CHPR: Dr. Rab, please tell us a little about yourself.

Dr. Rab: I am the associate medical director for field-based services for the Department of Mental Health in Los Angeles. I supervise the psychiatry component of the Homeless Outreach and Mobile Engagement (HOME) team—a multidisciplinary team that operates across Los Angeles County. I was the first full-time street psychiatrist hired by the Department of Mental Health in 2019, but our program has grown considerably since then.

CHPR: What’s a street psychiatrist?

Dr. Rab: Street psychiatry is a new field in mental health where psychiatric services are delivered in unstructured settings where unhoused individuals frequently reside, like the street. In addition to psychiatric evaluation and medication management, we place equal focus on ­building ­long-term relationships with our clients, so they’ll be more likely to engage with us in our efforts to secure housing for them.

CHPR: Where do your referrals come from?

Dr. Rab: We get referrals from general outreach teams, law enforcement, inpatient hospitals, clinics, and even family members. Referrals are assigned to the HOME team serving the geographic location where the individual is located.

CHPR: What’s a typical day like for a street psychiatrist?

Dr. Rab: A typical day starts off with an early-morning team meeting where we discuss the folks that are most concerning, like someone who had a drug overdose the previous day or recently appeared lethargic or confused. Next, we run through the list of all our unhoused clients and develop care plans that will help them move closer to being housed, since obtaining housing is our primary outcome measure. We then get in a car and deploy out to round on our clients. This involves finding our clients, meeting with them, bringing them medications, bringing them supplies for basic needs, working to advance rapport, and providing education about housing. We also check in with individuals whom we’ve housed to make sure they’re doing okay. Then in the afternoon we regroup to focus on the administrative work required to secure housing. We frequently go back out to the field in the afternoon if we are unable to find all the clients we intended to round on during the morning.

CHPR: How receptive have unhoused mentally ill individuals been to the HOME team’s efforts at connecting with them?

Dr. Rab: Before I answer that, I want to first talk about many unhoused people’s experiences. Their needs have often been neglected, for decades in some cases. Feelings of alienation, paranoia, and other mental health symptoms are often present. These individuals have possibly been attacked on the street. There’s a lot of mistrust, and many folks refuse services even when they critically need them. Outreach and engagement are at the core of what we do, to gradually open up their minds to the options we bring to the table. Once we gain their trust, they are usually pretty receptive to our outreach efforts.

CHPR: So, there is a lot of emphasis on building relationships.

Dr. Rab: Absolutely—building relationships is at the very heart of what we do. When I’m on the street, I’m a person first and a provider second. When we show up, we don’t ask “Are you taking your medications?” Instead, we ask “When is the last time you had a meal?” or “Your shoes look torn. Would you like some new ones?” Our focus is on their immediate needs, and this helps us engage with them.

CHPR: Do you encounter crisis situations, like where a patient is a danger to themselves or others, or is severely medically ill?

Dr. Rab: Yes, we do. Chronic homelessness takes a toll on people’s physical and mental health. The average age of death among these individuals when they have comorbid medical and psychiatric conditions is between 40 and 50 years of age (Peritogiannis V et al, Healthcare (Basel) 2022;10(12):2366). Crises are always looming in the background, and we do sometimes need to escalate care. We’ve developed our own crisis response and intervention strategy where, if we believe that someone meets the criteria for an involuntary hold, we are the ones who initiate the hold and help them get onto the gurney and get to the hospital. We do not utilize law enforcement for any of our involuntary holds. But my goal is always to avoid involuntary care. Many of the risk factors that put people in danger of crises come from being on the street, so our priority is to get them housed.

CHPR: And what do you do if it’s a situation where a conservatorship or guardianship is indicated?

