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Strategies for Reducing Chronic Street Homelessness Final Report Prepared for: U.S. Department of Housing and Urban Development Office of Policy Development and Research Prepared by: Martha R. Burt, UI John Hedderson, WRMA Janine Zweig, UI Mary Jo Ortiz, WRMA Laudan Aron-Turnham, UI Sabrina M. Johnson, WRMA Walter R. McDonald & Associates, Inc. (WRMA) Sacramento, CA The Urban Institute (UI) Washington, DC January 2004
ACKNOWLEDGEMENTS Many individuals have assisted us on this project; we would especially like to thank the following: • The researchers and program administrators who nominated potential sites. • The on-site people we interviewed individually, in meetings and in focus groups who shared their time, information, and insights with us. • Our advisory team members, Donald J. Baumann, Deborah Dennis, Linda Gibbs, Jean L. Hochron, Mark Hurwitz, Natalie Hutcheson, Pam Michell, Pat Morgan, Ann O’Rielly, and Robert A. Rosenheck, who have contributed their time, knowledge, and expertise. • Marina Myhre, our project Government Technical Representative from the U.S. Department of Housing and Urban Development (HUD), who has provided us with helpful support, observations and thoughts throughout the study. Other HUD staff members who have also provided acute comments on the projects research design, data analysis and report include Paul Dornan, Marge Martin, and Kevin Neary from the Office of Policy Development and Research, and Mark Johnston from the Office of Community Planning and Development. In addition, we would like to acknowledge the work completed by the following Walter R. McDonald & Associates, Inc. staff: Deborah Bass Rubenstein was fully involved in the early stages of this project, especially the research design and screening of sites; Charles Wheeler assisted in the report review; Gayleen Lentsch was in charge of report production; Cheryl Reed coordinated travel arrangements; Maricela Leyva-Perez and Jamie Vang provided administrative support. We appreciate the significant contributions that the above individuals made to carrying out the research and writing of this report, and they are not responsible for any remaining errors or omissions. The findings and views herein are those of the contractors and authors. The contents of this report are the views of the contractor and do not necessarily reflect the views or policies of the U.S. Department of Housing and Urban Development or the U.S. Government.
iii TABLE OF CONTENTS ACKNOWLEDGEMENTS ........................................................................................................ II EXECUTIVE SUMMARY .....................................................................................................XIII Why This Study Is Important.......................................................................................................xiii Purpose of the Research............................................................................................................... xiv Who, What, Where, and When? ................................................................................................... xv Findings––Key Elements of Success............................................................................................ xv How They Got Where They Are Today—Key Factors in History and Implementation............ xvii Trigger Events and Paradigm Shifts ....................................................................................... xvii Thoughtful, Analytic Process.............................................. ..................................................... xix New Strategies for Programs and Services................................................................................... xx Documenting Progress................................................................................................................ xxii How Do They Pay For It?..........................................................................................................xxiii Implications................................................................................................................................ xxiv Implications for Policy........................................................................................................... xxiv Implications for Practice........................................................................................................ xxvi Implications for Research ..................................................................................................... xxvii CHAPTER 1: INTRODUCTION................................................................................................ 1 Why This Study Is Important.......................................................................................................... 1 Purpose of the Research.................................................................................................................. 2 Who, What, Where, and When ....................................................................................................... 3 Birmingham, Alabama................................................................................................................ 4 Boston, Massachusetts ................................................................................................................ 5 Columbus, Ohio .......................................................................................................................... 5 Los Angeles, California .............................................................................................................. 6 Philadelphia, Pennsylvania ......................................................................................................... 6 San Diego, California.................................................................................................................. 7 Seattle, Washington .................................................................................................................... 7 Report Organization........................................................................................................................ 8 CHAPTER 2: ELEMENTS OF SUCCESS................................................................................ 9 What Does It Take? ........................................................................................................................ 9 Introduction..................................................................................................................................... 9 Paradigm Shift .............................................................................................................................. 10 A Clear Goal of Ending Chronic Street Homelessness ................................................................ 10 Strong Community-Wide Level of Organization ......................................................................... 11 Strong Leadership and an Effective Organizational Structure ..................................................... 12 The Importance of Key People Exercising Leadership ............................................................ 12 Effective Organizational Structure ........................................................................................... 12 Significant Resources from Mainstream Public Agencies............................................................ 13 Ability to Capitalize on Trigger Events....................................................................................... . 13
Table of Contents iv Significant Involvement of the Private Sector.............................................................................. 14 Private Businesses..................................................................................................................... 14 Foundations and Nonprofit Organizations................................................................................ 15 Commitment and Support from Elected Officials ........................................................................ 15 Outcome Evaluation Mechanisms for Program Support and Improvement................................. 16 Openness to New Service Approaches ......................................................................................... 16 Strategies to Minimize Negative Neighborhood Reactions to Locating Projects......................... 17 Conclusions................................................................................................................................... 17 CHAPTER 3: NEW STRATEGIES FOR PROGRAMS AND SERVICES ......................... 19 Outreach........................................................................................................................................ 20 Philadelphia’s Outreach Coordination Center .......................................................................... 20 San Diego’s Police-Based Outreach Teams ............................................................................. 21 Other Outreach Efforts with Direct Housing Connections....................................................... 22 Other Outreach Efforts Without Direct Housing Connections................................................. 23 New Approaches to Permanent Supportive Housing (PSH)......................................................... 23 Housing First Models................................................................................................................ 25 Safe Havens .............................................................................................................................. 25 Low Demand—Breaking the Linkage Between Housing and Service Acceptance................. 26 New Approaches to Addressing Substance Abuse ....................................................................... 26 Harm Reduction........................................................................................................................ 27 Other Approaches ..................................................................................................................... 28 Housing Configurations and Supportive Services ........................................................................ 29 Preventing Homelessness Upon Institutional Discharge .............................................................. 31 Client-Level Coordination Mechanisms....................................................................................... 32 Databases .................................................................................................................................. 32 Multi-Agency Special Case Teams........................................................................................... 34 Multi-Purpose Service Centers ................................................................................................. 34 Processes to Alter Access to Mainstream Settings ....................................................................... 36 Co-location of Service Providers in Mainstream Agencies...................................................... 36 New Roles in Old Agencies...................................................................................................... 37 Conclusions................................................................................................................................... 38 CHAPTER 4: ASSEMBLING RESOURCES AND SUPPORTS.......................................... 41 Assembling Resources in Comm unities with Long Histories of Support .................................... 41 Philadelphia............................................................................................................................... 41 Columbus .................................................................................................................................. 43 Mobilizing Resources ”From Scratch” ......................................................................................... 44 San Diego.................................................................................................................................. 45 Los Angeles Veterans Affairs................................................................................................... 47 Progress Without Community-Level Commitment to Ending Chronic Homelessness................ 48 Seattle Program Structure Growing Out of ACCESS............................................................... 48 Conclusions................................................................................................................................... 49 CHAPTER 5: DOCUMENTING PROGRESS........................................................................ 51 Changes in the Number of People Found on the Street from Year to Year.................................. 51
Table of Contents v Philadelphia Counts of Street Homeless Persons ..................................................................... 52 Birmingham Street Counts........................................................................................................ 53 Seattle Street Counts................................................................................................................. 54 Boston Street Counts................................................................................................................. 55 Chronically Homeless Individuals Moved to Permanent Housing............................................... 56 Philadelphia Movement of Chronically Homeless Individuals into Permanent Housing ........ 56 San Diego Movement of Chronically Homeless Individuals into Housing.............................. 57 Birmingham Movement of Chronically Homeless Individuals into Permanent Housing ........ 58 Reductions in Costs of Providing Emergency Health, Mental Health, and Shelter Services....... 58 Reductions in Days Homeless, Hospitalized, or Incarcerated ...................................................... 60 Conclusions................................................................................................................................... 61 CHAPTER 6: HOW COMMUNITIES PAY FOR THEIR NEW APPROACHES............. 63 Introduction................................................................................................................................... 63 Local Funding ............................................................................................................................... 63 General Revenue Resources ..................................................................................................... 64 Special Taxing Mechanisms ..................................................................................................... 64 Use of Private Sector Resources............................................................................................... 65 State Funding ................................................................................................................................ 66 California .................................................................................................................................. 66 Other State Funding Streams .................................................................................................... 67 Federal Funding Other Than McKinney....................................................................................... 68 Self Support ............................................ ...................................................................................... 70 Funds Blending and Access.......................................................................................................... 70 Blending Funding from the Provider Perspective..................................................................... 70 Agencies As Funding Funnels to Ease Client Access to Services............................................ 72 Potentially Underused Funding Opportunities.............................................................................. 74 CHAPTER 7: POLICY, PRACTICE, AND RESEARCH IMPLICATIONS ...................... 77 Implications for Policy.................................................................................................................. 77 Implications for Practice............................................................................................................... 78 Implications for Research ............................................................................................................. 79 APPENDIX A: BIRMINGHAM ..............................................................................................A.1 Birmingham-Brief Description ........................................................................................A.1 Practices of Potential Interest to Other Jurisdictions .......................................................A.2 History and Context–How the Current System Evolved .................................................A.3 Approach to Chronic Street Homelessness......................................................................A.4 Program and Service Network.............................................................................A.5 Sector of Mainstream Agencies...........................................................................A.6 Use of Private Resources .....................................................................................A.6 Who Is Served?....................................................................................................A.7 Coordination Mechanisms ...................................................................................A.9 Pathways to Housing, Approaches and Models.................................................A.10 Selected System Components........................................................................................A.10
Table of Contents vi Prevention ..........................................................................................................A.11 Outreach/Drop-in ...............................................................................................A.11 Low Demand Transitional Residences ..............................................................A.12 Emergency Shelters ...........................................................................................A.12 Transitional Programs........................................................................................A.12 Permanent Supportive Housing .........................................................................A.13 Supportive Services ...........................................................................................A.13 Affordable Housing ...........................................................................................A.14 Documenting Reductions in Chronic Street Homelessness...........................................A.14 Street Counts......................................................................................................A.14 Movement of Street Homeless into Housing.....................................................A.15 Public Funding...............................................................................................................A.15 Community Relations ....................................................................................................A.16 Maintaining and Enhancing the System ........................................................................A.16 Site Visit Participants.....................................................................................................A.18 Acronyms.......................................................................................................................A.19 APPENDIX B: BOSTON ..........................................................................................................B.1 Boston–Brief Description ................................................................................................B.1 Practices of Potential Interest to Other Jurisdictions .......................................................B.2 History and Context–How the Current System Evolved .................................................B.4 Approach to Chronic Street Homelessness......................................................................B.5 Mainstream Agency Involvement....................................................................................B.7 Selected System Components........................................................................................B.10 Prevention ..........................................................................................................B.10 Outreach and Drop-in ........................................................................................B.11 Emergency Shelters ...........................................................................................B.13 Low-Demand Residences ..................................................................................B.13 Transitional Programs........................................................................................B.13 Permanent Supportive Housing .........................................................................B.14 Supportive Services ...........................................................................................B.15 Affordable Housing ...........................................................................................B.15 Documenting Reductions to Chronic Homelessness .....................................................B.16 Public Funding...............................................................................................................B.17 Community Relations and Advocacy ............................................................................B.19 The Future–Maintaining and Enhancing the System.....................................................B.19 Site Visit Participants.....................................................................................................B.20 Acronyms.......................................................................................................................B.22 APPENDIX C: COLUMBUS....................................................................................................C.1 Brief Description..............................................................................................................C.1 Practices or Potential Interest to Other Jurisdictions .......................................................C.2 History and Context–How the Current System Evolved .................................................C.3 Approach to Chronic Street Homelessness......................................................................C.5 Mainstream Involvement .................................................................................................C.7 Selected System Components........................................................................................C.10
Table of Contents vii Prevention ..........................................................................................................C.10 Outreach and Drop-in ........................................................................................C.11 Emergency Shelters ..................................... ......................................................C.11 Transitional Programs........................................................................................C.12 Permanent and Supportive Housing...................................................................C.12 Supportive Services ...........................................................................................C.16 Affordable Housing ...........................................................................................C.16 Documenting Reductions in Chronic Street Homelessness...........................................C.17 Public Funding...............................................................................................................C.19 Community Relations and Advocacy ............................................................................C.23 Elements of Good Neighbor agreements ...........................................................C.24 The Future–Maintaining and Enhancing the System.....................................................C.26 Resource Development ......................................................................................C.27 Improving Cost Efficiency.................................................................................C.27 Collaborative Investment Standards ..................................................................C.28 Evaluation ..........................................................................................................C.28 Communication..................................................................................................C.28 Site Visit Participants.....................................................................................................C.29 Acronyms.......................................................................................................................C.30 APPENDIX D: LOS ANGELES ..............................................................................................D.1 Los Angeles–Brief Description........................................................................................D.1 Greater Los Angeles Department of Veterans Affairs.....................................................D.2 Practices of Potential Interest to Other Jurisdictions .......................................................D.2 VAGLAHS ..........................................................................................................D.2 AB 2034...............................................................................................................D.2 Lamp Community ................................................................................................D.3 VAGLAHS History and Context–How the Current System Evolved.............................D.4 VAGLAHS Approach to Chronic Street Homelessness..................................................D.5 VAGLAHS Selected System Components......................................................................D.9 Outreach and Drop-in ..........................................................................................D.9 Emergency Shelters ...........................................................................................D.11 Transitional Programs........................................................................................D.12 Employment.......................................................................................................D.17 Case Management..............................................................................................D.17 VAGLAHS Documenting Reductions to Chronic Street Homelessness.......................D.19 VAGLAHS Community Relations and Advocacy ........................................................D.20 Los Angeles County AB 2034 Program ........................................................................D.21 AB 2034–Access to the System.................................. ...................................................D.23 AB 2034–Housing .........................................................................................................D.24 AB 2034–Documenting Reductions to Chronic Street Homelessness ..........................D.25 AD 2034–Model of Care ...............................................................................................D.26 Program Components–San Fernando Valley Community Mental Health Center .................................................................................................................D.26 San Fernando Valley Community, Mental Health Center, Inc......................................D.26 Outreach.............................................................................................................D.26
