The literature offers a number of schemes for describing systems and system change. We use two in this paper. The first focuses on signs that systems have changed, and the second focuses on the types of relationships among agencies that characterize systems at different stages of integration. Both schemes were used in the THCH evaluation (Burt and Anderson, 2006) to describe the changes occurring in the study communities.
Laying a New Foundation (Greiff, Proscio, & Wilkins, 2003, p. 7) identifies five signs by which one can recognize system change when it is complete, or nearly complete; change should be clear in all five areas (text in brackets [ ] is the present authors):
- A change in power: There are designated positions people with formal authority responsible for the new activity (not just committed or skillful individuals who happen to care about it).
- A change in money: Routine funding is earmarked for the new activity in a new way or, failing that, there is a pattern of recurring special funding on which most actors in the system can rely. [This could be new money, a shift in existing funding, or new priorities and criteria for accessing existing money].
- A change in habits: Participants in a system interact with each other to carry out the new activity as part of their normal routine not just in response to a special initiative, demonstration, or project. If top-level authorities have to command such interactions to take place, then the system has not absorbed them, and thus has not yet changed. [Service delivery improvements fit in here, ranging from referral hotlines and simplified application procedures, through case-by-case provider sharing of resources, up to and including services integration (through multi-agency teams, co-location, and the like) or systems integration (such as universal applications, merged funding streams, multi-agency goal-setting and follow-through)].
- A change in technology or skills: There is a growing cadre of skilled practitioners at most or all levels in the delivery chain, practicing methods that were not previously common or considered desirable. These practitioners are now expert in the skills that the new system demands and have set a standard for effective delivery of the new systems intended results.
- A change in ideas or values: There is a new definition of performance or success, and often a new understanding of the people to be served and the problem to be solved [i.e., new goals]. The new definition and understanding are commonly held among most or all actors in the system, such that they are no longer in great dispute. [For instance, a whole CoC could reorient itself toward ending homelessness, or at least toward ending chronic homelessness. Either of these events would be system change if followed by actual changes in behavior to assure movement toward the goal.]
Since people who are homeless interact with many systems, including homeless-specific agencies and the health, mental health, corrections, child welfare and foster care, public benefits, employment, and housing systems (as documented by Culhane et al., 2002 and Koegel et al., 2004, among others), achieving integration of these systems can make a significant difference in the manner and speed with which a households homelessness is resolved. Services and systems may be integrated to varying degrees, making it more or less simple to get individuals the range of services they need or to end homelessness through the combined, concerted, organized, and strategic actions of many different actors (Cocozza et al., 2000; Provan & Milward, 1995; Randolph et al., 2002). Services integration refers to the ability of a community to get any individual or family the services it needs, especially when the needs span two or more service systems. Services integration may be accomplished in a number of ways a common approach is the multi-agency casework team, whose members are able to marshal the resources of their respective departments efficiently and effectively to help individual clients. Systems integration refers to changes in two or more service systems that reorient the systems activities toward more efficient and effective achievement of common goals goals that may be new or long-standing.
The first author (Burt & Anderson 2006; Burt et al., 2000) has used a five-level scheme to describe integration stages isolation, communication, coordination, collaboration, and coordinated community response. These stages can represent the initial status of a potential system and the relationship of its component parts, and also the movement toward changes that are likely to end homelessness.
One can use the integration stages described below to benchmark a communitys progress from a situation in which none of the important parties even communicates, up to a point at which all relevant agencies and some or all of their levels (line worker, manager, CEO) accept a new goal, efficiently and effectively develop and administer new resources, and/or work at a level of services integration best suited to resolving the situation of homelessness for the largest number of people in the shortest period of time. The framework also recognizes the possibility of regression from one stage to previous ones if prevailing factors work against integration. Brief descriptions of these integration stages follow:
- Isolation recognition of the need to communicate about the issues that require a system solution is lacking, as is any attempt to communicate. Even worse than isolation is hostile communication, suspicion, and distrust. This was the situation in many communities at the time that HUD instituted the continuum-of-care application process. It still prevails in some communities as the reality of relationships between homeless assistance providers and government funding agencies.
- Communication talking to each other and sharing information in a friendly, helpful way is the first, most necessary, step. Communication must inform participants what their counterparts in other agencies do, the resources they have available to them, and the types of services they can offer. Communication may happen between front-line workers (e.g., a mental health worker and a housing developer), middle-level workers, and/or among agency leadership. It may occur among these personnel in two systems, three systems, and so on up to all the systems in a community. In many communities the parties who need to work together to create a coordinated system to end homelessness have not reached even this first stage. Everyone operates in isolation in hostile interactions that do not advance understanding or assistance for homeless people or the possibilities of preventing homelessness. Even when people know each other and sit on the same committees and task forces, they still may not communicate enough to share an understanding of the role each could play in ending homelessness. This latter situation is the norm in most communities people know each other but have not really gotten down to the hard work of listening to and hearing each other.
