Department of Health and Human Servces 
OFFICE OF

INSPECTOR GENERAL

ALCOHOL, DRUG, AND MENTAL 
HEALTH

SERVICES FOR HOMELESS 
INDIVIDUALS

Richard P. Kusserow

INSPECfOR GENERA

MACH 199  GENRA

OFFCE OF INSPECfOR 
The mission of the Offce of Inpector General (OIG), as mandated by Public Law 95-452
, as 
amended, is to protect the integrty of the Department of Health and Human Servce' (HHS) 
programs as well as the health and welfare of beneficiaries selVed by those programs. Th statutory 
mission is carred out through a nationwide network of audits, investigations, and inspections
conducted by three OIG operating components: the Offce of Audit Servce
, the Office of 
Investigations, and the Offce of Evaluation and Inpections. The OIG also inorm the Secretary 
of HHS of program, and management problems, and recommends courses to correct them. 
OFFCE OF AUDIT SERVICE 
The OIG's Offce of Audit Servce (OAS) provides all auditing servce for HHS
, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrng out their 
provide independent assessments of HHS programs 
respective responsibilities and are intended  tp 
and operations in order to reduce waste, abuse, and mismanagement and to promote economy and 
efficiency throughout the Department. 
OFFCE OF INTIGATIONS 
The OIG's Offce of Investigations (01) conducts criminal, civil, and administrative investigations of 
allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrchment by 
providers. The investigative effort of 01 lead to criminal convictions, adminitrative sanctions, or 
civi money penalties. The 01 also oversees State Medicaid fraud control units which investigate and 
prosecute fraud and patient abuse in the Medicaid program. 
AN 
OFFCE OF EVALUATION  INSPECTONS 
The OIG' s Offce of Evaluation .and Inspections (OEI) conducts short-term management and program 
evaluations (called inspections) that focus on issues of concern to the Department, the Congress, and 
the public. The fidigs and recommendations contained in these inpection report generate rapid 
accurate, and up-to-date information on the efficiency, vulnerabilty, and effectiveness of departmental 
programs. 
This report was prepared under the direction of Wiliam C. Moran, Regional Inspector General 
Offce of Evaluation and Inpections and Natalie Coen, Deputy Regional Inspector General, Offce 
of Evaluation and Inpections, Region V. Participating in this project were the following people: 
Heaquars 
Chcago. II 
Barbara Butz (Project Leader)  Emilie M. Baebel 
Jenner Antico  Susan E. Hardwick 
Pamela S. May  W. Mark Krhat 
Kate McFadden 
Emil J. Posavac  Department of Health and Human Servces 
OFFICE OF

INSPECTOR GENERAL

ALCOHOL, DRUG, AND MENTAL HEALTH

SERVICES FOR HOMELESS INDIVIDUALS

Richard P. Kusserow

INSPECfOR GENERA

002 
OEI-05-91- EXECUTIVE  SUMMARY

PUROSE 
This inspection examined how States use the Alcohol, Drug Abuse and Mental Health 
Servces (ADMS) block grant to serve homeless individuals with mental health, alcohol 
or other drug problems.

BACKGROUN 
Recent research suggests that approximately one-third of an estimated 600 000 homeless 
population are severely mentally il, at least 40 percent have problems with alcohol, and 
, it is estimated that at least 
an additional 10 percent abuse other drugs. In addition
one-half of the homeless mentally il population also have alcohol or other drug 
problems. 
The Department's response to homelessness is two-pronged: (1) specially targeted 
programs for homeless persons and (2) mainstream programs that serve them as part of 
their servce population. The 1987 Stewart B. McKinney Act is the government s major 
targeted response to the problem of homelessness; the McKinney Projects for 
Assistance in Transition from Homelessness (PATH) program targets the homeless 
population with dual diagnosis of serious mental ilness and substance abuse disorders. 
In terms of mainstream programs, the ADMS block grant is one of the Department's 
largest programs that could serve homeless persons. 
The ADMS block grant is administered by the Public Health Servce (PHS). States 
may use ADMS funds for grants to community mental health centers and for substance 
abuse prevention, treatment, and rehabiltation programs and activities. States are not 
mandated to serve the homeless population with ADMS monies; however, they may 
choose them as a special target population. 
ADMS funding for fiscal year (FY) 1991 is $1.33 bilion; nationally, 20 percent is being 
spent for mental health servces, and 80 percent for substance abuse treatment and 
prevention. ADMS dollars represent a small portion of total State mental health 
, they accounted for only 
expenditures; in 1987 2.3 percent of $9.3 bilion spent for 
State Alcohol and Drug Abuse Profie 
mental health nationally. According to the 
1990 
ADMS dollars represent about 20 percent of all funding for public sector alcohol and 
drug abuse treatment servces. 
AN METHODOLOY 
SCOPE 
Besides the ADMS block grant, this study looked at Medicaid and Supplemental 
Security Income (SSI). We examined the availability, accessibilty and appropriateness  of these mainstream programs for homeless individuals. This report presents findings 
concerning the ADMS block grant; two other reports present findings related to 
Medicaid and SSI. 
We spoke with 224 ADMS grantees in 10 States: California, Hawaii, Illnois, Ohio 
Oregon, Maryland, Missouri, New Jersey, New York, and Texas. A 
description of the 
methodology for this inspection is in Appendix A. 
FIINGS 
provi  th  inviLr 
Mdaatnay o n nuerw ho receie AsDeMreSs d opllrros vsaiy   sere homele  but lack 
sered and 
inls 
diff 
Homele  have proble tht are more depete sever  and 
to treat 
thn thoe of 
othe clits. 
Fcolr ith.e  mot part grantees provi the same seres to homele inivils as to othe
Some provi specil seres. 
inls 
Respondts say th tsher es are approprite for homele  but inomplete. 
freqtly refer  elsewhee for serces the do not provi but referals ma not
Th 
be efectie.

need 
Respondts strngly  are  to sere homele peons. 
agree that spcil approache 
RECOMMNDATIONS 
We conclude that it is critical for agencies to work together to develop the expertise 
needed to serve homeless individuals and to ensure comprehensive servces for them. 
Our recommendations emphasize the ideas of linkage and coordination among different 
levels of government, between government agencies, and within local servce systems. 
PHS-f 
Th  PHS shouli nprLovir t.e chnal astance to States and othe  grntees who
sere homele 
is 
Alcoho  Drg Abuse, and Mental Health Admtratin shoul  an adviory letter 
tToh   all Stateg wri t h ne roun of  letter shoul uncore th importnce
inlu  fug.  Th  inivls: 
for ADMS  to  the follwig compone in serg homele 
Specialized training for servce providers, shelter personnel, and volunteers, for 
dealing with the unique problems of this population. 
Developing Memoranda of Understanding or other tyes of formal agreements 
with other servce providers. Agreements would include information-sharing, 
cross-training, technical assistance, development of model programs (including  outreach, application procedures, resource referral, and coordination 
with the 
broader servce community), and model release plans (including housing) for 
institutionalized persons (Le. in jails or hospitals). 
COMM 
We received comments from PHS and the Assistant Secretary for Planning and 
Evaluation (ASPE). We wish to thank those who commented on this report. The text 
of their comments is in Appendix C. 
Although PHS concurs with the principles underlying our recommendations, they do not 
agree with us that the ADMS block grant is an appropriate mechanism to implement 
them. Instead, they propose to rely on their current McKinney-funded programs. 
We believe that both the McKinney Act and the ADMS block grant are valuable 
resources for improving servces to this population. A previous OIG study on the 
McKinney Act revealed widespread agreement among respondents that McKinney alone 
is not the solution to homelessness, and that greater efforts should be made by 
mainstream Federal programs to serve the homeless. The ADMS grantees in this study 
represent an extremely broad and diverse national network of providers, a large 
majority of whom are providing some level of servce to homeless individuals. We do 
not think that such a broad mainstream program, funded at $1.33 bilion, should be 
overlooked as a mechanism to address the problems identified in this study. We think 
that PHS, in bringing its resources to bear on this network, can help improve 
considerably the response of these providers to homeless individuals. 
We continue to recommend a strong technical assistance role for PHS. However we 
have modified our language in the recommendation slightly. We recognize that PHS' 
primary responsibilty is to States for the block grant, and to their local McKinney 
grantees, who in turn can work - and, we hope, would take every opportunity to do so 
with local ADMS grantees. 
We revised the first finding and made some editorial changes elsewhere in the report 
accommodate concerns raised by PHS and ASPE.  . . . . ....    .....     .....     ......      ..... .    . ... .  . . .. .   ... ...     .. ....  .    ... ...    .  ......       .......       .......       .......       ........       . ..... ..    . ...    ......      ......    ........    
..  ...   ...   ...   ....    .....     .....     ......      ......      ......      ..:...      ......      ......      ......      .......       .......       .......       .......       .......       .......       .......       .......       .......       .......       .......       .......       .......       .......       .......       .......       .......       .......       .......       .......       .......       .....     ....    ....    ....    ....    ....    ....    ...   ...  .  ...   ...   ...   ...   ..  ..  ..  ..  ....  
TABLE OF CONTENTS

