LOS ANGELES \u2015 Carla Brown waits on an air mattress, eager for her occupational therapist to arrive at her apartment next to the Hollywood Freeway, mere blocks from where she once camped on the sidewalk.<\/p>\n

She moved into the one-bedroom apartment on the second floor of PATH Villas Hollywood, a county-run apartment complex, in July, shortly after her 60th birthday. Inside the open-concept unit, the walls stand bare except for three Christian art prints hung near the front door.<\/p>\n

Brown brightens when Julian Prado, a tall 29-year-old with a nose piercing and black mustache, walks in toting a grocery bag with fresh ingredients for veggie tacos. Prado, a warm and supportive therapist, has been visiting weekly for six months to help Brown learn to live in permanent supportive housing, where clients live on their own but receive on-site support from a care team.<\/p>\n

Once inside, he spots gnats hovering above food rotting on dishes stacked in the kitchen. \u201cLet\u2019s clear some of this counter first,\u201d Prado says, running out to his car to retrieve gloves and cleaning supplies.<\/p>\n

Prado is one of 10 Los Angeles County occupational therapists assigned to unhoused and formerly unhoused clients. According to research by the California Policy Lab,<\/a> at least 1 in 5 single adults placed in permanent supportive housing in Los Angeles from 2010 to 2019 slipped back into homelessness or interim housing. The county hopes this new team can improve the likelihood of success in transitioning people indoors.<\/p>\n

Occupational therapists, who focus on cognitive and physical disabilities, are often associated with schools and health facilities, but their skills can fill a gap in homeless programs. Occupational therapists assist clients, most of whom have complex health conditions, in developing basic living skills, such as hygiene and cleanliness, which help prevent clients from getting evicted or slipping back onto the streets.<\/p>\n

