A CKNOWLEDGEMENTS iii 

A CKNOWLEDGMENTS

Numerous people contributed to the development of this manual. The 

document was produced by Policy Research Associates, under contract No. 

280-99-0601, Substance Abuse and Mental Health Services Administration 

(SAMHSA), U.S. Department of Health and Human Services (DHHS). Susan 

Wells, Advocates for Human Potential, and Francine Williams, M.A. and 

Deborah Dennis, M.A., of Policy Research Associates, wrote and edited the 

material in this document. Frances Randolph served as the SAMHSA 

Government Project Officer. 

D ISCLAIMER

The views, opinions, and content of this publication are those of the authors 

and do not necessarily reflect the views, opinions, or policies of SAMHSA or 

DHHS. 

P UBLIC D OMAIN N OTICE

All material appearing in this report is in the public domain and may be 

reproduced or copied without permission from SAMHSA. Citation of the 

source is appreciated. However, this publication may not be reproduced or 

distributed for a fee without the specific, written authorization of the Office 

of Communications, SAMHSA, DHHS. 

E LECTRONIC A CCESS AND C OPIES OF 

P UBLICATION

This publication can be accessed electronically through the following 

Internet World Wide Web connection: www.nrchmi.samhsa.gov. For 

additional free copies of this document please contact SAMHSA’s National 

Mental Health Information Center at 1-800-789-2647 

R ECOMMENDED C ITATION

Substance Abuse and Mental Health Services Administration. Blueprint for 

Change: Ending Chronic Homelessness for Persons with Serious Mental 

Illnesses and Co-Occurring Substance Use Disorders. DHHS Pub. No. 

SMA-04-3870, Rockville, MD: Center for Mental Health Services, Substance 

Abuse and Mental Health Services Administration, 2003. 

O RIGINATING O FFICE

Center for Mental Health Services, Substance Abuse and Mental Health 

Services Administration, 5600 Fishers Lane, Rockville, MD 20857 

DHHS Pub. No. SMA-04-3870 

Printed 2003 
iv 

T ABLE OF C ONTENTS

Page

Preface ................................................................................................................................... vii 

Using This Report ........................................................................................................................... x 

Section I: Before You Begin.......................................................................................................... 1 

1. Understand the Changing Context of Care and the Nation’s Response ...................... 3 

 The Changing Context of Care.................................................................................. 4 

 The Federal Response ............................................................................................... 6 

 Understanding the Population ................................................................................... 10 

2. Learn About the Population............................................................................................. 11 

 Individual Risk Factors ............................................................................................. 12 

 Service System Challenges ....................................................................................... 17 

 Societal Risk Factors................................................................................................. 23 

 Guiding Principles for a System of Care................................................................... 26 

3. Establish Core Values....................................................................................................... 27 

 The Concept and Practice of Recovery ..................................................................... 27 

 Person-Centered Values ............................................................................................ 29 

 System-Level Values................................................................................................. 30 

 Establishing a System of Care................................................................................... 32 

Section II: Plan for Services.......................................................................................................... 33 

4. Establish a Comprehensive, Integrated System of Care................................................ 35 

 Why Comprehensive, Integrated Services?............................................................... 35 

 Key Systems Integration Strategies and Mechanisms............................................... 37 

 Ensuring Adequate Resources................................................................................... 43 

5. Finance a Comprehensive System of Care...................................................................... 45 

 Access and Use Community Resources .................................................................... 46 

 Funding Sources ....................................................................................................... 48 

 For More Information................................................................................................ 54 

 Putting the Pieces Together....................................................................................... 55 

Section III: Organize Services ...................................................................................................... 57 

6. Use Evidence-Based and Promising Practices ................................................................ 59 

 Evidence-Based and Promising Practices ................................................................ 59 

 Other Essential Services............................................................................................ 68 

 SAMHSA’s Leadership in Evidence-Based Practices .............................................. 78 

 Developing Services That Will Last ......................................................................... 79 
v 

T ABLE OF C ONTENTS

Page

Section IV: Sustain Services.......................................................................................................... 83 

7. Measure Results................................................................................................................. 85 

 Why Measure Outcomes? ......................................................................................... 86 

 The Types of Outcomes That Should be Measured .................................................. 87 

 Barriers to Measuring Outcomes............................................................................... 90 

 Use of Management Information Systems ................................................................ 91 

 Connecting to Mainstream Resources....................................................................... 92 

8. Use Mainstream Resources to Serve People Who Are Homeless.................................. 93 

 A Wide Range of Available Resources..................................................................... 93 

 Making Mainstream Services Work for Homeless People........................................ 95 

 Moving Forward........................................................................................................ 100 

References ................................................................................................................................... 101 

Resources ................................................................................................................................... 121 

Tables

4.1 The Strategic Planning Process ................................................................................. 40 

4.2 Implementation Strategies......................................................................................... 42 

6.1 Essential Service System Components ..................................................................... 80 
vi 
P REFACE vii 

P REFACE

Helen was referred to the Thresholds (Chicago) Mobile Assessment Unit 

(MAU) by a local shelter. Shelter staff described her as “depressed, refusing 

to change her clothes, and flat.” Helen had been staying at the shelter for 

four months and described herself as homeless for the last three years. 

Though guarded, Helen revealed that she had experienced audio 

hallucinations since age eight, had prior substance abuse treatment, had 

never received mental health treatment, and had a history of physical abuse 

as evidenced by a large scar on her face. 

Helen didn’t want mental health services, but she did want her own place to 

live and a copy of her birth certificate. She accepted a bed in the Thresholds 

Safe Haven, a low-demand supportive residential program housed in the 

local YMCA. She got her birth certificate and continued to work with MAU 

staff on basic living skills such as shopping, hygiene, and food preparation. 

She also began seeing a psychiatrist at a mental health clinic located in the 

YMCA. Unfortunately, Helen stopped taking her medication and was 

hospitalized during a psychiatric crisis. 

When she returned to the Safe Haven, Helen made some different choices. 

She stopped drinking alcohol, stayed on her medication, and began to attend 

housing and social meetings held at Safe Haven. Over the next year, she 

began receiving disability benefits and started working with a Thresholds 

Assertive Community Treatment (ACT) team. She joined outings to the 

Museum of Modern Art and attended a microwave cooking class. 

The day came when Helen wanted to move to a large studio apartment in a 

Thresholds group home. She said she was ready to “cook her own meals 

again” and “get some space.” Staff and other members celebrated with her 

at her graduation party. In the 15 months the MAU, Safe Haven, and ACT 

staff worked with Helen, they came to view the scar on her face as both a 

reflection of her many internal scars and as a testament to her endurance. 

On graduation day, all you could see was her smile. 
viii B LUEPRINT FOR C HANGE

More than a decade after the Federal Task Force on Homelessness and Severe 

Mental Illness called it “unacceptable” for people with serious mental illnesses to 

live in unsafe and threatening conditions, more than 630,000 individuals are 

homeless in this country on any given night (Burt et al., 2001). About half of all 

adults who are homeless have substance use disorders, and many have cooccurring mental illnesses, as well. Yet, the outlook is far from bleak. Federal 

demonstration programs and the experience of hundreds of community-based 

providers offer a rich reservoir of evidence-based and promising practices. 

For example, recent studies reveal that the cost of providing permanent, 

supportive housing for people with serious mental illnesses is more than offset by 

savings incurred by the public hospital, prison, and shelter systems (Culhane et 

al., 2001). When nothing is done, people with serious mental illnesses and/or cooccurring substance use disorders who are homeless often cycle between the 

streets, jails, and high-cost care, including emergency rooms and psychiatric 

hospitals. This is inhumane, ineffective, and costly. 

Further, research reveals that people with serious mental illnesses and/or cooccurring substance use disorders who are homeless, once believed to be 

unreachable and difficult-to-serve, can be engaged into services, can accept and 

benefit from mental health services and substance abuse treatment, and can

remain in stable housing with appropriate supports (Lam and Rosenheck, 1999; 

Morse, 1999; Lipton et al., 2000; Rosenheck et al., 1998). Clearly, the time has 

come to end homelessness among people with serious mental illnesses and/or cooccurring substance use disorders. We know what works. Now we must put 

what we know to work. 

The Substance Abuse and Mental Health Services Administration (SAMHSA) 

and its Center for Mental Health Services, in collaboration with SAMHSA’s 

Center for Substance Abuse Treatment (CSAT), have developed this Blueprint 

for Change to disseminate state-of-the-art information about ending 

homelessness for people who have serious mental illnesses, including those with 

co-occurring substance use disorders. This edition of the Blueprint does not fully 

consider the growing knowledge base that addresses homelessness among people 

with substance use disorders who do not have a serious mental illness. A future 

edition will cover this in greater depth. This document is more than a review of 

current and past research. It offers practical advice for how to plan, organize, 

and sustain a comprehensive, integrated system of care designed to end 

homelessness for people with serious mental illnesses and/or co-occurring 

substance use disorders. 
P REFACE ix 

This effort comes at a time of increased national attention to the needs of our 

most vulnerable citizens. SAMHSA has received increased funding to help end 

homelessness among people with mental illnesses and substance use disorders, 

and recently submitted a report to Congress on the prevention and treatment of 

co-occurring disorders. SAMHSA also is participating in an interagency effort 

among the Departments of Health and Human Services (HHS) (SAMHSA’s 

parent agency), Housing and Urban Development (HUD), and Veterans Affairs 

(VA). These Departments have joined in an historic collaboration to provide $35 

million for the development of appropriate housing and supportive services for 

people who are chronically homeless, and together are sponsoring a series of 

policy academies for state and local policymakers to improve access to 

mainstream resources for this population. 

It is important that efforts to end homelessness address the substance use 

treatment needs of the population, given that recent estimates that nearly half of 

persons who are homeless have substance use disorders (Culhane, 2001). The 

Administration has expressed its commitment to reduce drug use, build treatment 

capacity, and increase access to services that promote recovery from substance 

use. It has pledged $1.6 billion over the next 5 years to do so. SAMHSA is not 

alone in these efforts. Across the country, states and communities are unveiling 

their own comprehensive plans to end homelessness. These plans focus on 

increased affordable housing opportunities, improved housing and service 

coordination, and better partnerships with mainstream systems and providers. 

Efforts to end homelessness can be modeled and supported at the Federal and 

state levels, but the real work takes place in the communities where people live. 

The human and financial toll of homelessness for people with serious mental 

illnesses and/or co-occurring substance use disorders is incalculable. Equipped 

with cost-effective solutions that work and the will to implement them, states, 

communities, and providers can begin the difficult but necessary work of systems 

change to the benefit of persons with serious mental illnesses and co-occurring 

substance use disorders. This Blueprint provides the knowledge and the 

strategies to do so. 

More detailed information on the research and practices featured in this report 

can be found in the References (beginning on page 101); many citations include 

web sites that contain documents or additional information. In addition, the 

Resources section includes contact information for some additional Federal, 

state, and national resources on homelessness, mental illnesses, and co-occurring 

substance use disorders. While inclusion on the resources list does not imply 

endorsement by SAMHSA or HHS, readers are encouraged to contact these 

organizations for more information or for technical assistance on specific topics. 

Additional information on homelessness and mental illnesses and substance use 

disorders is available on the SAMHSA web site at www.samhsa.gov.
x B LUEPRINT FOR C HANGE

U SING T HIS R EPORT

This Blueprint for Change is divided into eight chapters that comprise four 

sections: Before You Begin, Plan for Services, Organize Services, and Sustain 

Services. These sections reflect four action steps that states and communities can 

take to prevent or end homelessness among people with serious mental illnesses, 

including those with co-occurring substance use disorders (also referred to in 

this text as people with serious mental illnesses or co-occurring disorders). Each 

chapter presents current knowledge and specific strategies designed to carry out 

the action steps (see graphic, page xiv). A brief description of the contents of 

each chapter follows. 

C HAPTER ■■■■■■■■■■■■■■■■■■■■■■■■■

1 Understand the Changing Context 

of Care and the Nation’s Response. 

This chapter outlines the current state of community-based treatment 

for people with serious mental illnesses and/or co-occurring substance 

use disorders. It also highlights the Federal response to homelessness 

for this vulnerable group. 

C HAPTER ■■■■■■■■■■■■■■■■■■■■■■■■■

2 Learn About the Population.

This chapter examines the characteristics of people with serious 

mental illnesses and/or co-occurring substance use disorders who 

become homeless, and the barriers they face to regaining mental and 

residential stability and sobriety. 

C HAPTER ■■■■■■■■■■■■■■■■■■■■■■■■■

3 Establish Core Values. 

This chapter highlights the concept and practice of recovery and 

outlines a set of both person-centered and system-level values that 

must be the foundation for service delivery and systems change. 
U SING T HIS R EPORT xi 

C HAPTER ■■■■■■■■■■■■■■■■■■■■■■■■■

4 Establish a Comprehensive, 

Integrated System of Care. 

This chapter provides a set of principles and mechanisms designed to 

help build coalitions, integrate services, and effect systems change. 

C HAPTER ■■■■■■■■■■■■■■■■■■■■■■■■■

5 Finance a Comprehensive System 

of Care. 

This chapter provides an overview of funding sources for housing and 

supportive services, and principles to access and use these resources in 

the community. 

C HAPTER ■■■■■■■■■■■■■■■■■■■■■■■■■

6 Use Evidence-Based and 

Promising Practices. 

This chapter highlights a set of evidence-based and promising 

practices that respond to the housing, treatment, and support service 

needs of people with serious mental illnesses and/or co-occurring 

substance use disorders who are homeless. 

C HAPTER ■■■■■■■■■■■■■■■■■■■■■■■■■

7 Measure Results. 

This chapter examines the need to ensure accountability in an 

integrated system of care by demonstrating measurable results and 

performing ongoing monitoring and quality assurance. 

C HAPTER ■■■■■■■■■■■■■■■■■■■■■■■■■

8 Use Mainstream Resources to 

Serve People Who Are Homeless.

This chapter highlights the range of mainstream resources available to 

people who are homeless and ways to make mainstream programs 

both accessible and accountable to them. 
xii B LUEPRINT FOR C HANGE

Using this Report to Plan, Organize, and Sustain Services for 

People with Serious Mental illnesses or Co-occurring Disorders Who Are Homeless 

C HAPTER K EY L ESSONS

Section I. B E F O R E Y O U B E G I N 

1. Understand the Changing Context 

of Care and the Nation’s Response 

 Understand how treatment for serious mental 

illnesses and substance use disorders has 

evolved 

 Study the Nation’s response 

2. Learn About the Population  Recognize individual risk factors 

 Explore service system challenges 

 Learn about societal risk factors 

3. Establish Core Values  Understand the concept and practice of 

recovery 

 Support values that put people first 

 Create a system that supports recovery 

Section II. P L A N F O R S E R V I C E S 

4. Establish a Comprehensive, 

Integrated System of Care

 Develop the infrastructure for systems change 

 Engage in strategic planning 

 Participate in community-wide planning 

5. Finance a Comprehensive 

System of Care

 Streamline existing funding 

 Secure additional resources 

 Leverage new funds 

Section III. O R G A N I Z E S E R V I C E S 

6. Use Evidence-Based and 

Promising Practices

 Adopt or adapt evidence-based practices 

 Offer a comprehensive set of essential services 

 Make use of Federal resources, including 

toolkits, TIPS,1 and CAG2 and TCE3 grants 

Section IV. S U S T A I N S E R V I C E S 

7. Measure Results  Measure client-level outcomes 

 Measure system-level outcomes 

 Use management information systems 

8. Use Mainstream Resources to 

Serve People Who Are Homeless

 Use mainstream resources to prevent 

homelessness 

 Improve access to mainstream programs 

 Expand the capacity of mainstream programs 

 Promote coordination and collaboration 

 Build the infrastructure of housing and services 

 Create public awareness 

1

Treatment Improvement Protocols 

2

Community Action Grant 

3

Targeted Capacity Expansion 
S ECTION I 

BEFORE YOU BEGIN 

Strategies to prevent and end homelessness among people with serious mental 

illnesses or co-occurring disorders must be based on a strong foundation of 

knowledge about who these individuals are, why they are susceptible to 

homelessness, and what has been done to learn more about their characteristics 

and service needs. Much of what we know attests to both the extreme vulnerability 

and the remarkable resilience of this disadvantaged and disenfranchised group. 

We also know that people with serious mental illnesses and/or co-occurring 

substance use disorders who are homeless can and do recover. 

The first three chapters in this report—Understand the Changing Context of Care 

and the Nation’s Response, Learn About the Population, and Establish Core 

Values—provide a basic understanding of individuals with serious mental illnesses 

or co-occurring disorders who are homeless, and establish a set of values that 

underlie all work on their behalf. In these chapters, you will learn about the need 

to: 

 Understand how treatment for serious mental illnesses and substance use 

disorders has evolved; 

 Study the Nation’s response; 

 Recognize individual risk factors; 

 Explore service system challenges; 

 Learn about societal risk factors; 

 Understand the concept and practice of recovery; 

 Support values that put people first; and 

 Create a system that supports recovery. 

Additional information about the materials cited in these chapters can be found in 

the References. Organizations that offer technical assistance in these areas are 

listed in the Resources section. 

 

I N THIS

S ECTION

■ ■ ■ ■ ■ ■ ■ ■

Understand the 

Changing Context 

of Care and the 

Nation’s Response 

■ ■ ■ ■ ■ ■ ■ ■

Learn About 

the Population 

■ ■ ■ ■ ■ ■ ■ ■

Establish Core 

Values 

1
2 B LUEPRINT FOR C HANGE
 C HAPTER 1 : U NDERSTAND THE C HANGING C ONTEXT OF C ARE AND THE N ATION ’ S R ESPONSE 3 

■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ 1

Understand the Changing Context 

of Care and the Nation’s Response 

Homelessness has become an enduring presence in American society. Despite 

two decades of Federal support, statewide planning, and local initiatives, an 

estimated 637,000 adults in the United States are homeless in a given week, 

with 2.1 million adults experiencing homelessness over the course of a year 

(Burt et al., 2001). 

Most studies show that the majority of people who become homeless are without 

a place to live for only a short period of time. They usually become homeless as 

a result of an unexpected event such as an eviction, natural disaster, or house fire, 

and tend to have more social and economic resources to draw on than those who 

remain homeless for longer periods of time. 

A much smaller group of homeless people either is episodically homeless (i.e., 

have many episodes of homelessness but each for short periods of time) or is 

chronically homeless (i.e., have few episodes of homelessness but each for long 

periods of time). One study of shelter users in two large cities found that 80 

percent were temporarily homeless, 10 percent were episodically homeless, and 

10 percent were chronically homeless (Kuhn and Culhane, 1998). 

The estimated 200,000 people who experience chronic homelessness tend to 

have disabling health and behavioral health problems. Recent estimates suggest 

that at least 40 percent have substance use disorders, 25 percent have some form 

of physical disability or disabling health condition, and 20 percent have serious 

mental illnesses (Culhane, 2001). Often individuals have more than one of these 

conditions. These factors contribute not only to a person’s risk for becoming 

homeless but also to the difficulty he or she experiences in overcoming it. 

People who experience chronic homelessness also tend to be slightly older than 

those who experience shorter homeless episodes, are non-white, and male 

(Culhane and Kuhn, 1998). Families and youth experience chronic homelessness, 

as well. 

The estimated 200,000 people 

who experience chronic 

homelessness tend to have 

disabling health and 

behavioral health problems. 

C HAPTER
4 B LUEPRINT FOR C HANGE

T HE C HANGING 

C ONTEXT OF C ARE

Serious Mental Illnesses 

Gone are the days when people with serious mental illnesses spent most of their 

lives in large, impersonal state institutions. The locus of care for people with 

serious mental illnesses has shifted over the past 30 years from the state hospital 

to the community. The number of patients in state psychiatric hospitals dropped 

from 560,000 people in 1955 to 77,000 people in 1996 (Bachrach, 1996). 

Much of the decrease in the state hospital census can be attributed to 

deinstitutionalization, which sought, in part, to address well-publicized abuses in 

state hospitals by shifting treatment to the least restrictive setting for people with 

serious mental illnesses. Deinstitutionalization was abetted by the introduction in 

the 1950s of antipsychotic medication and by the creation of the Medicaid and 

Supplemental Security Income (SSI) programs in the 1960s that provided 

financial incentives for community care. 

However, the realities faced by people with serious mental illnesses in their 

communities were in stark contrast to the promise of deinstitutionalization. The 

Community Mental Health Centers (CMHC) Act of 1963 was designed to 

address the needs of people with mental illnesses in their communities, but the 

vast array of needed services and supports never materialized. 

