Ending Chronic Homelessness
Strategies for Action

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Contents

Executive Summary

Chapters:

  1. The Approach
  2. Defining Chronic Homelessness and Understanding Treatment and Support Needs
  3. How HHS Mainstream Service Programs Align With the Treatments and Services That Address Chronic Homelessness
  4. How The Plan Was Developed
  5. A Formal Statement of the HHS Comprehensive Plan to End Chronic Homelessness

Appendices

Chapter 1:
The Approach

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Background

Each year, approximately one percent of the U.S. population, some two to three million individuals, experiences a night of homelessness that puts them in contact with a homeless assistance provider. The estimate is conservative — it does not include those affected by natural disasters, nor those who do not contact a homeless assistance provider, e.g., who may be taken in by a friend or spend the night in a car.

The circumstances that cause homelessness for two to three million Americans are varied. However, research conducted since the late 1980's shows that interactions among the supply of affordable housing, poverty, and disability account for most of the precipitating factors. Among poor persons, the risk of a night of homelessness is far higher than for the general population. Somewhere between four to six percent of the poor experience homelessness annually. Most of these experiences are short-term and the individuals exit homelessness with minimal assistance and generally are not seen again.

But the subgroup that tends to be the most visible is a group of about 200,000 people who experience homelessness on a protracted or repeated basis. On any given night, this group will represent almost half of those who are homeless. This subgroup has been identified as the chronically or long term homeless. There is increasing consensus that we can take actions that will reduce and end this level of chronic homelessness.

Exploring Solutions

Beginning in March, 2001, the Secretary's office initiated several activities to improve the Department of Health and Human Services' (HHS) response to the services needed by persons experiencing homelessness.

Throughout these explorations, a leading concern was for HHS-assisted services to be more accessible to eligible homeless persons being placed in HUD-supported housing. Interdepartmental discussions had clearly identified new emphases that were making it increasingly important for applications for HUD's homelessness assistance to demonstrate the use of mainstream HHS treatment services to assist chronically homeless people. By summer's end, it was clear that the complexity of HHS' structure and program variety obviated a simple linear plan, i.e., one that involved an easily introduced change that expanded opportunities for access by homeless individuals.

The final development of significance came in the release of the Administration's budget for fiscal year 2003. President George W. Bush endorsed as goal of his administration ending chronic homelessness in a decade.

The Secretary's Work Group on Ending Chronic Homelessness

At the start of calendar year 2002, Secretary Thompson established the Secretary's Work Group on Ending Chronic Homelessness. He asked Deputy Secretary Claude Allen to lead the Work Group in a comprehensive review of the Department's relevant programs. The Work Group was to report recommendations for a Department-wide approach that would contribute to the Administration's goal of ending chronic homelessness and improve HHS' ability to assist persons experiencing chronic homelessness.

Representation on the Secretary's Work Group On Ending Chronic Homelessness:

  • Office of the Secretary
  • Administration on Aging
  • Administration on Children and Families
  • Assistant Secretary for Budget, Technology, and Finance
  • Assistant Secretary for Legislation
  • Assistant Secretary for Planning and Evaluation
  • Centers for Medicare & Medicaid Services
  • Health Resources and Services Administration
  • Office of the General Counsel
  • Substance Abuse and Mental Health Services Administration

The action simultaneously addressed two needs:

On February 28, 2002, Deputy Secretary Allen convened the first meeting of the Secretary's Work Group on Ending Chronic Homelessness. Representatives were chosen by agency administrators for their knowledge of agency programs and their ability to represent the agency authoritatively (Appendix A). Mr. Allen itemized charges to the Work Group members and offered a plan of approach to undertake four tasks:

  1. Define the population that experiences chronic homelessness and itemize their service needs.
  2. Analyze the response of relevant HHS mainstream assistance programs to the itemized service needs.
  3. Specify outcomes and objectives that would improve the response of these mainstream programs to long term and repeated homelessness.
  4. Offer actions the agencies could take that would improve access to and coordination of services that would contribute to reducing and ending chronic homelessness.

Charge to the Work Group:

  • Improve access to treatments and services
  • Improve coordination across these services
  • Identify strategies to prevent additional episodes of chronic homelessness
  • Itemize accountability and evaluation processes

An Interagency Subcommittee was formed immediately (Appendix B) and charged with pursuing each of the four tasks. The Subcommittee met formally over a dozen times and held numerous informal meetings to analyze data, formulate recommendations, and edit written work.

