City data reveals high percentages of “unsuccessful” exits from homeless shelters during 2020-23. These unsuccessful exits include a confirmed return to unsheltered homelessness or exits to destinations that are unknown or classified as “other.” These unsuccessful exits rose from 56.6% of all exits in 2020 to 79.8% of all exits in 2023.

These results clearly demonstrate that San Francisco’s shelters are not successfully guiding people on their journey out of homelessness. The conclusion is unavoidable: the homeless shelter system is in crisis.

The solution

When people experiencing homelessness first leave the streets, they are typically exhausted and traumatized, they may have serious unmet primary health needs, and they may also require support for substance use and mental illness. To help people address these various issues and take more effective first steps out of homelessness, San Francisco should create a new service model — the stabilization center.  

After entering a homeless shelter in San Francisco, guests typically receive insufficient treatment for their medical and behavioral health needs. Shelters connect residents with medical and behavioral health staff intermittently, often requiring them to go elsewhere for care or other services, which can result in a return to the streets.

The goal of the stabilization center would be to provide a safe place where people can first rest and address their medical and behavioral health needs. In contrast to the lack of privacy in most traditional, congregate shelters, the stabilization center would offer private rooms where they can stabilize for up to 30 days, or possibly longer in extreme circumstances. The center would have on-site staff to address serious health issues and provide more reliable access to basic health care. Ending homelessness is not just about shelter or housing. It’s about helping people reclaim their lives. If people leaving homelessness are able to rest, stabilize and heal, they will be more likely to succeed in becoming housed and staying housed.  

How it gets done

This project would create a pilot site for a stabilization center, which could serve as the first step of someone’s journey out of homelessness. The program is designed to provide three main functions: address the immediate health needs of unhoused people; restore their physical and mental health; and direct them to the most appropriate next step, such as behavioral health treatment, shelter, transitional housing, permanent housing or family reunification.  

To appreciate the value of the stabilization center, it is necessary to understand how San Francisco currently operates its shelter system. San Francisco’s homeless shelters are one element of the city’s response to homelessness, and the entry point to the system is called “coordinated entry.” Through coordinated entry, the city seeks to provide low barrier access points for adults, family and youth to connect with shelter, housing and services.  

When a person enters one of the city’s 11 coordinated entry locations, a staff member from a nonprofit service provider conducts an interview and offers immediate solutions if they are appropriate. For example, in a “Problem Solving” scenario, if a person is at risk of homelessness because of medical bills or car repairs, the staffer could provide $500 to address the person’s needs. If a person has family or friends in another city, the staff member could refer the homeless individual to San Francisco’s Homeward Bound program, which will buy the person a bus ticket.

The main activity of coordinated entry is to assess a homeless individual’s eligibility for housing. The staff member administers a uniform assessment, which includes detailed questions about the individual’s experiences with homelessness. If a homeless individual receives a high score on the assessment, the person is considered to be housing-eligible, which means that the person will receive government-subsidized housing, either permanent supportive housing or a time-limited subsidy, which is called Rapid Rehousing. After being deemed housing-eligible, an individual may then receive a spot in a homeless shelter or navigation center until the government-subsidized housing becomes available.

The path for people who are not housing-eligible is more tortuous. The city controls most access to homeless shelters. If no shelter beds are available, people experiencing homelessness continue to live on the streets. At the end of August, there were 447 names on the recently reactivated shelter wait list, but only 39 people had received a placement off of the waitlist in August. People fortunate to receive shelter have the opportunity to look for independent housing without a government subsidy. However, as revealed by the data cited at the beginning of this proposal, almost 80% of the people who enter shelter are exiting to the streets or some unknown destination that is probably not housing.

Why are so many homeless people leaving shelters for homelessness? The city should conduct a thorough investigation to produce a confident answer to this question. Until then, anecdotal evidence suggests that many people are abandoning their shelter beds because drug addiction and mental illness are drawing them back to the streets. Shelters do not have full-time behavioral health professionals, and shelter guests receive behavioral health services through infrequent appointments. The answer is to provide more intensive primary and behavioral health services to people experiencing homelessness as soon as they come indoors. That is the vision of the stabilization center.

The contrast with the current shelter system begins at the front door. Instead of requiring an assessment through coordinated entry, the stabilization center would be open for walk-in guests.  