In particular, fewer CMHCs than anticipated were created, and those established 

offered primarily clinic-based services that frequently were inaccessible or 

inappropriate for individuals with the most serious disorders. As a result, many 

individuals leaving institutions never connected with community-based mental 

health services. Others cycled in and out of jails and prisons. Without 

assistance, people with serious mental illnesses were among the first to be 

displaced when urban neighborhoods and single-room-occupancy hotels were 

gentrified in the 1980s. 

By the late 1970s, the Community Support Program (CSP), now administered by 

SAMHSA’s Center for Mental Health Services (CMHS), was adopted as the 

framework for developing a comprehensive range of services that would allow 

people with serious mental illnesses to live successfully outside of institutions. 

Some of the elements of the CSP approach included: outreach, income and 

medical assistance benefits, 24-hour crisis assistance, psychosocial rehabilitation, 

employment services, long-term supportive services, medical and mental health 

treatment, family support, residential services, case management, rights 

protection, and advocacy. Today, these elements remain as the cornerstone of 

comprehensive, community-based systems of care for people with serious mental 

illnesses. 

Some communities have programs specifically designed to serve people with 

serious mental illnesses who are homeless. These programs include emergency 

shelters, outreach programs, drop-in centers, transitional housing, and health 

Without assistance, people

with serious mental

illnesses were among the

first to be displaced when

urban neighborhoods and

single-room-occupancy 

hotels were gentrified in the

1980s.
 C HAPTER 1 : U NDERSTAND THE C HANGING C ONTEXT OF C ARE AND THE N ATION ’ S R ESPONSE 5 

care. Outreach programs have been effective in reaching people with serious 

mental illnesses who are homeless, especially those who are unable or unwilling 

to accept help from more traditional office-based providers. In many cases, these 

efforts are literally saving people’s lives. 

While, certainly, success stories exist, the numbers of people in need far exceed 

the capacity of programs that provide the intensive outreach and case 

management services required. Many people with serious mental illnesses 

receive fragmented and uncoordinated treatment, housing, and support services, 

if they receive them at all. They may cycle in and out of hospitals, jails, shelters, 

and life on the streets at enormous cost to both themselves and their 

communities. 

Substance Use Disorders 

In the not so distant past, “public inebriates” typically were sent to the drunk 

tanks of local jails to dry out. In 1956, the American Medical Association 

declared alcoholism a disease, lending support for medical treatment instead of 

incarceration. The 1971 Uniform Alcoholism and Intoxication Treatment Act, 

also known as the Hughes Act, officially decriminalized public drunkenness and 

mandated a medical treatment approach. 

Instead of being jailed, homeless people who were alcoholics were sent to 

publicly funded detoxification programs where they could receive some form of 

treatment (Stark, 1987). However, studies of detoxification programs for 

indigent people reveal that few individuals leave with referrals for treatment, and 

the majority of those who are given referrals do not use them. These results led 

the researchers to conclude that the [Hughes] Act had replaced the revolving jail 

door with a “padded revolving door” (Sadd and Young, 1987). 

Though medical treatment is still a mainstay for individuals with substance use 

disorders, this approach has its drawbacks for people who are homeless. 

Treatment is expensive, residential stays are short (often, no more than 28 days), 

and, without adequate discharge planning, individuals frequently return to the 

streets (McMurray-Avila, 2001). People with substance use disorders in day 

treatment programs may have no place to sleep at night. The combination of 

poverty and addiction are significant barriers to adequate housing, an issue that 

will be explored further in Chapter 2. 

In the 1970s, the social model emerged in California as an alternative treatment 

approach for alcoholism and other substance use disorders. Social model 

programs are peer-oriented rather than professionally led and focus on the need 

for behavior change through experiential learning and shared responsibility 

(McMurray-Avila, 2001). 

One study that assessed the effectiveness of social-setting detoxification for 

homeless individuals with severe alcohol dependence found that this approach 

was as safe and effective as hospital detoxification (Haigh and Hibbert, 1990; 

Zerger, 2002). Because social model programs are less costly than medical 
6 B LUEPRINT FOR C HANGE

treatment, they primarily serve indigent individuals. However, they struggle to 

secure funding from public agencies, and their services are rarely deemed 

reimbursable by third-party insurers (Zerger, 2002). 

Many individuals who are homeless have both substance use disorders and 

serious mental illnesses. A growing body of research supports the concept of 

integrated treatment for these individuals; that is, treatment for both disorders 

provided concurrently by the same clinician or team of clinicians in a single 

setting (Drake et al., 1998). Such treatment is particularly beneficial in helping 

individuals recover from substance use (Oakley and Dennis, 1996). However, 

few such programs exist. The significant unmet need for both mental health and 

substance abuse treatment means that those with the fewest resources are least 

likely to receive appropriate care. 

T HE F EDERAL R ESPONSE

Ending chronic homelessness among people with serious mental illnesses and/or 

co-occurring substance use disorders is an achievable goal. The Stewart B. 

McKinney Homeless Assistance Act of 1987 (P.L. 100-77)—known today as the 

McKinney-Vento Act—was the first and, to date, the only comprehensive 

Federal legislation to address homelessness. The Act included a number of 

provisions designed specifically to provide health and mental health care to 

people with serious mental illnesses and substance use disorders who are 

homeless. 

Amendments to the McKinney Act—made in 1988, 1990, 1992, and 1994—for 

the most part, have strengthened the provisions and expanded the scope of the 

original legislation (National Coalition for the Homeless, 1999). Since 

enactment of the McKinney Act, the Substance Abuse and Mental Health 

Services Administration (SAMHSA) of the U.S. Department of Health and 

Human Services, and the U.S. Department of Housing and Urban Development, 

have funded innovative housing and service programs, and research and 

demonstration projects to determine how best to serve people with serious mental 

illnesses and substance use disorders who are homeless. These programs served 

as a catalyst for further development of the evidence-based practices presented in 

this report. 

A Framework for Services 

The McKinney Act also established the Interagency Council on the Homeless 

(now the Interagency Council on Homelessness) to provide Federal leadership 

for activities to help homeless individuals and families. Comprised of the heads 

of major Federal departments that manage programs for people who are 

homeless, the Council convened the Federal Task Force on Homelessness and 

Severe Mental Illness in the early 1990s. When the Task Force released its 1992 

report, Outcasts on Main Street, it provided a national strategy and a 

comprehensive framework for addressing homelessness among people with 

serious mental illnesses, many of whom have substance use disorders. 
 C HAPTER 1 : U NDERSTAND THE C HANGING C ONTEXT OF C ARE AND THE N ATION ’ S R ESPONSE 7 

In particular, the Task Force recommended that Federal agencies help states and 

local communities develop integrated systems of treatment, housing, and support 

services for people with serious mental illnesses who are homeless. The 

framework for services outlined in Outcasts on Main Street—which included 

such key elements as outreach, case management, and a range of housing 

options—has withstood the test of time and rigorous evaluation, not only for 

people with serious mental illnesses but also for those with substance use 

disorders and co-occurring mental illnesses and substance use disorders, as well. 

Federal demonstration programs, particularly those of SAMHSA’s Center for 

Mental Health Services and Center for Substance Abuse Treatment (CSAT), and 

the experience of hundreds of community-based providers, have demonstrated 

that residential stability is a goal desired by, and attainable for, most people with 

serious mental illnesses and substance use disorders who become homeless. Key 

Federal efforts designed to prevent and end homelessness for people with serious 

mental illnesses and substance use disorders are highlighted below. 

McKinney Research Demonstration Programs 

Homeless Adults with Serious Mental Illnesses. Begun in 1990, this program 

was designed to test hypotheses from earlier research studies by developing 

effective service models for people with serious mental illnesses who are 

homeless. The five resulting projects were among the first longitudinal, 

experimental-design studies of housing and service interventions for this 

population. Each site was required to provide or arrange for outreach, intensive 

case management, mental health treatment, staff training, and service 

coordination. Results indicated that even people with the most serious mental 

illnesses who are homeless, once thought to be unreachable and difficult-toserve, can be reached by the service system, can accept and benefit from mental 

health services, and, with appropriate supports, can remain in community-based 

housing (CMHS, 1994). 

Homeless Adults with Substance Use Disorders. Between 1988 and 1993, the 

National Institute on Alcohol Abuse and Alcoholism (NIAAA), in consultation 

with the National Institute on Drug Abuse (NIDA), funded two rounds of 

demonstration projects. In all, 23 projects were funded to provide and evaluate 

community-based alcohol and drug abuse treatment and rehabilitative services 

for individuals with substance use disorders who were homeless or at imminent 

risk of becoming homeless. Results indicated that individuals with substance use 

disorders who are homeless need (1) services that address their tangible needs 

for housing, income, and employment; (2) access to flexible, low-demand 

interventions; and( 3) long-term continuous treatment and support. Researchers 

found that short-term treatment was ineffective with this group (McMurrayAvila, 2001). 
8 B LUEPRINT FOR C HANGE

SAMHSA/CMHS Homeless Programs 

Access to Community Care and Effective Services and Supports (ACCESS). 

The ACCESS program was designed specifically to test the hypothesis that 

integrated service systems will improve individual functioning, quality of life, 

and housing outcomes for people with serious mental illnesses who are homeless. 

Begun in 1993, the 5-year demonstration program featured 18 communities in 9 

states that were provided funds to enhance services, particularly outreach and 

case management, for the target population. One community in each state was 

designated the experimental site and was given additional funding to support 

systems integration activities. 

Results revealed that systems integration has a positive impact on housing 

outcomes for people with serious mental illnesses who are homeless. In addition 

to improved residential stability, individuals who received case management, 

treatment, and support services showed a marked decrease in mental symptoms, 

drug use, and minor criminal activity, and an increase in number of days worked 

(Rosenheck et al., 1998; CMHS, 2001a). 

Supported Housing Initiative. Begun in 1997, the Supported Housing Initiative 

was a two-phase, multisite study designed to examine and compare the 

effectiveness of various housing approaches for people with serious mental 

illnesses, many of whom were or had been homeless. Researchers compared a 

supported housing approach to other housing models on a number of outcome 

measures, including residential stability, housing satisfaction, quality of life, and 

empowerment. Findings from this study will identify key ingredients of the 

housing models, their effectiveness, and their relative costs to help inform policy 

and service program design (CMHS, 2001b). 

Projects for Assistance in Transition from Homelessness (PATH). CMHS 

provides ongoing leadership for people with serious mental illnesses who are 

homeless through its administration of the PATH formula grant program. PATH 

was created under the McKinney Act to provide funds to each state, the District 

of Columbia, Puerto Rico, and four U.S. territories to support service delivery to 

individuals with serious mental illnesses, including those with co-occurring 

substance use disorders, who are homeless or at risk of becoming homeless. 

Through outreach, case management, screening and assessment, staff training, 

alcohol and drug treatment for people with co-occurring disorders, and support 

services in housing, PATH-funded providers nationwide have set a standard for 

the delivery of services to people with serious mental illnesses who are homeless. 

In 2001, with an allocation of nearly $36 million, 399 local PATH-funded 

organizations served more than 64,000 people with serious mental illnesses. 

SAMHSA/CSAT Homeless Programs 

In 2001, CSAT received $10 million to administer the Homeless Addiction 

Services Initiative that supported grants to local nonprofit and public entities for 
 C HAPTER 1 : U NDERSTAND THE C HANGING C ONTEXT OF C ARE AND THE N ATION ’ S R ESPONSE 9 

the purpose of developing and expanding substance abuse services for people 

who are homeless. In 2002, CSAT, in coordination with CMHS developed and 

expanded community–based mental health and substance abuse treatment 

services for people who are homeless through the Grants for the Benefit of 

Homeless Individuals (GBHI). To date, CSAT and CMHS have jointly funded 

approximately 19 million in grants under GBHI. These funds support local public 

and nonprofit agencies for up to three years to provide either substance abuse 

services, mental health services, or both, allowing communities the flexibility to 

provide the services they believe to be most urgent. Both CSAT programs will 

enable communities to expand their capacity to provide treatment to people with 

mental illnesses and substance use disorders who are homeless, and to learn more 

about effective interventions. 

SAMHSA Collaborative Demonstration Programs 

Co-occurring Disorders. SAMHSA’s CMHS and CSAT initiated a study in 

1993 to test the effectiveness of different approaches to treating people with cooccurring mental illnesses and substance use disorders who are homeless. Crosssite findings indicated that an integrated approach is superior to a parallel or a 

sequential approach to treatment for co-occurring mental health and substance 

use disorders. Integrated treatment for co-occurring disorders reduced alcohol 

and drug use, homelessness, and the severity of mental health symptoms (CMHS 

and CSAT, 2000a). 

Preventing Homelessness. In 1996, CMHS and CSAT launched a two-phase, 3-

year initiative to document and evaluate the effectiveness of homelessness 

prevention interventions. These interventions focused on people with serious 

mental illnesses and substance use disorders who were formerly homeless or atrisk for homelessness, and who were engaged with the mental health and/or 

substance abuse treatment system(s). Prevention activities included supportive 

housing, residential treatment, family support and respite, and representative 

payees and money management. Results revealed that participants in the 

intervention programs showed improved treatment outcomes and residential 

stability. Programs that could offer direct access to housing, as opposed to 

linkage and referral, had the strongest housing stability and retention outcomes 

(DeLeon et al., 2000; Bebout et al., 2001; Tsemberis and Eisenberg, 2000; 

Coughey, 2000; Policy Research Associates, 2001.) 

Interventions for Homeless Families. Begun in 1999, CMHS and CSAT 

jointly fund and administer the Homeless Families Program. The 5-year program 

is designed to document and evaluate the effectiveness of time-limited, intensive 

interventions for providing treatment, trauma recovery, housing, support, and 

family preservation services to homeless mothers with mental illnesses and/or 

substance use disorders caring for their dependent children. A 3-year outcome 

evaluation phase, which includes both cross-site and site-specific studies of the 

interventions, began in 2001. Findings from the program will identify effective 

approaches for moving families from homelessness to housing, and for providing 

treatment and supports to help maintain residential stability and recovery (CMHS 

and CSAT, 2000b). 
10 B LUEPRINT FOR C HANGE

U NDERSTANDING THE 

P OPULATION

Research and practice reveal that communities can reach out to people with 

serious mental illnesses and substance use disorders; engage them in treatment; 

and create local partnerships to increase availability and access to affordable 

housing, employment, and treatment and supports to help prevent and end 

homelessness. Understanding how to do so, however, begins with knowledge 

about why people with serious mental illnesses and substance use disorders are 

vulnerable to becoming homeless and why they have a difficult time exiting 

homelessness. The next chapter examines individual vulnerabilities and systemic 

barriers in more detail. 
 C HAPTER 2 : L EARN A BOUT THE P OPULATION 11 

■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ 2

Learn about the Population 

People who are homeless are people first. They also may have disorders 

including serious mental illnesses and substance use. The fact that they have 

illnesses that may significantly disrupt their lives doesn’t diminish their rights, 

their responsibilities, or their dreams. People with serious mental illnesses 

and/or co-occurring substance use disorders become homeless because they are 

poor, and because mainstream health, mental health, housing, vocational, and 

social services programs are unable or unwilling to serve them. They also are 

subject to ongoing discrimination, stigma, and even violence. 

For example, probably no condition is as closely connected with homelessness as 

chronic alcohol dependence (Baumohl and Huebner, 1991). As Stark (1987) 

notes: 

Conceivably, the homeless could have been stereotyped as 

unemployed men who needed jobs or job training, as elderly people 

who needed our concern and care, or as individuals who were 

physically and mentally disabled. Because, instead, they were 

stereotyped as alcoholics, the societal answer to their problems often 

related to some form of institutionalization, whether jail or 

detoxification program. (p. 12) 

Unfortunately, some key facts about serious mental illnesses and substance use 

disorders are widely unrecognized or misunderstood. The most important fact is 

that people with serious mental illnesses and/or co-occurring substance use 

disorders can and do recover. Indeed, from a medical perspective, most mental 

illnesses today are considered to be as treatable as general medical conditions 

(HHS, 1999). Further, from a rehabilitation perspective, people with serious 

mental illnesses move beyond their disabilities to reclaim valued roles in society 

(Ahern and Fisher, 2001). 

People with serious mental 

illnesses and/or co-occurring 

substance use disorders can 

and do recover. 

C HAPTER
12 B LUEPRINT FOR C HANGE

People with substance use disorders recover, as well. Fifty-five percent of 

individuals who remain in Alcoholics Anonymous for more than 90 days will be 

sober after one year, and 50 percent will be sober after five years (Ringwald, 

2002). The very fact that people who have serious mental illnesses and substance 

use disorders have learned to survive on the streets speaks to their strength, their 

resiliency, and their perseverance, all protective factors that can be harnessed to 

help them recover. 

To help people with serious mental illnesses and/or co-occurring substance use 

disorders avoid becoming homeless or exit homelessness, communities and 

providers must understand who they are and why they are vulnerable. This 

chapter examines (1) individual risk factors, (2) service delivery challenges, and 

(3) societal or structural factors that make it difficult for people with serious 

mental illnesses or co-occurring disorders to escape homelessness. 

I NDIVIDUAL R ISK 

F ACTORS

Mental Illness 

Though only about five percent of people with serious mental illnesses are 

homeless at any given point in time, as many as two-thirds of all people with 

serious mental illnesses have experienced homelessness or have been at risk of 

homelessness at some point in their lives (Tessler and Dennis, 1989). The 

numbers are staggering, but they only begin to tell the story. 

The symptoms of serious mental illnesses1

 may increase vulnerability to 

homelessness. Depending on the disorder, people with a mental illness may 

experience a range of behaviors that threaten their housing stability. Individuals 

whose mental illnesses or co-occurring substance use disorders are untreated may 

disturb their neighbors, be a threat to themselves or others, miss rent or utility 

payments, or neglect their housekeeping, and be evicted. 

Serious mental illnesses can be cyclic in nature, and some individuals may 

experience a recurrence or exacerbation of their symptoms in situations that seem 

stressful or unpredictable. Further, because many people with mental illnesses 

have difficulty developing and maintaining comfortable social relationships, they 

may become lonely and isolated and have conflicts with family, employers, 

landlords, and neighbors. These conflicts can result in homelessness if 

 

1 For the purpose of the Blueprint, “serious mental illness” refers to having one or more of the following: 

diagnosed mental illness, diagnosable mental illness, condition attributable to a mental illness or co-occurring 

health conditions that include mental illness. The disorder is associated with significant limitations in the 

performance of one or more major life activities, including but not limited to the following: basic activities of 

daily life (e.g., bathing, eating, care for health condition), instrumental activities of daily life (e.g., domestic 

activities or managing money), interpersonal relations (e.g., regulating aggressive behavior), or school or 

work. The disorder has endured or can be expected to endure continuously or with major episodes for at least 

one year. 
 C HAPTER 2 : L EARN A BOUT THE P OPULATION 13 

appropriate treatment and services are not available. People who are hospitalized 

or jailed may lose their housing when they are unable to pay their rent. 

Alcohol and Drug Use 

Substance use is both a precipitating factor and a consequence of being homeless 

(Zerger, 2002). Notes McCarty (1990, p.1): 

Street life for homeless men and women abusing drugs and alcohol 

can be confusing, dangerous, and frustrating. Individuals shuffle 

unsteadily between detoxification centers, shelters, bus stations, 

subways, day programs, jail, abandoned buildings, and soup kitchens. 

It is a painful life complicated by, but also made more bearable 

because of, the use and abuse of alcohol. 

Researchers estimate that as many as half of all people who are homeless have 

diagnosable substance use disorders at some point in their lives (McMurrayAvila, 2001; Baumohl and Huebner, 1991). Alcohol abuse is more common, 

occurring in as many as 30 percent to 40 percent of people who are homeless 

(Stark, 1987; Baumohl and Huebner, 1991). Indeed, there still exists a cadre of 

older, white male, skid row alcoholics (Koegel and Burnam, 1987). Increasingly, 

however, individuals who are homeless and have substance use disorders are 

younger and include women, minorities, poly-drug users, and individuals with 

co-occurring mental illnesses (McMurray-Avila, 2001). They have less 

education and fewer skills than their older counterparts. 

Substance use and abuse frequently lead to loss of housing, and make it more 

difficult for individuals to find safe, sober housing once they become homeless. 

People with substance use disorders who are homeless face enormous 

competition for limited treatment slots. Those who do receive treatment are 

more likely to get care for a co-occurring mental illness (SAMHSA, 2002a). 

Co-occurring Disorders 

Substance use problems are a complicating factor for many people who have 

serious mental illnesses. An estimated 50 percent of adults with serious mental 

illnesses who are homeless have a co-occurring substance use disorder (Fischer 

and Breakey, 1991). Among veterans who are homeless, one-third to nearly onehalf have co-occurring mental illnesses and substance use disorders (Kasprow, 

Rosenheck et al., 2002). 

