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Nicole Boliaux, Deseret News
Karren Cardenas, 45, right, cries while thinking of her last Christmas outside the Catholic Community Services(200 S. and 500 W.) next to the Road Home, called "The Block," in Salt Lake City on Wednesday, March 8, 2017. Karren has lived on the street for seven years and hasn't seen her father or her six children in years. She suffers from nerve damage, high blood pressure and PTSD.

Editor's note: This is the second in a three-day series on homelessness, the issues that are keeping people living on the streets of Salt Lake City, and what can be done to help.

SALT LAKE CITY — Bare, frostbitten toes on size 14½ feet stand out in a crowd. These ones are scabrous and peeling, whitish and bluish with one entirely black and clearly gangrenous. They belong to a lanky African-American man nicknamed Preach, who on a balmy spring day is sunning himself on the sidewalk next to the Catholic Community Service center on Rio Grande Street.

Next to Preach is a brilliant purple pair of brand new size 16 basketball shoes, large enough to fit over his swollen feet, a gift from his brother who just got out of jail. He’ll put them on, he says, when he has some socks.

"Preach" sits on the sidewalk outside the Catholic Community Services (200 S. and 500 W.) next to the Road Home, called "The Block," in Salt Lake City on Wednesday, March 8, 2017. Preach was wearing shoes too tight which caused sores and for him to go without shoes in the cold which led to bad frostbite on his toes. | Nicole Boliaux, Deseret News

Preach knows he needs treatment fast, and he knows he can find it at the Fourth Street Clinic, a free site a few blocks up the road. Badgered by a friend, he grudgingly agrees to have his toes looked at. He doesn't trust doctors, he says.

Preach is one of about 200 people sprawled on the sidewalks and milling in the streets on this early spring day, just north of the Rio Grande Depot between the Road Home emergency shelter, where many sleep, and Catholic Community Services, where they often eat.

He’s been on the street now for 18 months, he says. He lived with his mom, who had an apartment and had been receiving disability, before she died of an opioid overdose. His mom's multiple painkillers were legally prescribed, he says, and he festers with resentment toward the medical profession for her death.

A stroll around the large block where Preach eats and sleeps is a walking tour of the issues Salt Lake City wrestles with as it fights against homelessness — from health problems to mental illness and addiction. It’s also ground zero for the battles raging now throughout Salt Lake County, as the city pushes to shutter the massive 1,000-plus bed Road Home emergency shelter and build smaller, dispersed facilities to replace it. The policy shift has set off a firestorm among citizens whose neighborhoods are earmarked for the new homeless resource centers.

"Preach" sits on the sidewalk outside the Catholic Community Services (200 S. and 500 W.) next to the Road Home, called "The Block," with Criss in Salt Lake City on Wednesday, March 8, 2017. | Eric Schulzke, Deseret News

The furor over homelessness is also causing whiplash among some Utah residents, who remember that just two years ago the national media heralded Utah's achievement in "winning the war on chronic homelessness." Now, state, county and local officials are dealing with the bitter battles over shelter locations and whether it will make any difference, even as problems continue to spiral around the Road Home neighborhood.

How did the conversation change so dramatically so fast? Is Utah, in fact, a model for addressing homelessness — or is it a mess?

Part of the explanation lies in understanding the difference between chronic and nonchronic homelessness. At the same time, a mounting drug crisis has put more people on the street — people whose addictions make them harder to help with housing programs.

Sources of confusion

According to “The Daily Show With Jon Stewart,” Preach shouldn’t be on Salt Lake City's streets at all. In 2015, the popular news satire show breathlessly announced that Utah had nearly solved chronic homelessness simply by giving the homeless homes.

"Preach" sits on the sidewalk outside the Catholic Community Services (200 S. and 500 W.) next to the Road Home, called "The Block," with Criss in Salt Lake City on Wednesday, March 8, 2017. | Eric Schulzke, Deseret News

The reporter, Hasan Minhaj, ambled through Salt Lake City, unsuccessfully seeking homeless people. “Have you seen any homeless?” he asked pedestrians in the business district. “Where did you hide them?” he asked Lloyd Pendleton, then director of Utah’s Homeless Task Force.

