A nurse from the Homeless Outreach Nursing Center (HONC) met Frank* by coincidence in the winter days of January 2013 as he was getting a dinner at a local meal site. At that time, Frank shared that his goals were to rent his own apartment and get a hat with a wide brim.

He continued after another visit with the nurse to share that he had traveled around the Midwest and most recently was staying at a shelter before he was asked to leave for “lack of progress.” The HONC Nurse suspected there was a severe and persistent illness that Larry was experiencing unknowingly. Aside from Frank’s eccentric dress, he was preoccupied with internal thoughts and his conversation was hard to follow and often incoherent. His comments would conflict with each other and he spoke of a time he spent in a “mental institution.” Ultimately, he would be diagnosed with Major Depressive Disorder with Psychotic Symptoms.

Frank did not have the capacity to meet his own basic needs, and was not connected to any service system. The HONC team met with the Autumn West Safe Haven staff and submitted a referral. Within three days, he was enrolled into Autumn West Safe Haven and had his own private room and access to daily meals, free laundry, hygiene products and supportive staff available 24 hours a day. He could begin to collect mail and establish himself as he addressed his most pressing needs.

Through the work of his Autumn West Care Coordinator, Frank was able to acquire a state ID, a social security card, Foodshare enrollment and accessed a mental health assessment and referral through the ACCESS Clinic at the Milwaukee County Mental Health Complex. He was able to clear all of his outstanding municipal tickets with the help of the program while continuing to follow through with Milwaukee County-funded mental health outpatient services.

Over the course of the next year, Frank remained engaged in his mental health treatment, and this information was subsequently used in referring him for SAIL services though Milwaukee County. He actively participated in Autumn West’s on-site Peer Support Groups and activities. The Autumn West staff observed improvements in both his health and self-confidence during this time.

By the time he was set to move from Autumn West into a subsidized apartment made possible by the Milwaukee County “My Home” program, Frank had been approved for social security disability, had a payee, and was assigned a Targeted Case Manager. Autumn West offered Frank a safe and supportive home for his 15-month transition period. His story reflects the prevailing successes found throughout the services offered at the Autumn West Safe Haven.

*Name changed for client anonymity.