People with both disorders are at greater risk for homelessness because they tend 

to have more severe mental symptoms, to deny both their mental illness and their 

substance use problems, to refuse treatment and medication, and to abuse 

multiple substances. Untreated, they may be antisocial, aggressive, and 

sometimes violent, and they have high rates of suicidal behavior and ideation. 

Once homeless, people with co-occurring disorders have more problems, need 

more help or are unable to benefit from services, and are more likely to remain 

homeless than other groups of people (Winarski, 1998). They are more likely to 
14 B LUEPRINT FOR C HANGE

be older, male, and unemployed; to be homeless longer and living in harsher 

conditions; and to suffer greater distress, demoralization, and alienation from 

their families. They tend to be isolated, mistrustful, and resistant to help (Dixon 

and Osher, 1995). Lack of appropriate treatment for co-occurring disorders 

means that even individuals who are motivated to get help may be unable to find 

it or have to face long waits. 

Physical Health Problems 

People with serious mental illnesses and/or co-occurring substance use disorders 

often have significant co-morbid medical conditions, including malnutrition, 

diabetes, liver disease, neurological impairments, and pulmonary and heart 

disease. Homeless people with alcohol disorders are in especially poor health; 

they experience both the deleterious effects of alcohol and of homelessness 

(Wright and Weber, 1987). Further, life on the streets makes it difficult for 

individuals to receive appropriate care for chronic conditions and often leads to 

such acute problems as upper respiratory infections, skin conditions, and serious 

dental health problems. In addition, people who are homeless, particularly those 

with serious mental illnesses or co-occurring disorders, are at risk for lifethreatening infectious diseases such as tuberculosis, Hepatitis B and C, and 

HIV/AIDS (Federal Task Force on Homelessness and Severe Mental Illness, 

1992; McMurray-Avila, 2001). 

Victimization 

The relationship among homelessness, mental illness, substance use, and 

victimization—including physical and sexual abuse—is multidimensional. 

People who have been abused are more vulnerable to ongoing stresses that may 

lead to mental illness, substance use, and homelessness. While the association 

between childhood abuse, mental illness, and substance use is increasingly 

recognized, a number of studies have found high rates of childhood physical and 

sexual abuse in adults who are homeless, as well (Fischer, 1992). Indeed, 

research points to high prevalence rates of sexual abuse and other trauma in the 

lives of people with serious mental illnesses and substance use disorders who are 

homeless, particularly women (Goodman et al., 1995; Herman et al., 1997). 

In studies that ask about lifetime abuse, between 51 and 97 percent of women 

with serious mental illnesses report some form of physical or sexual abuse, with a 

significant portion suffering multiple traumas (Goodman et al., 1997). Forty-one 

percent to 71 percent of women in treatment for drug or alcohol disorders report 

being sexually abused as children or adults, and more than one-third have been 

victims of violent crimes (Alexander, 1996). 

Abuse in childhood may leave individuals vulnerable to ongoing abuse in adult 

relationships. For some women, domestic violence precipitates homelessness. 

Mental health providers may treat women who have experienced physical and 

sexual abuse inappropriately by using such techniques as physical restraints or 

forced medication that may remind the women of the original abuse they suffered 

(National Association of State Mental Health Program Directors [NASMHPD], 
 C HAPTER 2 : L EARN A BOUT THE P OPULATION 15 

1998). These women require trauma-sensitive services to help them regain 

psychiatric and residential stability. 

Finally, people who are homeless may become victims of further assault on the 

streets and in shelters. Those individuals who have fewer resources and skills to 

overcome the effects of trauma—especially people who have serious mental 

illnesses, including post-traumatic stress disorder (PTSD)—are particularly likely 

to be victimized while homeless, and to suffer more severe consequences of 

ongoing abuse (Fischer, 1992). 

Minority Status 

Racial and ethnic minorities are dramatically overrepresented among homeless 

populations. Nationally, compared to all U.S. adults in 1996, individuals who 

were homeless were disproportionately Black non-Hispanics (40 percent versus 

11 percent in the general population) and American Indians (8 percent versus 1 

percent in the general population) (Burt et al., 1999). Though these percentages 

vary around the country, research shows that people of color comprise a 

disproportionate share of the homeless populations in their communities (Burt, 

1999). 

Some of these groups are at heightened risk for substance use disorders. The 

highest rates of alcoholism in the homeless population are found among 

American Indians, both men and women (Wright, 1987). Crack cocaine use is 

prevalent among homeless African-American men and women in urban areas 

(Zerger, 2002). 

Further, racial and ethnic minorities have less access to mental health services 

than do whites. They are less likely to receive needed care, and the services they 

do receive are likely to be poor in quality (HHS, 2001). 

Inattention to race and ethnicity creates significant barriers to successful 

treatment. Race, ethnicity, and culture influence how individuals express mental 

health problems, how they seek help, and how their problems can best be 

resolved (HHS, 2001). In addition, different racial and ethnic minorities respond 

differently to psychiatric medications (SAMHSA, 2002b). 

Race and ethnicity also are major factors in defining alcohol and drug use and 

corresponding treatment needs. For example, “the needs, perspectives, and social 

networks of younger African Americans addicted to crack cocaine will differ 

from those of older White skid-row-type alcoholics, and neither of these groups 

will have the same characteristics as chemically dependent Mexican Americans 

and Native Americans” (Conrad et al., 1993, p. 239). People of color who feel 

disconnected from society and have untreated mental illnesses and/or cooccurring substance use disorders may be difficult to engage into treatment, 

especially if outreach workers and treatment staff are not sensitive to their 

cultural and linguistic needs. 
16 B LUEPRINT FOR C HANGE

Sexual Minorities 

Homeless sexual minorities, especially youth, also are at increased risk for 

negative outcomes. Forty-two percent of homeless youth identify as lesbian, gay, 

or bisexual (Orion Center, 1986). Researchers comparing gay, lesbian, bisexual, 

and transgender (GLBT) homeless youth with their heterosexual counterparts 

found that GLBT adolescents left home more frequently, were victimized more 

frequently, used highly addictive substances more frequently, had higher rates of 

psychopathology, and had more sexual partners than heterosexual homeless 

youth (Cochran et al., 2002). 

Transgender individuals are especially stigmatized. They may become homeless 

as a direct result of job or housing discrimination. Researchers report that as 

many as 60 percent have been victims of harassment or violence, and 37 percent 

have experienced economic discrimination (Lombardi, 2001). 

Diminished Social Supports 

People with mental illnesses who become homeless have less contact with their 

families and are more likely to have poor family relationships than those who are 

not homeless. Relationships often deteriorate over time, as parents or other 

relatives become exhausted and frustrated caring for a relative who may have 

recurring periods of disturbing or frightening behavior. Without the ongoing care 

and persistent advocacy that family members provide, many people with serious 

mental illnesses are at greater risk for homelessness. 

Likewise, people with substance use disorders who are homeless have less social 

support than people who are not homeless. Yet, interestingly, among homeless 

groups, people who drink tend to report more support than people who don’t 

drink, in part because drinking can be a social activity (Fischer and Breakey, 

1987). Severing the bonds with their “friends” who use alcohol or drugs may 

compound feelings of social isolation among people who are homeless 

(McMurray-Avila, 2001). 

Criminal Justice System Involvement 

Homeless people, especially those with mental illnesses and/or co-occurring 

substance use disorders, come into frequent contact with the criminal justice 

system both as offenders and as victims. Often, homeless people are arrested for 

minor offenses, including trespassing, petty theft, shoplifting, and prostitution. 

Studies reveal that a person with a mental illness has a 64 percent greater chance 

of being arrested for committing the same offense as a person who does not have 

a mental illness (Teplin, 1984). A person’s contact with the criminal justice 

system may be even more likely following the enactment of “anti-homeless” 

legislation, including anti-begging, sleeping, and vagrancy ordinances, which is 

occurring in many of the country’s largest cities (National Coalition for the 

Homeless [NCH] and National Law Center on Homelessness and Poverty, 2002). 
 C HAPTER 2 : L EARN A BOUT THE P OPULATION 17 

People with substance use disorders who are homeless are more likely than 

persons who have not experienced homelessness to have arrest histories, to have 

been arrested in the past year, and to report felony convictions (Fisher and 

Breakey, 1987). Fifty percent of all arrests of homeless people relate to drinking 

in public spaces (McMurray-Avila, 2001). 

Though some individuals with serious mental illnesses or co-occurring mental 

illnesses and substance use disorders are diverted to treatment, the U.S. 

Department of Justice (DOJ) reports that nearly 284,000 people with mental 

illnesses were in jails and prisons in 1998 (Ditton, 1999). Twenty percent of 

state prison inmates, 19 percent of Federal prison inmates, and 30 percent of 

local jail inmates with mental illnesses were homeless in the year before their 

arrest (Ditton, 1999). In addition, offenders report a high incidence of substance 

use, and more than half are under the influence at the time of their crime (CSAT, 

in press). Among detainees with mental illnesses, 72 percent also have a cooccurring substance use disorder (Ditton, 1999). 

Despite research findings that people with substance use disorders benefit in 

particular from treatment while incarcerated, individuals with serious mental 

illnesses or co-occurring disorders may receive inadequate or inappropriate 

treatment in jails and prisons, if they receive any at all. Without an appropriate 

discharge plan, they are vulnerable to repeat cycles of homelessness. 

Finally, as noted previously, people with serious mental illnesses and/or cooccurring substance use disorders living on the streets or in shelters frequently 

are victims of criminal activity. Poverty, poor survival skills, and illegal activity 

place people with serious mental illnesses or co-occurring disorders in dangerous 

situations in which they are vulnerable to attack (Fischer, 1992). 

S ERVICE S YSTEM 

C HALLENGES

Fiscal Barriers 

Treatment Gaps 

Significant fiscal barriers prevent people with serious mental illnesses and/or cooccurring substance use disorders from receiving the care they need. Perhaps the 

most important of these are the ways in which limited funds are used in both the 

mental health and substance abuse treatment systems, which can result in 

significant gaps in the ability of both systems to treat people in need. 

Estimates are that about 20 percent of the U.S. population is affected by mental 

illnesses in any given year, but only one-third of people in need of mental health 

treatment receive it (HHS, 1999). On the substance use side, a recent report 

estimates that some 23 million people need treatment for alcoholism or the use of 
18 B LUEPRINT FOR C HANGE

illicit drugs, but fewer than one-quarter of individuals receive it (Horgan et al., 

2001). 

Coverage Gaps 

There are gaps in coverage, as well. The critical work of finding and engaging 

people who have serious mental illnesses and/or co-occurring substance use 

disorders into treatment is often not a reimbursable service. Payers who fund 

mainstream mental health and substance abuse treatment services favor clinic and 

institution-based care (Post, 2001). For example, Medicaid is a joint 

Federal/state program but is state-administered, and states vary considerably in 

the degree to which they conduct outreach to homeless people. Though 

Medicaid has instituted some outreach efforts, they are not specifically targeted 

to homeless people (GAO, 2000a). 

When case management is available to people who are homeless, caseloads are 

usually high, permitting little more than office-based contact and infrequent 

monitoring. Providers struggle to pay for services provided in atypical settings, 

such as shelters and on the streets, or nonmedical services, such as social model 

substance abuse treatment programs. 

Further, providers may be reluctant to serve people with no health insurance 

coverage, which is the case for many people with serious mental illnesses and/or 

co-occurring substance use disorders who are homeless. Many are eligible for, 

but unable to access, these benefits. Those covered by Medicaid or Medicare 

often are not attractive to providers in managed care systems that receive less 

reimbursement than they would under a fee-for-service arrangement (Bianco and 

Milstrey-Wells, 2001). 

 Persons with disabilities may be eligible for support through the Social Security 

Administration’s Social Security Income (SSI) or Social Security Disability 

Insurance (SSDI) programs. Persons who are poor and disabled or elderly may 

be eligible for the SSI program. Persons who have a sufficient work history and 

become disabled may be eligible for the SSDI program. Homeless people who 

have substance use disorders are less likely than those with serious mental 

illnesses or co-occurring disorders to be receiving Federal disability benefits 

(Baumohl and Huebner, 1991). This is in large part because individuals with 

substance use disorders, no matter how severe, are not considered disabled under 

Social Security Administration guidelines for the purpose of receiving SSI, 

unless they have other disabling health conditions not attributable to their 

substance use. 

However, people with substance use disorders often are unable to establish SSI 

eligibility without a coordinated effort to document the qualifying disability and 

consistent advocacy through the application and appeals process (C. Wilkins, 

personal communication, April 1, 2003). Also, even if SSI eligibility is 

established and the person is qualified for Medicaid, many states offer limited 

Medicaid coverage for substance abuse treatment services.
 C HAPTER 2 : L EARN A BOUT THE P OPULATION 19 

Categorical Funding 

Finally, categorical funding—which requires that providers offer only a specific 

type of service with funds from a particular source (Federal, state, local, private, 

etc.)—may make it difficult to tailor services to individual needs. In its report, 

Ending Chronic Homelessness: Strategies for Action, the U.S. Department of 

Health and Human Services (HHS) uses the phrase “funding silos” to describe 

this problem, which arises in part because most mainstream programs 

administered by HHS were created to respond to a unique need or population 

(HHS, 2003). The same is true for categorical programs in other Federal 

agencies, as well as in state and local programs. 

Funding silos lead to problems in coordination, eligibility, and flexibility, the 

HHS report notes. This is especially problematic for individuals whose 

disabilities cross service system boundaries. For example, few mainstream or 

targeted assistance programs pay for the sustained engagement and motivational 

efforts required to treat homeless people with co-occurring mental illnesses and 

substance use disorders. The HHS report notes: 

The most telling example of [eligibility gaps] involves homeless 

persons with substance use disorders and co-occurring mental illnesses 

and primary health care problems. They may have access to limited 

substance abuse treatments supported by the Substance Abuse 

Prevention and Treatment Block Grant. But, they may find that they 

do not meet eligibility criteria for receipt of Medicaid coverage, nor 

qualify as having a serious and persistent mental illness for access to 

services supported by the Community Mental Health Services Block 

Grant (p. 20). 

Categorical funding also is likely to cause gaps in coverage as an individual 

prepares to exit homelessness and is required to deal with multiple service 

agencies, each with its own case management staff (HHS, 2003). 

Fragmented Services 

People with serious mental illnesses and/or co-occurring substance use disorders 

who are homeless require a broad range of housing, health and mental health 

care, substance abuse treatment, and social services, all of which typically are 

provided by separate agencies with separate funding streams. The burden of 

coordination falls on the individual, but people with serious mental illnesses or 

co-occurring disorders, especially those who are homeless, are ill-prepared to 

negotiate a fragmented service system unaided. 

Lack of Discharge Planning 

Service system fragmentation is especially evident in the transition from an 

institution, such as a hospital or jail, to the community. Some people with 

serious mental illnesses may be released from a hospital before their symptoms 

are stabilized adequately, especially if their health insurance plan specifies a 
20 B LUEPRINT FOR C HANGE

predetermined length of stay. Others are released without adequate discharge 

plans. As noted previously, people with substance use disorders may be 

discharged from detoxification programs back to the streets. 

A lack of coordination between the hospital and community-based providers to 

ensure appropriate housing, treatment, income, and supports means these 

individuals fall through the cracks in the system and may become homeless. 

Many local officials also cite the absence of available resources as a significant 

barrier to helping people successfully make these transitions (Rickards and Ross, 

1999). 

The same is true for individuals leaving jails and prisons. Nationally, only onethird of inmates with mental illnesses in jails and prisons receive any discharge 

planning services. Frequently, they are released with bus tokens, a few pills, and 

the address of a mental health center (Bazelon Center for Mental Health Law, 

2001). They are subject to further arrest or to unnecessary hospitalization as they 

attempt to cope with their mental illnesses and life on the streets. Likewise, 

individuals with substance use disorders who are not connected to appropriate 

community services are more likely to cycle repeatedly between jail or prison 

and the community. 

Lack of Integrated Treatment for Co-occurring Mental Illnesses 

and Substance Use Disorders 

Substance abuse is an issue for at least half of all people with serious mental 

illnesses who are homeless. Typically, mental health and substance abuse 

services are provided by two separate systems, placing the burden of combined 

treatment on the individual and leading to higher rates of treatment 

noncompliance. People who are homeless also interact with the homeless service 

system. 

People with co-occurring disorders who are homeless frequently are excluded 

from mental health treatment programs because of their substance use disorder, 

from substance abuse treatment programs because of their mental illness, and 

from homeless service programs because of their mental illnesses and substance 

use disorders. Those who do receive care may get treatment for their substance 

use or their mental illness, but the vast majority of individuals do not receive 

treatment for both (Watkins et al., 2001). More recent models emphasize the 

integration of mental health and substance abuse treatment for people with the 

most serious disorders, but few such programs are available (SAMHSA, 2002b). 

Inadequate Screening and Assessment 

Screening and assessment of people with serious mental illnesses and/or cooccurring substance use disorders can be problematic in the best of 

circumstances, but homelessness adds another layer of difficulty. Outreach 

workers may conduct an initial assessment, which often has to be short and 

unobtrusive to avoid frightening away potential clients. A more complete 
 C HAPTER 2 : L EARN A BOUT THE P OPULATION 21 

assessment may be possible when clients have developed a greater degree of trust 

and comfort with outreach staff (Interagency Council on the Homeless, 1991). 

Adequate initial assessment of persons with serious mental illnesses or cooccurring disorders is made more difficult by the fact that shelter staff may lack 

the training or time to conduct a thorough psychiatric assessment, and there are 

few reliable screeners for co-occurring disorders. There are, however, some 

agreed upon early assessment tools for substance use disorders. A study of 

different assessment methods in Boston’s Long Island Shelter found that case 

managers could identify substance use problems by using a set of open-ended 

questions that include information on consumption patterns and personal 

problems associated with drinking (Garrett and Schutt, 1987). 

Self-reported substance use is a common assessment method, but the validity of 

self-reports has been called into question by several studies indicating that people 

vastly underreport the use of substances, especially illicit drugs (Zerger, 2002). 

An Institute of Medicine report on the treatment of alcohol problems notes that 

the validity of self-reports is decreased when items on the assessment are vague 

or overly general, contact with the respondent is brief, or the respondent is not 

aware that self-reports will be checked against other sources of information 

(Institute of Medicine, 1990). 

Determining the presence of serious mental illnesses in a person with a substance 

use disorder, or the presence of a substance use disorder in a person with a 

mental illness, is particularly difficult. Symptoms of mental illnesses and 

substance use may mimic or mask each other. Research indicates that identifying 

substance use disorders in acute-care psychiatric settings has been especially 

problematic, with rates of nondetection as high as 98 percent (Ananth et al., 

1989). While numerous instruments are available to assess mental illnesses or 

substance use, no single, agreed-upon assessment tool exists for co-occurring 

disorders (SAMHSA, 2002b). 

Lack of Access to Mainstream Services 

People who are homeless and have serious mental illnesses and/or co-occurring 

substance use disorders are eligible for a host of mainstream health, social 

service, and income support programs that are intended to meet the needs of all 

low-income people, not only those who are homeless. Though such programs are 

a valuable resource for providing needed services and supports, people who are 

homeless often face significant enrollment barriers (Post, 2001). 

For example, regulations may restrict eligibility for certain programs. Some 

individuals, such as single homeless adults without children, particularly those 

with substance use disorders and/or a history of felony or drug convictions, have 

limited eligibility for mainstream services. Individuals with a primary diagnosis 

of a substance use disorder, for instance, are excluded from receiving Federal SSI 

benefits. Other barriers include complicated application procedures and 

requirements made even more difficult by the lack of a fixed address or 

documentation required to apply for and receive benefits (HHS, 2003; GAO, 
22 B LUEPRINT FOR C HANGE

2000a; SAMHSA and Health Resources and Services Administration [HRSA], 

2002c). 

Further, many mainstream service providers have neither the resources nor 

experience to provide people who are homeless with many of the services and 

benefits for which they are eligible. In the absence of incentives to do so, many 

mainstream programs often fail to reach out to and serve people who are 

homeless, viewing it as a low-priority or as the responsibility of the homeless 

service system (SAMHSA and HRSA, 2002c). 

Lack of Client-Centered Services 

Many people with serious mental illnesses and/or co-occurring substance use 

disorders know what they need and how they want to be treated, but too often, 

their wants and needs are ignored. Treatment plans are designed for them, rather 

than with them, and their choices are limited. This affects both their willingness 

to engage in services and to remain in treatment. 