When a guest arrives at the center, staff would conduct a physical health assessment and provide on-site preventive and urgent care. Common health problems might include wounds, skin infections, asthma, hypertension, diabetes, sexual health issues, and screening for infectious diseases such as HIV and tuberculosis. Since people experiencing homelessness are often disconnected from the health care system, the stabilization center would enroll guests in Medi-Cal for ongoing health care coverage. Licensed on-site professionals would have the ability to make health care referrals for chronic conditions, emergency services and more specialized care.

With a behavioral health focus, the stabilization center would facilitate long-term mental health and substance use care. A psychiatric nurse practitioner would work with clients to evaluate and treat their mental health symptoms. The center’s staff would evaluate the efficacy and side effects of guests’ medication on a continuing basis. The most commonly distributed medications are likely to be antidepressants, sleep medication and antipsychotics.

In addition to providing individual care, the stabilization center would foster a sense of community by offering a schedule of groups and activities, including mental health and substance use support groups. These group sessions would create a platform for participants to share experiences, contemplate their journey, develop essential coping skills, and promote wellness. Cognitive behavioral interventions would further empower clients with practical tools to navigate life’s challenges within a supportive therapeutic environment.  

The center’s staff would prepare guests for the next steps of their journey out of homelessness. Once staff better understand a guest’s personal goals and challenges, they can prepare a treatment plan and make connections to the appropriate services. The stabilization center could promote family reunification through the city’s Homeward Bound program. If a client needs more intensive behavioral health services, the center could make a referral to emergency psychiatric services or a licensed drug treatment program. The stabilization center would be fully integrated with the city’s homelessness response system and could make downstream connections to shelter, transitional housing and permanent housing, depending on the client’s needs and the availability of these downstream resources.

In contrast to the chaotic and sometimes traumatic surroundings in congregate shelters, the stabilization center’s building would offer guests a private room and bathroom in a setting designed to promote stability and restore health. The site would be equipped with a community room, dining room and kitchen, and office space.  

With homelessness spending skyrocketing and the city’s budget under pressure, homelessness programs must deliver results while also efficiently using the city’s limited financial resources. One of the most cost-effective tools is to master lease buildings instead of deploying large amounts of capital to construct or buy a building. This proposal for the stabilization center envisions master leasing a former tourist hotel.  

Costs

We estimate the first-year budget, including operating and capital expenses, would cost $5.6 million. The budget includes $3.2 million for personnel, both to manage the site and to deliver health and other supportive services. The building lease, which would cover 75 private rooms, common areas and offices, would cost $1.2 million per year. Capital expenses would be kept relatively low because the leased facility would not require significant improvements to the building.  

Long-term, the stabilization center’s service model could help the city reduce unsheltered homelessness at a cost-effective price. The center is intended to help guests rest and stabilize during a short stay before taking their next steps out of homelessness. The project envisions an average guest stay of one month in the site’s 75 rooms, which would allow the site to serve 900 guests annually. Comparing this figure to the total operating expenses of $5.5 million means that the city would spend $6,138 for each guest to stay at the center for one month. That price is remarkably cost-effective because it would include the full cost of housing, meals and supportive services. In the current shelter system, the average monthly cost of one guest ranges from $4,948 to $6,000.

It makes sense that the cost of the stabilization center would be slightly higher than the current shelter system. The stabilization center would have more behavioral health staff and on-site medical and behavioral health services, which drive higher services costs than in shelters. However, the stabilization center would use cost-effective master leasing of converted hotels to keep property costs relatively low, and overall staffing levels would also aim for cost-efficiency.  

The hypothesis of the pilot program is that slightly more spending per person at the stabilization center would produce better long-term outcomes for guests. Compared to the current population moving through San Francisco’s shelters, the program’s cohort would be expected to enroll in more behavioral health programs, spend more time receiving treatment in transitional housing, and successfully exit to permanent housing in greater percentages.

It is important to note an essential caveat. For the center to serve approximately 900 guests per year, staff must be able to place guests in behavioral health facilities, shelter or housing. If bottlenecks exist in these downstream connections, the city should pursue innovative and cost-effective ways to expand capacity. For example, the Department of Homelessness and Supportive Housing is already hiring more housing specialists to help shelter guests find independent housing.

This program and others like it would amplify the potential of the stabilization center to connect people to the most appropriate next steps of their journey out of homelessness. We urge the relevant city departments to initiate this program. 

For more information on this proposal, contact Steve Adami at [email protected].