A critical component of a contemporary homeless system of service is a network of providers that cumulatively offers the array of services needed by those experiencing homelessness. Since the mid-1990s, there has been steady momentum toward affirming that only a collaboration of multiple agencies will succeed in addressing contemporary homelessness. This has been true because it is difficult for one agency, such as a housing program, to be expert in the multiple services a homeless person or family may need, or to secure the funding for these services. Establishing collaborations has become the currency by which these networks are being formed (SAMHSA, 2003a). These collaborations are often formalized in interagency bodies, memos of understanding, joint plans, and other manifestations that signal sharing of information, resources, and improved access to services.
One impetus to such collaboration began with HUDs implementation of the continuum of care concept in the mid 1990s (Burt et al., 2002). Since its introduction, the continuum concept has shown the resiliency to accommodate many different components. In its earliest introduction, it emphasized the array of services, primarily housing, that a homeless person may need to exit homelessness and move to self-sufficiency. HUD required that a community submit a request for funding that demonstrated how it would create this array. Importantly, the application for funding also had to show it had been developed in consultation with a specified panel of partners. Over time, the continuum concept has also been identified with the infrastructure that is implied if this panel of multiple partners formalizes its operations and functions to address homelessness in its community. HUD currently defines it as a plan:
The Continuum of Care is a community plan to organize and deliver housing and services to meet the specific needs of people who are homeless as they move to stable housing and maximum self-sufficiency. It includes action steps to end homelessness and prevent a return to homelessness (HUD, 2001).
Having a continuum of care, both as a plan and an infrastructure, is a necessity to compete for HUDs homelessness resources. Consequently, this requirement has had extraordinary influence on localities and states, leading to the formation of collaborations with an assortment of interested parties. This goes well beyond service providers to include private developers, faith-based institutions, education programs, police, banks, and others.
HUDs evaluation of the continuum of care approach (Burt et al., 2002) noted that when it was introduced, the continuum concept had the greatest impact on communities that had done relatively little to collaborate on homelessness. The evaluation, while preselecting high performing continuums early in this decade, showed that effective continuums increase communication among the organizations involved, improve coordination among providers, and serve more homeless persons. For homeless programs funded by the VA, a somewhat parallel effect has been reported. McGuire et al. (2002) found that relationships (i.e., communication and access to services) between VA programs and the community were strongest in the VA programs that actively supported community programs versus those that operated in a stand-alone mode.
These collaborations have been shown to yield other benefits for homeless people. The 1998 Symposium included an opportunity to report on a set of findings from the Access to Community Care and Effective Services and Supports (ACCESS) study (Randolph et al., 2002) a service/treatment evaluation looking at the creation of comprehensive systems of services to address homelessness and serious mental illness. However, several of the findings from the systems integration efforts of the ACCESS study are instructive here. Over the five years of support, all the communities in the study demonstrated increased systems integration, but in the subset of communities where integration was an intentional focus, it was more focused and partner-specific than in the comparison sites (Morrissey et al., 2002). Furthermore, high degrees of systems integration were beneficial for the homeless consumers served in the study. In settings where high system integration had been achieved, clients were better able to access and retain housing (Rosenheck et al., 2002).
With funding and policies, organizations can be motivated and supported to collaborate for the benefit of homeless people in the community. Collaborations may work best when they are expected to be focused and partner-specific since they may identify specific ways in which the organizations can coordinate their actions. Current homeless-specific funding places a priority on the delivery of a set of services to a designated homeless population, and collaborations are secondary. HUDs continuum of care is the exception. More could be done by programs and with amended legislation to support collaborations. In addition, several federal homelessness reports (ICH, 1992; HUD, 1994; U.S. General Accounting Office, 1999, 2000) have been instrumental in pointing out the importance of accessing a broader set of assistance programs to address homelessness.
Blended Funding Resources
The practice of blending both homeless-specific and broad assistance program resources began only in the past few years. This practice is one of the principal messages in the HHS plan (HHS, 2003) and is emphasized in HUDs latest annual funding competitions as the leveraging of additional service resources. The broader set of resources is often referenced as mainstream programs and covers broadly focused programs directed to helping those who are low-income or disabled with cash assistance, health coverage, training, education, and other forms of assistance (see CMS, 2003).
A series of Policy Academies for states (www.hrsa.gov/homeless), from 2001 to 2005, focused on helping states develop plans to address homelessness by tapping and coordinating these mainstream program resources. The ICH reports that 53 states and territories have begun to establish state-level interagency councils on homelessness where plans and blended resources are the focus. HUDs evaluation of continuums of care (Burt et al., 2002) also noted that engagement of mainstream services can be both independent of and embedded with the operation of local continuums. Both at the state and community levels, homeless systems of service increasingly recognize the need for collaboration and for the inclusion of mainstream programs in any collaborative network. For such networks to work most effectively, it is desirable for policies to be supportive and not hamper their functioning. There are several hurdles to overcome.