Studies examining the perception of need among the general homeless population 

often find discrepancies between what individuals want and what providers 

believe they need. For example, in a recent nationwide study of homeless 

assistance providers and clients, individuals rated their top three needs as help 

finding a job, help finding affordable housing, and help with housing expenses 

(Burt et al., 1999). Nine percent of respondents mentioned alcohol and drug use 

treatment as something they needed “right now” (the 13th most frequent 

response), and five percent mentioned detoxification (Zerger, 2002). 

Likewise, in a study of individuals entering the Center for Mental Health 

Services’ Access to Community Care and Effective Services and Supports 

program, researchers found that 88 percent of their expressed needs were not 

being met (National Resource Center on Homelessness and Mental Illness, 

1995). Oakley and Dennis (1996) conclude that “shelter, sustenance, and 

security needs should be met before addressing an individual’s need for 

treatment.” 

Retention in treatment is a significant problem for people in alcohol and drug 

treatment, especially those who are homeless. A study of the National Institute 

on Alcohol Abuse and Alcoholism Cooperative Agreement Program found that 

all grantees lost two-thirds or more of their clients to premature exit, and the 

majority lost more than 80 percent, regardless of the particular intervention they 

chose (Orwin et al., 1999). 

Some of the reasons for premature exit included lack of motivation, delay in 

starting treatment, and dissatisfaction with degree of program structure or 

program environment. In particular, individuals cited the need to give up their 

job or, for women, the inability to have their children with them, as reasons for 

leaving. When people with substance use disorders fail in treatment, they tend to 

return to the “highly precarious circumstances that precipitated their 

homelessness” (Orwin et al., 1999). 
 C HAPTER 2 : L EARN A BOUT THE P OPULATION 23 

Individuals reluctant to follow through on treatment goals that do not meet their 

needs increase their vulnerability to homelessness. They are difficult to reengage in services once they have had negative experiences with an unresponsive 

treatment system. 

S OCIETAL R ISK 

F ACTORS

Poverty 

People with serious mental illnesses are among the most impoverished in our 

Nation. The President’s New Freedom Commission (2003) found that: “People 

with mental illnesses have one of the lowest employment rates of employment of 

any group with disabilities—only about 1 in 3 is employed”. Because many are 

unable to work full-time, they must rely on public benefit programs, such as SSI. 

For many individuals with serious mental illnesses, such benefits provide their 

only means of support. As noted previously, people with substance use disorders 

are not eligible for SSI based on substance-related disability alone. Many work 

episodically, in part to support their addictions. 

In 2001, the monthly SSI payment was $531. Even with SSI supplements, 

provided by fewer than half the states, SSI recipients remain well below the 

Federal poverty level. In addition, though eligible to receive benefits, many 

people with serious mental illnesses are not enrolled. They face significant 

enrollment barriers, including lack of appropriate documentation and complex 

application procedures. These hurdles are particularly difficult for people who 

are homeless. The absence of a fixed permanent address makes it difficult to 

apply successfully for benefits since information about required appointments or 

the status of one’s application often is communicated by mail. Lack of benefits 

frequently leads to homelessness and the inability to exit homelessness. 

Lack of Affordable Housing 

A dearth of appropriate, accessible, and affordable housing is considered by 

many to be the number one barrier to residential stability for people with serious 

mental illnesses and/or co-occurring substance use disorders. Not one housing 

market in the United States exists in which an individual receiving SSI benefits 

can afford to rent a modest efficiency or one-bedroom unit. In 2000, people with 

disabilities receiving SSI needed to pay, on average, 98 percent of their SSI 

benefits to rent a modest, one-bedroom unit at fair market rent, as determined by 

the U.S. department of Housing and Urban Development (O’Hara and Miller, 

2001). 

Housing Barriers for People with Serious Mental Illnesses 

Many people with serious mental illnesses qualify for Federal Housing Choice 

(formerly Section 8) vouchers. These subsidies require that people pay only 30 
24 B LUEPRINT FOR C HANGE

percent of their income for rent and utilities. However, many people are on 

waiting lists for years before they receive a subsidy. Also, receipt of a Housing 

Choice voucher does not guarantee housing, particularly where affordable 

housing is in short supply. 

As a result, many people for whom SSI or SSDI are their only source of income 

are forced to live in overcrowded or substandard living environments that place 

them at physical and emotional risk. Others are living with aging parents or 

relatives, many of whom themselves are living on fixed, low incomes. Living 

precariously, people with serious mental illnesses are one small crisis—such as a 

rise in the cost of their medication—away from becoming homeless. Those who 

are doubled-up living with friends or other individuals in similar circumstances 

live at the whim of their hosts and may be evicted after a disagreement of even 

the most trivial matter. 

Further, many mainstream affordable housing providers are reluctant to serve 

people with serious mental illnesses, especially those who have been homeless. 

That reluctance in part is because of the misperception that people with mental 

illnesses need supervision or round-the-clock support, and in part because of their 

low incomes and lack of credit history. Until recently, even many mental health 

professionals presumed that most people with serious mental illnesses required 

supervised, treatment-oriented, group living arrangements to be successful in 

their communities. Research, however, provides strong evidence that people with 

mental illnesses neither need to nor want to live in such settings (Carling, 1993). 

Housing Barriers for People with Substance Use Disorders 

Housing is especially problematic for people with substance use disorders, 

particularly for those with co-occurring mental illnesses. Their behaviors place 

them at high risk for eviction, arrest, and incarceration. Once homeless, they are 

unlikely to succeed in treatment without the availability of safe, sober housing 

(Baumohl and Huebner, 1991; Stark, 1987). 

Few housing landlords (public or private), mental health agencies, and nonprofit 

developers will rent to people who are actively abusing alcohol or other drugs. 

Use of illegal drugs may be cause to deny admission or evict a person from 

federally assisted housing (Federal Register, 2001). Individuals who have 

engaged in drug-related criminal activity must be denied admission to public 

housing and most other federally assisted programs (Federal Register, 2001). 

Discrimination and Stigma in Housing 

Finally, despite statutes such as the Fair Housing Amendments Act, allegations 

of housing discrimination based on mental illnesses are common (HHS, 1999). 

Stigma and discrimination can be overt, such as vocal community opposition to 

group living situations, or they can be less obvious, such as steering public funds 

away from housing initiatives that serve controversial populations. 
 C HAPTER 2 : L EARN A BOUT THE P OPULATION 25 

The so-called “not-in-my-back-yard” (NIMBY) syndrome may affect individuals 

or it may affect broader public policy that affects people with serious mental 

illnesses and substance use disorders in housing and in social and health services 

(Federal Task Force on Homelessness and Severe Mental Illness, 1992). 

“NIMBY-ism” was a significant problem faced by the NIAAA grantees when 

trying to site housing for people with substance use disorders who were homeless 

(Conrad et al., 1993). 

Lack of Employment 

People who are homeless want and need to work, but few are employed in jobs 

that can help them escape homelessness. A recent nationwide survey of 

homeless assistance providers and clients found that 44 percent of homeless 

people were working, but most were employed in short-term jobs with low pay 

and no benefits (Burt et al., 1999). An earlier study revealed that 80 percent of 

the homeless population in inner-city Los Angeles was unemployed, but 66 

percent of individuals were looking for work (NIAAA, 1992). 

Among people with serious mental illnesses, the unemployment rate hovers at 90 

percent (HHS, 1999). Many people with serious mental illnesses are unable to 

work consistently, if at all, in part due to active symptoms of these illnesses. 

Frequently, they experience interruptions of education and employment. The 

low-paying, often menial jobs for which they qualify do not pay a living wage 

and usually do not include health care benefits, which leaves them vulnerable to 

becoming and remaining homeless. Further, many people who receive Federal 

income and entitlements are reluctant to seek employment because they fear the 

loss of benefits, including much-needed health insurance. 

People with substance use disorders often exhibit problem behaviors that 

interfere with job success. In the previously cited Los Angeles study, homeless 

people with alcohol disorders were more likely than those without alcohol or 

other disorders to report not working at all in the past year, to have worked fewer 

months at a greater number of jobs, and to have experienced a longer time period 

since their most recent job. However, they tended to be more successful in recent 

job experiences than homeless individuals with mental illnesses (NIAAA, 1992). 

Discrimination and Stigma Associated with Disabilities and 

Disadvantages 

Statutes such as the Americans with Disabilities Act and the Fair Housing 

Amendments Act spell out the rights of people with disabilities and the penalties 

for discriminating against them. Still, discrimination and stigma associated with 

mental illness, co-occurring substance use disorder, and homelessness often are 

major impediments to accessing housing and services (SAMHSA and HRSA, 

2002c). 

For instance, people with substance use disorders may be “ostracized, 

discriminated against, and deprived of basic human rights. Their families, 
26 B LUEPRINT FOR C HANGE

treatment providers, and even researchers may face comparable stigmas and 

attitudes” (CSAT, 2002). 

Further, despite the fact that public understanding of mental illnesses has grown 

since the 1950s, stigma and fear have increased. In a 1996 survey, the public’s 

perception of mental illnesses was frequently associated with the fear of violence 

(HHS, 1999). Selective media reporting may reinforce negative stereotypes 

linking mental illnesses and violence, though studies have shown that the 

absolute risk of violence posed by persons with mental illnesses is small (HHS, 

1999; Mulvey, 1994). 

Complicating the issue, providers of mental health, substance use, and other 

social services may have negative attitudes toward serving people who are 

homeless. Discrimination by landlords and other housing and service providers, 

in turn, may lead to fear and mistrust on the part of individuals, causing them not 

to seek the housing and supports they need (SAMHSA, 2002a). 

G UIDING P RINCIPLES 

FOR A S YSTEM OF C ARE

Providers of services to people with serious mental illnesses and/or co-occurring 

substance use disorders and people who are homeless face a daunting challenge 

to address their clients’ multiple, complex needs. But they cannot design 

programs for their clients; they must create them with their clients. Services for 

people with serious mental illnesses or co-occurring disorders who are homeless 

must be built on a foundation of core values that both put people first and support 

recovery from multiple conditions. The next chapter outlines a set of underlying 

principles to guide development of a comprehensive system of care for people 

with serious mental illnesses and/or co-occurring disorders who are homeless. 
 C HAPTER 3 : E STABLISH C ORE V ALUES 27 

■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ 3

Establish Core Values 

The values that underlie development of community-based services for people 

with serious mental illnesses and/or co-occurring substance use disorders who 

are homeless are as important as the individual service components themselves. 

Each of these values has at its center an abiding belief in the dignity and worth 

of the individual. 

Putting people first not only is the humane thing to do; but also it is the most 

effective way to help people with serious mental illnesses or co-occurring 

disorders escape homelessness. Research reveals that services that respect an 

individual’s right of self-determination are more likely to result in residential and 

psychiatric stability and sobriety (Srebnik et al., 1995; Shern et al., 2000). This 

chapter examines (1) the concept and practice of recovery, (2) person-centered 

values, and (3) system-level values that form the foundation for effective 

services to prevent and end homelessness among people with serious mental 

illnesses or co-occurring disorders. 

T HE C ONCEPT AND 

P RACTICE OF R ECOVERY

The good news is that people with serious mental illnesses and/or co-occurring 

substance use disorders can and do recover. Understanding the concept and 

practice of recovery is fundamental to the development of effective services for 

people with serious mental illnesses and/or co-occurring disorders who are 

homeless. 

A Definition of Recovery 

There are as many different definitions of recovery as there are individuals who 

recover. However, as mental health and substance abuse treatment systems 

move toward recovery-based systems of care, many have developed working 

definitions to guide their efforts. The Connecticut Department of Mental Health 

and Addiction Services has endorsed a broad vision of recovery as: 

Understanding the concept and 

practice of recovery is 

fundamental to the 

development of effective 

services. 

C HAPTER
28 B LUEPRINT FOR C HANGE

a process of restoring or developing a positive and meaningful sense of 

identity apart from one’s condition and then rebuilding a life despite or 

within the limitations imposed by that condition (Evans et al., 2002). 

For many, if not most, homeless individuals who have mental illnesses and 

substance use disorders, recovery will involve some type of professional 

intervention, including the use of medication, where appropriate. Evidencebased and promising treatment practices for people with serious mental illnesses 

or co-occurring disorders who are homeless are discussed in the next chapter. 

The following discussion examines other critical facets of the recovery process. 

Recovery from Substance Use Disorders 

The term “recovery” has been used extensively in the field of substance use, 

where it refers to a return to sobriety (Ralph, 2000). For many individuals, 

spirituality and peer support are critical to their recovery from addictions. Thus, 

for example, individuals in 12-step groups for recovery from addictions express 

their belief in a power greater than themselves. Secular substance use recovery 

groups, such as Women for Sobriety and Self-Management and Recovery 

Training (SMART), focus on individual empowerment and emotional growth. 

They share with the 12-step tradition a belief in the importance of self-help as a 

way to obtain and maintain sobriety. 

People with both a mental illness and a co-occurring substance use disorder face 

the daunting task of recovering from both disorders. Self-help groups 

specifically designed to meet the needs of people with co-occurring disorders, 

such as Double Trouble in Recovery, provide individuals the opportunity to share 

common problems and to help others in their recovery from both mental illnesses 

and substance use (Double Trouble in Recovery, 1997). 

Recovery from Mental Illness 

Use of the term “recovery” only recently has been applied to people with mental 

illnesses, in part because of the mistaken belief that having a serious mental 

illness is a lifelong condition. The most frequently cited study that disproves this 

notion is a longitudinal study of severely disabled individuals in Vermont. 

Investigators found that 34 percent of former hospital inpatients who received 

mental health services, including psychiatric rehabilitation, in the community 

achieved full recovery in both psychiatric status and social functioning, and an 

additional 34 percent improved significantly in both areas (Harding et al., 1987). 

Twenty-seven studies (including Harding’s) published between 1960 and 1991 

show equally promising rates of recovery from serious mental illnesses (Ralph, 

2000). 

More recent research examines the relationship between illness self-management, 

an evidence-based practice in the mental health field, and recovery from serious 

mental illnesses. Researchers found that illness self-management skills—

including greater knowledge of mental illnesses, coping skills, and relapse 
 C HAPTER 3 : E STABLISH C ORE V ALUES 29 

prevention strategies—play a critical role in people’s recovery from mental 

illnesses (Mueser et al., 2002). 

However, much of what is known about mental health recovery comes from the 

writings of mental health consumers themselves and supports what has been 

called the “simple yet powerful vision” (Anthony, 1993) of mental health 

recovery. Ultimately, recovery from a serious mental illness is a very personal 

process that involves the recovery of hope, of meaningful activities and 

relationships, and of self-esteem and self-worth. Many consumer advocates 

believe that recovery involves the development of both key relationships with 

supportive individuals and core beliefs about mental illnesses (Ahern and Fisher, 

1999). Accordingly, they believe an individual can recover regardless of whether 

he or she takes medication. 

Recovery from Homelessness 

Recovery from homelessness also is a process, according to a study conducted by 

SRI Gallup, Inc. Researchers defined recovery from homelessness as being 

sober, employed, and housed; they identified six themes that support this process: 

spirituality, self-insight, security, self-awareness, support, and suppression of 

poor self-concepts and negative attitudes (www.agrm.org/gallup.html, retrieved 

May 2, 2003). 

Lack of support or connection to others may be the single most important reason 

why people are homeless, according to the SRI Gallup survey. For many 

homeless people, outreach workers are the first to break through the isolation and 

begin to move people toward a life of greater health and personal stability. 

Outreach is about “compassion translated into concrete action. It is about 

regarding all human beings as intrinsically valuable.” (Kraybill, 2002). Personcentered values are at the heart of a system that empowers people with mental 

illnesses and substance use disorders to recover. 

P ERSON - C ENTERED 

V ALUES

The key values that support recovery can be described in a number of ways. For 

example, people with mental illnesses and substance use disorders who have 

survived trauma (defined as physical or sexual abuse) speak of “safety, voice, 

and choice” as the values that must guide services designed by and for them 

(NASMHPD, 1998). Researchers trying to quantify recovery to make it 

measurable use the terms “hope, taking personal responsibility, and getting on 

with life” (Noordsy et al., 2002). Spirituality and self-help are key tenets of the 

12-step approach to addictions. 

While these values are described similarly, some important points stand out. 

Choice. People with serious mental illnesses and/or co-occurring substance use 

disorders who are homeless should be given real choices in housing, treatment, 
30 B LUEPRINT FOR C HANGE

and support services. They should be informed of the full array of options 

available to them. Services cannot be “one size fits all”; they should be tailored 

to the individual’s needs. 

Voice. A well-known tenet of the mental health consumer movement says, 

“Nothing about us without us.” People who have serious mental illnesses or cooccurring disorders should have a say in the programs, policies, and services 

designed to serve them. 

Empowerment. Many people with serious mental illnesses or co-occurring 

disorders, especially those who are or have been homeless, are disillusioned with 

services they have received in the past and are disenfranchised from the service 

system. They should be educated and empowered to make choices in matters 

affecting their lives and to accept responsibility for those choices (Federal Task 

Force on Homelessness and Severe Mental Illness, 1992). For most, this should 

include participation in developing their treatment goals and recovery plan. 

Dignity and Respect. The use of people first language (e.g., people who have 

serious mental illnesses, people who are homeless) is more than an exercise in 

semantics. Language shapes thought, and treatment service providers must 

recognize that the people they serve deserve the same respect that providers 

expect from them. 

Hope. Hopelessness breeds helplessness and despair. For many, recovery of 

hope is essential for recovery from serious mental illnesses or co-occurring 

disorders. Recovery from these disorders is an achievable goal that makes all 

other goals possible. 

S YSTEM - L EVEL V ALUES

A recovery-oriented system of care, according to the Connecticut Department of 

Mental Health and Addiction Services, “identifies and builds upon each 

individual’s assets, strengths, and areas of health and competence to support 

achieving a sense of mastery over his or her condition while regaining a 

meaningful, constructive sense of membership in the broader community” (Evans 

et al., 2002). Specific system-level values that can help achieve this vision 

include: 

Believe in Recovery. Optimism is essential. Osher (1996) notes: “Consumers, 

families, and practitioners who maintain a hopeful attitude toward recovery are 

associated with effective [co-occurring disorders] treatment programs.” 

Make “Any Door the Right Door” to Services. People who are homeless and 

have serious mental illnesses and/or co-occurring substance use disorders should 

be able to enter the service system through any service “door” (e.g., mental 

health services, substance abuse treatment, welfare office, jail), should be 

assessed, and should have access to the full range of comprehensive services and 
 C HAPTER 3 : E STABLISH C ORE V ALUES 31 

supports they want and need (National Technical Assistance Center for State 

Mental Health Planning [NTAC], 2000). 

Use Mainstream Resources to Serve People Who Are Homeless. People with 

serious mental illnesses or co-occurring disorders who are homeless should be 

educated and empowered to gain access to mainstream resources (e.g., housing, 

mental health, and income support) for which they are eligible (Federal Task 

Force on Homelessness and Severe Mental Illness, 1992). Many people who 

become homeless are or have been clients of public systems of care and 

assistance, but they have been ill-served. Homeless assistance providers should 

help connect or reconnect individuals to mainstream programs, which is the only 

way to provide the long-term housing and services individuals require to break 

the cycle of homelessness (NAEH, 2000). 

Be Flexible/Offer Low-Demand Services. Services should be flexible enough 

to be delivered in sufficient amounts, duration, and scope to support recovery, 

based on an individual’s changing needs and preferences. Participation in 

treatment and receipt of services should not be required to gain access to housing. 

Individuals reluctant to enter treatment may require some type of low-demand 

service, such as a Safe Haven, to help engage them in more intensive 

interventions (see more about Safe Haven in Chapter 6). These strategies can 

provide safety and help meet immediate survival needs while providing an 

opportunity to engage individuals in more intensive interventions. 

Tailor Services to Meet Individual Needs. Each individual’s preferences, 

treatment history, strengths, needs, and motivations must be recognized and 

addressed in plans designed to help him or her avoid or exit homelessness 

(Federal Task Force on Homelessness and Severe Mental Illness, 1992). 

Develop Culturally Competent Services. Race, ethnicity, and culture influence 

everything, from how individuals express problems to whether or not they seek 

help and the type of services they will accept. At its core, cultural competence 

involves improved access to services and cultural adaptations that make services 

appropriate in cross-cultural settings (PATH Cultural Competence Workgroup, 

2001). At a minimum, providers should be multilingual and multicultural 

(Federal Task Force on Homelessness and Severe Mental Illness, 1992; HHS, 

2001). 

Involve Consumers and Recovering Persons. Mental health consumers and 

individuals in recovery from substance use disorders play an important role in 

helping to empower their peers to recover from serious mental illnesses or cooccurring disorders. They make valuable contributions as agency staff and as 

active members of planning councils and advisory boards. Many consumers and 

recovering persons operate programs and services designed to help their peers 

recover. 

