final report on project 25

D I P L O M A T P H A R M A C Y

Project 25San Diego’s Frequent User Initiative

Lessons Learned from Developing, Implementing, and Sustaining a Highly Effective Frequent User Program

KARINA PARTOVI

ADVISED BY: KRIS KUNTZ

EMAIL: [email protected]

FUNDING PROVIDED BY: DIPLOMAT PHARMACY

4100 S . Sag inaw S tree t , F l in t M I 48507 • te l ephone : 888 .720 .4450 • fax : 800 .550 .6272 • http://diplomat.is

mailto:[email protected]

http://diplomat.is/

http://diplomat.is/

Contents

Project Overview.............................................................................................................................5Executive Summary.....................................................................................................................5First Steps....................................................................................................................................6Implementing an Effective Program............................................................................................7Conclusion...................................................................................................................................8

Creation of Report...........................................................................................................................9Creation of Report.......................................................................................................................9 Acknowledgements....................................................................................................................9

Overview of the Homeless Situation ...........................................................................................11Homelessness as a National Issue.............................................................................................11Homelessness is Expensive.......................................................................................................11Homelessness in San Diego.......................................................................................................12

Father Joe’s Villages.....................................................................................................................13Overview of Project 25..................................................................................................................15

Definition of Frequent User.......................................................................................................15Background on Other Efforts....................................................................................................15What is Chronic Homelessness?................................................................................................16The Basics of Project 25............................................................................................................17The Set-Up.................................................................................................................................18How are Project 25 Clients Different from Other Chronically Homeless?...............................19What are the Desired Outcomes or Goals?................................................................................21

First Steps......................................................................................................................................23Recognizing the Problem...........................................................................................................23

San Diego’s 10 Year Plan .....................................................................................................23Getting the Right People to the Table...................................................................................23

Funding......................................................................................................................................24The United Way of San Diego County..................................................................................24Partnership with the County of San Diego............................................................................24

Lining Up the Housing Resources.............................................................................................24Sharing Data to Target Effectively............................................................................................25

Results From Effective Targeting..........................................................................................26Implementing An Effective Program............................................................................................27

Outreach.....................................................................................................................................27Attitudes Towards Clients.....................................................................................................27No Real Program Compliance Required...............................................................................29

Dip lomat Pro jec t 25

2

Outreach.................................................................................................................................29After First Contact.................................................................................................................30

High Intensity Supportive Services...........................................................................................32High Intensity Case Management Services...........................................................................32Round the Clock Availability................................................................................................32Income Obtainment ..............................................................................................................33Payee Services.......................................................................................................................34Life Skills Coaching..............................................................................................................35Providing Love......................................................................................................................35

Housing......................................................................................................................................36Using the Housing First Model.............................................................................................36Bridge Housing......................................................................................................................38Finding the “Right Housing”.................................................................................................39Landlord Relationships..........................................................................................................40From a House to a Home.......................................................................................................41

Harm Reduction.........................................................................................................................41Trauma Informed Care..........................................................................................................43

Health Services..........................................................................................................................44The Medical Home................................................................................................................44Medication Management.......................................................................................................47

Data Collection..........................................................................................................................48The Results: Did Project 25 Work?...............................................................................................50

Personal Stories.........................................................................................................................51Were the (Stated) Goals of Project 25 Met?..............................................................................52Redefining Success: Not Black or White..................................................................................53

Where is Project 25 Now?.............................................................................................................56Funding Issues...........................................................................................................................56

Lessons from Project 25................................................................................................................59Things to Consider.....................................................................................................................59Moving to a System-Wide Plan for Frequent Users..................................................................61

High Utilizer Work Group.....................................................................................................61Community Information Exchange...........................................................................................61

Implementing Project 25 in Flint...................................................................................................63Homelessness in Flint................................................................................................................63Flint’s Ten Year Plan.................................................................................................................63The Importance of Stakeholders................................................................................................65Comparison to Current Models of Fighting Homelessness in Flint..........................................66Possible Allies for Project 25 in Flint........................................................................................67

Habitat for Humanity ............................................................................................................67The Young Women’s Christian Association (YWCA) of Greater Flint ..............................68One Stop and Homeless Outreach ........................................................................................69

How to Create a Frequent User List in Flint.............................................................................70Putting All of the Pieces Together.............................................................................................70

Appendix A: Interview Sources Used...........................................................................................71Bibliography..................................................................................................................................73


3


4

Project Overview

Executive Summary

Homelessness in America is not a new phenomenon, nor is it a problem that is only seen in urban areas. Homelessness comes in all shapes and sizes, and there are various reasons why people become homeless. Similarly, there are a wide range of interventions and services for assisting someone with exiting homelessness and not returning. For the longest time, homelessness has been viewed as a social prob-lem; the idea was that morally there should be something done about this situation because it is inhumane for people to not have a roof over their head. More re-cently, however, there has been a growing body of research and reports that are concluding that homelessness is not only a social and moral problem but also an economic problem that is extremely costly to society. Communities all across the country are grappling with this problem - that at times seems unsolvable - and are trying to figure out effective and cost-efficient ways to end homelessness. San Diego, CA is one of those communities.

In 2013, San Diego had the fourth largest homeless population in the country. San Diego has one of the most expensive housing markets in the country as well as hav-ing one of the lowest vacancy rates in the nation. In addition to the housing situa-tion, other factors contribute to magnitude of the homeless problem including low wages, a large military presence, San Diego’s position as a border city, and a warm climate conducive to living outdoors. Father Joe’s Villages (FJV) has been provid-ing services to the homelessness and those in need for over 60 years. In 2011, FJV was selected to be the lead agency for Project 25, giving it the opportunity to reach out a different segment of the homeless population. Project 25, a program spear-headed by the United Way of San Diego with support from the County of San Diego and the City of San Diego, is designed to lower the costs created by and improve the quality of life for San Diego’s most “frequent users.” “Frequent users” are a relatively small subset of the chronically homeless population, so called because they use San Diego’s emergency service system but gain little to no benefits from doing so, causing them to cycle in and out of emergency rooms, hospitals, and jails. Frequent users drain the time, resources, and funds of the community but do not gain any long-term benefits from doing so, leading to a cycle of entering and exiting facilities with nothing to show for it. One person summarized the issue by saying “it [is costing] us one million dollars not to do something” for these citizens.i


5

Project 25 is designed both to reduce the expenses created by frequent users and improve their quality of life. It uses the Housing First approach, which places indi-viduals into a permanent housing arrangement immediately and then provides a bevy of social services, as well as an extraordinary commitment to client outreach - in short, providing clients with everything they need to obtain and maintain hous-ing. Project 25 has proven to be amazingly effective, both lowering the costs cre-ated by frequent users once in housing and improving the quality of life experi-enced by clients. This report is designed to give Flint, MI - or any other interested city - a blueprint by which the city can begin to implement a similar program.

First Steps

1.Recognizing the Problem: If communities are interested in starting a fre-quent user initiative there are few things that they will need to start with prior to beginning work with actual “Frequent Users.” The first step will be getting the community and stakeholders to recognize that a problem exists and have people commit to doing something about it. Once someone or a group of people step up and decide that something needs to be done they need to get the right people from various sectors to the table and begin plan-ning what the initiative would look like.

2.How to Fund It?: Project 25 was funded through the United Way of San Diego County as a 3 year pilot. Communities could use grant funding the ini-tially start an initiative and understand how it works and during the process try to engage other stakeholders to continue funding as a steady sustained effort.

3.Lining up the Housing Resources: Project 25 would not have been possi-ble without the inclusion of permanent housing resources. The San Diego Housing Commission was able to provide 25 permanent housing vouchers to the project while the County of San Diego was able to provide 10 housing subsidies funded by the Mental Heath Services Act (MHSA).

4.Sharing Data to Target Effectively: A large part of the success of Project 25 was being able to target the most frequent users of the emergency system in San Diego. Data was shared between a handful of entities to create a list of people who frequented multiple systems in the same time period. This al-lowed Project 25 to target people that were most in need and most expensive to the community.

Implementing an Effective Program


6

1.Outreach: Outreach was a key component to be able to engage and begin to build trust with potential clients. Project 25 utilized a variety of outreach methods including convening an outreach group, having medical records flagged in certain hospitals, and receiving professional clearances to enter jail.

2.High Intensity Supportive Services: Constant contact and an unmatched commitment to personal relationships with clients characterizes Project 25. Using the trust and respect between staff and clients that comes from gen-uine relationships, staff are able to assist clients in all aspects of maintaining housing and personal stability, including income obtainment and manage-ment and payee services.

3.Housing: Project 25 operates on a Housing First model, which assumes that stable and secure housing is a prerequisite to economic and personal stabil-ity. Under the Housing First model, housing is the foundation upon which all other progress is built, rather than being a reward given for proving stability. Although it is important for programs such as Project 25 to have temporary or bridge housing available for clients while permanent housing is being se-cured, the Housing First model calls for staff to provide clients with stable and secure housing as quickly as possible. This need for secure permanent housing also requires staff to work closely with landlords in order to obtain and maintain housing for clients.

4.Harm Reduction: Project 25 clients, who struggle with extremely severe ad-diction issues, would rather be homeless than become clean and sober. So, rather than forcing them to become clean and sober, Project 25 staff focus on reducing the harm caused by alcohol and drug use - if clients choose to use, staff will at least insure that their use does not cause them to be hospitalized or lose their housing.

5.Health Services: Frequent users are so named because of their overuse of emergency medical services. By providing accessible, preventative, and thor-ough health care and medication management, Project 25 decreases clients’ use of ambulance rides, emergency rooms, and hospitals.

6.Data Collection: Efforts to end homelessness would not be nearly as effi-cient without dedication to data collection. Commitment to accurate and thor-ough data collection is essential to any serious efforts to end homelessness.

Conclusion

Project 25, a program backed by San Diego’s United Way and run by St. Vincent de Paul Village, is designed to lower the costs created by and improve the quality of


7

life for San Diego’s most “frequent users.” “Frequent users” are a relatively small subset of the chronically homeless population, so called because they use San Diego’s emergency service system but gain little to no benefits from doing so, causing them to cycle in and out of jails, hospital rooms, emergency rooms, ambu-lances, and other EMS service providers. Project 25 is designed both to reduce the expenses created by frequent users and improve their quality of life. It uses the Housing First approach, a bevy of social services, and an extraordinary commit-ment to client outreach to address the needs of their clients, providing clients with all the resources and assistance they need to obtain and maintain housing. Project 25 has proven to be amazingly effective, both lowering the costs created by fre-quent users - once in housing, the use of EMS services drops dramatically - and im-proving the quality of life experienced by clients.


8

Creation of Report

Creation of Report

This report is a product of the Diplomat Pharmacy Fellowship. Diplomat Pharmacy in Flint, MI is dedicated to both patient service and community service, encourag-ing its employees to be leaders not just in the company but in the community. As part of this commitment to community service, Diplomat Pharmacy created a fel-lowship designed to allow undergraduate or graduate students to create a project that would improve the circumstances of the city of Flint. This report is an example of such a project, designed to give the city of Flint a blueprint to replicate Project 25 and aid Flint’s frequent user population. I was part of the first Fellowship pro-gram, in the summer of 2014.

This report was created by using multiple sources and methods. I had the opportu-nity to observe Project 25 in action for several weeks. This experience helped me immerse myself in this program. In addition to observations, one on one inter-views were performed with key Project 25 staff, members from the City 911 sys-tem, and several landlords and property managers that housed Project 25 clients. I also researched current homeless service providers of Flint and Genesee County in order to compare their methods to those of Project 25. Past research on frequent users, a variety of existing documents on homelessness and frequent users, media reports on Project 25, various websites, and past Project 25 conference presenta-tions were used in compiling the information for this report. For a full list of the resources used in the report please see Appendix A.

Acknowledgements

This report could not have been possible without the help of a vast group of peo-ple. Great thanks to everyone I interviewed for this report (a full list is above); their insight into Project 25 and the landscape of homelessness services in Flint was invaluable.

Great thanks also to the Diplomat team who supervised the fellows. Steve Wolbert was our leader, and Kali Lucas, Ashley Gonsler, and Jocelyn McDougal supported me throughout the project in any way they could. Thanks is also due to Diplomat owners Phil Hagerman and Jeff Rowe, whose insight and passion for community service led to the creation of the Diplomat Fellowship.Dip lomat Pro jec t 25

9

Special Thanks to Kris Kuntz, Program and Research Analyst at St. Vincent de Paul Village, who supervised me on this project. Answering what seemed like hundreds of questions and guiding my writing, Kris has supported me throughout the entire process of writing this report. Without him, none of this would have been possible.


10

Overview of the Homeless Situation

Homelessness as a National Issue

“By its very nature, homelessness is impossible to measure with 100% accuracy.”ii Due to the transient nature of those experiencing homelessness and of the state of homelessness itself, it is very difficult to get an exact measure of homelessness in the United States. However, as of 2013, the United States Interagency Council on Homelessness estimated that 610,042 people in the United States were homeless at any one point in time.iii Since there is no way to count all the people experienc-ing homelessness - one can only count those currently on the streets or living in shelters, while many could be living with friends or family or be in other non-hous-ing situations - it is more likely that these numbers are conservative estimates, which means that nearly a million people in the United States are experiencing homelessness on any given night.

Homelessness is Expensive

Dennis Culhane wrote that “homelessness is more expensive to society than the costs of solving the problem.”iv This may seem counter-intuitive, but years of re-search and experience back Culhane’s belief. In the case of Murray Barr (also known as Million Dollar Murray), considered by many to be the poster child of fre-quent users, “it had cost the taxpayers $100,000 a year to maintain Murray in a state of homelessness...what the taxpayers got for that public ‘investment’ was a man who lived and died on the streets.”v Not only is homelessness morally expen-sive, but it is financially expensive. Current models of fighting homelessness are in many cases ineffective, and the community spends money only to have no results and no end to homelessness or the suffering it causes. In other words, the commu-nity’s money is going into a black hole - there is nothing to show for their financial loss. It is taxpayers who are almost always the ones covering the costs frequent users create via the emergency services system, since frequent users often do not have insurance to cover their medical expenses. What Culhane realized was that “enormous sums of money are already being spent on the chronically homeless, and [he] saw that the kind of money it would take to solve the homeless problem could well be less than the kind of money it took to ignore it.”vi Almost all cutting-edge frequent user initiatives throughout the United States cause the community to gain back a significant portion of the money it would have lost had it stuck to Dip lomat Pro jec t 25

11

traditional methods of dealing with frequent users - in other words, the money it would have lost while doing nothing. Culhane notes that “once housed, [frequent users] substantially reduce their use of [emergency] services and in many cases the costs associated with the service reductions fully offset the costs of the inter-vention.”vii In other words, while doing nothing is expensive, doing something - usu-ally providing frequent users with permanent supportive housing - is both cost-effi-cient and morally sound.

Homelessness in San Diego

San Diego is one of the top ten largest cities in the United States of America, with roughly 3.2 million peopleviii in San Diego County and its eighteen incorporated cities.ix In 2014, it had the fourth largest homeless population of any metro area, surpassed only by New York City, Los Angeles, and Seattle.x 24% of that population is considered chronically homeless.xi One reason for this unfortunate statistic might be San Diego’s relatively high cost of living. The cost of living in San Diego was 36% above the national average in 2011, mostly due to housing costs.xii As of July 15, 2014, San Diego County’s Regional Task Force on the Homeless counted 8,506 homeless individuals, 58% of which had been homeless for a year or longer.xiii The vast majority are concentrated in San Diego City.xiv Three-fourths are male. Roughly one third suffer from high levels of substance abuse, and a little under half struggle with severe mental health issues. Half have used the emergency room at least once in the past year.xv Homelessness is a serious problem in San Diego - but it is a problem that is beginning to be solved.


12

Father Joe’s Villages

Father Joe’s Villages is Southern California’s largest homeless services provider,xvi designed to empower people in their journey towards self-sufficiency. Father Joe’s defines self-sufficiency as a person having Permanent Housing and Steady In-come.xvii Father Joe’s Villages serves nearly 1,500 individuals of all ages every day. Single adults and unaccompanied minors as well as families are served by different branches of Father Joe’s Villages. There are four partner agencies of Father Joe’s Villages, three of which are in the San Diego area.

St. Vincent de Paul Village, the largest branch of Father Joe’s Villages, shelters little under a thousand people every night.xviii It is “a one-stop-center,” with all ser-vices a client might require centered on one campus.xix The main services offered by St. Vincent de Paul can be found on the website, but a few of the major services are listed below:xx

• Emergency Shelter: Provides emergency shelter and bridge housing to single

adults. The emergency shelter stay is up to 31 days and residents are allowed to

remain in the bunk areas during the day.

• Transitional Housing: Provides housing and services to residents with a maximum length of stay of 12 months.

• Village Family Health Center:xxi St. Vincent de Paul’s Village Family Health Center is a federally qualified health center serving both the homeless and the tenants of Father Joe’s Villages Permanent Housing offering medical, dental, and psychiatric care. The population served by the Village Family Health Center is often charac-terized by having, “severe and complex medical and mental health conditions,” many of which are chronic, such as diabetes or hypertension. By getting a pa-tient’s physical and mental health under control, the Village Family Health Center allows patients to look past merely surviving and gives them a chance to focus on addressing issues of housing and employment. In turn, once a patient is in perma-nent housing, he or she is able to focus on his or her treatment for chronic condi-tions or other health concerns that he or she was not able to properly treat while homeless - in short, being housed helps one’s health improve, and vice-versa.

• Dual Residency Program: St. Vincent de Paul Village partners with the Uni-versity of California, San Diego (UCSD), primarily for UCSD’s Combined


13

Family Medicine and Psychiatry Residency Program (also known as the Dual Residency Program). This five-year program, for which the Health Center is the primary training site, trains UCSD medical students to address both the physical and psychiatric health of the patients who come through the health center. The idea behind the program is that patients can get all their health needs met by one professional, one “white coat,” instead of having a multi-tude of different doctors. Building relationships are crucial to earning the trust of those who are suffering homelessness - relationships are seen as re-sources. It is preferable to build a strong relationship with one doctor, one “white coat,” that the patient can then trust with everything, instead of hav-ing multiple weaker relationships with a variety of doctors.xxii xxiii

• Affordable and Permanent Supportive Housing: Father Joe’sVillages has five apartment buildings with 365 units of “affordable and supportive housing” avail-able in San Diego county, some of which house Project 25 clients. Of the 365 af-fordable units, 140 are designated as Permanent Supportive Housing for those with a history of homelessness and a disabling health condition. Tenants in those units receive wraparound supportive services.

Toussaint Academy of San Diego “is the only long-term residential program for

homeless youth in San Diego.”xxiv With room for 35 homeless and runaway youth between the ages of 14 and 18, Toussaint Academy provides its charges with tran-sitional housing and a fully array of supportive services in the hopes that the teenagers are able to achieve self-sufficiency - a central tenet of the work done at Father Joe’s Villages - and function as successful adults.xxv

Josue Homes is San Diego’s first and largest non-hospice care provider for people living with HIV/AIDS. Designed for those who are homeless as well as HIV positive, Josue Homes fulfills the Father Joe’s model by guiding residents towards self-suffi-ciency over an 18-month period.xxvi


14

Overview of Project 25

Definition of Frequent User

Project 25 targeted San Diego’s most “frequent users,” a relatively small subset of the chronically homeless population who are the greatest utilizers of the San Diego emergency services systems. Kelly Davis defines a frequent user as “a homeless person whose addiction problems or physical or mental health issues repeatedly land him in the hospital, emergency room, or jail, where he could end up costing taxpayers hundreds of thousands of dollars.”xxvii San Diego’s Ten Year Plan refers to this phenomenon as a “revolving door cycle of the chronically homeless going in and out of shelters, detoxification centers, County Jail, and emergency rooms.”xxviii The chronically homeless as a group tend to, “disproportionately use a larger share of public resources,” even in comparison to other people who are homeless, but frequent users are even more vulnerable and therefore require even more time, money, and resources from the community.xxix Despite all this, frequent users can-not or do not gain any benefit from their over-utilization of emergency medical and social services. To put it harshly, frequent users are “not only a drain on taxpayer dollars, but also [are] at risk of dying on the street” because the programs that al-ready exist are not working for them.xxx

The Lewin Group summarized the phenomenon of frequent users best: xxxi

“Frequent users area a small group of individuals with complex, unmet needs not effectively addressed in the high-cost acute care settings of emer-gency departments. These individuals face barriers in accessing housing and medical, mental health, and substance abuse treatment, all of which can contribute to frequent emergency department visits.”

