by
Linda B. Fosburg, Ph.D.
Deborah L. Dennis, M.A.
When passed in 1987, the Stewart B. McKinney Homeless Assistance Act (P. L. 100-77) was landmark legislation providing the first federal funds targeted specifically to address the needs of homeless persons. The McKinney Act originally consisted of fifteen programs providing a range of services to homeless people, including emergency shelter, transitional housing, primary health care, education, and some social service needs. By 1998, approximately one decade after the McKinney funds became available and research results on the impacts of funding were becoming available, it was appropriate to address the question—What works?
The National Symposium on Homelessness Research was convened in Arlington, Virginia on October 29th and 30th, 1998 under the auspices of the U. S. Departments of Housing and Urban Development (HUD) and Health and Human Services (HHS) for this purpose.(1) Approximately 175 persons (including researchers, practitioners, policymakers, and formerly homeless persons) attended. During the two-day meeting, all in attendance had an opportunity to participate. Authors of eleven research papers presented their findings. Facilitated discussion groups followed the research presentations. Designated respondents provided prepared comments and other attendees gave additional feedback to the authors. Plenary discussions were another source of feedback to the authors and symposium planners. Consequently, the original papers were revised and the symposium planners commissioned two additional papers for inclusion in this compendium of research papers on homelessness.
Planning for the symposium began in January 1998 by a HUD/HHS joint planning committee consisting of representative from the two Departments and a team of two contractors (Abt Associates Inc. and Policy Research Associates, Inc.). An expert panel, convened in March 1998, provided input on the structure, agenda, topics, and participants for the symposium. Two complementary initiatives supported the researchers efforts to synthesize the lessons and implications of research done on exemplary practices for homeless people. One initiative, Workshop on Exemplary Practices: Addressing Homelessness and Health Care Issues, sponsored by the U. S. Department of Health and Human Services, focused on what is known about effective service delivery strategies and current policy questions. The second initiative, the National Symposium on Homelessness Research sponsored jointly by HUD and HHS, incorporated papers from the workshop, commissioned additional researchers to investigate what is known about the effectiveness of various components of the continuum of care and what should be the emphases for future research, and convened a national forum to discuss the resulting papers.
Common Themes Derived from the Research Papers
The Symposium was an historic opportunity to assess what we, as a nation, have learned about how to address homelessness since the McKinney Act was enacted. While there is much that remains to be understood about the effectiveness of programs for specific subpopulations of homeless persons, the sentiment echoed by all in attendance was that we have learned a great deal about how to end homelessness.
We know that outreach works. We know that subsidized housing works. We know that involving homeless and formerly homeless people in the design and implementation of services is important to creating successful programs. We know that homeless people sometimes have complex needs. We know that case management and systems integration can help cement and support fragile interpersonal and interorganizational relationships, creating greater opportunity for positive client outcomes. We know that programs can be held accountable, that management information systems exist that can provide valid information for planning and policy, and that the communities can reliably and feasibly assess the local need for homeless services.
Some of the key themes that emerged from the papers commissioned for the Symposium as well as from the ensuing discussion were the following.
The symposium planning committee, with input from an expert panel, selected the topics for the research papers because of their relevance to various aspects of homelessness and potential contribution to the field. Hence, the research basis of the papers contained in this report varies from extensive to modest. Eleven of the research papers were presented at the National Symposium on Homelessness Research. After the symposium, the planners commissioned two additional papers (the third and fifth summarized below) for inclusion in this compendium. Each paper contains a wealth of information from the synthesized research that can inform future initiatives for homeless people by practitioners, policy makers, and researchers.
