In my work, I see the same people over and over again.

A man arrives from the emergency room with a discharge packet and a list of medications he does not understand. He has a serious mental illness. He hears voices he cannot ignore. He loses track of time and place. He cannot manage medications or basic needs. He has been using. He is unstable, but no longer in immediate danger. That is enough to send him out.

He cannot regulate his emotional state. He often resorts to aggression to communicate his needs. He is afraid, confused, and has never felt safe.

He is told to follow up. There is no clear place for him to go. This is not an exception. It is routine.

People cycle through emergency rooms in moments of crisis, medical, psychiatric or both. They are stabilized just enough to get through the immediate danger, then discharged — not because they are well, but because they are no longer the hospital’s responsibility.

They cannot pay. They are not a viable revenue stream. In a system shaped by cost, that fact carries more weight than their long term stability, their safety or their chances of recovery.

Their humanity is reduced to dollars and cents. We do not say this out loud. But we organize care around it.

Hospitals move people out as quickly as possible, especially those who are poor, uninsured or difficult to treat. The highest need patients do not stay. They are discharged to settings with fewer resources, less clinical capacity and staff who were never trained to manage that level of complexity.

They end up in places like mine.

I work in a supportive housing program in Philadelphia. We are not a hospital. We are not staffed like one. We are not resourced like one. But we are expected to absorb what hospitals discharge.

Someone arrives from the emergency room. We take them in. We manage medications, psychiatric instability, active substance use and escalating behavior. We do it without the clinical infrastructure those situations actually require. We watch for decompensation. We try to keep everyone safe. We make judgment calls that carry real consequences. We prioritize preserving participant autonomy.

We operate with fewer restrictions in order to keep people engaged. We hold ourselves to a high ethical standard because it is the only way this work makes sense. That standard is not always shared across the system.

In practice, hospitals often rely on narrow clinical thresholds to determine who qualifies for care. If someone is not deemed an imminent threat to themselves or others, they are discharged.

From where we stand, those decisions often ignore what happens next. I can raise concerns. I can document what we are seeing. But the final decision rests with the licensed clinician making that call. Once that decision is made, we are the ones expected to manage the consequences.

Eventually, most of these men destabilize again. They return to the hospital. Then back to us. The loop continues.

At times, I am on the phone with attending psychiatrists after a legal petition for involuntary treatment has already been approved. They decline to uphold it, citing no imminent threat based on a brief evaluation. I try to explain what we are seeing day to day. The call ends. The person is discharged.

This is often described as care coordination. It is not. It is cost shifting.

Hospitals reduce their burden. The risk is pushed onto shelters and supportive housing programs. The system appears to function, but the people inside it are no better off. In many cases, they are worse.

Addiction is often used as the explanation. It becomes a reason to discharge, to limit intervention, to frame the problem as behavioral instead of clinical.

The men I work with are living with severe mental illness layered with trauma, cognitive impairment and medical fragility. Substance use is part of the picture, but it is not the whole story. It reduces them to that label, makes it easier to move them along — and harder to treat. Meanwhile, the settings they are discharged to are expected to manage all of it with fewer tools, less training and far less support.

And it is getting worse.

The people coming through these systems today are sicker than they were even a few years ago. They are more complex, more medically fragile, more behaviorally acute. The resources available to meet those needs have not kept pace. So the pressure moves downward.

Onto staff. Onto programs. Onto places like mine.

We stretch. We improvise. We make decisions we were never trained or authorized to make. We hold situations together because there is no one else to hold them. And we are expected to keep doing it.

This is often called burnout. That is not quite right. This is what it looks like when responsibility is pushed onto people without the authority or resources to meet it. When institutions with the most capacity decide what they will not hold, and smaller systems are left to absorb the consequences.

There are real conversations happening about reducing emergency room use and improving efficiency. Those conversations matter. But if the strategy is to move high-need patients out of hospitals faster without building something stronger to receive them, then we are not solving the problem. We are relocating it.

Into shelters. Into supportive housing. Or directly back onto the street.

If we want different outcomes, we have to be honest about what is happening. Right now, the way we treat sick, homeless men with severe mental illness is shaped less by what they need and more by what institutions are willing to absorb.

Until that changes, this cycle will continue. It’s not because we do not understand the problem, but because we are choosing to manage cost instead of care.

Sam Beckett is a Chestnut Hill resident.