The Lewin Group also noted, “The prevalence of homelessness in the frequent user population and evidence that housing is a critical factor in addressing the health concerns of this population.” Thus the issue of frequent users is inextricably tied to that of homelessness and housing.

Background on Other Efforts

Frequent users are a nationwide phenomenon, first recognized by Dr. Jeffrey Bren-ner in Camden, New Jersey. He noted that “the people with the highest medical


15

costs - the people cycling in and out of the hospital - were usually the people re-ceiving the worst care.”xxxii Dr. Brenner was one of the first to realize that caring for these “frequent users” was both the humanitarian and the most financially sound thing to do. If these frequent users received proper care, their health and well-be-ing would improve, and they would not be as big a burden on the time, money, or resources of the EMS system.

Dr. Brenner was one of the first to start paying attention to the frequent-user phe-nomenon, but over the past few years other communities and other stakeholders have started addressing the issues of their own frequent users. Perhaps the most famous example of a frequent user is Murray Barr, “Million Dollar Murray,” as he was called. The national poster child for frequent user initiatives, he was well known to Reno police officers like Patrick O’Bryan, who observed that “it cost us one million dollars not to do something about Murray” - Murray, in this case, rep-resenting an average frequent user of the system.xxxiii

The twenty-first century has seen the start of several programs across the county designed to address the needs of frequent users. The Frequent Users of Health Services Initiative is compromised of six programs throughout the state of Califor-nia, and it joins more localized programs such as 1811 Eastlake in Seattle, the Se-rial Inebriate Program (SIP) and Project 25 in San Diego, and the 10th Decile Project and Project 50 (a comparable program to Project 25) in LA.xxxiv All programs were, like Project 25, designed to lower costs caused by and improve the quality of life for frequent users. Many that used the Housing First/Housing Plus model and/or the Harm Reduction model were successful.xxxv

What is Chronic Homelessness?

Chronically homeless is defined by the Department of Housing and Urban Develop-ment as an individual who:xxxvi

• Is homeless and lives in a place not meant for human habitation, a safe haven, or in an emergency shelter; and

• Has been homeless and living or residing in a place not meant for human habita-tion, a safe haven, or in an emergency shelter continuously for at least one year or on at least four separate occasions in the last three years; and

• Can be diagnosed with one or more of the following conditions: substance use dis-order, serious mental illness, developmental disability, post-traumatic stress dis-


16

order, cognitive impairments resulting from brain injury, or chronic physical ill-ness or disability.

The chronically homeless have traditionally compromised roughly 10% of the sin-gle homeless population, but they utilize at least half of the resources dedicated to aiding homeless individuals.xxxvii More recent reports estimate that the chronically homeless make up nearly 18% of the homeless population in the United States.xxxviii Dennis P. Culhane and Randall Kuhn write that “the chronically homeless popula-tion could be characterized as those persons most like the stereotypical profile of the skid-row homeless.”xxxix The chronically homeless “essentially live in the home-less assistance system, or in a combination of shelters, hospitals, the streets, and jails and prisons.”xl They “tend to be older, non-White, and to have higher levels of mental health, substance abuse, and medical problems.”xli The National Alliance to End Homelessness notes that “few people in this chronic group are likely to ever generate significant earnings through wages. While they may have some income from wages and/or public benefits, they will require long term subsidization of both housing and services because of their disabilities.”xlii Experts agree that permanent supportive housing and long-term care services are necessary to stabilize and pro-vide for this population, since they are unable to succeed within traditional param-eters, often due to disability or severe addiction issues.

The Basics of Project 25

Project 25 is a cutting-edge program, sponsored and funded by the United Way of San Diego and run by St. Vincent de Paul Village in addition to Telecare Corpora-tion, dedicated to improving the quality of life and reducing the costs caused by San Diego’s most “frequent users.” “Frequent users,” are a relatively small subset of the chronically homeless population who are the “most frequent users of ambu-lance services, emergency rooms, in-patient hospitalizations, mental health out-pa-tient and inpatient services, jail, and detoxification services.”xliii They cycle in and out of the emergency services and social services systems - and become familiar faces to those who work in these systems - but retain no long-term benefit from their over-use of the systems, all the time costing taxpayers money, resources, and time. Patrick O’Bryan, the Reno police officer who spent much of his time dealing with frequent users like Murray Barr, said that “it [is costing] us one million dol-lars not to do something” for the frequent users or the people who try to serve them.xliv

Project 25 aims to rectify this social outrage. “Project 25 is an innovative program designed to reduce the health care costs for [frequent users by providing] housing, Dip lomat Pro jec t 25

17

intensive case management, and a single medical home for primary and behavioral health care.”xlv In many ways, the premise is simple: if these frequent users need homes, or individualized case management, or special social services, it is given to them. “The idea [is] that if you take these people off the streets, you can give them a better life and save a lot of money in the process.”xlvi It is designed to provide fre-quent users with everything they could possibly need - permanent housing (as per the Housing First model), case managers dedicated to their well-being who are on the job 24 hours a day/7 days a week, and supportive “wraparound” services that weave a safety net so tight that no one could possibly fall through, including an ap-proach to substance abuse known as the Harm Reduction Model. The idea behind Project 25 is that housing stability and preventative (medical and personal) care would lead to decreased use and cost of services, in turn leading to an improved quality of life for the clients. Using this comprehensive system, as well as an em-phasis on data collection throughout the life of the program, Project 25 is designed to help the frequent user and, in turn, help the community. It does, however, re-quire “unprecedented collaboration” between community stakeholders in order to provide the Project 25 clients with the full range of services they need to succeed in permanent housing.xlvii “The goal of the program [is] to work with hospitals, law enforcement and emergency medical services to identify [frequent users] and get them housed and hooked up with [supportive] services,” which means that Project 25 requires the support of the 911, hospital, behavioral health, and law enforce-ment systems as well as social services in order to function to the most of its poten-tial.xlviii

The Set-Up

Project 25 began as a three-year pilot program in the spring of 2011;xlix the funding - of which there was $1.5 million - ran out in June of 2014.l

The United Way of San Diego was the main funder of Project 25.li The United Way chose St. Vincent de Paul Village to run the day-to-day operations of Project 25 - essentially, St. Vincent’s was in charge of making Project 25 work.lii However, St. Vincent’s only case managed 15 of the original 35 clients and managed housing for only 25 clients, though St. Vincent’s staff were responsible for collecting data on all 35 clients. Through another contract with the County of San Diego, Telecare Corporation case-managed and provided services to the rest of the Project 25 clients. In theory, the clients were divided - Telecare was to be responsible for those clients with “severe and persistent mental illness,” while St. Vincent’s was to take care of those who did not meet the criteria for severe and persistent mental


18

illness, which could have included physical health issues, substance abuse, or cog-nitive limitations. Yet the nature of frequent users meant that every client, includ-ing the ones managed by St. Vincent’s, struggled with mental illness.liii Telecare, however, is dedicated as an organization to managing severe and complex mental health issues, whereas St. Vincent’s is more focused on managing frequent users’ issues through the lens of addressing poverty and homelessness rather than men-tal health.liv lv

Project 25 was far more than just a project between St. Vincent de Paul and Tele-care Corporation. “More than 20 organizations and entities collaborated to help make this project a reality.”lvi For Project 25 to work, the entire community needs to come together to provide a comprehensive net of housing and non-housing ser-vices - a net woven so tight that no one can fall between the cracks. Comprehen-sive services mean that many different community stakeholders - landlords, hous-ing agencies, doctors, and social service providers, among others - need to come together to provide the services that will help frequent users reduce their use of emergency services and begin a steady life in permanent housing. Project 25 re-quires “unprecedented [amounts of] collaboration” pulling from all areas of the community.lvii It cannot work otherwise.

How are Project 25 Clients Different from Other Chronically Home-less?

It is important to note that not all frequent users are chronically homeless and more importantly not all chronically homeless are frequent users. According to the San Diego Downtown Partnership the average chronically homeless individual costs the community $36,624, but the average Project 25 participant (in other words, a high-risk frequent user) costs the community $120,841 - roughly four times as much. Malcolm Gladwell explains this phenomenon as one of a power-law distribution - where the heart of the issue is not with the average member of a group, but with an individual at one extreme end.lviii In this case, trying to end homelessness by focusing on the average homeless individual - who, compared to his chronically homeless counterpart, enters and leaves homelessness very quickly and does not return - could work for the majority of homeless people, but it would have little to no effect on the chronically homeless, who also happen to be the ones who are costing the community most. But even within the chronically homeless population, there is a power-law distribution of individuals who cost more due to a series of physical and psychological setbacks. Although St. Vincent de Paul Village has a long history of serving homeless individuals, including the chronically home-Dip lomat Pro jec t 25

19

less, frequent users are “a group of people [that] as social services providers, we’d never met before.”lix

This is partially because of the high risk of physical and mental health issues that come with chronic homelessness. To put it bluntly, homeless individuals - espe-cially chronically homeless individuals - get sick more often.lx “Health conditions and mortality rates within this population are similar to those found in developing countries,”lxi and “many [struggle] with severe mental illness.”lxii Both physical and mental health problems are found at a much higher rate in the homeless popula-tion (as compared to the general population) and especially in the chronically homeless population (not to mention the frequent user population). lxiii It may be that physical and mental illness lead to homelessness, but it is also true that home-lessness does not allow for proper care of these ailments. The best summary of this issue comes from Dr. David Buchanan: lxiv

“Homeless individuals suffer from high rates of physical and mental illness and experience mortality rates several times higher than the general popula-tion. Although homeless adults are hospitalized more frequent (and require longer inpatient stays) than a comparable sample of housed adults, their homelessness may diminish the long-term effectiveness of their hospital care. Back on the streets after hospital discharge, competing priorities (ob-taining food, clothing, and shelter) and substance use may divert their atten-tion from compliance with medications, other physician instructions, and fol-low-up appointments.”

What turns an ill chronically homeless individual into a frequent user is that they “often use emergency services, including the emergency department…because they lack other resources or access to primary care.”lxv This means that chronically homeless adults and particularly frequent users treat the local emergency room as a primary care office, and, since these individuals often have severe physical and mental health issues, they end up consuming a great deal of time, resources, and money. What makes the situation even more difficult is the presence of severe ad-diction. Frequent users are in many cases “alcoholic [or drug-addicted] individuals whose consistent and underlying use of alcohol puts their health at continued risk, whose other lifestyle choices make the need for emergency services persistently real, and who frequently use emergency services for non-emergencies.”lxvi The com-bination of physical illness, mental illness, substance abuse, and a lack of proper primary care come together to create the frequent user phenomenon. “All of [the frequent users who participated in Project 25, for example] have a mental health condition, substance abuse issues, and at least two major physical health issues.”lxvii


20

Perhaps more than any other group of homeless individuals, frequent users require the utmost possible physical and psychiatric care.

But frequent users, even more so than other chronically homeless individuals, are unable to be reached by traditional service providers. Frequent users “have long fallen through the cracks of care coordination, medical, and even health home pro-grams.”lxviii In many cases, “they have rejected or been rejected by the systems of care intended to help them.”lxix Not only do they need intense case management, they will “fail out of” any program that requires any sort of reformation. They can-not work within “requirements;” many frequent users have failed out of several other programs, either for behavioral issues or substance abuse. “Traditional chemical dependency treatment [in particular] has proved ineffective;” frequent users are generally unable to work within the bounds of sobriety.lxx Because of their complex medical and mental conditions, frequent users “just [aren’t] a good fit for other programs for the homeless.”lxxi They need programs designed espe-cially to serve their unique physical and psychological needs, since most frequent users are unable to adhere to any rules or regulations a traditional program would require of them.

In summary, frequent users are a particularly high-risk subset of the chronically homeless - arguably “our most vulnerable homeless population” - characterized by their overuse of the emergency medical system and other emergency social ser-vices.lxxii Considering that the chronically homeless as a group consume at least half of all public resources, “including EMS, detoxification, shelter, law enforcement, and psychiatric and correctional care,” the fact that frequent users are up to four times as expensive should be an indicator that the issues that surround frequent users are issues that need to be addressed as soon as possible - not just for human-itarian reasons, but for financial ones.lxxiii

What are the Desired Outcomes or Goals?

Project 25 staff presented the goals of the program as follows:lxxiv

• Decrease use and cost of emergency services

• Improve quality of life

• Housing stability and sustainability

• Access preventative care through medical home

• Obtain a permanent income sourceDip lomat Pro jec t 25

21

The model presented above is a bit misleading. The goals of Project 25 are not best summarized in a list, but as a process, with some of Project 25’s victories being necessary to achieve others. A description of the cause-and-effect of Project 25’s goals is below:

By providing permanent housing and a wrap-around system of supportive services - including preventative medical and mental health care and assistance with in-come obtainment - characterized by an extraordinary commitment to case manage-ment and client outreach, Project 25 hoped to decrease the use of the system by frequent users. This decrease would be both a benefit to the community - saving San Diego County time, money, and resources - and a benefit to the frequent user-clients, with the assumption that less use of emergency services directly corre-sponds with an improved quality of life.

The most fundamental goal of Project 25, however, is to improve the quality of life for its clients. “The goal of the program was to work with hospitals, law enforce-ment and emergency medical services to identify [frequent users] and get them housed and hooked up with services.”lxxv Project 25 case manager Jose Zaragoza said that “the desired goal is housing sustainability for long-term homelessness.” Put simply, to solve homelessness, the community needs to give frequent users a home. But just as important are the wrap-around social services provided before and after a client is moved into housing. Without intensive supportive services, the clients of Project 25 would not be able to function in society. Thanks to severe physical and mental health issues, compounded by years of drug and alcohol abuse, frequent users “are very severely impacted people. They have a lot of im-pairment, a lot of damage.”lxxvi Frequent users require intensive case management and a level of client outreach unparalleled by other homelessness service providers. Both housing and supportive services need to be provided for them, since they cannot get it themselves. Project 25 provides them with everything they need to obtain and maintain housing, including a devoted team of case managers and a host of supportive services.

Perhaps the most important goal, however, is not a tangible one. It is the gift of hope. “Most of our clients,” Zaragoza says, “lost hope out on the streets, and [we’re] giving hope back.”lxxvii Giving people - both providers and clients - the faith to believe that chronic homelessness can be solved is the first step in winning the battle against it.


22

First Steps

Recognizing the Problem

If communities are interested in starting a frequent user initiative there are few things that they will need to start with prior to beginning work with actual “Fre-quent Users.” The first step will be getting the community and stakeholders to recognize that a problem exists and have people commit to doing something about it. Once someone or a group of people step up and decide that something needs to be done they need to get the right people from various sectors to the table and be-gin planning what the initiative would look like.

San Diego’s 10 Year Plan lxxviii

San Diego County is one of the 100 communities encouraged by the Bush adminis-tration to address the issue of chronic homelessness by developing a Ten Year Plan. The Ten Year Plans created by many American communities, including San Diego, CA, and Flint, MI, are responses to this call for a “cure” to homelessness, particularly chronic homelessness.

San Diego’s Ten Year Plan is based off of Two Key Elements: a Housing First/Hous-ing Plus approach and a commitment to Preventing Homelessness. Project 25 ad-dresses the former of these by providing a Housing First/Housing Plus model.

Of Five Strategic Planning Areas identified by the Leadership Council that drafted San Diego’s Ten Year Plan, Project 25 begins to addresses the first three and can help inform the fourth: identify and secure sufficient permanent housing; develop housing plus wrap-around services model; strengthen intervention, outreach, and case management; and implement a systems-wide data collection, evaluation, and sharing plan.

Of Ten Key Performance Measures, Project 25 directly addresses three: annual re-duction in the number of chronically homeless people; progress in implementing comprehensive housing plus wrap-around model; and progress in establishing a centralized web-based data system that can be used to strengthen intervention, outreach, case management, and evaluation activities.lxxix

Getting the Right People to the Table


23

The first step in solving any problem is recognizing it as such. In order for Project 25 to take hold in the community, someone needs to take ownership both of the problem and its solution. Ideally, this person is a political or social leader who is both frustrated by the lack of solutions to the problem and willing to put all the weight of his or her position and personality behind a solution. A project as intense as Project 25 needs a leader who is willing to put lots of time and energy into en-suring that the Project is properly supported, whether financially or politically. lxxx San Diego’s Project 25 really got its start from the vision of the then Commissioner to End Chronic Homelessness, Brian Maienschein. Maienschein, a former City Council member, was very passionate about starting Project 25 and did an excel-lent job of getting the right people to the table to discuss what it would look like and start the planning.

Funding

The United Way of San Diego County

United Way of San Diego funded Project 25 as a three-year pilot program and chose St. Vincent de Paul to run the program, giving them $1.5 million to use for Project 25.lxxxi They also chose Telecare Corporation to aid St. Vincent’s by case managing and caring for some of the clients.lxxxii

Partnership with the County of San Diego

St. Vincent de Paul Village was responsible for collecting data on all 35 clients. Through another contract, Telecare Corporation case-managed and provided ser-vices to the rest of the Project 25 clients.

Lining Up the Housing Resources

One of the main goals of Project 25 is Housing Stability and Sustainability. Project 25 was granted 25 sponsor-based housing vouchers to accommodate the original number of clients it was expected to serve.lxxxiii Project 25 got these housing vouch-ers through the San Diego Housing Commission, San Diego City’s Public Housing Authority, which allowed it to free up (what would have been) Section 8 vouchers for its clients.lxxxiv Like Section 8 vouchers, the voucher requires that clients pay 30% of their income towards rent. However, many Project 25 clients have no in-come, in which case the voucher pays all the rent (up to $942). lxxxv Normally, fre-quent users would “fail out of” Section 8 vouchers, but these sponsor-based vouch-Dip lomat Pro jec t 25

24

ers allowed Project 25 to establish and manage its own requirements and limita-tions, which only excluded undocumented immigrants, registered sex offenders, and anyone convicted of manufacturing meth in public housing.lxxxvi The ten Tele-care clients who did not receive a sponsor-based voucher received housing through MHSA funds.lxxxvii

Sharing Data to Target Effectively

The United Way started by creating Memoranda of Understanding in order to ac-cess information from various providers without the client’s express consent. Only very necessary information was accessed, such as client name, client date of birth, number and type of services, and the costs of those services.lxxxviii Two local hospi-tals, the county jail/sheriff’s office, the city 911 system, and the county behavioral health services all provided their own lists.lxxxix St. Vincent de Paul compiled all five lists into one all-inclusive list and asked the five providers to re-run the new list, adding some new data and checking to see if people on other lists had also ac-cessed their services (even if they were not on the original list).xc After getting the responses from the five providers, St. Vincent’s revisited the general list and elimi-nated anyone who did not access at least two systems.xci Then assigned an esti-mated cost per unit of service to each service and then ranked all the names on the list by overall costs. After eliminating anyone who did not have over $50,000 in an-nual costs, the final list had 71 names. Project 25 picked the top 35 and com-menced searching for them in order to start outreach. However, 13% of the list was already dead by the time Project 25 started outreach, modifying the list a bit.xcii

The process by which the frequent user list was created in San Diego was thor-ough, but it was also time- and resource-consuming. For those who are interested in replicating Project 25 in their own counties and cities, it could be recommended that they only approach the 911 system in compiling their list. 911 services al-though costly, always end in an emergency room visit so the 911 list would be the “golden list.” In addition, those who frequent EMS and 911 services tend to also over-utilize other systems, so the 911 list could be the “gold standard” for anyone looking to create a frequent-user list.xciii

Specifically regarding the 911 system, matching identifying information and get-ting a persons homeless status is not an easy task. Multiple searches - by name, Social Security Number, date of birth - may be necessary since intoxicated individ-uals might not be always consistent with their information. San Diego at least has a series of algorithms that allow service providers to gather all the information on one person, with 35 possible ways to match a client to his or her profile, despite Dip lomat Pro jec t 25

25

multiple incidents in multiple locations. In order to verify homelessness, check the client address: either they will have no address or the address of a shelter or homeless service provider, or they might have said something else in the report that indicates homelessness.xciv

Results From Effective Targeting

Brian Maienschein wrote that “Project 25 was named for the number of people we originally thought would be served.”xcv However, by the time Project 25 was set to operate, it was ready and able to serve 35 individuals (a 36th was added later at the request of the City 911 system and the police department).xcvi These 35 individ-uals were the most extreme frequent users in San Diego. In 2010, the year before the program started, Project 25 clients spent upwards of $4 million of taxpayer money in the use of the system. A breakdown of the costs is below, from most to least expensive:

• Hospital Days: $2,626,712

• ER Visits: $987,371

• Ambulance Rides: $332,316

• Miscellaneous Charges: $147,600

• Law Enforcement: $135,430

Total Cost = $4,229,429xcvii

The average cost per Project 25 participant in 2010 was $120,841.xcviii

Of the 36 participants in Project 25, 30 were men and 6 were women. They ranged from 21 to 60 years of age, with the average age being 46. A little under half (15) had no health insurance, with several (7) relying on the county to provide health insurance, while some had Medicaid (9) and a handful had Medicare (5). Each one of them averaged 21 ambulance rides, 41 ER visits, and 10 hospital admissions (with 45 hospital days) in 2010.xcix c In doing so, the original 35 clients accessed ev-ery Emergency Room in San Diego County.ci


26

Implementing An Effective Program

Outreach

Attitudes Towards Clients

The CREED of St. Vincent de Paul informs every action and service provided for clients throughout the village, and Project 25 is no exception. Below is a Project 25-specific version of the CREED:cii

• Compassion: Poverty is more than just a client’s behavior. It is so hard to get out of this, and (we) providers have to recognize this if we want to help.

