Slide 1:

Preventing Chronic Homelessness – What Works?

Deborah Dennis
Policy Research Associates, Inc.
Delmar, NY

Policy Academy on Chronic Homelessness
Denver, CO
October, 2003

Slide 2:

Why Address Prevention?

• Until we address individual and system risk factors and the role of mainstream systems in creating and resolving chronic homelessness, we will never be able to end chronic homelessness
• Prevention of chronic homelessness is one of three goals in the HHS Secretary’s report on ending chronic homelessness

Slide 3:

Why Focus on Mainstream Programs?

• People who experience chronic homelessness are heavy users of expensive mainstream programs
• Levels of disability and poverty make people who are chronically homeless likely to be eligible for mainstream programs
• Approaches that work for this subgroup may make mainstream services more accessible for others

Slide 4:

How Can Chronic Homelessness Be Prevented?

• Identify risk and protective factors that could help identify and prevent chronic homelessness among persons at risk
• Identify and promote the use of evidence-based practices that are effective in preventing chronic homelessness

Slide 5:

Some Individual Risk Factors

• Chronic health conditions, mental illness and/or substance use disorders
• Limited or no social support networks
• Domestic violence and other victimization or trauma-related factors
• Family instability as a child (out-of-home placement, family homelessness, incarceration of a parent)
• Combat experiences for veterans

Slide 6:

Some System-Based Risk Factors

• Lack of permanent affordable housing
• Very low or no income
• Discharge from jail, hospitals, shelter, detox, and foster care

Slide 7:

Discharge from Institutions

Data from Massachusetts Housing and Shelter Alliance showed that people coming into shelters were well-known to the state’s mainstream systems

• 18-24 year olds aging out of state services
• Ex-offenders released from state or county facilities with no place to go
• People from detox at the beginning of their recovery
• People with mental or serious physical illnesses released directly from a hospital

Slide 8:

Discharge from Institutions

Marty Burt’s analysis of chronic homelessness finds that:

“On any given day, people who are chronically homeless may be found on the streets, in emergency shelter, in emergency health, mental health, and substance abuse treatment facilities or in corrections facilities.” (Burt, 2002)

Slide 9:

Hospital Discharges

Compared to men who had never been homeless…

Chronically homeless men with schizo-phrenia were more likely to have been discharged from their most recent psychiatric hospitalization against medical advice and had less adequate discharge planning for living arrangements, aftercare and finances (Caton et al., 1993).

Slide 10:

Discharges from Jails & Prisons

• Arrangements for housing are seldom considered when people exit corrections
• Benefits to which they were entitled before they entered have often been lost as well
  • Inmates with mental illness (16% of all inmates nationally) incarcerated for more than a year must reapply for SSI benefits upon release
  • They also often lose Medicaid upon incarceration even though federal regulations allow for suspension rather than termination of this benefit

Slide 11:

Transition from Foster Care

• People who are chronically homeless are 7-13 times more likely to have had an out of home placement than the general population (Burt et al., 2001)
• Thirty percent of youth leaving foster care experience homelessness within two years of discharge (Schwab Foundation, 2003)

Slide 12:

Evidence-Based Practices

• Few evidence-based prevention interventions
• Experience and research point to promising practices
  • Housing subsidies
  • Eviction prevention
  • Discharge / transition planning

Slide 13:

Housing Subsidies

• Studies repeatedly find housing subsidies one of the most effective interventions for preventing housing loss
• Receipt of subsidized housing is the primary predictor of housing stability among homeless families (Shinn and Weitzman)
• SAMHSA’s six-site study of homelessness prevention among people with mental health and/or substance use disorders found housing subsidies or access to supported housing was the strongest predictor of residential stability, regardless of level of disability.

Slide 14:

What States Can Do…

• The Missouri Department of Mental Health provides funding for temporary vouchers for people with serious mental illness who are on the Section 8 waiting list.
• Vouchers are administered by local public housing authorities and DMH provides services through contracts with local mental health agencies.