PAGE

EXCU SUMY

INODUCfON . 
Purpose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
Scope

Background

Methodology

FIINGS 
Many providers who receive ADMS dollars say they serve homeless 
individuals but lack data on numbers served and servces 
provided 
Homeless individuals have problems that are more desperate, severe 
and dicult to treat than those of other clients. . . . . . . . . . . . . . . . . . . . . . . . . .. 5 
For the most part
, grantees provide the same servces to homeless 
Some provide special servces 
individuals as to other clients. 
Respondents say their servces are appropriate for homeless individuals 
but incomplete. They frequently refer them elsewhere for servces they 
do not provide, but referrals may not be effective. ........................ 7 
Respondents strongly agree that special approaches are needed to serve 
homeless individuals effectively. ...................................... 8 
REcx 
i\110NS .......................................... 
APPENIX A: Methodology 
APPENIX B: Data Verication Sheet  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. B
APPENIX C: Agency Comments. . . . . . . . . . . . .  INTRODUCTION

PUROSE 
This inspection examined how States use the Alcohol, Drug Abuse and Mental Health 
Servces (ADMS) block grant to serve homeless individuals with mental health, alcohol 
or other drug problems.

SCOPE 
There is no definitive count of the number of homeless people in the United States 
(U.  ). The Urban Institute estimated in 1988 that between 567 000 and 600 000 are 
homeless in the U.S. on any given night. In March 1991, the U.S. Census Bureau 
counted 178 828 persons in emergency shelters and 49 793 persons at pre-identified 
street locations; however, they acknowledge that this is an undercount. 
Recent research suggests that approximately one-third of the homeless population are 
severely mentally il, at least 40 percent have problems with alcohol, and an additional 
10 percent abuse other drugs. In addition, it is estimated that at least one-half of the 
homeless mentally il population also have alcohol or other drug problems; we refer to 
such persons as the "dually diagnosed" in this report. This study focused on homeless 
individuals (as opposed to familes) with these problems; the' terms "the homeless" or 
homeless individuals" in the report refer strictly to this population. 
Federal efforts to assist homeless persons are two-pronged: (1) specially targeted 
programs directed at the homeless population, and (2) mainstream programs that serve 
homeless clients as a portion of their servce population. The major Federal targeted 
response is the 1987 Stewart B. McKinney Act (hereafter referred to as McKinney), 
funded for fiscal year (FY) 1991 at $682.3 milion. The McKinney Projects for 
Assistance in Transition from Homelessness (PATH) program, funded at $30 milion for 
FY 1992, targets the homeless population with dual diagnosis. A 1990 study by the 
Office of Inspector General found that while McKinney programs have helped meet 
emergency needs, respondents did not view McKinney as the long-term solution to 
homelessness; rather, they advocated greater Federal and State efforts through on
going, mainstream programs. 
This inspection looked at three major mainstream programs in the Department which 
could serve homeless individuals: the ADMS block grant, Medicaid, and Supplemental 
Security Income (SSI). This  concerning the ADMS block grant. 
report presents findings 
Two separate reports present findings related to Medicaid and SSI. 
We examined the availabilty, accessibilty and appropriateness of each of these 
mainstream programs for homeless individuals. "Availabilty" means whether a program  or servce exists in an agency or community and homeless individuals are eligible for it. 
Accessibilty" refers to the ease or diffculty homeless individuals have in finding and 
utilizing available servces. "Appropriateness" refers to whether available, accessible 
servces match the homeless client's needs in a broad sense. 
BACKGROUN 
The ADMS block grant, funded by the Public Health Servce (PHS) through the 
Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) was created 
under the Omnibus Budget Reconciliation Act of 1981. The block grant is currently 
administered by the Office for Treatment Improvement (OTI) in ADAMHA. A 
proposed reorganization plan for ADAMHA could affect the administration of this 
program. 
States may use ADMS block grant funds for grants to community mental health centers 
and for substance abuse prevention, treatment, and rehabiltation programs and 
activities. States are not mandated to serve the homeless population with ADMS 
monies; however, States may choose homeless persons as a special target population. 
ADMS funding for FY 1991 was $1.33 billon. Nationally, 20 percent was being spent 
for mental health servces and 80 percent for substance abuse treatment and 
prevention. However, this ratio varies significantly across States. In recent years 
substance abuse dollars have risen dramatically. In contrast, mental health dollars have 
remained stable or, in some years, even declined. Recently, there has been growing 
Congressional interest in how ADMS funds are being used, as well as some interest in 
separating the mental health from the substance abuse portion of the block grant. 
ADMS dollars represent a small portion of total State mental health expenditures. In 
1987, ADMS dollars accounted for only 2.3 percent of $9.3 bilion spent for mental 
health nationally. According to the  State Alcohol and Drug Abuse Profie  ADMS 
1990 
dollars represent about 20 percent of all funding for public sector alcohol and drug 
abuse treatment servces. 
Several Departmental initiatives impact the homeless population. Two of Secretary 
Sullvan s 1990 Program Directives relate to this study: 1) Expand the use of cost-
effective human servces to ensure the quality and availabilty of 
effective assistance; 
and, 2) Improve the health status of minority and low-income persons. Also, the 
Secretary has created a task force, chaired by the Director of the National Institute of 
Mental Health, which is charged with identifyng barriers to servce for severely mentally
il 
homeless persons.  METHODOLOY 
During pre-inspection we conducted an extensive review of literature, including program 
descriptions, Federal legislation and regulations, and articles, reports and research 
papers of all kinds. We also talked with persons at PHS, the Social Security 
Administration, Health Care 
Financing Administration; the National Association of 
State Alcohol and Drug Abuse Directors, the National Association of State Mental 
Health Program Directors and other related associations; foundations; and experts. 
spent two days with a special mobile assessment unit in Chicago. 
For the inspection on ADMS, we reviewed portions of the ADMS 1989 State reports 
and 1990 State plans. We collected additional data from 224 ADMS mental health and 
substance abuse grantees in 10 States: California, Hawaii, Ilinois, Ohio, Oregon 
Maryland, Missouri, New Jersey, New York, Texas. We spoke by telephone with the 
executive directors or program directors of these agencies about the inspection issues 
related to ADMS. With those who said they serve homeless individuals, we also 
discussed issues related to Medicaid and SSI. 
Our review was conducted in accordance with the  Interim Standards for Inspections

issued by the President s Council on Integrity and Efficiency. A detailed 
description of 
the methodology for this inspection is in Appendix A.  FINDINGS