To accomplish its work, the Subcommittee:

  1. Reviewed epidemiological and services research literature that documented what is known about those who experience long term and repeated homelessness and about treatments, services, and supports that are effective with these persons. This material is summarized in Chapter 2.
  2. Developed, administered and tabulated a service inventory for eight relevant mainstream HHS programs. The inventory sought not only to understand the administrative features of each program, but their specific response to the services needed by persons experiencing chronic homelessness. The findings are summarized in Chapter 3.
  3. Summarized what was learned from the inventory in the areas of
    1. a) administrative characteristics of the programs;
    2. b) regulatory or program design barriers to services identified by program officials;
    3. c) service coverage offered by relevant programs, including what was known about current access by homeless persons; and
    4. d) opportunities or concerns that program officials identified for improved access by chronically homeless persons.
  4. Convened a Listening Session on July 16 to benefit from the experiences of States, municipalities, and providers who had struggled with weaving together a comprehensive set of funding sources to address the complexities of chronic homelessness. Six presenters, including the executive director of the U.S. Interagency Council on Homelessness spoke to Work Group and Subcommittee members about their experiences, with particular attention to the use of HHS assistance to provide treatments and services responsive to chronic homelessness.
  5. Based on the above processes, the Subcommittee identified objectives under each of its charges that could position HHS to be more responsive to the issue of chronic homelessness. Numerous options were itemized that could contribute to implementing the objectives, with an emphasis on short term steps HHS could take that would support the Administration's goal of ending chronic homelessness. The Work Group selected and refined these options and developed goals and strategies for a comprehensive Department plan. The Work Group recommendations are presented in Chapter 5.

Throughout the process, the Deputy Secretary's office provided critical guidance and support for the completion of the tasks. Work Group members were kept informed via a series of progress reports that summarized progress and next steps and by their representatives on the Interagency Subcommittee.

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Chapter 2:
Defining Chronic Homelessness and Understanding
Treatment and Support Needs

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What is Chronic Homelessness?

The first attempts to describe the current generation of homeless persons were based on survey methods. The surveys were conducted during a specific time period, e.g, the month of February, and used a convenience sample, e.g., going to soup kitchens or providers that specifically assist homeless individuals. Survey methods are the source for a commonly cited figure for homelessness in the United States, viz., 600,000 persons are homeless on any given night. Survey approaches continue to be used and are a legitimate, valuable tool for understanding the prevalence of a condition, such as chronic homelessness, and for understanding the characteristics of those experiencing that condition.

As homeless assistance matured, information system technologies were introduced into many homelessness assistance settings. Administrative systems made another method of population description possible — one that described the users of homeless assistance over a long period of time rather than a snapshot in time. Longitudinal analyses of the service users confirmed important distinctions among homeless persons that had first been noted by the Institute of Medicine in 1988. Specifically, the group is not homogeneous and three important subgroups regularly appear:(1)

These subgroups emerge from actual utilization patterns in numerous cities and show relatively similar distributions: Approximately 80 percent of users are temporarily homeless, 10 percent are episodic, and 10 percent are chronic.

Applying the 10 percent estimate to the number of persons who are homeless annually results in a figure of approximately 200,000 individuals annually who will be chronically homeless.(2) The Department believes that by linking affordable housing with treatment and support services, substantial and permanent reductions in the occurrence of chronic homelessness are achievable.

What Characteristics Are Associated with Chronic Homelessness?

While chronic homelessness may be identifiable by a pattern of homeless duration, other facts associated with this subgroup add to our understanding.

  1. Disability: The presence of a disabling condition is almost universal in the population. These conditions involve serious health conditions, substance abuse, and psychiatric illnesses. The prevalence of a disabling condition runs as high as 85 percent having one of more of these chronic problems. In contrast, data from mid-1990's indicate approximately 12 percent of working-age persons have a moderate to severe disability. Disability is a highly relevant factor where services are concerned since certain kinds of disability are an eligibility portal for many HHS assistance programs.
  2. Heavy Use of Services: Persons experiencing chronic homelessness are heavy users of the homeless assistance system and of other health and social services. Although they constitute 10 percent of the users of homeless shelter assistance, they consume fully 50 percent of the days of shelter provided by that system.

    In addition, analyses in New York City indicate that use of expensive emergency room visits, uncompensated care, and involvement with the criminal justice system among the chronically homeless represent significant costs to local, State, and Federal programs. The analysis tracked the service costs attributable to a cohort of chronically homeless persons before and after their placement in permanent supportive housing. The following New York data were provided at the July 18, 2002 meeting of the U.S. Interagency Council on Homelessness and show the changes in annual health care costs for the 2 years after a person was placed in housing compared to the annual costs incurred for the 2 years preceding housing placement. For health care, the data clearly show placement in supportive housing is associated with overall reductions in health care costs.
    Psychiatric hospital $8,260
    Municipal hospital 1,771
    Medicaid-Inpatient 3,787
    Medicaid-Outpatient 2,657
    Annual savings (per person) $11,161

  3. Engagement with Treatments: More than a decade of research has shown that persons experiencing chronic homelessness frequently exhibit a pattern of being disconnected from conventional community life. Many have limited support systems, reflected in most being single adults with weak family connections. Many are from ethnic and racial minorities and research also shows they may be reluctant to interact with systems they do not understand or which do not understand them. Many have past experiences with mainstream services that did not effectively address their needs or prevent them from falling into homelessness. These characteristics contribute to the long or repetitive patterns of homelessness they exhibit. They also reflect why re-engaging a chronically homeless person with treatments can be challenging.
  4. Multiple Problems: Chronically homeless individuals fall within the subset of persons who present a complex set of multi-problem challenges to service providers. Like frail elders with complex medical conditions, HIV patients with psychiatric and substance abuse issues, or a TANF client with domestic violence or counseling needs, the service needs of chronically homeless people outstrip the in-house competencies of most providers.

    The needs of a chronically homeless person cross many service system boundaries.

    The Needs of a Chronically Homeless Person Cross Many Service System Boundaries.

    In addition to the issues noted above, extreme poverty, poor job skills, lack of education, and negative childhood experiences are common features of chronic homelessness. The figure above, first used in the briefing material to the Work Group, describes the array of complex service needs associated with chronic homelessness.

  5. Fragmented Systems: Both practice and research have shown that the chronically homeless person is most likely to face a service system that is fragmented and providers who are not able to summon the flexible or comprehensive set of treatments and services the person needs. For providers to be effective with such individuals, they must either become uniquely specialized or piece together an informal system of referrals and service collaborations with other providers to ensure access to at least some of the needed services. The homeless shelter system, in dealing with daily demands that routinely exceed capacity, typically is not able to reshape itself along either of these tracks. Without services that address the multi-problem nature of long term and repeated homelessness, multi-problem clients rarely progress out of the system.

What Treatments and Services Are Effective?

Responding to the needs of people who experience chronic homelessness poses significant challenges. Their needs include a broad range of services, from food, clothing and emergency shelter to treatment and income support, and cross many service systems.

However none of these services are as effective without safe, affordable housing. Years of federal demonstration programs and the experience of community and faith-based providers have shown what is effective in preventing and ending homelessness among people who have serious health and behavioral health disorders. Implementing evidence-based and promising practices is essential for a comprehensive, integrated service system that effectively reduces chronic homelessness.

The following services and treatment needs are organized into core and supportive services. The core services include those that are needed to move people from the streets into housing and to stabilize their conditions. The supportive services include those that are needed to reintegrate people into the community, such as with jobs, education and socialization. The full definitions for each of the services are presented in Appendix C. Appendix D lists representative published citations of the effectiveness for each service.

Core Services

Supportive Services:

To be effective, these services must be accessible and provided in a coordinated and flexible manner. This includes the option of being offered in non-office based settings (e.g., on the street or in shelters) and during non-standard operating hours, being able to increase or decrease service levels to accommodate changing needs over time, and keeping case files open even during periods of inactivity so that eligibility does not have to be re-established when an individual is ready to engage or re-engage.

Providers need the flexibility to operate with a "no wrong door, no reject" policy, meaning that services are made available to individuals no matter where they enter the system and whether or not they are willing to accept specific interventions that may be indicated. In addition, strategies such as co-location of services not typically offered under the same roof can help reduce fragmentation and increase access to services.

HHS, HUD, and VA have agreed on the characteristics of persons experiencing chronic homelessness and use the following definition in their collaborations:

An unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year or has had at least four (4) episodes of homelessness in the past three (3) years.

Why the Definition of Chronic Homelessness and the List of Treatments Are Relevant to HHS Assistance Programs

There are at least three reasons why understanding who experiences chronic homelessness and what treatments and services are effective is relevant to the HHS programs designed to assist poor and disabled persons.

First, these mainstream programs are extremely likely to have had substantial contact with these individuals prior to their becoming chronically homeless. Research studies show that persons experiencing chronic homelessness have long and extensive histories of involvement with the publicly-funded treatment system before their period of long term homelessness. These service experiences seemingly did little to prevent their slide into a pattern of long term homelessness.

No mainstream program wants to waste an investment it has made in helping clients make gains. Falling out of treatment and into a pattern of long term homelessness represents a set back to gains the client experienced from treatment and services. In addition to concerns about the efficient use of resources, this experience may mean the person is wary of re-engaging with the types of providers that were not attentive to his or her risk of becoming homeless.

Second, their homeless status does not mean that chronically homeless persons are no longer using mainstream service resources. As noted above, they are heavy users of services, often expensive inpatient and emergency room services, unguided by a comprehensive treatment plan. Mainstream programs continue to absorb at least some of the costs for these expensive and ad hoc treatments.

Third, the levels of disability and poverty that characterize persons experiencing chronic homelessness make them likely to be eligible for a number of the HHS mainstream programs. The fact that they are unsheltered should not restrict them from benefitting from this assistance, but their homelessness often presents so many challenges that access to these benefits is not ideal. If HHS can craft approaches that improve their access to mainstream HHS service programs, contributing to a reduction in chronic homelessness, these same approaches should work for other eligible homeless individuals. These approaches might, thereby, provide solutions for addressing homelessness among families or youth.

HHS recognizes that the characteristics of chronic homelessness are primarily conceptual. They help to distinguish a population that presents service providers with unique demands and unique opportunities. The characteristics are an assortment of various problems and eligibility criteria that are relevant to many of the assistance programs supported by the Department. The characteristics reinforce the multiple treatment needs suggested in the earlier figure, but they do not have the rigor or uniqueness to suggest a singular eligibility group.

Instead, chronic homelessness — as a group of individuals with multiple service needs — overlaps with the types of beneficiaries and services of many of the HHS mainstream programs. This overlap suggests the appropriateness of response by the mainstream.

The access chronically homeless persons have to the mainstream programs and the ability of these programs to deliver the needed treatments and services consumed significant attention prior to the development of recommendations. The results of this examination are presented in the following chapter.

Endnotes

1.  Institute of Medicine. Homelessness, Health, and Human Needs: Committee on Health Care for Homeless People. National Academy Press, Washington, DC, 1988

2.  Metraux, Stephen, Dennis P. Culhane, Stacy Raphael, Matthew White, Carol Pearson, Eric Hirsch, Patricia Ferrell, Steve Rice, Barbara Ritter, & J. Stephen Cleghorn. "Assessing Homeless Population Size through the Use of Emergency and Transitional Shelter Services in 1998: Results from the Analysis of Administrative Data in Nine US Jurisdictions." Public Health Reports 2001; 116: 344-352.

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Chapter 3:
How HHS Mainstream Service Programs Align
With the Treatments and Services That Address
Chronic Homelessness

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Mainstream HHS Service Delivery Programs

In 1999, the General Accounting Office (GAO) examined the extent to which Federal programs designed to assist low income and disabled persons responded to homelessness.(1) The report identified up to 50 programs in eight Departments and Agencies that provided relevant assistance. Almost one-third of these programs were specifically targeted to homeless persons (16 of the 50)(2), while the balance constitute some of the largest and best known of the Federal assistance programs such as Food Stamps, Medicaid, Public Housing, and Supplemental Security Income. Collectively, these programs serve millions of individuals. The report referred to these as non-targeted programs, but the phrase 'mainstream programs' has been widely used to embrace them.

GAO identified 12 relevant mainstream programs in HHS. The Work Group took these 12 programs as a starting point to explore improved access, coordination, and prevention activities related to chronic homelessness. Three were eliminated as being less applicable to chronic homelessness. Specifically, Head Start, the State Children's Health Insurance Program, and the Maternal and Child Health Services Block Grant were dropped from further consideration because they were not likely to address single, disabled, poor adults who primarily make up the chronically homeless population. Two others were collapsed into one program, based on advice from the Health Resources and Services Administration which administers them. Specifically, Migrant Health Centers were not treated as a separate program as GAO had done, but were subsumed within the Consolidated Community Health Centers cluster. This left 8 mainstream programs as the focus of the Work Group.(3)

Mainstream HHS Programs Selected for Their Relevance to Chronic Homelessness:

  • Medicaid
  • Temporary Assistance for Needy Families (TANF)
  • Social Services Block Grant
  • Community Services Block Grant
  • Community Health Centers
  • Ryan White Programs
  • Substance Abuse Prevention and Treatment Block Grant
  • Community Mental Health Services Block Grant

Are HHS Mainstream Programs Responsive to Chronic Homelessness?

Each of the eight programs was asked to provide responses for the following information:

All of these circumstances were integrated into an inventory that was completed by each of 8 mainstream programs. The compilation and review of these service inventory responses was carefully reviewed and contributed substantially to the Work Group's recommendations. In addition, experiences shared by States, municipalities, and providers in the Listening Session and lessons from a site visit to a homeless health care clinic by members of the Interagency Subcommittee members were considered.

Findings

1) Availability of Core and Supportive Services

Each program was asked to indicate for each core and supportive service whether that service was required or optional (e.g., could be selected from a menu of options; offered at State's discretion). Several findings are noteworthy.

As these programs have been authorized, there is substantial flexibility in the services that can be supported. Four of the 8 programs give the State discretion in selecting what services will be supported. The others feature both required and optional services that the State, city or community-based recipient may offer. Therefore, in administering these 8 programs, there is considerable opportunity for the State or grant recipient to tailor service responses to the unique circumstances of the service beneficiaries. These opportunities extend to including the services the identified in the previous chapter as effective in helping people break a cycle of chronic homelessness. (See insert and Table 1.)

In all of the programs, there are also restrictions on offering certain services. The most common exclusion was on support for inpatient care. Only Medicaid is authorized to provide inpatient services.

The only core service to be offered in all 8 programs was information and referral, but outreach, supportive case management and substance abuse services are available from at least 7 of the 8 programs.

Number of Mainstream Programs Supporting
Core Services
Information and Referral    8   
Outreach and Engagement    7  
Alcohol and Drug Abuse Services    7
Supportive Case Management Services    7
Health Related and Home Health Services, Including HIV/AIDS    6
Intensive Case Management Services    6
Discharge Planning    6
Mental Health and Counseling Services    5
Residential Treatment Services    5
Income Management and Support    4
Inpatient Services    1

Three of the 8 programs can support 10 of the 11 core services (inpatient coverage is excluded in each): TANF, Ryan White titles, and the Community Mental Health Services Block Grant. However, these programs also serve the most highly specified target groups — by family status or diagnosis. They may be accessible only by certain persons who are chronically homeless.

None of the 8 programs offers all of the core and supportive services. This fact contributes to the frequently cited complaint of community and faith-based providers that they must juggle multiple funding sources to sustain a program that provides comprehensive services to their clients. For example, in one northeastern state, an average homeless shelter uses 17 sources of Federal support and 5 State sources to compile the array of services needed by its clients.(4)

This factor also has implications for homeless people. They are most likely to encounter providers who are not able to offer the comprehensive set of services. Negotiating such fragmentation is especially challenging for a person dealing with impairments.

For supportive services, coverage appears to be somewhat better. Five of the 8 programs cover all of the supportive services. Transportation, primarily as it relates to accessing treatments and services, is covered by all 8 programs. However, as Table 1 shows, variability in coverage remains a pattern and it reinforces the fragmentation issue noted above.

Number of Mainstream Programs
Supporting Supportive Services
Transportation    8  
Education and Training    6
Life Skills    6
Child Care    6
Employment Services    6
Legal Assistance    5

2) Use of Available Services by Chronically Homeless Persons

Two inventory questions are relevant here.

Thus, while the majority of the programs do not identify homelessness as a circumstance for consideration, the characteristics of chronic homelessness appear to create few barriers for access to these services.

For each core and supportive service, the inventory also asked whether persons experiencing chronic homelessness used the service and if data were available on the extent of use. Since homelessness was generally not identified as a circumstance for consideration for receipt of services by these programs, it is not surprising that their administrative systems would not flag homelessness or former homelessness as a characteristics on which data could be tabulated.

Consistent with the observations in the 1999 GAO report — which found that mainstream, non-targeted programs could not document access by homeless persons — 70 percent of the inventory responses about service use by homeless persons are unknowns. The programs report that they have no data to inform them about access. Thirty percent of the responses are positive, indicating homeless persons do use the service. But officials were not able to provide hard data on utilization.(5)

Clearly, it is a challenge for HHS to provide a baseline to demonstrate current access to mainstream services by persons experiencing long-term homelessness. The challenge will have to be addressed in any Department attempt to document that efforts to reduce the prevalence of chronic homelessness or end it are successful.