Demographics and Geography: Estimating Needs
Martha Burt’s paper synthesizes the findings of nine studies of homeless populations over the past two decades. It describes the most comprehensive and latest data on important characteristics of homeless persons. It also summarizes the methodologies used by various jurisdictions to locate and describe homeless people and the factors that make them vulnerable to homelessness. The author documents that homelessness will vary among communities regarding the numbers, types of persons, and needs. She also states that different data sources may lead to different population appraisals and determinations of services needs. Based on this premise, the author provides local jurisdictions with recommendations for feasible and cost-effective methods to collect data on the local homeless population. The author underscores the importance of local data for local decision making as follows: “Having your own data eliminates local arguments about the existence of the problem and focuses attention on what to do about it” (p.1).
Special Populations of Homeless Americans
Robert Rosenheck, Ellen Bassuk, and Amy Solomon review the research on the subpopulations of homeless Americans and conclude that they represent of all segments of society. They are men and women, old and young, families and single people, whites and minorities, rural and city residents, persons with serious health problems and the able bodied. Some appear more vulnerable and in greater numbers than might be expected by their numbers in the population alone: e.g., single males and minorities. Despite their diversity, the subgroups share common needs. All are poor; they lack decent and affordable `housing, and do not have an adequate income. The similarities and differences found by the studies of the past 15 years are illuminating. They point out that despite the evidence of common needs, some subgroups are seen as “deserving” while others are not. They conclude that the evidence shows that services should be targeted by the needs of the specific individual, not by the subgroup characteristics.
Homeless Youth: Research, Intervention, and Policy
Marjorie J. Robertson and Paul A. Toro review the research on homeless youth. According to some estimates, at least 5% of youth aged 12 to 17 are homeless and most evident in metropolitan areas. While the research conducted to date is limited, the authors have synthesized the extant literature and described what additional information is needed to provide a more accurate and complete description of this subgroup of homeless people. The authors describe characteristics of homeless youth using standard demographics and include precursors such as family and residential instability and prior school experiences. They also describe homeless youths’ mental health, substance abuse, and health issues as well as their survival strategies while homeless. The authors discuss the intervention strategies that have been attempted after the youth have been homeless for some period. Although there is less literature on prevention, the authors present two basic approaches to homelessness prevention through primary prevention interventions and through prevention of repeated spells of homelessness. Finally, the authors provide recommendations for future studies using large representative samples of homeless youth, valid and reliable measurement tools, and assessment of both the youths’ strengths and problems.
Making Homelessness Programs Accountable to Consumers, Funders and the Public
Dennis Culhane, David Eldridge, Robert Rosenheck, and Carol Wilkins address the question: Are programs for homeless people delivering on their promises? This paper explores how performance measurement can provide program effectiveness indicators to consumers, funders, and the public, to improve programs. For example, consumer outcomes can inform whether consumer services are being delivered and consumer needs are being met. Program outcomes can provide funders with the information needed about future funding decisions. System outcomes can likewise provide the public with the information needed to ensure that community goals are being reached. The authors review the measurement strategies that can be used, ranging from simple and inexpensive to more complex and resource-intensive. They describe standard assessment tools that have been used at the three levels of accountability. Finally, they discuss the benefits of a cost benefit analysis, especially for homeless programs where cost comparisons with those of other institutions (e.g., hospitals, jails, mental institutions, etc.) can help to ensure continuing public support. They conclude that standardized information is a necessary basis for discussing the merits of existing and proposed policies and programs.
Giving Voice to Homeless People in Policy, Practice, and Research
The author of this paper, Nicole Glasser, brings her personal experience to this research assignment. She states: “Having personally walked many high roads and low roads as a consumer of mental health and homeless services, nothing makes more sense to me than allowing clients, or consumers of services to have a greater say in their services—from the direct provision of services, to policy, administration, and evaluation.” Consumer involvement in programs that serve homeless people has been growing. There is an increasing body of literature that supports the benefits of consumer involvement on the programmatic, policy, and administrative levels. Consumer empowerment ranges from participation in a community meeting or on an advisory board, to hiring consumer staff, to completely consumer-run programs and organizations. While there is resistance within any system to hand over power to a stigmatized group, once done, the system may find that it has higher quality and more responsive services. Research finds that consumers can perform as well as non-consumer staff and are especially skilled at engaging potential clients. Within consumer-run organizations, the focus of service delivery is on choice, dignity, and respect. There are a number of things that federal; state and local governments can do to encourage consumer involvement in decision-making, staff hiring, and the creation and survival of consumer-run organizations.