Findig #1: May provders who receive ADMS dollar say they serve homeless 
indidua 
but lack data on numbers served and servces provided. 
We contacted 224 mental health and substance providers who States identified as 
recipients of ADMS funds. Our first goal was to learn whether these 
providers serve 
homeless individuals at all, regardless of how many they serve or the extent of servces. 
On the basis of this very broad criterion, 168 of the 224 told us that they provide 
servces of some sort to homeless individuals. 
For many of these 168 grantees, ADMS dollars are a small portion of the budget. 
When we compared the ADMS grants of these 168 agencies (reported by States) with 
their annual budgets (reported by the agencies), we found that for 
roughly 60 percent 
ADMS dollars were only 10 percent or less of the annual budget. 
While we recognize that ADMS funds may be a small part of their budgets in some 
cases, we nevertheless believe that these agencies represent a broad and diverse 
network of mainstream providers whose servces can be important in a solution to

homelessness. They include community mental health centers, community health 
centers, cities and counties, regional boards, public and private not-for-profit agencies of 
all tyes, hospitals, school boards, and others. 
Whether ADMS dollars were a small proportion of their budget or not, we were 
interested in (1) whether these providers use ADMS funds, specifically, to serve 
homeless individuals, and (2) what ADMS-funded servces they provide to them. 
Unfortunately, few respondents were able to answer these questions. Some did not 
realize that their agency received ADMS funds; others knew but said that their agency 
does not track these dollars separately. And, we learned that few of these agencies are 
tracking homeless clients or the servces they receive, whether ADMS-funded or not. 
We then asked these respondents how many homeless individuals their agency served in 
the previous program year. Again, many did not know because they lack data. Fifteen 
percent did not answer the question at all and half only gave a ball-park estimate. For 
the few who did give a hard number, we were not always confident of its reliability. 
Sometimes we suspected that it represented a duplicated count or included all homeless 
clients served, including familes, rather than solely individuals with mental health 
alcohol or other drug problems.

The servces these respondents most often said their agencies provide - to all 
clients in 
general, and whatever the funding source - are: outpatient mental health and outpatient 
substance abuse servces. Half provide both of these servces, with mental health 
grantees far more likely to provide both than substance abuse grantees. Smaller  proportions provide inpatient mental health or substance abuse servces, or detox 
servces. A few grantees offer none of these servces but rather case management
information and referral, education, or prevention servces instead. 
The rest of this report presents what these 168 respondents said about the homeless 
individuals they serve and the servces they provide to them. We refer to these 
respondents subsequently in this report as "ADMS grantees. 
indidua 
Findig #2: Homeless  have problems that are more desperate, severe, and
difcut to treat than those of other clients. 
As a backdrop to any discussion of the availability, accessibilty and appropriateness 
the servces of ADMS grantees for homeless individuals with alcohol, drug or mental 
health problems, it is important to note that this is a very needy population. Over four-
fifths of our respondents said that the needs of the homeless clients they serve differ 
significantly from the needs of their other clients. 
Of the 293 comments they made about the differences between homeless individuals 
and other clients, 290 referred to the severity of the problems of the homeless. Only 
three respondents said that homeless people respond more positively to assistance 
compared to other clients; however, the reason given was that homeless clients "are 
more desperate." 
The overwhelming impression made by these respondents is that homeless persons are 
indeed more desperate. In Figure 1 is a list of some of the many ways in which they 
said the needs of homeless clients differ from those of their other clients. 
The most frequent comments emphasized 
that homeless individuals need more 
comprehensive servces, stable homes 
How Homeles Clients DUrer