Eligibility policies. Most mainstream program eligibility policies are established explicitly at the federal or state level by statute or regulations, or implicitly by funding levels, thus limiting flexibility at the local level. The most apparent limitation that affects good network performance is eligibility differences across programs. Eligibility standards are typically established separately and legislatively for each program funding stream, and it is rare for exactly the same criteria to be used across funding streams. For example, while all are intended to provide assistance to poor individuals or families, TANF, Food Stamps, and Medicaid have separate eligibility requirements. The U.S. Government Office of Accountability has recommended that a common eligibility application might be a solution to these multiple requirements (U.S. General Accounting Office, 2000). Several states have implemented consolidated application forms. Texas uses a single form to determine eligibility for Medicaid, SCHIP, TANF, Food Stamps, and long-term care (National Governors Association, 2007). Information provided on the form for one program also can be used to determine eligibility for one or more other covered programs.
Available funding. Social Security, Medicare, and Medicaid represent over 40 percent of the federal budget (Riedl, 2006). Past and anticipated rates of growth in these programs have raised concerns in many quarters about their long-term sustainability (Walker, 2006). Current budget deficits have prompted some to propose substantial cuts in mainstream programs for low-income and middle class populations. For example, the Stop Overspending Act of 2006 (S. 3521), while not enacted, proposed deep cuts in domestic discretionary and entitlement programs if spending containment targets were not met.
Barriers to participation. Concerned about growth in their outlays for Medicaid, the Kaiser Commission on Medicaid and the Uninsured/Kaiser Family Foundation reported that during 2004-2005 all states took action to control costs in Medicaid (Smith, et al., 2004). Goldstein (2006) cited such actions as states requiring that members sign compliance contracts or face penalties, imposing or increasing copayments, assigning patients to priority groups, and increasing documentation requirements. The Deficit Reduction Act of 2005 requires all Medicaid participants and applicants to provide proof of citizenship as a condition of eligibility. Missouri has passed a law to eliminate its current Medicaid program in 2008. Interestingly, states do not appear to be focusing their cost containment proposals on the 4 percent of Medicaid enrollees who account for nearly 49 percent of Medicaid expenditures (Sommers & Cohen, 2006, using data from the Kaiser Commission on Medicaid and the Uninsured).
Impacts of welfare reform. The welfare reforms of the mid-1990s have been closely monitored and systematically evaluated (Haskins, 2006). The Temporary Assistance for Needy Families program (TANF), created by the 1996 welfare reform law, shifted the focus of cash assistance away from aid to children in low-income families to temporary aid conditional on work. This created interesting parallels to the work requirements that accompanied charity in the 18th and 19th centuries. Since its implementation, TANF caseloads have declined by 60 percent, with 6070 percent of women leaving welfare being employed (Haskins, 2006). Other research (e.g., Miles & Fowler, 2006) has found that some current and former TANF families cannot pay their rent (2125 percent) and experience homelessness (744 percent). Interim final rules published in 2006 implementing changes in the TANF program, included in the Deficit Reduction Act of 2005, limit states flexibility in addressing employment barriers for TANF recipients, including adults in homeless families. Advocates for public assistance have pointed out that these rules opt for restrictive interpretations within the latitude available to the HHS (e.g., Lower-Basch et al., 2006).
The issues are significant because they demonstrate the challenges of accessing mainstream public assistance resources within the context of a homeless system of service. Not only are there degrees of freedom restricted by legislation and regulation governing these programs, but the ground many of them are based on has begun to shift. Although many of these actions remain proposed rather than enacted, they bear close monitoring by those involved in homelessness because of their troubling implications for the resources and policies needed for effective assistance networks.
The developments are also important to the direction in which a homeless system of service might develop. If mainstream resources continue or increase in importance as a source of assistance to homeless persons, the system could be subsumed or function as a specialty subsystem within the generic approaches to assisting low-income, disadvantaged, and uninsured populations. This pattern characterized the U.S. approach to homeless assistance until the contemporary wave of homelessness. Such a direction may have appeal to critics who feel that addressing homelessness has become its own industry. However, if mainstream resources become more difficult to access for all eligible people, including homeless persons, it would be a prima facie argument that the homeless system of service needs continued growth, development, and funding as our principal hope for addressing and ending homelessness.