Dr. Rab: There are a few occasions when we need to file for conservatorship/guardianship for chronically mentally ill patients who are gravely disabled and potentially dangerous to themselves via neglect. We only consider conservatorship after street stabilization and inpatient stabilization have repeatedly failed to improve overall function. When conservatorship/guardianship is indicated and can be safely initiated outside of a hospital, we initiate a specialized “outpatient conservatorship” process directly from the street, involving court proceedings that can be completed via videoconferencing. We also provide transportation for patients who want to attend court proceedings in person. Our process allows for conservatees to be placed directly into open residential settings where they can develop the skills needed to live more independently, and we have a dedicated unit that monitors their progress and works with their providers to eventually get them off the conservatorship and into independent living.

CHPR: How can an inpatient clinician best work with your street psychiatry team after we admit one of your patients to the hospital? Does your team get involved in discharge planning in some way?

Dr. Rab: We deeply value collaborating with inpatient facilities. Inpatient settings offer an opportunity to advance treatment goals and encourage patients to accept housing. The best way for an inpatient clinician to work with us is just to call us. We welcome the opportunity to visit our patients in a hospital and participate in treatment planning to any extent possible.

CHPR: In your work with emergency departments and inpatient units, do you ever encounter disagreements about whether the patient is ready for discharge and subsequent care by the street psychiatry team?

Dr. Rab: Disagreements often emerge over a patient’s discharge readiness, typically due to the patient being assessed in two separate settings. The HOME team evaluates patient function in real-life conditions where patients must be able to utilize the services available to address their basic needs. Hospital staff, in contrast, assess patients within the highly structured setting of an inpatient unit, potentially overestimating patients’ discharge readiness. But we’ve been able to address disagreements by educating hospital staff about the realities of life for patients on the street, and by showing them that when they follow HOME team recommendations regarding discharge readiness, more patients are successfully housed and remain in treatment, and high utilizers—meaning patients with frequent hospitalizations—are more likely to break the cycle of repeated admissions. At the same time, HOME teams make an effort to understand that hospitals must abide by their discharge criteria. By working collaboratively, even when disagreements arise, it’s easier to find a reasonable middle ground.

CHPR: This collaboration probably has a beneficial effect on patients’ experiences of inpatient hospitalizations.

Dr. Rab: Right. We have found that our patients are genuinely happy to see us in the hospital as we provide a familiar face. In fact, we have been able to encourage our patients to voluntarily accept medications in hospitals, which can avoid the need for involuntary medications and/or restraints.

CHPR: For clients who are open to medications, how do they obtain them?

Dr. Rab: We can’t just hand them a script of risperidone or aripiprazole and say “Please fill this at the pharmacy.” A lot of the people on the street with severe mental illness aren’t able to complete goal-directed tasks in that way. They might be too busy focusing on survival. Transportation might be an issue. They might not have the motivation to do it. So we typically bring the medications directly to them.

CHPR: What if a patient has side effects later in the afternoon after you’ve left, like a dystonic reaction? A client’s housing situation must impact your prescribing choices, right?

Dr. Rab: Right. We must be very careful about the medications we select. For example, a medication like quetiapine or olanzapine is super dangerous on the street. You don’t want to make someone sedated on the street. They might fall, they might get attacked, they might get robbed. So, we typically use medications that are not as sedating, like aripiprazole and risperidone, and we choose medications that have a long-acting injectable formulation (Glick ID and Olfson M, J Nerv Ment Dis 2018;206(5):378–379). We start low and go slow. Sometimes if someone develops a dystonic reaction, we might have to hospitalize them because it’s hard to manage severe extrapyramidal symptoms from the street, or we put them in a motel and then manage the side effects there. But luckily these situations are rare.

CHPR: How do you obtain lab work and imaging?

Dr. Rab: Labs are a critical part of how we monitor medications and health, and they’re necessary for housing. Clients need to get medical clearance and TB testing for housing, so we transport people to our sites where they can get lab draws. I am working on getting mobile labs set up so we can have a phlebotomist come out with us because often, clients will say “I don’t want to get in a car with you, but if you draw the blood here, I’m cool with it.” So, I want to make sure that we can do as many services curbside as we can. The more mobile we can make our services, like MRIs, CT scans, chest x-ray machines, medical services, the better, because otherwise there is an entire community of people who won’t be getting any care. I don’t know how realistic this goal is, but I’m working on it.

