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This interview with Margot Kushel, MD, director of UCSF’s Benioff Housing and Homelessness Initiative, discusses a viral video of a San Francisco art gallery owner spraying an unhoused woman with a hose, and what his actions and residents' subsequent reactions reveal about the responses to homelessness in San Francisco. Dr. Kushel said that conversation about the video, "is indicative, in some ways, of the state of our discourse around homelessness that we continue to blame the individuals who are experiencing homelessness for what has been a really widespread societal failure."

The complex care evidence base continues to grow, but meaningful involvement of people with complex needs in the research process is lacking. Hemal Kanzaria, MD, Associate Professor of Emergency Medicine at University of California San Francisco spoke with The Better Care Playbook to learn more about how involving people with lived experience in research can help strengthen the complex care evidence base. Dr. Kanzaria said, "The partners are working together in every one of those steps and recognizing the skill set that everyone's bringing to it. That makes the work better than anyone could do by themselves."

A new report estimates California could end homelessness by 2035 if it spent at least $8.1 billion every year on the problem. Margot Kushel, MD, director of the UCSF Benioff Housing and Homelessness Initiative said, “The main way to solve homelessness is through housing.” She pointed out that research shows California is short by 1 million affordable and available housing units for extremely low-income renters—those making less than 30% of area median income. “By shrinking that deficit, we will reduce homelessness,” she said. “It will take a sustained investment by federal, state and local governments to do it.”

Housing First focuses on getting people into permanent housing and offering them support services. A 7-year randomized trial of chronically homeless individuals found those in the housing-first group spent 90% of their nights housed and made less use of psychiatric emergency services and more use of outpatient mental health services compared to the control group. “The experiment intentionally sought to try housing first for the very most complicated patients—those who society says are most hard to house—and it worked,” said study co-author Margot Kushel, MD, who directs the UCSF Benioff Homelessness and Housing Initiative.

This feature article reports on overdose mortality in the city's supportive housing program, the cornerstone of an effort to help people rebuild their lives after bouts of homelessness. "Anything that can create community and safety and wellness in these settings is going to make a difference," says UCSF Benioff Homelessness and Housing Initiative's Kelly Knight, MD.

San Francisco and California have been reckoning with the issue of housing instability for years, but additional complexities arise as people experiencing homelessness grow older. In this Grand Rounds, Margot Kushel, MD, one of the world’s leading experts on homelessness, discusses the drivers and precipitants of homelessness and the health consequences of aging in the homeless population. Dr. Kushel is a professor of medicine and directs both the UCSF Center for Vulnerable Populations and the UCSF Benioff Homelessness and Housing Initiative.

During the COVID-19 pandemic, UCSF partnered with government and community groups to address racial, economic, and cultural barriers with the goal of providing equitable care to vulnerable people. The UCSF Benioff Homelessness and Housing Initiative spearheaded many of those partnerships. “The secret sauce was putting the community-based organizations in charge,” said Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, who envisioned a program to serve people experiencing homelessness that became a national model.

Programs in San Francisco that offer people living on the streets respite, shelter, and treatment often fall dismally short of the need. “There just isn’t enough of it,” Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, says. “Without the housing, it all falls apart.”

California’s homeless population has increased in recent years, and so has public investment in addressing homelessness, making understanding the size and needs of the state’s homeless population more important than ever. Discharge data from emergency departments (EDs) can help. PPIC researcher Shannon McConville and UCSF professor Hemal Kanzaria, MD outlined key findings from a new report and discussed the implications for policymakers.

The latest point-in-time count reveals the number of Californians without a stable place to call home increased by 22,500 over the past three years. Homelessness experts attribute the rise to precipitous drops in earnings during the pandemic among Californians already teetering on the edge. They also point to a worsening housing affordability crisis decades in the making. “We have to solve this rotting core in the center of California—we are a million units short of housing for extremely low-income workers,” said Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative.