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He has trust issues, you might say.

Just off a hospital stay at Moses Cone Behavioral Health, he refused to go to assisted living or a shelter, choosing to live under a bridge instead. If “choosing” is the proper term.

When it’s time for his community-based therapy — you know, that keystone of state “reform” — his Greensboro caseworker drives to the foot of the bridge to look for a signal.

If a grocery cart is parked there, that means he’s “home.” The caseworker then blows the car horn but never ventures to the bridge.

“He has the entire area booby-trapped,” explained his hospital social worker, Quylle Hodnett. “It’s sad for us when people can’t trust mainstream society. But that’s what life has taught him.”

Hodnett, part of a three-person social work unit at Cone’s psychiatric facility near Wesley Long Hospital, is deployed on the faltering front line of the mental health system. From here, there are two choices.

Patients needing longer hospital stays are sent to a state mental hospital, where the waits for beds are growing longer and the stays getting shorter. Or, after a stay at Cone, a patient could be deemed stable enough to be discharged into the community.

And though state hospitals, including John Umstead in Butner, have long included homeless shelter parking lots as drop-off destinations — whether or not there are beds available — Hodnett said discharging patients to live on the street is not an option for Cone.

So when patients have no money, no family to take them in, no disability benefit in sight, what happens when the shelters are full, as homeless advocates say they typically are?

“We beg,” Hodnett says, recalling another recent discharge. “We literally beg people: 'Will you help us, here? I don’t want to see this woman on the street. She won’t survive.’”

Specifically, this woman was a mother of three, clinically depressed after waiting two years for disability, only to be turned down for a third time. The family was staying in a mobile home in the county that was rent-free but had no working plumbing, a tumble-down roof and holes in the floor. Rats and snakes came in.

That was the picture Hodnett closed her eyes to at night and woke up to in the wee hours, knowing one thing was certain. If she called the DSS — as was her duty — Child Protective Service workers would be sitting at the family’s doorstep the day the mother was discharged from the hospital. The children would go to foster care, Hodnett was assured.

Then what?

“I was afraid the mom would become suicidal,” Hodnett said. “Here, she’s come in for help, a good mother — not a bad mother, no drugs or alcohol. Oftentimes, children keep the parent grounded. If you take that away, suicide is always a fear.”

Hodnett called in favors, found the family an apartment and persuaded a nonprofit to furnish it — just in time. But with so much emphasis on community-based treatment, why the scramble?

Longtime advocates say the criteria for who gets help has become too narrow. For example, if the mother of three was shown to be chronically homeless, or suffering from a dual diagnosis of substance abuse in addition to mental illness, she could have qualified for the county’s “Housing First” initiative under the 10-year plan to end homelessness.

The idea of the housing plan was to help find apartments for people who had previously exhausted an inordinate share of resources, continually cycling through jails, ERs and hospitals.

But when others who lack that paper trail are also being discharged from mental hospital stays earlier and with more severe symptoms — to free up beds for even sicker people — the scarcity of housing is at odds with treatment.

“These are professionals who really care, but their hands are tied,” said Eileen Silber, who serves on a Cone advisory board and is a past state president of the National Alliance on Mental Illness. “All of us who advocate know how short money is. We’re not trying to get a super-duper system. We just want a reasonable system.”

For Annie White, the county mental health agency’s new housing specialist, the most apparent need is for young women and people with children. Though local shelters for single adults typically stay full, and some put limits on how often a person can return, workers can usually find a shelter bed for those flexible enough to go out of town.

When all else fails, Hodnett said, social workers call the Path program in Winston-Salem or the Durham Rescue Mission: “They’re not likely to turn anybody away.”

Contact Lorraine Ahearn at 373-7334 or lorraine.ahearn@news-record.com