By Monica E. Oss, Chief Executive Officer, OPEN MINDS
Homelessness has risen steadily since 2017—with many effects. Consumers who are housing insecure have health care costs 2.5 times higher than their peers. And, housing instability has been found to increase interactions with the criminal justice system. Unhoused persons are 514 times more likely to be arrested and charged with crimes when compared to the non-homeless population, and those who are released from prison have an average three-year recidivism rate of 68%.
In addition, there are economic development issues created by homelessness—largely around its negative effects on tourism. As a result, there have been significant efforts in many communities to minimize homeless encampments and sleeping in public spaces. The city of Cleveland recently made unauthorized camping a misdemeanor and required camps that did not meet requirements to be cleared out within 14 days. Minneapolis has closed encampments twice in the past several days.
In North Carolina, where some areas are seeing an 11% decrease in tourism revenue attributed to the homeless population, there was a recent $1.5 million investment in expanding homeless beds. In Nashville, where homelessness has increased by 32% since 2022, the city approved a $50 million dollar plan to address the issue.
At the same time, Florida is moving in the opposite direction, creating camps. Legislation passed late last year prohibits homeless individuals from sleeping in public places and instead require that homeless individuals be housed in specific camps with access to sanitation and behavioral health services.
The question is how best to address the problem. There have been some recent successes with housing first models—at the Veterans Health Administration (VHA), reducing homelessness by 55%. But the approach is not without its critics, who believe the model is driving up costs of care with no definitive data showing quantifiable benefits.
In 2018, a federal court ruled that there could be no prohibition on sleeping in public spaces if there was no housing available. And in breaking news this week, the Supreme Court has agreed to review what will likely be a landmark case, Opinion In Johnson v. City Of Grants Pass. The case is based on the fact that Grants Pass, Oregon passed several ordinances criminalizing homelessness; however lower courts declared the ordinances unconstitutional as the number of homeless individuals was greater than the number of beds available to house them.
We got an up close look at one county’s approach to addressing the issue with Dr. Veronica Kelley, Chief of Mental Health and Recovery Services of the Orange County Health Care Agency in a recent Circle Roundtable, Innovating Behavioral Health For California’s Most Vulnerable Populations—CalAIM & CARE Court. Dr. Veronica Kelley spoke about the Care Court program—the state-funded Community Assistance, Recovery, and Empowerment program, better known as CARE Court .
CARE Court provides eligible consumers, primarily the homeless with untreated schizophrenia or other associated psychotic disorders, treatment and services that include free legal representation, counseling, medication, social services, and housing assistance. The implementation model varies across the state. Orange County launched the program on October 2, 2023.
“This is a voluntary program,” explained Dr. Kelley. “Legal counsel is always provided to an individual, and supported decision-making is part of the process. The whole point is to intervene early. So somebody who is experiencing untreated schizophrenia can get treatment now rather than waiting 20 years down the road when they’ve been put in jail multiple times because of their behaviors.”
Dr. Kelley explained that, if the consumer in question qualifies and agrees to treatment, the county does a full care plan and then looks for a provider organization that can provide a full-service partnership—the county will be using county-contracted providers who provide full-service partnership (FSP) programs. The court’s involvement in care lasts up to a year, but under special circumstances, a judge can agree to an additional second year. “In Orange County, we’re standing up a full-service partnership, which is wraparound services from one provider who provides every service someone could need,” explained Dr. Kelley. “That includes helping them with treatment, going to the grocery store to get their groceries, and making sure that they have a place to live. These are the folks who are also trained in treating refractory schizophrenia, a very difficult-to-treat disease. They would have to be trained on complex medical issues, comorbidities, and complex medication.”
Orange County, California isn’t the only jurisdiction creating partnerships with provider organizations to address the homelessness problem. Fairfax, Virginia issued a request for proposal (RFP) for programs to end homelessness including rapid rehousing, community emergency shelters, permanent housing support, homeless health care, and more. And the Minnesota Department of Human Services has a RFP to end homelessness for individuals with serious mental illness (SMI) or co-occurring substance use disorder (SUD) through homeless outreach services, housing support, equity, and peer services.
As more states include housing supports in their waiver programs expect to see more opportunities for the full service partnerships similar to those in Orange County. Addressing social determinants is a growing focus of payers and health plans alike.