Department of Health and Human Servces 

OFFICE OF 

INSPECTOR GENERAL 

COMMUNITY MENTAL HEALTH CENTERS 

AND HOMELESS PERSONS 

1' . S'EVICls

, 

"d3a 

JU GffBS BROWN 

Inspector General 

AUGUST 1996 

OEI-07-95-0061 
OFFICE OF INSPECTOR GENERA 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of the Department of Health and Human Servces ' (HHS) 

programs as well as the health and welfare of beneficiaries served by those programs. This 

statutory mission is carried out through a nationwide network of audits, investigations , and 

inspections conducted by three OIG operating components: the Office of Audit Services, the 

Office of Investigations , and the Office of Evaluation and Inspections. The OIG also informs 

the Secretary of HHS of program and management problems and recommends courses to 

correct them.


OFFICE OF AUDIT SERVICE 

The OIG's Office of Audit Servces (OAS) provides all auditing servces 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 

carryng out their respective responsibilities and are intended to provide independent 

assessments of HHS programs and operations in order to reduce waste, abuse, and 

mismanagement and to promote economy and efficiency throughout the Department. 

OFFICE 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 enrichment by providers. The investigative efforts of 01 lead to criminal convictions 

administrative sanctions, or civil money penalties. The 01 also oversees State Medicaid fraud 

control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 

OFFICE OF EVALUATION AN 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 findings and recommendations contained in these inspection 

reports generate rapid , accurate, and up-to-date information on the effciency, vulnerability, 

and effectiveness of departmental programs. The report was prepared in the Kansas City 

regional offce under the direction of Jim Wolf, Regional Inspector General. Project staff 

include: 

Kaas City Headquarers 

Dennis Tharp, Project Leader Wiliam M. Krushat, Branch Chief


Tim Dold, Team Leader Alan Levine, Program Specialist


Perry Seaton, Team Leader


Linda Paddock, Program Assistant


To obta a copy of thi report ca the Kaas City regional offce at (816) 4263697. 
EXECUTIVE SUMMARY


PUROSE 

To determine the extent that community mental health centers serve homeless 

persons. 

BACKGROUN 

The homeless population is a heterogenous group of men, women and children who 

have a variety of health care problems, including a high incidence of mental ilness and 

substance abuse/alcohol disorders. 

Community Mental Health Centers (CMHCs) are a major component of health care 

servces for people who are economically disenfranchised and homeJess. The centers 

primary objective is providing mental health servces to persons with mental ilness or 

emotional disturbances. They provide a broad range of servces, including individual 

and group counseling, psychosocial rehabilitation, therapeutic education, life skils 

training, day programs, and substance abuse counseling and treatment. CMHCs also 

tyically provide case management, medication management, and arrangements for 

residential servces. 

This report is based on a mail survey of 50 community mental heath centers and 86 

homeless shelters. Fifeen of the 50 centers had received special grant funding to 

specifically engage in outreach servces for homeless persons with mental ilness (e. 

the Projects for Assistance in Transition from Homelessness (PATH) grant program or 

the Access to Community Care and Effective Servces and Supports (ACCESS) grant 

program.) We also conducted on-site visits with two CMHC mental health care 

managers and five directors of homeless shelters to supplement information from the 

surveys. 

This study was requested by the Assistant Secretary for Planning and Evaluation as 

part of a broader effort to look at mainstream Federal programs addressing homeless 

persons. 

FININGS 

Communty Mental Health Centers Perform Outreach to Homeles; Persons 

All centers with PATH and/or ACCESS grants report that they conduct outreach by 

sending staff or volunteers off-site to areas where homeless persons with mental ilness 

may congregate. However, only 50 percent of those centers which did not receive any 

PATH or ACCESS funding perform outreach. 
Nearly all of the centers' staffs that conduct outreach go to emergency homeless 

shelters. Outreach staff visit and provide referrals at transitional shelters, street 

locations, soup kitchens, drop-in centers, parks, depots, and campgrounds. 

Approximately one-fourth also may go to county jails, public libraries, river banks 

psychiatric hospitals, churches, restaurants, and shopping malls. 

