Housing for Health tackles L.A.’s tough homeless problem- Interview with Director Marc Trotz

Marc Trotz is currently the Director of Housing for Health, a new program that creates a broad range of residential housing options linked to the public health system within the Los Angeles County Department of Health Services (DHS).   Mr. Trotz comes to LA with plenty of experience; he has spent the last twenty-five years working in the public sector on housing and health policies in the San Francisco Bay Area.  The majority of his work has focused on the development of supportive housing for the homeless, those with chronic health conditions, the elderly, and other populations in need of housing with on-site services.  Prior to working for the Los Angeles DHS, Mr. Trotz was the Housing Director for the San Francisco Department of Public Health, where he introduced and directed the Direct Access to Housing program.  Direct Access to Housing has been recognized nationally as a pioneering approach to housing and health improvement for people who have had long histories of homelessness coexisting with complex medical and behavioral health issues.  

Mr. Trotz strongly believes that housing is a health care issue and that stable and supportive housing environments are necessary to make meaningful and lasting improvements in the lives of homeless clients.  His work over the last twenty five years makes him a leader and innovator in the field. 

I interviewed Mr. Trotz in early 2013, to ask him about the new program in Los Angeles and the experience he brings from San Francisco. 

LS: What is the Housing for Health Program, and how did it come about? 

MT:  Housing for Health (HFH) is part of the LA County Department of Health Services (DHS), and we work with clinicians and health systems to create housing opportunities for L.A.’s homeless population.  Permanent supportive housing is decent, safe, and affordable housing linked to support services that provide homeless people with housing stability, improved health status, and greater independence and economic security.  This is the cornerstone of HFH's approach, and is quite different than more traditional systems of providing housing for the homeless, which often demanded that individuals “prove themselves”.  In traditional systems, in order to qualify for housing, homeless people were required to overcome significant barriers such as trauma, substance abuse, mental illness and extreme financial constraints while living out of a cardboard box.  When you are homeless, front burner issues like HIV status, taking psychiatric medications, or going to the doctor is not on the minds on those who are surviving on the streets.  In essence, we asked people to cure themselves before we offered them housing.  The reality is this does not happen, especially when a person is not housed. 

People who had been working on issues of homelessness for a while saw that our paradigms didn’t work, and it was an evolving shift in the housing movement.  With the advent of harm reduction strategies over the last few decades, there began “housing first” language.  Under the leadership of Dr. Mitchell Katz- at the time the director of the Department of Health Services in San Francisco- we started to put “housing first” language into action, and we minimized barriers to permanent supportive housing. We operated under the simple premise that if the health department had access to housing units, we could do a lot for our clients.  With the Direct Access to Housing program we were able to show that supportive housing can yield amazing results. For example, instead of spending $1500 to $3000 per day in the ER or hospital ward, we could spend $40/day in supportive housing and the health outcomes were better.  With housing, homeless persons reduced harm to themselves incrementally, and all sorts of wonderful things began to happen.

Our experience in San Francisco showed what could happen with the right expertise for homeless clients with multiple needs and comorbitities.  We brought our experience from San Francisco and currently work directly with L.A. DHS under the leadership of Dr. Katz, who relocated to Los Angeles in 2010 as the DHS Director of L.A. County. Essentially, we are trying to create thousands of housing exits out of the health care revolving door for homeless clients, and this is beginning to happen in many different ways as we scale up this new program in Los Angeles.  Health providers act as the agents who refer patients or clients to the HFH program.  This is an effective approach, as ERs and hospital systems know who is most in need of housing- they are the homeless patients who end up in our health system. 

LS:  What are the benefits of the HFH program?

MT: The cost to the public health system incurred by a relatively small but costly cohort of individuals, whom due to their lack of housing, remain hospitalized for greater lengths of time and/or have repeated and unnecessary contact with the public health system, is tremendous.  These people bounce from hospital to street to shelter.  The ability to house chronically homeless persons and high-utilizers of hospital inpatient and emergency services in supportive housing reduces cost to the public health system and also improves the health of those who get permanent supportive housing.   

Most health providers will tell you they are chasing their tails trying to fix the health problems in homeless patients. Providers know it’s not worth spending the time and money to address health issues if a person does not have somewhere to go, and we see time and time again how this doesn’t work well.  Homeless patients come back to the ER with the same or worse condition, and the process starts all over again.

