Imagine a person, a man, is sleeping outdoors, and time after time he has refused to truly engage with a street outreach worker. He stays by himself, has accepted water, food, hand warmers and other daily living necessities, but he does not seem interested in talking about housing, health or mental health services.
The person, let’s call him John, is observed lying on the streets (as benches have been removed around the city), rain or shine. He uses bottles to relieve himself in, and at times you can see that he has defecated on himself. John clearly needs help. He has been locked up regularly for public intoxication or obstructing a passageway. He is also known to the area’s hospital as he is submitted for complications from his diabetes and sometimes for frostbites or heat-related illnesses. At this point, John does not trust anyone anymore.
Then imagine a street outreach worker, Jane, who is fresh out of college with a social services degree. She is a staunch advocate, in her early 20s, and ready to help John. Soon she realizes she is out of her depth. She has reached out to other case managers, even her former teacher, and gotten a lot of tips on how to approach John, but nothing seems to work. She called mental health services on him, and a team submitted him for observation to a psychiatric ward from where he was released within 72 hours. Finally, she moves on and quietly leaves him some food and water on her rounds.
If the federal government has its way — or even our state legislature — we would arrest John and force him into treatment to give him the services he needs. That sounds good, right? The problem is that John still does not cooperate. The next step, according to federal documents we have already seen, is to lock him away indefinitely in a psychiatric facility at a cost of up to $2,000 per night and pump him full of medication.
Unfortunately, we don’t have enough of those expensive beds. So, then – as he does not cooperate, he will eventually be locked away for good in a mega shelter or a government-sanctioned camp at a high cost.
While this may sound like fiction to you, it may very well become a sad reality for the most marginalized people in our communities. Unless, of course, we stand up as one and say, this is not how we treat our neighbors!
But there is another course we can take at the local, the city level.
What if our outreach worker, Jane, had the ability to call in an interdisciplinary street outreach team that is trained to work with folks like John?
For years, I’ve been advocating for an interdisciplinary street outreach approach in Nashville. But funding was never available to hire the needed experts many of us in Nashville envisioned, including health professionals such as a nurse practitioner and a psychiatrist (at least part-time).
Different Street Outreach Models
There are a variety of different street outreach models, which are captured in-depth in the “Outreach Focused Street Outreach Framework” published by the National Alliance to End Homelessness and available on their site at endhomelessness.org.
To give you an idea of the different types of street outreach programs, I lifted three examples from the NAEH document (look it up for a comprehensive list of outreach program types):
- General Street outreach, “is designed to connect individuals experiencing unsheltered homelessness to emergency shelter and housing solutions; it also provides immediate, life-saving interventions. In many communities, these street outreach workers are responsible for conducting Coordinated Entry Systems (CES) assessments and are integrated into the broader CoC.”
- Clinical street outreach “encompasses health-, mental health-, substance abuse-, and co-occurring-focused outreach. This may include street medicine initiatives, where medical professionals operate mobile medical vans or deploy street outreach specialists to deliver healthcare services to those who are unable or unwilling to access traditional clinic settings or local healthcare systems. Clinical street outreach also provides linkages to voluntary mental health or substance abuse services for individuals with serious mental illness (SMI); place-based substance use disorder treatment focused on safety and harm reduction; mental health and substance use treatment; connection to main-stream resources; coordination of housing and supportive services’ and integration with the Coordinated Entry System.”
- Multidisciplinary Street Outreach teams “bring together professionals with diverse backgrounds and expertise, including peer support workers, behavioral health specialists, and physical health practitioners. By combining different skill sets and perspectives, these programs can provide comprehensive support tailored to the complex needs of people experiencing unsheltered homelessness. Multidisciplinary work is best when roles, expertise, and expectations are clarified.”
Assertive Community Treatment (ACT)
Just recently, I found a document I drafted in 2012 while I was working at Metro and trying to get dollars to create an Assertive Community Treatment (ACT) Team going. ACT is a team-based approach that includes professionals with different expertise such as nurse practitioners, a psychiatrist, social workers, peer support specialists, and professionals trained in substance abuse, wellness, and employment.
While some ACT teams are assigned to work with people once they enter housing, others start identifying people with severe mental health and/or substance use issues who are still living on the streets. Then they assist them with the housing process as quickly as possible while providing wraparound services, and the entire team continues working with that person once they are housed.
