NEAL CONAN, host:
This is TALK OF THE NATION. I'm Neal Conan in Washington.
Today we continue our series on an old theme - the fundamental human drive to solve problems. It's about ideas that look blindingly obvious in retrospect, but till the light bulbs switches on, seem like intractable dilemmas. Some of these solutions reflect technological or scientific advances, others reflect the dedication of remarkable people with both innovative ideas and the political and practical know how to make them happen. From time to time we'll introduce you to these people with ideas and proven records of success. Today it's a big problem, too: homelessness. The answer might seem simple - find them homes. But that costs money, a lot of money. And particularly in times like these, homes for the homeless, is not on the top of many political agendas.
The problem however will not go away. So many cities provide temporary shelters, a bed and a place to escape the cold and the dangers of sleeping on the street. Some cities, New York City among them, offer a one-way bus ticket out of town. Let's somebody else worry about it. Dr. Jessie Gaeta and a project called Home & Healthy for Good use another approach. We'll hear from her in just a moment. And we want to hear from you. What's worked where you live, to help the homeless, what's been tried and failed? Our phone number - 800-989-8255. Email us email@example.com. You can also join the conversation on our Web site at npr.org, click on TALK OF THE NATION. Later in the program, have you ever been buttonholed by a sidewalk activist. Did you cross the street to avoid it? But first, what works?
And Dr. Jessie Gaeta joins us from the studios of member station WBUR in Boston. Nice to have you on TALK OF THE NATION today.
Dr. JESSIE GAETA (Co-Founder, Home & Healthy For Good Project): Thank you, Neal. It's a real pleasure to talk with you.
CONAN: And tell us a little bit about this program. How it works?
Dr. GAETA: So, Home & Healthy for Good is a program that is run by the Massachusetts Housing and Shelter Alliance. It's a state-wide Housing First initiative or pilot. And I want to make sure your listeners are familiar with the term Housing First, right upfront. So, let me first kind of describe the traditional approach to individual homelessness in our country. It's called the Continuum of Care. And it's an approach that is almost a linear model of steps that a person would move through, all the way from the street, through shelters, through programs in shelters, then to transitional housing, and all of this to lead finally, at the end of this long continuum, to permanent supportive housing.
CONAN: A lot of these people have problems with alcohol or drugs, or other problems, and they need to address those along the way before they qualify for these further steps in the program.
Dr. GAETA: That's correct. The steps and the levels in this traditional model are very much compliance-based, meaning that you really have to successfully complete programs. For instance, you know, agreeing that you've a mental health diagnosis, being willing to have that treated or you know, agreeing to go through a program that deals with addiction and successfully completing that program…
Dr. GAETA: …before moving on to the next level.
CONAN: And Homes First is different in what way?
Dr. GAETA: It is. So, Housing First basically flips that old model upside down so that housing is what's provided first, right upfront. That housing itself is really the thing that is probably needed as a very basic element in order to have people begin to address whatever personal vulnerabilities might have contributed to their homelessness in the first place. Though it's thought of, really, as a foundation upon which to build - to build. So Housing First…
CONAN: Housing First.
Dr. GAETA: It's not just - I should say, it's also not just housing. But this is a form of what we call Permanent Supportive Housing, meaning that the housing is coupled very tightly with wraparound services in the home, in the form of most typically, of a case manager who is the link for this new tenants to mainstream services in any service industry - mental health, medical health, addiction, vocational training, life skills, that sort of thing.
CONAN: Now this sounds like it's going to cost a lot of money - the housing, to begin with, and all these services that you're providing to these people. And if you're going Housing First, you're going to be getting a lot of people who need a lot of services.
Dr. GAETA: That's correct. It does sound, on initial take, it sounds like it's going to be very expensive. But the interesting thing about this is that the opposite ends up being true. And that is that this type of program actually saves money.
CONAN: How come?
Dr. GAETA: Well, let me tell you first that Permanent Supportive Housing and Housing First are basically programs that are targeting the very longest term homeless people - chronically homeless people. And these, as a group, this is - these are people who have been homeless for years on end, sometimes decades even, and in order to qualify for a program like this, you not only have to be homeless for a long time, but you also have to have a disability, and the disability maybe mental illness, it maybe medical illness, etc.
And - so this is targeting, really, a group of people who are sick in someway, and for the most part, unable to work and who are experiencing very long term homelessness despite the system of care or the approach that we've put into place as a society to deal with this problem. So, they're really sort of failing the traditional approach that we've put in - that we put into place for Housing First.