• Respect: These (clients) are not people without strengths. They can survive in their world in a way we could not. Who they are matters. We can add to their skills set without changing them.

• Empathy: We try to put ourselves in their shoes and imagine what it must be like in their situation.

• Empowerment: We learn through assessment when we should do something for them, with them, or let them do it themselves. Sometimes making the client do everything on their own is not the answer. Frequent users have a lot of issues and cannot always “learn their own lessons” - giving them full responsibilities could mean kicking them back out onto the street. In some cases, they need our help (to keep an apartment clean, to work with a landlord, to get to a doctor’s appoint-ment on time), and we need to accept that. At times it may be totally necessary to do something for them but yet the goal is that over time they are doing those things with us and eventually they are doing it on their own.ciii

• Dignity: We expect the basics from our clients - we want them to stay in their housing - but it is crucial that we communicate this expectation in a dignified way. We should offer help and use our relationships with them to communicate, much like a parent teaching a kid to ride a bike. “You help them at first, you let go a little; if they fall you come back and hold them up again and try again and start over or keep going.” They may need their “training wheels” for the rest of their life, but at least they can ride on their own.


27

Even beyond the stated CREED, however, Project 25 makes a special effort to com-municate a sense of compassion and respect towards its clients. Many clients, fresh off the streets and deemed “failures” by other organizations, have not been treated with the dignity worthy of any human adult. They are treated like children, criminals, or general “lost causes.” Project 25 insists instead on “value[ing] you like a human being,” in the words of one client.civ Unlike many other programs, where clients are made to feel like they are the problem, Project 25 makes sure to offer clients “the only consistent and comprehensive services they [have] ever ex-perienced.”cv But “beyond just the services, interview participants appreciated the personal attention and respect they felt from staff.”cvi This sort of personal connec-tion, characterized by compassion and respect, is often seen as maternal, at least in the words of Jeremy Brenner:cvii

“People are people, and they get into situations they don’t necessarily plan on. My philosophy about [any kind of] primary care is that the only person who has changed anyone’s life is their mother. The reason is that she cares about them, and she says the same simple thing over and over and over.”

According to Brenner, simple love - whether towards a family member or a fellow human being - is life-changing for anyone. It seems to be the case for frequent users too. The basic care and respect demonstrated by staff made clients feel “that they were no longer living in the shadows but rather were functioning members of society.”cviii

This compassion and respect that Project 25 staff demonstrate towards clients is partially informed by an understanding of the Culture of Poverty from which clients come. One of the biggest mistakes service providers make when attempting to work with people in poverty is assuming that people in poverty have the same values and perspectives as those in the middle class or wealth. These perspectives are no less sophisticated and these values no “worse” than those of the middle class, but they are quite different, as informed by a very different worldview and the need to survive under a different set of circumstances. It is wrong of service providers to require a client to change “who they are” in order to get resources - at the very least, it is ineffective. Providers like Project 25 staff need to approach clients without judgment and without demands, otherwise communication and thus any programs offered will fail. In the case of Project 25, this means establishing re-lationships before asking clients to change anything about their lifestyle, and pro-viding resources before requiring compliance with any set of rules. Knowing how those in poverty think about and react towards the world can aid providers in com-


28

municating effectively and therefore will make the transition from poverty to self-sufficiency far easier.cix

No Real Program Compliance Required

Most programs designed to get people out of homelessness - indeed, most social services programs - require participants to follow a certain set of rules. But fre-quent users are usually so impaired physically and mentally (whether because of health, mental health, or addiction issues) that they are unable and often unwilling to comply with the rules presented to them. They refuse to get sober or clean; they get intoxicated and trash their apartments, which leads to eviction; personality dis-orders lead to altercations with landlords or visitors that land them in jail. In other programs, infractions of this severity mean that the client would be forced to leave the program. Project 25, however, refuses to abandon anyone. In the words of Project 25 staff, “there is no getting kicked out of Project 25.”cx No matter what a client does - no matter how many times they end up in the emergency room or the jail, no matter how many apartments they are forced out of, no matter how many mistakes they make - Project 25 staff refuse to leave their clients’ sides. They visit clients in jail, find new apartments for them when they have to leave their current one, and stick through the ups and downs of recovery and relapse.cxi “Even if [their] life falls completely apart,” Project 25 will stick by their clients.cxii Other programs require compliance with the rules - sobriety, general obedience, good behavior, etc. Frequent users, however, cannot comply, and therefore they reject the pro-gram or are rejected. By contrast, no one has dropped out of Project 25 or been asked to leave. Once a client is part of Project 25, he or she is in it for as long as they need it, no matter how low he or she sinks or how many times he or she re-lapses and recovers. Even if a client tries to push Project 25 away, Project 25 will not abandon that client. Project 25 director Marc Stevenson sums it up: “we [stick] by [them],” no matter what.

Outreach

Once the List of frequent users was created, it was up to Project 25 staff to find those frequent users to start offering them services. Several strategies were used for location and identification of potential clients.

Outreach Group:

Project 25 staff convened a group during the outreach phase to discuss clients that were being targeted for the program and to gain any insights to


29

potential whereabouts. Group members consisted of police officers, paramedics, ER and hospital social workers, jail staff, and various homeless providers and social services staff.

Hospital Flags:

Project 25 staff worked with one local hospital to create a flag on the pa-tient’s medical chart so that if they presented in the ER hospital staff would know that this person was eligible for the program. The hospital staff would talk with the patient and if they agreed to meet with Project 25 further, the hospital staff would call Project 25 and they would come meet the patient in the ER and discuss the program. Another hospital did the same thing except the social workers in the ER had a list of our patients and would keep a good eye out for them.

Jail In Reach:

Project 25 staff received Professional Clearances to be able to enter any County jail and meet one on one with a potential client while incarcerated. Project 25 staff would check the County of San Diego jail website daily which is available to the public to see if any of the potential clients were re-cently arrested and sitting in a jail cell. Most of the clients who enrolled in Project 25 were first contacted while incarcerated.

Ambulance Pick Up Locations:

Project 25 staff worked with the ambulance system to learn what were the regular pick up locations and addresses for potential clients. Most times the addresses varied but all within certain geographic locations. For example one potential client had almost all of his pickups from a certain 2 square block area in San Diego and through information learned in the Outreach Group meetings staff knew that he was Native American, was in a wheel chair, and did not have any toes. Project 25 staff were able to go to that lo-cation and performed street outreach and look for a Native American male in a wheel chair which they immediately found and the client was enrolled.

St. Vincent’s HMIS Database:

St. Vincent de Paul Village has over 90,000 unduplicated people in its Home-less Management Information System (HMIS) database, CSTAR™. Project 25 staff placed flags on potential clients in the database which allowed vari-ous staff within other programs at St. Vincent’s to assist with locating


30

clients. For example, clients were found for Project 25 through the public meal line, the medical clinic, and the front desk at the shelter.

After First Contact

Once found, Project 25 staff began offering services right on the streets, working first and foremost on establishing and building personal relationships between staff and clients. Staff would visit clients on the street or in the “camps” and pro-vide food, cigarettes, or other small but valuable resources in order to build trust with the client.cxiii These gifts were essential for establishing a relationship between staff and clients. In the world of poverty, people are viewed as resources, valuable in terms of what they can and do provide an individual. Friendship only takes place after a person’s value is established.cxiv Knowing this, Project 25 staff provided re-sources before trying to establish friendships.cxv

Over a period of months, staff simply visited clients on the streets (or in jail or the hospital), often with gifts but sometimes just to spend time together. Occasionally, the Project 25 doctor would perform street visits. In a couple of cases, staff show-ered and cleaned clients who spent their days sitting in their own feces.cxvi cxvii What-ever it took, Project 25 staff proved that they, unlike everyone else, were not there for the client only conditionally - they were there no matter what.

Project 25 is built on the trust and relationships established in the first few months of outreach. The staff on the streets would be the same staff that would be present when the client was in housing - it was essential that personal relationships were formed and strengthened over time. Using the personal relationships they built over the first few months of outreach, Project 25 staff were able to communicate effectively with clients and provide successful care, both because they understand who the clients were and what they needed and because the clients trusted the staff, knowing that they cared about them as individuals and that they would not try to trick them or force them to do anything they did not want to do. Project 25 staff stress repeatedly that the most important part of the program was the forma-tion and maintenance of relationships between staff and clients; it was the “magic dust” that allowed all of Project 25 to function.cxviii

Project 25 case manager Jose Zaragoza stresses that, in order for Project 25 to work, “you need people who are...willing to stick it through everything and any-thing.”cxix This includes hygiene issues - a man sitting in his own feces, a man who soiled himself in Wells Fargo and did not see anything wrong with it, a man with a malfunctioning colonoscopy bag - behavioral issues, addiction issues, physical Dip lomat Pro jec t 25

31

health issues, emotional issues - including strong distrust of authorities - and, most of all, hopelessness. “The main thing [they were] up against was...hopelessness.”cxx Faced with a system that was unable or unwilling to help them, most frequent users gave up on ever “getting better.” After all, if society saw them as “lost causes,” what was there to prove that they were anything else? “The level of hope-lessness in the beginning is really intense,” Zaragoza says. “We have to stand side-by-side with our clients in order to get them through the beginning and the [jour-ney towards] housing.” Relationships are the only thing that can cut through the overwhelming hopelessness frequent users live with. The “most important at-tribute [of a Project 25 staff member] is a knack for connecting with [frequent users], and understanding their difficulties.”cxxi This often does not require special training, just a basic human decency and a willingness to treat clients according to the CREED.

High Intensity Supportive Services

High Intensity Case Management Services

This relationship does not end once a client is in housing. Staff are in constant con-tact with clients. They are right beside them in every step they take. Staff get the clients ID and Social Security cards, they work with the landlords to obtain and maintain housing, they help clients fill out rental applications, they get the clients on food stamps, they drive clients to various appointments, they sit with clients in the doctor’s waiting room and in the appointments. If a client ends up in jail or in the hospital, staff come to visit them, to check in and help the client prepare for discharge, no matter how many times they have done this before. “Staff is proac-tive in determining what participants need...and in doing whatever it takes to de-liver the kind of consistent care that will lead to improved...outcomes.”cxxii In addi-tion, staff are often at a client’s apartment, either to help a client out with basic life skills or just to visit and spend time with the client. It is not just staff who perform home visits - the doctor can connect with patients remotely, and maintenance crews provided by St. Vincent de Paul visit in order to help with home repairs and improvements. This is but a sample of what Project 25 staff do; they are there for anything and everything a client might need.

Round the Clock Availability

Even when not physically with the clients, staff are accessible in case of an emer-gency. “The project keeps a 24-hour emergency line open for clients and their Dip lomat Pro jec t 25

32

landlords. All of the clients have [Project 25 director Marc] Stevenson’s [personal] cell phone number, too.”cxxiii Staff switch off on who mans the 24-hour emergency line, which Zaragoza says was “the biggest lifesaver” in Project 25.cxxiv

Project 25 is obviously extremely labor intensive. It fits in with the idea put forth by San Diego’s Ten Year Plan, which stated that “there must be a renewed invest-ment in case management, outreach, and intervention services.”cxxv This is because clients require “constant attention and assessment.”cxxvi These are high-needs peo-ple, whose complex physical and mental health issues have gone unaddressed for years, even for decades. In the words of Marc Stevenson, “these are crisis-oriented folks. If you aren’t set up to address crisis, then you’re probably not going to make a big impact on folks like this.”cxxvii Labeled by society as “lost causes,” what fre-quent users need more than anything else is someone who will not give up on them, someone who will stick with them through anything and everything they might have to go through.

All of this is part of the intensive case management offered by Project 25. Project 25 has only six clients for each case manager, ensuring that each case manager has enough time and energy to properly address all of their clients’ concerns and needs.cxxviii

Income Obtainment

Project 25 helps its clients get income, primarily through disability benefits such as Supplemental Security Income (SSI), or Social Security Disability Insurance (SSDI). Project 25 utilized the local Homeless Outreach Programs for Entitlements (HOPE) San Diego model which is based on the national best practice, SSI/SSDI Outreach, Access, and Recovery (SOAR) model. SOAR is “designed to increase ac-cess to SSI/SSDI for eligible adults who are homeless or at risk of homelessness and have a mental illness and/or a co-occurring substance use disorder.”cxxix SOAR is available in all fifty states.

Almost none of the Project 25 clients are able to maintain a job,cxxx either because of physical, emotional, or mental disability. The mental disability could either have been “natural” (the client was born with it) or it could have been caused by exces-sive alcohol abuse, which permanently damaged the client’s body and mind. In the words of Kenny Goldberg, the brains of frequent users are more often than not “pretty fried.”cxxxi When Project 25 started, only 2 of the 16 clients supported by St. Vincent de Paul Village had permanent disability benefits. At the time of this report only 4 of the 16 did not have disability benefits. Dip lomat Pro jec t 25

33

Project 25 has occasionally had to use creative ways to prove that their clients were disabled. In one case, a client who had pretty observable cognitive impair-ments would not stop drinking to be able to get the appropriate testing. However the client agreed to enter a two-week detoxification program, and then after the detox Project 25 staff picked the client up at the detox center and took the client to be tested, proving that the client’s mental capabilities were damaged even while sober. The client’s brain was permanently damaged, not temporarily impaired, by alcohol. After the test was complete, the client went back to drinking.cxxxii

Payee Services

Once on disability benefits, Project 25 clients can elect to have a staff member manage their money for them, essentially having a staff member take care of their finances because they are not able or willing to do it themselves. “In house payee services...manage [a client’s] income and ensure rent and other bills are taken care of.”cxxxiii Many frequent users are unable to manage their own money, spending it all on alcohol and then having nothing left for food or rent. Murray Barr, the poster child of frequent users, once threw away six thousand dollars in one week - proba-bly on alcohol - because he had no one monitoring him.cxxxiv Having someone else manage their money allows clients to take the decision to spend out of their hands, at least partially, and helps control their spending and substance abuse.

Project 25’s payee services are specially designed to fit the Harm Reduction model. Though labor-intensive, having a client opt into payee services means that Project 25 staff can monitor their alcohol consumption by monitoring the amount of money they have each day to pay for alcohol. Because of the risk that clients might abuse their money (buy a week’s worth of alcohol and drink it all in one night, for exam-ple), the clients often do not have access to more than one day’s allowance at a time.cxxxv Of course, clients are closely monitored, and the amount of money they re-ceive each day or the amount of times a week they receive money varies based on their behavior.cxxxvi The more sober a client is, the less often they get their money, and the more money they get with each distribution. At best, they receive money weekly; more often, they receive money in daily or tri-weekly doses. Money is dis-tributed in cash (since cashing checks costs money).cxxxvii

The most important part of payee services is managing the money for rent. Under the Project 25 vouchers, 30% of all income (including income from disability bene-fits) is to be set aside to pay for rent. Project 25 case managers set aside the 30%, as well as any additional money for bills, and budgets the rest for any additional expenses (setting aside money for the alcohol many clients need to have daily, as Dip lomat Pro jec t 25

34

well as food), so that clients do not spend their money quickly or rashly. Project 25 staff members will go grocery shopping with the client, help them choose their gro-ceries, and then let them pay for their own food with the money Project 25 has given them that day. It is a highly individualized system, closely monitored by Project 25 staff, which, like many other parts of Project 25, takes a lot of time and effort. Any leftover money is set aside while the staff member discusses with the client where the client would like that money to go - towards furniture, entertain-ment, or something else. Those clients on disability cannot have more than $2,000 in the bank by SSA rules, so Project 25 helps clients spend money to meet SSA re-quirements. Usually, extra money does not go towards extra alcohol, since clients are often limiting the amount of alcohol they drink under the Harm Reduction model. Project 25 staff also encourages clients to save up enough money for a de-posit in case they have to move for whatever reason.cxxxviii

Life Skills Coaching

For the first three years, Project 25 had a life skills coach who would support clients with the “non-clinical” aspects of maintaining housing although one could argue that these “non-clinical” services were the most important. These included hygiene upkeep, laundry, stocking the fridge and pantry with food, keeping apart-ments clean and up to standards to maintain vouchers, getting to doctor’s appoint-ments, and going grocery shopping, among other things. Anyone interested in replicating Project 25 should certainly consider having a life skills coach, if only to help lighten the load on other Project 25 staff members, but having a separate po-sition is not entirely necessary if the other staff are willing to pick up the slack. Any and every staff member of Project 25 or a similar program “has to be willing to pitch in and help...out - everyone does everything here.”cxxxix The person helping clients out with laundry or grocery shopping does not have to be a life skills coach or a case manager; he or she just has to be a staff member with whom the client has a relationship built on trust and respect.

Providing Love

There is one more job a case manager has that Project 25 staff did not plan for: friend. Jose Zaragoza, Marc Stevenson, and Kris Kuntz agreed that the biggest thing that Project 25 needed to adjust for was “the loneliness factor.” Once in housing, clients lost all forms of social interaction that they were accustomed to. There were “no more passersby, [no] other homeless people, [no] people giving them” food or money.cxl In order to deal with the newfound loneliness, clients did Dip lomat Pro jec t 25

35

not “think to join a softball team or a church group;”cxli they instead invite those they knew on the streets into their new home. This may seem generous or hos-pitable, but it almost always causes serious problems for the new homeowners. Those who “visit” take advantage of their host, either trashing the place and caus-ing the landlord to ask the client to leave, or squat and set up their own homeless camp in the apartment and refuse to leave. Either situation endangers the client’s housing, and the latter even endangers the client’s safety if the client does not re-gain control over the situation. Project 25 has had to move clients after both types of incidents. Other clients deal with the loneliness by drinking.cxlii

Once they realized the problem, Project 25 staff stepped in to help their clients - if they needed friends, staff may try to fit that role, although they do so very care-fully. This is what Zaragoza was referring to when he said that “the biggest life-saver was the 24-hour access phone line.”cxliii Clients call and talk to staff members for hours, and staff let them. For those who are really struggling, staff increase vis-its. Loneliness, among Project 25 staff, is considered a real crisis, only superseded by life-threatening emergencies.cxliv The offering of human connection was both the reason staff were able to connect with clients initially, and, unlike housing, it was not something that could be given once. Without family or friends, Project 25 staff were the only social connection clients had in their new homes.cxlv By responding to concerns - no matter how small - “as close to in the moment as we can,” Project 25 staff prove that they value the client as a person and their relationship with the client.cxlvi So far, the loneliness factor has meant that no one ever really “graduates” Project 25. Clients’ only social ties are to staff, and so they continue to need the staff, even as their other issues become more manageable.cxlvii Project 25 has strug-gled to effectively support clients with receiving the social aspect they crave - the staff are extremely dedicated, but clients do not have a social life independent of Project 25.

