**[Slide 1:]{.underline}\
\
**Characteristics and Service Needs of People Experiencing Chronic
Homelessness\
\
Deborah Dennis\
Policy Research Associates, Inc.\
Delmar, NY\
\
Policy Academy on Chronic Homelessness\
Olympia, WA\
April 28, 2004

**[Slide 2:]{.underline}\
**

Chronic Homelessness

HHS, HUD, DOL and VA use the following working definition in their
collaborations:

An unaccompanied individual with a disabling condition who has either
been continuously homeless for a year or has had at least four (4)
episodes of homelessness in the past three (3) years.

**[Slide 3:]{.underline}\
**

How Many?

-   80% of the estimated 2-3 million people who experience homelessness
    each year exit within 3-4 weeks

-   10% are homeless more episodically

-   10% experience chronic homelessness.

**[Slide 4:]{.underline}**

Why Address Chronic Homelessness?

-   They have greater difficulty exiting homelessness on their own

-   Although small in numbers, they use half of all emergency assistance
    for people who are homeless

-   Placing them in supportive housing saves money.

**[Slide 5:]{.underline}\
**

Who Are They?

-   At least 75% male, 40% of whom are veterans

-   At least 40% African American

-   Tend to be older.

**[Slide 6:]{.underline}\
**

What Issues Do They Face?

-   40% have substance use disorders

-   25% have physical disabilities or disabling health conditions

-   20% have serious mental illnesses

-   66% have more than one of these conditions.

**[Slide 7:]{.underline}\
**

What Prevents Them from Exiting Homelessness?

-   Persistent poverty

-   Lack of affordable housing

-   Disabling health and behavioral health conditions

-   Service system barriers.

**[Slide 8:]{.underline}\
**

Poverty

-   Most rely on public entitlement programs\
    (e.g., SSI, SSDI, VA) for income

-   Even with income support, they remain\
    below the federal poverty level

-   Many do not receive benefits they are entitled to

-   People with a primary diagnosis of a sub-stance use disorder are not
    eligible for SSI.

**[Slide 9:]{.underline}\
**

Housing

-   Lack of affordable housing options for very low-income people

-   People with disabilities on SSI must pay 105% of income to rent a
    modest one-bedroom unit at Fair Market Rent

-   Average wait for Section 8 rental assistance is now more than two
    years.

**[Slide 10:]{.underline}\
**

Disability

-   Have multiple needs that can't be addressed by one system

-   Burden of accessing and coordinating services and treatment falls on
    the individual

-   Stigma and discrimination are major barriers to accessing housing
    and services.

**[Slide 11:]{.underline}\
**

Service System Barriers

-   Service systems and funding are fragmented

-   Administrative procedures are restrictive and burdensome

-   Resources (housing and services) are insufficient

-   Treatment and services programs are sometimes ineffective.

**[Slide 12:]{.underline}\
**

The Challenge...

-   To ensure that people who experience chronic homelessness have full
    access to both targeted and mainstream programs.

**[Slide 13:]{.underline}\
**

Mainstream Federal Programs

**Income/Employment**

-   Department of Labor programs

-   SSI/SSDI

-   TANF

**Services**

-   Medicaid

-   Mental Health Block Grant

-   Substance Abuse Block Grant

-   Community Health Centers

-   Community Services Block Grant

-   Social Services Block Grant

**Housing**

-   Section 8

-   HOME

-   HOPWA

-   Community Development Block Grant

-   Section 811

**Veterans Programs**

**[Slide 14:]{.underline}\
**

Blueprint for Change:

Ending Chronic Homelessness for Persons with Serious Mental Illnesses
and/or Co-Occurring Substance Use Disorders\
\
December 2003\
Substance Abuse and Mental Health Services Administration U.S.
Department of Health and Human Services

**[Slide 15:]{.underline}\
**

SAMHSA Blueprint

-   Dispels myths about people who are chronically homeless

-   Establishes that housing, treatment and services work for this
    population

-   Works from a strong set of person-centered and recovery-based values

-   Identifies evidence-based and promising practices that can be
    adapted to local contexts

-   Provides a Federal perspective on addressing chronic homelessness.

**[Slide 16:]{.underline}\
**

Before You Begin...