CONAN: That's sort of touch love approach. Yeah.
Dr. GAETA: Yes.
CONAN: But if these people have disabilities and they are out on the street, they are going to be going to the emergency room a lot. They are going to be demanding all kinds of service. They are going to end up in criminal justice system a lot too.
Dr. GAETA: That's correct. This group of people are using emergency rooms and being hospitalized at astronomical rates. I really think of them as - this group - as the highest utilizers of our state's Medicaid systems, primarily, and let me give you some examples about how often a chronically homeless person maybe needing emergency medical care, which is quite expensive. I'll tell you that a doctor I worked with named Jim O'Conell(ph) followed a group of 119 chronically homeless street dwellers over the course of five years in Boston. And he asked the question: how often is this group of people needing to use the emergency room or being hospitalized? And he found that this group of a 119 people, over the course of five years, used the emergency rooms in Boston over 18000 times.
Dr. GAETA: And required hospitalized 900 times, which doesn't even speak to the number of hospital nights they spent in the hospital. So you can see that's quite an expensive group from medical point of view. And so our hypothesis is that that if you can provide a supportive housing environment that's really a basis for beginning to build and improve health and manage chronic disease of whatever sort, that you may actually see a decrease - a such a decrease - in the need for emergency room, emergency room use and hospitalization, that you may actually be able to afford this expensive proposition of housing and support services.
CONAN: We are talking with Dr. Jessie Gaeta of the - co-founder of Home & Healthy for Good at our member station in Boston, WBUR. And we're talking as part of our series What Works. If you're involved in homeless programs around the country, what works? What doesn't? Give us a call: 800-989-8255. Email us: firstname.lastname@example.org. And Aden(ph) joins us from Vallejo in California.
ADEN (Caller): Hi there.
CONAN: Hi, Aden.
ADEN: Good morning. Thanks for taking my call. I had - we have kind of a hard time here because, you know, the city's gone broke and nobody wants to send any money here. But we have a large homeless community which was living in White Block, which was kind of living in the bird migration, where the birds - you know, it smells like bird poop all the time, and there's nowhere for them to go.
We have one homeless shelter, I think, which beds about 40 or 50 people. And there was 150 extra people living in White Block, which the police kicked out probably about two months ago.
CONAN: And where did they put them?
ADEN: They just evicted them from privately owned land, saying they couldn't be here anymore, and they just didn't care where they went. This was about the time that Sacramento had all the stuff about tent city, and I had written a letter to the newspaper saying, you know, this - these people are us. We are them. It's just by luck that none of us are sitting there wondering where we're going to be next week, and I think I'm trying to get awareness of this with people, that it could be any of us.
ADEN: I just don't know how to start something here.
CONAN: But it just sounds like these tactics are just moving the problem from one place to another.
ADEN: Right. They're just kicking it around like they're playing soccer, where we really have to deal with it. And I really believe that if you work with these people and open your eyes and see them - they are human beings. They're our neighbors. They're people who are in the community. If you have something to offer them, whether it's time, you have extra food, you know, help these people.
CONAN: Is there a plan to house these people?
ADEN: No. And Mare Island is a naval base…
CONAN: I think a former naval base. Yeah.
ADEN: Right, which is now part of the city. And there's actually some barracks that are there. There's three buildings, and I tried to contact the city about it, and they said that there's - you know, each building has about 150 rooms, which is similar to, like, student housing when you go to college.
ADEN: Three buildings. That's over 450 places where people can live. And I think, you know, if we as a community - yeah, we're broke. But I think those people have a lot more to offer if we can house them, clean the area up, help them. They're going to help our community.
CONAN: And be able…
ADEN: Nobody seems to pick it up.
CONAN: Dr. - let's get - thank you very much, Aden, by the way, for the call. And it's a problem that I think a lot of places have, Dr. Gaeta, and this idea of a barracks at a former naval base - and there are other conflicts, but the fact is, so many governments like that in California are just so stretched at this moment with money.
Dr. GAETA: Well, let me say to that, that local governments are stretched in part because of how expensive this group of people is without housing.
What we've been able to show in Massachusetts is that a chronically homeless person living in shelter or living outside is costing more than about $26,000 per person per year just in medical costs: emergency room use, ambulance use, etc.
CONAN: And how much does housing cost per person?
Dr. GAETA: The housing costs - the housing plus Services cost about 15-and-a-half thousand dollars, but when you take into account the fact that the costs -the medical costs come down with housing to $8,500 a year, there's more than enough left to pay for this housing.