CHPR: How hard is it to locate your clients, given that so many of them are unhoused?

Dr. Rab: Locating folks is a challenge. Most people on the street are just like you and me. They tend to have routines and they typically stick around an area that they’re familiar with and where they receive community resources. But some people walk around for miles. Part of our outreach is to connect with individuals and understand their routines.

CHPR: Can you give us an example of a successful case?

Dr. Rab: I’ll share a story that was featured on CBS national news. This was an individual whom I found walking around aimlessly, in soiled clothing, delusional. He wasn’t open to medications, but he was open to us taking him to McDonald’s and getting him breakfast. So, we did that for two months, and while we were buying him some food, we provided education about housing options, and by the end of a couple of months, he agreed to housing. There was no treatment involved, there was just a human connection over breakfast that allowed him to transform his life. Along the way he gave us a telephone number, and when we called, we discovered it was the number for his long-lost brother whom he hadn’t spoken to in over 15 years. We were able to reunite him with his family. Housing alone transformed his presentation dramatically. He began smiling more often. With better access to food and restrooms, his face looked fuller and he was always dressed in clean clothes. He enjoyed watching TV and had access to books. He even started journaling. We discussed medications several times, but he was not interested in taking them. However, despite refusing medications, he improved dramatically just by having stable housing and food and developing social connections. He’s maintained his housing, tends to his activities of daily living, and reaches out for help when he needs it.

CHPR: That’s a great case. Do you have tips for how to talk about housing with someone who is hesitant or reluctant?

Dr. Rab: It’s important to offer housing that’s compatible with people’s current lifestyle. If they’ve been living on the street in a certain area, I try to offer housing in that same area, not on the other side of the county. I also tell them “How about you try sleeping there for a couple of days and see how you like it?” That’s how I offer housing. It’s not this complete 180 on what they’ve been using and uprooting their established lifestyle for decades with a snap of a finger.

CHPR: How do you help them get housing?

Dr. Rab: We have created what we call the housing pipeline. HOME teams have contracts with ­temporary as well as permanent housing options. Permanent housing options are in short supply, but there are many temporary housing options, like motels, shelters, and licensed facilities with residential services, so if someone agrees to housing, we can move them into this more readily temporary housing immediately. We then continue stabilizing their medical and psychiatric health while working on securing permanent housing either through a housing voucher for their apartment if they can sustain independent living or through permanent board and care facilities if they need support with activities of daily living.

CHPR: How do you assess what type of housing will be best for a person?

Dr. Rab: I ask questions like “What is it about this intersection that you like? What is it about that spot? Can we recreate that somewhere else?” Often their community simply consists of local people who drop off food for them, but they don’t want to lose this lifeline. So, when I engage someone, I’ll say “Okay, now I’ll be bringing food to you when you move into this new setting.” My team tries to become the individual’s new community. Also, we think of housing as just the first step. We also want to help these individuals with occupational rehabilitation, social connections, hobbies, and fun activities. We want to make sure that they thrive and live productive and happy lives. We’re working on developing wellness and rehabilitation programs, and we just recently began to give our clients cellphones with Netflix so they can watch TV shows. We want to add some of the spice of life—otherwise, they might just sit and smoke cigarettes for the next five years. We don’t want that.

CHPR: Do some people fall back into homelessness?

Dr. Rab: About 10%–15% of people fall back, but the majority of people get placed into permanent housing. We supervise how well they get established in their new environment, and if it’s not working out, we’ll move them to a place that may be a better fit.

CHPR: Are there street psychiatry programs in other cities besides Los Angeles?

Dr. Rab: Street psychiatry is a growing specialty that is present at many programs across the nation. There are outreach programs featuring components of street psychiatry in San Francisco, New York, and Boston, among other places.

CHPR: Thank you for your time, Dr. Rab.