ProLodges Saves and Changes Some of Austin's Most Vulnerable Lives
Can the city keep them open?
By Austin Sanders, Fri., Jan. 1, 2021
When Alejandro Hernandez moved into the motel room provided for him this summer, he was relieved to no longer worry about getting run over by a car while sleeping. Before being admitted to Protective Lodging, at one of the five properties bought or leased by the city to protect unhoused Austinites from COVID-19, Hernandez had been living under I-35 at 38th½ Street for the last six years. "You've got to be careful out there," Hernandez told us in the hallway of his "ProLodge," while awaiting an appointment with the CommUnityCare street medicine team. "You've got to always watch for cars, because if you roll into the street, you might get run over."
A comfortable, secure place to sleep is just one of the benefits Hernandez has come to appreciate about life at ProLodge 4. "I'm 62 years old and I don't like myself," Hernandez said. "I really don't like myself being out in the street for so long. But this room, it's the best thing [the city] has done for me. It's given me a place to shelter myself, wash myself, brush my teeth, and comb my hair. I've been able to take a breath."
For those who have lived for a year or more on the street, having a room to call their own, where they can lock the door and know their belongings are secure, is no small life improvement. It may be one of the most important benefits of non-congregate transitional housing facilities, like the ProLodges, where guests have rooms of their own. A locked door gives peace of mind, as they know that things – sometimes, literally everything they own – will be secure. It also frees up energy for people to concentrate on the long, hard work of resolving their homelessness.
In our interviews with people who have stayed at ProLodges, with the outreach workers who helped place them there, and with the health and human services providers who have cared for them, we heard a lot of agreement with what Hernandez told us. Being able to "take a breath" is one of the most profound changes that can happen in the life of someone experiencing long-term homelessness.
"The ProLodges have been the single most important program the city has done for homelessness," Leah Hargrave, who has done street-level homeless outreach with Mosaic Church for the past seven years, told us. The claim is more than striking; when viewed alongside the persistent frustration that so many front-line providers express with the systems in which they try to help people succeed, it's next to astonishing.
But the turnarounds Hargrave has seen back up her enthusiasm. One man, in his 60s, suffering from alcoholism and hospitalized after complications from other chronic conditions, was able to recuperate and enter substance-abuse treatment while staying at a ProLodge. He is now working at Goodwill and has reconnected with his family.
Another client, a 69-year-old woman who Hargrave was sure would die on the street, is now preparing to sign a lease on her own apartment after a five-month stay at a ProLodge. "ProLodges have allowed people to get used to housing," Hargrave explained. "If you put someone immediately into housing, it doesn't always work out. I had one client who moved into housing but still slept in front of his building on the concrete for a month. It's such a hard step to transition into stable housing."
High Cost, High Value
Yet ProLodges were conceived as a temporary response to the pandemic. Even as the program was met with near-universal praise, from the street outreach teams all the way up to Council chambers, word began to spread in early November that the city was planning to close some or all of the ProLodges before year's end. A common question arose – why?
They are expensive – from late March through December, city staff estimates, operations at the five ProLodges cost about $15 million. Some of that outlay will be recouped from the Federal Emergency Management Administration, but that reimbursement is capped at 75% and doesn't cover supportive services offered at the ProLodges, only housing costs. Thus far, the city has not received any reimbursement from FEMA.
To control its costs, the city planned to phase out the ProLodges as their guests were placed in other housing programs. But after feedback from Council and service providers, that strategy has changed, interim Homeless Strategy Officer Vella Karman told us on Dec. 21. "All five ProLodges will remain in operation for the foreseeable future," Karman said. "There is no plan to close them ... and some of the [other] programs we have in place [have been] pivoted to focus on housing people specifically at ProLodges."
For example, on Aug. 27 Council authorized new case manager positions at the Downtown Austin Community Court, supported by federal COVID-19 relief grants earmarked to address homelessness. As of early December, two case managers and a supervisor had been hired, with interviews ongoing for three more positions, and the DACC team was working with nine guests at ProLodges. The city estimates that 100 people will be housed over the next two years. From the same federal funding stream, Council also authorized a contract with Caritas of Austin on Dec. 10 for $7.5 million to transition ProLodge guests into rapid rehousing (RRH) programs. Caritas leads a collaboration known as Best Single Source Plus, and will coordinate with another dozen agencies in BSS+ to find or create those RRH options.
"We Go To Our Patients"
The five properties have housed around 530 people at different times since March. As of early December, 275 guests lived at the five properties; they receive three meals a day, access to medical care offered on-site by the CUC street medicine team, case management from one of several partner agencies, and behavioral telehealth services provided by Integral Care. Together, the combination of wraparound services available – but, crucially, not forced upon anyone – can lead to the transformational change Hargrave has seen.