Offer Long-Term Followup Support. Recovery from mental illnesses and cooccurring substance use disorders is neither a linear nor a short-term process. 

Relapse is to be expected, and individuals may require long-term followup 
32 B LUEPRINT FOR C HANGE

support, especially after they move into housing or gain employment. Short-term 

fixes are neither cost-effective nor humane. 

E STABLISHING A 

S YSTEM OF C ARE

Clearly, people with serious mental illnesses and/or co-occurring substance use 

disorders who are homeless have significant, complex needs that must be 

addressed if care is to be effective and recovery is to be achieved. The many 

state and community agencies that serve people with serious mental illnesses or 

co-occurring disorders who are homeless must work together to plan a 

comprehensive, coordinated system of care that supports their clients’ individual 

needs for recovery from multiple conditions. 

The next two chapters of this report comprise Section II: Plan for Services. They 

offer practical approaches for developing strategic partnerships and securing the 

support needed to begin. 
S ECTION II 

PLAN FOR SERVICES 

The needs of people with serious mental illnesses and/or co-occurring substance 

use disorders who are homeless cannot be addressed by a single service system. 

Indeed, both research and practice in recent years reveal that services for people 

with serious mental illnesses and/or co-occurring substance use disorders who are 

homeless must be offered as part of a comprehensive, integrated system of care. 

Partnerships with other providers and service systems can increase residential and 

clinical stability and prevent homelessness (Davis et al., 2002; Rosenheck et al., 

1998). 

Thus, community agencies that serve people with serious mental illnesses or cooccurring disorders who are homeless must work together to build a strong 

foundation for systems change and to secure the support needed to establish and 

maintain services. The next two chapters—Establish a Comprehensive, Integrated 

System of Care and Finance a Comprehensive System of Care—describe the steps 

necessary to help build those coalitions: 

 Develop the infrastructure for systems change; 

 Engage in strategic planning; 

 Participate in community-wide planning; 

 Streamline existing funding; 

 Secure additional resources; and 

 Leverage new funds. 

Additional information on the materials cited in these chapters can be found in the 

References. Organizations that offer technical assistance in these areas are listed in 

the Resources section. 

 

I N THIS

S ECTION

■ ■ ■ ■ ■ ■ ■ ■

Establish a 

Comprehensive, 

Integrated System 

of Care 

■ ■ ■ ■ ■ ■ ■ ■

Finance a 

Comprehensive 

System of Care 

33
34 B LUEPRINT FOR C HANGE
 C HAPTER 4 : E STABLISH A C OMPREHENSIVE , I NTEGRATED S YSTEM OF C ARE 35 

■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ 4

Establish a Comprehensive, 

Integrated System of Care 

People with serious mental illnesses and/or co-occurring substance use 

disorders who are homeless need multiple services, including housing, health 

care, mental health services, substance abuse treatment, income supports and 

entitlements, life skills training, education, and employment. These services 

typically are provided by multiple agencies in different systems, leaving 

individuals to coordinate their own care. They may receive duplicate services 

at multiple agencies or no services at all. This chapter examines both the need 

for a comprehensive, integrated service system, and the steps and strategies to 

achieve systems change. 

W HY C OMPREHENSIVE ,

I NTEGRATED S ERVICES ?

The concept of integrating human services to improve outcomes for individuals 

with multiple and complex needs is not new. For more than 30 years, active 

efforts to integrate human service systems have been called by such names as 

community integration, comprehensive services, community support systems, 

and a Continuum of Care (Dennis et al., 1999). In its 1992 report, Outcasts on 

Main Street, the Federal Task Force on Homelessness and Severe Mental Illness 

set as a goal for the Nation, “an integrated service system for homeless people 

with severe mental illness.” Clearly, progress has been made, but much remains 

to be done. 

Without housing, services and 

supports cannot be effective. 

C HAPTER
36 B LUEPRINT FOR C HANGE

Systems integration efforts have taken on special urgency in an era of increasing 

needs and limited resources. Contemporary systems integration efforts are driven 

by several important factors. The relaxation of some Federal program 

regulations—through block grants and special waivers, for example—creates 

opportunities to promote integrated services. In addition, some Federal/state 

programs, including Medicaid managed care and welfare reform, may prompt 

collaboration among diverse agencies in order to meet mandated financial 

objectives and client outcomes (NASMHPD and CMHS, 1999). 

The Definition of Systems Integration 

At its most basic, systems integration is designed to change service delivery for a 

defined population and involves fundamental changes in the way agencies share 

information, resources, and clients (Dennis et al., 1999). In particular, systems 

integration focuses on reducing barriers, coordinating and improving existing 

services, and developing new programs to improve the availability, quality, and 

comprehensiveness of services (Miller, 1996). 

Systems integration efforts require the creation of formal relationships among 

agencies within and across systems. Systems integration cannot succeed without 

an emphasis on integrated services, as well (Agranoff, 1991; Cocozza et al., 

2000). 

The Creation of a Seamless System of Care 

The ultimate goal of systems integration is to improve outcomes for people with 

serious mental illnesses or co-occurring disorders who are homeless. To do so 

requires creating a system of care that is seamless to the individuals being served. 

Indeed, full integration assumes a system-wide policy that makes “any door the 

right door” to receive needed treatment and services. This means that people 

with serious mental illnesses or co-occurring disorders who are homeless must be 

able to enter the service system through any service door, be assessed, and have 

access to the full range of comprehensive services and supports they want and 

need (Federal Task Force on Homelessness and Severe Mental Illness, 1992). 

This approach challenges the ways in which systems with different funding 

streams, philosophies, and missions typically offer services. However, by 

responding collaboratively to address the multiple needs of people who are 

homeless, service systems benefit from a more efficient use of limited resources. 

Individuals benefit from client-centered services that place the burden of 

coordination on the systems that are serving them (NTAC, 2000). 

Barriers to Integrating Services 

Despite distinct advantages to both systems and clients, the barriers to integrating 

service systems are both broad and deep. As one observer notes, “While 

everybody is in favor of coordination, nobody wants to be coordinated.” 

(Feldman, 1976). 
 C HAPTER 4 : E STABLISH A C OMPREHENSIVE , I NTEGRATED S YSTEM OF C ARE 37 

Some specific system-level barriers to effective integration include: 

 Well-established programs and a specialized work force; 

 Interagency turf battles; 

 Funding limitations; 

 Lack of technology and resources to support information needs; 

 Lack of available services; 

 Size and complexity of the service system; 

 Lack of political will and mechanisms to channel public support; and 

 Legislative and political opposition. 

(NASMHPD and CMHS, 1999; Yessian, 1995; Rochefort and Dill, 1994;

Agranoff, 1991; Feldman, 1976) 

The tools to address these barriers include the key strategies and mechanisms for 

systems integration highlighted below. Sometimes Federal or state regulatory, 

statutory, or budgetary requirements must be relaxed to make it easier for 

agencies to collaborate with one another. However, even small changes in the 

way agencies relate to one another can pave the way for greater cooperation on 

behalf of people with serious mental illnesses or co-occurring disorders who are 

homeless. 

K EY S YSTEMS I NTEGRATION 

S TRATEGIES AND M ECHANISMS

Successful systems integration is based on all the knowledge a community has at 

its disposal about the population to be served. In particular, research and 

experience have demonstrated that services for people with serious mental 

illnesses or co-occurring disorders who are homeless should be recovery-focused, 

culturally competent, flexible and individualized, and client-centered. Further, 

the full array of services that individuals need must be in place or must be 

created. This makes it essential that individuals with mental illnesses and 

substance use disorders who are homeless have access to all mainstream benefits 

and services for which they are eligible. 

For instance, the importance of making a variety of safe, affordable housing 

options available cannot be overstated. Without housing, services and supports 

cannot be effective. Finally, individuals must be supported while making 

transitions among services (e.g., from transitional to permanent housing) or from 

an institution to the community. 

Each of the specific steps outlined is critical to making systems change a reality. 

The strategies required to carry out each step will vary depending on the local 

needs, resources, and community priorities; however, strategies that have proven 

successful in other jurisdictions offer useful guidance (Foster et al., 1998; Hoge 

and Howenstine, 1997; Ridgely et al., 1998). 
38 B LUEPRINT FOR C HANGE

Develop the Infrastructure for Systems Change 

Choose a Change Agent 

A dedicated staff person brings energy and attention to the task of systems 

integration. This person should be capable of providing the leadership necessary 

to engage key stakeholders from all service sectors. Key leadership 

characteristics for such a person include “vision, entrepreneurship, political 

astuteness, a respect for diversity, and a talent for managing complexity.” 

(Yessian, 1995). The systems integration coordinator must be highly respected 

and independent of the key collaborators to avoid the impression of favoritism or 

an imbalance of power. 

Secure Adequate Resources 

Money is a necessary, though not sufficient, ingredient of systems integration. 

Without flexible funding or regulatory relief, systems integrators begin in a weak 

position (Yessian, 1995). The next chapter includes an overview of strategies to 

support services for people with serious mental illnesses and/or co-occurring 

substance use disorders who are homeless. 

Build a Coalition of Key Stakeholders 

Building a coalition of key stakeholders is critical to the systems change process. 

This group must include individuals with the authority to commit their 

organizations and their resources to needed changes (Agranoff, 1991). Such 

groups may vary in size and composition, organizational structure and process, 

and missions and objectives (Cocozza et al., 2000). In general, however, 

coalition membership should be inclusive rather than exclusive and should 

involve consumers and recovering persons in an active role (Kaye and Wolfe, 

1995). Other important stakeholders might include: 

 Executive branch leaders from state and local governments (e.g., 

governors, mayors); 

 Agency heads from state and local departments of housing, mental 

health, substance use, health, Medicaid, welfare/social services, 

education, homeless services, transportation, labor, criminal justice, etc.; 

 Health, mental health, substance abuse treatment, and homeless 

assistance providers; 

 Faith and community-based organizations; 

 People who are homeless or formerly homeless; 

 Consumers and recovering persons and their families; 

 Members of the business community; and 

 Advocacy groups. 

HHS has sponsored a series of state-level Policy Academies designed to develop 

the infrastructure for systems change. The Academies create or reinforce 

relationships among key stakeholders in selected states (e.g., the governor’s 

office, state legislators, key program administrators, and stakeholders from the 

public and private sectors) who can work together to improve access to 

mainstream services for people who are homeless. 
 C HAPTER 4 : E STABLISH A C OMPREHENSIVE , I NTEGRATED S YSTEM OF C ARE 39 

Nurture the Coalition and Continue to Form Partnerships 

Relationships with key stakeholders must be nurtured to engage them fully in the 

process. Other important parties may be identified along the way and should be 

similarly engaged (NTAC, 2000). Once a coalition is established, members can 

begin to build relationships and develop a common language, define their 

mission, and create a structure for working together (Kaye and Wolff, 1995). 

Building a coalition is a means to systems change but is not an end product. 

Collaborative planning is an ongoing process that involves building new 

relationships and securing commitment from all players to carry out a 

community’s plan to address homelessness. When forming new or re-evaluating 

old relationships, individuals must be aware of preconceived notions about the 

services and resources of other stakeholders and be open to understanding new or 

different perspectives. Engaging in active listening and focusing on ideas rather 

than people support honest expression of ideas and information sharing (HHS, 

HUD, and Interagency Council on the Homeless, 1999). 

Engage in Strategic Planning 

Developing a formal plan for action is a critical ingredient of the collaborative 

planning process (HHS, HUD, and Interagency Council on the Homeless, 1999; 

and HomeBase, 1999; HHS, undated). This is best accomplished by strategic 

planning, summarized in Table 4.1. Engaging in this process helps both 

delineate the parameters of the systems integration effort and set specific goals 

and objectives. Without such a plan, systems integration efforts have no 

direction, no means to evaluate their progress, and no basis on which to build 

trust (Dennis et al., 1999). 

Define the Issue 

Before a community can develop a plan to integrate care for people who are 

homeless, it must be clear about the services it currently offers and the existing 

gaps or unmet needs. Data that indicate where people are not being served or are 

underserved in the system, along with anecdotal examples that point to barriers 

or gaps in the system, should be discussed openly to help the group produce a 

shared definition of the problem (NTAC, 2000). 

Such data may include “hard” data such as admissions and clinical encounter 

information from programs that serve people with serious mental illnesses or cooccurring disorders and people who are homeless. “Soft” information from key 

informant interviews and focus groups with system stakeholders also may be 

considered (NTAC, 2000). 
40 B LUEPRINT FOR C HANGE

Table 4.1 

The Strategic Planning Process 

S TEPS A CTIVITIES

1. Define the Issue 

 Identify existing services and resources, 

and gaps or unmet needs in the system. 

Share and discuss data to reach agreement 

on the definition of the problem or issue. 

2. Create a Shared Vision 

 Use imagination and brainstorming to 

create a “preferred future.” Don’t be 

constrained by current resources. 

3. Develop a Plan 

 Identify goals/objectives and strategies to 

achieve them. Assign responsibility for 

tasks to implement each strategy. 

Establish timeframes for completion. 

4. Implement the Plan  Carry out selected strategies/mechanisms, 

as assigned. 

5. Monitor Progress  Collect outcome data and monitor 

progress. Allow for ongoing input and 

refinement of strategies, as necessary. 

Create a Shared Vision 

When the group has identified the problem or problems it wants to address (e.g., 

lack of discharge planning for individuals with serious mental illnesses or cooccurring disorders leaving a hospital or jail), members can develop a shared 

vision or mission statement to create an integrated service system (National 

GAINS Center, 1999). When creating this vision, the group should not be 

constrained by the system’s current configuration or resources. Rather, the 

vision should represent the “preferred future,” or what the system could look like 

if integration were achieved (NTAC, 1999). Ultimately, a vision statement 

should be simple, concise, and clear, and should immediately engage all parties 

(NTAC, 2000). 

Develop a Plan 

When the group has defined its mission, it should develop a formal plan that 

specifies recommendations for change. Such a plan documents the specific 

goals, objectives, and strategies to make the vision a reality. For example, the 

group may decide that it needs to implement formal discharge planning policies 

to keep people with serious mental illnesses or co-occurring disorders from 

becoming homeless when they leave a jail, a detoxification program, or a 

psychiatric hospital. The plan also should assign responsibilities for tasks and set 

timeframes for completion (Kaye and Wolff, 1995). Procedures to measure 

outcomes to ensure accountability should be built in, as well. 
 C HAPTER 4 : E STABLISH A C OMPREHENSIVE , I NTEGRATED S YSTEM OF C ARE 41 

 

Implement the Plan 

A number of mechanisms may be used to achieve a community’s specific goals, 

as highlighted in Table 4.2. These include co-location of services, pooled or joint 

funding, and streamlined application procedures. For example, a homeless 

services provider may station a case manager at the jail to help create discharge 

plans for people with serious mental illnesses and/or co-occurring substance use 

disorders who are at risk of homelessness. 

Many of these strategies have been successful in promoting systems integration 

in other communities, including those involved in the ACCESS (Access to 

Community Care and Effective Services and Supports) demonstration program, 

administered by SAMHSA’s Center for Mental Health Services. Findings from 

the ACCESS program evaluation indicate that successful implementation 

depends, in part, on the specific strategies selected. Certain mechanisms, such as 

the use of interagency agreements, appear to be easier to implement. Others, 

including the development of interagency management information systems or 

the establishment of common eligibility criteria, require time and a wellfunctioning infrastructure to implement successfully (Cocozza et al., 2000). 

Monitor Progress 

Incremental improvements as well as long-term accomplishments can be 

highlighted by collecting and analyzing data (NTAC, 2000). For example, a 

community might measure the number of days homeless after leaving jail as an 

indicator of successful discharge planning efforts for people with serious mental 

illnesses or co-occurring disorders at-risk of homelessness. This information also 

can be used to make mid-course corrections in the implementation plan, as 

necessary. 

Successful evaluation efforts require the establishment of guidelines for 

consistent data collection, performance standards, and reporting. Quality 

assurance can be linked to funding (e.g., written into contracts) as a means of 

ensuring compliance and promoting effective practices. Strategies for evaluating 

outcomes are described further in Chapter 7. 

Seek Technical Assistance 

The value of technical assistance at critical junctures is an important strategy in a 

successful systems change initiative. Communities sometimes need an outside 

facilitator to help with the strategic planning process or an evidence-based 

practice expert who can advise on implementing a specific service component 

(Pitcoff, 1997; Dennis et al., 1999). It also may be helpful to visit and talk with 

others who have already implemented a similar approach or system component in 

another community. Being able to identify specific technical assistance needs 

and to seek help early in the process can help communities avoid losing the 

momentum needed to achieve lasting change. 
42 B LUEPRINT FOR C HANGE

Table 4.2 

Implementation Strategies 

Co-locate services—Provide multiple services in a single location for 

“one-stop shopping” for users. 

Train and cross-train staff—Train own staff or staff from other 

agencies about a particular topic or agency’s services. 

Create interagency agreements or memoranda of understanding—

Enact agreements among agencies, either formal or informal, that 

specify arrangements to share information and referrals or coordinate 

services. 

Implement interagency management information systems (MIS)—

Develop MIS and computerized client tracking systems that link 

agencies, promote information sharing, simplify referrals, and facilitate 

clients’ access to services. 

Use pooled or joint funding—Try aggregating or combining funds to 

create new services or resources to support interagency activities. 

Develop uniform applications, eligibility criteria, and intake 

assessments—Create a standard process or form used by multiple 

agencies that an individual completes only once. 

Use interagency service delivery teams—Establish interdisciplinary 

teams from different agencies that address the multiple needs of clients 

in an integrated manner. 

Make some flexible funding available—Use noncategorical funding 

to fill gaps in services, purchase expertise, or leverage additional 

resources. 

Consider special waivers—Apply for or implement waivers in 

regulatory, statutory, or budgetary requirements that reduce barriers 

and promote access to services. 

Consolidate programs or agencies—Combine multiple agencies or 

programs under a central administrative structure to reduce fragmented 

services. 

Participate in Community-Wide Planning Efforts 

Systems change can’t happen in a vacuum. A number of local and statewide 

planning processes can bring key stakeholders to come together and create a plan 

for services. The needs of people with serious mental illnesses and/or cooccurring substance use disorders who are homeless must be represented in these 

plans. In addition, these groups may have valuable data and ideas to share, and 

their members may include some of the key players you need on your team.
 C HAPTER 4 : E STABLISH A C OMPREHENSIVE , I NTEGRATED S YSTEM OF C ARE 43 

For example, the Continuum of Care process is more than an application for 

HUD Homeless Assistance funds. According to HUD, a Continuum of Care plan 

is “a community plan to organize and deliver housing and services to meet the 

specific needs of people who are homeless as they move to stable housing and 

maximum self-sufficiency. It includes action steps to end homelessness and 

prevent a return to homelessness.” (HUD, 1999). 

Mental health and substance abuse services providers must participate in 

Continuum of Care planning to ensure that the needs of the individuals they serve 

are represented in requests for homeless assistance funds. Likewise the HUD 

Consolidated Plan, needed to access mainstream housing resources, is a strategy 

for holistic community planning. State and community Consolidated Plans are 

built on public participation. The volume, How to Be a “Player” in the 

Continuum of Care: Tools for the Mental Health Community, is an excellent 

resource in this regard (Technical Assistance Collaborative, 2000). 

 (Technical Assistance Collaborative, 2000). 

Finally, in response to the Supreme Court’s 1999 decision in Olmstead versus 

L.C., most states have created task forces or commissions to develop plans to 

serve people with disabilities in less restrictive settings (GAO, 2000b). CMHS 

provides funds and technical assistance for statewide coalitions that are 

addressing barriers to full community integration for adults and children with 

mental illnesses. Because people with serious mental illnesses and/or cooccurring substance use disorders leaving institutions are at risk for 

homelessness, and those living precariously in the community are at risk for 

unnecessary hospitalization, key stakeholders in the mental health services, 

substance abuse treatment, and homeless service systems must be active players 

in developing statewide Olmstead plans. 

E NSURING A DEQUATE 

R ESOURCES

Devising a formal plan and getting the commitment of top-level leaders and key 

stakeholders are critical to any successful systems change effort. However, while 

necessary, they are not sufficient alone to make change a reality. Planning must 

be linked to adequate financial resources. Finding ways to leverage resources, 

make better use of mainstream resources, and pursue new sources of funding are 

essential. Improved coordination among existing funding sources also is 

necessary. The next chapter describes strategies to support housing and services 

for people with serious mental illnesses or co-occurring disorders who are 

homeless. 
44 B LUEPRINT FOR C HANGE
 C HAPTER 5 : E STABLISH C ORE V ALUES 45 

■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ 5

Finance a Comprehensive System 

of Care 

Financing housing and support services for people with serious mental illnesses 

and/or co-occurring substance use disorders who are homeless is a challenge 

for local providers. The public mental health and substance abuse treatment 

systems, as well as the system of services for people who are homeless, have 

multiple players. These include public and private mental health and substance 

abuse treatment providers, and general and specialty health care providers, as 

well as the social welfare, housing, criminal justice, employment, and education 

systems, among others. The funding streams that finance these systems and 

services are complex and sometimes contradictory, with competing incentives 

among funding sources. 