more social supports, and basic medical 
from Other Cl1ents 
care. Person after person stressed that 
their homeless clients were the neediest  . Lak boe/J1le or drag-tre env1enl 
among the needy, that being homeless 
. Lack lupport networlttamlly/frlendl 
exacerbates all other physical or 
. Prblema ar more cb1D1c 
emotional problems while at the same 
. Ar more 11 than other cUen"
time creating new problems. One 
nee 
. Have concurrnt medica 
respondent summaried the 
sense of 
. Nee mor comprehensi'9 I8Mce 
many other comments: "They 
re at the  nee  trent 
absolute bottom when they get to  . Need baic  met lor  to lucced 
us." 
Respondents also pointed out that 
Figure 1 
homelessness increases the difficulty of 
treating mental ilness and substance 
abuse. Many said that homeless people often require long-term treatment yet live day to-day; display a very short time perspective, thinking of only the immediate future; 
need mental health treatment, but distrust , and fear those who try to help; or are 
, resist
transient - "a moving target " as one respondent called them. 
Respondents reported that it can be too difficult to provide long-term treatment, even 
when a homeless person requests help. Some said that it is 
necessary to stabilze these 
clients with temporary housing, food or medical care for treatment to be effective. 
Others said that when homeless people seek servce, it may well be during an acute 
crisis; they may demand immediate attention when they approach an agency, wanting 
only a "quick fix." They may approach an agency numerous times for such help, cycling 
in and out for short periods rather than remaining for long-term treatment. 
Given their many needs, homeless clients must seek out help from . a vast array of 
servce providers: welfare agencies, Social Security district offices, community mental 
health centers, community health centers, clinics, emergency rooms, alcohol or drug 
programs, shelters and food pantries, and others. The severity of their problems may 
make it difficult for them to find appropriate help on their own. 
sae 
Findig #3: For the most par grantees provide the  servces to homeless 
indidua 
as to other clients. Some provide special servces. 
Less than one-quarter of the ADMS grantees who serve homeless individuals do any 
outreach targeted specifically at them. Rather, homeless individuals come to them in 
variety of ways. The most frequently mentioned is "walk-ins;" nearly 70 percent 
mentioned this. However, they are also referred by social servce agencies, shelters or 
missions, police, and the courts. Substance abuse grantees were more likely than 
mental health grantees to report walk-ins (73 vs 60 percent) and court referrals (48 
19 percent); mental health grantees were more likely to mention hospital referrals (32 
vs 18 percent) and general, non-targeted outreach (30 vs 16 percent). 
Once they make their way into these agencies, homeless individuals are most likely to 
receive the same servces as non-homeless clients. The most frequently mentioned 
servces which they share with other clients are residential treatment, outpatient mental 
health counselig, outpatient substance abuse counseling, and case management. 
addition, 20-25 percent of our respondents mentioned that their agency provides other 
servces such as psychotropic medication, information and referral, medical care 
vocational rehabiltation, or job placement. 
Forty-five ADMS grantees (29 percent) also make special servces of some sort 
available to homeless individuals: 35 percent of the mental health grantees and 25 
percent of the substance abuse grantees. These servces differ primarily by being more 
intensive and beginning to address fundamental needs for housing, food, and medical 
care. Many of these respondents also said they use special servce-delivery approaches 
such as outreach, drop-in centers, or case management to serve homeless individuals.  Seventeen of these 45 grantees receive McKinney funding of some sort for these special 
servces. Three-quarters of them said they had developed these servces in response to 
a Federal or State initiative; 40 percent specifically mentioned McKinney. This was the 
only evidence we found that of a specific Federal initiative that had influenced ADMS 
grantees to develop servces specifically for homeless individuals. The majority of 
ADMS respondents we spoke with - most of them agency directors or program 
directors - knew little about McKinney programs or Federal policies on homelessness in 
general. 
Findig #4: Respondents say their servces are appropriate for homeles indivdua 
but incomplete. They frequentl refer them elsewhere for servces they do not provde 
effece. 
but referral may not be 
Respond belie tht the agen' seres  genll 
are  apprprite for homele
invils. 
Despite differing perceptions of the homeless population and their needs, most 
respondents described their agencies' servces , in a general sense, as appropriate for 
them. However they express a sense of frustration at not being able to 
provide a 
sufficiently broad range of servces for homeless people, sufficiently flexible servces to 
engage them in treatment, and sufficiently intensive servces to meet their needs for for 
stability, structure, and social support. 
Comments about the appropriateness of servces reflect the fact that this is not a 
homogeneous population. Respondents did not agree about the best way to approach 
treatment for homeless individuals, nor did they recommend any single approach as the 
most appropriate. Indeed, their comments reveal that they feel pulled in conflcting 
directions in working with them. 
inls 
resndts 
Almt aU  refer homele  to othe agenc for seres 
theelves do not offer However clits ma not  ma not be able to 
follw though, or 
seres 
acces  eLrewhee. 
Ninety-six percent of respondents report making referrals; over 80 percent report 
making "frequent" referrals. The most common referrals are for: emergency, 
permanent, or transitional housing; primary medical or dental care; and vocational 
rehabiltation or training. More referrals are made to social servce agencies and 
emergency shelters than to other  providers. A number of respondents 
tyes of servce 
commented that some of their homeless clients need vocational training but there is no 
vocational program to refer them to. 
Referral may not be effective. A number of respondents said homeless people will 
often not continue to search for an agency even upon referral. Follow-through may 
take more persistence or resources than the life circumstances of homeless persons 
allow. Lacking a watch or money for transportation, for example, can make it difficult  to follow through. Or, sometimes homeless persons may not follow through because, as 
one respondent noted, they "have lost hope. 
Referral may also not succeed because access to the servces where homeless clients are 
referred is limited. We asked respondents whether homeless individuals have problems 
accessing servces from 
other mental health or substance abuse providers in their 
communities. Over 80 percent of them said there were problems; two-thirds mentioned 
multiple problems. 
As ilustrated in Figure 2, some of these 
problems relate to the instability of 
homeless individuals and their transient 
Problems the Homeles Pace
lifestyle, and others to the servce system  in Accesing Trment
itself. The most frequently mentioned is 
that other servce providers see homeless 
./Provid8r1 le8 them CD undesirable clients 
individuals as undesirable clients, either 
./ Be/Ilots nol available; wa1tng lilts
because they look or act strange, are 
./Ho appropriat proiders to 
dirty or unkempt, resist treatment, don  reler to 
follow through with appointments, don  ./Homeleu ca t pa; put at bottom 01111 
conform to agency procedures or rules  ./Homelea CD Iralient/hCl 10 contact 
or "agencies know that treatment of the  ./ Homeles lack IrclJrtal.oD 
homeless is a lot of work, so they don 
encourage them." Other frequently 
mentioned barrers were: waiting lists or 
Figure 2 
lack of openings in a program, lack of 
transportation, and a lack of health insurance or funds to pay for servces. 
Nearly one-fifth of our respondents said there are no appropriate servce providers 
available to which to refer homeless individuals; a few specifically mentioned a lack of 
programs for the dually diagnosed. And, some respondents commented generally that 
there is community resistance towards developing programs because residents fear 
homeless people. 
Findig #5: Respondents strongl agree that speal approaches are neeed to serve 
indidua 
homeles  effectely. 
Respondents were in marked agreement that, in terms of reaching a long-term solution 
to homelessness for this population, servces must be modified in some way to serve 
them effectively. 
Some of the more general suggestions made were: (1) homeless individuals need to be 
approached in ways that engage them in treatment; (2) comprehensive servces are 
needed to stabilze these clients, since treatment cannot be expected to be helpful with 
people who return to parks or metal grates to sleep at night; and, (3) servce providers 
should offer less compartmentalized, more flexible servces. The picture that emerges  of an "ideal" servce provider is one that reaches out to homeless clients and
, at a single 
location, meets all their needs - not only those most immediately evident (such as food 
shelter, and medical care) but those related to alcohol or drug dependence, mental 
ilness, lack of housing, and joblessness. 
Respondents made many other more specific suggestions on how servces 
to this 
population could be enhanced: special outreach; a housing component of some kind; 
medical servces; specially-trained staff; better coordinated programs to overcome the 
fragmentation of the social welfare system; and, special programs for the dually 
diagnosed. 
On a related issue, we asked respondents whether they thought that homeless 
individuals need separate mental health or substance abuse programs designed 
specifically for them, that is, programs set apart from the traditional treatment system. 
We found that opinion was split on this issue: 54 percent favored separate programs 
and 42 percent felt that they were neither needed or desirable. Significantly, however 
almost three-quarters of those opposed to separate programs, stil felt that traditional 
servces should incorporate different approaches of some kind - special outreach, for 
example - to reach this population.  RECOMMENDATIONS

Ths study confirmed earlier findings that homeless individuals have severe, multi
faceted problems. Their many needs range from the basics of food and shelter to more 
complex needs for mental health and substance abuse treatment. Agencies try to meet 
these many needs, but experience great difficulty in doing so - often due to lack of 
resources. 
As stated in our findings, 96 percent of ADMS respondents told us that they must refer 
clients to other providers for servces they are unable to provide. Yet the referral 
process is often an obstacle for homeless people seeking help. Some lack the skills to 
follow through; others may not have transportation to the 
assortment of agencies they 
must visit for servces. The result is that many homeless individuals fall through the 
cracks and go unserved. This, combined with various obstacles inherent in the servce 
system itself that limit the availabilty or accessibility of servces, may limit access to 
servces for them.

We conclude that it is critical for agencies to work together to develop the expertise 
needed to serve homeless individuals and to ensure comprehensive servces for this 
population. Our recommendations emphasize the ideas of linkage and coordination 
among different levels of government, between government agencies, and within local 
servce systems. The themes of linkage and coordination are stressed in all three 
separate reports on SSI and Medicaid). We 
reports related to this inspection (see 
named servce integration a priority for the 
should also note that the Secretary 
homeless population in a speech in the 
spring of 1991. 
In many States, linkage and coordination are already priorities, while in others they 
have yet to be developed. At the end of our study, we spoke with the coordinators for 
the McKinney-funded Projects for Assistance in Transition from Homelessness (PATH) 
programs in the 10 sample States to generally discuss potential recommendations arising 
from this study. They agreed that linkage and coordination are critical elements for 
servng such a needy population. 
Constructing recommendations that will have widespread impact is difficult, since there 
is such a large variety of servce providers and funding streams. Furthermore, the 
scope of our recommendations is limited by the nature of ADMS as a block grant 
program. Also, we are mindful that ADMS grantees are only one group of providers 
among many who serve homeless individuals, and that ADMS dollars are only one 
piece of the funding pie. 
Nevertheless, we do consider ADMS a valuable resource for homeless individuals. 
ADMS grantees represent a large network of servce providers nationally who can 
supply both treatment and other needed servces. It appears that the majority are  already servg homeless individuals, albeit in a limited way for the most part. We 
believe, therefore, that the ADMS block 
grant should not be overlooked as a resource
for homeless individuals. 
Our goal in these recommendations is to faciltate a first step toward a long-term 
solution for homeless individuals who are mentally il or have alcohol or other drug 
problems. They are designed to help reduce the number of homeless individuals who 
go unserved and to ensure comprehensive servces that are accessible and appropriate 
for this population. 
Recommendation #1: The PHS should provide technca asistace to States and other 
indidua. 
PHS-fuded grtees who serve homeless 
The technical assistance provided should include, but not be limited to, the two items 
specified in Recommendation #2 below. 
ADAM 
Recommendation #2: The  should isue an advory letter to al States with 
the nex round of fudig. The letter should undersre the importce for ADMS 
grantees to include the followig components in servg homeless indidua with 
menta heath, alcohol, or drg problems: 
Specialized training for servce providers, shelter personnel, and volunteers for 
dealing with the unique problems of this population. For example, agency 
personnel should be trained to work with staff from State mental institutions 
jails, nursing homes, and other residential settings to develop release plans for 
individuals coming out of these institutions. 
Memoranda of Understanding or other formal agreements 
with other agencies in 
the community. These would address information sharing, cross-training, 
technical assistance, development of model programs (including outreach 
application procedures, resource referral, and coordination with the broader 
servce community), and model release plans (including housing) for 
institutionalized persons. 
Other agencies would include, but not be limited to, Social Security district 
offces, McKinney-funded providers, local mental health and substance abuse 
authorities and departments, and local welfare offices. 
COMM 
We received comments from PHS and the Assistant Secretary for Planning and 
Evaluation (ASPE). We wish to thank those who commented on this report. The text 
of their comments is in Appendix C. 
Although PHS concurs with the principles underlying our recommendations, they do not  agree with us that the ADMS block grant is an appropriate mechanism to implement 
them. Instead, they propose to rely on their current McKinney-funded programs. 
We believe that both the McKinney Act and the ADMS block grant are valuable 
resources for improving servces to this population. A previous OIG study on the 
McKinney Act revealed widespread agreement among respondents that McKinney alone 
is not the solution to homeless ness, and that greater efforts should be made by 
mainstream Federal programs to serve the homeless. The ADMS 
grantees in this study
represent an extremely broad and diverse national network of providers, a large 
majority of whom are providing some level of servce to homeless individuals. We do 
not think that such a broad mainstream program, funded at $1.33 bilion, should be 
overlooked as a mechanism to address the problems identified in this study. We think 
that PHS, in bringing its resources to bear on this network, can help improve 
considerably the response of these providers to homeless individuals. 
We continue to recommend a strong technical assistance role for PHS. However we 
have modified our language in the recommendation slightly. We recognize that PHS' 
primary responsibilty is to States for the block grant, and to their local McKinney 
grantees, who in turn can work - and, we hope, would take every opportunity to do so 
with local ADMS grantees. 
We revised the first finding and made some editorial changes elsewhere in the report 
accommodate concerns raised by PHS and ASPE.  APPENDIX A