Housing

Using the Housing First Model

With the Housing First model, permanent housing is the foundation upon which a set of services is built. The United States Interagency Council on Homelessness de-scribes Housing First as such:cxlviii

“Housing First is an approach and framework for ending homelessness that is centered on the belief that everyone can achieve stability in permanent


36

housing directly from homelessness and that stable housing is the founda-tion for pursuing other health and social services goals..Implementing Hous-ing First at project level, including in permanent supportive housing models, means having screening practices that promote the acceptance of applicants regardless of their sobriety or use of substances, completion of treatment, and participation in services. At the community-level, Housing First means that the homeless crisis response system is oriented to help people obtain permanent housing as quickly and with few intermediate steps as possible.”

Simply put, Housing First means that clients get housing before anything else - be-fore they get a job, get sober, or get “cleaned up” in any way. “Housing First re-moves the requirements for sobriety, treatment attendance, and other barriers to housing entrance.”cxlix There are “no strings attached” to the housing, because pro-ponents of Housing First believe that “permanent shelter is the necessary first step to help a person deal with issues like addiction and mental illness.”cl Housing, in this model, is not a prize to be won by demonstrating good behavior or playing by the rules; housing is the foundation upon which all further success or progress must be built. Without housing, Moreno and others argue, no one can truly im-prove their quality of life or “move forward” in any significant way. “The factors that led to homelessness can be most successfully addressed from a permanent home, rather than requiring a homeless person to achieve sobriety or mental health standards before they qualify for permanent housing assistance.”cli Life with-out a place to call home, they believe, is too unstable; until clients have their own permanent place to call home, they cannot properly concentrate on anything else. As such, once a client is engaged, “the first thing Project 25 does it get a partici-pant stable housing;” housing is the axis around which all other services revolve.clii

“To establish positive long-term outcomes, successful Housing First models must be accompanied by appropriate and comprehensive supportive services.”cliii Such a model is called Permanent Supportive Housing or Housing First/Housing Plus. Per-manent Supportive Housing is made up of “two key components: a voucher for rent assistance [and other forms of housing assistance], and a package of supportive services like mental health and substance abuse counseling, medical services and help living independently.”cliv It is believed to be “the quintessential solution to chronic homelessness.”clv As with everything Project 25 does, it is extremely labor intensive because of the comprehensive nature of Permanent Supportive Housing.

For the most part, “Housing First approaches have primarily targeted homeless people with serious mental illnesses and co-occurring substance use disorders,” who could not succeed in traditional programs due to an inability to obey program Dip lomat Pro jec t 25

37

rules or to get clean and sober.clvi Mary Larimer et. al. noted that “HF is more ac-ceptable to the target population than treatment” because it does not require so-briety or participation in treatment.clvii Many chronically homeless individuals, espe-cially those struggling with addiction issues, reject traditional programs because they are made to feel like they need to change who they are in order to “earn” ser-vices or housing. Housing First does not require anything from its participants; it simply recognizes that they need housing, and it gives it to them without requiring them to “earn” it.

Housing First has been proven to improve the quality of life of those chosen to par-ticipate in it. “In cities across the United States, permanent supportive housing has been shown to be an effective and efficient way to take the chronically homeless off the street.”clviii The 1811 Eastlake project in Seattle demonstrated that simply putting chronic inebriates (chronically homeless individuals struggling with alco-holism) in housing led to “improvements in the life circumstances and drinking be-havior of this chronically homeless population while reducing their use of expen-sive health and criminal justice services.”clix 1811 Eastlake did not require its par-ticipants to get sober or to attend any sort of treatment program; it simply put its participants in housing and connected them to the social services they needed to avoid excessive use of the EMS and jail systems. A similar program in Chicago found “that a housing and case management program for chronically ill homeless adults reduced hospitalizations and emergency department visits.”clxThis simple model had powerful results: participants reduced their alcohol consumption while also reducing their use of the health care and criminal justice systems.

Bridge Housing

Project 25 case manager Jose Zaragoza urges anyone interested in replicating Project 25 to “make sure to expedite the housing voucher process...if there is any way to expedite the housing process, that would be really good for the clients.”clxi Clients need to have ID and SSN cards before they begin the housing process; if there is any way either the program or the county could quicken the process by which a client gets into permanent housing, they should do so for the sake of the clients. Because of the time that it may take to obtain documents, find an available unit, and have an inspection performed by the San Diego Housing Commission there needed to be a place for someone to stay in the mean time.

St. Vincent de Paul Village Executive Director, Ruth Bruland, summarized the use of bridge housing as follows:clxii


38

“Each patient will have the option to use [an emergency shelter] bed at St. Vincent de Paul Village as a place to stay while the person awaits placement into their permanent apartment. Temporary housing might last between 30-60 days. Temporary housing can also be provided if the person has to move from one apartment to another because of behavior issues and there is a gap in housing.”

This temporary housing ensures that clients will not have to live on the streets while waiting for their permanent housing arrangements to be finalized. St. Vin-cent de Paul Village used its Paul Mirabile Center, which provides emergency shel-ter and transitional housing for about 350 people, for the bridge housing for Project 25 clients.clxiii

Finding the “Right Housing”

The San Diego Housing Commission gave Project 25 a list of available housing units, but these were generally too expensive or frequent users did not qualify to live there. Therefore, Project 25 reached out to the community to find housing for its clients, looking for housing the way anyone else would.clxiv This led to Project 25 having a “scattered site model,” with clients spread throughout San Diego City,clxv both in housing provided by St. Vincent’s and non-St. Vincent’s housing. The Hous-ing Commission did not provide deposit money. In the beginning of Project 25, an outside source provided the deposit money Project 25 would put on a housing unit for a client, but over time staff were able to get clients on disability “so they have an income to save up themselves.”clxvi

But finding the “right” housing for individuals is a process, not a single event. Project 25 staff stress that “moving should not be seen as a failure.” There are many possible reasons a client might move: he or she might have behavioral issues that cause conflict with landlords or other tenants; he or she might turn violent be-cause of behavioral issues or because of the influence of drugs and alcohol; he or she might let “guests” into the apartment who are disruptive or dangerous; in one case, a client started distributing drugs from the apartment.clxvii clxviii Sometimes, Project 25 staff can work with landlords to come to an agreement that will allow the client to stay in the apartment, but sometimes that is not an option. But Project 25 will never give up on a client - no matter how many housing units a client goes through, Project 25 staff will help him or her find another. As of March 2014, 21 of the 36 clients of Project 25 have had to move at least once, but all but 2 have been successful in their second housing unit.clxix


39

Part of obtaining and maintaining housing for a chronically homeless individual is understanding his or her perspective on “guests.” In the culture of poverty, people are viewed as resources. If someone gains housing, it is expected that he or she “share” the housing with other homeless individuals, “who [see the client’s] new home as a place for them to crash, too.”clxx Thus the client opens his or her home to “share” and the “guests” set up camp in the housing and never leave, treating the housing unit as if it is their own. This jeopardizes a client’s housing situation, and sometimes his or her safety as well. One Project 25 client had to be moved after “guests” who would not leave threatened him. Another ended up in jail after fight-ing a woman who would not leave his apartment.clxxi This concern over guests, how-ever, does not apply to significant others or family members. Several Project 25 clients have a loved one living with them.clxxii clxxiii

Landlord Relationships

Project 25 staff stress that “landlord relationships are essential.”clxxiv One of the most important parts of Project 25 is establishing a relationship and a trust with the landlords as well as with the clients, for without housing Project 25 would fall apart. “Maintaining a good relationship with landlords who rent to Project 25 ten-ants is key to the program’s success.”clxxv When approaching a landlord, Project 25 staff are very upfront about who the new tenants are and what they are struggling with.clxxvi They explain the Harm Reduction model and educate the landlord about the needs and likely behavior of their clients.clxxvii Before the client moves in, staff also give the landlord money for the credit check, educates the landlord about the client’s credit history,clxxviii and make the down payment on the apartment.clxxix

Staff are always present to facilitate interaction between clients and landlords if need be. Project 25 made sure that staff “were always...available to assist with any issues [the landlords may] have.”clxxx They provide the landlords with their contact information, so that they can call at any time with any concerns or issues they may have. The 24-hour emergency line that Project 25 maintains for clients is also open to landlords.clxxxi If the landlord calls with any concern, Project 25 staff “make a high presence” and immediately come to the housing unit to deal with the issue. It is essential that landlords see that Project 25 staff are their partners in taking care of the client and in dealing with the issues that often come with housing frequent users.clxxxii Thanks to this level of commitment, landlords saw Project 25 staff as “very attentive to [their] needs” and “extremely helpful.”clxxxiii Although relation-ships with clients had “its ups and downs,” landlords noted that Project 25 staff were always “very supportive.”clxxxiv They also noted that Project 25 staff went


40

“above and beyond” to help landlords weather the crises that often came with Project 25 clients.clxxxv Just like they devoted themselves to taking care of their clients, Project 25 staff dedicated themselves to helping the landlords who offered clients a place to live. Often, this commitment means that landlords are willing to take on more Project 25 clients, even if the first experience was not a good one, be-cause the Project 25 staff is so attentive and cooperative.clxxxvi

In addition, St. Vincent de Paul Village maintenance staff will come to the housing unit to clean, to repair anything broken or damaged by clients or to make home im-provements that the clients do not trust the landlord to make.clxxxvii

No Project 25 client has ever been evicted. “When we know it’s not working [be-tween a client and a landlord],” Project 25 director Marc Stevenson says, “we ask for a 30-day notice so that we avoid an eviction process.” Landlords credited Project 25‘s “leadership” as being the reason they did not have to resort to evic-tion. Project 25 moves the client out themselves and keeps their belongings in their own storage unit so that the landlord “doesn’t have to deal with it.”clxxxviii Although landlords have asked people to leave, it has never been a legal eviction, thanks to Project 25 staff’s attention and commitment to both their clients and the landlords.

From a House to a Home

One small but important piece of securing housing is making it feel like someone’s home, rather than another homeless camp, albeit with a roof and shower. Steven-son explains that “if you take somebody off the street and you put them in a house and they came in with nothing and they still have nothing in the home, they don’t feel much different than when they were on the street.”clxxxix A house needs both ba-sic furniture - “a bed, kitchen table, chairs, that kind of thing”cxc - and personal knick-knacks - photos, magazines, vases, decorations, artwork - in order to become a home. Making a house a home makes the client feel empowered, like the space is his or her own, gets them to value the housing, and makes it easier for them to protect it from “guests” who may turn into squatters.

Harm Reductioncxci

Project 25 uses a Harm-Reduction Model when it comes to dealing with the addic-tions many of its clients face. Harm Reduction (HR) is defined as a range of public health policies and interventions designed to reduce harmful consequences of hu-man behavior - even if this behavior is illegal. Under Harm Reduction, staff do not try to force an addict to stop his or her behaviors entirely, but they manage them Dip lomat Pro jec t 25

41

so that minimal harm is done. Harm Reduction is a fairly common practice; some examples are listed below:

• Needle exchange programs

• Condoms/safe sex, STD/HIV prevention

• Seatbelts

• Designated driver

• Methadone clinics

• Managed Alcohol Programs

Most of the Harm Reduction techniques were aimed at alcohol use. Marc Steven-

son noted, “we know they are going to drink anyway, so we have to help make sure

it’s as minimal damage as possible.”cxcii Project 25 certainly encourages abstinence at every opportunity, but it does not force a client to stop drug or alcohol use. In-

stead, they manage use and prioritize “immediate (and achievable) goals.” In Project 25, staff might practice Harm Reduction by developing a plan with the client which could include the Project 25 staff delivering a “lighter” form of alcohol (such as beer) so that the client does not use “heavy” alcohol (such as vodka) in-

stead.cxciii Alternatively, staff doles out only a certain amount of money every day to a client, so that they can only buy a certain amount of alcohol per day. Other op-

tions include encouraging clients to drink later in the day, drink only at home, pre-

scribing vitamins that are necessary for alcohol-worn-down bodies, planning moni-

tored drinking, or reminding clients to call the 24-hour emergency phone line if they need help reducing the amount of alcohol they consume or eliminating it alto-

gether. In addition, staff encourage clients to eat before drinking, so they do not drink on an empty stomach, and they teach clients to “drink quietly” so they do not become noisy or violent and disturb landlords or neighbors (which may lead to be-

ing asked to leave).cxciv Project 25 empowers its clients to choose their own alcohol-related goals: safer drinking, reduced drinking, or quitting. The focus is on “realis-

tic goals that they can accomplish” and that they want to accomplish. Project 25 does not want to force their clients to do anything; requirements for sobriety would The goal of Harm Reduction is an improved quality of life for the client, and it en-

courages better health and responsibility. By choosing to use Harm Reduction rather than to demand abstinence, Project 25 is able to work with chronic alco-Dip lomat Pro jec t 25

42

holics and drug users, all of whom would reject any service that required absti-nence before they received aid. According to Project 25 staff, “harm reduction val-ues pragmatism and humanism” above the idealism from which abstinence-only programs are based. They “are going to drink with or without us,” and it is consid-ered more practical to manage the drinking rather than eliminate it. Abstinence is the “main goal” of Project 25, but staff would never force anyone to become sober who did not want to. For those who are willing, however, there are several small steps towards sobriety.cxcv A few of the Project 25 clients have decided to stop drinking on their own.

The reality of frequent users is that many of them will try to quit drinking, but they will often relapse and “go right back to where they started.” Then Project 25 will come help them again, and they will get better, but then they will relapse again, and the cycle will start over. Project 25, however, is prepared to deal with the cy-cle of abstinence and relapse as often as they need to. There is no limit to the num-ber of times Project 25 will help a client through the cycle of relapse and absti-nence. In fact, they learn to expect the ups and downs of the cycle. “Stevenson pre-pares his team for client relapses, [urging them to] ‘work with what’s real...let’s not come in with judgment.’”cxcvi Stevenson and the Project 25 team are dedicated to working with their clients “no matter where they are in the cycle,” using differ-ent tactics and methods to deal with the different stages of the cycle.cxcvii The em-phasis is on meeting the client where they are - a tenet of Project 25’s work. No matter how low a client seems to have sunk, Project 25 is there to help them through it.

Harm Reduction, however, is not a good fit for everyone. A few people in Project 25 have such severe health issues that any amount of alcohol is bad for them. There is no safe way for them to drink. Many suffer from reverse tolerance, which means that they are able to get drunk on a lot less alcohol than they used to. This means that they cannot work with a drinking limit plan. In cases like this, Project 25 staff focuses instead on what Stevenson calls “other HR treatments,” which fo-cus on other aspects of physical health, mental health, and addressing trauma.cxcviii They continue to encourage abstinence (though they never force it), but, unlike for those on HR treatment, staff does not supply or control the alcohol they consume. They focus instead on trying to get clients to agree to periods of abstinence and en-courage small eliminations of alcohol, rather than managing their consumption.cxcix

Trauma Informed Care


43

Trauma Informed Care is a organizational structure and treatment framework de-signed to allow both service providers and clients/patients to fully comprehend and respond to the effects of all types of trauma in a safe, empowering environment. The principles of Harm Reduction also play a role in the trauma-informed psy-chotherapy and general care Project 25 clients receive. As is typical for Project 25, there is no judgment, no “punitive sanctions” for using substances or getting into trouble with the law. Harm Reduction and trauma-informed care encourage open and honest talk about the serious issues clients deal with, including substance abuse, health and mental health, and trauma. The majority of Project 25 clients have experienced trauma in their lives. Many have been physically attacked on the streets, many have experienced traumatic head injuries, many have been molested. All of the six women have experienced domestic violence or rape. Trauma-informed care focuses on retaining the dignity of its patients and making sure they feel safe as they work through their issues. It “focuses on improving functioning over ‘fix-ing’ something ‘broken,’” with the goal of encouraging its patients to cope using healthier methods.cc

Health Services

The Medical Homecci

Dr. David Folsom, the medical director at St. Vincent de Paul Village Family Health Center (VFHC), personally provides the medical and mental health care for half of the clients of Project 25 who are case managed by St. Vincent’s (in addition to sev-eral Telecare clients); other St. Vincent’s doctors care for the other half of the St. Vincent’s clients. Dr. Folsom, however, is in charge of making sure that “nothing falls through the cracks” - if a client/patient is about to run out of medication or needs to connect with a specialist, or if another doctor is unavailable, Dr. Folsom is the one who is called in to take care of it. Project 25’s philosophy is that no client/patient should ever be made to wait when it comes to their health - to do so might mean that he or she ends up back in the emergency room.

The focus, as is true for the VFHC in general, is on “preventative care.” By ad-dressing the patient’s issues as quickly and fully as possible, Dr. Folsom and his team attempt to ensure that a patient does not go to the emergency room for is-sues that, if treated properly, can be solved by a primary care team. “We don’t completely prevent hospital and emergency use,” Dr. Folsom says, “but we greatly reduce it.”ccii Dr. Folsom’s mission is essential to the core promises of Project 25: providing frequent users with housing and supportive services, especially medical Dip lomat Pro jec t 25

44

care, will both improve their quality of life and reduce emergency services systems use and cost.

When he meets a client/patient for the first time, Dr. Folsom says that he does not create a treatment plan or treatment goals based on that first meeting. He first identifies the patient’s “pressing needs, [the ones] that we can help them with right away.” Dr. Folsom suggests that anyone interested in replicating Project 25 “focus on a couple concrete things you can do to help [the patient], and the grand [treatment] plan [will come] together slowly over time as you get to know” the pa-tient. Treatment plans are very individualized, and therefore a personal knowledge of each patient is necessary to create a treatment plan that will properly address his or her needs and goals.

The length of time between visits varies between patients. If a patient is doing well, Dr. Folsom or another St. Vincent’s doctor will only see them once every 6-8 weeks. If a patient is struggling, they come to the VFHC once a week. The average patient sees his or her doctor once every 2-3 weeks. Often, Dr. Folsom says, the patient has “so many problems that you need multiple visits to deal with all the problems.” Project 25 clients have a whole host of physical and mental health is-sues, which are often complexly intertwined with substance abuse issues. “We’ve got this complex group of people,” Dr. Folsom says, “and just like our bone marrow transplant patients, they need complex solutions, they need complex teams.” In or-der to address everything a patient needs addressed, constant monitoring, team-work between the doctors and other Project 25 staff, and multiple visits to the clinic are necessary.

Dr. Folsom believes that “there is really no typical appointment.” Project 25 pa-tients have more frequent visits and longer visits than typical patients, even those who are chronically homeless. However, one constant throughout all patients is ad-dressing the struggles of substance use/abuse and treatment/medication adher-ence.

Project 25 patients are treated under a system known as “Concierge Medicine.” “Concierge Medicine” allows a patient to access a 30-60 minute appointment (rather than a 10-minute one) with a doctor, who has the luxury to more properly concentrate on his or her patients, since a doctor working Concierge Medicine has far fewer patients than regular doctors. This sort of “24/7 personal attention” usu-ally comes at a steep price, but for Project 25 patients, it is simply part of the treat-ment plan. If they need medical attention today, they will get it today. Any issues they have are dealt with immediately, which is part of Project 25’s commitment to


45

intensive case management and constant monitoring of its clients. “Project 25 par-ticipants need a lot of medical and psychiatric care;”cciii Dr. Folsom estimates that 10% of his working hours are spent dealing with the 20 Project 25 patients whose health St. Vincent’s manages.