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While their role is still rare, it\u2019s not new. Occupational therapists have been deployed by nonprofit homelessness services around the country for years. The U.S. Department of Veterans Affairs<\/a> has used therapists in its homeless program since 2008. But as homelessness proliferates in California, Caitlin Synovec of the National Health Care for the Homeless Council, an advocacy group, said Los Angeles County has the advantage of coordinating across a robust social services network and can reach people no matter what stage of homelessness they\u2019re experiencing.<\/p>\n
\u201cLos Angeles County\u2019s model is special in that it allows individuals to access occupational therapy at different touch points as they move from street medicine to transitional housing to permanent supportive housing,\u201d Synovec said. \u201cIt\u2019s really unique.\u201d<\/p>\n
This isn\u2019t Brown\u2019s first housing placement.<\/p>\n
In 2019, after she had been living on the street for nearly a year, a nonprofit helped place her in an apartment in Rowland Heights, in the San Gabriel Valley. With permanent supportive housing, clients live alone but have a case manager and can receive on-site assistance from social workers and other support staff.<\/p>\n
\u201cI just couldn\u2019t handle it, being on the streets,\u201d Brown said, sitting on her walker. \u201cNobody can. It\u2019s terrible out there.\u201d<\/p>\n
Carla Brown says the transition into housing has been challenging, but she hopes she can serve as inspiration for other unhoused people who want to move indoors. \u201cI don\u2019t know what\u2019s gonna happen in the future,\u201d Brown says. \u201cBut I\u2019m still here.\u201d (Molly Castle Work\/KFF Health News)<\/span><\/figcaption><\/figure>\n
While in Rowland Heights, cataracts robbed her of her ability to see. As her physical health declined, her living space deteriorated and the county declared it unsanitary, citing rotten food, vomit-stained sheets, and blood.<\/p>\n
Managers began the eviction process, but Brown worked with county staff members to relinquish her unit so it wouldn\u2019t jeopardize her housing voucher. She was placed in an assisted living facility in 2021. Her vision returned once she had eye surgery.<\/p>\n
Brown transferred to Villas Hollywood in 2023, but once there, the property management staff, again, cited cleanliness issues in her apartment: discarded food, piles of clothing, vomit in the bed, and a mice infestation.<\/p>\n
This time, Brown had Prado\u2019s help to declutter her apartment. Her bedroom is no longer a sanitation issue. But Brown has taken to avoiding the bedroom, convinced the mess will return if she goes back in.<\/p>\n
\u201cIt was getting to be ridiculous,\u201d Brown said. \u201cI had to put a clamp on it.\u201d She now sleeps on an air mattress in the living room.<\/p>\n
Living indoors has been difficult: Brown still thinks of grabbing her tent and returning outside for a few nights. She compares leaving the street to breaking an addiction.<\/p>\n
\u201cIt\u2019s like stopping smoking. Sooner or later, you need that hit,\u201d she said.<\/p>\n
$\"Julian$
Julian Prado cuts tomatoes as he and Carla Brown prepare veggie tacos. Prado is a member of Los Angeles County\u2019s occupational therapy team helping newly housed individuals adjust to life indoors.(Molly Castle Work\/KFF Health News)<\/span><\/figcaption><\/figure>\n
Deborah Pitts, a professor of clinical occupational therapy at the University of Southern California, said it\u2019s common for clients to go from being outside in a constant fight-or-flight state to feeling isolated and directionless once in housing, staring at a calendar of empty days. They face tasks they may not have done in decades, such as laundry, cooking, cleaning, and managing finances.<\/p>\n
At the same time, many clients have cognitive impairment and complex health conditions that complicate their transition.<\/p>\n
USC researchers found in a series of studies<\/a> that by the time clients are placed in housing, 90% of residents age 39 or older reported two or more chronic physical or mental health conditions. They also have a high prevalence of geriatric conditions, including difficulty walking and urinary incontinence, at a higher rate than housed adults 20 years older. The phenomenon is known as accelerated aging.<\/p>\n
Where a case manager might misread a client\u2019s cognitive impairment as complacency, therapists are trained to identify disabilities and adapt the environment or the task to a client\u2019s needs, said Heidi Behforouz, medical director of Los Angeles County\u2019s Housing for Health program, which administers the occupational therapy program.<\/p>\n
For example, if a client is struggling to recall where they\u2019ve stored items in the kitchen, a therapist might remove the cabinet doors to improve visibility. Or if a client isn\u2019t taking their pills, a therapist wouldn\u2019t just suggest a pill box; they\u2019d also work with a nurse to figure out if the client needs larger fonts or different colors to differentiate pills.<\/p>\n
\u201cSometimes cognition doesn\u2019t get better,\u201d Pitts said, \u201cbut function can get better.\u201d<\/p>\n
Brown said Prado has helped her a lot with her transition. Recently he\u2019s been encouraging her to get out into the community. For example, since she\u2019s passionate about her Christian faith, Prado has been encouraging her to return to church.<\/p>\n
Prado said a key part of his work is helping clients find meaningful activities to fill their days. He has offered to attend services with her.<\/p>\n
\u201cI don\u2019t know what\u2019s gonna happen in the future,\u201d Brown said. \u201cBut I\u2019m still here.\u201d<\/p>\n
$\"Carla$
Carla Brown offers to show Julian Prado how she crisps tortillas to make hard-shell tacos. Los Angeles County is using occupational therapists to help prevent newly housed clients from getting evicted or slipping back onto the streets.(Molly Castle Work\/KFF Health News)<\/span><\/figcaption><\/figure>\n
The county\u2019s occupational therapy team has worked with nearly 160 clients thus far, but Brown is just one of approximately 15,000 residents navigating the transition to permanent supportive housing. Statewide, an estimated 172,000 people are experiencing homelessness<\/a>.<\/p>\n
The team, funded through a mix of county and state grants, plans to hire eight more therapists in the coming months. County officials hope to expand further but have yet to find additional sustainable funding.<\/p>\n
One potential solution would be to get the state\u2019s Medi-Cal program, California\u2019s version of Medicaid, to cover occupational therapy so therapists can bill directly for services without a prescription from a doctor or a licensed practitioner. But county officials said that supplemental funding would be needed with or without a prescription because Medi-Cal reimbursement rates tend to be too low.<\/p>\n
Back in the kitchen, Brown scrapes food into the garbage disposal as the keys to her home dangle off a lanyard around her neck. Prado sprays cleaner and wipes the countertop. As they finish scrubbing the dishes, the two exchange jokes and laugh.<\/p>\n
\u201cSometimes you have one thing planned, and then you hit a barrier, but that\u2019s OK,\u201d Prado said. \u201cI always tell my clients that \u2018I\u2019m going to use my knowledge to support you in this task, but, ultimately, you\u2019re in the driver\u2019s seat.\u2019\u201d<\/p>\n
Once the cooking area is cleared, Brown pours olive oil into a pan and shows Prado her trick for crisping tortillas. She hands Prado a cutting board and tells her sous-chef to cut the tomatoes.<\/p>\n
\u201cI adore him,\u201d says Brown. She catches Prado blushing. \u201cLook! He\u2019s turning red.\u201d<\/p>\n
Once the tortillas are fried and the tomatoes chopped, they load tomatoes, shredded lettuce, and cheese into the hard shells. Prado takes a taco as they say their goodbyes.<\/p>\n
He\u2019ll be back next week.<\/p>\n
This article was produced by <\/em>KFF Health News<\/em><\/a>, which publishes <\/em>California Healthline<\/em><\/a>, an editorially independent service of the <\/em>California Health Care Foundation<\/em><\/a>.<\/em>\u00a0<\/p>\n
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