Centers Receive Referral from a Varety of Sources


Although 21 percent of the centers' homeless clients with mental ilnesses are selfreferrals, the majority of homeless clients are referred from emergency shelters 

hospital emergency rooms, police, state psychiatric hbspitals, and the jail/court system. 

Only 17 percent (15 of 86) of the homeless shelters report that they do not refer their 

clients to the CMHCs for mental health servces. 

A Majority of Shelters Rate their Relationship with Communty Menta Health 

Centers as Positive; Some Problems Do Emerge, However 

Over 69 percent of the homeless shelters rate their relationship with the local mental 

health center as either satisfactory or excellent. However, 20 percent believe that the 

quality of mental health servces at the centers is unsatisfactory or poor. They cited: 

weakness in providing immediate crisis intervention servces; not enough individual 

therapy; shortage or lack of assignment of case managers and therapists; and clients 

being given standard prescribed medication without really being listened to. 

Centers Provide Referral for Other Health Cae and Social Servces 

Most centers report providing referrals for other health care servces such as substance 

abuse servces, inpatient psychiatric servces, medical outpatient servces, and referrals 

for medical assistance benefits/entitlements and programs such as Aid to Families with 

Dependent Children and Food Stamps. 

Centers Cite Barers in Providig Servces to Homeless People, Especialy Difculties in Contiuity of Cae and Avaiabilty of Servces in the Communty 

Community mental health centers report that they face barriers in tryng to serve 

homeless persons, especially since many of those persons with mental ilness are also 

substance abusers. Over one-half of the homeless shelters also responded that clients 

have problems accessing center services. Barriers include the clients' inability or 

unwillngness to follow through on a plan of care and shortage of necessary servces 

for homeless persons with mental ilness. 

OPPORTUIE FOR IMROVEMENT 

Overall, community mental health centers and homeless shelters seem to be 

coordinating their efforts to help homeless people. However, there are stil 

opportunities for improvement. We recognize that resources are limited and that not 
all services that are needed can be provided within current funding levels. We offer 

the following suggestions to centers wishing to re-examine and prioritize their 

programs for serving homeless persons with mental ilness. 

Improve Communication and Inormation Sharg with Homeless Shelters 

Communication and information sharing could take the form of periodic meetings to 

discuss problem areas, beneficial activities, statistical reporting techniques, and the 

joint monitoring of homeless persons with mental ilness. Centers which do not 

engage in outreach activities could do so; those centers which already do could 

develop even more assertive outreach programs. Also, community mental health 

centers could work with homeless hotlines in their service area to provide urgent care 

or crisis intervention for those needing immediate attention. 

At the Federal level, the Substance Abuse and Mental Health Servces Administration 

(SAMHSA) could be instrumental in supporting further research on the topic of 

homeless persons with mental ilness and their difficulties in obtaining appropriate 

mental health care and counseling.


Offer Comprehensive Servces to Address Indidual Needs 

Counseling servces could be offered to specifically address individual needs. These 

could include: substance abuse counseling (since many clients have a dual-diagnosis of mental ilness and substance abuse) and physical and/or sexual abuse counseling. 

Centers could provide more intensive case management to members of this 

population. CMHCs could also work with housing programs to develop a variety of 

housing options. 

AGENCY COMMNT 

We received formal comments from the Administrator of SAMHSA and the Assistant 

Secretary for Planning and Evaluation. Both agreed with the findings in the report. 

The Administrator of SAMHSA emphasized the need to work more closely with shelters and housing providers and for more research on homelessness and mental 

ilness. Copies of the full text of their comments are included in Appendix A. 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . .. . . . ... . 

TABLE OF CONTENTS 

PAGE 

EXECU SUMY 

INODUCTON. . . . . . . . . . . . . . 1€

FININGS. . . . . . . . . . . . . . . . . . . 4€

Outreach. . . . . . . . . . . . . . . . . . . . . 

Screening Protocols. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4€

Referral Sources. . . . . .. . . . 5€

Relationships with Shelters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5€

Health Care and Social Servce Referrals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6€

Servce Barriers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7€

OPPORTU FOR IMROVEMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8€

AGENCY COMMNT. . . . . . . . . 9€

APPENDIX A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-

INTRODUCTION


PUROSE 

To determine the extent that community mental health centers serve homeless 

persons. 