GEN 
COMM 
REGARING TH DATA 
We collected both qualitative and quantitative data for this 
inspection. The
qualitative data presented in the reports is not weighted. Quantitative ADMS data 
was used to make national projections (described later in this Appendix) 
based on 
weighted State averages for our sample States. For the most part, data collected 
ADAM 
from  States and respondents was for 12 month periods representing 
fiscal years 1989 or 199. 
In general, data from States and respondents regarding ADMS expenditures was very 
difcult to obtain as well as extremely variable. They rarely kept this data in a
complete or uniorm manner. Also, State fiscal years varied, as did those of 
respondents. 
STATE SAMLE SELCTON 
We used a stratified, multi-stage methodology in choosing States, since we intended 
to make national projections with the quantitative data. We wanted to talk to 
ADMS grantees and certain McKinney-funded grantees (descnbed later in the 
Appendix), who could discuss Medicaid and SSI. Thus we divided the 50 States into 
two categories: those with both ADMS grantees and more than one 
McKinney 
grantee, and those with ADMS grantees and one or no McKiney 
grantees. (As
noted in the Methodology section, McKinney respondents were Health Care for the 
Homeless grantees or grantees of research and demonstration projects funded by 
ADAMHA.) We selected six States from the first 
category and four States from the
latter. The sample States from each category were selected, with replacement, based
on probabilty proportional to the estimated FY 
1991 ADMS funding. 
The table lists the sample States, estimated amount of ADMS 1991 funding, and the 
States' percent of total ADMS funding. The sample represents a significant portion 
of total ADMS funds. 
ESTIMTED ADMS PERCENT OF TOTAL 
FUS  FUS 
STATE  FOR FY 1991  ADMS 
California  $151 048,450  13% 
Hawaii  077 746 
Ilinois  484 994 
Maryland  274 979 
Missouri  789,494  New Jersey  169 435 
New York  103 642, 170 
Ohio  814 
Oregon  12,583 566 
Texas  804 
Total  $559 530 452  47% 
Total FY 1991 
Estimated 
ADMS Funding  187 357 962 
SAMLIG MEODOLOY FOR ADMS REPONDEN 
We intended to sample 30 
grantees from each State which would represent a 
proportional mix of mental health and substance abuse grantees. Respondents were 
program directors or managers. The number of 
grantees sampled in each of these
two categories was determed by the proportion of FY 89 mental health ADMS 
funding to substance abuse funding in each State. This was the most recent year for 
which States had this inormation. We contacted the 10 States and asked for the 
amount of ADMS funds they received in FY 1989, and the total amount that went to 
mental health grantees and substance abuse grantees. In addition, we asked for a 
listing of the mental health grantees and substance abuse grantees and the amount of 
ADMS funding each received. 
In most States, mental health and substance abuse grantees were then 
selected with 
probabilty proportional to the amount of the ADMS grant received. In instances 
where the grant money was given to counties, we selected six counties proportional 
to mental health and substance abuse funding. We then selected five 
grantees
within each county with probabilty proportional to the amount of the ADMS grant 
received. 
There were some exceptions to these two basic methodologies. In those States 
where the amount of ADMS grant money for 1989 was not readily available, we 
chose a simple random sample of grantees. In instances where a grantee 
subcontracted over 50 percent of its ADMS funds, we asked the grantee to identify 
the two subgrantees who received the largest proportion of grant funds, whom we 
then intervewed. 
Several grantees were dropped because they were no longer receiving ADMS funds 
in FY 1991. Our final 
sample consisted of 224 grantees in 10 States. There were 95 
mental health and 129 substance abuse grantees. The subsampling in each State was 
independent of that conducted in any other State. 
A 
 Ths methodology enabled us to capture, in most cases, a signficant portion of
States' ADMS funds in our sample. The following table gives the percent of ADMS 
mental health and substance abuse FY 
1989 funds sampled in each State. 
PERCENT OF SAMLED  PERCENT OF SAMLED 
ADMS MENTAL HEALTH ADMS SUBSTANCE ABUSE 
FUS 
TO TOTAL STATE  FUNDS TO TOTAL STATE 
ADMS MENTAL HEALTH ADMS SUBSTANCE ABUSE
FUS  FUS 
STATE 
California  24%  12% 
Hawaii  82%  54% 
ilinois  62%  46% 
Maryland  41%  35% 
Missouri  77%  39% 
New Jersey  45%  22% 
New York  12%  28% 
Ohio  12%  44% 
Oregon  68%  39% 
Texas  78%  14% 
We spoke with sampled respondents by telephone. Our first objective was to learn if
the grantees served homeless individuals. We did not pursue further 
questions with 
the 56 grantees who said they do not serve the homeless. We 
discussed the 
availabilty, accessibilty and appropriateness of their servces and 
Medicaid and SSI 
for this homeless population, with 168 grantees who did serve them. We also asked 
respondents to provide basic data on their total agency budget and ADMS grant 
clients served, including homeless clients, and Medicaid reimbursement. 
ADMS PROJECTONS

We made two national projections in this inspection: (1) the percent of ADMS going
to grantees that told us that homeless individuals were among their served 
population, and (2) Medicaid funds as a percent of total budget of the 
grantees.
The projections are based on what these ADMS 
respondents told us. In some cases 
they could not give us numbers, or could only give estimates. The Data Verification 
Sheet we sent to respondents prior to callng them is in Appendix B. 
The definition of "homeless" we asked respondents to use in providing this
information was: "A person who is not a member of a homeless family, and who 
lacks stable housing (including a person whose primary residence during the night is 
a supervsed public or priate facilty that provides temporary ling accommodations
or a person who is a 
resident in transitional housing. 
A 
 These projections are based upon unbiased estimates derived from the sample of 
grantees  withi  each State. Estimates of the totals, and the variance associated with 
each total, accounting for the sub-samplig 
within each State, were calculated using 
methods described by Cochran . Given these totals, the percentages, as ratios, were 
easily derived. 
The results of these estimates are presented, by State and overall, in the following
tables. 
1 Cochran, William G., (1977)  Sampling Techniques. John Wiley & Sons, New 
York, Sec. 11.9, pg. 306. 
A  Percent of ADMS Money Associated with 
Grantees Servng Homeless 
Mental Health  Substance 
Grantees 
i\buse CJrantees