3) Concerns and Opportunities

To benefit from the insights of program officials about the relevance of their program to addressing chronic homelessness, the program officials were invited to offer observations about concerns or opportunities in five areas:

  1. Regulation or administrative issues (e.g., flexibility and limitations in designing service content, role of States in designing program, eligibility specifications, opportunities to apply for waivers or expansions, legal/civil rights concerns)
  2. Patterns of funding (e.g., how traditions influence fund distribution toward new issues, services, client groups, or groups of providers)
  3. Capacity issues (e.g., resource trends in the Program, treatment gaps, models of effective interventions, competencies of provider staff)
  4. Fragmentation of services (e.g., degree of specialization by service or funding, program culture on client referral and linkage, prevalence of one-stop service approaches, integration of providers into HUD's continuum of care planning processes)
  5. Priorities, incentives and motivations (e.g., priority placed on addressing homelessness in the Program, emphasis on cost containment, emphasis placed on the underserved, nature of the performance that is incentivized)

Several of these areas yielded information from program officials that was even more clearly expressed in the July 2002 Listening Session with States, municipalities and providers.

Fragmented funding led to the following issues for chronic homelessness:

Capacity Issues: The capacity of the programs to respond to chronic homelessness was expressed in several forms.

Implications of the Findings

The findings presented above represent a consolidation of statements, tabulations, or observations accumulated during several months of information seeking. Few of the findings are unique to any one service program; they tended to cover concerns and opportunities involving multiple programs and agencies. The next chapter briefly describes the processes used to distill the accumulated information and to develop recommendations for a comprehensive approach for the Department.

TABLE 1
HOMELESS-RELEVANT SERVICES AVAILABLE IN HHS ASSISTANCE PROGRAMS(a)
Services Provided —

HHS Mainstream Assistance Programs

CORE SERVICES   SUPPORTIVE SERVICES
Out-
reach
Primary Health Care Alcohol & Drug Abuse Services Mental Health & Counsel-
ing Services
In-
patient Services
Suppor-
tive Case Mgt
Intensive/
ACT Case Mgt
I & R Income Mgmt & Support Resi-
dential Treat-
ment
Dis-
charge Planning
No. of Core Services Offered Life Skills Child Care Educa-
tion & Train-
ing
Employ-
ment Services
Legal Trans-
portation
No. of Suppor-
tive Services Offered
Community Mental Health Services Block Grant (CMHSBG) X X X X   X X X X X X 10 X X X X X X 6
Community Services Block Grant (CSBG) X   X     X   X       4   X X X X X 5
Consolidated Community Health Centers (CHCs) (b) X(c) (d) (d) (b) (b)   X X(e)   X(f) 4     X(g)     X(h) 2
Medicaid k X(l) X(m) X(n) X(o) X X(p) X(q) X(r)   (s) X 9 X(t)     X(u)   X(v) 3
Ryan White Act X X X X   X X X X X X 10 X X X X X X 6
Social Service Block Grant (SSBG) X X X X   X X X   X   8 X X X X X X 6
Substance Abuse Prevention & Treatment Block Grant X   X     X X X   X X 7 X X       X 3
Temporary Assistance for Needy Families (TANF) X(w)   X(x) X(x)   X(w) X(w) X(w) X X(w) X(w) 10 X(w) X(w) X(w) X(w) X(w) X(w) 6
No. of Programs Offering Service 7 6 7 5 1 7 6 8 4 5 6   6 6 6 6 5 8  
Notes:
(a)  Services provided refers to those that are required, eligible or covered in each program.
(b)  A supplemental service available to some but not all centers.
(c)  In-home services not a requirement of the program.
(d)  Mental health service include services of a psychiatrist, psychologist, & other appropriate mental health professionals. These services are supplemental; most centers do not have extensive mental health services.
(e  Through referrals to other providers.
(f)  Patients are followed in the hospital either directly with privileges or through appropriate referral mechanisms.
(g)  Limited to health education
(h)  Transportation, as needed for adequate patient care. Residents of catchment area served by the Center with special difficulties of access to services provided by the Center may receive such services.
(I)  Outreach & engagement are required in Head Start, but are not specific to homeless persons.
(j)  Not used.
(k)  All provided Medicaid services are State administered and limited in amount, duration, and scope.
(l)  As administrative expense (50 percent match).
(m)  Physician, outpatient hospital, home health for persons eligible for nursing facility services, rural health clinic services, lab & x-ray, FQHC services. Eligible/covered include clinic, optometrist/eyeglasses, prescribed drugs, prosthetic devices, dental.
(n)  Eligibility requires meeting categorical requirements other than substance abuse.
(o)  If physician service or in-patient hospital. Eligible/covered: prescription drugs & additional services under a waiver program.
(p)  State option
(q)  Service may be created using State plan option(s).
(r)  May be part of case management services or service provided by managed care organizations.
(s)  If inpatient hospital, nursing facility, intermediate care facility for mental retardation, or psychiatric residential treatment facility for persons under 21 years of age.
(t)  Particularly under a waiver program.
(u)  Specialized therapies only (e.g., occupational, speech, & physical).
(v)  May be covered to receive medical care as program or administrative costs by a state.
(w)  State option, but families are the clients, not individuals.
(x)  Service must be non-medical in nature.