Getting patients to the VFHC, however, is often a struggle in and of itself. Clients are often unwilling or unable to remember their appointments or get themselves to the clinic at the appointed time. Thanks to their experiences with the health care system, many frequent users have a strong distrust of medical professionals. No-shows are common, particularly in the beginning of the Project 25 lifespan. To counter this, case managers will call a client the night before to remind them of ap-pointments, pick up a client and drive them to the appointment, sit with them in the waiting room and in the appointment, and drive them home. Having case man-agers escort patients has proved to be highly effective. Another option is to have a “tele-visit.” In a tele-visit, a Project 25 staff member would bring an iPad over to the client’s house and sit with them while the client and his or her doctor engage over FaceTime. Again, the presence of a staff member allows the client to feel se-cure and cared for, and engaging with his or her doctor in the comfort of his or her home allows the client to feel comfortable and build a rapport with the doctor in a “safe zone.” In the beginning of the Project 25 lifespan, Dr. Folsom performed street visits, and he also performs actual home visits a couple of times a year. In addition, in the early days of Project 25, “there were incentives for people to make their medical visits and complete other important tasks,” such as money for to-bacco or extra food cards. Now, however, the incentives are no longer necessary, and the real incentive for clients to make appointments lies in the loyalty to their relationships with Project 25 staff members and their doctors.

Over time, and with the help of case managers or other staff members, clients start to build a rapport and a relationship with the doctor, so the point where they feel comfortable coming into the clinic for their appointments. As with everything Project 25 does, relationship is key. The relationships between staff and clients al-low staff to convince clients to take a leap of faith, as it were, and trust the doc-tors; the relationships that develop between the doctors and the patients allow the patients to trust the doctor enough to come into the clinic and take their medical advice.

The University of California San Diego (UCSD) Dual Residency program also allows patients to build a rapport with one doctor, rather than multiple doctors. Many of the UCSD residents work closely with Project 25 patients. In addition, Project 25 utilizes a Medical Home or Health Home Model, in which “all of a person’s health-Dip lomat Pro jec t 25

46

care is coordinated through a health home, with a primary care doctor involved in coordinating this care and ensuring that someone has a picture of the whole pa-tient.” The idea behind a Health Home model is that one primary doctor oversees all aspects of a patient’s healthcare, rather than fragmenting different parts of a patient’s care among different doctors and taking the risk that some things fall through the cracks. By having one center of care, so to speak, the Health Home Model ensures that medical caretakers have all of the patient’s information in one place, which allows for more efficient methods of care.cciv Alternatively, a California Bill describes the Health Home Model as a cost-efficient and humane model that includes “comprehensive case management, hospital discharge planning, and con-nection to social services” for frequent users and other Medi-Cal users with chronic conditions.ccv Under this description, a Health Home Model is an entire pro-gram, similar to Project 25.

Twice a month, the entire Project 25 team sits down with Dr. Folsom to monitor and discuss every client/patient whose medical needs are met by St. Vincent’s. The team discusses what each client is being treated for, how treatment is going (in-cluding if the client is keeping his or her appointments), and if changes in treat-ment are necessary. They determine if a client needs to see a specialist (such as a cardiologist) outside of the VFHC, and, if so, if a case manager needs to accom-pany them to make sure the client keeps the appointment. They also discuss medi-cation management.ccvi In between meetings, Dr. Folsom keeps in close contact with Project 25 staff, calling or texting them several times a day every day.

Medication Management

Thanks to a complex combination of mental and physical health issues, Project 25 clients are often on a multiple-medication regiment. The most common medications prescribed to Project 25 clients are blood pressure medications, anti-depressants, and medication for pain and for anxiety. These medicines are prescribed by Dr. David Folsom, the medical director at St. Vincent de Paul Village, and are “tied to the plan and treatment goals” set for every client/patient by the Project 25 team.ccvii

Since Dr. Folsom also runs the VFHC,ccviii St. Vincent de Paul Village provided Project 25 with a nurse, Michelle Whitney, whose primary role is medication man-agement for the clients, which means that she fills the medication containers each week.ccix Each client who volunteers for medication management has seven medica-tion containers, one for each day of the week, so as to prevent medication overdose or abuse.


47

Medication can be picked up by the client at the Project 25 office, but more often staff deliver medication to the client’s home, as Project 25 has discovered that de-livering medications increases the chance that clients will actually take their medi-cation. Medication distribution and delivery is the first order of business every day. Along with medication, staff deliver cigarettes (of which they have a freezer-full at the office), the daily allowance of money, and vitamins.ccx

The nurse is in contact with Project 25 staff almost every day, to ensure that medi-cations were delivered or to provide general nursing services for the Project 25 clients, which she does for about twelve hours a week. Ms. Whitney also reviews patient charts at minimum once a week, “reading progress, finding out about medi-cation changes” from Dr. Folsom (with whom she communicates frequently), and more. She considers herself “the bridge between the doctor and clients, [the one in the middle of] the giving and receiving of medical information.”ccxi

If it is unsafe to deliver the medications, the staff will not deliver. An “unsafe” situ-ation would be one in which the client is too intoxicated to accept the medication and one in which medication could pose a danger to a client’s health. In case of an “unsafe” situation, the staff member will return the medication to either the doctor or the nurse. Whenever the client wants to get their medication (usually the next day), they have to come to the doctor and speak to him before receiving medication directly from him. As is with all of Project 25, there is no judgment towards or de-mands made on the client. The doctor simply explains why the staff member could not deliver the medication - for example, saying “it is unsafe for you to mix alcohol and medicine.” After the doctor has cleared the client, medication delivery contin-ues as before.ccxii

Because Project 25 clients are high-risk patients, there is always a concern that they could be abusing their medication. To prevent medication abuse as much as possible, Dr. Folsom and the Project 25 staff constantly monitor clients and their use of medication. At the twice-a-month meeting,ccxiii the team examines and dis-cusses each patient. The following questions are addressed: Why are we giving the client these medications? Are the medicines working? How is delivery working out? Are the clients taking the medications the way they were intended to be taken (i.e. not abusing the medication)? Like everything else in Project 25, medication is constantly monitored. If the medicine is not longer necessary or causing more harm than help, Dr. Folsom stops prescribing it.ccxiv

Some people may have mixed views regarding the way medications and medication deliveries are incorporated into Project 25. To this, Dr. Folsom explains that “we


48

are dealing with people in Project 25 who are at the really extreme end of sub-stance abuse - they’ve failed multiple treatment programs before. We’re taking a really pragmatic approach.” It is true that these medications “would not normally be prescribed to these patients.”ccxv Dr. Folsom, like the rest of the Project 25 team, believes in the power of the Harm Reduction model. He remarks that Project 25 clients “have [already] failed out of other programs which are hard-nosed,” and cites both the need for general flexibility and the importance of viewing each client as an individual with his or her own strengths and needs.ccxvi Harm Reduction is about providing the greatest amount of aid and preventing as much harm as possi-ble. Giving the clients medication helps them cope with their physical and mental ailments, and if the Project 25 team suspects abuse, they will first try to stop it, and if they cannot, they will remove the medicine from the client. Overall, medica-tion management is just as labor-intensive and requires as much painstaking care as any other aspect of Project 25.

Data Collection

Data is crucial to the survival of any frequent user initiative; “improved data collo-cation will increase the ability to measure outcomes.”ccxvii Prior data collection on frequent user initiatives have not been consistent.ccxviii But Project 25 means to rec-tify that. In fact, California State Assembly Representative Brian Maienschein writes that Project 25 “gathered the most robust set of data ever collected on homelessness in San Diego County.”ccxix

St. Vincent de Paul Village is responsible for the data collection on Project 25 for all 36 patients.ccxx Kris Kuntz has been working with Project 25 since it began in Spring 2011 as was responsible for collecting all of the data for Project 25. He be-lieves that “a full-time data collector is necessary to show that the outcomes are on-going [in other words, that the program gets better over time], which allows the project to continue to survive.”ccxxi He works with Project 25‘s 32 data partners (in-cluding 22 hospitals) in order to gather the statistics needed to track Project 25’s progress. The 32 partners send data on a quarterly basis and compare it to the baseline established in 2010, the year before Project 25 began to intervene in the lives of their frequent-user clients.ccxxii A final report on the cost-effectiveness of Project 25’s will be completed by the Fermanian Business and Economic Institute at Point Loma Nazarene University.

It is often hard to access data because of confidentiality issues. Permission of the

client is required in order to access and use this information. Project 25 created a Dip lomat Pro jec t 25

49

single consent form that all clients and all data partners used.ccxxiii In the words of

Kelly Bennett, “Project 25 has built uncommonly open relationships with those agencies to track the data.”ccxxiv This incredible collaboration and painstaking thor-oughness led to the highly accurate and exhaustive data results presented later in this report.


50

The Results: Did Project 25 Work?

Project 25’s success has been extraordinary. In 2010, the year prior to the imple-mentation of Project 25, the original 35 clients of Project 25 cost the San Diego community $4,229,429, mostly through hospital stays and ER visits. Two years into the program, the same 35 people now only cost the community $1,574,838 - a cost saving of $2,654,591.ccxxv ccxxvi

In 2010, the 35 original clients of Project 25, as a collective group, visited emer-gency rooms throughout San Diego County 1,418 times. They rode in the ambu-lance 736 times, spent 1,568 days in the hospital, 890 days in jail, were admitted to the hospital 345 times, and were arrested 90 times.

Over the first twelve months of Project 25, these measures showed drastic im-provements both in cost savings and in quality of life. Project 25 clients now visited the emergency room only 487 times. They rode in the ambulance 279 times, spent 659 days in the hospital, 697 days in jail, were admitted to the hospital 153 times, and were arrested 35 times. That translates to a 65% decrease in emergency room visits, a 62% decrease in ambulance rides, a 60% decrease in hospital days, a 22% decrease in jail days, a 56% decrease in hospital admittances, and a 61% decrease in arrests. The only “increase” Project 25 saw was in days in permanent housing.

In the second year of the program, Project 25 clients spent only 568 days in the hospital, visited the emergency room 506 times (a slight increase from the previ-ous year), spent 280 days in jail, rode in the ambulance 241 times, were hospital-ized 105 times, and were arrested only 17 times. Comparing these numbers to the baseline data recorded in 2010, there was a 64% decrease in emergency room vis-its, a 67% decrease in ambulance rides, a 64% decrease in hospital days, a 69% de-crease in jail days, a 70% decrease in hospital admittances, and a 81% decrease in arrests.

Overall, “St. Vincent’s data shows that this approach [of Housing First/Housing Plus] was even more successful than we had hoped.”ccxxvii Project 25 is a financial and humanitarian success. In the words of Brian Maienschein, “the project is sav-ing taxpayers millions of dollars each year while serving our most vulnerable homeless population...thanks to Project 25, they are all housed and receiving treat-ment.”ccxxviii Not only have costs and over-utilization of the emergency medical, law enforcement, and social services system dropped dramatically, Project 25 clients are permanently housed and are receiving the social services they need to stay Dip lomat Pro jec t 25

51

healthy and stable. In short, Project 25 has succeeded beyond anyone’s expecta-tions.

Personal Stories

San Diego’s #1 frequent user was a woman who was actually not in the original 35 clients. She was added to Project 25 after EMS services “begged” staff to take her in.ccxxix In the year prior to her entrance in Project 25, she spent over 200 days in jail, visited the ER 150 times, rode in the ambulance only a few times less than that, and was arrested about 25 times. After one year in Project 25, however, her life had drastically improved. In her first year with Project 25, she was in jail only a little over 50 days, visited the ER about 60 times, rode in the ambulance a little over 50 times, and was arrested less than 10 times. Project 25 helped her obtain her own apartment and SSI benefits. She now attends her medical appointments and has reconnected with her family.ccxxx She also goes to church, Alcoholics Anony-mous, and Narcotics Anonymous.ccxxxi

Douglas “Hutch” Hutchinson (pictured on title page) was one client many consider one of Project 25’s greatest success stories. Before Project 25, Hutch was a “hard-core alcoholic” who had “probably abused every drug known to man.” His drinking had left him, like many other Project 25 clients, permanently impaired.ccxxxii The only place he called home was the corner of 10th Avenue and B Street. There seemed to be no hope for him; the only hope in his life was that he would “drink himself to death.”ccxxxiii But Project 25 had different hopes for him. The Project 25 staff, includ-ing Dr. Folsom, met him on the streets and started providing health services. Over time, they earned Hutch’s trust, and eventually they got him to agree to try hous-ing. But his first housing experience was disastrous. “He actually kind of freaked out, the four walls were getting into him and he ended up exiting that housing. But we stuck with him on the streets. We got him to go along with getting back into housing.”ccxxxiv Using the relationships they had already built with him, Project 25 staff got Hutch into permanent housing, and then they turned their focus to help-ing him maintain his housing and his health. Using the Harm Reduction model, Stevenson convinced Hutch to quit vodka and turn to beer instead, and, once that was accomplished, to limit the amount of alcohol he had a day. Hutch eventually decided on his own to quit drinking “so I can see what’s going on in the world.”ccxxxv He was eleven months sober when he passed away of natural causes in his own apartment in July 2014.ccxxxvi

The media and St. Vincent de Paul have both published many other success sto-ries.ccxxxvii Dip lomat Pro jec t 25

52

As was promised at the beginning of the program, no one has left or been rejected by Project 25. Everyone who was taken on by Project 25 is still cared for by Project 25 staff. Five participants have died. Three of the five passed away from natural causes, one died of a heart attack that might have been caused by a heroin over-dose, and one died from a traumatic head injury. Four of the five were replaced by other frequent users (the fifth, Douglas Hutchinson, passed away after funding for Project 25 ceased).ccxxxviii

All but one of the current clients of Project 25 are in permanent housing, the one exception being in a substance abuse treatment facility. All have health insurance; most have obtained permanent disability benefits.ccxxxix Some are even conquering the “loneliness factor” and starting to build relationships and small communities outside of Project 25. Best of all, “there are a lot of [clients] who are [now] inde-pendent - [we] only see them once every two weeks or [so]. They are largely self-sufficient. Of course they still use some services, but for the most part these people are largely independent.”ccxl As a group, Project 25 clients are “using less emer-gency services and requiring less intensive case management” than they did at the beginning of the program.ccxli In 2010, they were the “worst of the worst;” service providers had given up on ever helping them. Now, in 2014, many of them are what no one ever expected they could be: stable.

Were the (Stated) Goals of Project 25 Met?

This report summarized the goals of Project 25 as follows:

By providing permanent housing and a wrap-around system of supportive services - including preventative medical and mental health care and assistance with in-come obtainment - characterized by an extraordinary commitment to case manage-ment and client outreach, Project 25 hoped to decrease the use of EMS systems by frequent users. This decrease would be both a benefit to the community - saving San Diego County time, money, and resources - and a benefit to the frequent user-clients, with the assumption that less use of emergency services directly corre-sponds with an improved quality of life.ccxlii

Project 25 met every single one of its goals:

• Permanent Housing: all but one of Project 25’s clients are in permanent housing; the one exception is in a substance abuse treatment facility.ccxliii


53

• Wrap-around System of Supportive Services: all of Project 25’s vast supportive services, both housing-related and non-housing related, are detailed throughout this report.

• Medical and Mental Health Care: the majority of Project 25’s clients are being treated at the St. Vincent de Paul Village Family Health Center by either Dr. Fol-som or one of his team. Under the “one white coat” policy, clients see the same doctor for physical and mental health issues.ccxliv

• Assistance with Income Obtainment: the majority of Project 25’s clients, aided by staff, have succeeded in obtaining SSI, SSDI, through the HOPE SD processccxlv There are a few clients who have been denied SSI, but Project 25 staff are cur-rently appealing those decisions.ccxlvi

• Extraordinary Commitment to Case Management: everything Project 25 does is defined by labor-intensive, thorough care informed by the St. Vincent’s CREED.ccxlvii

• Decrease of the Use of Emergency Services: in the first year alone, Project 25 cut the use of services by at least half for each service, and use continued to decline in the second and third years, saving the county time, money, and resources.ccxlviii

• Improved Quality of Life: Project 25 has improved the health of its clients and given them both permanent housing and a wrap-around system of supportive ser-vices dedicated to improving their quality of life. Clients are “growing more sta-ble, using less emergency services and requiring less intensive case manage-ment,” and they get better the longer they are in housing.ccxlix But, more than that, Project 25 provided clients with a group of people who refused to give up on them and who showed them that their lives were worth living. One Project 25 client told San Diego City Beat that “life is good...I have no complaints. I’m here, I’m above dirt. Thanks to Project 25.”ccl Hutch was “just happy to have his own private space.”ccli One woman said that “this program brought my life back.”cclii Several clients, Hutch included, “didn’t think [they] would live this long...[they] didn’t want to live.”ccliii Project 25 did not just give people a better life - in many cases, they gave them their life back. It gave hope to the most “hopeless cases” and to the county in general. It proved that even the most frequent users can be helped.

Redefining Success: Not Black or White

Despite Project 25’s astounding success, staff members caution anyone interested in replicating Project 25 to be realistic about their goals for clients. Frequent users Dip lomat Pro jec t 25

54

are not like many other individuals who struggle with homelessness. “These are very severely impacted people. They have a lot of impairment, a lot of damage...many of them won’t experience the wonderfulness of life, even if they were to get completely sober and try to improve, because life has pretty much passed them by, and they’re impacted.”ccliv Their health, mental health, and addic-tion issues mean that many of them will probably never be fully self-sufficient.cclv This does not mean that they cannot be stable - many have achieved stability within the boundaries of Project 25 - but even the most stable of Project 25 clients will require monthly check-ins and continued access to Project 25’s services for the rest of their life.cclvi

However, just because Project 25 clients will not act like average citizens does not mean that Project 25 was a failure. First of all, these clients are no longer con-stantly in and out of the emergency room or the jail. But in terms of their quality of life, “although [their] condition is still fragile...[their] daily [lives are] far better than [they] once imagined.”cclvii It is not that they are not successful; it is that suc-cess for a group of frequent users this impaired needs to be redefined. For exam-ple, not many Project 25 clients are completely clean and sober. But the vast ma-jority are good tenants and good neighbors. With the help of Project 25, they keep their apartment clean and up to standard, they keep noise levels down, and they pay their rent on time. They keep their doctor’s appointments. They take their medicines. And, in many cases, they fight their addictions, sometimes enjoying pe-riods of sobriety.

Through the Harm Reduction model, Project 25 staff help clients get used to using less alcohol, both in terms of quantity and in terms of “strength” (i.e. from vodka to beer). Many even manage to spend some time clean and sober, whether for a day, a week, a month, or longer. When they do relapse, it is often for shorter periods of time, or the drinking does not cause as much harm as it once did. But wherever the client is in the cycle of recovery, abstinence, and relapse, Project 25 stands by them. It does not matter how many times the cycle has been repeated. Staff’s atti-tudes towards clients’ sobriety follows the motto: “hope for the best, but prepare for the worst.” Project 25 Director “Stevenson prepares his team for client re-lapses...‘let’s work with what’s real,” he said he tells his team. ‘Let’s not come in with judgment.’”cclviii

Partially thanks to the ever-present cycle of relapse and recovery, it is important for staff to realize that at least some of the clients will need help or supervision for the rest of their lives. Kuntz divides Project 25 clients into three groups. About a third of clients - the most severely impaired - will need intensive services for the Dip lomat Pro jec t 25

55

rest of their lives. Another third had been largely stabilized by the end of the three-year pilot program. Though they will remain connected to supportive services, they can be “graduated” to a lower intensity of services, allowing Project 25 staff to ex-pand the program to include more clients. The final third might one day be able to “graduate” to less intensive services, but they need more time than the three-year pilot program.

All clients, no matter if they have “graduated” or not, will need to maintain perma-nent housing and stay connected to the wrap-around services, especially case man-agement, that help them maintain their health and housing. Without it, they would likely fall back into old habits. Murray Barr, the poster child of frequent users, thrived when he was placed in a treatment program that was “the equivalent of house arrest,” and only relapsed when he was let go from the program. “When he was monitored by the system he did fabulously...there are some people who can be very successful members of society if someone monitors them.”cclix Frequent users are among those people. Because of their physical, emotional, and mental impair-ments, they will need the support of Project 25 staff and connection to supportive services for as long as needed. But just because they are not fully “independent” does not mean that they are incapable of living their lives. They can be “very suc-cessful members of society;” they just need to have the support to do so.