Pendleton answered that 10 years earlier Utah started placing the chronically homeless in apartments, using a philosophy known as Housing First. “We have reduced our chronic homeless population by 72 percent since 2005,” he told “The Daily Show.”

Later that year, Gordon Walker, director of Utah’s Division of Community and Housing, told the Deseret News that the state’s chronic homeless numbers had been cut by 91 percent over the previous decade, from 1,932 in 2005 to just 178 in 2015.

The 91 percent figure took hold, appearing in coverage touting Utah as a proven model for solving chronic homelessness in the Washington Post, NBC News, and L.A. Times.

It was a stunning achievement, if true. But it was not quite what it seemed.

First, while most news accounts did mention that chronically homeless people are a small subset of the overall homeless population, headlines fed confusion on this point in the public mind, said Tamera Kohler, director of the state's Community Services Office for the Utah Department of Workforce Services.

The definitions matter, and are legally fixed by federal law. The nonchronically homeless are those on the street for brief periods, and they don't have a formal disability. The nonchronic group, experts say, include up to 85 percent of those who sleep in emergency shelters over the course of a year. These clients often end up couch surfing with friends and family before ultimately finding stable housing.

The chronically homeless, in contrast, is a much smaller group. To qualify as "chronic," clients must be homeless for an entire year or have been homeless for at least four periods over the past three years which together total 365 days. They must also have a diagnosed disability, for which serious mental illness or disabling drug addition both qualify.

The chronically homeless make up 22 percent of the overall homeless population nationwide, and does account for the vast majority of the costs in crisis services.

The second point of confusion that caught Utah off guard was that homelessness was a moving target. It did not sit still and wait to be solved: it mutated, shifted and grew, both nationwide and locally.

Despite a recovering economy, the total number of individuals who had contact with the state's network of homeless services rose in recent years, from 12,241 in 2014 to 13,614 in 2016. The Road Home reported that in 2016, its emergency shelters served more than 8,000 unique individuals, and it is on pace to top 9,000 this year — more than double the pre-recession annual count from 2004 through 2007.

Homeless members of Salt Lake wait outside the Catholic Community Services (200 S. and 500 W.) next to the Road Home, called "The Block," in Salt Lake City on Wednesday, March 8, 2017. | Nicole Boliaux, Deseret News

Finally, there was confusion about how the chronically homeless were counted and categorized, leading to disputes over how much Utah had actually accomplished.

Kohler places some blame for the 2015 confusion on federal agencies that changed definitions and methods of counting the homeless during the previous decade.

Once a year on a night in January, the state does a comprehensive homelessness census, the Point in Time Count, required by federal law. This involves counting by hand the number of people on streets and in shelters throughout the state

But this count is as much an art as a science, and, as Kohler notes, definitions shift over time. But some of the confusion was also errors made by Utah officials. As much as 85 percent of Utah's touted reductions in chronic homelessness in Utah may have been due to changes in how the homeless were counted, according to Kevin Corinth, an economist at the American Enterprise Institute.

Prior to 2009, Corinth says, Utah mistakenly counted clients in transitional housing (semipermanent housing for up to two years) as chronically homeless. This inflated Utah’s chronic homeless numbers. When the mistake was corrected in 2010, the correction created an illusion of sudden and dramatic progress.

Kohler says she fears that focusing on the disputed claims from 2015 obscures the larger point. “We’ve taken 900 people who fit the strict definition of chronically homeless,” she said, “and put them into permanent housing.”

And all disputes notwithstanding, Utah's Housing First strategy does seem to be having an impact on the chronic homeless population. The state’s chronic rate is now among the lowest in the country: In 2016, just 6 percent of Utah’s homeless population were deemed chronic, compared to 22 percent nationwide.