CONAN: We'll talk more with Dr. Gaeta about how to deal with the problem of the homeless. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.
(Soundbite of music)
CONAN: This is TALK OF THE NATION. I'm Neal Conan in Washington. Today, our focus is on What Works, part of our series on finding real solutions to what seem like intractable problems.
Last week, we talked about a program that helps children in Harlem break the cycle of poverty. You can hear that conversation with Geoffrey Canada and find out more about the What Works series at npr.org. Just click on TALK OF THE NATION.
Today, what works to end chronic homelessness? Dr. Jessie Gaeta co-founded the Home & Healthy for Good program in Massachusetts, a program that's helped nearly 400 people, with a retention rate of 84 percent. It's also saved a lot of money.
What's worked where you live to help the homeless? What's been tried and did not work? 800-989-8255. Email us: email@example.com. And you can also join on that aforementioned Web site. That's at npr.org. Click on TALK OF THE NATION.
And let's see if we can get another caller on the line. This is Caroline, Caroline with us from Sacramento.
CAROLINE (Caller): Hello?
CONAN: Yes, you're on the air, Caroline. Go ahead, please.
CAROLINE: Oh, all right, thank you. I have a question about what has happened in Sacramento, and that is many people have been put in houses, some in foreclosed houses, that type of thing. Many of them do not want to be enclosed and have either left - there was one house that was burned down because a campfire was built, and I have heard about that chronically over the years.
I'm wondering if there could be - if your guest could respond to - could there be some sort of screening that might have the people chosen that want to live inside for the various solutions that may come out, and those that really are not going to stand the confinement be left alone outside with some sanitation provided, because it is just moving it from one place to another. And I'll take my answers or comments - well, I'll hold on if you want to…
CONAN: That's all right, Caroline. Go ahead, Dr. Gaeta.
Dr. GAETA: For this question, I think there's a misconception that homeless people don't want to be in homes or enclosed in homes. And I understand that perception, but I've come to find out, really, from working with homeless patients for years, that the vast majority of homeless people want, more than anything else, keys to an apartment.
They want keys to their own place. They want a home to be able to call their own. And, you know, there was skepticism about - in the beginning about whether or not people wanted to go into housing, and then if they did go into housing, whether or not it could be successful for people who have been living outside or in shelters for a long time.
And what we've seen after about three years now of putting almost 400 people into supportive housing is that the retention rate in housing, first of all, is very high. It's 84 percent after three years now. And we've really prioritized the most longest term and the most disabled people for housing. So that sort of disproves the myth that people don't want to or aren't able to safely be in housing.
So - but I do appreciate your idea of really taking into account what a homeless person needs and wants, when you consider what type of housing is best and what type of supportive services are best. And I think that is a wise thing to really involve a homeless person in the decision-making.
CAROLINE: Okay, thank you very much.
CONAN: All right, Caroline. Thanks very much for the call. If the benefits are being reaped - most - with the most-chronic people who have these diseases, who use emergency services, the emergency room and the hospitals and end up in the criminal justice system a lot, don't those benefits go down as you try to address the problem of people who are less chronically homeless?
Dr. GAETA: Well, we've got a long way to go before we get there.
(Soundbite of laughter)
CONAN: Oh, I understand that. But nevertheless, but if you're talking about solving a problem, as opposed to another way of managing it, you're going to run into the law of diminishing returns, no?
Dr. GAETA: Yes. That is a possibility. So, you know, right now we're dealing with highest utilizers, subsets. So, of course, we're seeing these cost savings because of a decrease in the medical care being used.
If we move on, if we're able to solve chronic homelessness and move on to people who are experiencing much shorter-term homelessness, I think we'll find, actually, that the emergency shelter system is actually working the way it was initially intended to work for this group of people, in large part.
You know, most people who are short-term - who experience short-term homelessness are able to move in and out of the shelter system within, actually, just a couple weeks and move out of homelessness, just through - you know, because of their own social support systems and because of some of the systems put into place in the shelters and the programs that are there to help them.
The people who are not doing well with this approach are long-term homeless people who are, what we call in medicine, have tri-morbidities, which means they have very layered mental illness, medical illness and addiction.
And so you're right that the cost savings of this type of program, intensive services in a home, would probably not be realized in the larger homeless population. But I also am not sure that such intensive support services, for instance, would be needed in the larger homeless population. And I think that, you know, the emergency shelter system is working for people who are only transiently homeless.