True success, in Project 25, is defined as “stability.” Those clients who require only minimal services, who can perform most tasks on their own, and who only need to meet twice or once a month can be considered stable, and, although they do not leave Project 25 (and never will), the program can be expanded to take in more fre-quent users who need it. Project 25 never lets any of its clients go, but a “large portion of current clients” are stable enough to graduate “to less intense services,” freeing up staff resources and time to tend to new clients.cclx No one leaves Project 25, but some clients become stable enough that staff members can add new clients to the program.


56

Where is Project 25 Now?

Funding Issues

The success of Project 25 has exceeded all expectations. However, United Way’s funding was only for the three-year pilot program, and the money from United Way ran out in June of 2014. Moreover, despite the incredible success of Project 25, staff have struggled with finding a permanent funding source. No one doubts that Project 25 works, and everyone who Project 25 director Marc Stevenson and his team have approached have expressed interest in keeping the project going. How-ever, no one is willing to step up and be the sole funders to keep Project 25 alive. “Given the numbers, Stevenson didn’t expect that finding more funding would be so difficult.”cclxi Admittedly, he and others “should have started [looking for funding] earlier,” instead of assuming that impressive results would guarantee funding after the contract with United Way was up.cclxii

Stevenson has discussed Project 25 with the City of San Diego, San Diego County, hospitals, Medi-Cal Managed Care Plans, and the Veterans’ Administration. “Each has shown interest but no one has made a commitment [to fund Project 25] yet.”cclxiii

Stevenson suspects that, although everyone recognizes that Project 25 works and wants to see it continue, no one wants to bear the costs of financing the whole project. In Stevenson’s words, “I think right now the biggest problem is not that people aren’t willing to fund this. It’s that a single agency is probably nervous about being the one to fund the whole thing.”cclxiv

Ruth Bruland, St. Vincent de Paul’s executive director, estimates that it will take roughly $550,000 to both sustain the current Project 25 clients and add another twenty or so frequent users to the program.cclxv That is far less than the $4.2 million per year it would cost to do nothing for these frequent users. In 2010, the hospitals were the ones bearing the brunt of the costs,cclxvi so initially the hope was that the hospitals would be the ones to fund Project 25 once the United Way grant was up.cclxvii The hospital were “very, very interested” in the work Project 25 was doing, but they hesitated to fund the project. With the passage of the Affordable Care Act, frequent users were no longer a significant financial drain since most were en-rolling into Medicaid. So although frequent users continued to overburden the hospital system and its resources, hospitals are now able to get some reimburse-ment for those services.


57

Whereas in 2010 the hospitals were the ones bearing the brunt of the frequent-user costs, after the Affordable Care Act that burden shifted to insurance compa-nies providing Medicaid and Medicare.cclxviii So Project 25’s focus has also shifted. “Had we had a crystal ball,” Bruland says, “we would have started talking to the insurance companies much sooner,” since Medicaid and Medicare are now the ones who would be saving money if frequent users were properly cared for.cclxix Fre-quent users are a serious drain on the Medi-Cal system - the same serious drain they used to be on the hospital system. “4% of disabled Medi-Cal beneficiaries drive almost 50% of Medi-Cal costs.”cclxx Currently, “the ultimate goal” of the fund-ing process is for “the Medi-Cal Plan [to provide] most of the sustaining” funds for Project 25.cclxxi

Many of Project 25’s employees had to leave to seek other employment, although the main case managers - Stevenson and Zaragoza - Dr. Folsom and his team, and Kuntz, the data collector, are still working with the Project 25 clients. Stevenson assures those who ask that, despite the fact that the funding has run out, the cur-rent clients of Project 25 are not in any danger of losing their homes or their ac-cess to Project 25’s host of supportive services, including case management. “There’s no way that our agency would try to let these folks fall back onto the streets.”cclxxii Project 25 clients, even the most stable, continue to depend on staff for help communicating with landlords and managing their money, and that has not changed despite the fate of Project 25. Although lack of money will keep Project 25 from expanding, St. Vincent de Paul Village has made a commitment to care for the sixteen clients under its care for as long as they need.cclxxiii Those clients under Tele-care have until 2016, when Telecare’s contract with the county expires. However, the special vouchers Project 25 made for its clients ensure that all clients will con-tinue to keep their permanent housing.cclxxiv

At the time of the report, Project 25 has signed a contract with one of the Medicaid Managed Care Plans to take on one of their most expensive homeless individuals. Project 25 staff hopes that this trend with continue and that the health plan along with other Managed Care Plans that Project 25 staff are in discussion with will start to fund Project 25 and refer them their most expensive frequent users of the Medicaid system who are also chronically homeless.

This report has proven that Project 25 is a financial and humanitarian success. However, the experience of San Diego’s Project 25 has also proven that it will take strategic planning to ensure that Project 25 will survive beyond its original pilot phase. It is recommended that anyone interested in replicating Project 25 plan in advance on how to make Project 25 financially sustainable - not just for the initial Dip lomat Pro jec t 25

58

pilot phase, but for long-term continuation, so that it does not face the same fate as San Diego’s Project 25.


59

Lessons from Project 25

Things to Consider

Project 25 was in a unique position to be effective thanks to its position within St. Vincent de Paul Village. St. Vincent’s provided Project 25 with a whole host of housing and supportive services - some Project 25 clients live in St. Vincent’s sup-portive housing; Dr. Folsom of the Family Health Center and his whole clinic pro-vided healthcare to the clients; St. Vincent’s maintenance crews are available to repair any damages Project 25 clients might make to their housing units or to up-grade or fix any infrastructure in the housing units, which was an important part of maintaining a relationship with the landlord. In short, Project 25 was blessed by having access to a whole host of services and resources that St. Vincent’s was able to provide. Any replication of Project 25 will likely have to rely on an extensive net-work of collaboration - an “unprecedented [amount of] collaboration”cclxxv - from multiple service providers in order to have access to all the resources that Project 25 had as a result of being part of St. Vincent de Paul Village.

Project 25 staff compiled a list of “lessons learned” from Project 25 - many of which have already been mentioned throughout this report - that might be of inter-est to anyone wishing to replicate Project 25:cclxxvi

• Project 25 is extremely labor intensive.

• It is essential to get the right staff on board. A client population with this level of disability requires staff who are “willing to stick [with] it through everything and anything.”cclxxvii

• Clients need constant attention and (re)assessment throughout the course of the program.

• Staff need to understand the cycles of progress (also known as the cycles of absti-nence-relapse-recovery).

• Staff need to know how to apply the right strategy to each stage of progress. Dif-ferent strategies work for the same person in different stages of their cycle of progress.

Project 25 Director Marc Stevenson and Project 25 case manager Jose Zaragoza both noted that the housing process was tedious and required plenty of paperwork, Dip lomat Pro jec t 25

60

even with the special housing-based vouchers Project 25 had, which meant that clients were not able to move into their homes as soon as they would have liked. Both staff members suggested finding a way to streamline the process; Stevenson specifically suggested allowing receipts for an ID or a Social Security card to sub-stitute for a government ID, which is normally required to get housing, even with housing vouchers. Stevenson also urges future Project 25-like endeavors to “stick with the scattered site model” so that clients have a choice of where to live and to maintain a close relationship with landlords and treat their complaints with the same care and urgency one would treat a client complaint.cclxxviii Zaragoza adds that it might be a good idea to have a “Starbucks card” for each landlord or partner - in other words, a budget set aside to get coffee with Project 25’s partners so that the staff can visit with the partners and have a chance to talk with them about clients/patients. It is important to stay connected to the partners, and a “Starbucks card” provides a causal way for staff and partners to sit down and check in with each other.cclxxix

Zaragoza also warned that “one of the things we didn’t take into consideration [were the consequences of] taking [the] chronically homeless and putting them [into a] house - they are not used to living inside - it’s claustrophobic.” Both the claustrophobia and the “loneliness factor” need to be addressed if a client is to be successful in housing. Zaragoza also spoke about needing to set aside resources to accommodate the significant others of Project 25 clients - they cannot be left be-hind, or else staff risks losing the client - and about how the 24-hour access line was “very important but...overwhelming.” The former is addressed easily; the lat-ter can be remedied by having a slightly larger staff (currently, only Stevenson and Zaragoza qualify to cover the 24-hour access line). It helps, Zaragoza says, that Project 25 grants its staff flexibility with their hours. As long as a staff member works eight hours a day every weekday (evenings and weekends are covered by the 24-hour access line and whoever is covering that line), no matter when he or she works those eight hours, he or she has done his or her job for the day. This is important in dealing with clients who might need staff at odd hours of the day or night.cclxxx

The most important thing to consider, however, is the sustainability of Project 25. Dr. Folsom admits that Project 25 staff did not start thinking about sustainability until less than a year before their funding ran out. “We are good at soliciting dona-tions/grants,” Folsom writes, “but not good at business propositions.”cclxxxi It is rec-ommended that any endeavors to recreate Project 25 in other counties have a sus-tainability plan before the project even begins operation. Knowing that the project


61

will be financially sustainable frees staff up to concentrate on the actual work of the project instead of spending time trying to get money to keep the project going. The fate of San Diego’s Project 25 is a lesson to be learned for future endeavors: Project 25 works, but unless there is a reliable, long-term source of funding for the project, the potential effectiveness of the program is severely compromised.

Moving to a System-Wide Plan for Frequent Users

Project 25 has done a good job with highlighting the problem of frequent users lo-cally by compiling very compelling service utilization and cost data. This data has shown that by investing in programs to address homeless frequent users that in turn there is a large return on investment both fiscally and socially. Through Project 25 and other efforts to address frequent use in the community local leaders are trying to move beyond a pilot program intervention to a larger scale system wide plan to address more people.

High Utilizer Work Group

Project 25 staff along with representatives from various sectors began meeting to start to draft a plan for how the community can begin to address frequent users both those who are homeless and housed. Topics that are being discussed in this group include advocating for the prioritization of frequent users as a part of San Diego’s Coordinated Assessment process, understanding the diverse needs of over 1,400 high utilizers (Ranging from 6 ambulance rides in year to over 100) through-out the City, and trying to develop interventions that will adequately address vary-ing levels of frequent users while being cost effective.

Community Information Exchange

In August 2014, San Diego officially launched the Community Information Ex-change (CIE) with the first use case being homeless frequent users. CIE is a sys-tem that currently connects a few homeless providers (St. Vincent de Paul Village and People Assisting the Homeless (PATH)) and the City 911/EMS system through a shared database with the hopes of expanding to hospitals, law enforcement, and other social services.cclxxxii CIE links or unites databases used by first responders so that all the information on one client is in one place, which allows for coordination of care and treatment. “A central goal [of any frequent-user-centric program is] to invest in and stimulate the development of a comprehensive, coordinated system of care to address the needs of frequent users.”cclxxxiii Coordination of care is a vital


62

part of any program that wants to aid frequent users or homeless individuals in general - there are plenty of care facilities that already exist, but they often do not work together. Integration and cooperation - “partnership across systems of care” - are key to effective care, especially for a population who has issues that are so complicated.

A comparable program, the Management Information System (MIS), was prevalent in Philadelphia and New York in the early 1990s. It was used to create “a data ar-chive of shelter users” and “identify distinct patterns of shelter use,” and a similar program could be helpful in addition to a CIE. These types of “integrated adminis-trative database infrastructures” could potentially be combined to present a holis-tic approach of any particular client, which would allow providers to access and process data much more efficiently than they would otherwise.cclxxxiv As has been stressed throughout this report, it will take a major collaboration between multiple service providers in order to provide the best quality care for frequent users. “De-veloping a county-wide system to promote appropriate utilization of emergency services while fostering safety and well-being requires involvement of many county services.”cclxxxv

Project 25 was considered CIE’s “guinea pig,”cclxxxvi piloting CIE’s Beacon Alert. The Beacon Alert is set up so that Project 25 staff can work directly with the EMS sys-tem with the goal of responding to crises immediately and in real time.cclxxxvii It has a system of messaging alerts for all service providers on the people in their care, so that if a client engages with the EMS system or another social services provider, all those responsible for or interested in their care will be alerted.


63

Implementing Project 25 in Flint

Homelessness in Flint

Flint is one of the top ten largest cities in the state of Michigan and is the largest city and county seat of Genesee County, containing about a fourth of the county’s 418,408 people. Flint’s 10 Year Plan to End Homelessness, presented in 2007, recorded 1,172 individuals experiencing homelessness in the winter of 2005-2006. As is true with any population count of the homeless, this is a conservative esti-mate; even so, it shown that about 1% of all of Flint’s citizens were homeless that winter.cclxxxviii

There is no one reason for the high prevalence of homelessness in Flint. Several

factors, including “an increase in unemployment, a dilapidated housing stock, and

a shortage of decent affordable housing,” all contribute to the rise in homelessness in Flint and Genesee County.cclxxxix Some of these issues are found throughout the state of Michigan. Michigan, which in 2010 had a homeless population of 100,176 people,ccxc “had the largest decrease in household median income in the nation.”ccxci The average family income in Michigan was only $725/month in 2010.ccxcii This trend is apparent in Flint, where 32.5% of people in 2007 were “reported to be liv-ing below the poverty level, making Flint the most impoverished large city in Michigan.” Unemployment is both cause and effect of these unfavorable economic conditions, and 89% of homeless individuals in Flint are unemployed. In addition, the Flint 10 Year Plan lists a whole host of challenges facing those who wish to end homelessness in Genesee County, most of which are related to the current eco-nomic climate (including a lack of resources for service providers).ccxciii

Flint’s Ten Year Planccxciv

Flint is a city determined to change challenges into opportunities. In 2007, Flint/Genesee County published a Ten Year Plan to End Homelessness. Community stakeholders actively invested in the report included the Flint/Genesee County Continuum of Care, Community Collaborative, Department of Human Services, Genesee County Community Mental Health, and United Way of Genesee County, facilitated by Michigan State University and coordinated by Metro Housing Part-nership, Inc. These stakeholders created a list of goals for Flint/Genesee County, many of which would be directly addressed by Project 25:Dip lomat Pro jec t 25

64

• Identify existing resources and gaps in the community

• Creation of affordable housing units, permanent supportive housing and group homes for the chronically homeless

• Establishment of substance abuse treatment programs targeted to homeless pop-ulation

• Establishment of job training programs that will provide opportunities for eco-nomic self-sufficiency

• Establishment of counseling programs that assist homeless persons in finding housing and managing finances

• Provision of supportive services such as health care assistance that will permit homeless individuals to become productive members of society

• Provision of service coordinators or one-stop assistance centers that will ensure that chronically homeless persons have access to a variety of social services. Sup-port the efforts of United Way’s System of Care work groups to utilize existing in-formation hubs such as the Resource Center to develop a more efficient, more ef-fective human services system for Genesee County

• Eliminate duplication and develop a seamless provision of housing/homeless re-lated services

• Ensure leveraging of mainstream and private sector resources

• Maximize development of community partnerships

• Increase the capacity of community support services

• Address barriers to affordable housing

• Increase permanent supportive housing stock

• Plan, implement, and maintain the Homeless Management Information System (HMIS)

Of Flint’s Five Goals to End Homelessness, Project 25 directly addresses the first two: to increase the quality of data and the quality of local planning to end home-lessness, and to expand supply of and ensure access to affordable and safe hous-ing. For the latter goal, Project 25 fits the Housing First/Housing Plus model that Flint recognizes will be most effective in ending homelessness. It also addresses


65

the last goal, which is to build a political agenda and public will to end homeless-ness, particularly among key community stakeholders.

The Importance of Stakeholders

Jim Dunford, San Diego’s city medical director, suggested that the following com-munity stakeholders would be interested in Project 25 or similar programs, as they are often the ones who are responsible for frequent users (this is based off of Flint and Genesee County):ccxcv

• Hospitals, including any vocal MD leaders - Hurley Medical Center would be the main stakeholder, although McLaren Health Center would also be an important supporter

• Homeless shelters

• Faith-based community organizations, such as churches

• Emergency Medical Services: below are a list of Genesee County’s biggest EMS providers, in alphabetical order.

• Community EMS, Inc.

• Genesee County EMS (DVA Ambulance Inc.)

• Patriot Ambulance Service

• Pro Med

• Stat EMS LLC - has a contract with Hurley Hospital

• Swartz Ambulance Services

• Police department - Flint Township Police Department

• Fire department(s)

• Sheriff’s department - Sheriff’s Office of Genesee County - Sheriff Robert J. Pickell

• Sobering centers

• Mental health services - Genesee Health System’s Mental Health Services would be the main stakeholder in this group


66

• The Business community - many local businesspeople, concerned with keeping the streets around their shops “free” of homelessness, would be willing to back solutions to the issue of homelessness

• City attorney - Peter M. Bade

• Public defenders

• Any interested politicians - Mayor Dayne Walling, among others

In addition to this list, based on the experience of sustaining Project 25, one could add any insurance companies, especially any working with Medicaid or Medicare, that are responsible for the homeless population or particularly the frequent users of Flint. Michigan, as one of the states that opted into Medicaid expansion, can use Medicaid to sustain a Project 25-like program.ccxcvi

Comparison to Current Models of Fighting Homelessness in Flint

There are many wonderful homeless service providers in Flint and Genesee County which do amazing work with Genesee County’s homeless and at-risk population. However, most of them are not designed to care for frequent users. Genesee County service providers, like any successful service provider, are designed to aid specific populations, and they are very effective in aiding those populations. Very few of these providers, however, are able to provide for the needs of frequent users.

Some providers, for example, require sobriety:

• Carriage Town Ministries: a Christian-based emergency shelter system, Carriage Town Ministries has a “zero tolerance” policy towards drugs and alcohol. Anyone who is struggling with addiction issues must go to rehab; anyone who cannot be rehabilitated is asked to leave.ccxcvii

• Shelter of Flint: Shelter of Flint provides emergency, transitional, and permanent housing, but it cannot serve anyone who is under the influence of drugs or alco-hol.ccxcviii

• Flint Odyssey House Inc.

• Our Home Transitional: a program designed for female veterans and their chil-dren, Our Home Transitional has no program for substance abuse. Clients must be clean and sober before they can be helped.ccxcix


67

• Phinisee Outreach Shelter for Women

• Salvation Army Adult Rehabilitation Center Arc

Other programs are designed to be temporary shelters rather than permanent fix-tures in the client’s lives:

• My Brother’s Keeper provides two programs to aid homeless men regain self-suf-ficiency: an emergency shelter available for up to 45 days and a special veterans’ program available for up to six months. In addition, Pastor Patrick McNeal “hates Housing First” as a model “because then there are no ramifications for behavior.” He insists that punishment is sometimes necessary to change behavior.ccc Project 25, however, firmly believes that a Housing First model is necessary for clients to address any issues they may have with illness or addiction.

• Carriage Town Ministries (also see above) is described as being “not a forever place.” Most clients stay less than six months. Reverend Tom Travis insists that clients “need to think about the future” rather than rely on Carriage Town ser-vices for an unspecified period of time.ccci

Frequent users need stability and long-term support, which these programs - usu-ally designed for the transitionally homeless rather than the chronically homeless - are not designed to provide. In addition, frequent users require constant care and cannot survive in a program that would reject them for “bad behavior” or would terminate services after a certain amount of time. More often than not, they have already failed out of such programs.

Others are designed for children and youth:

• Building Strong Women, Inc.

• REACH Runaway Program (for ages 10 to 17)

• Traverse Place Transitional Housing for Youths Age 17-20

Possible Allies for Project 25 in Flint

There are some service providers existing in Genesee County, however, that could help Project 25 or a similar program in its mission to aid and care for frequent users.

Habitat for Humanity


68

Habitat for Humanity is an organization “dedicated to eliminating poverty housing and homelessness from the world.”cccii Habitat for Humanity builds or rehabilitates permanent housing for those without a proper place to call home. For anyone look-ing to replicate Project 25 in Flint and Genesee County, Habitat for Humanity could potentially be a partner to provide permanent housing for Project 25 clients, provided that the clients fit Habitat’s criteria.