Housing First

But a stroll north from the Rio Grande Depot drives home how many chronic or near-chronic people are still on the streets.

There’s Preach, of course, with his frostbite and gangrene. In addition to distrusting doctors, he is wary of authority figures. This seems to stem from beatings he said his father gave him when he was a young child.

“The adults in my family didn’t do anything about it," he says. "They just turned their eye. People will be blind to things they don’t want to see. The worst thing I could ever see is a little child getting hurt.” He puts on sunglasses to hide his tears.

Sitting next to him is Karren Cardenas, on the street now for seven years, not having seen or heard from her father or her six children in that time. Addicted to heroin, depressed and openly suicidal, she alludes to sexual assault she suffered on the street.

Criss, left, comforts Karren Cardenas, 45, right, outside the Catholic Community Services 200 S and 500 W next to the Road Home, called "The Block," in Salt Lake City on Wednesday, March 8, 2017. Karren has lived on the street for seven years and hasn't seen her father or her six children in years. She suffers from nerve damage, high blood pressure and PTSD.| Nicole Boliaux, Deseret News

Today, the street as a whole looks dirty, crowded and uncomfortable, but not particularly dangerous. It's lunchtime, and an earnest young couple with a large plastic bag is passing out McDonald's hamburgers. A trio of shiny SUVs pulls up and a line forms as home-school moms and kids set up slow cookers and begin ladling out soup into paper bowls.

In the middle of the street, a bulky man with bushy dark hair and a curly beard does slow squats, contemplating the asphalt. It’s not clear whether he is stoned, mentally ill, or both. But at this rate, he’s not getting any soup.

Karren Cardenas, 45, right, cries while thinking of her last Christmas outside the Catholic Community Services(200 S. and 500 W.) next to the Road Home, called "The Block," in Salt Lake City on Wednesday, March 8, 2017. Karren has lived on the street for seven years and hasn't seen her father or her six children in years. She suffers from nerve damage, high blood pressure and PTSD.| Nicole Boliaux, Deseret News

On the corner, across from The Gateway shopping district, two Taser-armed security guards from the Road Home help a nearly catatonic woman with wildly dilated eyes to her feet. She stumbles out into the street in a stupor.

For decades, homeless experts viewed these problems as insoluable. But there is a proven solution to hard-core, chronic homelessness, argues Sam Tsemberis, the godfather of the Housing First movement: simply help people into homes.

Tsemberis, who pioneered the new approach in the early 1990s in New York City, says he has mixed feelings about Utah’s 15 minutes of Housing First fame. He likes that the coverage sparked a national dialogue about solutions to homelessness. “The downside,” he said, “was that Utah’s experience was not exactly as advertised.”

The traditional model for homeless support, Tsemberis said, is called Continuum of Care. In that model, service providers offer shelter but require that clients be sober or under psychiatric care before they are given a permanent home. This often leaves clients on the street, Tsemberis said, bouncing in and out of rehab or psychiatric treatment, constantly returning to old friends and addiction triggers or falling off their meds.

If offered a home instead, Tsemberis argued, even the toughest cases also achieve surprising stability. In 2004, he led a controlled study in New York City that found that 80 percent of seriously mentally ill homeless clients who received apartments retained them for at least two years, which ran sharply counter to the underlying assumption of the Continuum of Care model.

CJ shows bed bug eggs on a watch outside the Catholic Community Services (200 S. and 500 W.) next to the Road Home, called on "The Block," in Salt Lake City on Wednesday, March 8, 2017. CJ and many other homeless people say that the Road home has a bad bed bug problem along with mold and unsanitary conditions. | Nicole Boliaux, Deseret News

“There is no empirical support for the practice of requiring individuals to participate in psychiatric treatment or attain sobriety before being housed,” Tsemberis and his co-authors concluded.

Once people are housed and stable, Housing First advocates say, the program costs very little, particularly when it focuses on the toughest cases, including those most likely to use ambulances or emergency rooms or have encounters with the police.

