From Homelessness to Housing – and Hope

September-October 2019


From Homelessness to Housing – and Hope-a
Illustration by Larry Moore

Beneath a busy highway overpass in downtown Pittsburgh, a memorial wall honors 165 individuals known to have died while homeless in Allegheny County between 1989 and 2018. Every December, on the Winter Solstice, Pittsburgh Mercy's Operation Safety Net holds a candlelight vigil there to commemorate the lives lost on the streets during that year.

Each small, rectangular, brass plaque on the cement wall features the name of an individual whose story might have had a happier ending. Each plaque begs a question I'm sure many who work with those experiencing homelessness have asked themselves: Could this person's death — these other deaths — have been prevented?

Since I came aboard as Pittsburgh Mercy's president and chief executive officer in January 2019, I've learned so much about the many unique programs offered by Pittsburgh Mercy. They are rooted in the caring tradition of the Sisters of Mercy, who first came to Pittsburgh from Ireland in 1843 to minister to the sick, poor and uneducated. Like those first sisters, Pittsburgh Mercy embraces wellness and makes sure people's basic needs are met. It's hard to address a person's health when they don't have a roof overhead, know where their next meal is coming from, or are living with mental health or substance use disorders, as some do.

Under a decade of leadership by Sr. Susan Welsh, RSM, my predecessor who retired as president and chief executive officer earlier this year, this health and wellness organization made a conscious effort to create its own holistic medical home model to provide user-friendly, community-based programs along a continuum of care that meets people where they are in life and embraces the whole person — body, mind and spirit.

Pittsburgh Mercy has many doors through which those experiencing or at risk of homelessness can enter, receive care and ongoing support, and exit with a key to their own home, a better quality of life and hope for the future. In my first meeting with Jack Todd Wahrenberger, MD, MPH, Pittsburgh Mercy's chief medical officer and medical director of Pittsburgh Mercy Family Health Center, he explained that "there is no wrong door." A person in need of services can enter through behavioral health and/or addiction services, medical or physical health services, or programs for those with intellectual disabilities, veterans,
persons reentering the community following incarceration — and through programs for those experiencing homelessness.

Some doors aren't visible ones, especially when the process starts outside a bricks-and-mortar setting. The effort to house someone can begin as medical care under a bridge, with a visit by an outreach team from Pittsburgh Mercy's Operation Safety Net, a medical and social services outreach program for persons experiencing homelessness. While housing programs can be offered without outreach teams, direct care on the streets, where the most vulnerable people live deep in alleys and under bridges, opens a level of trust that is a powerful tool for engagement and helps empower people to make important life transitions.

In my discussions with our colleagues, I've learned the causes of homelessness are complex, many and vary for each person. Some common themes include mental illness, substance use, unemployment, inconsistent income, poverty, domestic violence and fractured support systems. Gentrification is also a culprit as housing costs escalate and established residents may have no recourse but to relocate to the street. The most vulnerable end up under bridges. Providing persons who are street homeless with housing and wraparound support services reduces hospital stays and saves the overall health care system money.

There are so many stories that illustrate the journeys of street homeless individuals who are welcomed through Pittsburgh Mercy's doors. When I asked our team to share a success story that captures the continuum of care, one that stood out was about a Pittsburgh-area veteran, who began a bout of off-and-on homelessness after he was laid off from his job 20 years ago. Living in survival mode, he bounced from our Winter Shelter to another shelter, the YMCA, couch surfed and slept in a parking garage some nights. Medically complex with a history of alcoholism that sometimes left him passed out on the street, he was a frequent user of emergency services. After he began working with a case manager, he obtained food stamps, medical assistance through Medicaid, and, with the help of Operation Safety Net's Project HELP, a free legal clinic, eventually Supplemental Security Income (SSI).

About the same time in 2013, the veteran secured housing through our scattered-site housing program. He began paying his own utility bills, keeping medical appointments and maintaining sobriety. Because of his success in achieving stability, he transitioned from one of our housing programs to his own Section 8 apartment. The housing case manager reminded him that Operation Safety Net's door is always open – and he still calls from time to time.

The philosophy at Pittsburgh Mercy is, "Mercy for all. Come to us as you are. We can worry about everything else later." But I've learned that it's not only that welcoming, open-arms attitude that makes our community health and wellness organization a shelter in life's storm; it's the reverence and love shown toward the persons served. Respect, not disdain, is key. Across the board, our focus is on engagement.

Shelters continue to be the first step off the streets for many individuals. Pittsburgh Mercy's Winter Shelter, operated with support from Allegheny County Department of Human Services, is a low-barrier shelter, meaning shelter first, thereby allowing even those with substance use disorders to seek a warm haven and access services during the winter months. Bethlehem Haven, a provider of shelter, housing and services to vulnerable women in Allegheny County and part of the Pittsburgh Mercy Family of Care, also offers an emergency shelter.

