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iAUDIT! - One of the key components of Housing First is providing “wraparound services”, the support programs needed to keep people housed and help them readjust to mainstream life. For the one-half to three-quarters of homeless people with substance abuse or mental health issues, the most effective programs are Full Service Partnerships (FSP’s). According to the County’s Department of Mental Health, “Adult Full Service Partnership (FSP) programs are designed for adults ages 26-59 who have been diagnosed with a severe mental illness and would benefit from an intensive service program. The foundation of Full Service Partnerships is doing “whatever it takes” to help individuals on their path to recovery and wellness and is considered the highest level of care in County services to people with mental illnesses. Full Service Partnerships embrace client driven services and supports [sic] with each client choosing services based on individual needs. Unique to FSP programs are a low staff to client ratio, a 24/7 crisis availability and a team approach that is a partnership between mental health staff and consumers.” In other words, FSP’s are the fabled “wraparound services” we hear so much about.
Studies have shown FSP’s are among the most beneficial and cost-effective programs for assisting people dealing with serious mental health issues. They not only stay housed longer, but they enjoy a higher quality of life and adjust to the routine of ordinary living faster. For this reason, the State Department of Health Care Services/Mental Health Services Division mandates that 76 percent of a County’s MHSA funding should be dedicated to Community Services and Support (CSS) programs, of which FSP is a component; in turn, 51 percent of CSS funds should be allocated to FSP efforts. In fiscal year 2023-24, the County Department of Mental Health has budgeted $360,780,440, for its FSP programs. FSP programs are funded by revenue from the state Mental Health Services Act (MHSA), a one percent tax on Californians who make more than $1 million per year.
Unfortunately, as with most County homelessness programs, there is a huge difference between what should be and what is. In 2020, the California State Auditor issued a report on L.A. County’s use of MHSA funds and found several problems, including a lack of coordination among various programs, resulting in clients falling out of the program with no follow-up. The auditor’s report stated, “Los Angeles’s staff acknowledged the weaknesses in the county’s system for coordinating continued care with medical facilities, stating that in some cases the county is only aware of individuals being discharged from short‑term holds if the treatment facilities holding them decide to notify it”. This statement is eerily similar to LAHSA’s admission before LA’s City Council that it may not know if someone leaves Inside Safe housing unless the site manager tells it, and LAHSA admitting it doesn’t enforce the status reporting requirement among its contractors.
The County’s FSP program suffers from the same problems that plague other elements of local government homelessness agencies: a lack of accurate data, no coordination of services across providers, and no accountability. The County consistently fails to fund its FSP programs at the mandated level. According to the County Department of Mental Health’s annual MHSA report, the fiscal year 2023-24 FSP budget is $360,780,440, out of a total CSS budget of $1,268,359,320; FSP programs were 28 percent of the total CSS budget, not the mandated 51 percent.
The County’s 2023-24 report on its use of MHSA funds projected it will serve 7,145 clients by the end of the fiscal year. While this may sound impressive, surveys indicate there are as many as 34,000 homeless people who need mental health care. In addition, County budget reports say, in the three fiscal years between 2019 and 2022, between 32.5 percent and 38 percent of FSP clients either lost contact or decided to leave the program, further reducing the number of people who receive services. The County even had trouble getting its own staff psychiatrists to appear at court conservatorship hearings; the State Auditor found that in 10 of 20 cases reviewed, the treating physician failed to appear, meaning the client/patient was kicked loose from the program.
The problems plaguing L.A. County’s programs are not unique. On January 25, 2023, the Mental Health Services Oversight and Accountability Commission issued a “Report to the Legislature on Full Service Partnerships”. This report is especially relevant because it comes from the state department that controls MHSA funding to counties and raises important questions about the way counties report service statistics and outcomes.
The report cites three serious weaknesses in FSP program reporting:
- The State faces data quality challenges that impede its capacity to fully understand the effectiveness of FSPs in preventing homelessness, justice involvement, and hospitalization.
- Despite regulatory requirements, counties do not appear to be allocating mandatory minimum funding levels to support FSP programs.
- California has not established sufficient technical assistance and support to ensure the effectiveness of FSP programs and support improved outcomes.
The state’s lax oversight and lack of support has enabled counties like Los Angeles to shirk their responsibility for providing vital services to the unhoused communities. The State Auditor’s report provided the County with recommendations to improve its operations and performance reporting. The report described the County’s response: “Los Angeles’s response indicates that it will only adopt our recommendation to the extent that resources become available and the Legislature acts on our associated recommendations. Given the importance of linking individuals to mental health services, we believe that Los Angeles should take steps now to improve how it identifies individuals who need services and links those individuals to services.” In other words, the County will change only if it is forced to change.