In regards to housing the homeless as a health issue- it’s amazing how many health systems don’t focus on this.  When we started doing this work in San Francisco and talked to doctors and nurses, they told us we need a place to put homeless people.  “Housing is health care” and this is obvious to those that care for homeless clients. When you do get a homeless person into a stable living environment, it’s wonderful to see how someone can bounce back. 

To get specific, the HFH program benefits individuals and the Los Angeles community by improving the health and wellbeing of a vulnerable population that typically experiences chronic homelessness, high rates of disability, multiple un-treated health conditions, and early mortality.  This has been shown to decrease health costs and overall costs as well. 

LS:  What services are provided as part of the HFH program? 

The HFH program is not one unified program.  We partner with different groups in order to make available all different kinds of housing for our clients.  For example, in our 100-unit housing structure for the homeless on Skid Row, there will be on-site case management with on-site support services that will be able to support any and all things that a newly housed person needs.  We are working towards a health clinic within the building on Skid Row that will serve our clients in the building and other tenants in the immediate area.  In South LA, the HFH program is more dispersed because the housing units are spread out.  We have created a roving team that will provide support services to 15 sites.  We are working on increasing access to recuperative care and other stabilization environments so that we can facilitate immediate placement out of hospitals.  In every permutation, we provide intensive case management and access to high quality healthcare.

LS:  What are the unique features of the HFH program?

In the early years of the supportive housing movement, there was a housing project for patients with each type of disease state- mental illness, HIV, substance abuse, etc.  Making housing dependent on specific diagnoses can be helpful, but often serves as another barrier to housing.  Our approach is more integrated:  we serve homeless clients with complex behavioral and health issues that lack housing. Given the years of experience we have, we know that when we minimize barriers to housing, this is often the key to improved health.

While there are a lot of tools and organizations out there determining who the most vulnerable chronically homeless are – we know from experience they are in the ER, in public hospitals and clinics, and we have taken leadership on this.  Health providers are the referents within the system that bridge the connection to housing for homeless clients. 

We are just getting started in Los Angeles but we can already see the positive results of our work and the support within DHS and the greater housing and health community.  We want to collaborate with any and all entities that can join us in helping to provide housing stability and improved health outcomes for homeless people. 

LS:  How can physicians and other clinicians help those with substandard housing or who are homeless? 

It’s not always easy for health providers.  I’ve spent some time in homeless clinics and I have seen how hard it is to find the time to address a patient’s housing issues.  In a way, that is what HFH is trying to address – we can serve as the housing experts to the health system so that when a provider or hospital social worker recognizes homelessness a key issue, they can refer that person to HFH.  It is nearly impossible for health care providers to stay on top of the always-changing housing world.

There can be some reticence on the part of doctors about how well people can do in supportive housing.  But again, that is all part of the cross learning we are in the middle of doing.  Part of our job is to explain and demonstrate how supportive housing , while not a traditional healthcare issue can provide a significant range of support and health services and have tremendous health improvement outcomes.

LS: What advice would you give a city that wants to try to build a program like HFH? 

I would say try to be as creative as possible in finding residential resources for the homeless that are high utilizers of health services.  There are a lot of different ways of finding a housing unit for someone and for a program to be successful it will have to be flexible about what can be used.  In many cities, the need is more than non-profit affordable housing programs can absorb.  Programs need to employ more “guerilla tactics”, partnering with anybody and everybody and constantly look for housing units.  In addition, programs should strive to be in sync with health care providers, because tightly linking a permanent supportive housing program to the health system enables appropriate utilization of resources and the cost saving needed to support community based housing. If the health system identifies who is in most need of housing, progress can be made on highest utilizers of health services among the homeless.  This has been effective in San Francisco, and we are hoping to replicate it 10 fold here in L.A.

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For more information on Permanent Supportive Housing and its cost-effectiveness in various programs throughout the U.S., the following resources may be useful:

Housing Chronically Homeless Veterans: Evaluating the Efficacy of a...

Project 50: The Cost Effectiveness of the Permanent Supportive Hous...

Housing and Health: Time Again for Public Health Action

About the Author:  Linda Sharp, MD is a physician at Harbor UCLA Medical Center in Los Angeles, CA.  She is also a content editor for HealthBegins.

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