On a typical day, Amber Ruth, a licensed social worker and mental health professional at People Incorporated, Minnesota’s largest community based mental health provider, is out and about — at homeless encampments, in drop-in shelters and at public libraries — helping to connect people with the services they need to treat their mental health and substance use issues.
On a recent Tuesday morning, when Ruth was working her regular weekly drop-in hours at St. Paul’s Rondo Community Library, she completed a mental health assessment for a woman in crisis and helped her get signed up for an intensive residential treatment services (IRTS) bed run by People Incorporated. “I was able to work with our central access team to find her a place,” she said. “She was picked up from the library and brought into IRTS within an hour-and-a-half.”
This rapid response to community needs is made possible by the recent expansion of People Incorporated’s Access and Recovery Center (ARC) services, which now include substance use and outpatient mental health support. This expansion, which brings Ruth and other mental health care workers out of the office and into the community to provide essential services where they are needed, represents a significant step in delivering compassionate, integrated care to underserved people in the Twin Cities, said Veronika E. Mix, People Incorporated vice president of community engagement.
“What makes this program different from how we used to do our work is that we are really now based in the community,” Mix said. She said Ruth and her colleagues are embedded in the community, going out and meeting people who may feel uncomfortable asking for help or don’t know where to get it: “We’re going to the right places, to those locations, those shelters. When we come around, people on the street know us. They say, ‘People Incorporated is here.’ They know we can help.”
Previously, Ruth, a 20-year People Incorporated employee, worked as part of the St. Paul Police Department’s Community Outreach and Stabilization (COAST) unit. When the department disbanded the unit in September 2024, People Incorporated, with the encouragement of staff like Kristin Sierra, senior licensed program manager, decided to expand its services and continue that programming with Ruth in the same role.
“She’d found a niche with the unsheltered population, going into the encampments with our outreach team because there are so many barriers that people face with not having a phone, not having transportation,” Sierra said of Ruth. “People know her and trust her. It only made sense to continue that role with as little disruption as possible.”
The Twin Cities’ unsheltered population continues to grow, Sierra said, and many members of that community struggle with untreated addiction and mental illness. Having an experienced, accessible mental health professional like Ruth — someone who knows the state social service system inside and out — is key to keeping vulnerable members of the community as safe and healthy as possible. That’s why Sierra and her People Incorporated colleagues advocated for the ARC expansion.
Mix said this expansion will cost People Incorporated around $100,000 a year. “We do get referrals and payments from insurance,” she explained, “but also it is our mission to serve those individuals who are uninsured as well as those individuals who are living in poverty to help them get access to insurance and other things that would support their mental health. This carries a cost.”
Ruth’s workdays are varied. “I work primarily with unsheltered folks,” she said. “I’ve been able to build quite a few relationships with community organizations in the city. I try to keep those relationships healthy so they know to reach out to me if they interact with a person who is struggling and needs help.” She has established hours in central gathering points where people can seek her out. As she said: “I have open drop-in hours throughout the week at libraries, shelters, camps — wherever clients are in need. People are aware of my hours. Often they come to me.”
Ruth’s professional training and experience means that when she meets with a person in crisis she is qualified to conduct a same-day comprehensive evaluation, an essential step that’s key to making people eligible to receive state-sponsored mental health and addiction services.
“When a person is interested in these kinds of services, we catch them right then and get them referred into our system of care,” Sierra said. “Amber also meets with folks to help them apply for other benefits — or just fill in any gaps they have in services. She can help them get the care they really need.”
‘We have to help in the community’
The COAST program was developed to help build connections between the police department and community members with the help of mental health professionals like Ruth, who worked with the department as a People Incorporated employee. Department leaders say the decision to shut down the unit last fall was part of a larger plan to expand those services in the city. A new department program, called Familiar Faces, launched in December 2024, was designed to go beyond the assessment process, but People Incorporated staff felt that community need was great enough to support continuing Ruth’s work. They advocated with agency leadership to make that happen.
“Kristin and her team,” Mix recalled, “said ’We have to get help in the community. We have to be out there.’” While the nonprofit already has an outreach team that connects with community members, Ruth’s expertise is essential to actually getting the work done, she said: “Having licensed individuals like Amber Ruth available to do assessments right there, to do those clinical things for folks that are in need, is just essential to our work.”