Clients are chosen for Habitat for Humanity on a case-by-case basis. Anyone con-victed of a violent or sex-based felony is unable to work with Habitat for Humanity, for the safety of the volunteers. By law, each homeowner has to be able to pay a mortgage to Habitat for Humanity, so a steady income is a necessity. However, Juan Zuniga, program director of Genesee County’s Habitat for Humanity, con-cedes that it is possible for someone living off of disability to be able to afford a Habitat House, depending on his or her specific financial situation. More impor-tantly, the client needs to be capable (mentally and financially) of owning a home, which many frequent users are not.ccciii It is possible, however, that Habitat for Hu-manity would consider entering a partnership with Project 25 staff members, who would agree to help the client maintain the house and pay the mortgage.

The most important thing Zuniga looks for in a client, however, is a willingness to partner with Habitat for Humanity. In his words, “there are a lot of hoops to jump through” to qualify for a Habitat House, including Habitat’s “sweat equity” stipula-tion. Each adult receiving a Habitat House must be willing to “work” 250 hours with or for Habitat for Humanity in exchange for his or her house. However, this “work” is not required to be physical labor.

Habitat for Humanity is not new to partnerships with the community. Genesee County’s Habitat for Humanity partners with Metro Community Development, a HUD certified housing and credit counseling for clients who may need it. Habitat also works with Lowe’s and Home Depot for housing materials and local churches for volunteers. Genesee County’s Habitat is also beginning to form partnerships with programs interested in providing transitional housing.ccciv

The Young Women’s Christian Association (YWCA) of Greater Flint

The YWCA runs a SafeHouse Emergency Shelter for women and children affected by sexual assault and domestic violence. Clients have access to food and clothing, personal advocacy, childcare, specialized children’s activities, housing advocacy, support groups, educational classes, referrals to community resources, and all YWCA services, including Counseling and Legal Advocacy Services.cccv There is no Dip lomat Pro jec t 25

69

limit on how long a woman can stay at the SafeHouse,cccvi and “upon leaving Safe-House, individuals may still access YWCA services, and may return to SafeHouse as often as needed.”cccvii

The YWCA accepts women with addiction issues; although it promotes a dry envi-ronment, it “doesn’t disqualify anyone” based on addiction issues. Clients are con-sidered on a case-by-case basis. The only requirement is that clients do not ver-bally or physically threaten other women or children or staff.cccviii

All of the six women in San Diego’s Project 25 have experienced domestic violence or rape.cccix As such, they would all qualify to stay in the YWCA’s SafeHouse. For any woman experiencing domestic violence or sexual assault, the YWCA would be the best place she could go to get herself stabilized and ready to move forward. However, if domestic violence or sexual assault is “not the primary issue,” as is the case of many frequent-user women, the YWCA will refer the client out to services that might better serve the needs of the client. The YWCA serves a small popula-tion of women very well, and although a few Project 25 clients fit the YWCA clien-tele, not all do.

One Stop and Homeless Outreach

One Stop and Homeless Outreach is an outreach and referral program designed to

connect homeless and at-risk individuals with programs and services within Gene-

see County. A part of the Housing Assessment Resource Agency (HARA), it is de-

scribed as being “a single point of entry to receive comprehensive services;” the

one place where homeless or at-risk individuals can go to receive references to a comprehensive system of housing and housing-plus services. One Stop and Home-less Outreach provides clients with a “little yellow book” filled with all the informa-tion they need to access any service provider in Genesee County.cccx

In addition, One Stop and Homeless Outreach partners with many service providers in Genesee County, including many of the providers listed above in this report. One Stop and Homeless Outreach is useful to anyone interested in replicat-ing Project 25 because it is already a center of connection for many service providers. As has already been stated in this report, Project 25 will require an “un-precedented [amount of] collaboration” among pre-existing service providers in or-der to provide a comprehensive system of care to clients.cccxi Project 25 clients will need housing services, non-housing services, health services, and intensive case management in order to improve their quality of life and reduce their use of emer-Dip lomat Pro jec t 25

70

gency services. One Stop and Homeless Outreach could help a Project 25-replica-tion connect to the services it needs for its clients, much like St. Vincent de Paul Village was able to do for San Diego’s Project 25.

How to Create a Frequent User List in Flint

Many cities already have an automatic system that ranks 911 callers (or those whom the call is about) by frequency, but if this does not exist it is relatively easy to rank the callers manually.cccxii In Flint, for example, one would approach the EMS companies listed at the beginning of this report and ask each company to make a list of their fifty most frequent users.cccxiii In Flint, it is suggested that, if it is impos-sible to approach all six EMS providers, to focus on Stat EMS LLC, which has a contract with Hurley Hospital and would likely see the most frequent users, and Genesee County EMS (DVA Ambulance Inc).

Putting All of the Pieces Together

Flint has the potential to create a successful frequent user initiative. Many re-sources that could aid a Project 25-like project exist in some capacity already; it will be up to Project 25 staff to adjust the resources to fit their needs. There are plenty of service providers in Flint that have a wealth of experience with the local homeless population, and their help will prove invaluable in establishing and run-ning Project 25. Non-traditional providers will also be important to Project 25. The most notable of these will be the 911 system, with whom Project 25 will have to work to develop a comprehensive list of Genesee County’s most frequent users. Most importantly, however, Project 25 needs a passionate and dedicated leader to bring all these resources together and bring all these allies to the table. This leader will need to be able to manage all of Flint’s resources in order to best serve Project 25. San Diego’s Project 25 staff are willing if necessary to come to Flint to assist with this effort in the future.


71

Appendix A: Interview Sources Used

• San Diego (Alphabetical order):

• Anne Jensen: EMT-P; RAP coordinator for San Diego EMS-Rural/Metro of San Diego and San Diego Fire-Rescue Department.

• Dr. David Folsom: the medical director of St. Vincent de Paul Village and the head doctor for Project 25

• Deena and Randy Stein: Owned apartment complex in San Diego

• Denice Crane: Property Manager

• Ericka Jardine: Property Manager

• Dr. Jim Dunford: San Diego’s City Medical Director of EMS

• Jose Zaragoza: Project 25 case manager

• Kris Kuntz: Program and Research Analyst at St. Vincent de Paul Village

• Marc Stevenson: Project 25 director

• Michelle Whitney: Project 25 nurse

• Flint/Genesee County:

• Ann Kita: Service Coordinator and Crisis Counselor at the YWCA of Greater Flint

• Carrie Miller: founder and executive director of Our Home Transitional in Genesee County

• Doris P. Collins: founder and director of Phinisee Outreach Shelter for Women in Genesee County

• Juan Zuniga: program director of Genesee County Habitat for Humanity

• Kasie White: director of One Stop Genesee

• Liz Ruediger: director of development of Shelter of Flint

• Major Mary Thomas: major at Salvation Army Adult Rehabilitation Center Arc in Genesee County


72

• Patrick McNeal: founder/operator/pastor of My Brother’s Keeper in Genesee County

• Rev. Tom Travis: chaplain of Carriage Town Ministries in Genesee County


73

Bibliography

Bennett, Kelly (2013) Two Years In, It’s Still Day by Day for Project 25 Tenants,

Voice of San Diego.

Buchanan, David et. al. (2006) The Effects of Respite Care for Homeless Patients: A

Cohort Study, American Journal of Public Health 96(7) pg.1278-1281.

Corporation for Supportive Housing (2014) AB 361: Reducing Costs & Health Dis-

parities Among High-Cost Medi-Cal Beneficiaries, Los Angeles County.

Corporation for Supportive Housing (2014) AB 361: Health Homes: Frequently

Asked Questions, Los Angeles County.

Culhane, Dennis P. (2008) The Cost of Homelessness: A Perspective from the

United States, European Journal of Homelessness 2 pg.97-114.

Davis, Kelly (2014) Got a spare $550,000 for Project 25?, San Diego City Beat.

Dillon, Liam (2014) One of San Diego’s Most Successful Homeless Programs Is Out

of Money, Voice of San Diego.

Dunford, James V. et. al. (2006) Impact of the San Diego Serial Inebriate Program

on Use of Emergency Medical Resources, Annals of Emergency Medicine 47(4) pg.

328-336.

Folsom, David (2014) Project 25: Sustaining a Frequent User Initiative, Presented

at the National Health Care for the Homeless Conference in New Orleans, LA.

Folsom, David, Stevenson, Marc, & Kuntz, Kris (2014) Project 25: San Diego’s Fre-

quent User Initiative, Presented at the 2014 CA Health Care Symposium in Ana-

heim, CA.

Gawande, Atul (2011) The Hot Spotters, The New Yorker January 24, 2011.Dip lomat Pro jec t 25

74

Gladwell, Malcolm (2006) Million Dollar Murray, The New Yorker February 13,

2006.

Goldberg, Kenny (2014) Project 25 Helps San Diego Homeless Get Off Streets And

Out Of Emergency Rooms, KPBS.

Kuhn, Randall & Culhane, Dennis P. (1998) Applying Cluster Analysis to Test a Ty-

pology of Homelessness by Pattern of Shelter Utilization: Results from the Analysis of Administrative Data, American Journal of Community Psychology 26(2) pg. 207-232.

Kuntz, Kris (2013) Creating a Comprehensive Frequent User List for Outreach, Presented at the International Homelessness Research Conference in Philadelphia, PA.

Larimer, Mary E. et. al. (2009) Health Care and Public Service Use and Costs Be-fore and After Provision of Housing for Chronically Homeless Persons With Severe Alcohol Problems, Journal of the American Medical Association 301(13) pg. 1349-1357.

Leadership Council of San Diego (2005) Plan to End Chronic Homelessness in the San Diego Region, United Way of San Diego.

Linkins, Karen W., Byra, Jennifer J., & Chandler, Daniel W. (2008) Frequent Users of Health Services Initiative: Final Evaluation Report, The California Endowment and the California HealthCare Foundation.

Maienschein, Brian (2014) Project 25 Needs a Stable Home in San Diego, Voice of San Diego.

National Alliance to End Homelessness (2006) A Plan; Not a Dream: How to End Homelessness in Ten Years, National Alliance.

Sadowski, Laura S. et. al. (2009) Effect of a Housing and Case Management Pro-gram on Emergency Department Visits and Hospitalizations Among Chronically Ill Homeless Adults, Journal of the American Medical Association 301(17) pg.1771-1778.

San Diego Regional Task Force on the Homeless (2014) WeALLCount Data & Re-sults, San Diego County Regional Task Force on the Homeless.


75

St. Vincent de Paul Village (2014) Project 25: Cost Effectively Addressing Home-lessness in San Diego, St. Vincent de Paul Village & United Way of San Diego.

St. Vincent de Paul Village (2014) Project 25: Cost Effectively Addressing Home-lessness in San Diego: Project 25 Results and Future, St. Vincent de Paul Village & United Way of San Diego.

Stevenson, Marc, Folsom, Dave, & Kuntz, Kris (2012) Using Harm Reduction Strategies with Frequent Users of Emergency Services: Project 25, Presented at the San Diego Meeting of the Minds Conference in San Diego, CA.

Thornquist, Lisa et. al. (2001) Health Care Utilization of Chronic Inebriates, Pre-sented at the Society for Academic Emergency Medicine Annual Meeting in At-lanta, GA pg. 300-308.

Toros, Halil, & Stevens, Max, under Moreno, Manuel. (2012) Project 50: The Cost Effectiveness of the Permanent Supportive Housing Model in the Skid Row Section of Los Angeles County, County of Los Angeles Chief Executive Office Service Inte-gration Branch.

United States Interagency Council on Homelessness (2014) Implementing Housing First in Permanent Supportive Housing, United States Interagency Council on Homelessness.

United States Interagency Council on Homelessness (2014) Opening Doors: Fed-eral Strategic Plan to Prevent and End Homelessness: Update 2013, United States Interagency Council on Homelessness.

Walker, Steve & Hutchison, Pete (2007) Flint/Genesee County Collaborative Ten Year Plan to End Homelessness, Flint/Genesee County Collaborative.


76

Endnotes


77


78


79


80


81


82


83


84


85


86


87


88


89

i Malcolm Gladwell, “Million-Dollar Murray,” The New Yorker 13 Feb. 2006: http://archives.newyorker.com/?i=2006-02-13#folio=106.

ii United States, National Coalition for the Homeless, How Many People Experience Homelessness? (Wash-ington, DC: National Coalition for the Homeless, 2009).

iii United States, United States Interagency Council on Homelessness, Opening Doors: Federal Strategic Plan to Prevent and End Homelessness: Update 2013 (Washington D.C., United States Interagency Council on Homelessness, April 2014).iv Dennis P. Culhane, “The Cost of Homelessness: A Perspective from the United States,” University of Pennsylvania January 2008: 97-114.

v Culhane.

vi Gladwell.

vii Culhane.

viii United States, San Diego County Regional Task Force on the Homeless, 2014 WeALLCount (San Diego: San Diego County Regional Task Force on the Homeless, July 15 2014).

ix United States, Leadership Council of San Diego, Plan to End Chronic Homelessness in the San Diego Re-gion (San Diego: United Way of San Diego, Sept. 2005).

x David Folsom, Marc Stevenson, and Kris Kuntz, Project 25: San Diego ’ s Frequent User Initiative, 2014 Health Care Symposium (St. Vincent de Paul Village & United Way of San Diego, 2014).

xi For a definition of chronic homelessness, see “what is ‘chronic homelessness?’” United States, San Diego County Regional Task Force on the Homeless, 2014 WeALLCount Data & Results (San Diego: San Diego County Regional Task Force on the Homeless, July 15 2014).xii St. Vincent de Paul Village, Winning Outcomes 2011 (2011).

xiii San Diego County Regional Task Force on the Homeless, 2014 WeALLCount Data & Results.xiv San Diego County Regional Task Force on the Homeless, 2014 WeALLCount.xv San Diego County Regional Task Force on the Homeless, 2014 WeALLCount Data & Results.xvi Father Joe’s Villages and Partner Agencies, “Home Page,” 15 July 2014 <http://my.neighbor.org/Home_page>.

xvii Winning Outcomes (2011).

xviii Father Joe’s Villages, “Partner Agencies,” 16 July 2014 <http://my.neighbor.org/Partner_agencies>.

xix St. Vincent de Paul, “About: FAQs,” 16 July 2014 <http://www.svdpv.org/about.html?tabinterfaceid=7#tab5>.

xx Some need only be mentioned, while others deserve further explanation. For more information, please

visit the St. Vincent de Paul website: <http://www.svdpv.org/>.

xxi For further information, see “Healthcare Services.”

xxii Marc Stevenson, Personal interview, 28 May 2014.

xxiii Dr. David Folsom, Personal interview, 22 July 2014.

xxiv Father Joe’s Villages, “Partner Agencies,” <http://my.neighbor.org/Partner_agencies>.

xxv Toussaint Academy of San Diego, “Home Page,” 16 July 2014 <http://www.toussaintacade-my.org/index.html>.

xxvi Josue Homes: National AIDS Foundation, “Welcome,” 16 July 2014 <http://www.nationalaids-foundation.org/index.html>.

http://www.svdpv.org/

http://www.nationalaidsfoundation.org/index.html

http://www.nationalaidsfoundation.org/index.html

http://www.toussaintacademy.org/index.html

http://www.toussaintacademy.org/index.html

http://my.neighbor.org/partner_agencies



http://my.neighbor.org/home_page

http://my.neighbor.org/home_page

xxvii Kelly Davis, “Got a spare $550,000 for Project 25?” San Diego CityBeat 28 May 2014 <http://www.sdcitybeat.com/sandiego/article-13055-got-a-spare-$550000-for-project-25.html>.

xxviii Plan to End Chronic Homelessness in the San Diego Region (2005).

xxix David Folsom, Sustaining Project 25 (National Health Care for the Homeless Conference, New Orleans: May 2014).

xxx Davis.

xxxi Karen W. Linkins, Jennifer J. Brya, and Daniel W. Chandler, Frequent Users of Health Services Initia-tive: Final Evaluation Report, ed. The Lewin Group (The California Endowment and the California Health-Care Foundation: August 2008).

xxxii Atul Gawande, “The Hot Spotters,” The New Yorker 24 Jan. 2011: http://www.newyorker.com/magazine/2011/01/24/the-hot-spotters?currentPage=all.xxxiii Gladwell.

xxxiv If interested in reading more about these different programs, please see the bibliography.xxxv These two models will be further discussed later in the report.xxxvi United States, U.S. Department of Housing and Urban Development Office of Community Planning and Development, Notice on Prioritizing Persons Experiencing Chronic Homelessness and Other Vulnerable Homeless Persons in Permanent Supportive Housing and Record-keeping Requirements for Documenting Chronic Homeless Status (U.S. Department of Housing and Urban Development Office of Community Plan-ning and Development, 28 July 2014).xxxvii United States, National Alliance to End Homelessness, A Plan: Not a Dream: How to End Homeless-ness in Ten Years (National Alliance, 2006).

xxxviii San Diego County Regional Task Force on the Homeless, 2014 WeALLCount.xxxix Randall Kuhn and Dennis P. Culhane, “Applying Cluster Analysis to Test a Typology of Homeless by Pattern of Shelter Utilization: Results from the Analysis of Administrative Data,” University of Pennsylvania Scholarly Commons 1 April 1998: 207-232.

xl A Plan: Not a Dream: How to End Homelessness in Ten Years (2006).

xli Kuhn and Culhane.

xlii A Plan: Not a Dream: How to End Homelessness in Ten Years (2006).

xliii St. Vincent de Paul, “Programs and Services: Changing Lives: Project 25,” 22 July 2014 <http://www.svdpv.org/permanenthousing.html?tabinterfaceid=7#tab4>.

xliv Gladwell.

xlv Ruth Bruland and David Fulsom, “Project 25 at St. Vincent de Paul Village: Medi-Cal Managed Care Health Plan Proposal: Cover Letter.”

xlvi Liam Dillon, “One of San Diego’s Most Successful Homeless Programs Is Out of Money,” Voice of San

Diego 20 May 2014 <http://voiceofsandiego.org/2014/05/20/one-of-san-diegos-most-successful-homeless-programs-is-out-of-money/>.

xlvii Using Harm Reduction Strategies: Project 25 (2012). This will be further discussed in “Things to Con-sider.”

xlviii Davis.

xlix Maienschein.

l Dillon.

li Kris Kuntz, Personal interview, 30 June 2014.

http://voiceofsandiego.org/2014/05/20/one-of-san-diegos-most-successful-homeless-programs-is-out-of-money/

http://voiceofsandiego.org/2014/05/20/one-of-san-diegos-most-successful-homeless-programs-is-out-of-money/

http://www.newyorker.com/magazine/2011/01/24/the-hot-spotters?currentpage=all

http://www.newyorker.com/magazine/2011/01/24/the-hot-spotters?currentpage=all

http://www.sdcitybeat.com/sandiego/article-13055-got-a-spare-$550000-for-project-25.html



lii Maienschein.

liii Kris Kuntz, Personal interview, 30 June 2014.

liv Telecare Corporation, “Home,” 29 July 2014 <http://www.telecarecorp.com/>.

lv Kris Kuntz, Personal interview, 30 June 2014.

lvi Maienschein.

lvii Stevenson, Folsom and Kuntz, Using Harm Reduction Strategies.

lviii Gladwell.

lix Bennett.

lx David Buchanan et. al., “The Effects of Respite Care for Homeless Patients: A Cohort Study,” American Journal of Public Health July 2006: 1278-1281.

lxi Mary E. Larimer et. al., “Health Care and Public Service Use and Costs Before and After Provision of Housing for Chronically Homeless Persons with Severe Alcohol Problems,” The Journal of the American Medical Association 1 April 2009: 1349-1357.

lxii Brian Maienschein, “Project 25 Needs a Stable Home in San Diego,” Voice of San Diego 6 June 2014:

<http://voiceofsandiego.org/2014/06/06/project-25-needs-a-stable-home-in-san-diego/?utm_source%3Dfeedburner%26utm_medium%3Dfeed%26utm_campaign%3DFeed%253A%2Bvoice-of-san-diego-all-articles%2B(All%2Barticles%2Bvoice-ofsandiego.org%2B--%2Bfull%2Bfeed)>.

lxiii Kuhn and Culhane.

lxiv Buchanan.

lxv Lisa Thornquist et. al. “Health Care Utilization of Chronic Inebriates,” Academic Emergency Medicine 9 (4): 2002: 300-308.

lxvi Thornquist.

lxvii Kenny Goldberg, “Project 25 Helps San Diego Homeless Get Off Streets And Out Of Emergency