As a result, providers of services to people who are homeless rely on a myriad of 

often tenuous funding sources that they describe with terms like “house of cards” 

and “patchwork quilt.” (HRSA, 1998b). Generally, these sources include funds 

from the Federal government, as well as from private funders, and state and local 

governments (Burt et al., 1999). 

To help address homelessness over the long-term, communities need to know the 

various sources of funding that exist and how to use them effectively. This 

chapter provides (1) principles for accessing and using resources to provide 

housing and supportive services in the community, and (2) an overview of public 

and private funding sources available for this purpose. 

 

To help address homelessness 

over the long-term, 

communities need to know the 

various sources of funding that 

exist and how to use them 

effectively. 

C HAPTER
46 B LUEPRINT FOR C HANGE

A CCESS AND U SE 

C OMMUNITY R ESOURCES

The fragmented nature of programs and funding makes it difficult for 

communities to meet the needs of people with serious mental illnesses and/or 

substance use disorders in an efficient and cost-effective manner (NAEH, 2000). 

Frequently, these individuals make use of high-cost services such as emergency 

rooms and inpatient care. They may be discharged to the community with no 

after-care plan. Further, resources for housing and support services increasingly 

are limited. In light of these realities, communities continually must look for 

new ways to use scarce resources more effectively through better integration and 

coordination (Glover and Gustafson, 1999), while seeking further resources to fill 

known service gaps. 

Identify System/Service Gaps 

A plan to finance housing and services should flow naturally from, and perhaps 

be a part of, an agency’s strategic plan (McMurray-Avila, 2001). Once a 

community has identified its needs for housing and services and has specified the 

goals and strategies it will use to meet those needs, it must examine how existing 

housing and services resources are being used. By identifying service system 

gaps and the costs imposed by these gaps, communities can begin to see where 

existing resources can be used more effectively and where new funding may be 

needed. 

Integrate, Coordinate, and Streamline Existing Funding 

The first step to make better use of existing resources is to find ways to integrate, 

coordinate, and streamline existing funding (Wilkins, 2002). Top-level 

management of agencies that fund housing and services must commit their 

organizations to interagency partnerships or agreements that promote more 

efficient use of existing resources. 

For example, two or more agencies may decide to submit joint funding 

applications, or to commit funds to support the creation of new services or help 

leverage additional resources. They also may choose to aggregate funds from 

multiple sources where they can do so and still meet statutory and reporting 

requirements attached to these funds. When communities have more effectively 

combined and used existing resources for housing and services, they will have a 

better sense of where new investment is needed to fill the remaining gaps in the 

service systems (McMurray-Avila, 2001). 

Identify New Resources 

Often, new program resources will consist of existing Federal, state, or local 

funds that can be targeted to better respond to locally identified needs for housing 

and services for people who are homeless. Categorical programs, restricted to 

serving only certain target populations, often can be tapped as a resource. For 
 C HAPTER 5 : E STABLISH C ORE V ALUES 47 

example, monies designated for individuals with HIV/AIDS may serve 

individuals who are homeless, many of whom are at risk of, or infected with, 

HIV. Funds from such programs may be used to serve some but not all of those 

in need. 

The current array of targeted homeless assistance programs is not large enough or 

well-funded enough to meet long-term housing and support needs of people who 

are homeless (NAEH, 2000). Therefore, mainstream resources—including such 

Federal and state resources as Medicaid, Temporary Assistance to Needy 

Families (TANF), the mental health and substance abuse block grants, and the 

Home Investment Partnerships (HOME) program—represent a critical potential 

source of funding for people with serious mental illnesses and/or co-occurring 

substance use disorders who are homeless. While many people who are 

homeless qualify for these programs, they often are unable to access the services 

that these programs offer (GAO, 2000a). 

Funds from mainstream programs can be used to provide income support, 

housing assistance, and supportive services, including outreach, case 

management, and Assertive Community Treatment. Broadening eligibility 

criteria for a program or targeting a portion of program funds to meet the needs 

of people who are homeless can provide additional sources of support. 

For example, a state may seek a waiver under the Medicaid program to increase 

the number of individuals it serves or to provide additional services targeted to 

vulnerable individuals. Frequently, this means creating a managed health care 

system that may, or may not, serve homeless people well. Coordinating 

mainstream resources with discretionary funds such as tax revenues, which 

provide support for individuals not eligible under categorical programs, can be an 

effective strategy to meet a community’s overall housing and service needs. 

Communities should explore other sources for new funding, as well. For 

example, a housing trust fund, established at the state or local level, can provide a 

dependable, flexible, and ongoing source of dedicated funding to meet the 

housing needs of low-income people, including those who are homeless (Brooks, 

1999; AIDS Housing of Washington, 2000). Private sector resources, including 

foundations and businesses, also should be considered as potential sources of 

funding for programs and services. 

Leverage Funds 

Frequently, existing resources can be used to leverage new sources of funding. 

For example, communities may “use funds provided through existing and/or new 

grant programs that are targeted to homeless people to leverage matching 

allocations from mainstream funding and greater access to mainstream service 

systems” (Corporation for Supportive Housing [CSH], 2002a, p. 36). In 

particular, funds for supportive services may be used to leverage funds for 

housing, and vice versa. Forming partnerships between state and local 

governments, and with the private sector, can be an effective way of leveraging 

available funds from all sources. 
48 B LUEPRINT FOR C HANGE

F UNDING S OURCES

The balance of this chapter provides examples of public sources of funding—

such as those available through the Federal government and state and local 

governments—as well as private sources, including business and foundations. 

This listing is not exhaustive; rather it provides a sampling of the major kinds of 

resources available. Each varies in terms of its use and requirements. Many can 

be combined creatively to offer a full range of housing and supports needed to 

end homelessness among people with serious mental illnesses and/or cooccurring substance use disorders (HRSA BPHC, 1997; Siemon, 1990). 

In seeking resources to implement and sustain plans to address homelessness, 

communities need to consider all possible sources of funding, not just those 

mentioned here. While getting started often requires piecing together funds 

available from time-limited sources, communities should strive to find sources 

that are both reliable and predictable, if they are to sustain housing and supports 

over the long-term. Often, this means securing mainstream housing and service 

dollars for individuals who have been relying on categorical or time-limited 

funds. 

Public Funding 

Public funding sources for services and housing include resources specifically 

targeted to meet the needs of people who are homeless, as well as nontargeted, 

mainstream resources that may or may not include people who are homeless as a 

priority population. Such nontargeted programs typically are designed to serve 

low-income people or people with special needs more generally. Potential 

sources of public funding are described briefly in this section. Web sites that 

provide further detail on public funding sources are listed at the end of the 

chapter. 

Targeted Homeless Assistance 

Programs specifically targeted to meet the needs of people who are homeless 

include those originally created under the Stewart B. McKinney Homeless 

Assistance Act and its amendments. While many such programs were established 

under this Act, those most relevant to meeting the housing and support service 

needs of people with serious mental illnesses and/or co-occurring substance use 

disorders who are homeless are discussed below. These include programs 

administered by the Departments of Health and Human Services, Housing and 

Urban Development, and the Veterans Administration (GAO, 1999a). 

HHS Programs. HHS administers three programs specifically designed to meet 

the needs of people who are homeless and who may have serious mental health 

and/or substance use disorders. 

 The Health Care for the Homeless (HCH) program, administered by the 

Health Resources and Services Administration, awards grants to 

community-based organizations—including community health centers, 
 C HAPTER 5 : E STABLISH C ORE V ALUES 49 

local health departments, hospitals, and nonprofit community 

coalitions—to improve access to primary health care, mental health 

services, and substance abuse treatment. HCH funds support the 

provision of primary health care, substance abuse treatment, outreach, 

case management, provision of or referral to mental health services, and 

assistance in obtaining housing and entitlements (HRSA BPHC, 2001). 

 The Projects for Assistance in Transition from Homelessness (PATH) 

program, administered by SAMHSA’s CMHS, awards formula grants to 

states and territories to support community-based services for people 

with serious mental illnesses and/or substance use disorders who are 

homeless or at-risk of homelessness. PATH funds can be used to support 

a range of services, including outreach, screening and assessment, case 

management, mental health services, and substance abuse treatment, 

provision of or linkage to supportive services, and a limited set of 

housing services (CMHS, 2001c). 

 The Grants for the Benefit of Homeless Individuals (GBHI) program, 

administered by SAMHSA’s Center for Substance Abuse Treatment, 

provides funds to develop and expand mental health and substance abuse 

treatment services for people who are homeless. Grants are awarded to 

local public and nonprofit agencies to provide either substance abuse 

services, mental health services, or both, allowing communities the 

flexibility to provide the services they believe to be the most urgent 

(SAMHSA, 2002a). 

HUD Homeless Assistance Programs. HUD administers four key targeted 

programs that can be used to fund the development, operation, and supportive 

services of emergency, transitional, and permanent housing for people who are 

homeless. 

 

 Emergency Shelter Grants are formula grants to states and local 

governments for the purpose of providing emergency and transitional 

housing, and are coordinated through the Consolidated Plan, a 5-year 

comprehensive housing plan required of communities to access HUD 

housing resources. 

 Supportive Housing Program (SHP), Shelter Plus Care (S+C), and 

Section 8 Moderate Rehabilitation Single Room Occupancy (SRO) 

program funds are awarded through an annual competition that requires 

communities to engage in a coordinated strategic planning process and to 

submit a comprehensive Continuum of Care plan to address 

homelessness. SHP funds may be used for the development and 

operation of transitional and permanent housing, and for supportive 

services. S+C funds may be used to provide rental assistance for 

permanent housing, with required matching funds for supportive 

services. Section 8 SRO funds can be used for rental assistance in singleroom-occupancy dwellings. 
50 B LUEPRINT FOR C HANGE

VA Programs. The VA administers several programs that specifically meet the 

needs of veterans with mental illnesses and/or substance use disorders who are 

homeless (Department of Veterans Affairs, 2002). 

 The Domiciliary Care for Homeless Veterans program provides funds to 

VA medical centers to support the delivery of health, mental health, 

substance abuse, and other social services in residential treatment settings 

for veterans who are homeless. 

 The Homeless Chronically Mentally Ill Veterans program supports 

mental health services, substance abuse treatment, case management, and 

other rehabilitative services in community-based residential treatment 

settings for veterans with chronic mental illnesses who are homeless. 

 The Health Care for Homeless Veterans program supports outreach and 

assessment, treatment, case management, and referral to communitybased residential care for veterans with serious mental illnesses and 

substance use disorders who are homeless. 

 The HUD-VA Supported Housing program, administered jointly with 

HUD, provides permanent supportive housing and treatment for veterans 

with serious mental illnesses and substance use disorders who are 

homeless. 

Mainstream Resources 

A number of nontargeted or mainstream programs serving low-income people 

and people with disabilities also may provide eligible individuals who are 

homeless with housing, services, and supports. This includes an array of health, 

welfare, mental health, substance use, housing, and veterans’ assistance 

programs. Efforts to increase access to these programs for people who are 

homeless are essential. 

HHS Programs. HHS administers a number of mainstream programs, for which 

homeless people may be eligible, that also can be used to provide services and 

supports (GAO, 1999a). 

 Medicaid is the largest Federal entitlement program providing health care 

for certain low-income and medically needy people, including people 

who are elderly, blind and disabled, and other special groups. The 

program is funded jointly through a Federal-state partnership. Within 

Federal guidelines, each state administers its own program and sets its 

own criteria for eligibility, type, amount, duration and scope of services, 

and payment as outlined in the State Medicaid Plan. Optional services, 

such as the rehabilitation option and the targeted case management 

option, can be used to provide many of the supportive services needed to 

help maintain people with serious mental illnesses or co-occurring 

disorders in housing (CSH, 2002a). 
 C HAPTER 5 : E STABLISH C ORE V ALUES 51 

 Temporary Assistance to Needy Families funds are provided to states 

through block grants to help low-income families become self-sufficient. 

States have flexibility to design programs that meet the needs of eligible 

populations, including homeless families with children. Cash assistance, 

work-related assistance, and other supportive services are included. In 

addition, several states and localities have recently begun innovative 

programs using TANF or state maintenance-of-effort funds to provide 

housing assistance to families making the transition from welfare to work 

(Straka et al., 2001; Sard and Lubell 2000). 

 Community Mental Health Services Block Grant funds are formula grants 

to states and territories to create comprehensive, community-based 

systems of care for adults with serious mental illnesses and children with 

severe emotional disturbances. Funds are used at the discretion of states 

to provide services such as health, mental health, rehabilitation, 

employment, housing, and other supportive services. Most states provide 

services specific to adults with serious mental illnesses who are 

homeless. In some cases, states have used block grant funds to provide 

services in supportive housing (Emery, 2001). Mental health block grant 

funds also may be used to provide services for individuals with substance 

use disorders within certain guidelines (SAMHSA, 2002a). 

 Substance Abuse Prevention and Treatment Block Grants also are 

formula grants to states and territories, in this case, to fund alcohol 

prevention and treatment activities, prevention and treatment related to 

other drugs, and primary prevention programs. All individuals who have 

alcohol or substance use problems are eligible for services, including 

people who are homeless, or persons with co-occurring substance use 

disorders. 

 Community Health Centers, supported by discretionary project grants, 

provide preventive and primary care services to medically underserved 

populations; many have specific programs designed to serve individuals 

who are homeless. 

 Community Services Block Grants are formula grants to states to support 

a range of services designed to address poverty and to promote selfsufficiency among low-income members of communities, including those 

who are homeless. 

 Social Services Block Grants, also formula grants to states, can be used 

to support a range of services to prevent, reduce, and eliminate 

dependency and increase self-sufficiency among community residents. 

Using Medicaid to Finance Supportive Services in Housing. Medicaid 

represents a potentially reliable source of mainstream funding to support many of 

the health-related services provided in supportive housing. Further, it provides 

opportunities for states and local communities to leverage additional Federal 

matching funds for services, permitting a greater portion of HUD resources to go 

toward permanent housing. 
52 B LUEPRINT FOR C HANGE

The Corporation for Supportive Housing (CSH) recently examined opportunities 

to fund services in supportive housing using Medicaid (CSH, 2002a). CSH 

found that while major challenges still exist, many governments and supportive 

housing providers have succeeded in using Medicaid to finance supportive 

services in housing. 

For example, under Medicaid’s rehabilitation option, providers can be 

reimbursed for services aimed at improving skills and functioning impaired by 

mental illnesses and, in some states, substance use disorders. The targeted case 

management option can be used to support goal setting and linkage to health and 

other social services. Through partnerships with Federally Qualified Health 

Centers, providers can deliver health, mental health, and substance abuse 

treatment services to people living in supportive housing. 

Additionally, states may use Medicaid waivers to allow funds to be used in more 

flexible and creative ways to fund supportive services in community-based 

settings. While these strategies and their implementation vary from one state or 

community to the next, they offer promise for expanding the use of Medicaid to 

fund supportive services in housing. 

HUD Programs. A number of HUD programs are designed to expand affordable 

housing opportunities for low-income people or people with disabilities, 

including those who are homeless (TAC, 1999). 

 Public Housing is developed, owned, and managed by public housing 

agencies (PHAs) under contract with HUD. HUD provides a subsidy to 

cover operating and management costs of the units, and tenants generally 

pay 30 percent of their incomes toward rent. PHAs are allowed to 

establish local preferences for income targets and tenant selection and 

must submit a 5-year plan that outlines these preferences and 

demonstrates their consistency with the local needs and strategies 

identified in the consolidated plan. 

 The Housing Choice Voucher Program, formerly referred to as the 

Section 8 program, is the largest Federal program targeted to very lowincome households, including people with disabilities (TAC, 2002). 

Administered through state or local PHAs, the program offers four types 

of assistance: tenant-based rental assistance; project-based rental 

assistance; homeownership assistance; and down payment assistance. 

Tenant-based assistance is the most common form, offering subsidies 

that allow tenants to pay 30 percent of their income toward housing costs 

in a unit of their choice. 

 The Home Investment Partnerships program (HOME) is specifically 

designed to expand the supply of affordable housing for low and very 

low-income people. Program funds are controlled through the 

consolidated plan and awarded via formula grant to states and local 

jurisdictions. Partnerships among government and nonprofit 

organizations and private industry are required to develop and manage 

safe, decent, affordable housing. Funds may be used for homeownership, 
 C HAPTER 5 : E STABLISH C ORE V ALUES 53 

rental housing production, and tenant-based rental assistance, and are 

easily combined with funds from HUD’s Homeless Assistance Programs. 

 Housing Opportunities for Persons with AIDS (HOPWA) supports the 

provision of both housing and services for people with Acquired Immune 

Deficiency Syndrome (AIDS). Funds are awarded by block grant to 

states and large metropolitan areas and can be used for a variety of 

activities, including housing information and coordination assistance; 

acquisition, rehabilitation, and leasing of property; rental assistance; 

operating costs; supportive services; and technical assistance (TAC, 

1999). 

 Community Development Block Grants (CDBG) are formula grants to 

states and to “entitlement communities” (as defined by HUD) to provide 

decent housing and suitable living environments for moderate and lowincome people. CDBG funds also are controlled through the 

consolidated plan and can be used for housing rehabilitation or 

construction, including shelters and transitional housing facilities, and for 

supportive services such as counseling, employment, and health care. 

 The Section 811 Supportive Housing for Persons with Disabilities 

Program awards funds competitively to community based nonprofit 

organizations to develop and operate supportive housing for people with 

disabilities. Funds may be used for new construction, rehabilitation, or 

acquisition; for project-based rental assistance; and for supportive 

services to address the health, mental health, or other needs of people 

with disabilities. 

Other Mainstream Federal Programs. Several other nontargeted Federal 

programs can be used to provide services and supports to people who are 

homeless and have serious mental illnesses and/or co-occurring substance use 

disorders (National Abandoned Infants Assistance Resource Center, 1997). For 

example, the Social Security Administration’s SSI program provides income 

support to low-income individuals and those with disabilities, including people 

with serious mental illnesses and/or co-occurring substance use disorders who are 

homeless. Individuals with a substance use disorder as their primary disability 

are not eligible for SSI or the Medicaid benefits that accompany it. 

Programs administered by the U.S. Department of Labor (DOL) can be used to 

support job training and employment services. The VA offers various types of 

assistance to veterans and their dependents. The U.S. Department of Treasury’s 

Low-Income Housing Tax Credit (LIHTC) program can be used to fund the 

development of new supportive housing. These and other sources of Federal 

funds offer possibilities for creating housing and supports in an overall system of 

care and should be examined by communities, as well. 

State and Local Resources. State and local governments administer many of 

the Federal programs mentioned earlier. They can either provide services 

themselves or can contract with local providers to offer services with these funds. 
54 B LUEPRINT FOR C HANGE

In addition, many states and localities use their own resources for programs 

specifically designed to meet the housing and support service needs of people 

with serious mental illnesses and/or co-occurring substance use disorders who are 

homeless. Examples include programs, such as state tax credits, that can fund 

housing development, as well as programs that fund operation costs and/or 

supportive services. 

Private Funding 

Though public funding is crucial to providing the housing and supports needed to 

end homelessness, it only can go so far. Private-sector contributions, such as 

those from local businesses, corporations, private donors, and foundations, can be 

critical sources of funding, as well (The Foundation Center, 2000; McCambridge 

et al., 1992). Most private funding, however, is time-limited. While it cannot 

substitute for more secure, long-term commitments, it can be used to leverage or 

match other resources. 

Often, foundations invest in new and untested, but promising, practices. These 

funds may be used to leverage public funding to help sustain programs over the 

long-term. In addition, some private funders are willing to invest in building the 

capacity of organizations, to help them diversify funding and tap into sources to 

sustain the funder’s initial investment. 

Competition for private funds is growing as more and more organizations 

recognize the need to fundraise from private sources, particularly for affordable 

housing development. Finding donors whose mission is compatible with the goal 

of addressing homelessness; building relationships with representatives of 

corporations, foundations, and other potential donors; and being able to market 

and submit a strong proposal for funding are all essential to obtaining private 

support. 