The medical services have made a particular impact. Dr. Audrey Kuang, who leads the homeless health care team at CUC, explained that people living on the street are often focused exclusively on survival: Where is my next meal coming from? Do I have time to fly signs and earn a few bucks before catching a bus to a community kitchen? Where am I sleeping tonight? With those kinds of questions occupying a person's mental space, long-term health concerns – heart conditions, diabetes, even debilitating vision problems – become less urgent.
But when the first ProLodge opened on March 28, as Austin strove to quickly scale up its response to the public health emergency, on-site medical services were not part of the package. Nonetheless, the launch came at an opportune time – one day after the first COVID-19 case was reported at the Downtown Salvation Army (in what became the first, and to date only, outbreak in Austin's shelters). "The first thing we needed was just a building to put people in," Kuang said. "We didn't know what we were doing and learned a lot of hard lessons on the way."
On-site care came in mid-May with the launch of the fourth ProLodge. Kuang and her fellow physician-advocates brought the philosophy of street medicine to the ProLodge program – "We don't wait for people to come to us," as Kuang put it, "we go to our patients." Safety protocols kept the CUC team from seeing patients in their own rooms, so they commandeered conference and dining rooms at the motels to provide care.
On a Wednesday afternoon in early December, the Chronicle observed the team at ProLodge 4 do this work. Once a week, the nurse practitioners on the team assemble in a spare guest room at the motel, which becomes their remote office. There, they spend the day reviewing files and seeing patients, who may need prescription refills, or follow-up care as they recover from hospital stays, or preventive services such as cancer screenings.
Kuang and her team say that on-site care at the ProLodges provides guests with an alternative to emergency room visits that, on top of being a sub-optimal and expensive way to provide care, grew more hazardous with the pandemic. According to data provided by Austin-Travis County Emergency Medical Services, 911 calls for service placed from ProLodge 1 stabilized at around 20 per month starting in May, when CUC began making its weekly visits to each ProLodge. Even as the number of guests grew, those call levels remained consistent.
Regina Evidente, a family nurse practitioner on the street medicine team, told us, "There are limits to the care we can provide here" at a non-medical facility, "but we can build trust and rapport. I encourage patients to see us every week, because eventually, they may trust me enough to act on a referral to a specialist at a brick-and-mortar clinic. Sometimes that means a patient will see a cardiologist for the first time in a decade, or renew a glasses prescription that hasn't been reviewed in years."
That trust between doctor and patient can be leveraged to improve chances of success throughout the homelessness response system. From the outreach provided by EMS Community Health Paramedics and the Homeless Outreach Street Team, to the direct care provided by CUC and other practitioners, to the case management that can ultimately lead a person into stable housing, incremental success builds trust and strengthens the supports helping ProLodge guests build new lives – all accessible from the comfort of their temporary home.
Feedback at Street Level
The ProLodges encountered early challenges. While prospective guests received medical screenings to identify those put at higher risk by COVID-19, those screenings didn't translate directly into priority admission for the most vulnerable, and it would be weeks before on-site services were available to meet guests' medical needs. The outreach teams and practitioners pushed for changes, and by midsummer the screening process became more diligent.
Such on-the-fly improvements to the ProLodges prototype have solidified the program's success. Decision makers at the city and county adapted after absorbing feedback from the street-level workers who best understood client needs; because the CUC street medicine team, CHPs, HOST, and others were listened to, the ProLodge concept could better deliver on its core promise of saving lives.
There is still room to improve. Integral Care began providing case management and counseling services to people at ProLodges on April 20, but much of that work – it's unclear how much – has been done virtually. Spokesperson Anne Nagelkirk told us services have been provided "in person on-site as well as via telephone," but others – who requested anonymity to protect relationships with Travis County's largest behavioral health provider – told us that on-site services have fallen short.
When the first COVID-19 cases were identified in Austin in March, several weeks before the first ProLodge opened, Integral Care pulled its clinical staff from the field throughout the city and began offering most of its services over the phone. At one point, a sign at the entrance of one of the ProLodges read "Please note: Integral Care staff are unable to answer the door for face-to-face contact." The sign provides instructions for how to reach staff at the motel and how to "possibly" arrange a meeting in case a guest needs paperwork signed or to drop something off.
As one would expect, telehealth works well for people who have phones, or at least access to a device, and who aren't too unwell to use them when they need behavioral health support, which can be at any time. Among Austin's unhoused, even those who have phones risk them being lost or (frequently) stolen, or breaking, or running out of minutes or battery life in a place without charging options, or losing reception. At the ProLodges, each motel room has a landline, so guests could have regular access to counseling as needed.
