No matter how well developed and functional a homeless system of service, its success will be limited without an accompanying effort to prevent homelessness. Since the 1998 Symposium presentation on homelessness prevention (Shinn & Baumohl, 1999), no models or policies have emerged that would parallel the breakthroughs occurring in homeless service systems. Guidance documents from the ICH for developing 10-year plans on homelessness emphasize the inclusion of a prevention component and itemize such suggestions as:
- create discharge planning protocols from jails, substance abuse and mental health treatment facilities, foster care, etc.,
- dedicate housing resources for individuals discharged from inpatient psychiatric care, and
- centralize funding and service delivery to increase coordination (ICH dated).
Discharge planning receives frequent mention in state plans to address homelessness (see www.hrsa.gov/homeless) and is the only system-level prevention approach noted in the community plans analyzed by the National Alliance. However, when HHS undertook an exploratory study to determine if it was possible to evaluate the degree to which discharge planning prevented subsequent homelessness, the results were not encouraging (Moran et al., 2005). The study looked at documents, policies and procedures, and staff actions within a convenience sample drawn from four classes of institutional or custodial care:
- adult inpatient psychiatric treatment,
- residential treatment centers serving children and youth,
- residential treatment programs for adults with substance abuse disorders, and
- foster care independent living programs.
The study concluded that an evaluation of whether discharge planning prevented homelessness among exiting clients could not be conducted as yet. Discharge planning was not a distinct process in these settings, and discharge planning practices could not be separately identified from other program services. For persons in settings where there are long periods of custody and a distinct exit period, such as prisons, discharge planning processes are probably well developed and offer real possibilities for helping clients avoid homelessness as they reenter community life. But much remains to be done to clarify the contribution of discharge planning to the prevention of homelessness.
As is evident from the ICH list above, prevention also tends to cover a broad range of activities, and this contributes to a lack of focus and a lack of progress in moving from assertion to actual demonstration of preventive effects. The label of homelessness prevention is applied not only to processes, such as discharge planning, but also to services that enhance housing stability or improve a persons level of functioning and to programs of social justice, such as access to affordable housing, living wages, and poverty reduction (e.g., NAEH, 2006b). Perhaps more progress could be made in addressing homelessness prevention if we were more explicit about the type of homelessness being prevented and the subgroup of people to which the prevention interventions were being applied. At least three distinct approaches to prevention can be identified in the literature:
- Prevention through placement: processes to secure housing and community integration for vulnerable groups exiting long periods of custodial care.
- Prevention of relapse: services, treatments, and supports specifically delivered to formerly homeless people and intended to prevent the reoccurrence of homelessness.
- Tenancy preservation: services and interventions directed to housed beneficiaries of social service programs who exhibit risk factors likely to lead to the loss of housing. As noted above, one study suggested that discharge planning remained too elusive a process in many settings to be assessed for its contribution to homelessness prevention. This only suggests the need for clarification and refinement so that it can be studied as the premiere example of the first item in the list above, a placement strategy.
Relapse prevention, the second item in the list above, has accumulated a substantial amount of literature, as attested to by the housing stability studies reviewed elsewhere in the Symposium. Much of the support has come from the applications of behavioral health case management approaches such as ACT and critical time intervention (CTI) (Herman et al., in press). But this literature is in need of a systematic review to help narrow the set of interventions that appear to contribute to relapse prevention and to determine what other populations might be assisted by these services.
While Shinn and Baumohl (1999) raised numerous and appropriate cautions about the feasibility of the third focus, it remains conceptually relevant (e.g., NAEH, 2006b). The history of homelessness in the United States tells us that the low-income populations who are the beneficiaries of these public assistance programs are the first to experience problematic homelessness. There is merit in trying to develop interventions that prevent them from losing their housing, but two components remain undeveloped.
First, we lack a refined set of indicators, whether clinical or situational, that denotes risk of this event (Burt et al., 2005). Second, the range of intervention options is so inclusive it keeps us from being able to focus on a potential set of actions to try, and from developing a cohesive prevention strategy (Burt et al., 2005). The following have been suggested as preventive approaches to housing loss (Burt et al., 2005):
- cash assistance,
- training in financial management,
- representative payees,
- training in household management,
- clinical interventions, such as assertiveness training and trauma services,
- development of affordable housing
- training in household management,
- advocacy for a living wage.
To ensure substantive contributions to the topic of homelessness prevention at the next Symposium on Homelessness Research, there are clear challenges for leadership, improved conceptualization, and focused work on this topic.
Is the Issue Affordable Housing?
No discussion of homelessness prevention, however, can ignore the problem of affordable housing in the United States. As noted earlier, Karr (1992) has suggested that policies since the 1920s have either failed to emphasize the production of affordable housing or contributed to its loss. The Joint Center for Housing Studies (2006) recently indicated that between 1993 and 2003 the largest loss of rental housing stock occurred in the units accessed by the lowest income groups: the number of units renting for $400 or less in inflation-adjusted terms fell by 13 percent a loss of more than 1.2 million.
The study further indicated that among the nations 34 million renters, 22 percent face a severe cost burden, paying 50 percent or more of their income for rent. However, among the lowest income group, 70 percent face a severe cost burden. Rapidly increasing housing costs in many communities have even led to proposals for the creation of workforce housing so that teachers and firemen can afford to live where they serve (Bell, 2002). But perhaps most compelling is data from HUDs report to Congress on worst case housing:
In 2003, there were 78 rental units affordable to extremely low-income renters for every 100 such households, but only 44 were available for these households (the remainder being occupied by higher-income households) (HUD, 2003).
This severe shortage availability of less than half of the needed number of affordable units has extraordinary implications for any effort to prevent homelessness. Substantial numbers of extremely low-income renters face a severe cost burden, cannot find affordable housing, or are forced into homelessness or doubling up with others. For some households, this is a temporary situation from which they recover without ever interacting with the homeless system of service. For many others, the situation guarantees a steady supply of customers flowing into the homeless service system. Any prevention strategy must reckon with affordable housing, either in the production of units or in the adequacy of subsidies to help the poorest families and individuals with their rents.