Table of Contents viii Emergency Shelters ...........................................................................................D.27 Transitional Program .........................................................................................D.27 Permanent Supportive Housing .........................................................................D.27 Supportive Services ...........................................................................................D.27 AB 2034–Community Relations and Advocacy............................................................D.28 Lamp Community ..........................................................................................................D.28 Lamp Community History .............................................................................................D.28 Lamp Community Model...............................................................................................D.29 Lamp Community Components.....................................................................................D.29 Street Outreach...................................................................................................D.29 Low Demand Transitional Housing...................................................................D.33 Lamp Community Housing................................................................................D.32 Member-Operated Business and Other Employment Services..........................D.34 Supportive Services ...........................................................................................D.34 Lamp Community–Documenting Reductions to Chronic Street Homelessness.....................................................................................................D.35 Lamp Community–Community Relations and Advocacy.............................................D.36 Site Visit Participants.....................................................................................................D.37 Acronyms.......................................................................................................................D.40 APPENDIX E: PHILADELPHIA............................................................................................E.1 Philadelphia–Brief Description........................................................................................ E.1 Practices of Potential Interest to Other Jurisdictions ....................................................... E.2 History and Context–How the Current System Evolved ................................................. E.3 Mayoral Support and Public Leadership.............................................................. E.4 Demonstration Program Participation.................................................................. E.6 Turning Points and the Role of Advocacy–No Movement Without Tension............................................................................................... E.7 The Struggle for 1515 Fairmont .......................................................................... E.7 T he Sidewalk Behavior Ordinance ...................................................................... E.7 Approach to Chronic Street Homelessness...................................................................... E.9 Program and Service Network............................................................................. E.9 Involvement of Mainstream Agencies............................................................... E.10 Who Is Served?.................................................................................................. E.13 Coordination Mechanisms ................................................................................. E.14 Pathways to Housing, Approaches and Models................................................. E.16 Documenting Success .................................................................................................... E.17 Street Counts...................................................................................................... E.17 Movement of Street Homeless into Housing..................................................... E.18 Selected System Components........................................................................................ E.19 Prevention .......................................................................................................... E.19 Outreach and Drop-in ........................................................................................ E.19 Safe Havens and No/Low Demand Residences................................................. E.20 Emergency Shelters ........................................................................................... E.20 Transitional Programs........................................................................................ E.21 Permanent Supportive Housing ......................................................................... E.21
Table of Contents ix Supportive Services ........................................................................................... E.21 Affordable Housing ........................................................................................... E.22 Public Funding............................................................................................................... E.23 Maintaining and Enhancing the System ........................................................................ E.23 Developing or Adapting New Approaches........................................................ E.24 Budget Cuts........................................................................................................ E.25 Community Relations and Advocacy ............................................................................ E.25 Initial Resistance................................................................................................ E.25 Continuing NIMBY Issues ................................................................................ E.27 Role of Consumers in Advocacy and Shaping Policy ....................................... E.27 Continued Vigilance .......................................................................................... E.29 Site Visit Participants..................................................................................................... E.30 Acronyms....................................................................................................................... E.34 APPENDIX F: SAN DIEGO..................................................................................................... F.1 San Diego–Brief Description........................................................................................... F.1 Practices of Potential Interest to Other Jurisdictions ................................................... …F.2 History and Context–How the Current System Evolved ................................................. F.3 Approach to Chronic Street Home lessness...................................................................... F.7 Program and Service Network............................................................................. F.7 Involvement of Mainstream Agencies................................................................. F.7 Who Is Served?.................................................................................................... F.8 Coordination Mechanisms ................................................................................... F.8 Pathways to Housing, Approaches and Models................................................. F.11 Selected System Components........................................................................................ F.11 Outreach and Drop-in ........................................................................................ F.12 Emergency Shelters ........................................................................................... F.12 Low Demand Transitional Residences .............................................................. F.13 Transitional Programs........................................................................................ F.13 Permanent Supportive Housing ......................................................................... F.13 Supportive Services ........................................................................................... F.15 Affordable Housing ........................................................................................... F.16 Documenting Reductions in Chronic Street Homelessness........................................... F.17 Movement of Street Homeless into Housing..................................................... F.17 Public Funding............................................................................................................... F.18 Maintaining and Enhancing the System ........................................................................ F.20 Community Relations .................................................................................................... F.20 Site Visit Participants..................................................................................................... F.21 Acronyms....................................................................................................................... F.23 APPENDIX G: SEATTLE....................................................................................................... G.1 Seattle–Brief Description.................................................................................................G.1 Practices of Potential Interest to Other Jurisdictions .......................................................G.1 History and Context–How the Current System Evolved .................................................G.3 The Continuum of Care Plan ...............................................................................G.5 Approach to Chronic Street Homelessness......................................................................G.5
Table of Contents x Agency Interactions at the City and County Wide Level ....................................G.6 Agency Interaction at the Case Level ..................................................................G.7 Selected System Components..........................................................................................G.8 Prevention ............................................................................................................G.9 Outreach and Drop-in ..........................................................................................G.9 Emergency Shelters Focused on the Chronic Street Homeless Population ....................................................................................G.14 Safe Havens and No/Low Demand Residences.................................................G.15 Case Management................... ...........................................................................G.16 Permanent Supportive Housing .........................................................................G.18 Supportive Services ...........................................................................................G.22 Affordable Housing ...........................................................................................G.23 Documenting Reductions to Chronic Street Homelessness...........................................G.25 Public Funding...............................................................................................................G.27 Community Relations and Advocacy ............................................................................G.29 The Future–Maintaining and Enhancing the System.....................................................G.31 Site Visit Participants.....................................................................................................G.33 Acronyms.......................................................................................................................G.35 APPENDIX H: GLOSSARY ................................................................................................... H.1 APPENDIX I: METHODS.........................................................................................................I.1 Site Selection .................................................................................................................... I.1 First Screening Round........................................................................................... I.2 Safe Havens .......................................................................................................... I.3 Veteran Affairs Homeless Programs .................................................................... I.3 BID-Sponsored Programs ..................................................................................... I.4 NIDA Demonstration Programs ........................................................................... I.4 California’s Integrated Services for Homeless Adults with Serious Mental Illness........................................................................................... I.5 New York City Programs...................................................................................... I.5 Other Programs ..................................................................................................... I.5 Second Round Screening ...................................................................................... I.6 Site Visits.......................................................................................................................... I.7 Discussion Guide for use with Candidate Sites ................................................................ I.8 History/Overview/Context Discussion Guide................................................................. I.13 Outreach-Caseworker Discussion Guide ........................................................................ I.16 Data Issues Discussion Guide......................................................................................... I.19 Program-Specific Discussion Guide...............................................................................1.21 Focus Group Discussion Guide for Participants of Programs to End Chronic Street Homelessness.......................................................................................... I.25 REFERENCES........................................................................................................................... J.1
Table of Contents xi LIST OF CHARTS AND TABLES Charts Chart 5.1: Counts of Street Homeless Individuals In Philadelphia, 1998-2003…….. ...........52 Chart 5.2: Counts of Street Homeless Individuals, Birmingham 1995-2003 .........................53 Chart B.1: Strate gic Homeless Planning Group.. ..................................................................B.6 Chart C.1: Summary of 2003 Revenue Sources for Operations and Services Costs of Rebuilding Lives ...................................................................C.22 Tables Table 1: Key Elements Identified in Study Communities of Success Reducing Chronic Street Homelessness............................................................................... xix Table 2: Evidence of Success in Reducing Chronic Street Homelessness ...................... xxvi Table 5.1: Per-Bed Cost for Operations and Services of Franklin County Service Systems Used by Homeless Men with Long-Term Needs .......................59 Table 6.1: Federal Sources Invested in Ending Street Homelessness.....................................69 Table 6.2: Potentially Underused Funding Sources For Ending Chronic Street Homelessness...............................................................................................75 Table A.1: City of Birmingham: Agencies Involved in Reducing/Ending Chronic Street Homelessness...............................................................................A.8 Table A.2: Street Counts of Birmingham Homeless Population .....................................…A.15 Table A.3: Local Agency Investments in Ending Street Homelessness..............................A.17 Table B.1: City of Boston: Agencies Involved in Reducing/Ending Chronic Street Homelessness.............................................................................................B.9 Table B.2: Boston Investments in Ending Street Homelessness .........................................B.18 Table C.1 Per-Bed Costs for Operations and Services of Franklin County Service Systems Used by Homeless Men with long-Term Needs.......................C.4 Table C.1: City of Columbus: Agencies Involved in Reducing/Ending Chronic Street Homelessness...............................................................................C.6 Table C.3: Roles of Key Collaborators..................................................................................C.8 Table C.4: Rebuilding Lives: Supportive Housing Projects................................................C.14 Table C.5: Per Unit Costs (Operations and Services) for Rebuilding Lives Projects...............................................................................................................C.15 Table C.6: Local Agency Investments in Ending Street Homelessness..............................C.21 Table C.7: Summary of Operations & Services for Projects Currently Operating or Funded ..........................................................................................C.26 Table C.8: Total Estimated Funding Needs for Additional Rebuilding Lives Units.........................................................................................................C.27 Table D.1: Department of Veterans Affairs Network of Agencies Involved in Ending Chronic Street Homelessness ..................................................................D.6 Table D.2: Supportive Housing Developed by the Greater Los Angeles VA and Community Partners.............................................................................D.13
Table of Contents xii Table D.3: AB 2034 Network of Agencies Involved in Ending Chronic Street Homelessness...........................................................................................D.22 Table D.4: Lamp Community Network of Agencies Involved in Ending Chronic Street Homelessness.............................................................................D.31 Table E.1: City of Philadelphia: Agencies Involved in Reducing/Ending Chronic Street Homelessness............................................................................. E.11 Table E.2: Local Agency Investments in Ending Street Homelessness................ .............. E.24 Table F.1: City of San Diego: Agencies Involved in Reducing/Ending Chronic Street Homelessness............................................................................... F.9 Table F.2: Local Agency Investments in Ending Street Homelessness.............................. F.19 Table G.1: City of Seattle: Agencies Involved in Reducing/Ending Chronic Street Homelessness.............................................................................G.10 Table G.2: Local Agency Investments in Ending Street Homelessness..............................G.29
xiii EXECUTIVE SUMMARY Why This Study Is Important The goal of ending chronic homelessness has achieved national prominence in a very short time. It was first articulated in July 2000, when the National Alliance to End Homelessness included it as part of its ten-year plan to end homelessness altogether. The Department of Housing and Urban Development (HUD) Secretary Mel Martinez announced his agency’s acceptance of this goal in his keynote speech at the National Alliance’s 2001 conference one year later. Then President Bush made “ending chronic homelessness in the next decade a top objective” in his FY 2003 Budget. Also by 2003, the Interagency Council on Homelessness had been reinvigorated to guide and coordinate the efforts of Federal agencies, two New York Times lead editorials argued forcefully for that goal, the U. S. Conference of Mayors adopted it, and more than 100 cities and some states have committed themselves to developing a plan by 2004 to end chronic homelessness in the next 10 years. 1 HUD’s goal, and the goal of many communities, is to end chronic homelessness. We have titled this report strategies for “reducing” chronic street homelessness because no community has yet succeeded in ending it, and we wanted the title to indicate that we are documenting progress, not complete success. This is an experimental time for programs to reduce chronic street homelessness. The many communities that have resolved to end chronic homelessness have to learn about successful approaches, 2 construct their own strategies, and locate the necessary resources to fulfill their plans. These communities can benefit from the experiences of homeless service providers who have been willing and able to participate in developing and implementing new approaches. Given the scope of what needs to be done, integrated community-wide approaches hold the most promise of succeeding. HUD sponsored this project to identify and describe community-wide approaches that are working in cities around the country. 3 We selected seven communities that were reputed to have made progress in reducing their chronic street homeless population and would be able to document that progress. After conducting site visits, we found that only three of the seven have developed a true community-wide paradigm, but that each of the seven communities had noteworthy strategies to reduce chronic street homelessness. We also discovered common elements in the seven communities’ approaches that appear to maximize progress. This report describes these common elements and their role in approaches to reducing chronic street homelessness. Communities just beginning to develop their own plans for reducing chronic 1 For examples, see State and Local Plans to End Homelessness at the National Alliance to End Homelessness webpage http://www.endhomelessness.org/localplans/. 2 Throughout this report we use the term “approach” to indicate the set of strategies and mechanisms of coordination being employed by a community to reduce chronic street homelessness. 3 HUD’s Policy Development and Research Office funded the study, in consultation with the Office of Special Needs Assistance Programs/Community Planning and Development, which administers HUD’s homeless-related program s and funding opportunities.
Executive Summary xiv homelessness should be able to find illustrative practices and programs that they can learn from and adapt to their own situations. Purpose of the Research This project’s aim was to identify successful community-wide approaches to reducing homelessness and achieving stable housing for the difficult-to-serve people who routinely live on the streets. It was also to document these successful approaches in a way that will help other communities trying to address this problem. We included as “street homeless” single adults who spend significant time on the streets, although they may also use emergency shelters from time to time. Most of the people to be helped will also be “chronically” homeless, which we defined as being disabled and either being continuously homeless for a year or more or having had at least four homeless episodes during the last three years. This definition of “chronic” homelessness corresponds to the definition recently adopted by the Interagency Council on Homelessness. Disabilities or disabling conditions often include severe and persistent mental illness, severe and persistent alcohol and/or drug abuse problems, and HIV/AIDS. To the extent that community approaches address these, they can assist a greater proportion of chronic street homeless people to leave homelessness. This study sought to answer several questions about strategies that communities use to reduce chronic street homelessness: • Does the community have a long-term plan for reducing/preventing chronic homelessness? What is its approach and what are the elements? What led to this approach and how was it identified? What needs of which homeless people does it address? • How was the approach implemented? What challenges were encountered? What opportunities were used? • How is the approach administered and coordinated? What is the role of each stakeholder? • How is the approach funded? Do requirements of the funding sources create any barriers or promote any successes? • Did implementation include efforts to reduce local resistance by including community members? How? How successful have these efforts been? • Can the community document its progress, either by showing that the numbers of street homeless people have decreased or by showing that programs are accepting this population and helping them leave homelessness? • How else do communities use data to bolster their case for making the investment to end chronic street homelessness?
Executive Summary xv Who, What, Where, and When? In 2002, HUD contracted with Walter R. McDonald Associates, Inc. and its subcontractor, the Urban Institute, to conduct a study to answer the aforementioned research questions. We sought communities appropriate for site visits through recommendations of key informants and a literature search for evaluated projects, identifying over 120 possible programs and communities. We called community and program representatives to help us identify appropriate communities to visit. Criteria for selection included that the community have an approach to reducing chronic street homelessness, that it be community-wide, and that there be evidence to document that the approach actually succeeded in reducing chronic street homelessness. HUD asked us to find community-wide approaches to reducing chronic street homelessness because its analysts suspected that such a focused commitment might be necessary for substantial progress. For our purposes, “community-wide” means that a jurisdiction such as a city or a county has made a conscious commitment to reducing chronic street homelessness (as opposed to all homelessness), and has mobilized resources for that specific purpose. We were able to find three communities that met all three criteria, and several others that met the criteria but only for specific sub populations such as veterans, people with severe mental illness, or people with co-occurring disorders. We visited some communities that did not meet the criterion of having a community-wide approach because we reasoned that many communities throughout the country would benefit from knowing what could be accomplished even without a community-wide approach, as not all communities will be able to begin with a community-wide commitment. The seven communities visited were: • Birmingham, Alabama; • Boston, Massachusetts; • Columbus, Ohio; • Three projects in Los Angeles, California—one focused on homeless veterans, one focused on mentally ill offenders in the county jail system, and one focused on chronic street homeless people in the downtown “Skid Row” area; • Philadelphia, Pennsylvania; • San Diego, California; and • Seattle, Washington. We conducted site visits to each of these communities, ranging in length from two to five days depending on the complexity of the community’s approach and the components we chose as the focus of our visits. We interviewed between 40 and 90 people per site, including focus groups at each site of 5 to 10 formerly street homeless people. Representatives at each site had the opportunity to review for accuracy our description of their community and its activities for reducing chronic street homelessness (which appear as Appendices A through G). Findings––Key Elements of Success We identified 11 key elements in the seven communities visited, shared by many approaches for reducing chronic street homelessness. Most important, we found five of these elements to be
Executive Summary xvi present in the communities that have made the most progress toward reaching this goal, and have called these elements “essential.” The most important element, shown in the first row of Table 1, is (1) a paradigm shift in the goals and approaches of the homeless assistance network. The essential recognition underlying the paradigm shifts we observed was that existing approaches and homeless assistance networks were not reducing or ending homelessness, particularly chronic or street homelessness. 4 Recognizing also that they wanted to end chronic street homelessness, these communities adopted that goal and found new or modified existing approaches that brought greater success. We did not find any connection between having a well-established homeless assistance network and experiencing a paradigm shift; the first was not a prerequisite for a shift, nor did it guarantee that one would occur. Among the communities we visited, four (Boston, Columbus, Philadelphia, and Seattle) have extensive programs and services in every aspect of their continuum of care, run by experienced providers and developed over many years with both Federal and local funding and support. Two of the four have experienced a paradigm shift while two have not yet done so. While having a well-developed network does not produce a shift, however, once a shift occurs an established and extensive network of services and providers that work well together offers an advantage as a community proceeds with the planning and program development needed to launch new approaches. This is what happened in Columbus and Philadelphia. On the other hand, San Diego's homeless assistance network had major gaps, especially in the area of permanent supportive housing. The pre-shift system was developed by the local network of nonprofit agencies, without much focus on the chronic street population and without much participation by the public and business sectors. San Diego's paradigm shift involved both a new focus––on the chronic street population––and new players––public agencies and the business community. The next four elements appear to comprise an important combination that, working together, turn a paradigm shift’s promise into a reality. These are (2) setting a clear goal of reducing chronic street homelessness, (3) committing to a community-wide level of organization, (4) having leadership and an effective organizational structure, and (5) having significant resources from mainstream public agencies that go well beyond homeless-specific funding sources. It is important to note that these elements characterize community activities to reduce chronic street homelessness after a paradigm shift, but need not already be in place. Some may exist before the shift (Columbus and Philadelphia had all except the goal of ending street homelessness). We observed the most progress toward ending chronic street homelessness at the community level where these elements worked together as they did in Columbus, Philadelphia, and San Diego. Even when an organization or network experiences a paradigm shift affecting a subpopulation rather than a whole community, we found these same four elements as the engine underlying their success in building on their paradigm shift, as they did in two examples from Los Angeles (the work of the Department of Veterans Affairs with homeless veterans and the Mental Health and Sheriff’s Departments’ joint work with mentally ill offenders). 4 The old paradigm was that street homeless individuals should be cared for more by charitable, often religious, organizations rather than by mainstream public agencies. The old paradigm relied heavily on emergency shelters, transitional housing, and sobriety-based programs. The old paradigm did not plan, or expect, to end chronic street homelessness.
Executive Summary xvii The first five elements, working together, allowed several of our communities to capitalize on a trigger event or catalyst, while in at least one other, a trigger event was the catalyst for developing the first five elements. The remaining elements in Table 1 contributed to a community’s ability to sustain its commitment and guide the development of its new approaches. These are (7) significant involvement of the private sector; (8) commitment and support from mayors, city and county councils, and other local elected officials; (9) having a mechanism to track progress, provide feedback, and support improvements; (10) being willing to try new approaches to services, and (11) having a strategy to handle and minimize negative reactions to locating projects in neighborhoods (NIMBY responses). How They Got Where They Are Today—Key Factors in History and Implementation All successful community and subpopulation approaches started from one place—key stakeholders recognized that to end chronic street homelessness, they had to focus specifically on that goal, understand the characteristics of chronically street homeless people, and plan programs and services designed to attract them. Even in communities that had a well-established homeless assistance network, stakeholders realized that they were not reducing or ending chronic street homelessness, and would have to do things differently if they wanted to succeed. As already described, they underwent a paradigm shift in the way they approached homeless assistance programs and services for the hardest-to-serve chronically homeless people. Trigger Events and Paradigm Shifts In most of the communities we visited, a trigger event galvanized the approach we observed. The event was impending downtown development in Columbus and San Diego, a proposed anti- homeless city ordinance in Philadelphia and Birmingham, consumer and service provider protests at the Department of Veterans Affairs in Los Angeles and municipal buildings in Philadelphia and San Diego, and an invitation to develop a pilot program for a new funding source for the Los Angeles County Sheriff and Mental Health Departments’ integrated services program. The two communities that already had strong organizational structures and leadersh ip (Columbus and Philadelphia) were able to capitalize on these trigger events with relative ease and speed. But it is important to note that several communities and public agencies that did not have an organized leadership structure or well-developed public agency involvement and investment before the trigger event (for example, San Diego and two of the Los Angeles programs) were able to use the event to re-examine their situation, decide to take action, organize themselves, mobilize resources, and make and carry out plans for approaches that address and reduce chronic street homelessness. Thus these four communities were able to turn these events to their advantage and gain commitments to new goals and new resources, rather than allowing the event to worsen the circumstances of street homeless people. The event itself is often perceived locally as a watershed moment—the catalyst that began the process that resulted in the current commitment to reduce or end chronic street homelessness.
Executive Summary xviii Dept. of Veterans Affairs AB 2034 Lamp Community Paradigm Shift Yes Yes Yes Yes Yes No No No No Clear Goal Set Yes, reducing street homelessness Yes, reducing street homelessness Yes, reducing downtown street homelessness Yes, reducing veterans' homelessness Yes, reducing homelessness among mentally ill offenders Yes, reducing street homelessness in Skid Row No Yes, reducing homelessness among people with serious mental illness No Community-wide Approach YesYesYesNoNoNoNoNoNo Organizational Structure and Leadership Specifically for Reducing Chronic Street Homelessness Nonprofit lead agency with authority and resources Government agency with authority and resources, plus a Mayor’s Task Force and a voluntary association of all interested parties Voluntary association of government agencies and business interests, with resources VA is lead agency, with resources, of a network of VA and contracted nonprofit housing and service providers Mental health agency is lead, works with Sheriff, directs network of contracted nonprofit mental health providers Mini-continuum None specifically for reducing chronic street homelessness, but starting a subcommittee that will have this focus None specifically for reducing chronic street homelessness None specifically for reducing chronic street homelessness Mainstream Agency Involvement Strong Strong Strong Strong Strong Weak Weak Strong, but not specifically for reducing chronic street homelessness Weak Catalyst Trigger Event Yes Yes Yes Yes Yes No Yes No No Private Sector Involvement Strong Strong Strong Weak Weak Weak Strong Weak Some Local Elected Official Commitment Strong Strong Strong Weak Weak Weak Weak Strong Weak Progress-tracking Mechanism Yes Yes Yes Yes Yes No No No No New Approaches to Services Yes Yes Yes Yes Yes Yes No No Yes Strategy to Combat NIMBY Yes Yes No Some Some No No No Yes Table 1: Key Elements Identified in Study Communities of Success in Reducing Chronic Street Homelessness 1 In Columbus, Philadelphia, San Diego, Birmingham, Boston, and Seattle, we sought community-wide approaches to ending chronic street homelessness. In Los Angeles, we did not look for a countywide or even a citywide approach, examining instead two systems focused on particular subpopulations of interest and one mini-continuum focused exclusively on chronically street homeless people. Seattle Element Community 1 Columbus Philadelphia San Diego Los Angeles Birmingham Boston Type of Element Essential Contributing
Executive Summary xix Even in communities that have not, as yet, adopted reducing chronic street homelessness as a community-wide goal, some networks have developed with a focus on reducing homelessness among chronically street homeless people in response to unique opportunities or the commitment of a public agency. Seattle used the ACCESS program targeting severely mentally ill homeless people to help create a service network that still operates to the advantage of mentally ill street people, and also developed a set of programs and services targeted specifically toward substance abusing street homeless people. In Boston, the Massachusetts Department of Mental Health has committed extensive resources to programs and services for homeless people with severe mental illness, including specialized emergency and transitional shelters/housing and extensive discharge planning to avert a return to homelessness after psychiatric treatment. It takes the change in vision—the paradigm shift in what communities are trying to accomplish—to make significant progress toward reducing chronic street homelessness within a community or for a subpopulation. Excellent individual programs will surely exist—we visited many of them—and they may have great success in helping individual homeless people leave homelessness. But without the paradigm shift, communities probably will not take the steps to develop innovative approaches and mobilize the resources that are necessary to reduce chronic street homelessness. Thoughtful, Analytic Process The approaches making the most progress toward ending chronic street homelessness were based on an extensive investigation of needs and options. Decision makers learned about the numbers, problems, and service needs of their chronically homeless population, through special surveys, focus groups, and “hanging out.” They read evaluation reports and visited other communities that already had approaches they were considering. They invited speakers to town to discuss options. Columbus and Philadelphia provide examples of this analytical process. They each had community-wide data on emergency shelter use from which they learned that 10 to 15 percent of the people who used emergency shelters throughout the year used 50 percent or more of shelter resources (bed nights). They reasoned that if they could move these chronically homeless people into permanent housing arrangements, both they and the homeless assistance system would benefit. Armed with pertinent information, the more advanced communities developed an approach that in all instances involved strategies to address both “opening the back door” (helping people leave homelessness) and “closing the front door” (preventing people from becoming homeless). Strategies of both types require the active cooperation and investment of mainstream agencies. Building this commitment occurred through various approaches, depending on the community. In Columbus, which already had a central organization and involvement of mainstream agencies, the route was through a special project, Rebuilding Lives, which included a survey of street homeless people and analysis of the results and their implications for the types of programs and
Executive Summary xx investments that would be needed. The final report addressed the whole community, explained the strategy and its rationale, and organized buy-in from many stakeholders to develop 800 units of low-demand permanent supportive housing explicitly for the chronically homeless people in shelters and on the streets, to augment the community’s existing array of permanent supportive housing. In contrast, San Diego began without an existing central organization coordinating the efforts of its mainstream public agencies. Interested parties organized informally, took their time, talked with everyone, and allowed consensus to grow as increasing numbers of public agencies and private interests were invited to participate. Ultimately the plan they developed received unprecedented endorsement and support from both city council and county board of supervisors, plus significant business commitments. Finally, communities with successful approaches set goals and timetable s, put someone in charge, track their progress, make sure they get feedback on how they are doing, and periodically take time to reflect on progress and what adjustments or new commitments might be required. New Strategies for Programs and Services Most of the communities we visited have assessed and adopted new approaches to programs and services for the street homeless population, or have modified existing ones (as a result of the thoughtful, analytic process). They have also increased commitments to existing programs and services to better approximate the level of need among chronically street homeless people, who include many of the hardest-to-serve homeless people. They have severe mental illnesses, substance abuse disorders, HIV/AIDS, and physical disabilities, often occurring together. They have been homeless a long time, often have no ties to family, and rarely have any resources. Their skills are oriented toward survival on the streets, not to living in housing. Most chronically street homeless people have used emergency shelter—some only briefly, but others for long periods of time. Many have been frequent users of detoxification facilities, and have had some contact with the mental health system as both outpatients and inpatients. Many will not use programs that require sobriety to enter, as they will not stop using drugs and alcohol, at least at first. In addition many are not able to comply with plans or “make progress” from the time they enter a program, as many transitional programs require them to do. The long stays of people in emergency shelter clearly indicate that emergency shelters generally do not succeed in moving these people out of homelessness. The people on whom this project focuses are, by definition, those for whom these programs and services have not produced long-term solutions to homelessness. Their resistance to standard approaches has been a challenge to communities committed to ending chronic street homelessness. In the experience of the communities we visited, reaching that goal has required rethinking their services and offering new approaches. Most communities we visited have adopted one or more of: • Housing First models that place people directly from the streets into permanent housing units with appropriate supportive services, including safe haven programs for people with
Executive Summary xxi serious mental illness and similar programs for people whose primary problem is addiction; • Transitional versions of Housing First that let people bypass emergency shelters; • Breaking the linkage between housing and service use/acceptance, so that to keep housing, a tenant need only adhere to conditions of the lease (pay rent, don’t destroy property, no violence), and is not required to participate in treatment or activities; • Low demand or “harm reduction” conditions where sobriety is “preferred but not required,” which often translate into a “no use on the premises” rule for projects that use HUD funds; and • Restructuring existing activities such as outreach to increase their effectiveness at connecting street homeless people with services and housing; and • Discharge planning from jails and mental health hospitals to prevent street homelessness among individuals leaving these institutions. In addition, many communities have developed mechanisms for facilitating service delivery to individual clients, helping them to take advantage of what the system has to offer. Some of these are specialized versions of case management, and some are tools to support effective case management. They include: • Database technology and information sharing that allows staff members of one agency to know what services a client might be receiving from other agencies; • Multi-agency teams designed to include the range of expertise required to meet the broad spectrum of services needed by chronic street homeless individuals; • Multi-purpose service centers where clients can receive more than one type of service within the same building; and • Processes to improve access to mainstream agencies, such as locating intake workers at homeless service provider sites. Low-demand housing approaches appear to be very successful at attracting chronic street homeless people. According to focus groups with street homeless people and outreach workers during our site visits, as well as other research (Rosenheck et al., n.d.; Shern et al., 1997; Tsemberis and Eisenberg, 2000), these low-demand programs can bring difficult-to-recruit individuals into permanent supportive housing. People will come in, they do use services even though not required to, they do reduce their substance use, and mostly they do not return to the streets. Other mechanisms facilitate the process of recruiting people into the housing programs and assuring that, with maximum efficiency and effectiveness, they get the array of services they need.
Executive Summary xxii In addition to the new approaches, making a commitment to ending chronic homelessness often means increasing the availability of existing programs and services that help people to leave homelessness. Such actions might include increasing access to case managers and reducing case manager caseloads. Short-term and medium-term addiction recovery programs might be expanded to fill gaps, so that people are not left without a program when they are not yet secure in their recovery. The availability of housing subsidies might be expanded. It takes many components to create a successful system. Some will be new, others old. Birmingham, for instance, has some successful programs based entirely on sobriety and transitional rather than permanent supportive housing. But serious commitment to ending chronic street homelessness necessitates a paradigm shift, part of which involves the willingness of a community and its homeless assistance providers to consider approaches that have been proven to work even though they may, at least initially, represent a significant departure from traditional programs. Documenting Progress We sought out programs and communities that not only were doing important things to end street homelessness, but also had the evidence to document their progress. Collecting such evidence is not easy, and it can take many forms: • Changes in the number of people found on the street from year to year, coming from consistently administered and analyzed street counts; • Increases in the percentage of chronically street homeless people who ?¾ Move directly from street to permanent supportive housing, or other combinations of services that lead to permanent housing in the community (for example, safe havens and then PSH); ?¾ Receive other combinations of services that lead to permanent housing in the community (for example, transitional housing followed by moving into affordable housing with decreasing supportive services, for people in recovery where substance abuse is the primary issue); • Costs avoided by reducing inefficient utilization by homeless people of health, mental health, shelter, and law enforcement services; • Reductions in undesirable outcomes for homeless people (such as days homeless, hospitalized, or incarcerated); • Increases in receipt by homeless people of entitlement public benefits (such as Supplemental Security Income, Medicaid, or food stamps); and • No reappearance in the homeless service system (documented through a community-wide homeless management information system). Many factors may influence the level of homelessness, including street homelessness, in a community, no matter how organized or complete the efforts to end it. In the communities we visited, interviewees attributed increases in the level of chronic street homelessness or changes in
Executive Summary xxii i other measures of progress to a poor economy and resulting unemployment, shutting down one or more large SRO hotels where poor single people had lived, closure of state mental hospitals, and persistently high housing costs. Even in the face of these countervailing factors, the communities we visited were able to substantiate their progress at reducing chronic street homelessness, or helping chronically street homeless people obtain housing, in a variety of ways (see Table 2). Other communities might be able to develop the types of evidence shown in Table 2, which they could use to convince local stakeholders that investing in programs and services to reduce chronic street homelessness will produce measurable results. Philadelphia and Birmingham street counts show reductions over a number of years, with Philadelphia’s decreases paralleling increases in safe haven and permanent supportive housing units, and Birmingham’s paralleling increases in both transitional and permanent supportive housing, as well as emergency shelter expansion. As shown in Table 2, at least some programs in most communities can document progress in bringing chronically street homeless people into supportive housing and in helping them retain that housing. Lengths of stay in programs that have been in operation long enough for tenants to remain stably housed for years average three to five years. Some programs can also document the proportion of leavers who went to and remained in affordable housing in the community. In one Philadelphia program 67 percent of 90 people who left permanent supportive housing were living in “regular” affordable housing. Columbus, Philadelphia, and San Diego have also made good use of cost data to show the most cost-effective models of providing services (Columbus) or the cost of emergency services that could be avoided through permanent supportive housing (Philadelphia and San Diego) or transitional housing and treatment for serial inebriates (San Diego). Cost avoidance studies showing that PSH does not cost much more than “doing nothing” have recently achieved national prominence (Culhane, Metraux, and Hadley, 2002; Rosenheck et al., 2003), and can be considered a more humane investment of public funds. These results are one reason why an increasing number of jurisdictions are committing themselves to ending chronic homelessness. How Do They Pay For It? Finding the resources to pay for new programs and services is always a challenge. The experience of these seven communities indicates very strongly that reducing chronic street homelessness requires significant investment of mainstream public agencies, bringing both their commitment and energy, and local dollars. The goal cannot be met if the homeless assistance network providers are the only players, and Federal funding streams the only resources. The communities and service networks enjoying the greatest success in reducing chronic street homelessness all capture resources from many different funding streams. The local agencies that control these funding streams have made the decision to devote not only Federal resources they control, but also their own state and local resources, to achieving the goal. In addition, some communities have created special funding streams that help support permanent housing programs and supportive services. These include a housing tax levy (Seattle), tax increment
Executive Summary xxiv financing generated by a redevelopment agency and reinvested in permanent supportive housing (San Diego), community redevelopment bonds (Philadelphia), special state funding streams (California’s Integrated Services for Homeless People with Mental Illness, and its Supportive Housing Initiative Act), and investments by Business Improvement Districts and other associations of downtown businesses and corporations (Birmingham, Columbus, Philadelphia, San Diego). Implications The findings from this p roject have some important implications for policy, practice, and research. We summarize them here. Implications for Policy During site visits many respondents offered suggestions for how Federal policy and Federal agencies could help them as they pursue their goal of ending chronic homelessness. Their suggestions reflect their own experiences of what has helped them, and also what they feel could continue to ease the way toward reaching their goal. These include suggestions for Federal, state, and local agencies. • Federal agencies should: ?¾ Continue to prioritize community-wide planning and integrated approaches for reducing chronic homelessness in general, and street homelessness for people with severe mental illness, chronic substance abuse, HIV/AIDS, or any combination in particular; ?¾ Make technical assistance widely available to communities that are starting to plan an approach to reducing street homelessness; and ?¾ Facilitate opportunities for practitioners and planners to observe new approaches in action, speak with consumers, see results, and consider how these practices could be applied in their own community. • Federal legislative action should increase the flexibility of Federal agencies to blend their funding to support innovative community-wide practices that integrate services to reduce chronic homelessness across local agencies.
Executive Summary xxv Department of Veterans Affairs AB 2034 Lamp Community Street count reductions Estimates of street populations do not yet show reductions Summer counts since 1998 -6%, 1998-2003 -42%, 1998-2000 increase between 2001 and 2003 due to poor economy Counts in 1995, 2001, and 2003 -10%, 2001-2003 -33%, 1995-2003 No reductions; only 5 of past 16 years have seen street counts over 200; 4 have been the 4 most recent years Annual counts for 24 years, increases in street homelessness every year 1998-2002 of 10-40%, +260% between 1998 and 2002 Formerly street homeless people moved to PSH with stays of 1 year plus Has created (to date) 370 of 800 intended PSH units and moved chronically street homeless people into them, the vast majority of whom are still there Agency 1: of 186 people in 4 PSH programs, 73% had been in PSH for 1+ years (avg. LOS=3.2 years) Agency 2: of 146 people in 2 PSH programs, 72% in PSH for 1+ years, 44% for 2+ years One program reports 70% (177) of current enrollees were mentally ill and chronically homeless, now in PSH; most of other enrollees are in TH One program reports 75 (48% of leavers) went from TH to PSH, of whom 81% have stayed 1+ years One program reports 135 (38% of leavers) went from ES to PSH, and 78 (22% of leavers) went from ES to TH Agency 1-70-78% in 3 PSH programs remain 1+ years Agency 2-in 2 PSH programs, average LOS is at least 3 years Formerly street homeless people moved to permanent affordable “regular” housing Agency 1-of 90 who left PSH, 67% living in stable housing; 13% returned to homelessness; 13% unknown Same program reports 18 (11% of leavers) went from TH to regular housing and have not returned Financial advantages Estimates cost- effectiveness of different housing- service combinations Estimates cost of chronic shelter use vs. PSH, safe havens 1. Fifteen high medical service users cost $1.5 million over 18 months 2. One arrest for a serial inebriate costs $1470 versus $977 for a month of TH plus outpatient treatment Other Reduced emergency beds due to more PSH and Safe Havens One program reports that after 1 year participants had 73% fewer days homeless, 35% fewer days hospitalized, 55% fewer days incarcerated 16-25% fewer homeless days (national VA evaluation study); also fewer hospital days 65% fewer days homeless, 74% fewer days hospitalized, 80% fewer days incarcerated Reduced homeless, hospital, and in carcerated days (just for AB 2034 people) Birmingham Boston Seattle TABLE 2: EVIDENCE OF SUCCESS IN REDUCING CHRONIC STREET HOMELESSNESS Type of Evidence Community Columbus Philadelphia San Diego Los Angeles
Executive Summary xxvi • State and local agencies should: ?¾ Adjust rules and regulations to facilitate access to benefits, programs, and services for chronically street homeless people; ?¾ Establish procedures and invest resources in housing and services to assure that people leaving psychiatric care, substance abuse treatment, correctional facilities or foster care do not become homeless; and ?¾ Facilitate state and local public agency and nonprofit provider interest in and capacity to serve clients with co-occurring disorders, by, for example, improving liaison and integrated service arrangements among mental health, substance abuse, medical care, and housing authorities; or requiring dual certification for all contract agencies and staff. Implications for Practice One of the primary reasons for conducting this study was to learn what different communities actually do that is effective in reducing street homelessness. The practice implications summarized here are distillations of information, opinion, and experience from many of the sites we visited. Communities desiring to advance in their efforts to end chronic homelessness, including street homelessness, should look carefully at the experiences of the places we visited and explore how they may adapt proven practices to their own situation. The body of this report includes “practices of potential interest to other communities,” complete with people to contact to learn more, and contact information. Brief descriptions occur throughout the report, but details may be found in the site appendices, which begin with brief summaries and contact information. Readers should browse these appendices to learn about practices and see whether any of them might be appropriate for their own community. • If a community is intent on reducing chronic street homelessness, it is vital that it take steps to build the capacity to work with people who have co-occurring disorders. ?¾ Homeless providers need to develop dual competence and dual certification— mental illness and substance abuse issues must be handled together. ?¾ Mainstream mental health and substance abuse agencies need to have an integrated approach to mental illness and substance abuse for chronically street homeless people. Mainstream agencies also need to accept that stable housing contributes to their clients’ well being—possibly as much as medications and other official “treatments.” They should consider creating positions of housing developers and coordinators, and making housing and housing stability a priority. ?¾ Housing providers need to understand the benefits of supportive services to their whole tenant base and not just to those who were homeless. In the communities we visited, some housing providers had realized the advantages of having supportive services available. The Plymouth Housing Group of Seattle reported that their tenants’ average tenure increased from 18 months to 36 months, once
Executive Summary xxvii services were made available. Services associated with Shelter Plus Care were located at Sunshine Terrace in Columbus, a high-rise 180-unit building operated by the public housing authority, to provide support to the tenants who receive Shelter Plus Care subsidies (about one-fourth of all tenants). Other tenants may and do use these services, resulting in stabilized housing tenure for all tenants, as well as contributing to the good neighbor image Columbus cultivates for its permanent supportive housing programs. • To develop and implement strategies for reducing chronic street homelessness, communities require strong, skilled leadership. The insti tutional location of the leaders is not as important as the capability and commitment of the individuals. But individuals, however good their leadership skills, must have the backing and resources of local mainstream agencies and elected officials if they are to succeed. Implications for Research The implications of our study for research are not as direct as those for policy and practice. They stem more from what we did not find, and what we could not document, than they do from what we were able to see and evidence we were able to collect. As we examined our findings, many gaps in knowledge appeared—types of evidence we wish we had, or wish were stronger, to establish with greater confidence which directions and practices were fruitful and should be emulated in other communities. The research suggestions presented below are those that we think will help fill the most glaring gaps in our current knowledge and provide the most useful information to show effective approaches to ending chronic street homelessness. • Longitudinal tracking studies should be funded to document housing stability and follow people once they leave supported housing. A primary outcome to observe in this research would be housing stability and what factors contributed to it. These studies would be most relevant to conduct for formerly street homeless people with severe mental illness and co-occurring disorders. They should examine housing stability both within the homeless assistance network and after leaving it. • Conduct research that compares the effectiveness and cost-effectiveness of different pathways into permanent housing for different subpopulations. Ideally this research should use random assignment intervention studies; if that is impossible, it must employ meaningful comparison groups. ?¾ Pathways to examine should include (1) directly from the street into permanent supportive housing, (2) transitional housing as a step before permanent supportive housing, (3) safe haven as a step before permanent supportive housing, and (4) transitional housing with expectation of movement into affordable housing in the community (no supportive services). ?¾ Approaches to test, within pathways, should include (1) sober versus harm reduction models, (2) voluntary versus coerced treatment (the latter through drug court or its equivalent), (3) different physical structures and service delivery
Executive Summary xxviii mechanisms (for example, scattered site, only-formerly-homeless single site, and mixed-use single site), and (4) if transitional housing is part of the pathway being tested, what is the optimal duration of transitional housing to increase the odds of maintaining recovery. • Support a reasonable sample of permanent supportive housing providers to collect and maintain better data on their tenants, and assemble these data at the national level. This approach would be less expensive by far than the ideal research designs described in the first two bullets, but would still contribute significant new data on important issues, including the effectiveness of permanent supportive housing. Data would need to be collected (1) at intake about tenant histories, (2) during residence, and (3) after people leave permanent supportive housing, to document continued success or return to homelessness. To give this approach the greatest chance to contribute high quality information, a national research effort would have to be established to manage data collection within programs and conduct the follow-up interviewing, if one wanted to assure acceptable completion levels.
1 CHAPTER 1: INTRODUCTION Why This Study Is Important Today’s recognition of homelessness as a social problem is about two decades old. First responses were to treat the problem as an emergency situation. Policy evolved over the years to include recognition that many of the people finding themselves homeless would need more than an emergency bed for a few nights, weeks, or even months to get themselves back into regular housing. Some communities began as early as the late 1990s to reorient themselves toward ending either chronic homelessness or all homelessness, and to establish action steps and a time frame in which to do so. At its national conference in July 2000, the National Alliance to End Homelessness unveiled a ten-year plan to end homelessness altogether. A significant part of that plan is a blueprint to end chronic homelessness in the same time frame. The plan drew on evaluations that show we know how to create programs and supportive services to bring people in off the streets and help them retain housing, and on research that estimates the number of chronically homeless people to be few enough (between 150,000 and 250,000) to make a reasonable target for a successful policy. Two years later, additional research (Culhane, Metraux, and Hadley, 2002) showed that the policy might be close to cost-neutral in public monies as well. Since 2000, this goal of ending chronic homelessness has expanded dramatically. By 2003 the President had endorsed it and reinvigorated the Interagency Council on the Homeless to guide and coordinate the efforts of Federal agencies. Two New York Times lead editorials argued forcefully for that goal, the U. S. Conference of Mayors had adopted it, and more than 100 cities and states around the country had committed themselves to developing plans that would make it a reality. These plans usually have at least two aspects—helping chronically homeless people leave homelessness for good by establishing permanent supportive housing or other supportive networks, and stopping the flow of people likely to experience chronic homelessness by offering housing and appropriate supports for vulnerable people leaving institutions such as substance abuse treatment, psychiatric, or correctional facilities. This is an experimental time for programs to reduce chronic street homelessness. The many communities that have resolved to end chronic homelessness have to learn about successful approaches, 5 construct their own strategies, and locate the necessary resources to fulfill their plans. These communities can benefit from the experiences of homeless service providers who have been willing and able to participate in developing and implementing new approaches. Given the scope of what needs to be done, integrated community-wide approaches hold the most promise of succeeding. 5 Throughout this report we use the term “approach” to indicate the set of strategies and mechanisms of coordination being employed by a community to reduce chronic street homelessness.
Chapter 1: Introduction 2 HUD sponsored this project to identify and describe community-wide approaches that are working in cities around the country. 6 We selected seven communities that were reputed to have made progress in reducing their chronic street homeless population and would be able to document that progress. After conducting site visits, we found that only three of the seven have developed a true community-wide paradigm, but that each of the seven communities had noteworthy strategies that were working to reduce chronic street homelessness. We also discovered common elements in the seven communities’ approaches that appear to maximize progress. This report describes these common elements and their role in approaches to reducing chronic street homelessness. Communities just beginning to develop their own plans for reducing chronic homelessness should be able to find illustrative practices and programs that they can learn from and adapt to their own situations. We found that the most successful of the study communities had experienced a paradigm shift that changed the goals and approaches of their homeless assistance network. This was especially powerful when combined wit h having a clear goal of reducing chronic street homelessness, a community-wide level of organization, strong leadership and effective organizational structure, and significant resources from mainstream public agencies. These and other key elements are described in detail in Chapter 2. The other chapters in the body of the report describe how the study communities implemented their strategies. The last chapter describes policy, practice, and research implications. The site visit appendices provide descriptions of how the elements operate together in each of the study communities. These appendices also include site contact information for practices of potential interest to other jurisdictions. None of the study communities have achieved the final goal of ending chronic homelessness, but all provide examples of useful strategies. A few of our study communities have a more complete approach than the others, but all of them are working on improvements. Purpose of the Research This project’s aim was to identify successful community-wide approaches to reducing homelessness and achieving stable housing for the disabled, difficult-to-serve people who routinely live on the streets, and to document these successful approaches in a way that will help other communities trying to address this problem. We included as “street homeless” single adults who spend significant time on the streets, although they may also use emergency shelters from time to time. Most of the people to be helped will also be “chronically” homeless, which we defined, as does the Interagency Council on the Homeless, as being disabled and either being continuously homeless for a year or more or having had at least four homeless episodes during the last three years. We use the phrase “chronically street homeless” in describing those single adults who meet both criteria. To be successful at the task of reducing chronic homelessness, community approaches must address disabilities such as severe and persistent mental illness, severe and persistent alcohol and/or drug abuse problems, and HIV/AIDS. For succinctness of 6 HUD’s Policy Development and Research Office funded the study, in consultation with the Office of Special Needs Assistance Programs/Community Planning and Development, which administers HUD’s homeless-related programs and funding opportunities.
Chapter 1: Introduction 3 writing, often in this report we will simply use the terms “chronic homelessness” and “chronically homeless individuals” in referring to the people who are the focus of our inquiry. This study sought to answer several questions about strategies that communities use to reduce chronic street homelessness: • Does the community have a long-term plan for reducing/preventing chronic homelessness? What is its approach and what are the elements? What led to this approach and how was it identified? What needs of which homeless people does it address? • How was the approach implemented? What challenges were encountered? What opportunities were used? • How is the approach administered and coordinated? What is the role of each stakeholder? • How is the approach funded? Do requirements of the funding sources create any barriers or promote any successes? • Did implementation include efforts to reduce local resistance by including community members? How? How successful have these efforts been? • Can the community document its progress; either by showing that the numbers of street homeless people have decreased or by showing that programs are accepting this population and helping them leave homelessness? • How else do communities use data to bolster their case for making the investment to end chronic street homelessness? Who, What, Where, and When In 2002, HUD contracted with Walter R. McDonald Associates, Inc. and its s ubcontractor, the Urban Institute, to conduct a study to answer the research questions. HUD asked us to find community-wide approaches to reducing chronic street homelessness, to the extent possible, because its analysts suspected that such a focused commitment might be necessary for substantial progress. We sought communities appropriate for site visits through recommendations of key informants and a literature search for evaluated projects, identifying over 120 possible programs and communities. Screening phone calls to community and program representatives helped us identify appropriate communities to visit. Criteria for selection included that the community have an approach to ending chronic street homelessness, that it be community-wide, 7 and that there be evidence to document that the approach actually succeeded in reducing chronic street homelessness. (The selection methods are described further in Appendix H.) 7 For our purposes, “community-wide” means that a jurisdiction such as a city or a county has an effective cross- agency collaborative approach. See Chapter 2 for a fuller discussion of this term.