- Coordination staff from different agencies work together on a case-by-case basis and may even do cross-training to appreciate each others roles and responsibilities. Again, coordination or cooperation may happen among front-line workers or middle-level workers, and/or involve policy commitments for whole agencies by agency leadership. It may occur among these personnel in two systems, three systems, and so on up to all the systems in a jurisdiction.
Coordination may also be services integration. Multi-agency teams that help specific individuals obtain appropriate services are examples of coordination, as are multi-service centers where a homeless person can connect with many different agencies but there is no overall case coordination. However, at this stage, no significant changes have occurred in the services each agency offers or how the agencies do business. Coordination does not involve major changes in eligibility, procedures, or priorities of any cooperating agency. It merely means they agree not to get in each others way and agree to offer the services they have available when it is appropriate to do so, albeit sometimes in new locations or through new mechanisms such as a multi-agency team. It does not entail any significant rethinking of agency goals or approaches.
- Collaboration collaboration adds the element of joint analysis, planning, and accommodation to the base of communication and coordination, toward the end of systems integration. Collaborative arrangements include joint work to develop shared goals, followed by protocols for each agency that let each agency do its work in a way that complements and supports the work done by another agency. Collaboration may occur between two or more agencies or systems, and usually does involve system change to varying degrees.
Collaboration cannot happen without the commitment of the powers-that-be. In this respect it differs from communication and coordination. If agency leadership is not on board supporting and enforcing adherence to new policies and protocols, then collaboration is not taking place (although coordination may still occur at lower levels of organizations). Because collaboration entails organizational commitments, not just personal ones, when the people who have developed personal connections across agencies leave their position, others will be assigned to take their place. They will be charged with a similar expectation to pursue a coordinated response and will receive whatever training and orientation is needed to make this happen. Collaboration in this sense can be seen in many examples given throughout this paper, including Connecticuts three waves of integrated state funding for PSH, the ways the Massachusetts Department of Mental Health has developed partnerships to produce PSH, Minnesotas 10-year plan to end homelessness, Portland/Multnomah County, Oregons three-way funding structure for PSH, Seattle/King County, Washingtons funders group, and Columbus/Franklin County, Ohios Rebuilding Lives initiative.
To the three stages that promote better services and supports for homeless people, we add a last stage, which is collaboration involving all of the critical and most of the desirable systems and actors in a community. This type of response has sometimes been called a coordinated community response (CCR), and we adopt that terminology here to distinguish this type of community-wide collaboration with the long-range goal of ending homelessness from collaboration among two or three agencies. Coordinated community response is system change and integration, going beyond collaboration in several directions.
- First, all of the systems in a community essential to preventing and ending homelessness must be involved. This includes homeless assistance providers and agencies providing housing subsidies, and also those promoting the development of affordable and special needs housing. It includes agencies that fund supportive services, most frequently mental health and substance abuse agencies, but also employment and health agencies, and others offering services that may be needed to address the underlying factors that contributed to homelessness. It includes agencies such as law enforcement and corrections, mental hospitals and private psychiatric units, and other institutions discharging vulnerable people with disabilities who are at risk of homelessness and need appropriate housing. It often involves the business community, which is heavily impacted by street homelessness. Ideally, others will also be involved, including representatives of local elected bodies, funder representatives, and consumer representatives.
- Second, CCR involves a mechanism for seeing that individual clients or households receive the services they need that is, it integrates services, through one or more of several mechanisms. The result of this streamlined service delivery at the client level should be improved client outcomes as well as more efficient and effective use of resources. In the context of addressing chronic homelessness, service integration involves connecting services and housing to help clients with long-term homelessness and one or more disabling conditions to find and keep housing and reduce use of expensive emergency public services. An important finding of the Access to Community Care and Effective Services and Supports (ACCESS) demonstration, which may seem obvious in hindsight but was not actually anticipated, was that people got housed only when the housing agencies were at the table (Rosenheck et al., 1998, 2001, 2003b). In the context of preventing or ending family homelessness, weekly cross-system case management meetings and pooled resources among homeless intake, child welfare, and income maintenance agencies may be used to move families coming into shelter rapidly back into housing or even to keep children with their parent in permanent housing instead of allowing the family to become homeless and removing the children to foster care. By working together and developing the mechanisms to respond to their clients housing crises before a household becomes literally homeless, providers can intentionally serve all clients rather than opportunistically serve only those who come to them while others fall through the cracks.
- Third, CCR entails a functioning feedback mechanism. In many communities this is a monthly (or more frequent) meeting of those most actively involved in developing appropriate interventions or smoothing bureaucratic pathways. (This function should be different from a direct service meeting to facilitate matching clients with services and housing units, even though both meetings may involve the same players.) Some communities have also found that forcing themselves to collect data on their progress and then to review the data at the monthly meetings shows them what they have achieved, helps them identify and resolve bottlenecks, and provides a powerful positive incentive.