NEW JERSEY  100.  64. 
MISSOURI  92.  91. 7% 
CALIFORNIA  45.  77. 
OHIO  75.  83. 
ILLINOIS  66.  93. 
NEW YORK  64. 
Strata Avg  71.5%  72.4% 
TEXA
82.4%  75. 
Mi 
87.  100. 
OREGON  98.  84. 
HA WAIl  38.  60. 
Strata Avg  72.4%  74. 
Overall Avg  71.8%  75. 
Std. Err.
 21.8%  21.8% 
Precision  49.  47. 
L 90% CI
 35.  39. 
U 90% CI  107.  111.6% 
Because of the extreme variabilty in the data, the upper 90 percent confidence limit 
exceeds 100 percent. Logically, the upper limit should be truncated at 100 percent. 
The coefficient of variation for Mental Health programs is 30 percent and that for 
Substance Abuse programs is 29 percent. 
2 The precision is defied as the semi-width of the confidence interval as a 
percent of the estimated mean. 
i\ 
 Medicaid Funds as a Percent of Total Budget 
by Type of ADMS Grantee 
NEW JERSEY 
18. 
MISSOURI 
13. 
CALIFORNIA 
16. 
OHIO  25.  12. 
ILLINOIS 
NEW YORK  35. 
13.  13. 
TEXA 
1.6%  1.8% 
MAYLD

15. 
OREGON  28. 
HAWAII 
1.7% 
Weighted Avg 
Std Err  82%  87% 
Precision  33.  25. 
ev. 
20.  15. 
L 90% CI

U 90% CI 
12. 
This data demonstrates less variabilty than that in the ADMS funds data. However 
the coefficient of variation is below 10 percent for only one of the estimates, the 
percent homeless among Mental Health grantees. 
mean. 
3 The 
precision is defined as the semi-width of the confidence interval as a 
percent of the estimated 
A  OT 
SAMLIG MEODOLOY FOR  REPONDEN 
Gra 
McKi 
The 33 McKinney grantees in our sampled States included 25 Health Care for the 
Homeless grantees and 8 other providers who have received McKiney research 
demonstration grants from either the National Institute for Mental Health or the 
National Institute on Alcohol Abuse and Alcoholism. We spoke by telephone or in 
person with these respondents. The focus of our discussions was the availabilty, 
accessibilty and appropriateness of Medicaid and 
SSI. We were especially interested
in comparig their perspectives - as providers whose mandate is to serve the 
homeless - with those of ADMS grantees, who have a much broader mandate. 
Soc Secu Ditrt Ofe Respond 
These 25 respondents included district managers, assistant district managers and 
claims and servce representatives in district offces near the McKinney grantees in 
the sample. We discussed their experiences servng this population, their opinions
about how to enhance access to SSI for them, and their views on the role of SSI in a 
long-term solution to homelessness. 
State Medaid Staff 
For background, we reviewed portions of the Medicaid plan for each of the 
sample States, looking at eligibilty criteria and servces relevant to 
homeless mentally 
il or substance abusing individuals. We then talked by telephone with 16 Medicaid 
staff in the 10 States to clarify our understanding of eligibilty and servces, and to 
ask if there were any special State Medicaid policies, procedures or special initiatives 
which affect this population. 
A 
 APPENDIX 

DATA VERICATION SHEET 
Please have the following background information available for our telephone 
discussion; do not  , we want this data for Federal 
return it to us by mail. If possible
Fiscal year (FFY) 1990. However, if you maintain data on a State fiscal year (SFY) 
or calendar year instead, please tell us when we call. 
Please provide only the information that you maintain in your existing management 
information system; otherwse, do not generate it  We realize that 
specifically for us. 
you may not know or keep some of this information. In this case, we ask that you 
provide your best estimate, if you are comfortable with doing so. If not, just tell us 
you don t know. 
For FFY. SFY or Calendar 1990 ACTUAL or  ESTIMATED 
1. Total agency budget: 
2. Total ADMS  block grant 
funds received: 
3. Total McKinney funds 
received: 
4. Total clients served by your 
agency (unduplicated count; all 
programs or servces): 
5. Total clients served by your 
agency (unduplicated count) 
with ADMS dollars: 
1 Alcohol, Drug Abuse and Mental Health Servces Block Grant  ........................
DATA VERICATION SHEET 
PAGE TWO 
homeless individuals 
6. Total 

over 18 served by your agency

(unduplicated count) ..........

a. # 
mentally il (no

substance abuse problem):

b. # substance abusers (not

mentally il): 
c. # dually diagnosed

(both problems)

homeless individuals over 
7. Total 

served by your agency

with ADMS dollars (unduplicated 
count) 
a. # 
mentally il (no

substance abuse problem):

b. # substance abusers (not

mentally il): 
c. # dually diagnosed

(mentally il and

substance abusing) 
8. Total Medicaid reimbursement 
OR percent of total agency budget 
that was Medicaid reimbursement 
9. Number OR percent of total 
clients served by your agency 
who were on Medicaid 
homeless 
10. Number OR percent of total 

individuals over 18 served by 
your agency who were: 
on Medicaid:

on SSI:

2Person who is not a member of 
a homeless family, and who lacks stable housing 
(including a person whose primary residence during the night is a supervsed public 
or private facilty that provides temporary living accommodations, or a person who is 
a resident in transitional housing.  APPENDIX C

AGENCY COMMNT

C - 1
 . -
DEPARTMENT OF HEALTH 
&. HUMAN 
SERY-ICES 
PubliC Health Service 
Memorandum 
FEB -7 199

Date

From
 Assistant SecreL3ry 
for Health

Office 
S ub,eCt  of Insrector General (OIG) Draft Report " 
Alcohol Drug, 
and Ment.-l Health Services 
for Homeless Individuals 
Inspector General 
, OS 
are the 
At t a c he d  Purbe 1p i oc rHte .a  I t h S e r vi c e ' s (p H S) co mm en t s  on the
subject OIG draft 
The report recommends 
that PHS:
(1) provide technical assistance 
to State and local Alcohol

Drug Abuse , and Mental Health Services 
(ADMS) Block Grant
recipients and other PHS-funded 
grantees who serve homeless
individuals 
, and (2) issue an advisory letter 
to all States
underscoring the importance for ADMS grantees to include
specialized training and 
formal agreements with other community
social services agencies 
in serving homeless individuals with
alcohol 
, drug abuse , or mental health (ADM) problems. 
We concur with the principles underlying 
these recommendations
and explain that the ADMS Block Grant may 
not be the most 
Ca po pnrog pr ersisa  t e me c h ani s m t 0 imp 1 e men t the r e c 0 mm end a t ion s .
chose to target the problems of the homeless
population through  Act. 
the McKinney  The McKinney Projects for
Atasrsgisettasn ce in Transition from Homelessness is the program that
the homeless population with dual diagnoses 
of serious
mental illness and substance abuse disorders. 
In our comments , we note that PHS has provided and will
continue to provide a variety of technical assistance 
to the