CONAN: And let's talk with Paula, Paula calling us from Route 404 in Delaware.
PAULA (Caller): Hi, yes. One of the things that I wanted to say is I work in a federally qualified health care center, and we find that with the homeless population, a lot of them have been incarcerated. And because of that, they're excluded from any programs for housing that are run either by the local or state governments because of their history of incarceration. And I really think that that needs to be addressed because once they've been consequenced once and gone to prison and paid their dues back to society, I just think that they continue to suffer the consequences of their incarceration and get excluded from so many programs that could normally help them.
CONAN: Is that a problem in Boston, Dr. Gaeta?
Dr. GAETA: It is a problem, and I think there are some ways around this. So you're right that, you know, chronically homeless people are incarcerated at pretty high rates, and that will often exclude them from housing opportunities because of past queries or background checks or whatever. And one way that we've kind of worked around that here is that we've had progressive shelters in Massachusetts agree to really try this permanent supportive housing by, first of all, working with landlords who they've built up relationships over time with and who are willing to rent to formerly homeless people.
But the shelters have also, in some cases, actually purchased properties and rehabbed them and have been able to, in a way, sort of be their own landlords for homeless - chronically homeless people who they know very well and who are - you know, who they know how to support, and they know the risks up front.
So one way to get around that is to work very closely with landlords, to build relationships with landlords over time, or to have shelters actually begin to convert their resources from sheltering to housing and to become landlords themselves as organizations.
CONAN: Paula, thanks very much.
PAULA: (unintelligible) Thank you.
CONAN: Yeah, bye-bye. Can I ask you, Dr. Gaeta? I know that this idea developed in a lot of different places and a lot of different times. How did you get involved in this?
Dr. GAETA: Oh, that's a good question. I came out of residency training in Boston and entered this field immediately, having known that I wanted to do this for a long time. And I basically practiced internal medicine in shelters and outdoors for a few years before I really began to feel frustrated by the difficulties I was having treating chronic disease in those settings.
And, you know, for instance, I was learning to be able to estimate how long a person had been homeless - a patient had been homeless simply by examining their teeth and their skin and their joints. You know, for example, I watched this progressive physical deterioration that occurs the longer a person is homeless. And this unjust link between homelessness and poor health is most painfully clear to me as I watch my patients die very prematurely, in fact, at an average age of 47, which really speaks to the degree of disease in this group of people.
And so at some point, I felt so frustrated by writing prescriptions for insulin and for blood-pressure medications and for - you know, frustrated by trying to treat cancer in this setting that one day it sort of clicked.
It clicked that what I really need to be doing is working on a prescription to an apartment, for keys to an apartment, that if there was a way for me to advocate for housing, then I would have much better outcomes in trying to manage the chronic diseases of people in this - in these settings than I could with any other medical intervention.
So I really started to think of it as a medical intervention. In fact, I have started teaching medical students that homelessness is a medical condition with a mortality rate that is parallel to that of some cancers, in fact. And that's really how I've started to think of this.
So I think of it as a public health issue, and housing is really a social determinate of health that needs attention from the medical community.
CONAN: Let's get another caller on the line. It's interesting. Amy, Amy calling from Kansas City.
AMY (Caller): Hi. I spent roughly six months homeless. I was living out of my car. This was several years ago, and I got to know quite a few people by going to the soup kitchens and dining with them and talking with them. And I found out a lot about these people. The one thing I found out that people who -anyone who committed a crime in Missouri would end up in a halfway house in Kansas City. And when they kick you out of there, you're on your own. So a lot of those people were, you know, homeless in Kansas City. I met several people who said they never wanted a home around them. They never wanted four walls because they've been incarcerated for so many years and that they were doing just fine on their own.
These people - you'd be amazed at how adaptable they could be and how they hide their camp and how they protect themselves. And so I do believe there's a lot of homeless people that wish to stay homeless. I also know that there are a lot of homeless people who would never even consider giving up their drinking and their drugs, even if it meant getting an apartment. And, actually, for them getting an apartment sounds like a humongous responsibility, and it's just a place for them to sit and do nothing.
CONAN: Well, let me just follow up on that point you've just mentioned, Amy. And Dr. Gaeta, the requirement, as I understand your description of this, is not - they don't have to give up drinking or drugs to qualify in the housing first theory of - so, in a way, aren't you subsidizing their continued alcoholism and their continued drug use?
Dr. GAETA: No. And first of all, that's correct, that sobriety or being clean from drugs and alcohol is not a requirement for housing, just to like it is not for me or for my friends.