BACKGROUN 

The homeless population is a heterogenous group of men, women and children. They 

include long term street dwellers, residents of homeless shelters and temporary living 

quarters, the economically disadvantaged, single men and women, families with 

children, as well as runaway and castoff youths. Homeless individuals have a variety of 

health care problems, including a high incidence of mental ilness and substance 

use/alcohol disorders. 

Community Mental Health Centers (CMHCs) are a major component of health care 

servces for people who are economically disenfranchised and homeless. The centers 

primary objective is providing mental health servces to persons with mental ilness and 

persons with emotional disturbances. They provide a broad range of mental health 

servces, including individual and group counseling, psychosocial rehabilitation 

therapeutic education, life skills training, day programs, and substance abuse 

counseling and treatment. CMHCs also typically provide case management 

medication management, and arrangements for residential servces. 

Public Law 102-321 , the Alcohol, Drug Abuse and Mental Health Administration 

Reorganization Act, mandates a vigorous Federal leadership role in mental health 

servces delivery and policy development. The Act significantly increases the attention 

and resources devoted to the mental health servce needs of children and adults. The 

Center for Mental Health Servces (CMHS) in the Substance Abuse and Mental 

Health Servces Administration (SAMHSA) works closely with other Federal agencies 

whose programs and policies affect the lives of persons with mental ilness. The 

CMHS also works closely with State and local governments and the private sector to 

assure continuity, integration of servces, and access to comprehensive systems of care. 

The CMHS provides national leadership to (I) ensure the application of scientifically 

established findings and practice-based knowledge in the prevention and treatment of 

mental disorders; (2) improve access, reduce barriers, and promote high quality 

effective programs and servces for people with, or at risk for these disorders, as well 

as for their families and communities; and (3) promote the rehabilitation of people 

with mental disorders. It also composes and retains a listing of all community mental 

health centers. While having no direct administrative control over mental health 

center servces, the agency compiles statistical information on the facility location 

telephone numbers, servces available, and years of operation of all centers 

nationwide. 
The Stewart B. McKinney Homeless Assistance Amendment Act of 1990 authorized a 

new Federal grant program to deal with the needs of people who are homeless and 

have serious mental ilnesses. The program--known as Projects for Assistance in 

Transition from Homelessness (PATH) --funds community-based outreach, mental 

health, substance abuse, case management and other support servces, as well as a 

limited set of housing services. Each year, the PATH program distributes about $30 

milion through formula grants to each State and U.S. territory to provide services to 

people with serious mental ilnesses, including those with co-occurring substance use 

disorders who are homeless or at risk of becoming homeless. In many States, PATH 

funds are the only Federal dollars available for outreach services within the mental 

health system. 

Beginning in fiscal year 1993, the Department of Health and Human Servces (in 

collaboration with the Departments of Housing and Urban Development, Labor 

Education, and Veterans Affairs) provided Access to Community Care and Effective 

Servces and Supports (ACCESS) grants to nine States. This innovative 

interdepartmental demonstration project integrates housing, treatment and support 

servces for homeless persons with mental ilness. The ACCESS initiative flows 

directly from the work of the Federal Task Force on Homelessness and Severe Mental 

Illness and is founded on the assumption that the integration of fragmented servces 

wil substantially contribute to ending homelessness among persons with severe mental 

ilness. 

METHODOLOGY 

The inspection focused on the extent of outreach and servces provided by community€

mental health centers to the population of homeless persons with mental ilness. 

There are approximately 3 000 community mental health center providers nationwide. 

However, we focused on 569 centers that had previously received Federally funded 

construction grants, a subset of the " 1995 Mental Health Directory" issued by the Survey and Analysis Branch of the Center for Mental Health Servces. Since Federally grant-constructed centers constitute only a fraction of community mental health 

centers nationally, our findings would not be considered representative of all centers€

only those which received Federal funding.€

We purposefully excluded mental health centers located in cities with populations of 

000 or less because most rural centers do not have homeless shelters in their 

service area. From this revised universe, we selected a random sample of 75 centers. 