States and its other grant recipients. We highlight activities
undertaken by the Alcohol 
, Drug Abuse , and Mental Health
Administration to address the programmatic needs of homeless
individuals with ADM disorders. 
We identify activities

administered by the National 
Institute on Alcohol Abuse and

Alcoholism that evaluate 
the effectiveness of comprehensive

service interventions designed 
to meet the special needs of
various subgroups of homeless individuals. 
Lastly, we mention
research and demonstration programs administered by 
the
National Institute of Mental Health for homeless mentally ill
individuals. 
not 
Tho ugh we  d 0  on the r 
s p e c i f i call y co mm e n t  e co mm end a t ion s
the companion OIG draft 
reports on Medicaid and Supplemental
Security Income (551) for homeless individuals, we see these
programs as essential components of an overall strategy for
meeting the needs of homeless individuals with ADM disorders.
We are pre par e d to  t a k e a p pro p ria te  a c t ion s t 0 b ring a b 0 u t  g rea t e r coo per at ion and co 11 a b 0 rat i  n bet ween PHS pro g r ams and 
Medicaid and 551. 
We include also  a series  of te  hnical comments for your 
c;o'1sideracion. 
o.lh 
Mason  , Dr. 
achClent  ""  ""
PUBLIC HEALTH SERVICE (PHS) COMMENTS ON THE OFFICE OF INSPECTOR 
GENERA (OIG) DRAFT REPORTS  " ALCOHOL, DRUG, AND MENTAL 
HEALTH SERVICES FOR HOMELESS INDIVIDUALS: 
MEDICAID

AND HOMELESS INDIVIDUALS: " AND "SUPPLEMENTAL

SECURITY INCOME AND HOMELESS INDIVIDUALS"

Genera 1 Commen ts

These three reports present the 
findings and recommendations of a

study looking at three large
, main-stream programs that could

serve homeless individuals as part of their service population:
the Alcohol, Drug Abuse , and Mental Health Services (ADMS) Block

Grant; Medicaid; and Supplemental Security Income. All three 
reports rely on the same methodology: interviews with Federal

program staff and national organization 
representatives; and

telephone surveys of a sample of local ADMS grantees in ten

randomly selected States 
, McKinney Mental Health Care for the

Homeless Block Grant and research demonstration 
grantees in those
States, as well as staff in the State Medicaid and Social 
Securi ty district of fice in the same areas as the McKinney
responden ts . 
The general findings across the three 
studies agree with

from other sources. 
inforra tion  For example, these studies
document the extensive service 
needs of homeless individuals and

accessing and maintaining
ethe ldiifgficuiltbies itlheiy  ftacye   for  in 
these services. Enhanced coordination of the 
many programs that provided services to the homeless population

studies. 
is generally a common theme in many 
The divergence of
opinion between service providers and mainstream program 
officials over the role of those 
programs in providing assistance
to homeless individuals has also been frequently discussed. 
However, much of this information is anecdotal; very little
systematic data is available with the exception of a few studies 
in individual localities or treatment settings. 
Wtoe  aulsso.  want to emphasize two general issues which are of concern
The first issue concerns the use of language. Using " the
homeless 
" to refer to individuals is depersonalizing; being 
homeless is difficult enough without also losing a sense
identity. 
The substitution of "homeless persons,  homeless
individuals, 
" or even  the homeless population" would help
considerably. 
Secondly, we want to re-emphasize that, despite
the careful wording around the estimates, the report will leave

the imp.ression that significant amounts of ADMS Block Grant money

are being spent on services to homeless individuals with alcohol

drug abuse and mental disorders. As stated in the report,

roughly 75 percent of local providers receiving ADMS funding

provide some level of service to homeless individuals. However,
numer of 
the level of service , and the  homeless individuals
receiving 
it, could be as little as one outpatient visit to one 
homeless person in the past year. 
C-4
 ... ...
We have no specific comments on the recommendations contained in 
the reports on Medicaid and Supplemental Security Income. We do,
however, see these 
programs as essential components of an overall 
national strategy for meeting the needs of homeless individuals 
wi th ADM disorders. We are prepared to take whatever actions are 
appropriate to bring about greater cooperation and collaboration 
between PHS programs serving the target population and Medicaid 
and Supplemental Security Income. 
OIG Recommendations 
The PHS should provide technical assistance to State and

local ADMS grantees and other PHS funded grantees who serve 
homeless individuals. (The technical assistance provided
should include 
, but not be limited to, the two items 
specified in Recommendation No.  2 below. 
The ADAM should issue 
an advisory letter to all States 
wi th the next round of funding. The letter should
underscore 
the importance for ADMS grantees to include the 
following components in serving homeless individuals with
mental health 
, alcohol, or drug problems: 
Specialized training 
Memoranda of Understanding or other formal agreements

with other agencies in the community. 

PHS Comment

We concur with the principles underlying these two

recommenda tions  However, we do not believe that the ADMS Block 
Grant is the appropriate mechanism with which to implement the
recommendations. 
Congress has chosen to target the problems of 
Act. 
the homeless population by the passage of the MCKinney  The 
McKinney Projects for Assistance in Transition from Homelessness 
(PATH) is the program which targets the homeless population with 
dual diagnosis of serious mental illness and substance abuse
disorders. 
staff 
The PATH program specifically provides for 
training, including training of individuals who work in shelter,
mental health clinics 
, substance abuse programs and other sites 
where homeless individuals require services.

In addition, PHS has provided and will continue to provide a wide 
grants. 
variety of technical assistance to recipients of its  For
example, ADAM 
currently funds several specialized 
clearinghouses and technical assistance centers dealing with the 
programmatic needs of homeless individuals with ADM disorders. 
Also, the National Institute on Alcohol Abuse and Alcoholism
(NIAA) currently 
administers the Community Demonstration Grant 
Program for Alcohol and Other Drug Treatment for Homeless  Individuals, and the Cooperative Agreements for Research

Demonstration Projects on Alcohol and Other Drug Abuse Treatment

for Homeless Persons. These two programs are evaluating the

effectiveness of comprehensive 
service interventions designed to

meet the special needs of various 
subgroups of the homeless

In addition, the 
popula tion.  NIAA supports a numer of other
research grants that are looking at the relationship 
of alcohol

use and homelessness. These 
research and research demonstration

projects will provide the basis for 
this technical assistance. 
The National Institute of Mental Health also administers the 
McKinney Research Demonstration  III 
Program for Homeless Mentally 
Adul ts and the Mental Health Research Program on Homeless
Individuals. 
However, PHS is unable to directly provide technical assistance
to local ADMS grantees. We believe that the States are in a 
better position to develop training for local grantees and to
encourage the development of agreements among providers.
 --  --  --  ---- - - 
Technical Comments

Page i, first paragraph under " The figures given

BACKGROUND" 
in this paragraph do not reflect the mo  recent research. The 
paragraph should be rewritten as follows: 
Recent research suggests that approximately one-third 
of the homeless are severely mentally ill, at least 40 
percent have problems with alcohol, and an additional 
10 percent abuse other drugs. In addition, it is 
estimated that at least one-half of the homeless 
mentally ill population also have alcohol or other drug
problems. 
This is also true on page 1 of the introduction, in the second

paragraph under " Scope. "

It is fairly well

ePagse it, a4tbh palriagsraphh, elasdt s entence 
State Alcohol and Drua Abuse Profile, National
Association of State Alcohol and Drug Abuse Directors, 
1990) that
the ADMS Block Grant, nationally, represents approximately 
20 percent of all funding for public sector alcohol and drug 
abuse treatment services. Accordingly, this information should

be used in lieu of the last sentence as it currently reads. 
Page i, third paragraph under " Please change the

last sentence to read: "StatesB ACaKGrROeUN.D " not required to specifically
serve the homeless population with ADMS monies; however, States
may fund services for homeless mentally ill persons and homeless
substance abusers. 
Page ii 
, second paragraph under  Please change
problems " to characteristics. " FINDINGS"

The same sentence is in the Table 
of Contents.