Chapter 1: Introduction 4 We were able to find three communities that met all three criteria, and several others that met the criteria but only for specific subpopulations such as veterans, people with severe mental illness, or people with co-occurring disorders. We also visited four communities that did not meet all criteria. We reasoned that many communities throughout the country would benefit from knowing what could be accomplished even without a community-wide approach, as not all communities will be able to begin with community-wide commitment. The seven communities visited were: • Birmingham, Alabama; • Boston, Massachusetts; • Columbus, Ohio; • Three projects in Los Angeles, California—one focused on homeless veterans, one focused on mentally ill offenders in the county jail system, and one focused on chronic street homeless people in the downtown “Skid Row” area; • Philadelphia, Pennsylvania; • San Diego, California; and • Seattle, Washington. We conducted site visits to each of these communities, ranging in length from 2 to 5 days depending on the complexity of the community’s approach and the components we chose as the focus of our visits. We interviewed between 40 and 90 people per site, including focus groups at each site of 5 to 10 formerly street homeless people. Representatives at each site had the opportunity to review for accuracy our description of their community and its activities for ending chronic street homelessness. Below we present a short introductory sketch of our sites in alphabetical order. The complete descriptions are in Appendices A through G. Birmingham, Alabama Metropolitan Birmingham Services for the Homeless, the entity orchestrating most of the homeless network planning and development that occurs in Birmingham, is a membership organization with no formal authority or control over its members. The network of programs and services developed to encourage people to move from the streets into housing includes outreach, emergency shelter, and transitional and permanent supportive housing. A safe haven 8 is just being developed, with an anticipated opening date of December 2003. Employment and community 8 Safe havens are very low cost or free housing programs for homeless persons who, at the time, are unwilling or unable to participate in mental health treatment programs or other supportive services. Safe havens provide low demand housing with no limits on length of stay. The Stewart B. McKinney Homeless Assistance Act, as amended in 1992 by Public Law 102-550, authorized the Secretary of the Department of Housing and Urban Development (HUD) to make grants for such housing, but not all th e programs we refer to receive these grants.
Chapter 1: Introduction 5 service are important emphases in programs working with people whose homelessness is complicated by chronic substance abuse. Birmingham has been the site of an ongoing research project funded by the National Institute on Drug Abuse that has had considerable success in treating homeless addicts. Agencies have developed some innovative ways to blend the interests of property owners and poor people to create affordable housing with very little government funding, and have involved the business community in other ways to address street homelessness. Boston, Massachusetts Boston has mayoral-level community-wide planning and program development, extensive involvement of mainstream agencies and funding from state and local general revenues, and an extensive and committed community of service providers and advocates working with homeless people. Through a collaborative network of programs and services, the city moves several thousand individuals out of homelessness each year through services such as street outreach and drop-in centers, emergency shelter, substance abuse and mental health treatment, medical services, educational programs, career development and employment services, transportation, and transitional and permanent housing programs. The city has a highly developed approach to discharge planning and homelessness prevention for people with severe mental illness, and is very focused on affordable housing production and preservation. Columbus, Ohio The lead agency for the homeless service system in Columbus is the Community Shelter Board (CSB), an independent nonprofit agency founded in 1986 by a group of civic leaders, business associations, local government leaders, and representatives from a variety of foundations. CSB does not provide any direct services within the community, nor is it an original source of money for homeless assistance services. Its main responsibilities are resource development and investment, service delivery coordination and planning, program accountability, and systems change and public policy reform. The Community Shelter Board currently allocates $7.5 million annually to 14 partner agencies for programs serving homeless individuals and families in Columbus. The community’s main strategy for ending chronic homelessness is embodied in an initiative known as “Rebuilding Lives.” It is a community-based initiative developed by the Scioto Peninsula Task Force in response to problems created by downtown redevelopment along the part of the riverfront known as the Scioto Peninsula. The task force was charged with developing a coordinated, targeted, cost-effective method of providing shelter and services to homeless individuals and families. Launched in July 1999, the Rebuilding Lives initiative focuses on ending homelessness and “rebuilding lives” by meeting the short-term needs of homeless individuals through an improved safety net of emergency shelters and by establishing 800 units of permanent supportive housing programs for homeless individuals with long-term needs. It includes opportunities for people with severe mental illness, addictions, HIV/AIDS, and combinations to leave the streets for permanent housing with supports in a “housing first” approach that can be as short as three weeks from first contact on the streets to lease signing.
Chapter 1: Introduction 6 Los Angeles, California Unlike the other cities we visited, Los Angeles does not offer a single coordinated system for reducing chronic street homelessness, although the Los Angeles Homeless Services Authority (LAHSA) provides funding and guidance for local nonprofit agencies with programs that address homelessness and coordinates the county’s Continuum-of-Care applications, in which most of the county’s 88 entitlement jurisdictions participate. What Los Angeles does offer, because o f its immense size, are several specialized continuums to meet the needs of frequently underserved subgroups of homeless individuals. We visited three such networks that have been working diligently to end chronic street homelessness—the Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS), Lamp Community, and a state-funded program known as AB 2034 after its legislative bill number. AB 2034 offers integrated services to mentally ill homeless people, and is administered in Los Angeles by the Los Angeles County Department of Mental Health (LAC-DMH). The Department of Veterans Affairs and Lamp Community both offer comprehensive services for homeless individuals, while the AB 2034 program is primarily a funding and coordinating mechanism for service delivery to prevent homelessness upon release for mentally ill offenders in the county jail population. Although these programs do not all work in concert with each other, there is significant overlap among the systems. For example, Lamp Community is a funded program under AB 2034 and at least one VA partner agency collaborates with Lamp Community to provide housing for Lamp guests. Another organization, Shelter Partnership, collaborates with both the AB 2034 program and Lamp Community by providing technical assistance in many areas including housing development, funding, and grant writing. Shelter Partnership also touches many agencies through its advocacy for homeless individuals and its shelter resource bank, which provides surplus merchandise to homeless agencies. Philadelphia, Pennsylvania Mayor Wilson Goode in 1988 created the Office of Services for the Homeless and Adults. The office director eventually became a “homeless czar,” a position that the next two mayors have maintained and expanded. The current “czar’s” official designation is the Deputy Managing Director for Special Needs Housing. Having someone in this position means there is a single person whose obvious job it is to resolve issues about homeless services. This is the Mayor’s point person on homeless issues, held responsible for emergency shelter directly but also expected to interact with mainstream systems and coordinate activities more broadly to address homelessness. Through this office and in partnership with a strong array of providers, advocates, and businesses, the city has planned for and subsequently undertaken extensive investment in programs and services to end homelessness. A major focus of Philadelphia’s efforts has been people experiencing chronic street homelessness. The network of programs and services developed to encourage people to move from the streets into housing includes extensive outreach, entry-level safe havens and other low demand residences, emergency shelters, transitional housing programs, permanent supportive housing programs of various configurations, and supportive services purchased or supplied directly by city agencies. These latter services include outreach, mental health and substance abuse treatment and intensive case management, and primary health care. Community development corporations (CDCs), including several created and run by homeless assistance
Chapter 1: Introduction 7 providers, have been active in creating affordable housing that may be occupied by formerly homeless and other persons. San Diego, California The Ad Hoc Committee on Downtown Homelessness is San Diego’s lead entity for planning and developing resources to end street homelessness in the downtown area. Important differences about San Diego’s approach from the community-wide approaches in Philadelphia and Columbus include the informal nature of its lead entity, extensive involvement of the downtown redevelopment agency, Centre City Development Corporation, the Downtown San Diego Partnership, and local law enforcement and the courts in addressing street homelessness, along with the more expected city and county agencies . San Diego’s downtown area has undergone redevelopment in recent years, adding a convention center, considerable waterfront development, office buildings, and both market rate and affordable housing. With development of each major downtown section, the homeless street people who frequented the area found themselves displaced. As downtown revitalized, the issue of street homelessness became a focus of discussion. Two police department programs to address street homelessness were already under way when the decision was taken to build a new major league ballpark downtown, in an area that had become the most recent center of street homelessness. The impending ballpark development galvanized San Diego businesses and government agencies to get serious about reducing street homelessness in a responsible way. The network of programs and services developed to encourage people to move from the streets into housing includes outreach, much of which is linked to multi-agency team community policing strategies, emergency shelter, safe havens, and transitional and permanent supportive housing. Seattle, Washington Seattle does not have one authority responsible for community-wide strategies to address chronic homelessness. Yet over time, the region has developed an approach to this population as homeless service providers, low-income housing providers, and other agencies involved with chronic street homeless people have cultivated working relationships and capitalized on Federal and local funding opportunities to expand programming. No community-wide coordinating entity controls and manages the full spectrum of resources and services targeting chronic homelessness. Instead, individual nonprofit service providers and government agencies have taken it upon themselves to tackle the problem of chronic street homelessness through specialized service offerings. Some of these agencies work together to meet the needs of their clients while others operate service structures representing the full continuum of care under their own umbrella. Local government leaders—primarily from Seattle and King County—have sponsored various coalitions and task forces over the years that have brought these agencies together to analyze needs, establish priorities, and plan for specific projects and system improvements. Seattle has also responded to Federal funding guidelines concerning programming strategy and initiatives to reduce chronic street homelessness.
Chapter 1: Introduction 8 Report Organization We have tried to make this report accessible and practical in several ways. First, we have analyzed the information gathered from the seven communities in cross-cutting chapters that give an overview of a particular topic, including: • Chapter 2. Elements of Success • Chapter 3. New Strategies for Programs and Services • Chapter 4: Assembling Resources and Supports • Chapter 5. Documenting Progress • Chapter 6. How Communities Pay For Their New Approaches • Chapter 7. Policy, Practice, and Research Implications Second, we present full descriptions (in Appendices A through G) of the seven communities we visited and the ways they have approached the job of ending chronic homelessness. These chapters are structured similarly, beginning with a brief community overview followed by a section recapping three to six practices of potential interest to other jurisdictions, including contact information for each practice and a community contact. So readers can go directly to the source to find out more about practices they might want to examine more closely. Each appendix then has sections for the history of the community’s approach, a description of that approach, documentation of progress, details of selected system components, funding, maintaining and enhancing the system, and community relations. Third, the report’s final chapter discusses the implications of the findings for policy, practice a nd research concerning approaches to reducing chronic homelessness.
9 CHAPTER 2: ELEMENTS OF SUCCESS What Does It Take? This chapter introduces the elements that made efforts to reduce chronic street homelessness successful in the study communities. The following chapters elaborate on important aspects of the elements and their interactions, and end with implications for policy, practice, and research. Although we provide examples in the report chapters, the site report appendices provide a more complete description of how the elements of success work together in a specific community. Introduction We identified 11 key elements shared by many of the approaches successfully reducing chronic street homelessness. Five of these elements, in combination, are essential for the strongest approaches. In addition to these five elements, trigger events were an important catalytic element for four of our study communities. Five other elements when present contributed to making an approach stronger. The elements were: Essential Elements: • A paradigm shift; • A clear goal of ending chronic street homelessness; • Community-wide level of organization; • Strong leadership and an effective organizational structure; and • Significant resources from mainstream public agencies. Catalyst Element: • Trigger event--capacity to capitalize on triggering events. Contributing Elements: • Significant resources from the private sector; • Commitment and support from elected officials; • Outcome evaluation mechanisms for program support and improvement; • Openness to new service approaches; and • Strategies to minimize negative neighborhood reactions to projects.
Chapter 2: Elements of Success 10 Paradigm Shift Of the five essential elements the most important was a paradigm shift away from traditional homeless program goals and approaches. The old paradigm was that street homeless individuals should be cared for more by charitable, often religious, organizations rather than by mainstream public agencies. The old paradigm relied heavily on emergency shelters, transitional housing, and sobriety-based programs. The old paradigm did not plan, or expect, to end chronic street homelessness. The new paradigm emphasizes reducing and eventually ending chronic street homelessness through an integrated community-wide approach that includes substantial participation by mainstream public agencies. Part of the paradigm shift was the adoption of an explicit goal to end chronic street homelessness. A second part of the shift was communities recognizing that their existing homeless assistance network was not reducing homelessness and that they had to do something different. Permanent supportive housing programs had to expand, they had to be structured to accommodate people with co-occurring disorders, and clear and simple pathways from the street into housing had to be available. The general homeless service programs may remain, but the new programs, supported with new resources, contribute the most to reaching the goal of ending chronic street homelessness. The paradigm shift to low-demand permanent supportive housing on a broad scale affects policymakers, funders, program planners, and service providers. The new approaches can be especially challenging for traditional housing developers and social service providers. For mental health and social service providers, low-demand environments mean they cannot require tenants to use services, and they have to deal with both mental health and substance abuse issues, and do so simultaneously. In addition, tenants may not use their services consistently, thus reducing reimbursements on which the providers may rely. For housing providers, a low-demand residence means that tenants may not act as predictably as the property managers might wish. For both, the challenges are as much philosophical as financial, in that the new m odel demands that they conduct business in ways that had formerly been considered not just impractical but wrong (Grieff, Proscio, and Wilkins, 2003). A Clear Goal of Ending Chronic Street Homelessness The most successful community-wide approaches have an explicit goal of ending chronic street homelessness. Two communities, Columbus and Philadelphia, have adopted the goal of ending chronic homelessness, which has turned their priorities away from emergency and even transitional programs. They invest heavily in permanent supportive housing and have stabilized (Columbus) or actually reduced (Philadelphia) the number of emergency shelter beds they support as they work to move persistent shelter stayers (Philadelphia) and street homeless people (both cities) into permanent supportive housing. Columbus follows a “housing first” model for chronic street homeless people, moving them directly from the streets into permanent supportive housing, still with low demands. Philadelphia also tries to bypass emergency shelter for street homeless people, but has focused more on safe havens as an intermediate step toward permanent housing and has only recently begun to develop its first “housing first” program.
Chapter 2: Elements of Success 11 San Diego has set itself the goal of ending downtown street homelessness, which is a paradigm shift from the city’s earlier ways of dealing with street homeless people. It has some unique ways of addressing street homelessness among chronic inebriates and those with severe mental illness and co-occurring disorders, thanks to a police department that has long been in the forefront of community-oriented and problem-solving policing. San Diego developed several safe havens and is working on developing more permanent supportive housing, with active involvement of the local redevelopment authority and the business community. Strong Community-Wide Level of Organization A community-wide level of organization exists when agencies are working together to end chronic street homelessness. As we describe organizational approaches, it helps to think about three levels of contact or working together for two or more agencies—communication, coordination, and collaboration (Konrad, 1996; Melaville and Blank, 1991). 9 These levels are hierarchical—agencies cannot coordinate without communicating, and cannot collaborate unless they both communicate and coordinate. The hierarchy reflects the extent to which agencies pay attention to other agencies, perhaps change their own ways, and make a joint effort to reach shared goals. We use these hierarchical terms very carefully throughout this report and define them as follows: • Communication. Agencies are at the level of communication if they have accurate knowledge of each other’s existence, service offerings, and eligible clientele. They will also know how to access each other’s services, and may refer clients to each other. They may have shared involvements through meetings, committees and task forces, but they do not have mechanisms in place to support each other’s work. • Coordination. Agencies are at the level of coordination if in addition to communicating they support each other’s efforts to obtain resources for clients. However, they do not deliberately work to develop shared goals and structure their operations to meet these goals. • Collaboration. Agencies are at the level of collaboration if they work with each other to articulate shared goals, analyze their operations to determine how they may achieve those goals, and make the changes dictated by this analysis. Of course agencies may relate to each other below the level of communication—that is, they do not know these things about each other, do not interact in any way, interact negatively, and/or hold inaccurate views of each other. In most communities at most times, most agencies operate toward each other at the level of communication or worse. This is “business as usual”—it takes work to get beyond it. Collaboration may mean that agency staff members fulfill new roles or restructured roles; co- locate, team, or otherwise work together with staff of other agencies; merge money, issue joint 9 Some may prefer the term “cooperate” to “coordinate.” We think they mean the same thing in the context of the levels we are describing, and use “coordinate” because it was used in previous work.