But even for people without the challenges faced by many experiencing homelessness, navigating a complicated phone tree to schedule an appointment can be difficult. The value of ProLodges is magnified by offering barrier-free access to services, and for guests who need more intensive psychiatric support, telehealth services may never be adequate to meet the need for care.
If You Don't Have Money ...
The circumstances that lead any person into homelessness, or that keep someone from exiting, are unique and individual. The experience of exiting homelessness, or beginning to with a stay at a ProLodge, is likewise varied.
Leo Scott moved to Austin about one year ago, after stints living on the streets of Columbus, Ohio – where he was born and raised – Houston, Atlanta, and New York City. In his assessment, Austin has been the worst place to live unsheltered, despite the relative comfort he has enjoyed at a ProLodge since summer.
"Austin is a city where if you don't have money, you don't have nothing," Scott told us. In Atlanta, he had regular access to laundry and food, but could not land himself in a housing program. He's had similar challenges here. Scott asked his case manager about moving into transitional housing at a site where one of his friends was living but was told it wasn't the right fit for him.
Scott expects to be in more permanent housing by February, but the wait has been hard on him, and he's frustrated. "I'm 40 years old, and I want my own place to lay my head," he told us. "Austin has all this money to build new train stations, but not enough money to help people like me stay where we want? It's bullshit."
Before the pandemic, the city had aligned itself with a strategy to purchase motel properties to convert for rapid rehousing and permanent supportive housing, adding to Austin's scarce supply of apartments for single adults who need a stable environment and access to services to remain housed. Many of those involved tell us that, as COVID-19 response and relief have occupied the city's energies, the ProLodges have been a de facto pilot for that strategy, which on its own has struggled to get off the ground. Council approved the first motel purchase and conversion in November 2019, and a second one in October of this year; both are currently being used as ProLodges.
Niki Kozak, the housing for health systems manager with the Ending Community Homelessness Coalition, says that while the program's value as a model and template for long-term housing is clear, the ProLodges as currently operating may not be sustainable. "They are a bit expensive to run," Kozak told us. "And more money spent on transitional housing means less money available for permanent supportive housing." Building out more PSH is the current focus for ECHO and its partners; keeping up with that demand, and meeting the goals of the city and ECHO's housing plans, will require as much money as can be made available from the city's growing, but still finite, pool of housing dollars.
According to the joint city-county Emergency Operations Center, 303 people have exited from a ProLodge stay. Of those, 107 entered another housing program, be it RRH, PSH or other transitional housing. Eight are known to have gone to health care facilities, and 15 to one of the city's shelters; 78 exits were classified as "other," which, per a spokesperson, can include leaving for a job opportunity or to stay with friends or family, as well as entering hospitals, nursing homes, the justice system, and other institutions. The remaining 95 guests did not participate in an exit interview.
A Time For Reflection
With the new DACC and Caritas programs, more of the remaining ProLodge guests will go into RRH, along with being wait-listed for placement in the city's scarce PSH units. Typically, funding for RRH, which is designed to keep those who abruptly lose stable housing (disasters, unemployment, medical crises, family violence, jail release, etc.) from entering long-term homelessness, lasts for six to 12 months. Those we talked to expressed concerns that, while federal COVID relief funds are available now, will remain in place for two years, and can meet the immediate needs of those exiting ProLodges, they will eventually run out. Some of those being served will not be ready or able to find housing or live without support services; at its core, the PSH model presumes those services will be needed by at least some residents for their whole lives. What will happen to them?
The tension between funding adequate services to meet the present need and creating long-term stability with robust supportive housing has long been felt by ECHO and the city's Homeless Strategy Division, now located within Austin Public Health, as they steer the city and county, and their many partner agencies, toward the goal of ending chronic homelessness for good. Karman expects a new permanent hire for a homeless strategy officer will be made early in 2021, strengthening the broader efforts to resolve this tension. Dianna Grey, who has worked as a consultant for social service agencies providing support to people experiencing homelessness, will serve as the permanent Homeless Strategy Officer beginning Jan. 4, strengthening the broader efforts to resolve this tension. Meanwhile, the people living at ProLodges are just enjoying safety and comfort that they've lacked for a long time, while preparing for what comes next.
For 70-year-old Genaro Robles, his stay at ProLodge 4 has been a time to reflect on his life, which includes a tour in Vietnam followed by a career installing school gymnasiums in four different states. Mainly, he's focused on how to be a positive influence in the lives of his children and grandchildren. "I was doing well for a while, taking care of my family," Robles told us while showing off his room, where his daughter would soon be joining him as a caretaker.
"But now I can barely afford to take care of myself. I don't want my daughter or grandkids to struggle like I have at times. I'm hoping that when I leave here, we can get a place close to their school, so my daughter can go off to work and I can take care of my grandkids when they're not in school."
For our gallery chronicling ProLodge 4, visit austinchronicle.com/photos.
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