- Fourth, CCR includes an ongoing mechanism for thinking about what comes next, asking what needs to be done, how best to accomplish it, and, finally, what needs to change for the goals to be accomplished. This mechanism can take one or more forms, such as task force or council, regular stakeholder meetings, and quarterly retreats. Whatever the mechanism, it must translate into shared decision-making and strategic planning at multiple levels as well as the expectation that each part of the system will modify its own activities to support and complement the work of the other parts.
- Fifth, it is a great deal easier to maintain the first four elements of a CCR if someone is being paid to serve as coordinator to organize and staff the interagency working groups and committees necessary to accomplish community-wide goals.
- Finally, a coordinated community response is never a done deal. If it is really doing everything expected, including identifying remaining gaps and continuing to seek ways to improve the system, it continues to evolve. We do not attempt to assess communities discussed in this paper using this framework except in a few examples, but changes from one stage to another should be obvious from community changes described below. The evaluation section of the paper discusses how the framework can be used to measure the impact of system change efforts as they mature and evaluations are formalized.
It is most fruitful to use this scheme to characterize movement and change rather than a steady state or a comprehensive overview. We follow this principle in Exhibit 1 below, where we give brief examples of movement from one level to another, focusing sometimes on relatively narrow but still challenging integration efforts such as that of the Skid Row Homeless Healthcare Initiative in Los Angeles and sometimes on the broadest possible efforts to mobilize all elements of a community to address the ultimate goal of ending homelessness.
Changes from Level to Level: Examples
|From No Communication to Communication
- Work in Rhode Island made PSH a recognizable concept to state legislators and agency officials, so they could begin to think about how to promote it. A parallel effort brought housing developers and operators and service providers together for the first time to develop potential teams to create more PSH.
- Work in Portland, Oregon, and Seattle brought the agencies with mental health and substance abuse services funding to the table for the first time, to talk with housing development and operations agencies.
- In Chicago, efforts to change the way we do business got people talking with each other in entirely new ways and brought new stakeholders into the process.
- Work in Los Angeles Skid Row brought the many agencies providing primary health care to homeless people to the same table for the first time, to talk about how to stop their patients from falling through the cracks.
|From Communication to Coordination
- In Los Angeles, the Skid Row Homeless Healthcare Initiative has developed a division of labor and coordination mechanisms among providers, established structures for obtaining specialty and recuperative care from clinics and hospitals beyond Skid Row, and created numerous additional mechanisms to assure better health care delivery and follow-through, including new funding mechanisms.
- The primary public and private funders of homeless services in Indianapolis, Indiana, have been meeting regularly for years to discuss issues related to homelessness. They all agreed in principle with and supported the Blueprint to End Homelessness, but maintained their own allocation processes. Today, they are working on a master investment strategy that outlines how each funding source will be targeted to achieve the implementation of the Blueprint over the next five years. The investment strategy also talks about the use of mainstream funding, such as Medicaid, Indianapolis Housing Authority vouchers, Indiana Housing Trust Fund, and criminal justice funds, for the Blueprint.
|From Coordination to Collaboration
- In Chicago, the Illinois Department of Human ServicesDivision of Substance Abuse brought together multiple homeless and mainstream agencies that traditionally coordinated services with one another, and created a multidisciplinary, multi-agency outreach team to serve persons with chronic substance use disorders in response to a Substance Abuse and Mental Health Services Administration grant opportunity.
|From No Communication to Collaboration
- Three Los Angeles city agencies with responsibility for different aspects of housing had never worked together. They began meeting to develop an affordable housing plan for the city. From this modest beginning, they evolved to a joint RFP for the development of PSH that blends these agencies resources to provide capital and operating funding commitments in the same package. This movement involved several firsts first time working together, first time developing a shared goal, first time issuing a joint RFP, and first time blending funding. Still missing, however, is the countys part the supportive services.
|Moving toward a Coordinated Community Response
- Portland and Seattle have brought the relevant parties together at several levels, from the commitments of local elected officials to the joint activities of PSH providers to the integrated funding strategies of relevant public agencies. Integrated work that began with a focus on chronically homeless individuals has spread in both communities to encompass plans, activities, and specialized funding for preventing and ending family homelessness, drawing in still more players.
|Working in Reverse Unintended Consequences
- Changes in one system, undertaken for its own internal reasons, often cause changes in other systems that no one ever intended or even thought about. An example particularly relevant to ending homelessness comes from Markowitzs (2006) analysis of reductions in public mental hospital beds before 1990 leading to increased homelessness among people with mental illness and their subsequent increased probability of arrest and incarceration, with the result that the proportion of incarcerated people with major mental illnesses increased. One systems change is two other systems disaster, which efforts to end homelessness are still trying to untangle.