Endnotes

1.  General Accounting Office. "Homelessness: Coordination and Evaluation of Programs Are Essential." GAO/RCED-99-49. Wash, DC: 1999.

2.  HHS is responsible for five programs specifically targeted to homeless persons. Three of these were acknowledged in the GAO report:

HHS is also responsible for a Federal Surplus Real Property program that transfers surplus Federal land and buildings to organizations that use it to provide homeless assistance. Since the latter program was not a direct service program, it was not included in the 1999 GAO study. Finally, in 2001, HHS added its newest targeted program: Cooperative Agreements for the Development of Comprehensive Drug and Alcohol Treatment for Systems for Homeless Persons, stressing service delivery to those with substance use problems. All of these programs emphasize service responses to homelessness and cumulatively report assisting more than 600,000 homeless persons annually. In this report, the emphasis was on the contribution the non-targeted HHS programs can make to reducing and ending chronic homelessness. The Department acknowledges the vital contributions the targeted programs are already making in addressing chronic homelessness and the de facto role they will play in a comprehensive approach.

3.  This is not meant to convey that other HHS assistance programs are not relevant or applicable to chronic homelessness. The selection of these eight was consistent with expectations established by the earlier GAO study and provided a diverse sample of HHS programs for consideration.

4.  Personal communication to W. Leginski from L. Hatton, May 2002.

5.  The authorization for some of these mainstream programs may restrict whether the Department can obtain specific data on homelessness. Only the Community Health Centers reported data for the service of primary health care, indicating that the service was provided to 80,000 homeless persons.

6.  "Eliminating the Silos" January 2002. The Midwest Welfare Peer Assistance Network: Madison, WI. p. 2.

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Chapter 4:
How the Plan Was Developed

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Addressing the Charge

The overall charge to the Work Group was to develop and recommend a comprehensive approach for how the Department could contribute to the Administration's goal of ending chronic homelessness in a decade. The approach had to be responsive to three(1) components of the original charge. Each of these components has been restated as a separate charge addressed by the plan.

  1. To improve access for persons experiencing chronic homelessness — 'determine what actions can be taken to expand access to treatments and supports for chronically homeless persons.'
  2. To improve service coordination — 'identify partnerships at the federal, national, state, and local levels to improve coordinated service delivery.'
  3. To prevent additional chronic homelessness — 'identify and address the risks of homelessness faced by current service participants' and 'provide treatments and supports that contribute to housing stability.'

The Administration's goal to end to chronic homelessness in a decade has been incorporated into the charge by offering both short term recommendations, reflecting actions for the next two years, as and recommendations that would allow the Department to evolve and adapt throughout the decade.

The Structure of the Plan

A comprehensive plan for HHS on chronic homelessness should demonstrate parallels to the HHS strategic plan to permit its possible consolidation into the HHS strategic plan. Therefore, the Work Group has used the components of the HHS strategic plan — mission, goals, objectives, and strategies — to structure its recommendations.

The mission and goals are readily derived from the overall charge and the three component charges noted above. Within each of the three goals, the Work Group formulated objectives — statements that are unique to each goal and articulate what the Department might try to accomplish. They have been stated with a long-term focus, but could be modified based on experience or policy.

For each set of goals and objectives, strategies that implement the goal and its objectives have also been listed. These strategies have a shorter time frame: It is generally the Work Group's expectation that they would be focused on during the next two years.

