Last October, Travis Fisher finally got a roof over his head.
After living on the streets of the French Quarter for years, Fisher said he was placed in a subsidized apartment in Central City and began seeing a counselor in hopes of getting the depression, post-traumatic stress disorder, and alcohol addiction that had grown more acute while he was homeless under control.
But Fisher said he soon stopped hearing regularly from his caseworker. And when summer came and the apartment's small air-conditioning unit failed to cool it down, Fisher said, he decided he was better off sleeping behind the French Market.
He hasn't been back to the clinic, more than an hour's walk from the French Quarter, in months. "People just slip through the cracks constantly," said Fisher.
For over a year, city officials and nonprofit partners have worked to connect hundreds of people living on the city's streets with subsidized housing as part of a plan by Mayor LaToya Cantrell's administration to shelter all 1,500 people experiencing homelessness in the city by the end of 2025.
Over 740 people have been housed so far, and most of the city's larger homeless encampments have been cleared. But as leaders aim to keep streets clear long-term, they're confronted by a major obstacle: New Orleans' sparse, siloed collection of mental health treatment options that fail to adequately prepare the highest-need people to transition into housing and remain stably housed.
Roughly 75% of people who moved from homelessness to housing from 2020 to 2022 had a serious mental illness, according to a recent UNITY of Greater New Orleans study.
Though city officials and nonprofit leaders say housed people often have easier access to mental health and other services, service providers also concede that people can quickly slip back into homelessness if mental health care is insufficient. And some say that homeless people with severe mental health challenges require long-term residential treatment to become stable enough to be housed in the first place. That option doesn't exist in New Orleans.
"It's not just about putting a person in a brick building ... it's also wrapping around them the supports that have to do with the activities of daily living," said Rochelle Head-Dunham, executive director of Metropolitan Human Services District, one of 10 state-chartered behavioral health treatment agencies across Louisiana. "We don't have enough funding, capability, infrastructure invested to support these things."
With pressure high on city officials and providers to tackle the city's homelessness issue, local leaders are eyeing solutions. In January, Metropolitan is launching a street psychiatry program, modeled after similar programs in cities across the country, that will allow providers to diagnose and administer psychiatric medication on the street without requiring a clinic appointment.
Other efforts, such as a long-term respite care program, are in the planning phases, said Nathaniel Fields, director of the city's homeless services office, though he declined to share details.
"The big gap that we have is mental health," said Fields. "We need more resources. That's just it, period."
Gaps in resources
As caseworkers make their way through city encampments, shelters, and streets , they've encountered many people that they believe can stay housed over the long term, including people struggling with mental illness and addiction.
"Housing is a critical mental health intervention," said Joe Heeren-Mueller, community engagement director with UNITY, who noted that clients also receive case management throughout the housing process. "For people experiencing behavioral health and housing crises at the same time, their ability to stabilize mentally improves when they have the safety and security that housing affords."
UNITY has also said that 97% of people under its care stay housed long term, though records on individual cases are not made public.
But caseworkers have also encountered people who resist housing or struggle with living independently -- including those whose mental health has deteriorated after living on the street with limited access to treatment.
Currently, the primary option for mental health counseling and psychiatric care for homeless New Orleanians is at one of four clinics in the city run by Metropolitan Human Services District.
But those services are by-appointment only, making them difficult to access for people living on the street, who often lack a cell phone or means of transportation.
There are some mobile treatment options for those with severe mental illness. Assertive Community Treatment, a Medicaid-funded program operated by local governments across the country, has teams that can provide psychiatry services outside of a clinic. Cantrell's administration also launched a mobile crisis intervention unit last year to help deescalate crisis situations.
The referral process for Assertive Community Treatment can be lengthy, however, and space is limited. The city program provides little follow-up with patients, and is often only involved when an acute crisis leads to a 911 call.
Lastly, behavioral health units at local hospital emergency rooms can accommodate patients for a brief stay. But with no longer-term treatment option to send them to, homeless patients often return to the street with no plan for long-term care.
"It's just a gap in service delivery altogether," said Tyesha Davis, director of the city's Mobile Crisis Intervention Unit. "It's 'You're better, cool, you're free to go.'"
'Set up to fail'
To successfully treat the most severe mental illness among the homeless population, officials and service providers say that the city would need a "transitional" option: residential facilities with intensive treatment.
"Some people will need a couple of weeks or a couple of months to stabilize, transition," before they might be ready for housing, said Fields.
Fields said that the city would need assistance from the state to open such a facility, but that the city has not made this request.
The city should also work to expand support for people after they are housed, he said. As part of the city's housing plan, formerly homeless residents are connected with a caseworker who can help connect clients to more intensive mental health treatment. But many of the same challenges -- transportation, inadequate staffing, waitlists -- still apply.
Jessica Lovell, director of DePaul USA New Orleans, a homeless services organization, said that caseworkers are too overwhelmed by their caseloads.
"You need to spend so much time with someone to get them from point A to point B to point C, and it's not set up for that to happen in reality," said Lovell. "People are set up to fail, we as case managers are set up to fail."
In some cases, lack of support can lead people to fall back out of housing, something Fisher said happened to him. After years of living on the street, he struggled with "maintaining and upkeeping a household that falls apart around you," he said.
Heeren-Mueller said he was unable to speak about individual clients or to verify whether Fisher was a client of UNITY or a different social services agency overseen by the organization.
"Our members are committed to providing all our clients with high-quality, consistent services," said Heeren-Mueller. "There are incidents where people fall out of housing. When that happens, we make every effort to reconnect people to housing."
New efforts
While mental health care providers in New Orleans are clear-eyed about the gaps in services for homeless and newly housed people, some say they are hopeful about recent efforts to change things.
In January, Metropolitan Human Services plans to launch a new street psychiatry team that will work with the city's homeless outreach providers to diagnose and administer psychiatric medication to people living on the streets and in shelters. The team will use a mobile clinic housed inside a RV to bring services to "people who are unwilling or unable to come to care," said Head-Dunham. And unlike Assertive Community Treatment programs, people won't need a referral to receive care.
Cities across the country have launched similar programs in recent years. In Los Angeles, for example, a large-scale street outreach program of 18 teams makes rounds with 1,700 homeless patients almost every day. It's a major shift within the field of psychiatry, which has long relied on controlled clinic environments to administer medication, and one that has generated concern from some about patient consent and whether those resources should be dedicated to housing instead. But street psychiatrists across the country say they've seen promising results.
"You are dealing with your hands tied on how to help people," said Head-Dunham. "We have got to do something to address these needs."