Ending Homelessness, One Person at a Time

Jun 22, 2017, 12:00 PM, Posted by

Santa Monica has been one of the first U.S. cities to use homeless statistics in identifying those who most urgently need care and services. They share five key lessons from their efforts.

Homeless individual in California

When people think of us, many envision a wealthy beach community dotted with hip boutiques and bistros overlooking beautiful sunsets.

But here in Santa Monica we face stark, complicated issues—including homelessness—like any other city. In fact after seven years of stability, our homeless population spiked significantly this year (2017) to 921. This is a 26 percent increase over 2016. It’s part of a regional homelessness crisis in Los Angeles County, which also saw a 23 percent increase that stems from a lack of affordable housing.

Believe it or not, the problem was once even worse. In 2005, we counted nearly 2,000 people experiencing homelessness!

So we’ve confronted the problem by prioritizing those who need help the most and getting them into housing as quickly as we can, through an approach called Housing First.

Here are lessons we’re taking to heart as we continue our work.

Focus on “Who,” not “How Many”...

Nearly a decade ago, we became one of the first U.S. cities to create a by-name priority list of people facing chronic homelessness. The list is based on factors such as how long they’ve been on the street, how often they visit the emergency room, and their health and mental health history. These are people who are frankly the most likely to die if they don’t get the housing and services they need.

Focusing on “who” rather than “how many” has led us to rethink our city’s overall social services safety net which provides short- and long-term housing, reaches out to people on the streets, and offers employment, health and substance abuse services. It’s also led us to rethink our contracts with social service providers. Through this approach, we’re doing whatever it takes to engage prioritized people over the long term rather than only helping those who are willing to participate right away as some traditional outreach programs do.

We take prioritization seriously. The city assigns to social service agencies 10 percent of participants in their city-funded homeless program. Outcomes for those individuals are reported separately and their cases are discussed monthly by local and regional partners who share resources and ideas, all with the goal of moving people off the streets.


We recognize that true community-wide well-being can’t be achieved without addressing the needs of our most vulnerable.


Connie’s story illustrates the impact that this level of coordination can have. She was homeless for years, bouncing between the streets and shelters while battling alcohol dependency and health challenges. The Santa Monica Police Department’s Homeless Liaison Program (HLP) officers realized how badly Connie needed help and connected her to St. Joseph Center, a social services agency that helped her get shelter and treatment. St. Joseph Center also recommended her to the city’s Homeless Community Court, a problem-solving court program that helped address her legal issues while also connecting her to additional services. With support from a variety of agencies that provided interim housing, substance use treatment, and health care, Connie secured permanent housing and graduated from homeless court. Now she’s enrolling in college courses that she hopes will lead to a good job and a brighter future.

This “coordinated assessment” approach is now considered a best practice among experts and required by the Department of Housing and Urban Development for homeless assistance programs that receive federal funding.

It’s all-hands on deck.

We created the list of people facing chronic homelessness by examining statistics from our first responders—police, corrections officers, emergency room personnel and paramedics—and using a tool that calculates each person’s vulnerability. This helps us pinpoint those facing the most barriers to services. We then allocate resources to them based on urgent need, rather than relying on a first-come, first-served approach where we wait for people to ask for help.

Many different sectors help us focus on serving those who are the most vulnerable. Representatives from our police and fire departments, the human service department, and our City Attorney’s office meet biweekly to discuss our prioritized people and coordinate efforts. The police HLP team is a crucial partner as our direct line to people on the street. For example, if John has an appointment to sign his lease paperwork for a permanent supportive housing unit at 10 a.m., his case manager might call the HLP team and ask them to find him in the morning and remind him of his appointment, while reporting his location back to his case manager so the organization’s outreach team can pick him up.

Business owners play a number of critical roles as well. They contact the city to tell us about homeless people they regularly see near their businesses. They also recruit their employees and other community members to volunteer at nonprofits that work with the homeless and to help count those experiencing homelessness during our annual one-day count each January.

This work is expensive—but only in the short term.

Prioritizing the most vulnerable requires highly paid credentialed staff and flexible pools of money for “whatever it takes” to get people housed, including expensive treatment programs like medical detox. But the outcomes can reduce other costs down the line, for example by reducing calls to first responders and emergency room visits for chronic health problems. A 2009 study found the public costs for people in supportive housing in Los Angeles County averaged $605 a month, compared to $2,897 for similar people experiencing homelessness.

Commit long-term.

Once clients are housed, they typically need ongoing care management. Consequently, a manager’s caseload never goes down in a Housing First model. Resources are usually directed to getting as many folks housed as possible, with very little left to serve people who are no longer homeless. We’re aiming to keep serving people over the long haul. As housed people get more secure, we connect them with mainstream services, such as mental health clinics and step-down programs that help ease their transition.

Focus on prevention.  

Providing a homeless person with a place to live is incredibly meaningful. But preventing homelessness in the first place is just as essential. Prevention is an incredibly difficult challenge, but we’re creating a stronger safety net for people, including low-income renters and the elderly, who are at imminent risk for homelessness.

When our fire department or safety department go out to enforce a fire or building code, they keep an eye out for seniors at risk of losing their apartments because of hoarding, mental decline or physical frailty that prevents them from keeping their unit clean and in good shape. Our Senior Task Force provides financial assistance, direct services and cleanup services, to get the unit up to code, as well as wrap-around support, such as health services and in-home care, to prevent the violation from happening again. We also offer some financial assistance to low-income people having trouble paying rent, and case management to help them come up with a plan for being able to keep affording their housing.

Our hope is that with efforts like these, we can one day eliminate homelessness from our community entirely.


About the author

Margaret Willis is Santa Monica, California’s human services administrator.