Chapter 2: Elements of Success 12 requests for proposals, apply together for new money to do new programs in new ways; actively support each others’ work; have mutual feedback mechanisms to assure continued appropriate service and program delivery; and/or other mechanisms and activities that reflect a purposeful, well-thought-out commitment to work together to reach common goals. Collaboration can occur between two agencies, or among several agencies. When it extends to include all or most agencies in a community focused on the same population with the same goals, we call it a strong community-wide level of organization. Strong Leadership and an Effective Organizational Structure Strong leadership within an effective organizational structure was crucial in the development of successful community-wide approaches. The Importance of Key People Exercising Leadership Ultimately, it is people and not systems that make things happen—especially in the beginning. Individual personality and devotion played an extremely important role in the development of the homeless assistance systems we visited. In most of these communities, a few people have been such essential players that it would be hard to imagine that without them the system would be what it is today. They have not all played the same roles. Some have been idealistic inspirers who brought public and private resources to focus on the issue of chronic street homelessness and stick with it, although their role in the actual organization of services might have been slight. Some have been socially and politically skilled organizational masterminds who knew what it would take to get an aggregation of programs and personalities to become a system focused on chronic street homelessness. Some have occupied vitally important positions in government agencies and persisted over many years in bringing those agencies to the table, keeping them there, and seeing that agency resources were applied to homeless issues, including chronic street homelessness. And some have been instrumental in bringing about a significant meeting of minds because they insist on cooperation and accountability, yet have a high tolerance for tension and the ability to channel it toward useful outcomes. It is vital to recognize the role played by people who really care, and who have the ability to translate that caring into structures of cooperating individuals, programs, and agencies. Without them the homeless assistance systems in their communities would look far different. We cannot describe the actions and effects of all the leaders in all the communities we visited. However, in the Appendices we describe a few leaders and the effects of their leadership, to show the range of positions in which communities have found leadership, and the capacity of people operating in any position to offer leadership and make a difference. Effective Organizational Structure The seven communities we visited for this project have very different structures through which they have developed assistance networks for chronically street homeless people. Most of the communities we visited did not begin their endeavors in the homeless arena with a focus on reducing or ending chronic street homelessness. These focused structures evolved, some over
Chapter 2: Elements of Success 13 decades, with varying degrees of local political support and local funds. Consequently, they emerged in diverse forms. In Columbus a nonprofit lead agency received strong authority and resources from city, county, business, and philanthropic interests some years before the new initiative. In Philadelphia a combination of a city agency with authority and resources, a Mayor’s Task Force, and a voluntary association of all interested parties each play their roles. San Diego developed an informal but well organized group of leaders from relevant positions in the city and county governments and a downtown business association. What these organizational structures had in common were strong links to elected officials and mainstream governmental and private sector resources. They were not working only in the context of programs for homeless persons. The organizational membership also crossed over city, county, and private sector boundaries. While always coordinating with service providers, the lead organizations did not always include them as full members. Significant Resources from Mainstream Public Agencies Ending chronic street homelessness requires resources far beyond those commanded by agencies, programs, and networks exclusively focused on working with homeless people. Major commitments of resources are needed from mainstream public housing, health, mental health, substance abuse, welfare and other agencies. Mainstream public agencies have four roles to play with respect to ending chronic homelessness. These are facilitating homeless people’s access to their services, developing specialty approaches, establishing funding priorities, and contributing leadership of various types. All of the communities we visited for this study have significant involvement of mainstream public agencies; some have major, sustained commitments and participation in leadership to end chronic homelessness. Most communities in the nation enjoy considerably less mainstream agency involvement, and could benefit from increasing the effectiveness of such partnerships. Getting mainstream public agencies to the “homeless” table takes planning, persistence, and sometimes power. It also often takes being able to present the case for their involvement as a mutually beneficial situation in which mainstream agencies are able to serve “their own” clients better by joining forces with the local homeless assistance network. The mainstream agencies whose own missions coincide most closely with the goal of ending chronic homelessness, and hence the ones that will have the greatest incentive to work with homeless assistance networks toward that end, include housing and community/neighborhood/economic development agencies; health, mental health, and substance abuse agencies; and to an increasing extent, corrections agencies. Ability to Capitalize on Trigger Events In several of the communities we visited, “trigger events” stimulated re-examination of the community’s approach to chronic street homelessness. The experiences of these communities in turning trigger events with potentially disastrous consequences for homeless people into
Chapter 2: Elements of Success 14 opportunities for growth and change provide examples for other communities seeking to develop new approaches to chronic street homelessness. In two communities the trigger event was proposed development on land that was “home” to many homeless people. In Columbus it was prospective redevelopment of the Scioto Peninsula along Columbus’ riverfront; in San Diego it was the prospect of a new downtown ballpark. In two other communities the trigger event was a proposed city ordinance to criminalize street homelessness. One city, Philadelphia, actually passed such an ordinance but not before it had undergone considerable revision and resources had been appropriated to ameliorate its harshest conditions. In the other city, Birmingham, the ordinance was defeat ed but mobilizing to be sure that happened stimulated some significant forward movement in addressing street homelessness. Significant Involvement of the Private Sector In addition to governmental agencies, we found that private businesses and foundations were often mainstream organizations making significant contributions to reducing street homelessness. Their involvement is described more fully in Chapter 4 on assembling resources and supports, but we note a few examples here. Private Businesses Many of the communities we visited have been promoting central city redevelopment. In the past many downtown businesses and developers have had a kneejerk reaction against providing services to their neighborhood’s street homeless people, fearing that services would attract more homeless individuals. However, in four of our communities, businesses and their associations took leadership roles in programs providing services to help end street homelessness. These were Birmingham, Columbus, Philadelphia, and San Diego. In the late 1990s the Birmingham City Council was considering an ordinance that would have banned “urban camping,” a measure clearly aimed at street homeless people in the downtown area. The proposal galvanized support for an alternative—active outreach programs to bring people off the streets without criminalizing them. Advocates of the ordinance complained that street homeless people were creating problems such as panhandling, litter, poor sanitation, and safety concerns. Advocates for the homeless population wanted to develop a more constructive and less punitive approach. The mayor created a Task Force on Homelessness to address the issue. As an outgrowth of the Task Force, the City Action Partnership (CAP)––the city’s Business Improvement District––funded an assistance-oriented uniformed patrol. CAP officers provide services downtown that range from directing shoppers to stores to helping case managers locate homeless individuals when they need to deliver medications or other services. CAP prepares pamphlets listing resources by needs with addresses and maps for food, shelter, clothing, and employment services. CAP officers routinely coordinate with outreach workers from several programs to facilitate assistance to street homeless people. Columbus businesses play a major role in Community Shelter Board (CSB) fundraising and strategic planning. Business leaders predominate on the CSB’s governing board of trustees and have led it to adopt an outcomes-based funding model that has won the respect of agencies and
Chapter 2: Elements of Success 15 the general public. CSB leverages public grants with corporate fund raising, and private dollars make up over 20 percent of CSB’s annual revenue. The private funding helps support innovative programs that have brought Columbus national recognition as a community with creative and effective homeless assistance programs. Foundations and Nonprofit Organizations Organizations such as the United Way, which address a wide range of community needs, have the potential to make significant contributions to a community’s efforts to end chronic homelessness. In Columbus the United Way helps fund supportive housing for Rebuilding Lives. In Columbus United Way also supports emergency shelter and other CSB initiatives including Rebuilding Lives. The total United Way commitment to the CSB is $1.0 million. In Boston the United Way funded $4 million of emergency shelter, transitional housing, and support services; cash, and in-kind donations from businesses, religious and civic organizations totaled over $3.6 million; and over 50 foundations contributed over $7 million. Cash donations from individuals to programs were also substantial, totaling an additional $12.5 million. Commitment and Support from Elected Officials Commitment and support from mayors, city and county councils, and other elected officials can be a significant contributing element in the progress of community-wide efforts toward reducing chronic homelessness. In at least three of our sites, mainstream city officials and business leaders played a seminal role in initiating collaborative programs to end homelessness. Philadelphia’s Mayor Goode created an Office of Services for the Homeless and Adults and appointed a de facto “czar” of homeless assistance programs who orchestrated planning and implementing a wide set of services; subsequent mayors maintained and expanded these efforts. Boston’s Mayor Menino placed ending homelessness high on his agenda, created a homeless planning committee and pressed mainstream city agencies to become involved. In San Diego mainstream business leaders and city officials involved in mitigating the potential displacement of street homeless persons expected from the construction of a new baseball stadium were among the founders of the interagency Ad Hoc Committee on Downtown Homelessness, which is developing solutions involving housing and services for the special needs homeless population. State and national political environments also have a significant impact on community approaches to reducing chronic street homelessness. This may be especially true at the state level, which requires a wider mobilization of support than city or county initiatives. Many state assemblies and governors would not follow the examples of California and Massachusetts in making large fiscal commitments to programs to end homelessness. Winning support from elected officials for state and other mainstream funding of programs to end homelessness is greatly facilitated by demonstrations of positive outcomes and cost effectiveness. The potential savings from innovative programs may be demonstrated by developing good estimates of how much homeless persons are costing the public through conventional emergency services and law enforcement programs.
Chapter 2: Elements of Success 16 Outcome Evaluation Mechanisms for Program Support and Improvement Agencies and planners in the communities we visited use data to demonstrate that programs are operating as designed and having successful impacts. The primary types of data we found to document progress in ending chronic street homelessness were: • Changes in the number of people found on the streets from year to year; • Increases in the number and percentage of chronically street homeless people who have moved into permanent housing; • Reductions in costs of providing emergency health, mental health, and shelter services; • Reductions in days homeless, hospitalized, or incarcerated; and • Less recidivism in the homeless assistance system, as documented by street counts, program operations and outcome data, and interagency homeless management information system (HMIS) data. Some street counts were greatly enhanced by asking the homeless individuals background questions. We found examples of communities maintaining information on services provided to individuals in linked emergency shelter and outreach databases, which help in monitoring program activity, evaluating impacts, assessing needs, and planning programs. Some communities also used information systems to demonstrate the incurred costs of providing mainstream emergency services to chronic street homeless individuals––money that could be saved by effective programs to end homelessness. Good administrative record information on homeless-related program operations and outcomes also provide support for program planning, policy design, and system development. In addition, a good homeless management information system can facilitate case management by providing workers access to better case history information and knowledge of what other programs may be serving the client. Finally, some agencies and communities are using analyses based on sound data to support community relations and pr ogram advocacy work. Openness to New Service Approaches Contributing to the progress of the study communities was their openness to new service approaches. Ending chronic street homelessness requires new approaches to homeless service delivery. It requires new ways of helping people (such as harm reduction), new ways of providing old services (such as housing first), new agency relationships (such as joint provision of mental health and substance abuse services, or agency mergers), and new investments in effective approaches (such as permanent supportive housing). It can also involve redesigning service systems to create better matches between people’s needs and the services they receive. One such shift involves reserving emergency shelter and other forms of short-term assistance for those with acute needs who are homeless for the first time or as the result of a crisis, while those with chronic needs receive longer-term supports (including effective treatment for co-occurring mental illness and substance abuse) and permanent housing. (Columbus and Philadelphia are
Chapter 2: Elements of Success 17 using this strategy.) Reducing chronic street homelessness also results from effective outreach and engagement strategies, especially those that are able to link people directly to housing. Finally, new approaches to prevention can prevent people with chronic disabilities from becoming homeless in the first place. Strategies to Minimize Negative Neighborhood Reactions to Locating Projects Frequently, some neighborhood residents resist locating projects for homeless persons in their neighborhood—the “not in my backyard” (NIMBY) reaction. Communities can minimize NIMBY by establishing standards that include looking for favorable locations, planning appropriate structures and activities, and involving the neighborhood in planning. However, the success of these mitigating activities is affected by economic, cultural, and political factors beyond the control of programs. Planning and opening new sites are especially volatile activities that require agencies to establish good communication with neighbors and work to mitigate potential adverse effects. Public meetings with frank descriptions of the project, testimony by neighbors of similar projects, and opportunities for people to express their concerns are essential. (Columbus, Philadelphia, and Seattle employ the strategy of using testimony by people who had seen past projects start up in their neighborhoods.) Forming advisory committees with neighbor representation that address how to resolve problems is also crucial. A good practice is to select locations where rezoning is not necessary and where facilities can be built that improve the neighborhood by removing eyesores and trouble spots. Our sites were able to implement this practice without concentrating their projects in the lowest income areas. Communities should also have policies that ensure programs are good neighbors once a facility opens. Good neighbor agreements can help promote community relations in the areas of property maintenance, neighborhood codes of conduct, community safety, communication and information, and agreement monitoring and compliance. Agencies can foster better community relations through open houses, making meeting rooms available to neighborhood organizations, participating in neighborhood watch projects and involving the public in fix up and fund raising activities. Staff members can educate neighbors on ways of interacting with homeless individuals and ways of addressing issues they create as a group. Homeless and formerly homeless individuals can be effective spokespersons to call public attention to their concerns and help develop programs to remedy their problems. These individuals can personalize and associate a human face with the issues by speaking at public meetings. Conclusions This chapter focused on the elements of success separately to provide a cle ar portrayal of each, however, the combined effects of the elements are what power the greatest community progress toward the goal of ending chronic street homelessness. Of particular importance is the paradigm shift toward a community-wide focus on eliminating chronic street homelessness through mainstream public agency programs including permanent supportive housing.
Chapter 2: Elements of Success 18 As we repeatedly stress, this is an experimental time for programs to reduce homelessness, new approaches are being tried and the evaluations of their success are still in emergent stages. Nevertheless, our analyses of the seven study sites, as well as information gathered about other locations during the site selection process, suggest that certain elements are essential for a community to make significant progress toward the goal of ending homelessness. The essential elements were: the paradigm shift; a clear goal of ending chronic street homelessness; community-wide level of organization; strong leadership and an effective organizational structure; and significant resources from mainstream public agencies. At most of our sites, catalytic trigger events combined with a capacity to capitalize on the event led to significant improvements in the community’s approach. We also found the following elements contributed to making a community’s approach more effective: significant resources from the private sector; commitment and support from elected officials; outcome evaluation mechanisms for program support and improvement; openness to new service approaches; and strategies to minimize negative neighborhood reactions to projects. Our list of elements emerged and changed over the course of the study, and we do not view it as exhaustive and immutable. It is a snapshot of what we saw happening at this time. The next chapter of the report presents some specific strategies that the communities were incorporating into their approaches for reducing chronic homelessness.
