By David Liebler.

Falling through the cracks – it’s a phrase we often hear when it comes to our most vulnerable populations. In Placer County, though, a concerted effort is under way to focus on chronic homeless individuals who have traditionally needed assistance from a variety of agencies and programs.  And this effort is working; county staff is helping individuals find housing, linking them to needed resources – and changing their lives.

As one of 18 counties participating in the State’s Whole Person Care Pilot Program, Placer County has developed a custom-designed program to provide intensive case management through four different service bundles:

  • Engagement – A focus on building a positive relationship with program participants so they will be open to receiving additional services.
  • Complex Comprehensive Care Coordination –Comprehensively assess each participant and develop a treatment plan so participants can focus on goals that are meaningful to them.
  • Housing – Assist participants in finding housing, training them on how to become good tenants and other assistance as needed.
  • Medical Respite – A six-bed facility that provides individuals a place to stay after being discharged from the hospital so they can heal and not have to return to the hospital.

“We really decided to target people who were experiencing homelessness – and especially people who were experiencing homelessness who were being served by multiple systems of care, but who weren’t getting good outcomes,” explains Placer County Health Officer Rob Oldham. Many of these individuals have behavioral health or substance abuse problems, issues compounded by the high cost of housing in the County. The end result was they were living on the streets.

The program is unique because it focuses on very low number of caseloads, projecting to serve about 450 people over the five years, — and only about 100-150 at any one time. This allows for intensive care and coordination.

“It’s a client-centered program. If they are looking for help with mental health issues, with substance abuse issues… if they are looking to improve social-support systems, if they want help getting a job, there’s a wide range of things we are willing to help them with,” says Geoff Smith, the Program Manager for Whole Person Care in Placer County.

While the program focuses on intensive case management, the investment can ultimately save money. Studies have shown that it costs much less to house individuals experiencing homelessness than to pay for other services, such as emergency care or incarceration.

Housing Coordinator Sam Nowell is on the front lines, working directly with the clients. The work with each client can be time intensive, but those efforts are paying off. “Our program was created to fill a gap … we are able to take people that were not connected to other programs,” she says. “We take the population that has fallen through the gaps in the past.”

She talks about how many clients had given up on trying to secure housing on their own.  Finding affordable housing in Placer County can be extremely difficult, especially for individuals who have been homeless and may be dealing with mental health or substance abuse issues.  This is where the Whole Person Care staff comes in – to help them search for appropriate housing within their budget, to assist in filling out applications and meeting with landlords, to help them learn how to be good renters. Once a client has obtained housing, county staff helps link them to community resources to help them achieve independence.

“I can’t over-emphasis how hard it is to take care of a mental-health issue or a medical problem or to keep a job if you don’t have housing,” Smith says. “Once housing is stable, then people can really take care of other things in their life. There’s nothing else you can worry about when you’re homeless.”

A key component of the program is collaboration. “We work with nonprofits and other government agencies  to help our clients meet their needs.  Anything they might need to make their transition smoother, we link them to,” Smith explains. This could mean helping clients obtain a Social Security card, find a local church or needed transportation. But an important first step is housing. And Placer County just reached a milestone by permanently housing its 100th client.

For program participant Ellen who had cancer surgery last year, the program “has meant everything to me. Without the permanent housing, I don’t know where I would be. I now have a whole support system.”

Program Manager Smith’s eyes light up when he talks about how the program has helped people get off the streets and receive the help they needed. “It’s been an amazing opportunity to do this and to see how much of a difference it’s made in the lives of these people. … It’s just incredible. There are no words.”

Formerly homeless, Donovan and his wife Elizabeth now live in a two-bedroom apartment thanks to the program.  “They reached out and helped us when we needed it the most. Placer County gave us the strength to move forward and that the future would be brighter and better. “

And for Ellen, Elizabeth, Donovan — and nearly 100 other Placer County residents — that future is definitely looking brighter and better.

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Originally posted at the California Association of Counties.