered homeless on the streets of Athens suffer from mental illness and/or substance abuse.
Note: These data were not reported in the 2023 PIT Report published through Athens-Clarke County but was included for submission to the HUD Exchange.
Considering the above data exclusive to Athens-Clarke County, aligned with the data from the UCSF study indicating "The majority (82%) reported a period in their life where they experienced a serious mental health condition,” one can only conclude that mental illness and substance abuse are 2 main drivers of homelessness in Athens-Clarke County.
Appropriate mental health housing, as California and New York are suggesting, is crucial to reducing unsheltered homelessness. Georgia relies on Community Service Boards such as Advantage Behavioral Health (ABH) to provide mental health care and substance abuse treatment to indigent residents and others. Georgia has recently passed legislation to mandate mental health care on parity with other medical care for insurance purposes. These are steps in the right direction. However, capital funding for more mental health housing (through CSBs) and further decentralization of services (through CSBs) into ALL counties are needed to relieve the burdens on counties like Athens-Clarke, who admittedly has become a ‘hub for homeless services’.
We know from our own homeless data collected in Oct 2022, looking at questions asked of individuals specifically in the July 2021 ACC PIT count, reviewing and noting addresses/driver’s licenses of homeless individuals involved in police reports, and Advantage reporting 40% of client services in Athens are for those originating from other counties, roughly half (give or take) of unsheltered homeless on the streets in ACC originate from other surrounding counties, with some individuals originating from other states - even out of the country (recently several identified families panhandling with children stated they crossed illegally from Mexico into Texas, originating from Europe). Other counties and hospitals from outside Athens-Clarke County have repeatedly dropped off homeless individuals in need of services. Georgia SB62 was passed to discourage counties and medical facilities from randomly dropping off homeless individuals into neighboring counties (the practice of giving “courtesy rides” to “suspicious persons”) and audit homeless service providers to measure performance, specifically those in the Balance of State Continuum of Care (outside of the other 8 Continua of Care regions).
Increasingly the ACC General Fund will be used to replenish funding originally from the federal CARES Act and now from ARP SLFRF and ARP HOME allocations for expanding homeless services. In addition to the usual federal HUD HOME and CDBG funding, ESG and other Georgia Department of Community Affairs (DCA) project funding, the FY24 ACC General Fund budget now includes $825,000 unsourced from state and federal agencies with additional operational funding of ACCPD mental health co-responders.
Currently, Athens-Clarke County is contemplating how to spend $5 million of ARP SLFRF money designated to “reduce homelessness”. The recommendations from consultant Cloudburst are due anytime and the vote for authorization is scheduled for October 2023. We will be updating soon on their Draft Report. In our opinion, the Barber Street Camp experiment failed because it was too costly and did not provide adequate mental health treatment. If the goal was to get people into permanent housing it failed. As reported, only 40 people over the year were placed in permanent housing while spending over $1.66 Million. On an average monthly basis, 15-20 unsheltered homeless individuals come to the camp and leave. In essence, we are providing a ‘homeless campground’ of sorts, encouraging a nomadic lifestyle, with no accountability for ‘steps’ forward. Mental Health treatment services are scant and only available ‘if’ the person gets to Advantage Behavioral Health, participates in psychiatric evaluation, and medical treatment, including medications available from their on-site pharmacy. Consider this while understanding what California and New York are doing.
Understanding the prevailing wisdom from street outreach is to ‘meet people where they are’, meaning that initiative for change must come from the individual, at some point, for the ‘mental health’ and ‘safety’ of the community, courts need authority to prescribe compassionate care, particularly for those with severe and persistent mental health illness (e.g. psychosis, other issues).
What interaction do unsheltered homeless have with our court system?
In 2015 ACCPD was awarded the Justice Mental Health Planning Grant from the Bureau of Justice Assistance. This allowed for initial data collection from Oct-Dec, 2015. A resolution to join the Stepping Up Initiative and work to reduce the number of people with mental illness in jail was adopted in 2017. Another Grant was awarded in 2017 and ACCPD created the Crisis Intervention Response Unit specifically to respond to calls with suspected behavioral health component. Current understanding is there are 3 units, with possible funding for 7 units, but staffing is difficult.
This 2015 system map demonstrates the interactions between First Responders (blue), Emergency Health Services (Grey), Mental Health Services (purple), County Jail (red), Judicial System (orange) and the Treatment and Accountability Court (yellow) described below. The numbers indicate individuals flowing through the process Oct-Dec 2015.