In 2002, a rigorous Housing First in New York City study by researchers at the University of Pennsylvania found giving severely mentally ill an apartment saved local hospitals and agencies $16,282 per year in estimated crisis health and legal costs, costing a net of just $995 per person per year with housing costs included. An even larger and equally careful study by the federal government in Canada, also focused on the severely mentally ill, found similar savings.

Black or white

Around the bend from Rio Grande Street, a few dozen young men mill around with no apparent purpose. But their purpose soon becomes clear. A visitor walking through this crowd is accosted three times in 20 yards by men who ask, "You need black or white?" He shakes his head, unsure of the question. Finally, the third man helpfully explains. "Drugs, man!"

Black is heroin and white is crack cocaine, said Salt Lake police Sgt. Brandon Shearer. They are sold in "balloons," tiny bits of plastic wrap twisted at the end, and users will often buy one of each and inject them together, known as "speedballing."

This is Salt Lake's open air drug market, located on the street corner by the city's largest homeless shelter. Police round-up dealers weekly, Shearer said, but it's clear they don't consider getting arrested much of a threat.

Nearly everyone in Rio Grande homeless nexus has some sort of drug problem, said Dennis Kelsch, homeless services director for Salt Lake’s Catholic Community Services, a major force in the city’s homeless services scene. And for the addicted, Kelsch notes, there are no shortage of triggers here.

The problem is getting worse, Kelsch said. The clientele is younger, and the drugs are harder. As recently as six years ago, he says, most of the people on these streets were over 50 and alcoholic. Today, the clientele has shifted decades younger, he says, and opioids dominate.

“These are young people," Kelsch said.

Criss, left, cleans the area around where she stays outside the Catholic Community Services (200 S. and 500 W.) next to the Road Home, called "The Block," in Salt Lake City on Wednesday, March 8, 2017. Chris, originally from Ohio, has been exited from the Road Home until March 12 and has relapsed since being removed from the shelter. | Nicole Boliaux, Deseret News

A 2008 survey of 25 cities by the U.S. Conference of Mayors asked 25 cities for their top three causes of homelessness. Substance abuse topped the list at 68 percent as the primary cause of homelessness for single individuals. And surveys of homeless people have found that about two-thirds of homeless people report that drugs or alcohol played a major role in their displacement.

Tsemberis says the best estimates are that between 50 percent and 80 percent of the chronically homeless nationwide are out there at least in part due to serious substance abuse issues. And many of those, he says, are dual diagnosis, addicts who also suffer from mental illness, with the drugs often a form of self-medication.

Serious substance abuse problems are tougher than mental illness for Housing First to address, Tsemberis said. Most of the 15 percent to 20 percent of clients who wash out of his Housing First programs are serious addicts.

“The problem is that they mostly use with others,” Tsemberis said. “The in and out of frequent guests quickly becomes a lease violation. Some guests won't leave. Apartments are lost. After several cycles of this, it becomes clear the person needs a harm reduction program in a secure building where someone else is in charge of the front door."

Near the corner of 200 South and 500 West, within a stone’s throw of the open drug market, is the home of the Salt Lake Police Department’s Community Connections Center, opened last summer.

According to Lana Dalton, the center's manager, there is a nexus between Utah’s sharply rising housing costs and the opioid addiction epidemic. As housing prices rise, she said, addictions, low-paying jobs and expensive apartments don’t mix.

“They end up using what funds they have for what they feel they really need,” she said, “which will be the drugs.”

A Community Connections staffer bursts into the lobby, alerting a pair of police officers that a client needs help. A tall African-American man is walking quickly across the street, past the Road Home, and around the corner. The man is “off his meds,” unstable, and might harm himself. A pair of crisis support police officers rush out to take him to the hospital.

Criss, left, folds and reorganizes clothes outside the Catholic Community Services (200 S. and 500 W.) next to the Road Home, called "The Block," in Salt Lake City on Wednesday, March 8, 2017. Chris, originally from Ohio, has been exited from the Road Home until March 12 and has relapsed since being removed from the shelter.| Nicole Boliaux, Deseret News

Looking to the future

The misunderstood publicity wave and miscounted numbers of 2015 came and went, with lingering confusion and sheepishness. But Utah’s policymakers at all levels still see themselves on the cutting edge of homeless policy.