Sierra can’t emphasize enough the importance of the assessment process. In order to be eligible for services like residential addiction treatment, mental health counseling or many kinds of housing support, a licensed professional needs to spend time with an individual and assess their mental and physical health as well as other needs. Ruth’s deep experience means that she knows how to talk with people, how to do those assessments and how to move forward quickly to access support.
“If we meet someone whose mental health is more symptomatic and they clearly need more support, we can get them into our crisis beds or Intensive Residential Treatment services very quickly,” Sierra said. “This can happen either the same day or the next day.”
Sierra said Ruth completes somewhere between 30-40 assessments a month. While that number may seem high, there are many more people out there, on the streets, at the library, in shelters, who desperately need assistance. “There is much greater need, but Amber is only one person,” she said. “It is a lot.”
The assessment skills that Ruth brings boosts People Incorporated’s ability to make significant change in their clients’ lives, Mix said. “Same-day assessment is so key for an individual to really allow us to ask those questions and identify, ‘What are your needs?’ and helps us to understand how we can help them.” Perhaps a client needs to participate in one of People Incorporated’s crisis programs. Or intensive residential treatment. Or long-term housing or case management.
“The biggest difference with what Kristin and the team have done with expanding this to the community is being on the street, being right there and making themselves available to meet the needs of those individuals,” Mix said.
While People Incorporated has traditionally focused its efforts on St. Paul, it’s expanding its reach to Minneapolis. “We are just finding out who our community partners are there and building up referrals,” Sierra said. In Minneapolis, People Incorporated workers are, Sierra explained, “riding the trains, meeting with individuals and doing mental-health evaluations right on the trains. We’re also offering more support or handing out our cards.”
While this expansion comes at a cost, Mix said it didn’t take long for Sierra and her colleagues to convince her and other members of People Incorporated’s senior leadership team that the investment was needed.
“We had to do something,” she said. “We couldn’t just continue to see so many individuals who are struggling. At People Incorporated, we specialize in helping people with substance abuse. How do we meet the needs of individuals who need crisis help? We have to be in the community. Once we get that assessment done, we can get them into our programs immediately so we can identify their long-term journey.”
The benefit of connection
Ruth’s decades of experience and deep connections make her indispensable, Sierra said. “Amber is everywhere in the community. She’s pretty well known in St. Paul. If people meet someone who needs an assessment or an evaluation, they know they can call Amber.”
Being part of the community for so long helps build deeper connections with people whose bad experiences with authority figures breeds a strong sense of distrust, Ruth said. She understands that it takes time to prove her motivation, that she’s in it to help people in need, not to control their lives. Being out and accessible is an essential part of getting that message across. “I am mobile,” Ruth said. “I go to the consumer where they are most comfortable. We meet where they are to help fill those voids and build that trust.”
Being a constant presence in places where people struggling with mental illness, addiction and homelessness congregate makes it easier for those people to feel like they can trust her, Ruth said. But it takes time. Just the other day, she was able to help connect a client with essential support programs. “It took them three years to get comfortable with me, but when they were ready, they knew where they could find me at the right moment.”
And once the wheels get set in motion, change can happen quickly.
Take the person who met with a People Incorporated Access and Recovery staff member on a recent Wednesday. “They are unsheltered, have a severe and persistent mental Illness, are not on medications, have recently lost their job and are just facing a lot of barriers with getting to therapy or medication management,” Sierra said. When the client agreed to do a 90-day program with People Incorporated’s intensive residential treatment service, she explained, “I was able to message our central access contact center, ask if there were any beds open. They were able to locate a bed at one of our Minneapolis facilities and that person got admitted the next day.”
Being in the right place at the right time takes commitment, Mix said, but it’s a commitment that staff at People Incorporated are willing to make. To them, she said, the effort required to meet clients in their preferred environment is worth it; when the opportunity to help arises, they want to be there.
“It’s about meeting people where they are, not waiting for them to call our contact center or even walk into the library,” Mix said. “It’s about riding on those trains, riding on the buses, being present in those gathering spots so individuals can really have access to us. A huge barrier for individuals wanting help is access, not knowing where to go, so we go to them.”
Andy Steiner
Andy Steiner is a Twin Cities-based writer and editor. Before becoming a full-time freelancer, she worked as senior editor at Utne Reader and editor of the Minnesota Women’s Press. Email her at asteiner@minnpost.com.
