A transformative care strategy imported from Trieste, Italy, will soon be implemented in Hollywood, according to journalist Rob Waters. Hollywood has the second-highest concentration of homeless people in Los Angeles, which itself is deeply affected by the twin pairing of homelessness and mental health neglect – 36,000 people are homeless in LA, three quarters of whom are unsheltered, and 30 percent have been diagnosed with a substance abuse disorder or “mental disorder.”
While the US system of care for mental health focuses on medical approaches, compliance, and documentation, Trieste has a more holistic approach, ensuring that all facets of life, from physical needs (for food, clothing, and shelter), to community connection and employment, are met. Roberto Mezzina, who was Trieste’s director of mental health until October of 2019, is quoted in Waters’ article as saying:
“American society has the most striking contradictions— especially Los Angeles. The system is very complicated—patchy and fragmented and existing in chaos. The jails became like hospitals, and the hospitals can become like jails. In this situation, to create a new experience and new pathway for care is not easy. It’s not enough to create a good community mental health center and then scale it up. You have to change the imbalance of power between service providers and service users.”
There have long been efforts to create access to better care for the most vulnerable and homeless. Recently, Kerry Morrison, the former director of the Hollywood Property Owners Alliance, pushed for the most vulnerable homeless residents of Hollywood, who she deemed the Hollywood Top 14, to receive better care. She hoped to create access to treatment and new shelters, which resulted in a search that unearthed Trieste.
Trieste, Italy, especially as compared to LA, had an inclusive, humane, and effective community mental health system. Hoping for the same for LA, Morrison brought many local leaders to check the city out for themselves, including LA District Attorney Jackie Lacey, Superior Court Judge James Bianco, and Jonathan Sherin, a psychiatrist and the director of mental health services for LA county for the past three years.
Whatever Morrison did in Trieste, it worked – California’s Mental Health Services Oversight and Accountability Commission voted in May of 2019 to allot $117 million over five years to finance a pilot study based on Trieste’s system of care. These funds are unrestricted, and as such, do not need to follow the federal rules that guide programs such as Medicaid. If the pilot shows success in Hollywood, Morrison and Sherin hope to expand the program across LA County.
“Our system has been driven almost entirely by medically oriented approaches and funded based on allowable services with cumbersome bureaucratic requirements,” Sherin said in Waters’ article. “We spend our time making sure that we’re compliant and that we’re taking care of the auditor, instead of engaging people as human beings, identifying what they need, and addressing the other issues in their lives.”
The proposal is not without empirical support – psychologist Dave Pilon, who helped develop the Hollywood pilot, led an experiment in the early ’90s that provided intensive case management as well as a full range of services for clients diagnosed with “severe mental illness.” Their funding, like the Hollywood pilot, was not earmarked solely for clinical services and could be spent on any service.
The results were positive – their clients spent less time in the hospital, were less likely to be institutionalized, were more likely to work at jobs and participate in leisure activities, were more likely to say they were satisfied with their services, were more connected to their therapists, and had more income, among other outcomes. The costs were higher (around $10,000 more per client), but Pilon believes that the pilot’s plan to shift funding priorities and invest in more social and rehabilitative services lends it a good chance to be at least revenue-neutral.
The pilot intends first to evaluate the needs and functional ability of each client in the Hollywood area on a tiered scale with proportionately higher funding allocated for higher tiers. Users would be re-evaluated each month. The program aims to reduce the time spent by staff members documenting their activities below five percent and to make clinical services’ ancillary‘ behind ‘primary’ psychosocial services.
Next, there will be outreach teams of nurses, social workers, and peer specialists to serve as 24/7 first responders to a crisis. There will also be new facilities, such as a respite center, a residential center, and an urgent care center, all of which aim to reduce the burden on emergency departments, paramedics, and police for psychiatric services. Finally, there will be a peer-support model of paid peer-support workers.
There are key differences between Italy and the US, of course. Specifically, Italy has very low levels of homelessness, a robust social safety net, a history of deinstitutionalization and community mental health, and very little reliance on involuntary treatment. The pilot is still subject to approval by the LA County Board of Supervisors, but Sherin is optimistic that the official approval will come soon. Their approval will open the doors for a year of planning and stakeholder engagement, with the program ideally beginning in early 2021.
“This kind of transformation will require broader efforts as well,” writes Waters. Quoting Keris Myrick, the county mental health department’s chief of peer services, he concludes:
“Creating change ‘is not incumbent on just the staff, the providers, and the peers that are doing all of this work in support of people. It’s incumbent on the community. When you come through the door of the Peer Resource Center, everybody who’s in this building has a responsibility to help that person. And I think that’s where we kind of miss the boat in America.”
Waters, R. (2020). A New Approach To Mental Health Care, Imported From Abroad. Health Affairs, 39(3). DOI: 10.1377/hlthaff.2020.00047 (Link)