In 1993, I was the medical director for the first health plan to provide a managed care model for the Texas Medicaid population. This program started in Travis County and included management of the limited mental health services covered by Medicaid through an HMO network model. Within the first few months of the program, I was made aware of an out of network hospital in Center Point, Texas that was filing Medicaid claims for inpatient detoxification services. At that time, Medicaid coverage for substance addiction was limited to inpatient detoxification only (rehabilitation services were not covered). I had a general idea where Center Point was, but I could not understand how so many Medicaid patients from Travis County were ending up there for 30 days of detoxification. My wife and I took a drive to Kerr County one Sunday afternoon and found the Starlite Village Hospital at the end of a private drive, off of a county road, and inside a cattle guard next to an emu ranch. The hospital did have a sign out front with the words “24 Hour Emergency Room” under a big red arrow pointing to a side door.
My purpose in recounting this story is not to make a point that inpatient acute detoxification services are not the same as inpatient rehabilitation services, which were not a benefit of the Texas Medicaid program until 2010. My point is that the Starlite Village Hospital (which is now the Starlite Recovery Center) is located in the middle of nowhere for a reason. It removes patients with substance addiction from an environment where they might have access to alcohol and drugs of abuse. Controlling the environment is a key to success for inpatient and as well as outpatient rehabilitation programs. That is why most patients who can afford it are referred to treatment centers several states away from where they live. You will not be successful with substance abuse rehabilitation if a patient continues to live under a bridge in downtown Austin, or anywhere in downtown Austin for that matter. Some sort of stable housing outside of downtown Austin is required.
In previous articles I have written that we will not solve the issue of chronic homelessness if we do not address the root causes of chronic homelessness. Members of the Austin City Council often state that the causes of homelessness in Austin are lack of affordable housing, wage stagnation, economic segregation and poverty, and incarceration. These are the causes of homelessness for the population experiencing temporary displacement. The Council also quotes data from the Housing and Urban Development Point-in-Time surveys to quantify and qualify homelessness in Austin. These surveys have been conducted in Austin by a homeless advocacy group, the Ending Community Homelessness Coalition (ECHO). According to the 2020 report based on a 6-hour long survey effort, the total homeless count in Austin was 2506, 37% were sheltered, 61% were white and 38% were female. The Point-In-Time surveys are done by municipalities to request federal funding from the Department of Housing and Urban Development. They are incredibly inaccurate as a full accounting of the homeless, and over-survey sheltered populations vs. unsheltered populations.
For example, an audit in 2019 by Front Steps (the organization operating the Austin Resource Center for the homeless) reported 9000 unique individuals received homeless services in Austin. That is almost four times more than the homeless population estimated by the Point-in-Time count. It is likely that most of the sheltered population was captured in the ECHO survey. This means that the unsheltered population is much larger than they estimate. The Point-in-Time count also provides no information about causes of homelessness, migration patterns, or even the need for specific services (like treatment for substance addiction). It does not even attempt to identify or define the number of people who are chronically homeless.
There are actually very few scientific surveys of the chronically homeless population. Most studies have surveyed primarily sheltered populations which are more likely to be families or female, younger, non-disabled, and importantly, temporarily displaced. One of the best studies of the chronically homeless population was done in Manhattan in 2009. I would argue that Austin is now a large metropolitan city and our homeless population is probably similar to that of Manhattan. In that survey of chronically homeless individuals, 67% were chronically homeless and unsheltered, and that group was 90% male, 31% white, about 47 years of age, and had spent almost 10 years on the streets on average. 84% had a history of lifetime mental illness, lifetime substance abuse, or a serious medical issue, and 76% had been incarcerated. In this group 67% had a history of lifetime substance abuse. This is very different from the Austin ECHO survey. (see the full text publication of the Manhattan survey here: https://ps.psychiatryonline.org/doi/10.1176/ps.2009.60.7.978?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed).
Based on this and other similar scientific surveys, the root causes of chronic, unsheltered homelessness are mental illness, substance addiction, habitual criminal behavior, and intellectual and physical disability.
If two-thirds of the chronically homeless and unsheltered population have a history of lifetime substance abuse, and that population is significantly undercounted, we have a much bigger problem than the Austin City Council has admitted to. You will not substantially reduce chronic homelessness in Austin without addressing substance addiction. So how do you get homeless individuals with substance addiction into recovery? First, you have to have treatment programs organized and staffed for this population. Then there are three steps: active engagement, incentives for participation in treatment, and a stable environment. All three steps would be supported by transitional or permanent housing.
More than half of homeless individuals with substance addiction refuse treatment when offered voluntary programs. A lot less than 50% actively seek help for their addiction – only about 10% of the US population with substance addiction have received treatment. So active engagement is required. Active case management is also needed for this population to encourage sustained engagement and completion of addiction treatment. I have used and taught the Transtheoretical Model of behavior change (James Prochaska, et al), which was influenced significantly by experience with treatment of substance addiction. It is an excellent model for case management. This model guides patients through stages of behavioral change based on self-defined goals. The model anticipates that patients will have setbacks, and provides support tools when this occurs. Reward systems for attainment of goals are helpful. Continued housing can be a reward for continued participation in a treatment program. That provides an incentive and a stable environment.
One last story. During my time as a practicing physician, I performed examinations for patients being admitted to Shoal Creek Hospital (now Ascension Seton Shoal Creek). Most of the patients that I admitted were referred by criminal defense attorneys, and probably did not need to be hospitalized. They were there because of a drug or alcohol related arrest, and their attorneys felt it would good for their case to show the judge they were seeking treatment. I do not know whether individuals admitted for this reason benefitted from their inpatient stay, but it was clear to me that interaction with the criminal justice system was an incentive for engagement in a treatment program. For all of those who advocate decriminalization of drug use in the homeless population and otherwise, I would suggest that you consider this.
Waterloo to Austin 