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