F OR M ORE I NFORMATION

As noted, the public sources of funding listed in this chapter represent a sampling 

of the major kinds of resources that are available to fund services and housing for 

people who are homeless and have serious mental illnesses and/or co-occurring 

substance use disorders. The following web sites include more information on 

Federal funding opportunities, including discretionary funding for homeless 

services available through SAMHSA: 

U.S. Department of Health and Human Services (HHS) 

www.hhs.gov 

 Substance Abuse and Mental Health Services 

Administration (SAMHSA) 

www.samhsa.gov
 C HAPTER 5 : E STABLISH C ORE V ALUES 55 

 Health Resources and Services Administration 

www.hrsa.gov

 Centers for Medicaid and Medicare Services 

www.cms.gov 

U.S. Department of Housing and Urban Development (HUD) 

www.hud.gov 

U.S. Department of Veteran’s Affairs (VA) 

www.va.gov 

U.S. Social Security Administration 

www.ssa.gov 

P UTTING THE P IECES 

T OGETHER

An integrated, well-financed system of care for people with serious mental 

illnesses and/or co-occurring substance use disorders who are homeless is only as 

good as the services it offers. Further, the services will be of little use if they are 

not accessible, acceptable and of personal value to the people they are designed 

to serve. 

The next chapter comprises Section III: Organize Services. It features an indepth discussion of evidence-based and promising practices for people with 

serious mental illnesses and/or co-occurring substance use disorders who are 

homeless. 
56 B LUEPRINT FOR C HANGE
S ECTION III 

ORGANIZE SERVICES 

Planning is the first critical step in developing an integrated, comprehensive 

system of care for people with serious mental illnesses and/or co-occurring 

substance use disorders who are homeless. When the planning is done, the real 

work begins. The good news is that communities and providers don’t have to 

reinvent the wheel. There is a wealth of information about the programs and 

services that are most effective for people with serious mental illnesses and/or cooccurring substance use disorders who are homeless. 

The next chapter—Use Evidence-Based and Promising Practices—can help select 

the most appropriate services for clients based on research evidence and provider 

experience, including how to: 

 Adopt or adapt evidence-based practices; 

 Offer a comprehensive set of essential services; and 

 Make use of Federal resources, including toolkits, Treatment Improvement 

Protocols, and Community Action Grant and Targeted Capacity Expansion 

grants. 

Additional information on the materials cited in this chapter can be found in the 

References. Organizations that offer technical assistance in these areas are listed in 

the Resources section. 

 

I N THIS

S ECTION

■ ■ ■ ■ ■ ■ ■ ■

Use EvidenceBased and 

Promising 

Practices 

57
58 B LUEPRINT FOR C HANGE
 C HAPTER 6 : U SE E VIDENCE - B ASED AND P ROMISING P RACTICES 59 

■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ 6

Use Evidence-Based and 

Promising Practices 

The good news about service provision for people with serious mental illnesses 

and/or co-occurring substance use disorders who are homeless can be summed 

up simply: We know what works. Now we need to put what we know to work. 

This is not to say that the work is done, however. On the contrary, there is a 

need for continued research into effective interventions for groups with specific 

needs, such as trauma survivors, and for individuals with severe disorders. 

However, evidence-based and promising practices can be used immediately to 

help prevent and end homelessness for people with serious mental illnesses 

and/or co-occurring substance use disorders. SAMHSA plays a key role in 

getting information about evidence-based practices into the hands of the people 

who deliver services. 

This chapter examines (1) a range of evidence-based and promising practices that 

have proven effective to prevent and end homelessness among people with 

serious mental illnesses and/or co-occurring substance use disorders, and (2) 

additional needed service system components of a comprehensive service 

system. The full array of services and supports essential to address homelessness 

among people with serious mental illnesses and/or co-occurring substance use 

disorders are summarized in Table 6.1 on page 80. 

E VIDENCE - B ASED AND 

P ROMISING P RACTICES

Federal research and demonstration programs and the experience of hundreds of 

community-based providers have shown that the services described here help 

decrease symptoms of mental illnesses and substance use, and increase 

residential stability for people with serious mental illnesses or co-occurring 

disorders who are homeless. Communities can adopt or adapt these practices to 

local needs. 

Evidence-based and promising 

practices can be used 

immediately to help prevent 

and end homelessness. 

C HAPTER
60 B LUEPRINT FOR C HANGE

Outreach and Engagement 

Compared to people with serious mental illnesses and/or co-occurring substance 

use disorders who are housed, individuals who also are homeless are likely to be 

more severely impaired, to have more basic service needs, and to be unwilling or 

unable to seek treatment (Federal Task Force on Homelessness and Severe 

Mental Illness, 1992). If they won’t seek help, help has to go to them. 

Once considered a nontraditional service, outreach now is recognized as the 

initial, most critical step in connecting or reconnecting a person who is homeless 

to needed health, mental health, substance abuse, and social services and to 

housing. However, people who are homeless are not focused initially on 

receiving mental health or substance abuse treatment. Outreach workers must 

meet them “on their own terms and on their own turf” (Federal Task Force on 

Homelessness and Severe Mental Illness, 1992). Outreach workers find people 

on the streets, under bridges, in parks, and in shelters, and they focus on meeting 

the individual’s immediate needs for food, clothing, and shelter. 

This process of engagement is essential to develop the trust and rapport needed to 

help individuals accept more long-term services, the ultimate goal of outreach 

efforts. Regardless of how or where outreach is provided, successful outreach 

workers must adopt a nonthreatening approach; must be flexible in the number 

and types of services offered, as well as the manner in which they are provided; 

and must make numerous contacts over extended periods of time (Interagency 

Council on the Homeless, 1991; McMurray-Avila, 1997). Outreach workers who 

have been homeless and are recovering from mental illnesses and/or co-occurring 

substance use disorders may be especially effective at engaging individuals who 

are difficult to reach (Van Tosh, 1993; Dixon et al., 1994). 

What the Research Says. Outreach, whether in shelters or on the streets, is 

effective (CMHS, 2001c; Lam and Rosenheck, 1999; Tsemberis and Elfenbein, 

1999; Morse et al., 1996; Bybee et al., 1995). Given the opportunity, most people 

with serious mental illnesses and/or co-occurring substance use disorders who are 

homeless are willing to accept treatment and services voluntarily. Indeed, skilled 

outreach teams eliminate the need for involuntary treatment for most individuals. 

A study of individuals enrolled in the SAMHSA Access to Community Care and 

Effective Services and Supports program who were contacted through street 

outreach revealed that even individuals with the most severe disorders, who are 

the most reluctant to accept treatment, will enroll in services and show improved 

outcomes when served by an outreach team (Lam and Rosenheck, 1999). 

A study of the effectiveness of outreach with homeless people who abuse 

substances found that nearly half of persons contacted through outreach became 

enrolled in services (Tommasello et al., 1999). More important, those contacted 

through outreach had significantly higher levels of substance use than walk-in 

clients, and were more likely to be engaged in HIV risk behaviors. This indicates 

that outreach can be successful in reaching individuals most in need of services. 

Consistent, caring, personal relationships, and the introduction of services at the 

client’s pace are critical elements in outreach efforts designed to engage people 
 C HAPTER 6 : U SE E VIDENCE - B ASED AND P ROMISING P RACTICES 61 

who are homeless into treatment. Unfortunately, few health insurance programs 

consider outreach a reimbursable expense. Outreach is the most common service 

offered by providers who receive SAMHSA’s Projects for Assistance in 

Transition from Homelessness (PATH) funds; for more than one-third of these 

providers, PATH funds are their only source of outreach revenues. 

Housing with Appropriate Supports 

People without homes need housing; that goes without saying. Yet, to match 

housing to an individual’s needs, several factors are at work. For example, 

housing for people with serious mental illnesses historically has been in some 

type of congregate setting such as a group home, but preference studies show that 

people with serious mental illnesses want to live in integrated, regular housing 

rather than in segregated, mental health programs (Carling et al., 1987; Brown et 

al., 1991). 

Initially, some individuals, especially those with substance use disorders, may 

require a type of low-demand housing, such as a Safe Haven, to help them reengage in services (see the section on Low-Demand Services in this chapter for 

more information about Safe Havens). Indeed, while the provision of housing 

increases retention in substance abuse treatment for people who are homeless, 

individuals do less well when high-intensity services are required as a condition 

of housing (Orwin et al., 1999, p. 45). Ultimately, people with substance use 

disorders need safe housing with the appropriate level of support to help them 

maintain their treatment gains. 

Second, housing is necessary but not sufficient to help individuals with serious 

mental illnesses and/or co-occurring substance use disorders who have been 

homeless regain psychiatric and residential stability and maintain sobriety. They 

require unique, flexible supportive services that are not a requirement to maintain 

housing. The Corporation for Supportive Housing defines these services as those 

(1) designed to maximize independence; (2) flexible and responsive to individual 

needs; (3) available when needed; and (4) accessible where the individual lives 

(CSH, 1996). 

What the Research Says. Providing supportive services to people in housing is 

effective in achieving residential stability, improving mental health and recovery 

from substance abuse, and reducing the costs of homelessness to the community

(Culhane et al., 2001; Lipton et al. , 2000; Tsemberis and Eisenberg, 2000; 

Rosenheck et al., 1998; Shern et al., 1997; Goldfinger and Schutt, 1996; Hurlburt 

et al., 1996). Recent studies indicate that supportive housing may be costeffective, as well (Culhane et al., 2002; Houghton, 2001). 

Most people with serious mental illnesses who are homeless prefer supportive 

housing, and they do well, despite widely held assumptions about the need for 

more structured housing for people with the most severe disorders. In fact, many 

people can move directly from homelessness to independent housing with 

supports. However, the transition from homelessness to housing is a critical time 

requiring intensive support and attention. Many individuals who have lived on 
62 B LUEPRINT FOR C HANGE

the streets feel isolated and disoriented when they begin living inside; services 

may have to be increased, rather than decreased, at this time (Susser et al., 1997). 

Finally, research also reveals that consumer choice in housing is critical for 

success and that housing subsidies are a key component to making housing 

affordable for this group. However, as noted previously, subsidies do not 

guarantee that housing will be available. 

Cost Studies 

A study that tracked 4,679 homeless people with mental illnesses placed into 

service-enriched housing in New York City found reductions in housing and 

service costs compared to a control group of homeless people with similar 

characteristics who were not placed into service-enriched housing. The housing 

was created as part of the 1990 New York/New York Agreement to House 

Homeless Mentally Ill Individuals, a joint initiative between New York City and 

New York State that created and continues to maintain 3,615 units of affordable 

housing supported with clinical and social services (Houghton, 2001). 

Researchers (Culhane et al., 2002) found that people placed in supportive 

housing had marked reductions in shelter use, hospitalizations, length of stay per 

hospitalization, and time incarcerated. Before placement in supportive housing, 

homeless people with serious mental illnesses used about $40,451 per person, per 

year in services (1999 dollars). Placement in supportive housing was associated 

with a reduction in services use of $16,281 per housing unit per year (Culhane et 

al., 2002). Much of the savings resulted from fewer and shorter stays in state 

psychiatric hospitals, as well as decreased shelter use. 

Results from the Connecticut Supportive Housing Demonstration Program, 

conducted from 1993 to 1998, are similar. Researchers found that supportive 

housing created positive outcomes for tenants while decreasing their use of acute 

health services and increasing their use of less expensive ongoing and preventive 

health care (CSH, 2002a). Also, property values in the neighborhoods 

surrounding the supportive housing have increased or remained steady since the 

housing was developed. 

Multidisciplinary Treatment Teams/Intensive Case 

Management 

People with serious mental illnesses and/or co-occurring substance use disorders 

who are homeless have complex problems that require comprehensive treatment 

and services. A multidisciplinary treatment team provides individuals with a 

type of “one-stop shopping” to arrange for or provide all of the services they 

require. 

Assertive Community Treatment (ACT) is a good example of this approach. 

Begun in the late 1970s with the Program of Assertive Community Treatment in 

Madison, Wisconsin, ACT is acknowledged as a successful approach to 

providing a full range of community-based services to people with serious mental 

illnesses and/or co-occurring substance use disorders. ACT teams feature a 
 C HAPTER 6 : U SE E VIDENCE - B ASED AND P ROMISING P RACTICES 63 

multidisciplinary group of mental health, substance use, and social service 

specialists who provide, or arrange for, each individual’s clinical, housing, and 

rehabilitation needs. Client/staff ratios are low (typically 10 to 1), and services 

are available around the clock. 

The ACT model has been modified successfully to meet the needs of people who 

are homeless. For example, because some people who have been homeless have 

trouble forming trusting relationships, they may be assigned to one or two 

members of the team, rather than the whole team. All team members are 

knowledgeable about each client, however (Dixon et al., 1995). Many ACT 

teams use mobile outreach to serve people who are unwilling or unable to come 

to them. 

What the Research Says. ACT and similar models of intensive case 

management reduce inpatient hospitalization, decrease substance use and 

symptoms of mental illnesses, and increase community tenure for people with 

serious mental illnesses and/or co-occurring substance use disorders who are 

homeless. Regular assertive outreach, lower caseloads, and the multidisciplinary 

nature of the services available on these teams lead to positive treatment and 

housing outcomes (Ziguras and Stuart, 2000; Morse, 1999; Lehman et al., 1997; 

Morse et al., 1997; Burns and Santos, 1995; Dixon et al., 1995). 

The provision of substance abuse services on an ACT team is a critical ingredient 

of success. Research indicates that ACT is not effective in reducing substance 

use when the substance abuse services are brokered to other providers and are not 

provided directly by the ACT team (Morse et al., 1997). 

 

Integrated Treatment for Co-Occurring Serious Mental 

illnesses and Substance Use Disorders 

Mental health and substance abuse providers frequently cite the problem of cooccurring serious mental illnesses and substance use disorders as the most 

difficult situation they face. Individuals with co-occurring disorders tend to be 

more symptomatic, to have other multiple health and social problems, and to 

require more costly care (NASMHPD and NASADAD, 1999). They are at risk 

for homelessness and incarceration. Among people with serious mental illnesses 

who are homeless, approximately half have a co-occurring substance use disorder 

(SAMHSA, 2002b). 

Providers struggle to fund and develop effective approaches to treat people with 

co-occurring disorders who are homeless. Three common approaches are: 

 Sequential approach. The individual receives treatment first for one 

disorder and then for the other, with treatment provided by two different 

agencies. 

 Parallel approach. Two different providers, one offering mental health 

services and the other providing substance abuse treatment, treat the 

individual simultaneously. However, treatment plans rarely are 

coordinated. 
64 B LUEPRINT FOR C HANGE

 Integrated services approach. The individual participates in concurrent 

and coordinated clinical treatment of both mental illnesses and substance 

use disorders provided by the same clinician or treatment team, often in a 

single agency. Unfortunately, such programs are rare. 

What the Research Says. An integrated approach is superior to a parallel or a 

sequential approach to treatment for people who have co-occurring serious 

mental illnesses and substance use disorders. Integrated treatment reduces 

alcohol and drug use, homelessness, and the severity of mental health symptoms 

(CMHS and CSAT, 2000a; Drake et al., 1998; Drake et al., 1997). Though 

people with co-occurring disorders who are homeless drop out of treatment 

programs in high numbers, the SAMHSA’s Collaborative Demonstration 

Program for Homeless Individuals had retention rates as high as 74 percent in its 

programs that offered integrated treatment. Individuals did best when their 

treatment was combined with other services such as housing, legal services, and 

income support. Further research is needed to confirm the effectiveness of this 

approach for people with less severe disorders. 

Motivational Interventions/Stages of Change 

Many homeless individuals with substance use disorders are not ready for 

abstinence-oriented programs (Oakley and Dennis, 1996). Further, they also may 

lack the motivation to engage in active treatment. Motivational interventions that 

emerged in the substance use field (Miller and Rollnick, 1991) have been adapted 

for people with serious mental illnesses and/or co-occurring disorders, as well as 

for people who are homeless. 

Motivational interventions include a range of clinical strategies designed to 

enhance motivation for change, including counseling, assessment, multiple 

sessions, and brief interventions. The five key principles of motivational 

enhancement are (Swanson et al., 1999; CSAT, in press): 

 Express empathy; 

 Note discrepancies between current and desired behavior; 

 Avoid argumentation; 

 Refrain from directly confronting resistance; and 

 Encourage the individual’s belief that he or she has the ability to change. 

Further, motivational enhancement techniques must be matched to the client’s 

stage of recovery and often are integrated as part of the Stages of Change Model 

(Prochaska and DiClemente, 1992). This model describes predictable stages of 

change for people with substance use disorders from precontemplation to 

contemplation, determination, action, maintenance, and relapse prevention. 

What the Research Says. Research has demonstrated that motivational 

enhancement techniques are associated with greater participation in treatment 

and positive treatment outcomes. These outcomes include reductions in 

consumption, increased abstinence rates, better social adjustment, and successful 

referrals to treatment (Landry, 1996; Miller et al., 1995). A positive attitude 

toward change and a commitment to change also are associated with positive 
 C HAPTER 6 : U SE E VIDENCE - B ASED AND P ROMISING P RACTICES 65 

treatment outcomes (Miller and Tonigan, 1996; Prochaska and DiClemente, 

1992). 

Modified Therapeutic Communities 

Therapeutic communities (TCs) have been implemented as a method to address 

substance use disorders for more than 30 years. The concept is based on a clearly 

defined theoretical model that views drug abuse as a disorder of the whole 

person, requiring a focus on conduct, attitudes, moods, values, and emotional 

management. The community is the therapeutic method in a TC. 

Modified therapeutic communities (MTCs) adapt the principles and methods of 

the TC to the needs of individuals with co-occurring mental illnesses, as well as 

the needs of those who are homeless. Key modifications for people with cooccurring disorders include increased flexibility, decreased intensity, and greater 

individualization (Sacks, 2000). MTCs for people who are homeless, often 

developed in shelter settings, incorporate services to address clients’ multiple 

needs, such as education, vocation, legal, and housing placement services 

(Zerger, 2002). 

What the Research Says. Recent studies of the MTC approach reveal 

significant decreases in drug use and criminal activity, and increases in 

psychological functioning and employment (DeLeon, 2000; Rahav et al., 1995; 

Sacks et al., 2001). MTCs tend to result in more positive outcomes for 

individuals with the most severe mental illnesses and for those who remain in 

treatment for longer periods of time (Zerger, 2002). Several studies have found 

MTCs to be cost-effective relative to the provision of services as usual (French et 

al., 1999; McGeary et al., 2000). 

Self-Help Programs 

Self-help programs represent a central feature of most substance abuse treatment 

plans and recently also have become an important source of support for 

individuals with mental illnesses. During the past decade, dual recovery/selfhelp programs also have emerged as an important adjunct to treatment for people 

in recovery from co-occurring mental illnesses and substance use disorders 

(Dupont, 1994; Pepper and Ryglewicz, 1996). 

Self-help approaches have their roots in Alcoholics Anonymous (AA) and have 

grown to address a wide variety of addictions. Narcotics Anonymous and 

Cocaine Anonymous are two of the largest self-help organizations in the area of 

chemical addictions (CSAT, in press). Recovery Anonymous and 

Schizophrenics Anonymous support individuals with mental illnesses 

(Chamberlin and Rogers, 1990). 

Self-help programs typically include the AA 12-step method, with a focus on 

developing personal responsibility within the context of peer support. However, 

specific applications vary according to the needs and orientation of individuals 

and agencies/communities. Secular groups emphasize individual empowerment 
66 B LUEPRINT FOR C HANGE

without focusing on the spirituality of the 12-step approach. Perhaps because of 

their low cost, and the fact that they provide an important source of support, selfhelp programs are among the most commonly used outpatient services for people 

with substance use disorders who are homeless (Zerger, 2002). 

What the Research Says. Self-help program participation decreases inpatient 

treatment and substance use and increases self-esteem for people with mental 

illnesses and substance use disorders. Individuals with mental illnesses in selfhelp groups report greater-self esteem, fewer hospitalizations, and better 

community adjustment (HHS, 1999). People with co-occurring mental illnesses 

and substance use disorders who are homeless experience a greater decrease in 

substance use when they have a high level of self-help group participation 

(Gonzalez and Rosenheck, 2002). 

Self-help groups specific to co-occurring disorders can be an important adjunct to 

recovery for people who have both mental illnesses and substance use disorders. 

One study found that people with higher levels of support and greater 

participation in dual recovery programs reported less substance use and mental 

health distress and higher levels of well-being (Laudet et al., 2000). However, 

these results did not hold true for people with co-occurring disorders who 

participated in the more traditional single-focus, self-help groups. 

