Billy resides in Hollywood. More specifically, he sits and sleeps on the cement sidewalk. When we first met him, he was gentle and had piercing blue eyes that seemed even brighter against his grimy, bronzed skin. His sweatpants were plastered onto his legs due to copious urine and feces, which we discovered while cutting his pants off. He is schizophrenic, which means he hears voices in his head, and he doesn’t care about his hygiene. His thinking isn’t very clear and most importantly, he doesn’t believe anything is wrong with him. He’s not interested in housing, and he can’t really say why. He is a meth user as well.
When asked if he was willing to restart his mental health medication, he agreed without any protest. We started a small dose of an oral antipsychotic and eventually he agreed to take the long-acting injectable version. He seemed only slightly better, able to have a more normal conversation and accepting of resources such as food. But not housing. After looking through his records with his permission, we were able to piece together that he suffered from heart failure, most likely due to his meth use, a common sequela to chronic meth use.
A couple months ago, we noticed that he had severe full body swelling, his breathing was more difficult, and his oxygen level was low. This is a sign of severe heart failure. We wanted to take him to the hospital, but he refused. We’ve learned the paramedics won’t take people to the hospital against their will. We called the mental health experts to evaluate him, and they agreed he was a danger to himself. He still refused to be taken by an ambulance and although they could have forced him, they chose not to. It was only when our co-worker offered him fries and a cola the next day that he agreed to go.
Now, in California, an adult can be hospitalized against their will if they are a danger to self, danger to others or gravely disabled. Grave disability is a legal term and, in California, is defined as a person who, due to a mental disorder, is unable to provide for basic needs such as food, clothing or shelter. However, most people with grave disability are not “accepted” by hospital psychiatrists as requiring hospitalization because, in the end, there is nowhere for them to go. Medical only pays for 72 hours of acute psychiatric treatment when at a “medical hospital.” There are few psychiatric hospital treatment placements available in California. A study from Rand showed that California requires 50.5 inpatient psychiatric hospital beds per 100,000 adults. The report dissects these numbers by type of bed, suggesting that these bed targets include 26 acute beds per 100,000 adult population and 24.6 subacute beds per 100,000 adult population. Taking into account how many beds California currently has, the results suggest that California is short 1,971 acute beds and 2,796 subacute beds.
Moreover, although there are no definitive numbers, we estimate there are only approximately 5,000 licensed and unlicensed mental health residential placements. Furthermore, there are more closures than openings of Board and Cares serving those with severe mental illness.
Once someone is hospitalized involuntarily, the psychiatrist is aware of the dire, limited resources and thus, the bar for grave disability is raised for the sickest of the sick – usually someone who is a harm to others or themselves. If someone does get admitted for their acute mental health crisis, after 72 hours, if they are still a danger to themselves or others, the psychiatrist can petition for a 14-day hold. Beyond 14 days, the psychiatrist must start thinking about whether the person needs to be conserved. If they need to be conserved, the hospital may have to wait six to nine months before a psychiatric stabilization placement is available. The patient doesn’t receive the environmental care that he or she needs, just medications. The hospital doesn’t get paid or gets extremely underpaid for what a “sick” person would bring in financially. Thus, hospitals are reluctant to even say someone needs to be conserved.
Billy was brought by our case worker to a nearby community hospital, along with a lengthy description of his inability to care for himself per our experiences while he had been living on the street. A psychiatrist placed him on a hold because of his heart failure. Billy also had a hand infection that required six weeks of intravenous antibiotics. So, they were able to keep him there for six weeks for his infection treatment because Medicaid pays for medical issues. They tried to send him to a skilled nursing home, but none would accept him because of his “age.” Skilled nursing homes are allowed to “cherry pick” which patients they accept. They prefer patients who are bedbound. But once the six weeks were up, a new psychiatrist asked Billy where he would go for food and shelter. Billy mentioned a shelter in Hollywood and so, despite urgings from multiple people to have him conserved, he was released. The psychiatrist told us that Billy was able to care for himself and take his life-saving medications.
What if a locked nursing home was available? What if it had a nurturing environment that allowed the patient to stabilize and enjoy his life to the best that his disease would allow? What if after months, Billy could go to a less restrictive home environment but still have 24/7 staff caring for his needs—while ensuring he’s allowed to be outside, enjoy activities, maybe even reconnect with his family? Places like this do exist. We call them Housing that Heals.
Housing That Heals is a vision for how housing, treatment and clinical services can be integrated to produce recovery, respect, community, and hospitality for people with serious mental illness and/or addiction.
Housing That Heals is a culture that respects civil rights, the right to life and health, and the right to therapeutic treatment before tragedy with a focus on delivering the appropriate care at the right time in the appropriate setting. The Housing That Heals culture relies on authentic mutually beneficial partnerships confirming the primacy of people, place, and purpose in addressing mental illness and addiction.
Housing That Heals is a model that delivers high quality, clinically necessary therapeutic residential treatment and services, and emphasizes recovery and community in a continuum of settings to produce stability, therapeutic outcomes, and improved health. The Housing That Heals model will end street suffering, end fail-first incarceration for mental illness, and bring people home to health, hope, and healing.
Housing that Heals is a right. That is what we are saying in SB 1466. We want to take care of Billy and people like him, but we can’t protect him unless we first deem that treatment and housing for those suffering from severe mental illness as a right.
My colleague saw Billy a couple days after his release. He had lost his heart failure and mental health medications. My colleague sent me a photo of him lying on “his” sidewalk. She wrote, “This is what Billy meant by being able to stay at a shelter and take his medications.”