Pittsburgh Mercy embraces the Housing First model, a national best practice using the philosophy that if you take care of a person's basic needs, such as shelter, they may be more open to other types of services. Pittsburgh Mercy has created a variety of teams to identify and address other issues people are facing, from mental health to substance use assessment and treatment to better networks to meet their overall medical and social service needs. These are not only doors of entry, they are pillars of support on the road to housing. Another point of entry that I'm proud of is Bethlehem Haven's Medical Respite program, which provides acute and post-acute medical care for persons experiencing homelessness, and those too ill or frail for a shelter or to be living on the streets. Each of those programs can help facilitate a path to permanent housing, including supported housing, private apartments and scattered site rental units in the community.

Bethlehem Haven also offers Rapid Re-housing, an approach that provides housing identification, move-in assistance, short-term rental assistance, case management and aftercare support. Safe at Home, another program, offers monetary and basic assistance to women who are homeless or at risk of homelessness. Bethlehem Haven has transitioned 3,927 women to permanent housing over the last 11 years — 77% of those served in its shelter and temporary housing programs. Through Bethlehem Haven's Homeless Diversion, Safe at Home, and Aftercare programs, an additional 1,749 families avoided homelessness and retained their housing. Even as I analyze these numbers as we work to improve services, I keep in mind that these are individuals who are on a journey to well-being, who after they are housed can focus on resolving other concerns in their lives.

In late 2018, Pittsburgh Mercy's parent, Trinity Health, provided a loan commitment of $3.5 million to Bethlehem Haven to develop a 32-40 unit affordable housing complex in the Uptown neighborhood of Pittsburgh. Although the area has experienced poverty and disinvestment over the past 50 years, it is now focused on creating a dynamic residential and commercial core through high-quality, integrated and sustainable development, greening and art. The housing complex will be available to vulnerable individuals who were formerly homeless, at risk of homelessness, and/or individuals with a disability with household incomes of approximately 50 percent of the area median income. The loan commitment is part of Trinity Health's Community Investing Program, established more than two decades ago as a way for Trinity Health to leverage its financial strength by investing in low-risk, low-interest rate loans to build infrastructure in our communities.

McAuley Ministries, Pittsburgh Mercy's grant-making foundation, got the project off the ground with a $200,000 grant, matched by local public funds, toward the acquisition of two nuisance properties on the project site. McAuley Ministries invited Bethlehem Haven to submit a grant request of $1 million to support the development of the affordable housing project, which will provide a local transition from shelters and other temporary housing options to safe, accessible, permanent housing in an area that is rapidly gentrifying.

While women are motivated to leave the shelter and rebuild their lives, Bethlehem Haven's chief executive officer Deborah Linhart has indicated to me that there just isn't a sufficient supply of small, extremely affordable housing units, which are the first rung out of homelessness. The project has arrived at a critical time. Allegheny County has a shortage of 17,000 affordable housing units to meet current needs — and the average rent for a one-bedroom apartment in Uptown Pittsburgh is now $1,146. The county's median income was about $56,000 in 2017, according to the U.S. Census Bureau.

Since 2014, more than 2,600 individuals have found a home through the efforts of Operation Safety Net and the support of other Pittsburgh Mercy programs. The funding to house these individuals has come through the U.S. Department of Housing and Urban Development's Emergency Solutions Grants program. Roughly 85% of people housed have remained in their new homes, with most achieving independence within two years. (Independence in this context is the ability to live on their own, though some still receive support services.)

McAuley Ministries has been supportive of affordable housing initiatives since its founding in 2008, awarding a total of $991,750 in grants as of June 2019 to Bethlehem Haven and Pittsburgh Mercy. In the last decade, the foundation has awarded $470,000 to Bethlehem Haven for its Rapid Re-Housing programs, permanent supportive housing, and pre-development property acquisition for the affordable housing project. Additionally, Pittsburgh Mercy has received $521,750 in grants from McAuley Ministries for case management that allowed Operation Safety Net to house individuals living on the street, development of Trail Lane Apartments, supportive services for Trail Lane, emergency rental assistance, and Operation Safety Net's River to Home program that transitioned 35 street homeless individuals into permanent supportive housing.

Pittsburgh Mercy offers a comprehensive range of services under a single organization on the path from homelessness to a new home. Housing someone is only the beginning. Pittsburgh Mercy has found that to have success in housing, individuals most often need ongoing support. In 2018, Pittsburgh Mercy served 2,541 people across its homeless programs.

Finding the fit for individuals who may be homeless and struggling with substance use disorders, mental health issues and chronic medical diagnoses can be a challenge. I am moved by our colleagues who day in and day out provide direct care for the underserved, for those who are most vulnerable and sometimes present challenging situations. Pittsburgh Mercy's Assertive Community Treatment teams each include a psychiatrist, nurses, therapists, case managers, drug and alcohol counselors, a peer support specialist, employment specialists, a forensics specialist (who works with the incarcerated population in jail and upon release) and other mental health professionals who work together to offer mental health, rehabilitation and support services to people in their homes. In addition to the Assertive Community Treatment and Integrated Dual Disorders teams, Targeted Case Management (Service Coordination) and Specialized Service Coordination professionals make home visits and link individuals to services and resources, including education, employment, mental health treatment, physical health care, wellness coaching and activities that promote social well-being.

