Lena Miller is CEO of Urban Alchemy, a San Francisco-based homelessness solutions provider and nonprofit.
Nearly every major U.S. city grapples with homelessness, addiction and street safety. Cities remain constrained by limited knowledge, stubborn habits and inert cultures of bureaucracy. As a psychologist with over a decade experience in the field, I find it troubling that we are not implementing a systematic, scientific approach to these pressing issues.
Workers on the front lines of addressing these crises are exhausted, disillusioned and demoralized. They are doing some of the most psychologically demanding work in America — work that is urgently needed yet often underpaid, under-respected and misunderstood. If cities want different outcomes, they must begin by taking this work, and the people who do it, far more seriously.
Fund what works, not what's familiar
Most shelter and social service models are more than 50 years old, built before synthetic street drugs and widening wealth inequality. Our models and services must keep up with the reality we’re living, backing services that are relevant, effective and measurable.
Providers should be required to use evidence-based models with statistically significant outcomes. We should hold homelessness and social services to the same rigor we expect in cancer research or air pollution policy. Models should be tested through peer-reviewed research and best practices, and city contracts should reflect those standards.
Urban Alchemy has invited universities, elected officials and public health departments to formally study our methods, program models and outcomes. Despite the scarcity of this kind of research, there have been few takers. One exception is Forrest Stuart, a Stanford University sociology professor whose anthropological study of work to reduce crime became the basis for his book dissecting the policing of poverty on Skid Row.
Shelters and social service providers with consistently weak outcomes should receive support to improve, but if they fail to meet baseline standards, they should lose funding. Cities can no longer afford a charitable model that centers the nobility of the provider rather than the results achieved for the people served.
If you hire a plumber to fix your toilet and they leave without it being repaired, you likely would not hire them again. Making the system fair to the organizations that meet or exceed benchmarks will effectively remove bias and corruption from the system, allowing a natural competition to arise in which providers strive toward quality and effectiveness.
Treat shelters like mental health facilities
Over the past four decades, prisons and jails have become the country’s largest mental health facilities. Now, homeless shelters are facing the same reality. At our shelters, most guests are living with mental illness, including substance use disorder. Yet shelters are not recognized or funded as settings for people with mental health needs.
For people to recover and move into independent housing, we must address their underlying trauma, medical needs and related challenges. We must meet clients where they are, bringing substance-abuse services like therapists and psychiatrists on-site to keep up with the demands of required medication and active treatment.
Shelters housing more than 100 people — where at least 60% of guests have a substance-use disorder or mental illness requiring medication or active treatment — should be required to provide on-site clinical care. That's a departure from the norm, where most public mental health patients must travel to a clinic to see their therapist or psychiatrist, leading to missed appointments and wasted physician hours.
Train and pay workers like the professionals they are
Unhoused populations often present physical infirmities, mental challenges and psychotic features that must be treated with prescription medication. It is imperative that staff are trained to deal with all possible challenges — psychotic breaks, severe depression, addiction, overdoses, violent attacks, chronic PTSD, wound care, the list goes on. Daily issues easily escalate into life-or-death circumstances.
Staff should be adequately trained on an established curriculum and demonstrate basic competencies, the same standards we hold of nurses, plumbers, bankers and other professionals. Currently, providers are left to set these standards, resulting in extremely varied levels of care and service across shelters.
Shelter and social services providers make slightly above minimum wage while being expected to run city-funded, unregulated, 24/7 facilities to help people permanently exit homelessness. Shelter workers must be compensated appropriately to reflect the level of stress and skill that is required to do the job, or shelters risk continuing the cycle of high turnover across the field.
Don't let elections reset the system
Mayors across the country have made addressing homelessness a top priority, but election season is the most dangerous time for service providers. Providers are often caught in the crossfire of changing administrations, personal politics and citywide budget deficits.
If we want real outcomes on homelessness, we must create consistency for our clients, providers and the communities we serve. We can level the playing field by collecting, analyzing and reporting all service outcomes and making them accessible to all stakeholders. We can foster a new era of service in which providers can prioritize offering the best product instead of competing with one another and focusing on relationships within City Hall.
The cost of inaction keeps climbing. Cities don't need more emotional debates about homelessness — they need the discipline to treat it like the solvable systems problem it is. That means funding what works, not what's familiar; training and paying workers like the professionals they are; and building contracts that survive an election cycle. The tools to do this already exist. What's missing is the will to demand them.