To Dance with Grace: Outreach and Engagement to Persons on the Street
Sally Erickson and Jaimie Page review the literature on outreach. By definition, outreach is the process of connecting or reconnecting a homeless individual to needed services. Much of the extant literature comes from mental health outreach programs. Because homeless populations vary by community, each community must tailor its outreach program to those in need. The authors cite several principles of successful outreach programs. These include: focus on individuals as people, recognition of the uniqueness of each individual, emphasis on empowerment and self-determination for homeless persons, delivery of outreach services with an attitude of respect, hope, kindness, advocacy, as well as flexibility and creativity. One of the developments in outreach, cited by the authors, is employment of consumers/peers/formerly homeless persons as outreach workers. Success stories in outreach abound, yet funding remains an outstanding issue. The authors encourage communities to include outreach explicitly in their Continuum of Care proposals.
A Review of Case Management for People Who Are Homeless: Implications for Practice, Policy, and Research
Over the past two decades, case management has become one of the most common practices in the delivery of services to homeless people, according the author, Gary Morse. Confusion over what constitutes case management abounds. To clarify, the author discusses several functional definitions of case management. He also presents case management approaches and models for various client subgroups and specialty areas. He concludes from his synthesis of studies on case management that there is strong support for the effectiveness of case management to help homeless people with severe mental illness into needed services, including stable housing. Frequent service contacts are critical to treatment retention and housing outcomes. Case management services are less effective with some clients than others. He also cites knowledge gaps about the effectiveness of case management for those with dual diagnosis, children, youths, women, or families; other mental disorders that are not classified as severe mental illness. Finally, he examines exemplary case management practices in terms of: staff skills and abilities, service principles, and organizational practices; and make recommendations for promoting exemplary practices
Balancing Act: Clinical Practices that Respond to the Needs of Homeless People
The occurrence of physical and/or mental illnesses is approximately two to six times higher for homeless people than for those who are housed (Wright, 1990). According to the authors, Marsha McMurray-Avila, Lillian Gelberg, and William R. Breakey, both types of illnesses have been implicated as “causes and consequences of homelessness for many individuals” (p.2). This is because the incidence of these illnesses creates vulnerabilities that can lead to the primary causal factors of homelessness: loss of income and home. After over a decade of practice with homeless populations, there is a growing agreement on what constitutes state-of-the art delivery of clinical services with homeless persons. The authors cite nine general principles that have emerged and discuss outcomes in terms of system-level and client-level outcomes. They conclude: health care programs need to be expanded into other areas (e.g., dental health); more extensive data on health care utilization, costs, and outcomes need to be collected; and retention programs for skilled practitioners to work with homeless people are needed.
Emergency Shelter and Services: Opening the Front Door to the Continuum of Care
Judith Feins and Linda Fosburg review the provision of emergency shelter and services to homeless persons in the U. S. They focus primarily on the Emergency Shelter Grant (ESG) program, which helps localities and states provide facilities and services to meet the needs of homeless people and, at the same time, aid in their transition from temporary shelter to permanent homes. In large part, this paper grows out of an evaluation of the ESG program conducted in 1993. Today’s emergency shelters provide many more services than “three hots and a cot” (or three meals and a bed). Nearly all ESG-supported shelters provide one or more supportive services to clientele. The authors describe the populations served and the effective practices used in delivering emergency shelter and services. The authors conclude that the problem of homelessness is not likely to disappear soon. More research emphasis needs to be placed on both ends of the continuum of care, especially on effective strategies for homelessness prevention and programs to ensure a transition to stable economic self-sufficiency.
