Pilot program to aid gravely disabled residents could improve housing, hospitalization rates

An evaluation of Los Angeles County's pilot program aimed at bolstering aid to gravely disabled homeless residents found the initiative could offer a promising framework to improve housing and health outcomes for this vulnerable population while also relieving overburdened psychiatric hospitals.

The UCLA Health-led study is published in the journal Psychiatric Services.

Led by the county and including a partnership of more than 40 different organizations and agencies, the outpatient conservatorship pilot program sought to offer wraparound housing, health care and social services to 43 homeless residents who had severe illnesses such as schizophrenia, delusional disorders, substance use disorders and other medical illnesses. Many of the residents had been homeless for more than five years.

Beginning in 2020, county officials prioritized offering voluntary services to these residents before referring any of them to an involuntary conservatorship, known as a Lanterman-Petris-Short Act conservatorship. For those referred to a conservatorship, the pilot program allowed the county's Homeless Outreach & Mobile Engagement team, known as HOME, to continue providing services to the resident in the least restrictive setting deemed appropriate, including street-based services in some cases, as the residents awaited their court proceedings.

At the end of the pilot program's first year, 81% of the 43 homeless residents were no longer unsheltered, according to the study. While the study did not include a matched cohort as a control group, the housing placement rates in the pilot program were significantly higher than those observed by the county in recent studies. In the year before the pilot program began, about 20% of all people served by Los Angeles County's homeless outreach had obtained housing placement within 12 months.

About 65% of the residents were placed under a conservatorship with most requiring treatment at a psychiatric hospital. More than half of these residents were able to leave these locked settings and transfer to licensed residential facilities earlier than would have been possible prior to the pilot program, according to study lead author and UCLA Health psychiatry professor Dr. Elizabeth Bromley.

"This pilot really shows that if you have a well-staffed, very assertive, expert team that is practicing with high intensity, they're able to both identify people who can benefit from conservatorship and they're able to build enough care continuity into the process to minimize the amount of coercion," said Bromley, who also serves as director of the UCLA-Los Angeles Department of Mental Health Public Mental Health Partnership.

The evaluation found a large number of the homeless residents were placed in acute psychiatric hospitals given the severity of mental illnesses, Bromley said. But the pilot program's results showed there are opportunities to minimize the time individuals spent in locked settings. For residents under a conservatorship under the pilot program, the average number of inpatient days was 97. This is at least two months less time compared to residents placed under involuntary psychiatric holds in Los Angeles County in recent years, according to the study.

The pilot program began prior to the enactment of California laws this year that reform involuntary conservatorship rules. One bill that took effect this year, Senate Bill 43, expanded the definition of a "gravely disabled" person to include those whose substance use prevents them from providing their own personal safety and medical care. The law allows the courts to place these individuals under an involuntary conservatorship.

Bromley said that it is the responsibility of state and local agencies to understand how to minimize coercion involved in processes that take away personal autonomy.

"Coercion is something we have to minimize in any situation that we can because it depletes trust in our systems, it makes people flee from services that might be helpful to them," Bromley said. "It needs to be very carefully and ethically balanced in terms of patient preferences and needs."