19 CHAPTER 3: NEW STRATEGIES FOR PROGRAMS AND SERVICES The number and variety of homeless assistance programs has grown tremendously since the late 1980s and early 1990s, becoming a $2 billion a year endeavor today (National Alliance to End Homelessness, 2000). Yet chronic homelessness remains a serious problem in many communities across the country, despite the system that has been developed to date. As communities come to recognize this reality, they may abandon their old paradigms of what works and shift to new approaches. We described in Chapter 2 how some communities have made this paradigm shift in terms of their general goals and methods. In this chapter we discuss more specifically some successful strategies for reducing chronic homelessness. Looking at the characteristics of most chronically homeless people, it is obvious that most have serious mental illnesses, substance abuse disorders, HIV/AIDS, or physical disabilities. Many have more than one of these major problems, any one of which frequently results in their being turned away from many traditional homeless assistance programs. Further, they have been homeless a long time, often have no ties to family, and rarely have any resources. Their skills are oriented toward survival on the streets, not to living in housing. Any effort that expects to reduce chronic homelessness to any significant degree must attract and hold the target population—something that traditional approaches have often failed to do, or the people would not still be homeless. First and foremost, there have to be effective ways to contact and recruit chronically homeless people into programs. Equally important, there must be something to offer them that they will take—the programs need to fit the people, rather than the reverse. Outreach, housing, and supportive services are obvious components of a solution, but as existing versions of these elements are not doing the job, or not all of t he job, new versions have had to be developed. Preventive efforts are also increasingly part of the picture, in the form of planning and providing housing and supports for people at high risk of homelessness on being discharged from institutions. More and more communities have recognized that their outreach, housing, supportive services, and discharge planning must incorporate the following abilities if they are going to be part of the solution to chronic homelessness: • The ability to attract people with addictions. Many chronically homeless people are initially unwilling to commit to sobriety. If programs cannot work with people who are still using alcohol and drugs, they cannot attract the hard-core street homeless people. • The ability to attract people with serious mental illnesses. Many chronically homeless people have serious mental illnesses that have affected their willingness to use shelters. They often find shelters intolerable because of overcrowding, or feel vulnerable and threatened by fellow residents, or the shelters themselves will not serve them because their symptoms are too disruptive. • The willingness and ability to accept and work with people with co-occurring disorders. Too many chronically homeless people have been caught in the demands of single-focus
Chapter 3: New Strategies for Programs and Services 20 agencies, within both homeless-specific and mainstream systems. Many agencies will not work with people’s mental illness until they stop using substances, or will not work with their substance abuse until their psychiatric symptoms are under control. At the same time communities have been seeing the advantages of interagency databases, multi- agency teams, multi-purpose service centers, and processes to increase access to mainstream agencies. In this chapter, we examine the ways that programs and services can reduce chronic homelessness by accommodating to the needs of the people they want to reach. Outreach Outreach and engagement are the first steps involved in connecting with street homeless people, bringing them off the streets, and linking them with other portions of the service system. Most chronically homeless people are unlikely to connect with even the best housing programs unless these first contacts are effective. Our study communities provide several examples of new strategies to make outreach more effective. Philadelphia’s Outreach Coordination Center Philadelphia’s Outreach Coordination Center (OCC) developed in 1998 as part of the city’s commitment to develop systematic approaches to ending street homelessness following enactment of a Sidewalk Behavior Ordinance. Its innovative aspects include outreach teams from several agencies working together and coordinated through a single entity, the OCC; daytime rather than nighttime outreach; direct access to safe havens and other low demand residences that were developed simultaneously; full cooperation and backup from city health, mental health, and substance abuse agencies; and a comprehensive database. The OCC also operates in an environment with existing and increasing permanent supportive housing resources. The OCC offers a coordinated point of contact for street homeless people. Outreach workers linked to the OCC are able to offer a wide array of services. Even more important, at a meeting of 17 outreach workers, all said they felt confident that the people they contact will receive the services if they are willing to accept them. One does not always find such confidence among outreach workers in other cities, as the services often are not sufficient to meet demand, or not geared to street homeless people. The OCC coordinates most of the city’s outreach efforts, including a 24-hour homeless hotline, one comprehensive response team, two mental health specialty teams, two substance abuse specialty teams (one peer and one professional), and emergency backup from city agencies. The teams cover center city and west and southwest Philadelphia, where the majority of chronically homeless individuals who avoid shelters are found. In addition to these regular street “beats,” OCC outreach workers respond to hotline calls from businesses, civic and neighborhood associations, and private citizens about homeless people in need. OCC has a case management component and access to the city’s list of available shelter beds. Representatives of all outreach teams meet monthly to review activities and needs. Through radio contact with teams, the OCC facilitates resolution of the immediate needs of any homeless person in contact with an outreach worker on the street that the worker cannot handle independently. OCC workers have also
Chapter 3: New Strategies for Programs and Services 21 conducted street counts of homeless people every quarter since 1998, and are now doing it monthly. Since its inception, OCC has maintained a database of all persons contacted by the participating outreach teams, averaging about 2,000 unduplicated individuals annually. OCC teams repeatedly see about one-fourth of those they contact over a span of years. These are the chronic street homeless people the teams try hardest to induce off the streets. The database provides a history of their service receipt and an excellent picture of who they are and what their needs are. Through common identifiers, the OCC database can be linked with the city’s database that chronicles most emergency shelter and some transitional housing stays. Using this link, OCC workers can see whether any of their consumers have used shelter, and how much. Conversely, the city’s analysts can assess the proportion of people making heavy use of emergency shelter who are also well known to outreach workers. San Diego’s Police-Based Outreach Teams San Diego city has two innovative outreach programs developed by and located in the San Diego Police Department—the Homeless Outreach Team (HOT) and the Serial Inebriate Program (SIP). Both can offer housing options that bypass emergency shelter, connecting street homeless people directly to safe havens, transitional housing programs, or residential treatment settings. HOT combines a police officer, a mental health worker, and a benefits eligibility technician in outreach teams operating during the day and evening hours to engage mentally ill street people and connect them to services. It also has access to “dedicated” safe haven beds to which it can bring people if they are willing to leave the streets. The team approaches people on the street or at homeless services. Each HOT team member’s skills and agency affiliation enhances those of the others, to make the combination more effective than any one or two acting without the others. Because they combine police and mental health expertise and authority, they are the only outreach teams on the streets that have the ability to remove people either voluntarily or involuntarily, in addition to building rapport and making referrals. The mental health worker opens up options for care that the police officer could not access, the police officer adds an element of protection and authority that the mental health worker could not command, and the eligibility technician offers connection to or reinstatement of benefits that serves as a positive inducement for street people to accept services. HOT focuses on people who are likely to have mental illness as a primary problem and are not likely to get arrested. HOT gets them into treatment facilities, safe havens, board and care facilities, and skilled nursing facilities, depending on their level and type of need. When HOT encounters alcoholics or other substance abusers it offers rehabilitation and help getting into appropriate care for those who are interested. SIP comes into play for chronic inebriates who do not voluntarily accept treatment. SIP is a collaboration of four city and five county agencies, including law enforcement, the city attorney’s office, the public defender, the Superior Court, health care, and homeless agencies working as a team in a court context. Mental Health System, Inc. is contracted to coordinate the program. SIP follows the Drug Court model in offering addicts a choice of jail or treatment, after assuring that the community was willing to pay for treatment if requested. SIP’s focus is on chronic alcoholics who populate the downtown streets of San Diego. Police officers arrest
Chapter 3: New Strategies for Programs and Services 22 chronic street alcoholics for public drunkenness, and bring them to jail and subsequently to court. Once arraigned, caseworkers approach each person, conduct assessments, and offer treatment plus transitional housing as an alternative to six months in jail (the maximum allowed under California state law) to those who pass the assessment. Many people eventually accept the offer, although they may first serve a full jail sentence or even two before they are convinced to try. The court monitors treatment compliance; leaving treatment means returning to jail. This approach is “something different” for this population, for which the revolving door of arrest and detoxification was not working. The approach is also designed to reduce the impact of public drunkenness on the community. Other Outreach Efforts with Direct Housing Connections In Los Angeles we also found innovative outreach efforts focused on well-defined subpopulations of chronically homeless people—veterans, and mentally ill criminal offenders. Both efforts were part of larger programs that included housing and supportive services as well as health, mental health, and other types of care. Their involvement in a collaborative network of public and private agencies and their connection to housing should make them interesting to other communities. The Veterans Affairs Greater Los Angeles Healthcare System has used Health Care for Homeless Veterans programs to conduct outreach to severely mentally ill veterans to link them with VA clinical services, contracted residential treatment programs, and contracted transitional or permanent supported housing programs. The VA operates some of these programs on its own campus, and has developed an elaborate system of contracts with nonprofit agencies to supply a variety of housing and service options. Also in Los Angeles, the County Sheriff’s and Mental Health Departments and nonprofit mental health providers collaborate in a partially state-funded program to prevent first or repeat homelessness among inmates of the county jail who have a serious mental illness. The program begins with integrated outreach focused on individuals who are homeless, at risk of homelessness or incarceration, and who have a serious mental illness. In Seattle, the Downtown Emergency Service Center (DESC) operates many programs and services that make it a mini-continuum in its own right, all focused on street homeless people. One of its programs is outreach, which is able to connect street homeless people to the various DESC offerings including transitional and permanent supportive housing. DESC’s Homeless, Outreach, Stabilization, and Transition Project (HOST) has Outreach and Engagement Specialists who work within specific geographic regions or in other targeted programs or facilities such as drop-in centers for women, local hospitals, and jails to find chronically street homeless people and help them connect to services and housing. Sometimes they approach potential clients directly and other times they develop an engagement plan with staff members from other agencies who have had interactions with the person. HOST staff members receive referrals from concerned citizens, jail, the Department of Social and Health Services, the mental health court, hospitals, the Harborview Medical Center Crisis Triage Unit, the Seattle P ublic Library, family members, and other mental health professionals, shelters, and drop-in centers.
Chapter 3: New Strategies for Programs and Services 23 Other Outreach Efforts Without Direct Housing Connections Every community we visited has outreach and engagement programs that are less fortunate than those already mentioned, in that they have no direct access to housing options for the street people they contact. However successful the outreach to people living on the streets, its value is limited in terms of ending chronic street homelessness if the community does not have adequate permanent supportive housing or safe haven resources. Large congregate emergency shelters are unlikely to succeed in breaking the cycle of chronic street homelessness among people with multiple disabilities. Traditional shelters also tend to be places where chronically homeless street people are not willing to go and stay for extended periods of time. During a focus group discussion of formerly chronically homeless men who were housed in various PSH programs, the group was asked what they would do in the absence of the program. Interestingly, several commented that they would never want to go back to a shelter—they were more willing to return to the streets than to a shelter. Nevertheless, many outreach programs are able to help street homeless people in a variety of ways even when they are not able to offer them a home. In addition to providing a regular contact and a reliable friend on the street, they are able to ease the difficulties of street living. We describe one such program here, of several we encountered during site visits—Seattle’s Mental Health Chaplaincy. The Mental Health Chaplaincy provides an outreach and engagement program for the most difficult and most vulnerable mentally ill street homeless people. Its outreach strategy involves long-term engagement with clients until they receive benefits and are comfortable entering into service or housing programs. The Chaplaincy program helped to develop and uses the Relational Outreach and Engagement Model currently promulgated by the National Health Care for the Homeless Council. 10 This model has four phases to working with homeless individuals: approach, companionship, partnership, and mutuality, which revolve around building and shaping a relationship with the client. The focus is to build trust with street people until they are ready to access services on their own terms. The Mental Health Chaplaincy typically will link its clients to other Seattle service providers such as Harborview Mental Health, local emergency rooms, the Downtown Emergency Service Center, and the Health Care for the Homeless Network. New Approaches to Permanent Supportive Housing The ultimate solution for ending homelessness of any type is housing. For chronically homeless people with disabilities, though, simple housing is not enough. Most people who have been living on the streets for many years have multiple barriers to independent living and are likely to need various treatment and support services for many years. A major innovative step in reducing chronic homelessness among people with disabilities was taken in the early 1990s (and even earlier in some places such as Philadelphia), when models of permanent housing with attached supportive services were developed. Demonstration studies sponsored by NIMH (Shern et al., 1997) showed that permanent supportive housing (PSH) was very successful at stabilizing its 10 The curriculum can be found at: http://www.nhchc.org.
Chapter 3: New Strategies for Programs and Services 24 tenants in housing, with retention rates at about 85 percent after two years or more. As PSH programs evolved, they embodied most or all of a set of principles since articulated by the Technical Assistance Collaborative as: 11 • The housing is affordable for people with SSI level incomes (residents usually pay 30 percent of income or about $160 per month); • There is choice and control over living environment; • The housing must be permanent (tenant/landlord laws apply, but refusal to participate in services is not grounds for eviction); • The housing is “unbundled” from but linked to services; • The supports are flexible and individualized: not defined by a “program”; and • There is integration of services, personal control, accessibility, and autonomy. Although it is not a principle, in the past a characteristic of many PSH programs has been that prospective tenants had to be “housing ready.” This almost always meant “clean and sober,” stabilized on medications if mental illness was an issue, and familiar with the rudiments of housekeeping. As a consequence, very few people entered these programs directly from the streets. The usual routes could be long, through emergency shelter and transitional housing programs. Another consequence is that as of 2002, a surprisingly small proportion of PSH units appear to be occupied by people that we would consider to have been chronically homeless— only about 20 percent, according to a recent Corporation for Supportive Housing estimate. 12 Thus, although some chronically homeless disabled people are being served in the PSH programs developed during the past decade, the people on whom this project focuses are, by definition, those for whom traditional programs and services have not produced solutions to homelessness. One group in particular, people with co-occurring mental illness and substance abuse, has traditionally been seen as “resistant to treatment.” They have been beyond the reach of many traditional homeless service providers, in part because they are “difficult” but also in part because providers have not been interested in trying to serve them, having enough easier people to serve. But as they comprise a significant share of street homeless people, communities committed to reducing street homelessness had to find ways to serve them. Their resistance even to PSH as it was being offered, and also the resistance of many providers to serving them, has challenged communities to develop permanent supportive housing operating on some new, or additional, principles. In the communities we visited, these include: • Housing first models that place people directly from the streets into permanent housing units with appropriate supportive services; 11 These are drawn from “Affordable and Accessible Housing: A National Perspective,” presentation by Emily Cooper, Technical Assistance Collaborative, Inc. to the Regional Housing Forum, November 13, 2002. 12 Wilkins, Carol. Presentation at Ending Long-Term Homelessness: Taking Supportive Housing to Scale conference, Columbus, Ohio, May 13-15, 2002.