Slide 15:

Eviction Prevention

• Promising practices include:
  • Representative payees and other financial management interventions
  • Landlord / tenant mediation services
  • Respite for family caregivers
  • Emergency rent and utility payments
• With the exception of representative payees, none of these practices has been rigorously studied.

Slide 16:

What States Can Do…

• In Minnesota, the legislature created a $50,000 fund to pay for rent for up to 90 days while an individual with serious mental illness is in inpatient treatment.
• The Alaska Department of Mental Health and Developmental Disabilities provides flexible service funds of up to $2,000 per client for any expense needed to keep the client in community-based housing.
• Pathways to Housing in NYC, a housing first model, uses money management -- one of two key tools (the other being ACT teams) -- to keep people who were chronically homeless in housing of their choice.

Slide 17:

Discharge / Transition Planning

• Discharge planning, linked to affordable housing and aftercare, is often recommended as a strategy to prevent chronic homelessness -- particularly for people with health and behavioral health disorders.
• Although this makes sense on logical grounds, there is no empirical evidence to support the efficacy of such efforts.
• This remains an important promising practice.

Slide 18:

What States Can Do…

• Massachusetts evaluates state agency contractors on performance measures that treat homelessness as a bad outcome and housing as a good outcome.
• These outcomes are tied to penalties and incentives for each system (corrections, mental health, etc.)
• Focus on transition planning has led to more integrated services in mainstream facilities. Prisoners can now be deemed eligible for Medicaid while still in prison and automatically enrolled on the day of their release. Many also make a community health center connection before leaving. (www.nhchc.org/discharge)

Slide 19:

What States Can Do…

• Philadelphia has recently begun to apply this same principle to shelter providers.
• Shelters are penalized when someone discharged from their shelter shows up homeless again.
• The incentive is for shelters to do more to place people in housing.
• Philadelphia has already begun to decrease its shelter beds by 5% annually as a result.

Slide 20:

What States Can Do…
Critical Time Intervention & Short-term ACT Services

• Are evidence-based practices for people who have experienced chronic homelessness.
• Provide intensive clinical services for 6-12 months during and following transition from shelters, hospitals or jails.
• Have been proven effective in maintaining residential stability and linkage to mainstream treatment and other support services after intervention is scaled back or withdrawn.

Slide 21:

What States Can Do…
Respite Care

• Boston Health Care for the Homeless operates 90 recuperative care beds that bridge the period following hospital discharge for people who are homeless
• Similar effort in Savannah, GA, is estimated to have saved two local hospitals $1.8 million, more than doubling their individual $250K investments.

Slide 22:

What States Can Do…
Transition Planning in Corrections

• There are no evidence-based transition planning practices in corrections.
• Multi-site studies of jail mental health programs have lead to a promising model.
• The APIC model promotes transitional services that begin in jail or prison and emphasize access to housing and clinical case management upon release (The National GAINS Center, 2002).

Slide 23:

What States Can Do…
Youth in Transition

• The federally-funded Independent Living Program for youth transitioning from foster care allows up to 30% of funds to be used toward housing for youth until they reach the age of 21.
• Bridge of Faith in Los Angeles is one example of a program using these funds to provide housing and services to young women transitioning from foster care while they take steps necessary to live on their own (NYT, 4/12/03).

Slide 24:

Conclusions…

• Policy makers and practitioners are urged to keep their goals clearly in mind…
• Preventing chronic homelessness is not identical with ending poverty or promoting economic self-sufficiency

Slide 25:

Conclusions…

• Some eviction prevention programs and discharge planning efforts seem promising, but none have been studied rigorously.

Slide 26:

Conclusions…

• Providing housing subsidies that target the worst-case housing needs (e.g., people who are chronically homeless) are probably warranted.

Slide 27:

Conclusions…

• Services to support people who have been chronically homeless in housing – particularly during periods of transition -- are also critical, but effectiveness has only been demonstrated for the most intensive clinical teams.