Page  After institutionalized 
persons, please
inseriti , last sentence 
" (e. g., in jails and hospitals). 
Table of Contents. The last word of the third finding,
servicese " should be corrected to read  services. 
Page 1, second paragraph under "  Plea:e 
add after 
dually diagnosed" a defining claSCOuPE"s  e, " those individuals with co
occurring mental health and substance use disorders. 
Page 2, as noted in the comment for page i, please change the
ph to read: " 
last sentence in the second paragr 
States are not 
required to specifically serve the homeless population with ADMS 
monies; however, ' States may fund services for homeless mentally 
ill persons and homeless substance abusers.
 , "

Page 2, fifth paragraph -- The Task Force on Homelessness and

Severe Mental Illness is chaired by the Director of NIMH.

Page 4 , the last sentence in the third paragraph needs to be

modified. We suspect that the first issue is that the counts

not 
unduplicated" and the second issue that respondents

were 
were reporting non-ADMS homeless 
, homeless 
families)  clients  (e.

Page 5, finding No.  , first paragraph -- Please clarify the
very needy population. 
Is this a reference to homeless persons
with ADM disorders or any homeless person? 
Page 6, figure 1 -- Please insert "persons" after homeless.

Also, the first bullet needs to be reworked. First, does

stable" home mean permanent housing? Second, should " stable

housing" be linked with "drug-
free environment?"

Page 7 , second paragraph -- We suggest deleting the last two

sentences. The first of these sentences, "This was the only...

is unclear, and the second sentence  the majority of ADMS...

is misleading. The interpretation of these statements could be

very different depending on who the actual 
respondents were. For
example, why would line workers know about funding sources (e. g. ,
Federal legislation)? 
The final sentence on this page about homeless clients and job

skills is too general and should be deleted 
unless there is more

can be said.

tha t 
Page 8, first paragraph -- As is, this paragraph has a victim

blaming tone, and needs to be toned down. For example, " Follow-
through may take more persistence or resources than the life 
circumstances of homeless persons allow. 
Consider the life 
circumstances of a homeless person, and the lack of resources

such as transportation or clocks. 
dPaigseo r8d, efrisg.u re 2 does not only address homeless persons with ADM
These problems are, however, often particularly
relevant to the homeless mentally ill population. 
Page 8, fourth paragraph, first sentence 
-- Please add after
dually diagnosed" a defining clause, " 
those individuals with co
occurring mental health and substance abuse disorders. 
Page 10, first paragraph, first sentence -- This sentence should 
read: "
be revised to  This study confirmed earlier findings that 
homeless individuals... 
Page 10, fourth paragraph, second sentence --
The title for the

PATH program is the McKinney Pro jects for Assistance in

C-8  Transition fI2  Homelessness 
(PATH) program. 
Page A2 , first sentence -- In the Sampling Methodology section,
please clarify who, specifically, were the desired respondents

for the sampled "grantees. 
clinicians?  Were they program managers or
Did it vary among the 30 grantees? 
Page B2. The footnote on the data verification sheet 
contains a

definition that differs from the one  is, 
provided on page A

we suspect , the one that was actually used.  3 and

The one on page A-
would appear to exclude those individuals who live on the
streets. 
Both definitions exclude the "
at imminent risk"
population included in most MCKinney programs. Both definitions
also include individuals living in transitional housing 
although
they are rarely included in other definitions of the 
homeless
popula tion.  ~~~
, "

(' 
Sec 
DEPARTMENT OF HEALTH a. HUMAN SERVICES	
\ Ofce of th 
""0 
18'ashingon . D.C. 20201 
199 
NO  2 2 
TO:	 Richard P. Kusserow, Inspector General 
FROM:	 Ass istant Secretary for Planning and
Evaluation 
SUBJECT :	 OIG Draft Reports: "Supplemental Income for Homeless
Individuals" 
Alcohol, Drug Abuse and Mental Health 
Services for Homeless Individuals" , and "Medicaid and 
(:V	
Homeless Individuals" 
 06"I-C 
-00(;&0

ooo  -fl-Od6 
OtEl- os-- 9/-
This memorandum provides comments on the three subj ect draft 
inspection reports which examined the availability, accessibility 
and appropriateness of the Supplemental Security Income Program 
(SSI), the Alcohol, Drug and Mental Health Services 
(ADMS) block
grant, and Medicaid programs for homeless individuals who have 
mental health, alcohol or other drug problems. 
that: 
In general, the assessments found 
1) most ADMS grantees
provide some, but usually not specialized, services to homeless 
2) the type and adequacy of those services are unclear 
people 
due to the lack of data on the quantity of services or their
impact: 
3) access to SSI and Medicaid programs is limited
al though special 
efforts are now being made by most SSA Field 
offices to increase access to SSI. 
Another finding is that most 
program providers and SSA field office staff recognize that 
especially difficult for the mentally ill or substance abusinit g
population to access SSI and Medicaid programs. 
Overall, the findings in these assessments are consistent with 
what we are learning from other studies and program monitoring,
particularly with respect to the need for improved 
linkage and
coordination among different levels of governent, between
government agencies, and wi 
thin local service systems.
Unfortunately, the data available for these assessments did not 
allow for more specific findings concerning numers 
served, the 
quality of services provided, or for descriptions of successful,
generalizable models.

Nevertheless, the findings and recommendations from these three 
assessments will help shape a current initiative to simplify
ill 
programs and make them more accessible to severely mentally 
homeless individuals. Your staff has already briefed the Federal 
Task Force on Homelessness and Severe Mental Illness and its 
outside Advisory Committee regarding these assessments. 
The Task 
rP-ta 
Force will recommend a plan of action 	 the end
th 
of January, 1992.
 . .
Page 2 - Richard P. Kusserow

editorial 
I have a few additional comments listed below and 
reports. 
comments written in the attached copies of these 
Alcohol Drua and Mental Health Services for Homeless Individuals 
The background section on page i should include a sentence 
or two in the discussion of the McKinney Act programs, on
the proj ects for Assistance in Transition from Homelessness 
(PATH) program, its purpose, and a clarification that while 
states award most of their PATH funds to ADMS grantees,
those funds are not included by grantees that report 
ill. 
providing services to the homeless mentally 
A statement in the background section indicates that the 
ADMS dollars spent for substance abuse treatment as a 
portion of state expenditures for this purpose is unknown. 
We understand that as of 1990, there is an indicator in the 
National Drug and Alcohol Treatment Utilization Survey that 
provides this information. 
In the findings section on page 4, the third paragraph under
finding 
#1, this statement should be reworded to clarify 
use an

that the dollars referred to go to grantees that 
unknown but crobablv small cortion of their grants to serve

this population. One could interpret the current statement

to mean that over 70% of their block grant funds serve this

population. 
percentages for 
Appendix A, pages 4 and 5 contain very low 
New York state ADMS funds that go to grantees serving the 
homeless, and the extent to which ADMS grantees in New York 
state seek Medicaid reimbursement for services. These 
estimates are so at odds with those for other states in the 
sample and with New York' s usual participation in such 
programs that you may wish to re-check them. 
Succlemental Securitv Income and Medicaid for Homeless

Indi viduals 
The same data issue concerning New York state described 
above for Appendix A of the ADMS Report applies to Appendix 
A of the reports on SSI and Medicaid as well. 
On page iii of the Executive Sumary, we suggest adding a 
recommendation to ensure that a national survey of the 
homeless population being planned for 1992/1993 include the
proportion receiving SSI benefits.  Page 3 - Richard P. Kusserow

The description of the targeted federal response to 
homelessness on page 1 of all three reports would be more 
complete with the addition of the following sentence after 
the second sentence of the fourt paragraph: n An additional 
$200 million in non-McKinney federal funds is targeted at 
II Total spending in these targeted 
the homeless population. 
programs will rise to over $1 Billion in FY 1992. 
:' G