Rooms,” KPBS 20 Feb. 2014: <http://www.kpbs.org/news/2014/feb/20/project-helps-get-homeless-san-diego-streets-and-o/>.

lxviii United States, Corporation for Supportive Housing, AB 361: Health Homes: Frequent Asked Questions (Los Angeles).

lxix Plan to End Chronic Homelessness in the San Diego Region (2005).

lxx Thornquist.

lxxi Goldberg.

lxxii Maienschein.

lxxiii Dunford et. al., “Impact of the San Diego Serial Inebriate Program.”

lxxiv Using Harm Reduction Strategies: Project 25 (2012).

lxxv Davis. There will be further descriptions of the benefits of housing and supportive services in the sec-tion “Project 25 in Action.”

lxxvi Goldberg.

lxxvii Jose Zaragoza, Personal interview, 26 June 2014.

lxxviii Plan to End Chronic Homelessness in the San Diego Region (2005).

http://www.kpbs.org/news/2014/feb/20/project-helps-get-homeless-san-diego-streets-and-o/

http://www.kpbs.org/news/2014/feb/20/project-helps-get-homeless-san-diego-streets-and-o/

http://voiceofsandiego.org/2014/06/06/project-25-needs-a-stable-home-in-san-diego/?utm_source%25253dfeedburner%252526utm_medium%25253dfeed%252526utm_campaign%25253dfeed%2525253a%25252bvoice-of-san-diego-all-articles%25252b(all%25252barticles%25252bvoiceofsandiego.org%25252b--%25252bfull%25252bfeed



http://www.telecarecorp.com/

lxxix It could be argued that Project 25 aims to address a forth performance measure, that of the number of chronically homeless who find and maintain employment. Almost none of the Project 25 clients are em-ployed, however many are receiving SSI or other disability benefits.

lxxx Jim Dunford, Personal interview, 12 June 2014.

lxxxi Kelly Bennett, “Two Years In, It’s Still Day by Day for Project 25 Tenants,” Voice of San Diego 8 April

2013 <http://voiceofsandiego.org/2013/04/08/two-years-in-its-still-day-by-day-for-project-25-tenants/>.

lxxxii For a further discussion of Telecare’s role in Project 25, see “Who Was Taking Part?”

lxxxiii Using Harm Reduction Strategies: Project 25 (2012).

lxxxiv Kris Kuntz, Personal interview, 28 May 2014.

lxxxv For more on client income, see “Income obtainment and retainment” and “Payee services.”

lxxxvi Marc Stevenson, Personal interview, 28 May 2014.

lxxxvii Using Harm Reduction Strategies: Project 25 (2012).

lxxxviii Kris Kuntz, Creating a Comprehensive Frequent User List for Outreach (International Homelessness Research Conference, Philadelphia, PA, June 2013).

lxxxix Folsom, Stevenson, and Kuntz, Project 25: 2014 Health Care Symposium..

xc Kris Kuntz, Personal interview, 28 May 2014.

xci Folsom, Stevenson, and Kuntz, Project 25: 2014 Health Care Symposium.

xcii Kuntz, Creating a Comprehensive Frequent User List for Outreach.

xciii Kris Kuntz, Personal interview, 28 May 2014.

xciv Anne Jensen, Personal interview, 23 June 2014.

xcv Maienschein.

xcvi Jose Zaragoza, Personal interview, 26 June 2014.

xcvii Folsom, Stevenson, and Kuntz, Project 25: 2014 Health Care Symposium.

xcviii Folsom, Sustaining Project 25.

xcix Folsom, Stevenson, and Kuntz, Project 25: 2014 Health Care Symposium.

c Folsom, Sustaining Project 25.

ci St. Vincent de Paul, Project 25: Cost Effectively Addressing Homelessness in San Diego: Project 25 Re-sults and Future (St. Vincent de Paul Village & United Way of San Diego).

cii Marc Stevenson, Personal interview, 28 May 2014.

ciii This will be further discussed later in the report.

civ Bennett.

cv Toros, Stevens, and Moreno, Project 50. Although this quote and the following describe Project 50 in Los Angeles, they are applicable to the way in which Project 25 in San Diego treats its clients according to the St. Vincent’s CREED.

cvi Toros, Stevens, and Moreno, Project 50.

cvii Gawande.

cviii Toros, Stevens, and Moreno, Project 50.

cix Marc Stevenson, Personal interview, 28 May 2014.

cx Kris Kuntz, Personal interview, 28 May 2014.

http://voiceofsandiego.org/2013/04/08/two-years-in-its-still-day-by-day-for-project-25-tenants/

http://voiceofsandiego.org/2013/04/08/two-years-in-its-still-day-by-day-for-project-25-tenants/

cxi Bennett.

cxii Kris Kuntz, Personal interview, 28 May 2014.

cxiii Kris Kuntz, Personal interview, 28 May 2014.

cxiv This knowledge is part of “Attitudes towards Clients” - understanding poverty and its perspective.

cxv Marc Stevenson, Personal interview, 28 May 2014.

cxvi Kris Kuntz, Personal interview, 30 July 2014.

cxvii Marc Stevenson, Personal interview, 28 May 2014.

cxviii Marc Stevenson, Personal interview, 28 May 2014.

cxix Jose Zaragoza, Personal interview, 26 June 2014.

cxx Gawande.

cxxi Gawande.

cxxii Toros, Stevens, and Moreno, Project 50.

cxxiii Bennett.

cxxiv Jose Zaragoza, Personal interview, 26 June 2014.

cxxv Plan to End Chronic Homelessness in the San Diego Region (2005).

cxxvi Using Harm Reduction Strategies: Project 25 (2012).

cxxvii Dillon.

cxxviii Folsom, Stevenson, and Kuntz, Project 25: 2014 Health Care Symposium.

cxxix SOAR, “About SOAR,” SOAR 2 August 2014 <http://www.prainc.com/soar/about/>.

cxxx Marc Stevenson, Personal interview, 28 May 2014.

cxxxi Goldberg.

cxxxii Kris Kuntz, Personal interview, 28 May 2014.

cxxxiii Bruland and Folsom, “Project 25 at St. Vincent de Paul Village: Medi-Cal Managed Care Health Plan Proposal: Cover Letter.”

cxxxiv Gladwell.

cxxxv Marc Stevenson, Personal interview, 28 May 2014.

cxxxvi Kris Kuntz, Personal interview, 28 May 2014.

cxxxvii Marc Stevenson, Personal interview, 28 May 2014.

cxxxviii Marc Stevenson, Personal interview, 28 May 2014.

cxxxix Marc Stevenson, Personal interview, 28 May 2014.

cxl Jose Zaragoza, Personal interview, 26 June 2014.

cxli Kris Kuntz, Personal interview, 28 May 2014.

cxlii Marc Stevenson, Personal interview, 28 May 2014.

cxliii Jose Zaragoza, Personal interview, 26 June 2014.

cxliv Marc Stevenson, Personal interview, 28 May 2014.

cxlv Kris Kuntz, Personal interview, 28 May 2014.

cxlvi Marc Stevenson, Personal interview, 28 May 2014.

cxlvii Kris Kuntz, Personal interview, 28 May 2014.

http://www.prainc.com/soar/about/

cxlviii United States, United States Interagency Council on Homelessness, Implementing Housing First in Permanent Supportive Housing (Washington D.C., United States Interagency Council on Homelessness, ac-cessed August 2014).cxlix Larimer.

cl Davis.

cli Plan to End Chronic Homelessness in the San Diego Region (2005).

clii Goldberg.

cliii Plan to End Chronic Homelessness in the San Diego Region (2005).

cliv Bennett. Both components of Permanent Supportive Housing - the vouchers and the supportive services - will be expanded on elsewhere in this report.

clv Plan to End Chronic Homelessness in the San Diego Region (2005).

clvi Larimer.

clvii Larimer.

clviii Plan to End Chronic Homelessness in the San Diego Region (2005).

clix Larimer.

clx Sadowski.

clxi Jose Zaragoza, Personal interview, 26 June 2014.

clxii Bruland and Fulsom, “Project 25 at St. Vincent de Paul Village: Medi-Cal Managed Care Health Plan Proposal: Cover Letter.” In this excerpt, “clients” are referred to as “patients”.

clxiii St. Vincent de Paul, “About: Our Campus: Paul Mirabile Center,” 1 Augut 2014 <http://www.svd-pv.org/pmc.html>.

clxiv Jose Zaragoza, Personal interview, 26 June 2014.

clxv Using Harm Reduction Strategies: Project 25 (2012).

clxvi Marc Stevenson, Personal interview, 28 May 2014.

clxvii Randy and Deena Stein, Personal interview, 15 July 2014.

clxviii Ericka Jardine, Personal interview, 26 June 2014.

clxix Folsom, Stevenson, and Kuntz, Project 25: 2014 Health Care Symposium.

clxx Bennett.

clxxi Davis.

clxxii Bruland and Fulsom, “Project 25 at St. Vincent de Paul Village: Medi-Cal Managed Care Health Plan Proposal: Cover Letter.”

clxxiii Folsom, Stevenson, and Kuntz, Project 25: 2014 Health Care Symposium.

clxxiv Folsom, Stevenson, and Kuntz, Project 25: 2014 Health Care Symposium.

clxxv Davis.

clxxvi Kris Kuntz, Personal interview, 28 May 2014.

clxxvii Using Harm Reduction Strategies: Project 25 (2012).

clxxviii Usually, a client’s credit history is not good, but the Project 25 staff assure the landlord that they will make sure that the landlord suffers no financial loss because of a Project 25 client.

clxxix Marc Stevenson, Personal interview, 28 May 2014.

clxxx Randy and Deena Stein, Personal interview, 15 July 2014.

http://www.svdpv.org/pmc.html

http://www.svdpv.org/pmc.html

clxxxi Bennett.

clxxxii Marc Stevenson, Personal interview, 28 May 2014.

clxxxiii Randy and Deena Stein, Personal interview, 15 July 2014.

clxxxiv Denice Crane, Personal interview, 11 June 2014.

clxxxv Ericka Jardine, Personal interview, 26 June 2014.

clxxxvi Kris Kuntz, Personal interview, 28 May 2014.

clxxxvii Kris Kuntz, Personal interview, 28 May 2014.

clxxxviii Marc Stevenson, Personal interview, 28 May 2014.

clxxxix Dillon.

cxc Dillon.

cxci Unless otherwise noted, all information comes from Using Harm Reduction Strategies: Project 25 (2012).

cxcii Marc Stevenson, Personal interview, 28 May 2014.

cxciii This section will focus on alcohol dependence, as alcohol is the main drug of choice among frequent users.

cxciv Marc Stevenson, Personal interview, 28 May 2014.

cxcv A list is detailed in Using Harm Reduction Strategies: Project 25 (2012).

cxcvi Bennett.

cxcvii Marc Stevenson, Personal interview, 28 May 2014.

cxcviii Folsom, Stevenson, and Kuntz, Project 25: 2014 Health Care Symposium.

cxcix Marc Stevenson, Personal interview, 28 May 2014.

cc Using Harm Reduction Strategies: Project 25 (2012).

cci Much of this section is informed by a personal interview with Dr. David Folsom. Dr. David Folsom, Per-sonal interview, 22 July 2014.ccii Goldberg.

cciii Goldberg.

cciv See “Father Joe’s Villages: Programs” for more details on the Dual Residency Program.

ccv United States, Corporation for Supportive Housing, AB 361: Health Homes: Frequent Asked Questions.

ccvi See “Medication management” directly below.

ccvii Folsom, Stevenson, and Kuntz, Project 25: 2014 Health Care Symposium.

ccviii See “Father Joe’s Villages: Programs” for more details on the Family Health Clinic.

ccix Michelle Whitney, Personal interview, 10 June 2014.

ccx Marc Stevenson, Personal interview, 28 May 2014.

ccxi Michelle Whitney, Personal interview, 10 June 2014.

ccxii Marc Stevenson, Personal interview, 28 May 2014.

ccxiii This meeting is described above in further detail in the section “Healthcare services.”

ccxiv Dr. David Folsom, Personal interview, 22 July 2014.

ccxv Folsom, Stevenson, and Kuntz, Project 25: 2014 Health Care Symposium.

ccxvi Dr. David Folsom, Personal interview, 22 July 2014.

ccxvii Plan to End Chronic Homelessness in the San Diego Region (2005).

ccxviii Folsom, Sustaining Project 25.

ccxix Maienschein.

ccxx Folsom, Stevenson, and Kuntz, Project 25: 2014 Health Care Symposium.

ccxxi Kris Kuntz, Personal interview, 28 May 2014.

ccxxii Folsom, Stevenson, and Kuntz, Project 25: 2014 Health Care Symposium. A partial list of the data partners is included.

ccxxiii Folsom, Stevenson, and Kuntz, Project 25: 2014 Health Care Symposium.

ccxxiv Bennett.

ccxxv St. Vincent de Paul, Project 25: Cost Effectively Addressing Homelessness in San Diego (San Diego: 9 April 2014).

ccxxvi Folsom, Stevenson, and Kuntz, Project 25: 2014 Health Care Symposium.

ccxxvii Bruland and Folsom, “Project 25 at St. Vincent de Paul Village: Medi-Cal Managed Care Health Plan Proposal: Cover Letter.”

ccxxviii Maienschein.

ccxxix Jose Zaragoza, Personal interview, 26 June 2014.

ccxxx Folsom, Sustaining Project 25.

ccxxxi Jose Zaragoza, Personal interview, 26 June 2014.

ccxxxii Goldberg.

ccxxxiii Davis.

ccxxxiv Dillon.

ccxxxv Davis.

ccxxxvi Kris Kuntz, Personal interview, 3 August 2014.

ccxxxvii Several can be found among the sources in the bibliography.

ccxxxviii Jose Zaragoza, Personal interview, 26 June 2014.

ccxxxix Folsom, Sustaining Project 25.

ccxl Jose Zaragoza, Personal interview, 26 June 2014.

ccxli Bennett.

ccxlii Folsom, Stevenson, and Kuntz, Project 25: 2014 Health Care Symposium. This summary can be found earlier in the report in “What are the desired outcomes or goals?”

ccxliii Folsom, Sustaining Project 25.

ccxliv See both “Father Joe’s Villages: Programs” and “Healthcare services.”

ccxlv See “Income obtainment and retainment.”

ccxlvi Marc Stevenson, Personal interview, 28 May 2014.

ccxlvii See both “Attitudes towards clients” and “Client outreach.”

ccxlviii See “Data.”

ccxlix Bennett.

ccl Davis.

ccli Goldberg.

cclii Bennett.

ccliii Gawande. Although this quote is not from a Project 25 client, it echoes the sentiments felt by many Project 25 clients.

ccliv Goldberg.

cclv Bennett.

cclvi Jose Zaragoza, Personal interview, 26 June 2014.

cclvii Gawande.

cclviii Bennett.

cclix Gladwell.

cclx Folsom, Stevenson, and Kuntz, Project 25: 2014 Health Care Symposium.

cclxi Dillon.

cclxii Folsom, Sustaining Project 25.

cclxiii St. Vincent de Paul, Project 25: Cost Effectively Addressing Homelessness in San Diego (San Diego: 9 April 2014).

cclxiv Dillon.

cclxv Davis.

cclxvi Folsom, Sustaining Project 25.

cclxvii Davis.

cclxviii Folsom, Sustaining Project 25.

cclxix Davis.

cclxx United States, Corporation for Supportive Housing, AB 361: Reducing Costs and Health Disparities Among High-Cost Medi-Cal Beneficiaries (Los Angeles).

cclxxi St. Vincent de Paul, Project 25: Cost Effectively Addressing Homelessness in San Diego (San Diego: 9 April 2014).

cclxxii Dillon.

cclxxiii Bennett. This includes St. Vincent’s original fifteen clients, in addition to the client added by EMS services.

cclxxiv Davis.

cclxxv Stevenson, Folsom and Kuntz, Using Harm Reduction Strategies with Frequent Users of Emergency Services: Project 25 (2012).

cclxxvi Using Harm Reduction Strategies: Project 25 (2012).

cclxxvii Jose Zaragoza, Personal interview, 26 June 2014.

cclxxviii Marc Stevenson, Personal interview, 28 May 2014.

cclxxix Jose Zaragoza, Personal interview, 26 June 2014.

cclxxx Jose Zaragoza, Personal interview, 26 June 2014.

cclxxxi Folsom, Sustaining Project 25.

cclxxxii Kris Kuntz, Personal interview, 28 May 2014.

cclxxxiii Linkins, Brya, and Chandler, Frequent Users of Health Services Initiative.

cclxxxiv Culhane.

cclxxxv Thornquist.

cclxxxvi Kris Kuntz, Personal interview, 28 May 2014.

cclxxxvii Marc Stevenson, Personal interview, 28 May 2014.

cclxxxviii United States, Steve Walker and Pete Hutchison, Flint/Genesee County Collaborative Ten Year Plan to End Homelessness (Flint: Flint/Genesee County Collaborative, April 2007).

cclxxxix Flint/Genesee County Collaborative Ten Year Plan to End Homelessness.

ccxc United States, Sally Harrison, Michigan ’ s Campaign to End Homelessness: 2010 Annual Summary (Lansing: Michigan’s Campaign to End Homelessness, 2010).

ccxci Flint/Genesee County Collaborative Ten Year Plan to End Homelessness.

ccxcii Michigan ’ s Campaign to End Homelessness: 2010 Annual Summary .

ccxciii Flint/Genesee County Collaborative Ten Year Plan to End Homelessness. All statistics are current as of 2007.

ccxciv Flint/Genesee County Collaborative Ten Year Plan to End Homelessness. Unless otherwise stated, ev-erything in this section is taken from that report.

ccxcv Jim Dunford, Personal interview, 12 June 2014. Another list of possible allies can be found below:

United States, National Alliance to End Homelessness, A Plan: Not a Dream: How to End Homelessness in Ten Years (National Alliance, 2006) pg. 12.

ccxcvi There is currently a bill concerning Medicaid being circulated in the Michigan state government that proposes using Medicaid funds for Project 25-like programs, but at the time of this report, nothing conclu-sive has been revealed. Kris Kuntz, Personal interview, 8 July 2014.

ccxcvii Reverend Tom Travis, Personal interview, 29 July 2014.

ccxcviii Liz Ruediger, Personal interview, 11 August 2014.

ccxcix Carrie Miller, Personal interview, 6 June 2014.

ccc Patrick McNeal, Personal interview, 6 June 2014.

ccci Reverend Tom Travis, Personal interview, 29 July 2014.

cccii “About Genesee County Habitat for Humanity,” Genesee County Habitat for Humanity 11 August 2014

<http://geneseehabitat.org/About-Us.html>.

ccciii Juan J. Zuniga, Personal interview, 6 June 2014.

ccciv Juan J. Zuniga, Personal interview, 6 June 2014.

cccv “SafeHouse,” YWCA Greater Flint 11 August 2014 <http://www.ywcaflint.org/site/pp.asp?c=8eLDJKMyD&b=61631>.

cccvi Ann Kita, Personal interview, 11 August 2014.

cccvii “SafeHouse,” YWCA Greater Flint 11 August 2014 <http://www.ywcaflint.org/site/pp.asp?c=8eLDJKMyD&b=61631>.

cccviii Ann Kita, Personal interview, 11 August 2014.

cccix Marc Stevenson, Personal interview, 28 May 2014.

cccx “One Stop and Homeless Outreach,” Resource Genesee 11 August 2014 <http://www.resource-genesee.org/web/GetHelp/OneStopHomelessOutreach.aspx>.

cccxi Marc Stevenson, Dave Folsom and Kris Kuntz, Using Harm Reduction Strategies with Frequent Users of Emergency Services: Project 25 (2012).

cccxii Anne Jensen, Personal interview, 23 June 2014.

http://www.resourcegenesee.org/web/gethelp/onestophomelessoutreach.aspx

http://www.resourcegenesee.org/web/gethelp/onestophomelessoutreach.aspx

http://www.ywcaflint.org/site/pp.asp?c=8eldjkmyd&b=61631




http://geneseehabitat.org/about-us.html

cccxiii See “The importance of people.”

final report on project 25

Documents