AMY: Okay. I must have heard that wrong.
Dr. GAETA: That's okay. But I think you bring up a couple other good points, Amy. But on the addiction side piece one more time, I want to say, too, that I really think of treatment outcomes for addiction as being completely different from housing outcomes.
Dr. GAETA: And the two aren't necessarily - I think that there's - they're exclusive of one another. And what I'm really talking about is trying to improve someone's housing outcome with a hope, of course, ultimately, that their treatment outcomes may improve as well. You talked about the responsibility of having a home and the stress of that. And they do think that is a big stress for…
AMY: It is. It's very daunting for them. I've seen people get apartments, and then within weeks just say I can't handle this.
CONAN: Can't deal with it. Yeah, but they're not getting some of the other -the social worker and the other kind of benefits that you're talking about, Dr. Gaeta.
Dr. GAETA: Yes.
AMY: Yeah. They have mental illness. They have drug and alcohol addiction…
CONAN: Amy, let Dr. Gaeta talk for a moment, please.
Dr. GAETA: Amy, I agree with you that for someone who's experiencing those kinds of problems, housing is a really daunting proposition. But this housing that I'm talking about, which I think, is most appropriate for someone with those kinds of problems is not just the four walls and a set of keys, and here, you need to figure out how to use a kitchen again for the first time in years. You need to, you know, mediate any disputes or issues you might have with neighbors or a landlord. You've got to figure out how to pay bills.
Instead, this housing really comes with intensive services that are offered in the home. And those are in the form of a case manager who knows this person -hopefully, ideally - well, even before the housing starts and helps this person through what can be a very difficult transition into housing.
If the person who knocks on the door three or four or even more times each week and says, you know, hi, how are you doing? How can I help you today? What's been hard? How can I help you sustain this tenancy and stay housed - which ultimately will probably lead to some improvements in your quality of life and relationships, chronic diseases, etc.
Dr. GAETA: So, the support of services are really important. They're almost, I think, just as important as the housing.
AMY: That's why (unintelligible) make a difference.
CONAN: Thanks very much for the call, Amy. Appreciate it.
AMY: Thank you.
CONAN: We're talking about what works with homelessness. You're listening to TALK OF THE NATION from NPR News.
And let's see if we can get another caller in. This is John, John with us from Davenport, Iowa.
JOHN (Caller): Hello. Thank you for taking my call.
CONAN: Go ahead, John.
JOHN: I am mentally ill. I have been homeless once and on the street three times. There's a difference between the two. I was told to speak only of my experience and not my research or my experience with NAMI. So, I will tell you that there are - Amy was right. There are number of people that don't want to get into housing. And as far as getting - the horrible things about being on the street are finding ways to stay clean, finding ways to get enough food. There are people that - there are - when I was on the street in Woodland, California, the Greater Baptist Church served a meal once a day for us.
I have slept under bushes. I have had to - I have had a car and been on the street. You're welcome to ask questions. I don't know what to say or would you be interested in hearing, since I've been told to speak only of my experience.
CONAN: Well, John. I'm just curious. As you speak of your experience, would a program like the one you've heard described have helped you? Would it help now?
JOHN: The important point of the program that you mentioned is that it is supportive, that it supports the person. They're not just saying - giving a set of keys and saying, okay, look you've got an apartment.
CONAN: Problem solved.
JOHN: Yeah. It's a matter of staying with them. It's a matter of providing them with means.
CONAN: And, John, I don't mean to cut you off, we just have very little time left. I wanted to give Dr. Gaeta a chance to respond.
Dr. GAETA: Sure. I really want to pick up on something that John said, and Amy as well, which was that many people may not actually want housing. And let me qualify something I said earlier: and that is that housing - typically and traditionally, as it's been offered to people who experienced homelessness in the past - has often come with strings attached, which I think are really hard to swallow if you're someone who has been through the experience of homelessness. So, housing, I think, is really important that it comes with no strings attached. And if you asked homeless people if they wanted housing with no strings attached, I think you might get a different answer.
CONAN: Now, Dr. Gaeta, thank you so much for your time today. And we'll follow the progress of your program.
Dr. GAETA: Thank you very much, Neal.
Dr. GAETA: Appreciate your coverage on this topic.
CONAN: Jessie Gaeta, co-founder of Home & Healthy for Good, with us today from WBUR in Boston. You can learn more about that program at What Works at npr.org.
This is TALK OF THE NATION.
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