Transitional Housing and Services: A Synthesis
According to Susan Barrow and Rita Zimmer, in 1994, when the U. S. Department of Housing and Urban Development first required applicants for federal funding of homeless programs to create a continuum of care, transitional housing became a “required” element of a comprehensive response. The authors discuss the boundaries among transitional housing, emergency shelter, residential treatment programs, and permanent supportive housing. They also examine the ways that typical programs vary, especially in terms of program outcomes in five categories: service engagement and utilization, behavioral measures, self-sufficiency measures, housing variables, and cost effectiveness. The authors conclude that transitional housing can be effectively implemented only in the context of adequately subsidized permanent housing and readily available supportive services. They also conclude that comparative research is needed between transitional housing models and other alternatives. Furthermore, more emphasis should be placed on consumers’ perspectives, especially their attitudes toward acceptance of services as a condition for remaining in housing.
Reconnecting Homeless Individuals and Families to the Community
Debra Rog and Scott Holupka characterize the circumstance of homelessness as personal isolation and a lack of connections with family, jobs, and community. This paper explores what is known about reversing the process and reconnecting homeless people with their personal self-sufficiency, with residential stability and employability, as well as with family and friends. The authors explore what has been learned about various aspects of the process. First they discuss the reconnection process to residential stability and describe several program strategies (e.g., Supportive Housing Program, Shelter Plus Care, and Section 8 Moderate Rehabilitation Assistance Single Room Occupancy) and evidence of effectiveness. Next, they explore the process of reconnecting homeless people with the job market through a variety of program strategies (e.g., Job Training for the Homeless Demonstration Program, and Next Steps: Jobs). The authors also discuss the research on reconnecting with family and friends. They conclude that the best prospects for success may be a “three-legged stool” approach that encompasses housing, services, and employment.
What Do We Know About Systems Integration and Homelessness?
Deborah Dennis, Joseph Cocozza, and Henry Steadman maintain that despite calls for comprehensive systems of care for homeless people over the past decade, little has been done in this regard. The authors define and differentiate between systems integration strategies (e.g., involvement of interagency coordinating bodies, strategic planning, and pooled or joint funding) and services integration strategies (e.g., involvement of case management, individualized service planning, and assertive community treatment). They demonstrate with numerous examples how communities have addressed systems and services integration and made it work for them. They conclude that successful systems integration requires the commitment of key decision-makers to an on-going process and the resources required to implement an effective system. Both systems and services integration strategies must ultimately be implemented simultaneously.
Rethinking the Prevention of Homelessness
Marybeth Shinn and Jim Baumohl review the current state-of-the-art in homelessness prevention and draw the same conclusion as the U. S. General Accounting Office (1990) did; it remains “too early to tell” what works in preventing homelessness. The authors discuss the logic of prevention and the basic definition of what is included in homelessness prevention. Next, they critique the conceptual and methodological problems. For example, while eviction prevention programs appear effective in some instances, they may be excluding people who are at higher risk of homelessness—those who do not have a lease, but who are precariously housed. Similarly, programs that target discharge planning or amelioration of domestic conflicts—even if 100% successful—may only reach a small proportion of those who are likely to become homeless in a given year. The authors conclude that while social services may be valuable for other reasons, services may not be the essential factor in preventing homelessness once access to subsidized housing is taken into account. Instead, the authors propose testing other models of homelessness prevention and point to the need for long-term followup. Otherwise, the ultimate results of a homelessness prevention program will remain inconclusive.
In summary, the thirteen research papers contained in this report offer many insights into what has been learned in the past two decades. Indeed, we have learned a great deal about how to end homelessness. Each of the papers offers its views on the emerging best practices and provides appropriate cautions where improved practices need to be developed and integrated into the current strategies for addressing the needs of homeless people.
(1) Three appendices accompany this report. Appendix A is the agenda for the symposium. Appendix B contains brief biographies of the authors of the research papers. Appendix C is a list of all symposium attendees.
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