Targeting Chronic Homelessness
During the contemporary wave of homelessness, providers have recognized that the population is heterogeneous. Programs and services have been differentiated by age, gender, family status, and disability, to name a few. Even the terminology of the homeless was abandoned within the field, both for its connotations of uniformity and for its elimination of the person having the experience. Special populations within the larger homeless population were well recognized (e.g., Rosenheck et al., 1999), but the public health model, the values of the caring professions, and legislation contributed to decades of service approaches that emphasized assisting as many as possible (see Gladwell, 2006).
|Potential Goals of the Homeless System of Service:
|Four Components of the System||System Aspect Examined|
|Significant Development||Consequences||Challenges||Future directions|
People experiencing homelessness
|Focus on chronic homelessness||
|Services and Treatments
Receive services (housing, treatments and supports)
|Evidence-based interventions with ACT and Housing First as potential candidates||
Delivered by providers
|Unknown: Possibility of adapting to change||
Working in a network of agencies, policies, and funding.
|Homeless councils and plans||
However, there is also a tradition of looking at that subset of users who account for a disproportionate amount of service use. For example, the Agency for Healthcare Research and Quality reported that in 2002, 5 percent of the U.S. non-institutionalized population accounted for 49 percent of the medical expenditures (Conwell & Cohen, 2005). Although this body of research was not systematically reviewed in this paper, looking at many of the published studies indicates that such high users have complex and debilitating physical conditions with frequent co-occurrence of psychological problems. Authors routinely conclude by recommending multidisciplinary, team-based care. Culhane and Kuhn (1998) were able to demonstrate that the field of homelessness has its high users of services. Specifically, examining unduplicated users of shelter services, they identified that approximately 10 percent of users accounted for 50 percent of the annual nights of shelter provided. This group was labeled chronically homeless because of their prolonged spells of homelessness. The study also revealed that levels of behavioral and primary health problems were higher for this group than for other shelter users. Many communities have proceeded to determine the extent of chronic homelessness within their homeless populations. For example, the Institute for the Study of Homelessness and Poverty published data from 24 states, covering more than 50 cities/counties, showing chronic homelessness ranging from a low of 7 percent to a high of 53 percent (Institute for the Study of Homelessness and Poverty, 2005).
As in the primary care field, looking at high-rate users raises good questions about how resources are being used and whether an improvement in services might benefit the client and the provider. The high service use by the chronically homeless led people in the field to ask: Is shelter doing this group any good if they continue to remain homeless for prolonged periods? Is this the best we can do with scarce resources? While no one would suggest that meeting basic needs for shelter and food for chronically homeless persons is misdirected, this was a moment when the field began to question whether we had over invested in shelter as a service, whether different types of approaches should be tried, and whether service dollars might go farther if we addressed chronic homelessness specifically.
In 2000, the National Alliance to End Homelessness (NAEH, 2000) published its plan and its challenge to the field to end homelessness in a decade. This goal and the paths to its realization have generated a substantial amount of interest and activity, noted throughout this paper. Partially in response to the Alliances declared goal, Secretary of HUD Mel Martinez announced that a goal of HUD would be to end chronic homelessness. President Bush endorsed this goal in his submission of the FY2002 HUD budget to Congress. Other federal departments were soon to endorse this goal, as was the ICH, the federal coordinating body on homelessness.
HUD, HHS, and the VA collaboratively developed a definition for a chronically homeless person as:
an unaccompanied individual with a disabling condition who has been continuously homeless for a year or more or has experienced four or more episodes of homelessness over the last 3 years. A disabling condition is defined as a diagnosable substance abuse disorder, serious mental illness, developmental disability, or chronic physical illness or disability, including the co-occurrence of two or more of these conditions (HUD, 2006).
HUDs goal of ending chronic homelessness is reinforced in its annual competition for homelessness funding. Since these annual resources form the backbone of the service response to homelessness in the U.S., they have exerted considerable influence in moving communities to this focus. The focus has also been reinforced by a highly effective campaign by the ICH to get cities and counties to commit to the goal of ending homelessness and chronic homelessness. As of mid 2007, more than 300 communities have published plans reflecting such goals (see the ICH Web site at http://www.usich.gov/slocal/10-year-plan-communities.pdf), and many communities participate in Project Homeless Connect, offering a one-day, one-stop model that reaches substantial numbers of their homeless citizens.
Targeting specific populations with specific services existed in the homelessness world primarily as programs serving demographic subgroups; for example, runaway/homeless youth, families, or people with disabilities (such as homeless persons with mental illness). While targeting chronic homelessness is certainly a goal at the federal level, as states and communities have developed plans they have not necessarily targeted chronic homelessness. The NAEH review of more than 260 city/county plans (2006c) indicates that only about a third of the community plans focus on chronic homelessness.
A homeless system of service does not require targeting of homeless subgroups, but the concept will be used subsequently to show how population reverberates throughout the model and fosters goal attainment. However, one of the first considerations is whether targeting is effective. Targeting has received a good deal of attention from the World Bank in its concern for improving the health status of extremely low-income people. Gwatkin (2002) concludes there is mixed evidence for targeting of health programs, although often because the targeting is inaccurate. When targeting is well designed and well implemented, he indicates it can be highly successful in achieving health status improvements.
