# Presentation: 644279

## Preventing Chronic Homelessness – What Works?

- Deborah Dennis
- Policy Research Associates, Inc.
- Delmar, NY
- Policy Academy on Chronic Homelessness
- Miami, FL
- December 10, 2003

## Why Address Prevention?

- Until we address the role of mainstream systems in creating and resolving chronic homelessness, we will never be able to end chronic homelessness
- Prevention of chronic homelessness is one of three goals in HHS Secretary’s report on ending chronic homelessness

## Why Focus on Mainstream Programs?

- People who experience chronic homelessness are heavy users of expensive mainstream services
- Levels of disability and poverty make them likely to be eligible for mainstream programs
- Approaches that work for this subgroup may make mainstream services more accessible for others

## How Can Chronic Homelessness Be Prevented?

- Identify risk and protective factors to help prevent chronic homelessness among persons at risk
- Use evidence-based practices to prevent chronic homelessness

## Some Individual Risk Factors

- Chronic health conditions, mental illness and/or substance use disorders
- Limited or no social support networks
- Domestic violence and other victimization or trauma-related factors
- Family instability as a child (out-of-home placement, family homelessness, incarceration of a parent)
- Combat experiences for veterans

## Some System-Based Risk Factors

- Lack of permanent affordable housing
- Very low or no income
- Discharge from jail, prison, hospital, shelter, detox & residential substance abuse treatment, and foster care

## Discharge from Institutions

- 	Data from Massachusetts Housing and Shelter Alliance showed that people coming into shelters were well-known to the State’s mainstream systems
- 18-24-year-olds aging out of State services
- Ex-offenders released from State or county facilities with no place to go
- People from detox at the beginning of their recovery
- People with mental or serious physical illnesses released directly from a hospital

## Hospital Discharges

- 	Compared to men who had never been homeless...
- 	Homeless men with schizophrenia were more likely to have been discharged against medical advice and had less adequate discharge planning for living arrangements, aftercare and finances (Caton et al., 1993).

## Discharges from Jails & Prisons

- Arrangements for housing are seldom considered
- Benefits have often been lost
- Inmates with mental illness (16% of all inmates nationally) incarcerated for more than a year must reapply for SSI benefits upon release
- Often lose Medicaid upon incarceration even though Federal regulations allow for suspension rather than termination of this benefit

## Transition from Foster Care

- People who are chronically homeless are 7-13 times more likely to have had an out of home placement than the general population (Burt et al., 2001)
- Thirty percent of youth leaving foster care experience homelessness within two years of discharge (Schwab Foundation, 2003)

## Evidence-Based Prevention Practices

- Few evidence-based interventions
- Several promising practices
- Housing subsidies
- Eviction prevention
- Discharge / transition planning

## Housing Subsidies

- Studies find housing subsidies one of the most effective interventions to prevent housing loss
- Receipt of subsidized housing is the primary predictor of housing stability among homeless families (Shinn and Weitzman)
- SAMHSA’s study of homelessness prevention among people with mental health and/or substance use disorders found access to housing subsidies or supported housing was the strongest predictor of residential stability --  regardless of level of disability

## What States Can Do...

- 	The *Missouri *Department of Mental Health provides funding for temporary vouchers for people with serious mental illness who are on the Section 8 waiting list.
- 	Vouchers are administered by local public housing authorities and DMH provides services through contracts with local mental health agencies.

## Eviction Prevention

- Promising practices include:
- Representative payees and other financial management interventions
- Landlord / tenant mediation services
- Respite for family caregivers
- Emergency rent and utility payments
- With the exception of representative payees, none of these practices has been rigorously studied

## What States Can Do...

- In *Minnesota*, the legislature created a $50,000 fund to pay for rent for up to 90 days while an individual with serious mental illness is in inpatient treatment
- The *Alaska* Department of Mental Health and Developmental Disabilities provides flexible service funds of up to $2,000 per client for any expense needed to keep the client in community-based housing
*Pathways to Housing* in NYC, a housing first model, uses money management -- one of two key tools (the other being ACT teams) -- to keep people who were chronically homeless in housing of their choice

## Discharge / Transition Planning

- Discharge planning, linked to affordable housing and aftercare, is recommended as a strategy to prevent chronic homelessness -- particularly for people with health and behavioral health disorders
- Although this sounds logical, there is no empirical evidence to support the efficacy of such efforts
- This remains an important promising practice

## What States Can Do...

*Massachusetts* evaluates contractors on performance measures where homelessness is a negative outcome and housing is a positive outcome
- These outcomes are tied to penalties and incentives for each system (corrections, mental health, etc.)
- Focus on transition planning has led to more integrated services in mainstream facilities. Prisoners can now be deemed eligible for Medicaid while still in prison and automatically enrolled on the day of their release. Many also make a community health center connection before leaving (_[www.](http://www.nhchc.org/discharge)__[nhchc](http://www.nhchc.org/discharge)__[.org/discharge](http://www.nhchc.org/discharge)_)

## What States Can Do...

*Philadelphia* has recently begun to apply this same principle to shelter providers
- Shelters are penalized when someone discharged from their shelter becomes homeless again
- The incentive is for shelters to do more to place people in housing and provide services to keep them there
- Philadelphia has already begun to decrease its  shelter beds by 5% annually as a result

## What States Can Do...Critical Time Intervention & Short-term ACT Services

- Are evidence-based practices for people who have experienced chronic homelessness
- Provide intensive clinical services for 6-12 months during and following transition from shelters, hospitals or jails
- Have been proven effective in maintaining residential stability and linkage to mainstream treatment and other support services *after* intervention is scaled back or withdrawn

## What States Can Do...Respite Care

*Boston* Health Care for the Homeless operates 90 recuperative care beds that bridge the period following hospital discharge for people who are homeless
- Similar effort in *Savannah, GA*, is estimated to have saved two local hospitals $1.8 million, more than doubling their individual $250K investments

## What States Can Do...Transition Planning in Corrections

- There are no evidence-based transition planning practices in corrections
- Multi-site studies of jail mental health programs have lead to a promising model
- The APIC model promotes transitional services that begin in jail or prison and emphasize access to housing and clinical case management upon release (The National GAINS Center, 2002)

## What States Can Do...Youth in Transition

- The federally-funded Independent Living Program for youth transitioning from foster care allows up to 30% of funds to be used toward housing for youth until they reach the age of 21
- Bridge of Faith in *Los Angeles* is one example of how these funds provide housing and services to young women transitioning from foster care while they take steps necessary to live on their own (NYT, 4/12/03)

## Conclusions...

- Policy makers and practitioners are urged to keep their goals clearly in mind...
- Preventing chronic homelessness is not identical with ending poverty or promoting economic self-sufficiency

## Conclusions...

- Some eviction prevention programs and discharge planning efforts seem promising, but none have been studied rigorously.

## Conclusions...

- Providing housing subsidies that target the worst-case housing needs (e.g., people who are chronically homeless) are probably warranted

## Conclusions...

- Services to support people who have been chronically homeless in housing – particularly during periods of transition — are also critical, but effectiveness has only been demonstrated for the most intensive clinical teams