While the time frame for these strategies may be short term, the actions they reflect are founded on the relatively well-defined repertoire of responses that the Department and its programs must work within. The Department's repertoire is summarized in the themes noted in the insert. One of more or these themes characterizes each of the strategies for action stated in the next chapter.

Recurring Themes for Opportunities Where HHS May Take Action:

  • Application processes, waivers, or conditions for HHS funding — Capitalizing on the work processes by which awards and entitlement programs are granted, such as application instructions, opportunities to request waivers from standard operations, or conditions that must be met to receive funding.
  • Tools, technical assistance, and training — Developing and delivering guidance such as curricula, blueprints, or best practices in the form of materials, training events, and technical assistance interventions such as site visits or specialized consultations.
  • Administrative flexibility — Examining opportunities for relief or flexibility in administrative practices that may be creating impediments for eligible persons to participate in an HHS assistance program.
  • Organizational realignment — Considering structural changes that would improve the administration of programs.

Action steps typically constitute the next component of a plan. However, since each of these strategies will need to be considered by the divisions of the Department that are responsible for the relevant program, action steps are not offered in this report. The final level of the plan presents examples. For each strategy, brief examples of how the strategy might be implemented have been developed. The examples apply either to specific operating divisions within HHS or may have broader Departmental application. The examples are illustrative; their viability under Department authority or regulation has not yet been vetted.

As the strategies are explored by the divisions that make up HHS, the examples may fall away or undergo substantial modification. Actions by Department and its components will be based on careful consideration of each of the following:

Feasibility of Recommendations

The Work Group was further assisted in developing its goals and strategies by program officials from the eight mainstream programs identified in Chapter 2. The officials were invited to review an extensive listing of potential recommendations and, using a standard response protocol, to identify:

The responses of the program officials were considered before shaping final suggestions. The desire was to ensure a mix of challenges, rather than a set of recommendations that might be too complex to be attempted or a set that was so elementary that it reflected actions that had already been taken in the programs.

The result of all of the processes described above is presented in the next chapter.

Endnotes

1.  A charge to the work group also called for establishing monitoring and evaluation benchmarks. The absence of data to inform the Department about a baseline suggested considerable developmental work would be needed before empirical benchmarks could be established. The plan includes a recommendation for this work.

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Chapter 5:
A Formal Statement of the HHS
Comprehensive Plan to End Chronic Homelessness(1)

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Mission: To end chronic homelessness in a decade.

Goals:

An Alternate Listing

The above approach organizes the goals and strategies under each of the original charges to the Work Group. Such an approach demonstrates the responsiveness of the Work Group to each charge, but is not the only way of presenting HHS' comprehensive approach. This alternative listing may also prove useful. Three restated goals describe the HHS plan to end chronic homelessness:

  1. Help eligible, chronically homeless persons receive health and social services;
  2. Empower our State and community partners to improve their response to the needs of homeless people; and
  3. Work to prevent new episodes of homelessness within the HHS clientele.

The strategies listed previously can be aligned with each of these restated goals to present a comprehensive approach. They are briefly paraphrased and aligned with one of the above goals:

Help eligible, chronically homeless individuals receive health and social services

Empower our State and community partners to improve their response to people experiencing chronic homelessness.

Work to prevent new episodes of homelessness within the HHS clientele

Closing Considerations

These recommendations form a basis for the programs of HHS to explore ways in which their actions can contribute to the Administration's goal of ending chronic homelessness. They are neither prescriptive nor exhaustive of the possibilities for programs. However, in recognizing that categorical program approaches have limits in responding to the needs of a multi-problem clientele, the Work Group explicitly avoided recommendations that create additional programs or funding streams. Success is not measured exclusively by the existence of a program, but from the accumulation of operations supported by:

The Work Group believes the Administration's goal of ending chronic homelessness combined with the recommendations offered above accumulate to provide these six supports. Their interaction will guarantee the Department's success.

Endnotes

1.  It is assumed throughout this document that no strategies will be implemented without seeking and attaining all relevant legislative and/or regulatory changes needed to ensure that all programs within HHS continue to operate within their given authority and mission. It is also assumed that, to the extent the strategies seek to impose any requirements on applicants as conditions of given awards, before doing so, programs will confirm that their authorizing authority and program/administrative regulations permit such imposition of conditions. It is further assumed that no proposals will be implemented without resolving any inherent budget implications.


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