Changes in the design and resources of mainstream programs that serve low-income people have had a substantial influence on the evolution of housing models for homeless people during the past decade. At the same time, priorities and program emphases for funding streams targeted specifically to preventing or ending homelessness, especially HUDs McKinney-Vento discretionary grants, have evolved along a number of dimensions. Finally, practices for serving homeless people have responded both to evidence and to changing philosophies and judicial decisions about how society treats its most vulnerable citizens.
Changes in income support and housing assistance. In some communities, the implementation of the welfare reform legislation enacted in 1996 had important effects both on patterns of homelessness among families with children and on the way in which providers think about serving families. Cash assistance is now temporary, and families reaching their TANF time limit or sanctioned for failing to comply with TANF rules are among those particularly vulnerable to housing instability (Mills et al., 2006). At the same time, providers helping families exit homelessness focus increasingly on stable employment because of the temporary nature of assistance for those who do not work. Some providers hope to see their clients leave homelessness with a wage high enough to pay for unsubsidized housing because of the increasing difficulty of gaining access to assisted housing.
The Housing Choice Voucher Program, the mainstream program best suited to providing permanent housing for homeless families, has become less available for that use over time due to budget cuts and shifting program priorities that reduce advantages that people leaving homelessness once had in competing for the limited number of subsidy slots. Access to HUDs assisted housing programs has become more difficult recently in many communities because waiting priorities for homeless families and individuals are no longer in effect. These priorities took two forms: (1) a preference on waiting lists for households experiencing homelessness that was equivalent to preferences for households with extreme rent burdens or living in substandard housing, and (2) special allocations of vouchers reserved for clients of the homeless services system. In addition to the discontinuation of priorities for homeless people, admission policies have been tightened across assisted housing programs for people with criminal records or poor housing histories (whether previously homeless or not), making it more difficult to enter public housing and the voucher and project-based Section 8 programs (Khadduri & Kaul, 2005).
Furthermore, according to HUD data cited by the Center on Budget and Policy Priorities, the number of households assisted by housing choice vouchers fell by about 100,000 between 2004 and 2006. Numbers of units in public housing and Section 8 projects declined starting in the mid-1990s. They were replaced by a comparable number of housing vouchers in the same communities, but more recently the number of vouchers has dropped as well, leading to an overall decline in the number of slots available in programs that permit people to pay no more than 30 percent of their income for housing.
For individuals, particularly people with disabilities, the picture is somewhat different. Supplemental Security Income (SSI) remains an entitlement, and providers have focused increasing attention on helping homeless people qualify for this important income source. Permanent supportive housing affordable to people who receive SSI continues to be produced by HUDs Section 811 program for people with disabilities; by the HUD McKinney-Vento grant programs; and by resources under the control of state and local governments, including funding from state mental health systems.
Some 4 million people receive SSI, yet housing that people with SSI can afford remains in short supply compared with the need. OHara and Cooper (2005) compared SSI income to the average cost nationwide of renting a one-bedroom apartment. In 2004, on average, a person receiving SSI needed to pay 109.6 percent of his or her monthly income to rent a modest one-bedroom unit. Like homeless families, individuals attempting to exit homelessness have been affected by the reduced availability of housing vouchers, public housing, and units in Section 8 projects that would help narrow the gap between incomes and housing costs.
The only federal housing program that has produced significant numbers of additional rental housing units since the 1998 Symposium, the Low Income Housing Tax Credit, has rents set at a fixed dollar amount rather than as a percentage of a households income, and those rents usually are not affordable for households with poverty incomes. In addition, choosing to allocate tax credit resources to programs targeted to homeless people often means states must trade off using limited resources for people who are homeless against preserving or expanding housing for people who are low-income but not homeless.
Shifting priorities in HUDs homeless assistance programs. HUD funding for permanent and transitional housing for people leaving homelessness comes largely through two McKinney-Vento programs the Supportive Housing Program (SHP) and the Shelter Plus Care (S+C) program. As of the early 1990s, each program had its own Congressional funding authorization. The SHP funded transitional and permanent housing as well as services. S+C provided permanent housing for persons with disabilities. S+C program funds could be used only for rental assistance, while services had to be leveraged from other funding sources.