In addition, we also selected two - three homeless shelters in the 75 cities in which the 

community mental health centers are located. 

We mailed surveys to 75 CMHCs, and received 50 responses. In addition, we sent 

surveys to 180 homeless shelter directors and received 86 completed surveys. Due to 

incomplete response rates, we did not always receive a returned survey from centers 

and shelters in the same area. The survey document did not make a distinction€

between access to mental health servces by homeless persons with serious mental€
ilnesses and access by those homeless persons with mental health needs but who do 

not have a serious mental ilness. 

We received surveys from: 

15 CMHCs with PATH and/or ACCESS grants. 

11 CMHCs that are located in cities receiving PATH or ACCESS grants. 

24 CMHCs which had no PATH or ACCESS funding. 

The inspection team analyzed the responses to the survey questions. These responses 

were quantified to determine such issues as the number of mental health centers that 

provide outreach servces, the quantity and type of referrals for mental health care 

treatment and counseling for homeless persons with mental ilness, and the extent of 

barriers that prevent access to servces. We also conducted on-site visits with two 

CMHC mental health care managers and five directors of homeless shelters to 

supplement information from the surveys. 

The characteristic center in our sample was a moderate to large-sized multi-servce 

center established in 1971 with a budget of $8. 8 milion, and seeing an average of 

nearly 5 000 undupIicated persons/users annually. There were about 224 homeless 

persons with mental ilness served annually out of a self-reported (estimated) 2 000 

homeless persons in each servce area. While homeless persons with mental ilness€

comprise about 4-5 percent of the centers' average user population , approximately 

only I percent of the average center s annual budget goes toward operating costs for 

servng homeless persons and conducting homeless outreach. 

This study was requested by the Assistant Secretary for Planning and Evaluation as 

part of a broader effort to look at mainstream Federal programs addressing homeless 

persons. This report is one of two related national reports on health care servces for 

the homeless. A companion report addresses the extent that Federally-funded 

Community Health Centers serve the homeless population. 

We conducted our review in accordance with the € Quality Standard for Inspectins 

issued by the President's Council on Integrity and Effciency. 
FINDINGS€

Community Mental Health Centers Perform Outreach to Homeless Persons€

All centers with PATH and/or ACCESS grants report that they conduct outreach€

sending staff or volunteers off-site to areas where homeless persons with mental ilness€

may congregate. However, only 50 percent of those centers which did not receive any 

PATH or ACCESS funding report performing outreach. Nearly all of the centers 

staffs that conduct outreach go to emergency homeless shelters. Outreach staff visit 

and provide referrals at transitional shelters, street locations, soup kitchens, drop- centers, parks, depots, and campgrounds. Approximately one-fourth also may go to county jails, public libraries, river banks, psychiatric hospitals, churches, restaurants and shopping malls. 

The most frequent outreach activity is a mental health assessment. This is followed by offering information on mental health servces available to shelter residents, providing 

general health care services, providing food/clothing, and conducting mental health 

training for shelter staff. Outreach services also cited by mental health centers include 

referrals to public assistance entitlements , housing assistance, psychiatric referrals, and transportation to psychiatric or medical appointments.€

While our respondents reported a varied practice among community mental health€

centers in providing outreach, 32 percent of the centers conduct daily outreach and 10 

percent conduct weekly outreach. Twenty-two percent reported a variety of 

responses: that they either perform outreach as needed, on a biweekly basis, or 2- days per week. 

Centers Adapt Screenig Protocols to Address Homelessness Issues 

Nearly one-half (48 percent) of the mental health centers surveyed report they have 

adapted treatment and screening protocols to specifically meet the needs of homeless 

persons with mental ilnesses. As part of this effort, emphasis is made to obtain the homeless status during the initial intake process. For instance, over three-fourth' s (76 percent) of the centers indicated they identify the housing/omeless status of new 

clients. Centers also perform comprehensive psychosocial assessments and discuss the€

housing status in the screening process.€

Of the centers reporting treatment recipient figures, nearly five percent of the mental health user population were homeless. From survey data, centers present a picture of€