Targeting, however, can also lead to resentment that attention and resources to other needy groups are diminished. Indeed, both the National Coalition for the Homeless (2003) and the National Policy and Advocacy Council on Homelessness (n.d.) have objected to the federal chronic homelessness terminology and emphasis because of the many homeless people who are excluded. Baumohl (2006) indicates that the definition sets up a selection bias, ensuring that those included are already likely to be eligible, by nature of the disabling condition, for other resources such as income from SSI and services through Medicaid. A third concern is the use of limited resources. One of the promises stated by federal agencies addressing chronic homelessness was:
By addressing the housing and service needs of persons who are chronically homeless, we will have more resources available to meet the needs of other homeless people (HUD/HHS/VA, 2003).
However, this promise has yet to be tested whether funds can be freed up using this targeting and whether they can be retained within these programs to assist other homeless people.
Housing concerns in connection with targeting chronic homelessness are also significant. Some estimate that access to 150,000200,000 units is required (NAEH, 2000). The creation of units is underway, stimulated by HUD funding incentives and the commitment of cities and counties to ending homelessness. The National Alliance identified 196,000 opportunities under development in recently analyzed plans (NAEH, 2006c). But both the production of units and the securing of subsidies and vouchers to place eligible persons in existing affordable units are formidable challenges. In addition to concerns about the sufficiency of voucher availability, there are concerns about the ability of the housing market to provide opportunities. A study for HUD (Finkel et al., 2003) reports that 71 percent of the Housing Choice Vouchers result in successful leases, down from an 81 percent rate in 1993 (Finkel & Buron, 2001). Affordable housing availability is addressed more fully in other Symposium papers and remains a significant challenge in ending chronic homelessness.
Availability of Services and Supports
In addition to housing, targeting requires the availability of services and supports to the residents. To date, of the service departments, only HHS has released a plan specifying how its services would contribute to ending chronic homelessness (HHS, 2003). The VA, which already integrates its homelessness activities within its health care system, is also responsive. But both these departments must work within the legislative parameters that determine how and to whom services may be offered. Perhaps as a consequence of gaps in implementation, the Senate Committee on Appropriations has regularly directed the ICH to submit a report to the House and Senate Committees on Appropriations on the efforts of every federal agency member of the ICH in ending and preventing homelessness (Senate Committee, 2006).
Successes to Date
Despite these many and legitimate concerns, the momentum on addressing chronic homelessness is underway and appears to have more positive results than adverse ones.
- As noted above, an increasing number of cities are beginning to see measurable reductions in both chronic and general homelessness as a result of this mobilization.
- The development of nearly 200,000 permanent housing opportunities has been noted.
- The ICH routinely reports on commitments to the goal of ending chronic homelessness by the federal departments and municipalities (see http://www.ich.gov/index.html and e-newsletter archive).
- States have become engaged in examining policies and internal collaborations that will address both chronic and family homelessness (see the Homeless Policy Academy Web site at www.hrsa.gov/homeless).
- The ICH has further encouraged states in their commitment to address homelessness by convening regional colloquies where states have shared experiences and ideas (ICH, 2005).
Tracking these developments also appears increasingly feasible. HUD requires its homeless assistance grantees to implement homeless management information systems (HMIS) and has created a methodology that will be able to report annually on changes in the population nationwide (HUD 2007). More than half of the HUD continuums of care have begun to implement HMIS, with many sites already operational. An active program of HMIS-specific technical assistance operates and numerous vendors exist to provide turnkey systems for communities. Many states have recognized the value of these systems and partner with communities to speed implementation, achieve economies of scale, and develop strong accountability systems for homelessness. Researchers also anticipate accessing HMIS data and being able to explore patterns of experience via time-series analyses.
HUD is candid about the capabilities and limitations of HMIS. Technology in all communities is still a hurdle. Such systems will generally cover only HUD-funded grantees and the persons who use them, and therefore the HMISs cannot be thought of as capturing the entire population. Where communities are each implementing stand-alone systems, there can be no undoing of duplication of users who cross municipalities. But the bottom line is that a technology is being widely implemented that will allow monitoring of this stated goal.
Future Opportunities for Targeted Action
Perhaps the most important aspect of focusing on chronic homelessness is the implication that the approach will be used to identify additional, future opportunities for targeted action. One fruitful direction, noted in the accountability paper in the Symposium (Culhane at al., 2007), is the development of a comprehensive intake assessment that leads to the unique specification of the services, providers, and networks with which each client will interact. Another direction continues to focus on taxonomies for homeless populations. New approaches will be needed here since those developed previously have relied mostly on demographic characteristics. Time-series approaches that were used to identify the chronic subgroup may not be sufficient for surfacing other subgroups. For example, factor and cluster analyses may be needed to chart out the complexities inherent in dealing with homeless families, where complex configurations of children at different developmental levels and parents with different presenting profiles are the norm. At least one recent survey, although limited to one city, found that each time the homeless population is assessed, it is aging (Hahn et al., 2006), and this suggests another example of the emergence of a complex profile of service needs that requires careful consideration. As with chronic homelessness, such subgroups identified for targeting may stimulate a focus on effective services for them, including housing, and the provider networks skilled at their delivery.