-   Understand the Changing Context of Care

```{=html}
<!-- -->
```
-   How treatment for mental and addictive disorders has evolved.

```{=html}
<!-- -->
```
-   Learn about the Population

```{=html}
<!-- -->
```
-   Recognize individual risk factors

-   Explore service system challenges

-   Learn about societal risk factors.

```{=html}
<!-- -->
```
-   Establish Core Values

```{=html}
<!-- -->
```
-   Supporting the concept and practice of recovery

-   Putting people first

-   Creating systems that support recovery.

**[Slide 17:]{.underline}\
**

Recovery...

A process of restoring or developing a positive and meaningful sense of
identity apart from one's condition and then rebuilding a life despite,
or within, the limitations imposed by that condition.

-   Recovery from substance use disorders.

-   Recovery from mental illness.

-   Recovery from homelessness.

**[Slide 18:]{.underline}\
**

Systems That Support Recovery...

-   Believe in recovery and prove it by offering choice, voice, dignity
    and respect, and hope.

-   Make "any door the right door" to services.

-   Use mainstream resources to serve people who are homeless.

-   Are flexible/offer low-demand services.

-   Tailor services to meet individual needs.

-   Develop culturally competent services.

-   Involve consumers and recovering persons.

-   Offer long-term follow-up support.

**[Slide 19:]{.underline}\
**

Step 1. Plan for Services...

-   Establish a Comprehensive, Integrated System of Care

```{=html}
<!-- -->
```
-   Develop a base for systems change

-   Engage in strategic planning

-   Participate in community-wide planning.

```{=html}
<!-- -->
```
-   Finance a Comprehensive System of Care

```{=html}
<!-- -->
```
-   Streamline existing funding

-   Secure additional resources

-   Leverage new funds.

**[Slide 20:]{.underline}\
**

Step 2. Use Evidence-Based and Promising Practices**\
\
Outreach and Engagement**

-   Meet immediate, basic needs for food, clothing, and shelter

```{=html}
<!-- -->
```
-   Non-threatening, flexible approach to engage and connect people to
    needed services.

**Housing with Appropriate Supports**

-   Includes a range of options from Safe Havens to transitional and
    permanent supportive housing

-   Combines affordable, independent housing with flexible, support
    services.

**Multidisciplinary Treatment Teams/Clinical Case Management**

-   Provides or arranges for clinical, housing and other rehabilitation
    needs

-   Features low caseloads (10-15:1) and 24-hour service availability.

**[Slide 21:]{.underline}\
**

More Evidence-Based and Promising Practices...**\
**

**Integrated Treatment for Co-occurring Disorders**

-   Coordinated clinical treatment of both psychiatric and substance use
    disorders

-   Reduces alcohol and drug use, homelessness, and severity of mental
    symptoms.

**Motivational Interventions/Stages of Change**

-   Helps prepare people for active treatment; incorporates relapse
    prevention

-   Must be matched to an individual's stage of recovery.

**Modified Therapeutic Communities**

-   Have been successfully adapted for people who are homeless and
    people with co-occurring disorders

**Self-Help Programs**

-   Often include the 12-step method, with a focus on personal
    responsibility

-   May provide an important source of support for people who are
    homeless.

**[Slide 22:]{.underline}\
**

More Evidence-Based and Promising Practices...

**Involvement of Consumers and Recovering Persons**

-   Serve as positive role models, help reduce stigma, and can help with
    outreach and engagement of others

-   Should be actively involved in the planning and delivery of
    services.

**Prevention Services**

-   Reduce risk factors and enhance protective factors

-   Provide supportive services to people in housing

-   Improve discharge planning from hospitals, jail/prison, shelters

-   Offer intensive support during transition from one setting to
    another

-   Make sure crisis intervention services address/prevent housing loss.

**[Slide 23:]{.underline}\
**

Other Essential Services

-   Primary health care

-   Mental health and substance abuse treatment

-   Psychosocial rehabilitation

-   Income support and entitlement assistance

-   Employment, education, and training

-   Services for women

-   Low-demand services

-   Crisis care

-   Family self-help/advocacy

-   Cultural competence

-   Criminal justice system initiatives

**[Slide 24:]{.underline}\
**

Step 3. Sustain Services

-   Measure Results

```{=html}
<!-- -->
```
-   Measure client-level outcomes

-   Measure system-level outcomes

-   Use management information systems.

```{=html}
<!-- -->
```
-   Use Mainstream Resources

```{=html}
<!-- -->
```
-   Use mainstream resources to prevent homelessness

-   Improve access to mainstream programs

-   Expand the capacity of mainstream programs

-   Promote coordination and collaboration

-   Build the infrastructure of housing and services

-   Create public awareness.