Chapter 3: New Strategies for Programs and Services 25 • Safe havens, a variation of Housing First that offers “as long as you need it” accommodation but that nevertheless is not intended to be permanent; • Low demand—breaking the linkage between housing and service use or acceptance; and • Harm reduction or “abstinence encouraged” approaches to sobriety. Housing First Models Housing First models place people directly from the streets into permanent housing units with appropriate supportive services, with no requirement that they be “housing ready.” The sole requirements are those that are usually expected of any renter—pay the rent, do not destroy the property, and refrain from violence. Housing is provided immediately, with few, if any, demands with respect to abstinence or accepting mental health treatment or other types of care, although these are offered and available. As one advocate for PSH and Housing First puts it , “we give them a key to their own door; they don’t have to leave it open, but we knock often.” Proponents of this approach argue that it is much easier to work on substance abuse and mental health issues when clients are stably housed than when they are on the streets or in a shelter. More and more communities are attempting to offer chronically homeless street people Housing First. Among the communities we visited, Columbus, San Diego, Seattle, and two of the Los Angeles sites offer Housing First programs, and Philadelphia is just starting to do so. Also, a growing body of research documents the success of Housing First models at keeping even the most disabled homeless people housed, and also saves some public costs for crisis emergency services (Anderson et al; 2000; Culhane, Metraux and Hadley, 2002; Martinez and Burt, 2003; Tsemberis and Eisenberg, 2000). Housing First programs are very popular among outreach workers, case managers, and their clients. Those we interviewed as part of this study reported that they could easily fill their permanent supportive housing programs with chronic street homeless people, and the tenants in such programs are very positive about them. Of course, slots in permanent housing programs are not always available. In Columbus, Ohio, recruitment for these programs tends to happen when a program first opens for occupancy. Turnover among tenants has been much lower than expected, so the most common way in is at start-up. Also in San Diego, efforts to recruit chronically homeless people directly from the streets into PSH (or safe havens when no PSH unit is immediately available) are ongoing and successful. Safe Havens “Safe haven” is a term used by HUD and others to describe a special type of housing program for chronically homeless people with serious mental illness, often with co-occurring substance abuse. A safe haven program usually takes a Housing First approach, and it may be either transitional or permanent housing. Most safe haven programs we talked with will let residents stay “as long as it takes” for them to feel comfortable moving on. Data from Philadelphia’s four safe havens indicate that the average length of stay is 1.3 years, and that most residents move on to PSH or to housing in the community, either independently or with family. Three of the
Chapter 3: New Strategies for Programs and Services 26 communities we visited, Philadelphia, San Diego, and Seattle, have safe havens, and Birmingham will open one in December 2003. In both Philadelphia and San Diego, capacity and turnover appear to be such that a safe haven bed is usually available when a street homeless person is ready and willing to take it. Seattle’s safe haven is usually full, however, and not able to accommodate the many more people on the streets who could and would use this type of program. Low Demand—Breaking the Linkage Between Housing and Service Acceptance A key component of Housing First and safe haven models is their willingness to accept tenants without requiring that they participate in services. As already mentioned, the only demand placed on tenants in these programs is that they adhere to the conditions of their lease (Housing First), or the equivalent without a lease (safe haven). An example of a restrictive condition that remains is that projects funded by HUD bar the use of illegal drugs on the premises. Another restriction is that some projects require clients to participate in a representative payee program for the purpose of assuring that the rent is paid. In many ways, the low demand concept entails significant changes that affect policymakers, funders, program planners, and service providers. The new approaches can be especially challenging for traditional housing developers and social service providers. For mental health and social service providers, low demand environments mean that a tenant does not have to use services, or use them consistently. Providers have to attract tenants to services, so the services, and the providers, have to be attractive to the very resistant people they are trying to serve. In addition, service providers may not be able to count on a predictable level of reimbursements for services, upon which their budgets may depend. For housing providers, low demand programs may mean that tenants may not always act as predictably as property managers might wish, and that housing managers may have to deal directly with tenants rather than going through service providers. For both, the challenges are as much philosophical as financial, because low demand housing sometimes means that they must now conduct business in ways that had formerly been considered not just impractical but wrong. 13 Much of the debate surrounding Housing First and safe haven models concerns how substance abuse and mental health issues are handled, to which we now turn. New Approaches to Addressing Substance Abuse A central tenet of low demand housing is not requiring sobriety. These sobriety “preferred but not required” conditions often translate into a “no use on the premises” rule for projects that use HUD funds. The terms “low” or “no” demand housing describe programs where abstinence may be encouraged but is not required or enforced. This is one aspect of a more general movement known as “harm reduction” within the broader health treatment community of which programs for disabled homeless people are a part. 13 Grieff, Debbie, Tony Proscio, and Carol Wilkins, “What Systems Change Is and Why It Matters to Supportive Housing,” A preview from an upcoming CSH publication, Corporation for Supportive Housing, January 2003, p. 13. Accessed July 7, 2003 online at http://documents.csh.org/documents/Communications/SystemsChangePreview.pdf.
Chapter 3: New Strategies for Programs and Services 27 Harm Reduction Harm reduction may guide the operations of either permanent or transitional supportive housing. Harm reduction is a set of practical strategies designed to reduce the negative consequences of drug use by promoting first safer use, then managed use, and finally abstinence if people can do it. 14 In their position statement on housing options for individuals with serious mental illness, the American Association of Community Psychiatrists advocates a full range of community-based housing types, including the following: • “Abstinence-expected (“dry”) housing: This model is most appropriate for individuals with substance disorders who choose abstinence, and who want to live in a sober group setting to support their achievement of abstinence. Such models may range from typical staffed group homes to supported independent group sober living. In all these settings, any substance use is a program violation, but consequences are usually focused and temporary, rather than “one strike and you’re out.” • Abstinence-encouraged (“damp”) housing: This model is most appropriate for individuals who recognize their need to limit use and are willing to live in a supported setting where uncontrolled use by themselves and others is actively discouraged. However, they are not ready or willing to be abstinent. Interventions focus on dangerous behavior, rather than substance use per se. Motivational enhancement interventions are usually built into program design. • Consumer-choice (“wet”) housing: This model has had demonstrated effectiveness in preventing homelessness among individuals with persistent homeless status and serious psychiatric disability (Tsemberis and Eisenberg, 2000). The usual approach is to provide independent supported housing with case management (or ACT) wrap-around services, focused on housing retention. The consumer can use substances as he ch ooses (though recommended otherwise) except to the extent that use-related behavior specifically interferes with housing retention. Pre-motivational and motivational interventions are incorporated into the overall treatment approach.” 15 Not surprisingly, the last two options are controversial, and projects that use HUD funds cannot permit illegal drug use on the premises. Nevertheless, for people with long-term deeply rooted problems, these options appear to be among the ones that work best, in part because they are the ones that this group of people is willing to try, and in part because the approach to services is one they can live with. Participants in focus groups for this project repeatedly stressed the importance of having control over their own service uptake, and that staff respect their right to move at their own pace. Harm reduction programs have been the last type of PSH to appear in many 14 Drawn from the Harm Reduction Coalition’s website http://www.harmreduction.org/prince.html, accessed July 7, 2003. 15 See Kenneth Minkoff, MD, “AACP Position Statement on Housing Options for Individuals with Serious and Persistent Mental Illness (SPMI),” June 18, 2001. Accessed on July 7, 2003 at: http://www.wpic.pitt.edu/aacp/finds/Housing-Revised.pdf.
Chapter 3: New Strategies for Programs and Services 28 communities, and in many areas programs using this approach are not available at all. Yet it has great potential for preventing and ending homelessness, especially among people who have “failed” sober group living. The fundamental belief underlying Housing First and most other low demand housing strategies is that individuals should not be left homeless simply because they are unable or unwilling to maintain abstinence. Among the communities we visited, Columbus and Seattle have extensive harm reduction-based programs, Lamp in Los Angeles was an early Housing First and harm reduction developer, Philadelphia’s safe havens and many of its PSH programs operate on a harm reduction model, as will the Housing First program it is getting ready to open, and San Diego has similar housing opportunities. Other Approaches In addition to harm reduction programs, we observed a number of other innovative intervention strategies for homeless chronic substance abusers during our site visits for this project. Two are expansions and enhancements of traditional detoxification programs, while a third combines community service and employment expectations with traditional clean and sober requirements. A fourth approach, San Diego’s Serial Inebriate Program, has already been described in the Outreach section of this chapter. The two examples of expanding traditional detoxification programs are Maryhaven Engagement Center in Columbus, Ohio and the Dutch Shisler Sobering Center in Seattle. People may walk into these programs on their own, or be brought by outreach workers or law enforcement officials. Once there, they are strongly encouraged to stay and sober up and then to move on to longer residential treatment programs. These communities have made an effort to develop extended residential treatment, recognizing that without it detox is usually just a revolving door. Several programs for homeless chronic substance abusers in Birmingham take a very different tack. They require sobriety, community service, and employment, as well as attendance at regular meetings related to staying clean. Community service begins immediately, at a level of 10-20 hours a week, and clearly functions as much more than a way to keep participants occupied. In a large focus group held in Birmingham with people who had been chronically homeless, most said that being required to perform community service was the first time in their lives that anyone had treated them as if they had something to contribute, and as if they had a community that would care w hat they gave. This was the turning point and beginning of self- esteem for most people at the focus group. Community service continues even after employment begins, which occurs as soon as a person’s sobriety indicates it is feasible. Programs have developed extensive networks of employers willing to hire program participants, and several programs said finding work for people was not a problem. Working continues the self-esteem boost begun by community service, and puts people on the road to self-sufficiency. Program graduates often help locate jobs, and some have become employers themselves, as well as organizers of community service opportunities. Noting that participants frequently could not sustain sobriety after residential treatment if they went back into the community, several Birmingham substance abuse programs developed transitional housing and affordable private housing. One has become the biggest affordable housing developer in the area, serving formerly
Chapter 3: New Strategies for Programs and Services 29 homeless and never homeless low-income people alike. In Birmingham, PSH is reserved largely for those with serious mental illness, with or without co-occurring disorders, and people with AIDS. Chronic substance abusers are expected to work from very early in their recovery, to contribute to the cost of their program (they pay for both emergency shelter and transitional housing as soon as they are working), and ultimately to become self-sufficient. Housing Configurations and Supportive Services PSH housing configurations vary a great deal, which in turn affects decisions about how to offer supportive services and whether it is also possible to create a supportive community of tenants. Completely scattered-site configurations (program participants occupy apartments wherever they can find them, usually no more than one or two in any single building) make demands on service delivery that are quite different from the opportunities offered by operating a dedicated building (one in which all tenants are part of the program). Other housing configurations include “clustered scattered” and mixed-use buildings. “Clustered” programs may operate a six- or eight- unit building completely occupied by program participants on a block with no other such buildings. Mixed-use buildings are usually large (100-300 units), with 20 to 25 percent of units set aside for program tenants. Other tenants may be never-homeless disabled singles, as is the case at Sunshine Terrace in Columbus, a public housing authority 811 building. 16 Or they may be “regular” low-income households, as in the unit set-asides in the San Diego buildings developed by Centre City Redevelopment Authority. Set-aside units may be master-leased by a PSH program or accessed through an understanding with landlords that on average, every fourth vacant unit will go to a program client. Another variation on “mixed” use is a building occupied entirely by formerly homeless people, in which tenants may include both singles and families. Support services in these programs may include case management, service referrals, instruction in basic life skills, alcohol/drug abuse treatment, mental health treatment, health care (medical, dental, vision, and pharmaceutical), AIDS-related treatments, income support, education, employment and training assistance, communication services (telephone, voice mail, e-mail, Internet access), transportation, clothing, child care, and legal services. The exact mix of services and who provides them can vary greatly from one community to another, and even from one program to another in the same community. This variation is partly a result of who does what in different communities, and partly due to the “piece-it-together-as-best-you-can” nature of assembling the many types of people, agencies, and funding streams needed to create a successful supportive housing program. Howe ver, the variety is also partly deliberate, as programs and communities sort out the most effective distribution of responsibilities among housing developers, property managers, on-site program service staff, and services delivered on and off site by staff of other agencies. And it is always influenced by housing configurations. Issues mentioned during our site visits that affect supportive services structure include: 16 The HUD Section 811 program provides “funding to nonprofit organizations to develop rental housing with the availability of supportive services for very low-income adults with disabilities, and provides rent subsidies for the projects to help make them affordable.” (From a HUD web page program description accessed on October 26, 2003 at http://www.hud.gov/offices/hsg/mfh/progdesc/disab811.cfm.)
Chapter 3: New Strategies for Programs and Services 30 • The appropriate division of labor between property management and case management. Most programs we visited have decided to separate these two functions, either by assigning them to completely different entities (such as a housing management company for the first and the program for the second) or by dividing their own staff into distinct property management and services teams. This eliminates the conflict of interest that arises in handling nonpaying tenants or other issues relating to lease conditions. • Whether to bring services into the residential site or encourage tenants to navigate community service systems. This is not a major issue in scattered-site programs, but it is in mixed-use and dedicated buildings. Program staff members say tenants often prefer that services come to them. As they use services more when the services are convenient, staff members have some motivation to accommodate the tenants. This is especially true as these are PSH programs where tenants are not expected to be working toward self- sufficiency, and the demand that they deal directly with service systems may be enough to prevent them from getting the services they need. • The extension of services to tenants of mixed-use buildings who are not part of the program, and who were never homeless. Several communities (Columbus, at Sunshine Terrace; Seattle, through Plymouth Housing) have found this to be both useful and cost- effective. • How to attract tenants to services when they are free to choose to use them or not. Housing First and safe haven programs need to make effective offers of service, as they cannot require tenants to use services. Program staff in many of the communities we visited characterized their role as making friends, being available, making suggestions, checking up, hanging out, creating and then attending social events such as barbeques or monthly birthday parties, either not having an office or never closing the door, and other similar measures. Tenant word-of-mouth is the best referral; acting in ways contrary to tenant free choice will quickly be known and compromise one’s ability to assist tenants. For many service professionals, this is really a whole new way of life. • How much the on-site program staff should know about what services tenants are accessing. Some programs arrange for sensitive issues such as mental health and substance abuse to be handled by contract service providers who offer their services on site but independent of the program staff. Tenants make their own arrangements to see these service providers, and information of what they wanted and what they got is never conveyed to the program staff. Strict confidentiality is maintained. Other programs handle these issues with program staff, still maintaining strict confidentiality and voluntary use of services. • How to maximize service dollars, which may also be related to facilitating tenant access to services. To facilitate client access, many homeless assistance programs use program staff, supported by grant monies, to provide health, mental health, substance abuse, as well as case management. Medicaid might be able to cover these services, freeing up grant monies, but the programs are not set up to maintain the records Medicaid requires, to do Medicaid billing, or to underwrite costs during what may be long lag times before reimbursement occurs. San Diego addresses many of these issues
Chapter 3: New Strategies for Programs and Services 31 simultaneously through contracts with nonprofit and for-profit behavioral health companies—see Chapter 6 for a description. Preventing Homelessness Upon Institutional Discharge One of the most effective ways of ending chronic street homelessness is preventing it from happening in the first place. This often involves commitment of resources to assure housing and services, and effective discharge planning from the many institutions that interface with chronically homeless people and those at risk of chromic homelessness: hospitals, treatment facilities, psychiatric institutions, correctional facilities, and sometimes foster care. In the absence of effective policies and practices around discharge, many of these institutions simply release people into local homeless shelters. Even discharge planning without commitment of resources to assure stable housing, is not sufficient to prevent homelessness. Discharge plans adequate to prevent homelessness typically include an estimated discharge date, collecting medical records, and making arrangements for post-release housing, medical and mental health care, and other community-based services. In some states this planning is the formal responsibility of the agency releasing the individual back into the community, while in other places it is done more informally by agency staff or community-based social service providers (Community Shelter Board, 2002). Our study discovered many examples of important prevention efforts, but did not focus strongly on them because we knew that HUD has two other studies focused specifically on prevention. One is on discharge planning to prevent street homelessness among ex-offenders, and the other is a more general look at the workings of successful community programs to prevent homelessness of all types. Philadelphia’s Housing Support Center (HSC). The HSC has a primary prevention focus for individuals (and families) at imminent risk of homelessness. It began operations in winter 2003, and when fully operational will bring together resources from Adult Services, Department of Human Services (child welfare), Community Behavioral Health, the County Assistance Office (cash assistance), the Philadelphia Housing Authority, and other public agencies whose clients face challenges to housing stability. It will serve as the city’s central referral point for all households needing help because they are facing or experiencing homelessness. Because Philadelphia has a homeless management information system that covers all emergency shelter and another that covers the street population, the city will be able to track whether people assisted by the HSC do indeed avoid becoming homeless. Psychiatric Institution Discharge Planning. A number of communities, including Boston and Columbus, have policies and structures in place to prevent people leaving public psychiatric facilities from becoming homeless. Correctional Institutions Discharge Planning. Boston and Los Angeles (County Sheriff’s Department), and at least some other California cities have programs to prevent homelessness among mentally ill offenders leaving correctional institutions. The Los Angeles program, funded through California state revenues in the AB 2034 program, involves careful interagency coordination as part of making discharge planning work. The Program Evaluator links the client with an agency in the area where he wishes to reside after discharge. If no housing is available in the client&rsquo