Beginning in the mid-1990s, HUD received lump sum McKinney-Vento appropriations instead of separate appropriation amounts for the SHP and S+C programs. Following that change, providers sought greater amounts of funding for eligible activities specifically, transitional housing and supportive services programs from the SHP program relative to the amount requested for permanent housing from both programs. For providers, SHP funding was one of a limited number of sources of services funding. Transitional housing was an attractive option because many providers did not have expertise in the development or management of permanent housing. As a result, the shift in the mix of transitional vs. permanent housing changed substantially. Whereas at one point more than roughly 60 percent of total funding was dedicated to permanent housing, by the late 1990s that percentage had declined to only 20 percent.
To renew emphasis on funding for permanent housing, Congress responded by mandating that at least 30 percent of McKinney-Vento funding (exclusive of S+C renewals) be used for this purpose. Concurrently, HUD began de-emphasizing the use of HUD McKinney-Vento funding for services by offering various incentives for applicants to use HUD funds for housing activities and mainstream sources for services. Recent HUD policies have also given continuums of care (CoCs) flexibility to reprogram existing McKinney-Vento funding during the renewal application process, which has prompted some CoCs to monitor more closely the effectiveness and outcomes of their housing and services programs. Given the scarcity of both mainstream and McKinney-Vento funding for permanent housing for homeless people, many CoCs are now working to redirect funding toward permanent housing.
There has also been an increasing emphasis on serving homeless people who are disabled. Since 2001, HUDs McKinney-Vento funding priorities have focused on addressing the needs of people who are chronically homeless. Through a federal interagency consultation process, chronically homeless people were defined as single individuals with a disabling condition who have been continuously homeless (on the street or in a shelter) for at least one year or have had at least four episodes of homelessness during the past three years. Many people meeting these criteria have histories of mental illness and co-occurring substance use disorders. There are human and public benefits to having this population stably housed: safe, secure, affordable places to live for people who are chronically homeless and less strain on costly emergency services and institutional care systems.
Changing views on participation in services. At the same time that priorities were changing for public programs that serve low-income people in general and people who become homeless, so too were the models developed by practitioners for combining housing and services. Although not mandated by HUD, the model common in the 1990s in many communities emphasized providing services linked to a continuum of housing settings in which people moved from emergency shelter to transitional housing (typically for 6 to 24 months) and then to permanent housing. Requirements that residents participate in services to acquire and maintain housing were permitted, although not mandated, under HUDs Section 811, S+C, SHP, and Housing Opportunities for Persons with AIDS (HOPWA) programs.
During the 1980s and 1990s, the difficulty that people with mental illness had in accessing scarce mainstream affordable housing resources prompted a number of mental health systems (including those in California, Connecticut, Massachusetts, New York, Ohio, and Pennsylvania) and their service providers to fund their own housing programs. While these initiatives helped meet the need for housing, many of these programs came with bundled supports; residents were typically required to accept the services offered with the housing program, and the services often were co-located with the housing.
Some homeless people met the service participation requirements of this type of housing and moved successfully (not necessarily sequentially) through the continuum. Many, especially those with serious mental illness and/or substance abuse issues, were less successful. Some advocates said that housing and services should not be bundled; that is, participation in services should not be a condition of obtaining or maintaining housing, and housing should not be used to induce people to comply with services. This was a particular concern of advocates for people with mental illness, who saw this model as a continuation of coercive practices under which mental health systems exercise enormous control over the lives and behavior of people with psychiatric disabilities (Allen, 2003; see also Diamond, 1996; Carling, 1993).
Many providers of transitional housing would not agree that services should be voluntary. Most transitional programs mandate participation in services, considering it their mission to set goals that move the resident towards self-sufficiency and to use program services to reach the goals.
The Supreme Courts Olmstead decision. A landmark legal decision also figured into the evolution in housing and services models for people with disabilities. In 1999, the Supreme Court held in Olmstead v L.C. that segregating people with disabilities in state institutions may be discriminatory under the Americans with Disabilities Act and that states may be required to provide community-based services rather than institutional placements for persons with disabilities. Regulations promulgated by the Department of Justice to provide guidance on implementing the Courts decision clarified that: A public entity shall administer services, programs, and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities (28 CFR, Section 130(d)).