The question that naturally arises is how such a record of failure has been allowed to continue for so long. City and County leadership has, in many ways, become an enabler of underperforming agencies, eternally hoping for corrective action, while doing nothing to require it, and imposing no consequences when agencies fail. In 2022, City Controller Ron Galperin called for major reform in LAHSA when news broke that staff members were throwing away food meant for the unhoused. In August 2023, L.A.’s City Council members expressed frustration with LAHSA’s lack of transparency and inability to track clients. Earlier in December, the current City Controller once again documented the agency’s poor track record of counting the number of people it serves. Yet LAHSA has never been subjected to any financial or administrative consequences.
What makes this enabling behavior so frustrating is that wraparound services are vital to the success of L.A.’s Housing First model. Too many people are “housed” only in the sense they are placed in a building—usually in a spartan apartment—with few if any support services. City and County officials claim shelter operators (most of them large nonprofits) are conduits for connecting clients and service providers, when in fact the operators are subject to laughably lax contract administration by LAHSA. Reading the program descriptions on agency websites, one would think services are being provided to everyone entering the shelter – housing system. Nothing could be further from the truth. Elected officials seem to realize wrap-around services are largely fictional. In May 2023, Supervisor Lindsey Horvath referred to the lack of services as “an embarrassment”. Mayor Bass has also stated her concern homeless people are not receiving needed services.
There is strong empirical evidence FSP services are seriously lacking in Los Angeles. A recent L.A. Times article describes the precarious financial position of housing owned by the Skid Row Housing Trust and the Aids Healthcare Foundation (AHF). The article states: “In prior statements, the [AHF] foundation said its problems are the same as those affecting other Skid Row landlords: little public support, old buildings and a tenant population beset by mental health issues and drug addiction. [italics mine]. Operations across its portfolio have run a more than $15-million deficit.” Indeed, AHF doesn’t even attempt to provide the services needed to make Housing First successful. The article states, “And citing costs, [AHF] chose not to provide social services for its residents even though expert research shows doing so is essential in keeping tenants with mental health and addiction challenges housed”. Services are a foundational premise of Housing First, which AHF and other providers ignore, and to which advocates choose to turn a blind eye.
In an earlier article, the former executive director of Skid Row Housing Trust was quoted as saying, “You get residents who have some kind of a meltdown, and they destroy their unit,” Cordero said, trying to sum up the challenge of managing these buildings even in the best of times. “And then we figure out how to get them the services they need and then they come back, and they destroy the new unit that they have gotten into, and then they destroy the third unit.” Two more articles cite the devastating effect of the opioid epidemic on the street and in Skid Row Housing Trust hotels.
In terms of dollar cost, the City of San Francisco has paid at least $33.5 million to hotels that were required to accept homeless people during the COVID pandemic, regardless of behavioral condition. Closer to home, the City of L.A. will pay the owners of the Mayfair Hotel $11.5 for repairs, plus another $83 million for the hotel itself.
All of these facts show how costly, in dollars and lives, it is to deny vital support services to unhoused people. Yet the City and County have consistently failed to provide those services. In an April 2023 study, the think tank McKinsey & Company noted chronically homeless people are six times more likely to suffer from serious mental illness than the shorter-term unhoused population. At the same time, the chronically homeless population increased by 18 percent between 2022 to 2023, and the unsheltered population increased by 14 percent, comprising more than 55,000 people—more than 73 percent of L.A. County’s homeless population. (LAHSA 2023 PIT count). As the McKinsey report points out, providing a stable living situation enhances the effectiveness of support services, yet the number of unsheltered people is increasing. At the same time, LAHSA has demonstrated its inability to track people who are sheltered. Adding insult to literal injury, the County Board of Supervisors recently approved a two-year delay in a program to provide services to people who fall into a broadened definition of grievously disabled due to mental illness or substance abuse. The program is the gateway into the new CARE court system, which is designed to help get the most seriously ill people—the target population of FSP programs—off the streets and into structured care.
Despite hundreds of millions of dollars of dedicated Measure H and MHSA money, the County does a dismal job of providing consistent long-term mental health and substance abuse care to the unhoused. Part of the problem is that services are voluntary; participants must willingly join support programs, and with Housing First’s No Barrier policy, there are no consequences if they refuse or drop out. Another complication is the disjointed nature of homelessness programming in L.A. Multiple County departments share the responsibility for providing services, and LAHSA, which is supposed to administer the Continuum of Care, has demonstrated time and again its inability (and unwillingness) to be a proactive and aggressive program administrator. The breakdown in communication and service provision between the City and County, and among County agencies, is well documented and certainly no secret. What seems astonishing is that our elected leaders pretend things are working, when the evidence of the opposite is quite clear with every disturbed person we see on the streets and every overdose death in our morgues.
(Tim Campbell is a resident of Westchester who spent a career in the public service and managed a municipal performance audit program. He focuses on outcomes instead of process.)