For purposes of this inspection, we defined outreach as: "an initial, continuing, and persistent effort to establish a trusting relationship essential in engaging, connecting, or

reconnecting homeless individuals to needed health, mental health, social welfare, and housing services.€
, 




homeless persons with mental illness that they serve. Some of the more interesting factors of the homeless client are noted in percentage data: 

Centers Receive Referral from a Varety of Sources


Although 21 percent of the centers' homeless persons with mental ilnesses are seJfreferrals, the majority of homeless clients are referred from emergency homeless 

shelters, hospital emergency rooms, police, state psychiatric hospitals, and the jail/court system. Whle 17 percent, or 15 shelters, indicated they do not refer to centers, the majority (or 83%) of the homeless shelters surveyed said that they refer their clients to 

the centers for mental health services. In addition, the shelters also refer to hospital 

emergency rooms, substance abuse counseling, homeless outreach counselors 

psychiatric social workers, medical clinics, hospital inpatient/outpatient, volunteer 

psychologists, and private psychologists and psychiatrists. 

A Majority of Shelters Rate their Relationship with Communty Menta Health 

Centers as Positive; Some Problems Do Emerge, However 

Over two-thirds (69 percent) of the homeless shelters rate their relationship with the 

local mental health center as either satisfactory or excellent. Only 13 percent report 

poor working relationships. (Eighteen percent did not respond or indicated that it was 

not applicable.


As a function of this relationship, two-thirds (67 percent) of the homeless shelter 

respondents report they receive positive comments about good or excellent quality of 

care from homeless persons with mental ilness that were referred to community mental health centers. Homeless shelter directors said they receive a diversity of 

comments from homeless people depending on the client's wilingness to receive help. 

One shelter director said The comments are highly subjective and entirely anecdotal. 

Many clients like their individual case workers but are frustrated by the slow 

incremental changes in their lives." A homeless shelter director noted 

(Clients)...appreciate the case management support.(They) feel that staff really care 
about their needs/issues...(They) appreciate the opportunity to receive services in a 

non-threatening setting." Another director indicated that "Clients are grateful to 

know they are not unique or strange... .Appreciate transportation..(The program 

is)...very effective in working through crisis and long-term depression. 

However, 20 percent of homeless shelters believe that the quality of mental health 

servces at the centers is unsatisfactory or poor. They cited: weakness in providing 

immediate crisis intervention services when homeless people are most vulnerable and 

wiling to accept help; not enough individual therapy to address their problems; 

shortage or lack of assignment of case managers and therapists; and clients being 

given standard prescribed medication without really being listened to. 

Other concerns enumerated by homeless shelter directors follow: 

Center appointments are given too many days ahead and the client may need 

immediate servce or may no longer be at the shelter on the appointment day. 

It takes too long to get an appointment...Clients cannot understand 

forms.....Clients cannot afford the sliding fee scale..... 

Clients do not understand why their cases are closed...Clients do not receive 

any follow-up servces once placed in housing....Clients do not know where to 

go or who to ask for help when they start to decompensate. 

Centers Provide Referral for Other Health Cae and Social Servces 

Most centers report providing referrals for health care servces. The main referral is 

to detoxification or other substance abuse servces, followed by inpatient psychiatric 

servces. Common referrals also include medical outpatient servces provided at such 

locations as free health clinics and public health clinics. The least common referrals 

are for dental servces at Community Health Centers, residential servces, emergency 

room treatment and services, and medical inpatient treatment. Centers also provide 

referrals for health care benefits/entitlements:€
, 

Ninety-four percent of the centers link those who qualify with assistance administered 

by the Social Security Administration. Centers also offer a full-range of other public 

assistance referrals: 

88 percent offer Food Stamp referrals.€

80 percent refer clients to the AFDC program.€

70 percent refer clients to the WIC program, if applicable.€

64 percent refer homeless persons with mental ilness to general€

assistance.€

24 percent refer to State disability, unemployment compensation 

housing agencies, legal assistance, and food banks. 

Centers Cite Barers in Providig Servces to Homeless People, Especialy Difculties in Contiuity of Cae and Avaiabilty of Servces in the Communty 

Although 64 percent of community mental health centers conduct an outreach 

program, centers report that they face barriers in trying to serve homeless persons 

especially since many of those persons with mental ilness are also substance abusers. 

