In Los Angeles, occupational therapists tapped to help homeless stay housed

KFF Health NewsJan 24 2024

Carla Brown waits on an air mattress, eager for her occupational therapist to arrive at her apartment next to the Hollywood Freeway, mere blocks from where she once camped on the sidewalk.

She moved into the one-bedroom apartment on the second floor of PATH Villas Hollywood, a county-run apartment complex, in July, shortly after her 60th birthday. Inside the open-concept unit, the walls stand bare except for three Christian art prints hung near the front door.

Brown brightens when Julian Prado, a tall 29-year-old with a nose piercing and black mustache, walks in toting a grocery bag with fresh ingredients for veggie tacos. Prado, a warm and supportive therapist, has been visiting weekly for six months to help Brown learn to live in permanent supportive housing, where clients live on their own but receive on-site support from a care team.

Once inside, he spots gnats hovering above food rotting on dishes stacked in the kitchen. "Let's clear some of this counter first," Prado says, running out to his car to retrieve gloves and cleaning supplies.

Prado is one of 10 Los Angeles County occupational therapists assigned to unhoused and formerly unhoused clients. According to research by the California Policy Lab, at least 1 in 5 single adults placed in permanent supportive housing in Los Angeles from 2010 to 2019 slipped back into homelessness or interim housing. The county hopes this new team can improve the likelihood of success in transitioning people indoors.

Occupational therapists, who focus on cognitive and physical disabilities, are often associated with schools and health facilities, but their skills can fill a gap in homeless programs. Occupational therapists assist clients, most of whom have complex health conditions, in developing basic living skills, such as hygiene and cleanliness, which help prevent clients from getting evicted or slipping back onto the streets.

While their role is still rare, it's not new. Occupational therapists have been deployed by nonprofit homelessness services around the country for years. The U.S. Department of Veterans Affairs has used therapists in its homeless program since 2008. But as homelessness proliferates in California, Caitlin Synovec of the National Health Care for the Homeless Council, an advocacy group, said Los Angeles County has the advantage of coordinating across a robust social services network and can reach people no matter what stage of homelessness they're experiencing.

"Los Angeles County's model is special in that it allows individuals to access occupational therapy at different touch points as they move from street medicine to transitional housing to permanent supportive housing," Synovec said. "It's really unique."

This isn't Brown's first housing placement.

In 2019, after she had been living on the street for nearly a year, a nonprofit helped place her in an apartment in Rowland Heights, in the San Gabriel Valley. With permanent supportive housing, clients live alone but have a case manager and can receive on-site assistance from social workers and other support staff.

"I just couldn’t handle it, being on the streets," Brown said, sitting on her walker. "Nobody can. It's terrible out there."

While in Rowland Heights, cataracts robbed her of her ability to see. As her physical health declined, her living space deteriorated and the county declared it unsanitary, citing rotten food, vomit-stained sheets, and blood.

Managers began the eviction process, but Brown worked with county staff members to relinquish her unit so it wouldn't jeopardize her housing voucher. She was placed in an assisted living facility in 2021. Her vision returned once she had eye surgery.

Brown transferred to Villas Hollywood in 2023, but once there, the property management staff, again, cited cleanliness issues in her apartment: discarded food, piles of clothing, vomit in the bed, and a mice infestation.

This time, Brown had Prado's help to declutter her apartment. Her bedroom is no longer a sanitation issue. But Brown has taken to avoiding the bedroom, convinced the mess will return if she goes back in.

"It was getting to be ridiculous," Brown said. "I had to put a clamp on it." She now sleeps on an air mattress in the living room.

Living indoors has been difficult: Brown still thinks of grabbing her tent and returning outside for a few nights. She compares leaving the street to breaking an addiction.

"It's like stopping smoking. Sooner or later, you need that hit," she said.

Deborah Pitts, a professor of clinical occupational therapy at the University of Southern California, said it's common for clients to go from being outside in a constant fight-or-flight state to feeling isolated and directionless once in housing, staring at a calendar of empty days. They face tasks they may not have done in decades, such as laundry, cooking, cleaning, and managing finances.

At the same time, many clients have cognitive impairment and complex health conditions that complicate their transition.

USC researchers found in a series of studies that by the time clients are placed in housing, 90% of residents age 39 or older reported two or more chronic physical or mental health conditions. They also have a high prevalence of geriatric conditions, including difficulty walking and urinary incontinence, at a higher rate than housed adults 20 years older. The phenomenon is known as accelerated aging.

Where a case manager might misread a client's cognitive impairment as complacency, therapists are trained to identify disabilities and adapt the environment or the task to a client's needs, said Heidi Behforouz, medical director of Los Angeles County's Housing for Health program, which administers the occupational therapy program.

For example, if a client is struggling to recall where they've stored items in the kitchen, a therapist might remove the cabinet doors to improve visibility. Or if a client isn't taking their pills, a therapist wouldn't just suggest a pill box; they'd also work with a nurse to figure out if the client needs larger fonts or different colors to differentiate pills.

"Sometimes cognition doesn't get better," Pitts said, "but function can get better."

Brown said Prado has helped her a lot with her transition. Recently he's been encouraging her to get out into the community. For example, since she's passionate about her Christian faith, Prado has been encouraging her to return to church.

Prado said a key part of his work is helping clients find meaningful activities to fill their days. He has offered to attend services with her.

"I don't know what's gonna happen in the future," Brown said. "But I'm still here."

The county's occupational therapy team has worked with nearly 160 clients thus far, but Brown is just one of approximately 15,000 residents navigating the transition to permanent supportive housing. Statewide, an estimated 172,000 people are experiencing homelessness.

The team, funded through a mix of county and state grants, plans to hire eight more therapists in the coming months. County officials hope to expand further but have yet to find additional sustainable funding.

One potential solution would be to get the state's Medi-Cal program, California's version of Medicaid, to cover occupational therapy so therapists can bill directly for services without a prescription from a doctor or a licensed practitioner. But county officials said that supplemental funding would be needed with or without a prescription because Medi-Cal reimbursement rates tend to be too low.

Back in the kitchen, Brown scrapes food into the garbage disposal as the keys to her home dangle off a lanyard around her neck. Prado sprays cleaner and wipes the countertop. As they finish scrubbing the dishes, the two exchange jokes and laugh.

"Sometimes you have one thing planned, and then you hit a barrier, but that's OK," Prado said. "I always tell my clients that 'I'm going to use my knowledge to support you in this task, but, ultimately, you're in the driver's seat.'"

Once the cooking area is cleared, Brown pours olive oil into a pan and shows Prado her trick for crisping tortillas. She hands Prado a cutting board and tells her sous-chef to cut the tomatoes.

"I adore him," says Brown. She catches Prado blushing. "Look! He's turning red."

Once the tortillas are fried and the tomatoes chopped, they load tomatoes, shredded lettuce, and cheese into the hard shells. Prado takes a taco as they say their goodbyes.

He'll be back next week.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.