Project 25: The Pilot Project Aimed at San Diego’s Most Difficult Homeless Cases Showed Promise, Then Died.

This story is part of our “What ever happened to …” series. These topics were once front page news, but have since slipped out of the spotlight. Read more stories in our series here.

Rooster was Project 25’s last new client.

The Vietnam War veteran was homeless and addicted to meth, living in an encampment along the San Diego River. He had health issues that often landed him in the hospital. His health insurance provider knew the only way to cut down on Rooster’s medical expenses was to get him into housing, so they contacted Project 25.

Launched in 2010, Project 25’s mission was to house and care for the region’s most expensive homeless people – the  ones racking up the most ER visits, ambulance trips, hospital stays and calls to police. People who were not only a drain on taxpayer dollars, but also at risk of dying on the street. People like Rooster.

In early 2015, Rooster’s insurance provider reached out to Project 25 administrators, offering to pay to enroll Rooster in the program, which would get him into housing coupled with intensive case management. Caseworkers were given scant information about his whereabouts. “Likely stays in riverbed,” they were told.

They found him in a camp deep amid the riverbed’s thick vegetation.

“You want a home?” Rooster remembers them asking. “No,” was his first answer. By his count, he’d been kicked out of five other programs. But after grilling the case managers about Project 25, he changed his mind.

I met Rooster in June of 2018. The 71-year-old had been living in his own apartment for three years. He was off meth and, with help from his case managers, was receiving regular medical care and taking his prescription medications. He’d ridden his bike a few blocks from his apartment to the Project 25 office, a small house on the Father Joe’s Villages campus, so I could interview him about his experience in the program.

At that point, because of lack of funding, Project 25, arguably San Diego’s most successful homelessness intervention, had been closed to new patients for two years.

Project 25 launched as a pilot in 2010, with the nonprofit United Way of San Diego County providing $1.5 million for three years. The goal was to identify the 25 most vulnerable and frequent users of public services, house them and manage their situations. Assemblyman Brian Maienschein, then United Way’s homelessness commissioner, told me he was sure the pilot would prove to be such a success that stakeholders – from private hospitals to local governments – would invest in Project 25’s growth.

Rent for Project 25ers was covered by federal housing vouchers. Case management was provided either by county mental health or St. Vincent de Paul (now known as Father Joe’s Villages). The housing came with almost no strings attached – it  was a true “housing first” program premised on the idea that drug or alcohol addiction or serious mental illness can be more easily treated when a person is housed.

Project 25 clients weren’t the sort to work and play well with others, said Marc Stevenson, who directed the program for Father Joe’s. One client I profiled, Hutch, got drunk the first night in his apartment and made such a mess, the property managers demanded he move out.

“But we stuck with him,” Stevenson told me. “And we got him into another unit.”

That was the story with many clients – their initial days, even weeks, in housing didn’t always go well, but Stevenson and his team were nimble and creative and found solutions for even the most difficult people to keep them housed and as healthy as possible.

In 2013, two years into the program, Project 25 participants had taken 600 fewer ambulance rides, were in the ER 1,100 fewer times and spent nearly 1,000 fewer days in the hospital compared with the year before they entered the program. The cost savings to hospitals alone was more than $2 million.

Not a single Project 25 client returned to the street. Everyone who entered the program remained housed. Several participants have died – including  Rooster and Hutch – but  from natural causes and in their own apartments. All participants became self-sufficient enough to be transferred to less-intensive case management.

The pilot ended in April 2014 – the  same year the Affordable Care Act expanded Medicare, which meant hospitals no longer needed to foot the bill for indigent clients. Gone was the financial incentive to keep the program going.

The United Way granted Project 25 an additional $100,000 and they secured a grant from the federal Substance Abuse and Mental Health Services Administration that, combined with contracts from a few health insurers, helped sustain the program for a couple more years.

In an interview in June 2017, Jim Dunford, then the Emergency Medical Services Director for the city of San Diego who worked on the Project 25 pilot, told me it was difficult to drum up support for a program that served a small segment of San Diego’s homeless population when there were thousands of people living on the street.