Barriers include the clients' inability or unwillngness to follow through on a plan of 

care and their unwilingness to go to a mental health center for servces. Another 

obstacle listed by many centers is the shortage of necessary servces for homeless 

persons with mental ilness. 

Over one-half (58 percent) of the homeless shelters reported that clients have 

problems accessing the centers' servces. Most of the items cited are well-known 

obstacles among the homeless population: lack of affordable transportation; lack of 

information about center servces; and an unwillngness to go to a center for mental 

health servces. 

Another problem identified by homeless shelters is that community mental health 

centers often target their services to those most in need and may not accommodate 

persons with mental health needs who are not among the most seriously impaired. In 

addition, centers may find that one problem is that once the client's appointment day 

arrives, homeless persons have often moved on to another location or shelter. 

Also, homeless persons with mental ilness located in cities which share State or county 

lines often find themselves positioned out of the appropriate center s jurisdiction or service area. One shelter responded Ilinois residents cannot be seen in an Iowa 

mental health center except for emergencies....." The non-evening, non-weekend hours 

of some centers were also noted to impact homeless persons with mental ilnesses. 
OPPORTUNITIES FOR IMPROVEMENT


Overall, community mental health centers and homeless shelters seem to be 

coordinating their efforts to help homeless people. However, there are stil 

opportunities for improvement. We recognize that resources are limited and that not 

all services that are needed can be provided within current funding levels. We offer 

the following suggestions to centers wishing to re-examine and prioritize their 

programs for serving homeless persons with mental ilness. 

Improve Communcation and Inormation Sharg with Homeless Shelters 

Communication and information sharing could take the form of periodic meetings to 

discuss problem areas, beneficial activities, statistical reporting techniques, and the 

joint monitoring of homeless persons with mental ilness. Centers which do not engage in outreach activities could do so; those centers which already do could develop even more assertive outreach programs. Also community mental health 

centers could work with homeless hotlines in their servce area to provide urgent care 

or crisis intervention for those needing immediate attention. 

At the Federal level, SAMSA could be instrumental in supporting further research 

on the topic of homeless persons with mental ilness and their difficulties in obtaining 

appropriate mental health care and counseling. 

Offer Comprehensive Servces to Address Indidual Needs 

Counseling servces could be offered to specifically address individual needs. These 

could include: substance abuse counseling (since many clients have a dual-diagnosis of mental ilness and substance abuse) and physical and/or sexual abuse counseling. 

Times for such sessions might need to be flexible to deal with the clientele 

inconsistency in keeping appointments. In addition, counselors could pro actively work 

with the homeless client, stressing the importance of continual therapy to achieve 

progress. 

Centers could provide more intensive case management to homeless persons with 

mental ilnesses. These servces could be provided on an ongoing basis in order to 

engage homeless persons with serious mental ilnesses into mental health services 

obtain housing, entitlements and mainstream servces on their behalf, and help them 

establish residential stability. 

Centers could work with housing programs to develop a variety of housing options. 

However, providing housing is not enough. Many homeless persons with mental ilness 

need intensive, on-site support to maintain their residential stabilty. Centers could 

provide supportive services to homeless individuals in their housing to help them 

achieve that stability. 
AGENCY COMMNT 

We received formal comments from the Administrator of SAMHSA and the Assistant 

Secretary for Planning and Evaluation. Both agreed with the findings in the report. 

The Administrator of SAMHSA emphasized the need to work more closely with 

shelters and housing providers and for more research on homeJessness and mental 

ilness. Copies of the full text of their comments are included in Appendix A. 
APPENDIX A 
DEPARTMENT OF HEALTH & HUMA SERVICES Public Health Service 

Substance Abuse and Mental 

Health Services Administration 

Rockville MD 20857 

JUL I 6 /99 

DATE: 

TO: Inspector General, DHHS 

FROM: Administrator, Substance Abuse and Mental Health Services Administration 

SUBJECT: OIG Draft Report: "Community Mental Health Centers and Homeless Persons 

OEI-07-95-00061 

Attached are the Substance Abuse and Mental Health Services Administration s comments on 

the subject Offce ofInspector General draft report. We appreciate the opportunity to review the 

report. We believe it provides valuable information about the extent to which Community 

Mental Health Centers serve homeless persons and look forward to receiving the final report. 