Pittsburgh Mercy opened Trail Lane Apartments in 2012 to provide housing stability for individuals experiencing homelessness as they worked to overcome addiction and mental health challenges. The residents who occupy the 16 private apartments have a home for life, with support staff available around the clock. Pittsburgh Mercy also has 10 units at Generations, an apartment building in a neighborhood that borders the city. That building is similar in nature, but staffed only on weekdays.

Once individuals are housed, Pittsburgh Mercy helps with benefits coordination, drug and alcohol services, legal assistance, mental and physical health services, recovery support and veterans' services. The Assertive Community Treatment teams help individuals with community living skills, such as using a laundromat or public transportation. They also equip the person with items needed to live on their own, such as furniture, a state photo identification card and a copy of their birth certificate. Things that are simple for most individuals are sometimes more difficult for those facing mental health or substance use challenges. I was heartened when I learned that Pittsburgh Mercy Family Health Center has opened a food pantry as a pilot program to combat hunger and address food insecurity for those seen there.

While behavioral issues can make housing options more difficult to find, so do financial barriers. Rent can be costly for those on fixed incomes, especially if they don't qualify for federal Housing and Urban Development funds or Section 8 vouchers. For persons trying to reenter the community after incarceration, housing and finances can be additional barriers.

I've been impressed by the innovative, integrative business model Allegheny County has implemented that recognizes the complex problems in today's world. Under this model, caseworkers from multiple organizations, including Pittsburgh Mercy, work together to mix and match services and share data from an array of programs, making person-centered decisions with a full-service view. Given that two-fifths of persons served are multi-need and receive services from three or more programs, the county is now able to provide person-centered service delivery for specific groups.

Allegheny County Department of Human Services (DHS) has been a strong advocate for the homeless population. At the U.S. Department of Housing and Urban Development-required Point in Time count on January 30, 2019, there were approximately 774 people, sheltered and unsheltered, experiencing homelessness in Allegheny County. There are also individuals at risk of homelessness who are in tenuous situations, such as living temporarily with friends or relatives, or at risk of eviction.

In addition to the Winter Shelter, Pittsburgh Mercy partners with Allegheny County DHS and three other providers to offer Healthy Housing Outreach, an innovative, three-year program that offers behavioral health services and other supports to individuals, families, youth and veterans who are experiencing homelessness. By partnering with health care providers, family services, the criminal justice system, landlords and others, Pittsburgh Mercy helps individuals access housing, stabilize health conditions and maintain permanent housing.

In the communities served by Pittsburgh Mercy, the doorway to solving housing issues is Allegheny Link, a part of the Allegheny County DHS that serves those who are homeless or on the verge of homelessness. After completing an assessment, Allegheny Link determines whether the person needs a security deposit and first-month rent, if they are in arrears with rent or need ongoing rental assistance, or if people who are living in the streets need a higher level of care.

Once I assumed my role at Pittsburgh Mercy, I was happy to finally meet Jim Withers, MD, FACP, founder and medical director of Operation Safety Net and an internationally recognized leader in street medicine. He shared with me that during his years of working with individuals who are homeless, he has discovered that health and housing are intimately related. That's something that Sisters of Mercy founder Catherine McAuley recognized back in 1824, when she used her inheritance from an Irish couple she had served for 20 years to build a large House of Mercy where she and other lay women would shelter homeless women and minister to the sick. Pittsburgh Mercy continues Catherine's mission and strives to bring her "mercy for all" approach full circle.

TONY BELTRAN is president and chief executive officer of Pittsburgh Mercy. Pittsburgh Mercy programs and its 1,700 employees serve people at more than 60 locations in Southwestern Pennsylvania.



Tony Beltran of Pittsburgh Mercy writes about the many doors through which patients can enter to move toward secure housing: some people come through behavioral health or substance use disorder treatment, others after medical procedures, still others through veterans' programs. The philosophy of "Mercy for all. Come to us as you are," allows Pittsburgh Mercy to design wrap-around services at any point of entry.

1. Pittsburgh Mercy embraces the Housing First model, a national best practice that presumes a person will be more receptive to other types of care once their basic needs are met. How does your ministry attend to basic needs once the immediate services are provided? How is attention to safety, nourishment and housing handled at the point of discharge? Who screens for these determinants of health and who connects patients with resources offered through your ministry or through partnerships you have formed?

2. What can we do to uphold the dignity of patients whose lives have taken an unexpected turn toward housing insecurity — veterans who've served their country, blue collar workers who can no longer find employment, single mothers with low-income jobs? What pastoral and counseling services do you provide or refer people to for support? What type of training is offered to co-workers to help them recognize any unconscious bias they may have toward persons who are homeless?

3. Tying health to housing is an expensive proposition. What would you say to people who argue that the health care industry is complicated enough and its resources limited enough without adding real estate and subsidized housing to its mission?


From Homelessness to Housing – and Hope

Copyright © 2019 by the Catholic Health Association of the United States

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