The Olmstead decision has had implications for both housing and services for people with disabilities, including those who are or may become homeless. On the housing side, states and the federal government have been encouraged to identify alternative housing for people in institutions who wish to live in the community. For example, HUDs ACCESS program provided voucher assistance to a set of communities to test the concept of using vouchers to help non-elderly persons with disabilities move directly from nursing homes to permanent rental housing. The Olmstead decision is also credited with the creation of policies that promote the most integrated models of permanent housing for people with disabilities. For example, state policies encouraging sponsors of housing developed with Low Income Housing Tax Credits to set aside a percentage of units for people with disabilities have created integrated housing settings in California, New Jersey, North Carolina, Louisiana, and other states.
On the services side, the Olmstead decision encouraged states to identify funding sources for community-based services. One source is Medicaids Section 1915(c) Home and Community-Based Services Waiver program. This program gives HHS authority to waive Medicaid provisions in order to allow long-term care services to be delivered in permanent housing in the community instead of in institutional settings. Certain subpopulations of homeless people with disabilities may qualify for these services, depending on the states Medicaid policies. Similarly, Medicaids Medical Rehabilitation Option is used in some states to provide case management, health, mental health, and substance abuse treatment services.
Lessons from evidence-based behavioral health practices. In response to the perceived need for new models, policymakers and practitioners looked for housing and service approaches that had been tested and found effective, particularly for homeless people with mental illness and substance use disorders. The focus on evidence-based practices was particularly prevalent in the medical, mental health, and substance abuse treatment fields, in which the federal government, foundations, and researchers promoted clinical interventions that research studies had shown to be effective. Within public mental health/behavioral health systems, the assertive community treatment (ACT) model gained credence as an effective way to engage homeless people with mental illness and substance abuse issues, a population that had been particularly challenging to serve in the emergency shelter and transitional housing programs of the 1990s.
In its pure form, the ACT approach uses multidisciplinary teams trained in mental health and substance abuse treatment, employability development, medical care, case management, and life skills training to reach out to homeless people on the street and in shelters to encourage them to enter more permanent housing. The service approach is client-focused and separates housing and other supportive services; that is, clients do not have to accept supportive services as a condition of entering or retaining housing. While not all communities have the resources to implement the ACT model in its pure form, aspects of the model, such as the emphasis on meeting clients where they are, offering but not mandating services, and providing services in-vivo (either in the clients home or in the community), have been adopted in many communities even though it is not clear that piecemeal application of what is designed to be an integrated model would be as effective as full implementation.
Emergence of housing first models. The emphasis on permanent housing and on chronic homelessness, together with the success of approaches such as ACT to providing services to people with chronic mental illness and persistent substance abuse, encouraged a new paradigm for meeting the needs of this vulnerable population. In recent years, more providers have come to view the continuum of care not as a sequential series of placements but rather as a menu of options, any of which might be appropriate for any particular client. Among those options, housing first approaches are being tested that emphasize rapid placement in permanent housing with no or minimal transitional placements or service requirements. Community-based support and treatment (some using the ACT team model or variations on it) help people maintain their housing.
The rapid housing placement aspect of the housing first approach is being used for both individuals with disabilities and families, although the service approaches differ somewhat. Programs serving single individuals with disabilities tend to focus heavily on housing placement and retention, with minimal service participation required either to enter housing or to retain it. Programs serving families also focus heavily on housing placement and retention up front, while typically also establishing service plans. Service plans are initially focused on the housing search process and short-term case management; once the family is in permanent housing, the plans focus on longer-term case management. Similar to housing first programs for single individuals with disabilities, service participation in programs serving families is typically voluntary. Engagement is a central component in working with both populations. Providers working with families must also take into account the needs and safety of children in determining how voluntary service participation should be. The vulnerability of children to dangerous or abusive parental behavior makes the issue of voluntary services different for families who become homeless with their children than it is for people who become homeless without accompanying children. Further, when family reunification or preventing the loss of custody is a goal, the parent needs to show credible progress to the child welfare system.
Debate continues over the effectiveness of the housing and service approaches associated with housing first and which elements of the model are most important. More broadly, the evolution toward community-based housing and services approaches, driven by funding priorities and emerging evidence-based practices, has spurred increased interest in identifying which housing and services approaches work best for whom, but so far has not resulted in a commensurate level of rigorous research to provide answers to these questions. In the next section, we describe further the evolution of housing models and review recent research findings on the implementation of these approaches and what is known about their outcomes for clients.