If you have any questions regarding these comments, please contact Nancy McGinness on 443-

1155. 

Nelba Chavez, Ph. 
COMMENTS OF THE SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES 

ADMINISTRA nON ON THE OFFICE OF INSPECTOR GENERAL DRAFT REPORT 

COMMUNITY MENTAL HEALTH CENTERS AND HOMELESS PERSONS 

OEI-07-95-00061 

Thank you for the opportunity to review and provide comments on the subject draft report. It is 

responsive to our earlier concerns and recommendations. We were not surprised to lear that all 

of the community mental health centers (CMHCs) in the study that received PATH or ACCESS 

funding also provided outreach, while only fifty percent of those that did not receive this funding 

provided outreach. Both the ACCESS and PATH programs have encouraged CMHCs to work 

more aggressively with the homeless population. 

We agree with the suggestions about the need for better communication between CMHCs and 

shelters, more assertive outreach to people in the shelters, more intensive case management and 

counseling for persons who are homeless and more housing resources. If the CMHCs are going 

to have an impact on reducing homelessness, they wil need to work more closely with shelters 

and housing providers. 

We also agree that there is need for more research on homelessness and mental ilness and that 

the Substace Abuse and Mental Health Services Administration could be valuable in supporting 

these knowledge development initiatives. The Center for Mental Health Services (CMHS) has 

fuded a number of research and evaluation studies on homelessness. The McKinney Research 

Demonstration Program, which was funded between 1990 and 1993, examined the effectiveness 

of different approaches to providing mental health treatment, housing, and related services to 

homeless adults who have severe mental ilnesses. The Dual Diagnosis Treatment 

Demonstration Program, funded jointly with the Center for Substance Abuse Treatment (CSAT) 

between 1993 and 1995 , identified and evaluated integrated approaches to treating homeless 

people with co-occuring mental ilnesses and substance use disorders. The ACCESS Program is 

a 5 year demonstration program, initiated in 1993, to identify effective strategies for creating 

integrated service systems so that people who are homeless and mentally il will have inediate 

access to mental health and substance abuse treatment, health care, housing and income supports 

and entitltements. Finally, CMHS and CSAT will support in the fall of 1996 a new knowledge 

development program to document homelessness prevention models for individuals with serious 

mental ilnesses and/or substance use disorders. As the findings from these programs are 

published, they are. providing importnt information regarding effective services and service 

delivery to people who are homeless and mentally ill. 
-.T€ h.." 

DEPARTMENT OF HEALTH &. HUh\AN SERVICES Office of (he SeCrelary


JUL I 7 '996 

Washington, D. C. 20201 

TO: June Gibbs Brown 

Inspector General 

FROM: Assistant Secretary for Planning and Evaluation 

SUBJECT: Comments on the OIG Draft Report: "Community Mental Health Centers and 

Homeless Persons," OEI-07-95-00061 

Thank you very much for the opportunity to review the above referenced report. Knowledge 

about the extent that community mental health centers (CMHCs) serve the homeless and how 

such servces can be improved is highly important. 

The report represents a major improvement over the Erst draft. We are pleased to see included in 

the report: people focused, rather than illness and homeless focused language used in describing 

the population; a definition of outreach; and the note that the survey questionnaire did not make 

distinction between persons with serious mental ilness and those who do not have a serious 

mental ilness. Most importantJy, we were pleased to see the analysis of the outreach data by 

looking at centers' receipt of Projects for Assistance in Transition from Homelessness (pATH) 

or Access to Community Care and Effective Services and Supports (ACCESS) funding. As a 

result of the inclusion of the PATH and ACCESS analysis we are better able to see that both the 

ACCESS and PATH programs have encouraged CMHCs to work more aggressively with the 

homeless population. 

We appreciate this opportunity to review this draft GIG report. We believe it provides valuable 

information about the extent to which CMHCs serve homeless persons and look forward to 

receiving the final report.