State and local officials are moving aggressively to streamline homeless services. In a few dizzying weeks in February and March, state, county and local officials served, volleyed and slammed proposals for multiple smaller, dispersed facilities to replace the current center on Rio Grande. Their efforts have met with an outcry about a lack of transparency in decision-making from citizens whose neighborhoods would be affected.

Lost in the disputes, Utah’s homelessness policy stakeholders fear, are the truly innovative programs behind the headlines.

With chronic homelessness now well below national levels, Utah is poised to expand the reach of its Housing First philosophy. The new program, called Homes Not Jails, targets the “persistently homeless,” or those who spent at least 90 but fewer than 365 days homeless in the past year.

These are people not yet in the chronic category but are in clear danger of slipping into that group through health, addiction or mental crises. The Homes Not Jails pilot will be operated by the Road Home, initially targeting 315 individuals. These clients will receive help in finding and paying for housing, along with medical care and counseling.

In addition to helping those at greatest risk, the program aims to free up space for those who only need temporary help — the vast majority of clients.

“Eighty percent of our clients have one episode and never need the shelter again,” Minkevitch said. But day in and day out, pressure for space in the shelters stems from the 20 percent of clients with the most persistent problems. “We literally have an 80/20 problem,” Minkevitch said.

Homes Not Jails will use a Pay for Success model, meaning private investors will put up the money and only get paid if results are shown. Clients will get assistance in housing, along with intensive case management, behavioral treatment and employment counseling.

A third party of researchers will then validate the results, and only if specific goals are met for reduced arrests, improved employment wages, and service hours worked by participants will investors be paid.

Because the agencies and nonprofit providers will now be working together with investors and researchers, Minkevitch said, “We’ll be able to see what works and doesn’t. We can innovate and tweak, and when we find what works, we’ll be able to scale up.”

No one is promising a silver bullet this time.

“I hope it changes the paradigm,” Salt Lake County Mayor Ben McAdams recently told the Deseret News. “We now have a system that was built in the 1980s to find people who are homeless and suffering and give them a meal and a bed. What I want is not just to alleviate suffering, but to put them on a path to greater stability and self-reliance.”

How to help in Salt Lake County:

The Road Home

(801) 359-4142

www.theroadhome.org

A nonprofit social services agency that provides emergency shelter, case management and emergency services to help the homeless transition back into the community.

The Fourth Street Clinic

(801) 364-0058

www.fourthstreetclinic.org

A medical clinic primarily serving homeless Utahns and offers primary care, dental care, and behavioral health care.

Volunteers of America

(801) 363-9414

www.voaut.org

A human services nonprofit that provides affordable housing and substance abuse treatment for the low-income and homeless.

Crossroads Urban Center

(801) 364-7765

www.crossroadsurbancenter.org

A grass-roots nonprofit organization that runs an emergency food pantry and thrift store to assist underserved Utahns.

Utah Food Bank

(801) 978-2452

www.utahfoodbank.org

A nonprofit that distributes food across all 29 counties in the state with direct service programs to children and seniors.

United Way of Salt Lake

(801) 736-8929

www.uw.org

The world’s largest privately funded charitable organization.

The Other Side Academy

801-953-0409

www.theothersideacademy.com

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A free two-year school where students learn vocational, pro-social and life skills. Available to men and women involved in the criminal justice system, the homeless, substance abusers and others.

The Inn Between

801-410-8314

www.theinnbetweenslc.org

A refuge where Utah's homeless men and women can die with dignity and receive professional hospice services.

Catholic Community Services

A social service agency that runs the St. Vincent de Paul Dining Hall and Weigand Homeless Resource Center, a day shelter for homeless individuals.

801-977-9119

www.ccsutah.org