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Case · 91

Individuals and Families Experiencing Homelessness

From an encampment to a signed lease in 90 days

Member

James

Service line

Individuals and Families Experiencing Homelessness

Location

San Diego County, CA

Duration

90-day field engagement

01 —

The outcome

A 54-year-old living unsheltered for four years with schizophrenia and untreated hepatitis C moved from a riverbed encampment to a permanent supportive housing unit — with his medications, his cat, and his ID.

Housed on Day 89

Headline result for James.

Day 89

Move-in date

From first field contact.

0

ED visits in 6 months

Down from 11 in the prior 6 months.

SVR12

Hepatitis C cured

Sustained virologic response achieved.

12/12

LAI injections on schedule

Delivered at home.

02 —

Background

Where the member started.

James had been camped along a riverbed for four winters. Prior housing offers fell through when paperwork demanded an ID he didn't have or a bank account he couldn't open.

In their words —

“They came to me until I trusted them enough to come to them. Nobody had ever done that before.”

— James, Community Supports Member

03 —

The challenge

What stood in the way.

  1. 01

    Untreated schizophrenia with intermittent medication access via the ED.

  2. 02

    Active hepatitis C, never treated.

  3. 03

    No ID, no Social Security card, no active Medi-Cal.

  4. 04

    Deep distrust of shelters after a prior assault.

04 —

Our approach

How we built the plan.

Move 01

Field-based clinical team visiting the encampment weekly, not asking him to come to a clinic.

Move 02

Housing-first: secure the unit while stabilizing everything else in parallel.

Move 03

Bring the pharmacy, the ID clinic, and the hep C treatment to him.

05 —

The solution

Step by step, what we actually did.

  1. 01

    Weeks 1–3 — Trust + benefits

    Weekly field visits; Medi-Cal reactivated; ID replacement filed; long-acting injectable antipsychotic started curbside.

  2. 02

    Weeks 4–8 — Housing match

    Housing Deposit + Housing Tenancy Sustaining Services applied to a permanent supportive unit; pet accommodation negotiated.

  3. 03

    Weeks 9–12 — Move-in + treatment

    Move-in coordinated; furniture and starter kit provided; hep C direct-acting antiviral treatment initiated.

06 —

Services involved

The full network on this case.

Enhanced Care ManagementCommunity Supports — Housing Deposits + Tenancy SustainingField-Based Behavioral HealthHepatitis C Treatment

Next —

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