In other words, they follow people from the street to housing and stay with them. Considering that the most difficult adjustment period for people with intensive health and mental health needs is the immediate 90-day transition after they first moved from the streets into their own housing, having a familiar team that has already built trusting relationships with their client is a great approach to stabilize people.
ACT teams have the experience to build relationships with people like John. It may take some time to get there, but developing trust and focusing on a long-term approach will prove more effective and lasting than a quick-fix, underfunded effort aimed at removing people out of sight.
We know this because we have enough research and evidence to prove what works. What is more, an interdisciplinary approach as offered by an ACT team would be available around the clock to provide John with the support he needs when he needs it.
I have seen such an approach when touring a program in New York City. They had an interdisciplinary outreach team with access to immediate shelter, and a specialized temporary housing program offered for people with severe mental illness. People could stay in those beds, which were observed by nurse practitioners 24/7, as long as they wanted. The goal still was to help every person access permanent housing with the needed wraparound support services as quickly as possible. For some, that meant the organization’s own supportive housing program. Others found housing opportunities elsewhere but were still supported, at least for a transition time, by the organization.
As a visitor to another city, things generally are presented in a positive way. After all, the point is to showcase to each other how great we are.
However, in this instance, I had spent a week with a small group of experts from cities in the U.S., Canada, Colombia, Mexico, Greece, and France. The goal was to have honest conversations about what works, what doesn’t work, and even if programs work — to understand that it is not easy or fast.
Let’s get back to Nashville. I was excited when, in 2022, Metro Council passed a resolution dedicating $9 million in federal one-time funding designated to stand up an ACT team. Well, that never happened.
ACT teams, on first examination, are considered a high-cost program. They have low case management ratios, meaning that on average a case manager/social worker does not work with more than 10-15 people. However, when we compare the per bed cost of these types of programs, they are definitely cheaper than putting people in jail (the cost is $115 per night in Nashville) or an in-patient psychiatric hospital (up to $2,000 per night).
A Starting Point for Nashville
What is a reasonable starting point to develop such an interdisciplinary outreach approach in Nashville, even if our city does not want to spend the money on an ACT team?
I was observing a recent community meeting in North Nashville where neighbors of the Nashville Rescue Mission’s women’s campus attacked staff from the Nashville Rescue Mission and wanted to bully them into spending $100,000 in security. They may succeed.
Now, in defense of the neighbors. They had understandably lost their patience and had documented proof of situations where people experiencing homelessness came on their porches to hang out, stole delivered packages, defecated in their yards, etc. I would not want to live like that in my home, would you?
But I also believe an interdisciplinary street outreach team could do more than one or two security officers who would only call police — an act that the neighbors themselves have been trying for months.
Metro has increased this year’s budget for the Office of Homeless Services (OHS) by $5 million to a total of $11 million. Imagine if OHS took the lead and were to take a planning and coordination lead and put some money into a program that they outsourced to staff a true interdisciplinary outreach team. In addition, OHS could designate two to three of its own outreach workers to collaborate with this team, especially in the beginning.
Here is where such a team would start:
- Engage with the neighbors and take the time to truly listen to their complaints.
- Identify the top 10 culprits, so to speak, and engage with them to understand what the issues are in terms of mental health. Start with those 10. Once a person is housed, make sure they have the appropriate service continuation. And immediately add another person to maintain a case load of 10 people in this area.
- Expand the program to other hotspots such as the folks who sleep on Drexel Street between the Mission’s men’s campus and Room In The Inn and identify the people with the most acute need in that area/those areas as well.
- Ensure that the team is not working in isolation and is working closely with the Nashville Rescue Mission, Room In The Inn, and other providers in the area. That team should also be connected to resources across the city including different city departments, nonprofits and for profits to offer health/mental health, recovery, and housing services. This is exactly the type of coordination OHS is charged to do.
- Stay connected with the neighbors and communicate with them throughout the process without violating people’s privacy. Continue to listen to the neighbors and if there is no progress over time, evaluate what next steps could be, including honest conversations that need improvement, since these types of efforts seem to show results in other cities.
It would take some sincere investment and effort on the city’s part and true leadership. But it is doable, and I bet it would show results more quickly and sustainably than spending $100,000 on a private security firm. Even a scaled down version of what I described above could be more effective.
What is our city’s goal? Is it to make homelessness invisible or is it to solve homelessness? I guess, moving forward, it’s up to city leaders to show us through their actions where their true priorities lie.
Judith Tackett is a longtime homelessness expert and advocates for housing-focused, person-centered solutions. Opinions in this column are her own.