When Shayan Rab, M.D., was hired as the first full-time street psychiatrist for the Department of Mental Health (DMH) in Los Angeles County, he Googled street psychiatry and got zero hits. “There wasn't much guidance on how to provide the service, what medications I should use, how I should stabilize someone, or how I should integrate services across the county,” he recalled. 

Now Chief of Psychiatry for Countywide Engagement & Field-Based Services, Rab recently described the creation of the HOME (homeless outreach and mobile engagement) Team, the first instance in which street psychiatry was truly integrated with specialty field-based mental health services.

Rab was speaking during a March 12 webinar hosted by the California Street Medicine Collaborative, which explored how street medicine can strengthen behavioral health care for Californians living unsheltered.

Going back to his early days in the program, Rab said he wondered how to take someone who is severely mentally ill with co-occurring medical problems, substance use, severe schizophrenia, poor insight into their mental health condition and transform their life and then reintegrate them into the community? “I had no idea,” he said, “but the streets will show you what you need to do. That's really what happened with me in my journey in the Department of Mental Health. At the outer limits of what street medicine can do, that’s where sometimes street psychiatry takes over for really complicated behavioral health recovery.”

Any specialist field-based mental health requires a multidisciplinary team involving a non-medical arm made up of community health workers, social workers, and substance use counselors. The medical arm has psychiatrists and nurses. The psychiatrists are the lead physicians for these teams and bring their subject matter expertise in the behavioral health space to the table. 

A team like this can provide outreach services, case management, access to shelters, and mental health triage, Rab explained. When you add the medical arm of psychiatry and nursing, you can offer a combination of psychiatric and medical services, which means you can provide nursing assessment and support psychiatric treatment and laboratory workup consultation with other sub-specialties, he added. “Here is the important part that the specialty mental health team brings to the table: You can get access to psychiatric residential placement. You can get access to inpatient and emergency psychiatric care coordination. You can get coordination with jail and mental health-related care coordination as well.”

The larger ecosystem of services for more complex cases starts opening up when specialty mental health services come to the table, Rab continued. “Now specialty mental health services have been available in DMH for quite some time. There was a metamorphosis, though, when DMH began building up its street psychiatry infrastructure.”

Rab defined street psychiatry as a form of street medicine that focuses specifically on mental health conditions, but it's still being medically driven, can integrate with a larger medical system and provide mental health services and collaboration with physical healthcare.

"Street psychiatry is essentially regular psychiatry that's been adapted for people who are not living in traditional settings — essentially people who are living in environments that are not intended for human habitation. This could be cars, the streets, or bus stops. This could be abandoned buildings,” he explained. “When you're practicing psychiatry in these types of settings, you can't use the traditional approach to psychiatry. You need something different. You need a different set of medications. You need a different set of rules for how you're going to work with people who are in these non-traditional environments. Our medications have a lot of side effects. You have to keep these in mind when you're caring for people within the reality of their living conditions.”

What are some goals of street psychiatry? “It might be very simple to state, but when I first show up to evaluate someone, I’m not trying to find out the list of their psychiatric diagnoses, and I’m not trying to find out how many times they've been psychiatrically hospitalized,” Rab said. “I’m trying to be a human being, so I can connect with this person and build a doctor-patient relationship so they trust me. That's the most important part. I want to overcome some of the the trauma they might have experienced at the hands of psychiatry. Remember, as psychiatrists, we put people in involuntary hospitalizations. We give people injections against their will. We've taken their rights away. Psychiatry doesn't have the best street cred, so I have to spend some time building a strong doctor-patient relationship and developing as much of a shared understanding of their mental health needs as I can.”

After that, he still doesn’t turn to diagnoses and medications. He turns to addressing their basic needs, their personal safety, any necessary medical care that they might need, activating all benefits. Then finally, when the individual is ready to take that journey with him, starting psychiatric treatment and starting their rehabilitation process. "Medications will not magically make someone transform their life. My psychiatric treatment might put someone in a more regulated emotional state, a more regulated mental state, where they can make those lifestyle modifications with us and try and transform their lives out of homelessness,” he said. 

At the same time, a street psychiatrist is well positioned to integrate system-wide interventions and resources. DMH is one of the largest mental health providers in the nation. “We can tap into those resources and bring them to the table to create a truly transformative plan that integrates all levels of care, because that's what our our folks need. They’re so deep into their self-neglect that they might not even realize the help that they need. So we need to activate a lot of resources to transform their life.”

The HOME Team integrated street psychiatry into specialty field-based mental health services. “There were no parameters for this. We had to build it from scratch, and we let our clients and the system teach us how we needed to build this,” Rab said. The HOME Team was designed to serve unhoused individuals with severe mental illness, who are challenging to engage, who are not providing for their basic needs, who are lacking insight into their mental illness, who are failing to benefit from traditional mental health services and less-intensive service, have co-occurring substance use and physical health needs and are on the brink of hospitalization. 

How do you help someone who is this impaired? Who is responsible for this individual? Historically, it's been hospitals, Rab said, “but we know that sometimes the hospital is not able to address all the needs for this individual. So a lot of cyclic hospitalizations were taking place, but no transformations were taking place. Street psychiatry was the missing link in this space, and that's one of the things the Home Team did for the Department of Mental Health,” he explained. “We built a model based on the foundation of the assisted community treatment (ACT) model. We took it to the next level.” They integrated outreach, street-based psychiatric treatment and housing services. They took all of the resources the department had and and brought it curbside to their clients. “Not only were we providing psychiatric treatment, we actually were providing street psychiatry with clinical infrastructure for stabilization.”

Rab said they realized that they would need to hand-deliver medications every single day, and that's what theye do on the Home Team. “We had to build an entire system where our psychiatrist can order medications through our system. It'll go to one of our partner pharmacies. The partner pharmacies will bubble pack the medications. It will shift them back to our system, where our nurse will receive the medication, log them in and hand it to our staff who are going out to do daily outreach. They will hand the medication to the client and observe them self-administer the medication and report back to the psychiatrist,” he said. 

This allows them to create a system where they can make sure that the clients are receiving and taking the medications, and the HOME Team can do a safety analysis to figure out how they can advance to long-acting injections for whatever treatment needs they have.

“This allowed us to very successfully start stabilizing folks on the street,” Rab said, “and once their mental health symptoms start improving, once their insight starts improving, once their judgment starts to improve, then we bring in all of the resources for housing that the Department of Mental Health has.”

Once they place the person into housing, they continue being their treatment provider. There is a supervision of long-term recovery that the Home Team is providing. It is only once someone is stably housed in a permanent situation do they hand it off to the rest of the DMH ecosystem so they can continue with this individual's care, managing the recovery, and then the Home Team focuses on the next person.

They are also integrated with acute care and the mental health court system. “With all of these partnerships across all of these different levels of care, specialty mental health is now operating in an ecosystem of care with clinical relationships across the board,” Rab said. “These relationships are what allow us to do what I call large-scale system navigation for our folks, because they need every single service that the entire system has and they need to be activated in a synchronous way. We can integrate all the interventions and have a shared vision for what recovery needs to look like.”