The 2015 data counted 1842 individuals arrested Oct-Dec with 706 of them being Advantage clients. Another 40 individuals referred to Advantage but never seen, leaving 1096 unaffiliated with Advantage. These data translate to 7.7 Advantage clients getting arrested every day. 40% of the total arrests were affiliated with Advantage Behavioral Health. This is all in-line with over half of unsheltered homeless individuals having mental health and/or substance abuse issues and ACCPD spending 8 hours per day on calls involving unsheltered homeless individuals (same individuals in many instances). 91% of the 706 Advantage clients had multiple arrests which shows the revolving door nature of our jail.
Bipolar Disorder was the top diagnosis of cases at 22% followed by Depressive Disorder at 19%.
The Courts
Governor Newsom on CA SB1338, “We are facing a confluence of crises: mental health, opioids, housing, and homelessness – and this transformative effort will ensure California is tackling these head-on in a comprehensive and inclusive way.”
California SB1338, signed in September of 2022, establishes the Community Assistance, Recovery, and Empowerment (CARE) Act, which would implement a new statewide procedure for treating persons with specified mental illnesses through the courts. A person is eligible for CARE court jurisdiction if they are 18 years of age or older; diagnosed with schizophrenia or another psychotic disorder; are not currently stabilized and in treatment with a county behavioral health agency; and currently lack medical decision-making capacity. An individual may be referred to the CARE court through a petition from specified medical and county professionals, specified peace officers, and specified persons in the individual’s life, such as a family member or roommate; an individual can also be referred from misdemeanor trial proceedings if they have been found incompetent to stand trial, or from conservatorship or AOT proceedings. Once a petition is filed, counsel and a ‘support person’ are appointed to assist the individual with the evaluation process.
In Athens-Clarke County we have established Accountability Courts, specific to discussion is the Treatment and Accountability Court (TAC) as indicated on the System Map above. The Superior Court in ACC has jurisdiction over the TAC which provides a probation alternative for persons who have been charged with a nonviolent criminal offense which is informed by their mental illness or mental disability. Eligible offenders agree to take responsibility for the criminal charge, follow a personalized treatment plan for the mental health condition and any substance abuse issue, and submit to close monitoring of individual progress by the Coordinator while they comply with the terms and conditions of probation as ordered. In Calendar year 2022 there were 45 new participants for all adult accountability courts with 20 total graduates (FY24 budget report). Successful outcomes with voluntary participation in the TAC are reported. However, these numbers are low relative to the number of homeless individuals on the streets who would benefit.
The main differences between the CA statewide CARE Court and our TAC are (1) TAC is Voluntary versus Involuntary CARE Court participation; (2) California is providing sustainable funding for mental health treatment housing with on-site services as described previously through a 2024 Ballot initiative.
In Georgia, the relatively new GHVP program provides permanent supportive housing through single residential apartments which provide no on-site services, only social worker visits. Thus participants must be transported at added expense for more comprehensive treatment. Currently, Advantage Behavioral Health is administering this program for 33 counties. A plus of this program is that the voucher travels with the client throughout the state. New to Georgia will be the construction of the mental health treatment housing (60 beds) to be located at Advantage Behavioral Health on Mitchell Bridge Road. SPLOST 2020 funding covers less than the half of the cost needed to construct. Another $4 million of ARP SLFRF money was allocated recently towards construction. A gap of several million dollars still exists. The $5 million designated for homeless services in ACC could easily be tapped for complete funding of this project, providing all the necessary mental health treatment housing sooner than later. Currently it is unknown how this funding gap will be filled. Application for an ARP State Grant is being made. Just think if we could take 40-50% of the unsheltered homeless off the streets of Athens to receive 24/7 mental health services for 12-24 months.
A Georgia state bipartisan effort to decentralize Community Service Board services into more counties, funding the construction of on-site mental health housing in more counties, and benchmarking the California CARE court for involuntary court directives for individuals with SPMI is imperative to ‘reducing homelessness’. This is NOT a partisan issue. It is an issue of safety and security for homeless individuals and other community members.
Governor Newsom is already receiving blow-back for his 2024 bond initiative. Why? Because funding for some existing homeless programming may be diverted. In response, Newsom’s office said, “What’s more upsetting is watching people continue to suffer on the streets with ineffective interventions and inability to access much needed treatment.”