“I think the long and short of Project 25 was, it became kind of a nice, interesting idea that never could really catch the attention of all these big players,” he said.

I wrote about Project 25’s funding dilemma in May 2014, when St. Vincent de Paul had just begun to approach insurance companies, trying to convince them that they’d save money by paying for case management instead of repeat ambulance rides and hospital stays (and, in at least one case, repeat Life Flight rides). But only four insurers – representing a total of 17 patients – signed contracts.

Then the state introduced a new pilot, called Whole Person Care (known in San Diego County as Whole Person Wellness). Under the new pilot, which ended in December 2020, homeless Medi-Cal patients with acute medical needs would receive case management through county contractors. The pilot didn’t include housing, but it took away the incentive for insurers to contract with Project 25.

Whole Person Wellness, Stevenson said, fell short of the kind of intensive case management Project 25 clients certain users needed. Another program, Health Homes, aimed to hook people up with care through community clinics, but someone eligible for Project 25 wasn’t going to seek care at a community clinic, Stevenson said.

“P-25 was successful because [case managers] involved themselves in the participants’ cycle of crisis, moved their dependence of the emergency services to the P-25 program staff and provided a medical home at our clinic that was willing to respond to crisis in certain ways,” he explained to me recently in an email.

“We did for them what they could not do for themselves and slowly moved them towards personal empowerment by helping them create relationships and trust in us, then relationships and trust in their doctors,” Stevenson said. “Where they used to call 911, they now called us. We also had housing vouchers to stop the cycle of homelessness and a budget that was supportive of our unique and spur-of-the-moment efforts to move them from crisis to stability, over and over again.

“But alas we created a very effective program that could not be replicated,” he concluded. “The other programs implemented in its place left out all the things that we found most effective in making it work.”

People I spoke to said Project 25 struggled to “scale up” – in other words, become a much larger program. It was hard to turn Project 25 into Project 100, much less Project 1,000.

“Scaling up a model does not usually increase the level of attention,” Stevenson said. “Likely quite the opposite.”

Ruth Bruland, chief program officer at Father Joe’s Villages, compared Project 25 to an Intensive Care Unit – a small, but necessary part of any hospital system.

“I don’t know why there isn’t a place in the larger spectrum of the San Diego region’s homeless services,” she said.

But Stevenson sees promise in a handful of programs, like street health teams, mobile medical clinics that provide medical outreach, the county’s Assertive Community Treatment program, or ACT, which targets high users of hospital psychiatric units and the Community Health program. Formerly known as the Resource Action Program, or RAP, it’s a team of paramedics, clinicians and a physician assistant that diverts high-needs people to community-based programs versus hospitals.

Ann Jensen, who oversees the Community Health program for the San Diego Fire-Rescue Department, said Project 25 had a spirit of “do what it takes.”

“And that’s what made it work,” she said. “I mean, it was amazing.”

Jensen said that a new law that takes effect in December expands the scope of practice for paramedics statewide, allowing them to be more proactive when helping homeless frequent users of emergency medical services. The law was inspired by RAP, which seeks to provide the same intensive case management that Project 25 provided.

“We actually don’t let go of patients until we feel like they’ve successfully latched on to their new service,” Jensen said. “And so we will take them, put them in housing, and we will visit them every day if we have to until we know that services kicked in.”

If a person doesn’t improve, RAP will ask the San Diego City Attorney’s office to consider placing the individual under a conservatorship, which can be a time-consuming, expensive process. The legal proceeding requires a judicial finding that a person is unable to care for themselves. The court then appoints a guardian to ensure the individual’s basic needs are met.   

“I think now [RAP] is a little bit more robust, so we do go further than we used to,” Jensen said. “But there is a point where you have to realize that the existing services are not enough to take care of the individual.

“It doesn’t happen that often,” she said. “But it does happen when somebody just will not stabilize. Honestly, that would be where Project 25 came in.”