Involvement of Consumers and Recovering Persons 

Individuals recovering from serious mental illnesses and/or co-occurring 

substance use disorders play an increasingly important role in helping their peers 

recover. Indeed, the social model approach to recovery from substance use 

disorders is built on the belief that individuals in recovery can help each other as 

much, if not more, than professional staff can help them. People with serious 

mental illnesses and/or co-occurring substance use disorders who have been 

homeless may be especially effective in reaching their peers who are reluctant to 

seek help. Shared experiences between prospective clients and workers may ease 

the engagement process. 

 

Some unique characteristics of staff in recovery and those who have been 

homeless include: their knowledge of the service system; their “street smarts”; 

their ability to develop alternative approaches; their flexibility, creativity, and 

patience; their understanding of an individual’s basic needs and preferences; and 

their ability to build rapport with people who are homeless. Consumers and 

recovering persons serve as positive role models, are a major force in the 

elimination of stigma and discrimination, and make good team members (Van 

Tosh, 1993). 

Programs run by consumers and recovering persons—including drop-in centers, 

recovery support programs, case management programs, outreach programs, 

businesses, employment and housing programs, and crisis services—may be 

more “user-friendly” for people who are homeless or at risk of homelessness. 

The focus of service delivery in these organizations is on choice, dignity, and 

respect (Glasser, 1999). Further, such programs provide meaningful work for 
 C HAPTER 6 : U SE E VIDENCE - B ASED AND P ROMISING P RACTICES 67 

consumers and recovering persons. Staff in recovery from mental illnesses and 

substance use disorders, and those who have been homeless, also enhance the 

sensitivity of the system to the needs of their peers. 

Finally, consumers and recovering persons should be involved actively in the 

design, implementation, and evaluation of community mental health and 

substance abuse services. They make valuable members of planning councils 

and advisory boards. People who were homeless can make equally important 

contributions to the development of services for people who currently are 

homeless. 

What the Research Says. Consumers and recovering persons can make a 

unique and valuable contribution as program and agency staff. In particular, 

consumers and recovering persons have experiences and characteristics that 

enhance their ability to provide services to individuals who are homeless 

(Glasser, 1999; Van Tosh, 1993; Dixon et al., 1994). Programs must be prepared 

to support staff in recovery with adequate supervision and workplace 

accommodations, if necessary, and to educate and train other staff about 

employment for consumers and recovering persons (Van Tosh, 1993; Fisk et al., 

2000). 

Prevention Services 

Services that prevent people with serious mental illnesses and substance use 

disorders from becoming homeless in the first place should be a critical 

component of a community’s plan to end homelessness. In its report, Outcasts 

on Main Street, the Federal Task Force on Homelessness and Severe Mental 

Illness called prevention efforts both humane and cost-effective (Federal Task 

Force on Homelessness and Mental Illness, 1992). Two years later, with 

publication of Priority: Home! The Federal Plan to Break the Cycle of 

Homelessness, the Interagency Council on Homelessness proposed a twopronged approach to address homelessness: (1) expanding services to help those 

who have become homeless, and (2) addressing structural inadequacies in 

housing and social services to help prevent people from becoming homeless 

(Interagency Council on the Homeless, 1994). 

Strategies designed to prevent homelessness among people with serious mental 

illnesses and/or co-occurring substance use disorders must be designed to reduce 

risk factors, such as lack of treatment for co-occurring disorders, which make 

individuals more susceptible to becoming homeless. Many of these risk factors 

have been discussed elsewhere in this report. Further, program planners and 

providers must work to enhance protective factors, such as supportive services in 

housing, that will mitigate against homelessness among vulnerable people (Lezak 

and Edgar, 1998). 

What the Research Says. Homelessness among people with serious mental 

illnesses and/or co-occurring substance use disorders can be prevented. 

Discharge planning, sometimes referred to as re-entry or transition planning, is 

one effective prevention strategy. Providing short-term intensive support 
68 B LUEPRINT FOR C HANGE

services immediately after discharge from hospitals, jails, or residential treatment 

has proven effective in preventing recurrent homelessness during the transition to 

other community providers (Rosenheck and Dennis, 2001; Shinn and Baumohl, 

1999; Lezak and Edgar, 1998; Averyt et al., 1997; Susser et al., 1997). 

Effective discharge planning should begin when an individual enters a hospital or 

jail. Elements of the discharge plan, which should be developed with the 

individual and should be culturally appropriate, include housing, health care, 

treatment, income, employment, entitlements, personal support, and life skills 

training (Rosenheck and Dennis, 2001; Shinn and Baumohl, 1999; Lezak and 

Edgar, 1998; Avery et al., 1997; Susser et al., 1997). 

In addition to discharge planning, studies show that subsidized housing helps 

prevent homelessness, even for people with serious mental illnesses and/or cooccurring substance use disorders. Income support also is critical, since housing 

affordability is a function of both income and housing costs (Shinn and Baumohl, 

1999). 

O THER E SSENTIAL 

S ERVICES

Housing, treatment, and support services are the backbone of a comprehensive 

system of care for people with serious mental illnesses and/or co-occurring 

substance use disorders who are homeless or at risk of becoming homeless. But 

these evidence-based and promising practices must be offered as part of a full 

range of services that are appropriate, accessible, and acceptable to consumers 

and recovering persons. 

The hallmarks of these services are outreach, choice, and ongoing support. 

Some of the services, such as psychosocial rehabilitation and supported 

employment, were designed for people with serious mental illnesses and have 

been adapted for individuals who are homeless. Other programs that were 

designed for people who are homeless also serve people who have serious mental 

illnesses and/or co-occurring substance use disorders. All of these efforts help 

prevent or end homelessness. 

Primary Health Care 

As noted previously, people with serious mental illnesses and/or co-occurring 

substance use disorders who are homeless are at risk for both minor and lifethreatening diseases, including diabetes, liver disease, tuberculosis, Hepatitis B 

and C, and HIV/AIDS. Life on the streets makes it difficult to receive 

appropriate care. 

Because of their low incomes, the high cost of health care, and inadequate or 

nonexistent private health insurance, most people with serious mental illnesses 

rely on Medicaid, Medicare, and other government programs to provide mental 

health services, medications, and general medical care. People with substance 
 C HAPTER 6 : U SE E VIDENCE - B ASED AND P ROMISING P RACTICES 69 

use as their primary disorder are ineligible for SSI and Medicaid, which increases 

their risk of homelessness and makes it especially difficult for them to get 

medical care once they become homeless. 

Further, people with serious mental illnesses who become homeless may be 

unable to enroll in these programs or continue to receive their benefits. 

Complicated eligibility requirements, lack of a permanent address, and untreated 

mental illnesses and substance use disorders make it difficult for individuals to 

obtain and maintain the benefits to which they are entitled (GAO, 2000a; CHSF, 

2003). As a result, they frequently use such high-cost services as emergency 

room and inpatient care. When they present in emergency rooms, they are at 

increased risk for hospitalization, where their medical conditions may prolong 

their stay. Their debilitated condition also makes them more vulnerable to attack 

on the street or in drop-in shelters (Fischer, 1992). 

Special health care programs designed for people who are homeless feature 

outreach and intensive case management to address an individual’s full range of 

needs. These include the Health Care for the Homeless (HCH) program, 

administered by the HRSA’s Bureau of Primary Health Care in HHS. 

HCH projects, many of which serve individuals who have serious mental 

illnesses and/or co-occurring substance use disorders, are designed to be 

comprehensive, accessible, and culturally competent in an effort to help patients 

exit homelessness (McMurray-Avila, 1997). Many of these programs use 

mobile, interdisciplinary treatment teams to reach people on the streets or in 

shelters rather than requiring facility-based care. 

Trauma-Sensitive Services 

Health care providers working with people who are homeless must screen for and 

address trauma, including past and ongoing physical and sexual abuse. 

Individuals unable or unwilling to speak about the trauma they have experienced 

may present with somatic disorders such as headaches and backaches. Untreated 

trauma may complicate the treatment for mental illnesses and substance use 

disorders, leaving individuals at risk for recurrent homelessness. 

Alcohol and Drug Abuse Services 

The goal of substance abuse treatment for people who are homeless is to prevent, 

deter, or eliminate substance use and addictive behaviors. Treatment services 

may include outreach, counseling and education, case management, day 

programs, detoxification, and self-help and peer support activities (McMurrayAvila, 2001). These services may be provided in outpatient settings and 

alternative living arrangements, such as residential treatment settings and 

community-based halfway houses. 

Substance abuse treatment is particularly critical for individuals with cooccurring mental illnesses. A recent study revealed that among homeless clients 

with co-occurring disorders, those who reported extensive participation in 

substance abuse treatment showed clinical improvement comparable to or better 
70 B LUEPRINT FOR C HANGE

than individuals without co-occurring disorders (Gonzalez and Rosenheck, 

2002).

Mental Health and Counseling Services 

People who are homeless must have access to a full range of outpatient and 

residential mental health services, including crisis interventions, individual 

supportive therapy, family or group therapy, medication management, and 

therapeutic approaches that address multiple problems. As noted previously, 

access to coordinated treatment for co-occurring mental illnesses and substance 

use disorders also is necessary and superior to other approaches for reducing 

alcohol and drug use, homelessness, and the severity of mental symptoms among 

people with co-occurring disorders (Carey, 1996; Drake et al., 1998). 

The use of medications within specific parameters is an evidence-based practice 

for people with serious mental illnesses. Guidelines for the use of medication are 

being established and evaluated, but there are a number of promising practices 

that can, and should, be adapted to individuals with serious mental illnesses, 

including those who are homeless. For example, many people with serious 

mental illnesses have benefited from a new generation of antipsychotic 

medications, sometimes called “atypical” drugs. Because these new drugs 

generally produce fewer side effects, individuals are more likely to continue to 

take them (HHS, 1999). 

Concern about cost and treatment approaches that require patients to “fail” on 

older medications first may keep some individuals from receiving these 

potentially beneficial drugs. In response, some states, such as Massachusetts and 

Texas, have issued guidelines about the use of the new generation medications. 

The Texas Medication Algorithm Project (TMAP) recommends the use of all of 

the atypical or novel antipsychotics, other than clozapine, for the initial treatment 

of schizophrenia (Mellman et al., 2001). 

Treatment for people with mental illnesses and/or co-occurring substance use 

disorders is complicated by the interactive effects of psychoactive medications 

and illicit drugs or alcohol, as well as by the effects of prescribed psychoactive 

medications on people who have substance use disorders (SAMHSA, 2002b). In 

addition, clinicians need to be aware that different racial and ethnic groups, as 

well as women and men, respond differently to psychiatric medications. For 

example, many Asians and Hispanics with schizophrenia may require lower 

doses of antipsychotics than Caucasians to achieve the same blood levels (HHS, 

1999). 

Psychosocial Rehabilitation 

The terms “psychosocial rehabilitation” and “psychiatric rehabilitation” often are 

used synonymously and interchangeably. Typically, psychosocial rehabilitation 

refers to a range of services, exclusive of clinical treatment, designed to help 

individuals with serious mental illnesses recover functioning and integrate or reintegrate into their communities. Psychosocial rehabilitation programs may or 
 C HAPTER 6 : U SE E VIDENCE - B ASED AND P ROMISING P RACTICES 71 

may not include the specific technology of psychiatric rehabilitation (P. Kramer, 

personal communication, December 3, 2001). 

Psychiatric rehabilitation, as defined and developed by the Boston Center for 

Psychiatric Rehabilitation, is a specific, well-tested approach to helping people 

with serious mental illnesses function with success and satisfaction in 

environments of their choice with the least amount of professional intervention 

possible (Anthony et al., 1990). According to the philosophy of psychiatric 

rehabilitation, recovering is what people with psychiatric disabilities do; 

psychiatric rehabilitation is what helpers do to encourage the recovery process

(Anthony, 1993). 

Because psychiatric rehabilitation is an approach and not a program model, it can 

be applied in a variety of settings or programs, including case management and 

vocational programs that serve people who are homeless. Typically, such 

programs focus on independent living and social skills training, psychological 

support for individuals and their families, housing, vocational rehabilitation, 

social support, and access to leisure activities. Psychiatric rehabilitation 

programs that serve people who are homeless may have an added emphasis on 

outreach and on building trusting relationships that will allow individuals to 

explore their choices and learn the skills they need to succeed. 

Randomized clinical trials have shown that participants in psychiatric 

rehabilitation programs have fewer and shorter hospital stays and are more likely 

to be employed (HHS, 1999). The emphasis on choice, on individual potential, 

and on real-world settings may be especially attractive to people with serious 

mental illnesses who are homeless and who have had prior negative experiences 

with professionally directed treatment programs. Indeed, studies of the use of 

psychiatric rehabilitation with people who are homeless indicate this approach 

successfully engages disaffiliated individuals, expands their use of human 

services, and improves their housing conditions, mental health status, and quality 

of life (Shern et al., 2000). 

Income Support and Entitlement Assistance 

People who are homeless need adequate income to help them secure and 

maintain housing. With limited work histories, they frequently must rely on 

Federal income and entitlement programs, including SSI. But many are not 

enrolled. Outreach to people with serious mental illnesses, especially those who 

are homeless, is essential to help them negotiate the benefits application, 

eligibility, and appeals process. The goals of outreach include (Bianco and 

Milstrey-Wells, 2001): 

 Providing accurate information about disability benefits and work 

incentive programs; 

 Helping individuals gather the required personal, financial, and medical 

documentation or referring them to programs that provide this assistance; 

and 

 Helping individuals file an application and mount an appeal, if necessary. 
72 B LUEPRINT FOR C HANGE

In response to the need for knowledgeable advocates to help individuals navigate 

complex program requirements, the Social Security Administration (SSA) 

established the Benefits Planning, Assistance, and Outreach program, authorized 

to fund community-based outreach projects in every State. Outreach providers, 

trained by SSA, are knowledgeable about other Federal benefit programs, as 

well, such as the TANF, Medicaid, and HUD programs. 

Knowledgeable case managers (including peer case managers) and clinicians can 

make an enormous difference in their clients’ ability to obtain and maintain 

disability benefits. With the client’s approval, case managers may request 

duplicate copies of SSA mailings, especially helpful for individuals who have 

difficulty understanding their responsibilities and responding in a timely manner. 

Case managers also may serve as representative payees for clients who need help 

managing their benefit checks, or who fear that checks sent to shelter addresses 

will be stolen. About 25 percent of individuals who receive SSI have a 

representative payee. 

Employment, Education, and Training 

People with serious mental illnesses and substance use disorders, including those 

with histories of homelessness, want and need to work. For many, work helps 

them recover from their disabilities. Further, income from work may help 

individuals regain and maintain residential stability (Shaheen et al., 2001). 

Adequate standards of living and employment are associated with better clinical 

outcomes. 

The same factors that place people with serious mental illnesses at increased risk 

of homelessness are challenges to obtaining and retaining employment (Lezak 

and Edgar, 1998). These include symptoms of their illness, lack of housing, 

stigma and discrimination, and co-occurring substance use disorders. Likewise, 

people with substance use disorders exhibit behaviors that often interfere with 

job success. 

Therefore, people who are homeless need more services and support than 

traditional job training programs offer. Successful job training programs for 

people who are homeless include comprehensive assessment, ongoing case 

management, housing, supportive services, job training, job placement services, 

and followup (Northern Illinois University, 1991). 

Employment program models effective for people with serious mental illnesses, 

including transitional employment, supported employment (an evidence-based 

practice), and individual placement and support, must be flexible in how they 

define success and be prepared to work with individuals who are homeless over 

the long-term. A “work-first approach,” as opposed to extensive pre-vocational 

training, can motivate a person who is homeless to address other problems in his 

or her life. Thus, employment programs must strike a balance between requiring 

complete abstinence or freedom from symptoms and tolerating some substance 
 C HAPTER 6 : U SE E VIDENCE - B ASED AND P ROMISING P RACTICES 73 

use-related behaviors or symptoms of mental illnesses on the job (Shaheen et al, 

2001). 

Because mental illnesses often emerge in late adolescence or early adulthood, 

education and career plans may be interrupted. Individuals re-entering school 

have similar support needs to people adjusting to a competitive work 

environment, including a full range of housing, health and mental health, and 

support services (Shaheen et al, 2001). 

Services for Women 

Gender-specific programs have been shown to improve retention and outcomes 

for women in substance abuse treatment (Zerger, 2002). For example, a Los 

Angeles study that examined women treated in publicly funded residential drug 

treatment programs found that participants in women-only programs had more 

problems at program outset, but they spent more time in treatment and were 

twice as likely to complete treatment compared to women in mixed-gender 

programs (Grella, 1999). 

Too often, however, treatment is geared to men and conducted with scant 

attention to women’s needs. For instance, women often dislike the 

confrontational approach common to substance abuse treatment. Further, the 

specific needs of mothers with children often are not met in existing treatment 

programs. In particular, research on homeless mothers with substance use 

disorders indicates that the lack of childcare is a significant barrier for many 

women seeking treatment (Zerger, 2002). 

Because physical and sexual abuse are so common among women who are 

homeless and those who have mental illnesses and substance use disorders, 

programs designed for women must include an active program of trauma 

recovery (Harris, 1996). Women who have become homeless after fleeing a 

dangerous household need specialized residential assistance. 

Low-Demand Services 

As noted elsewhere in this report, individuals with serious mental illnesses and/or 

co-occurring substance use disorders who are homeless initially may be reluctant 

to engage in services. They may have had negative experiences with the 

behavioral health care system, lack the motivation to begin treatment, or be more 

concerned about their immediate needs for food, shelter, and income. 

Experience has shown that flexible, low-demand services may accommodate 

individuals who initially are unwilling to commit to more extended care. The 

ultimate goal of such services is to increase an individual’s motivation for 

treatment and engage them in more intensive services (Zerger, 2002; McMurrayAvila, 2001). The need for such services was a major finding of the NIAAA 

Cooperative Agreement Program (NIAAA, 1992). 
74 B LUEPRINT FOR C HANGE

HUD recognized the need for low-demand services when it established its Safe 

Havens program for people who are homeless and have serious mental illnesses. 

Safe Havens are a type of supportive housing that serve individuals who, perhaps 

because of their illness, have refused help or have been denied or removed from 

other programs serving people who are homeless. Individuals are not required to 

participate in treatment but, as they are ready, are expected to re-engage in 

services and move to permanent housing with supports. 

For individuals with substance use disorders, a sobering station is a low-demand 

setting that accepts people who are intoxicated and serves as a first point of 

contact with the human services system (Baumohl and Huebner, 1991). 

Likewise, the presence of chemical dependency staff in a shelter or drop-in 

center may introduce individuals to the availability of substance abuse treatment 

(Zerger, 2002). 

Crisis Care Services 

People with serious mental illnesses are in danger of becoming homeless when a 

crisis occurs, including exacerbation of symptoms, other medical emergencies, 

family stress, or the loss of a benefit check or employment. This is especially 

true for people with co-occurring substance use disorders. Providers must 

recognize the importance of being able to respond quickly to people in crisis, 

help them on-site if needed, and provide short-term crisis facilities to avoid 

unnecessary hospitalization and homelessness. Interdisciplinary, mobile crisis 

teams provide immediate assistance and may link individuals to communitybased respite care (HHS, 1999). 

Family Self-Help and Advocacy 

As a result of their symptoms and behaviors, people with serious mental illnesses 

and/or co-occurring substance use disorders often strain the resources of their 

families to help and may become homeless as a result. Helping families cope 

with the difficult aspects of living with and providing ongoing assistance to their 

family members with serious mental illnesses may prevent these individuals from 

becoming homeless (Lezak and Edgar, 1998). 

If family members understand issues such as the cyclic nature of mental illnesses, 

possible side effects of medication, and what to do when symptoms flare, they 

often are able to help their relatives maintain residential stability. In some 

cultures, the family is considered critical to a person’s recovery from mental 

illnesses and substance use disorders, and family members should be involved in 

treatment, as appropriate. 

Respite services give families a much-needed break to the stressful responsibility 

of providing a home to a family member with a serious mental illness. In 

addition to their vital role as caretakers, family members can be successful 

advocates for improved treatment, increased funding, and ongoing research and 

education designed to improve the lives of all people with serious mental 

illnesses and/or co-occurring substance use disorders. 
 C HAPTER 6 : U SE E VIDENCE - B ASED AND P ROMISING P RACTICES 75 

Culturally Competent Services 

As noted previously, racial, ethnic, and cultural differences can determine how 

individuals define their problems, how they express them, whether or not they 

seek help, from whom they will accept help, and the treatment strategies they 

prefer (HHS, 2001). Practitioners, too, perceive clients through their own 

cultural lenses. 

The basic tenets of cultural competence—accepting differences, recognizing 

strengths, and respecting choices—are critical to providing appropriate services 

to people who are homeless, especially those who have serious mental illnesses 

and/or co-occurring substance use disorders. While homeless people do not 

represent a separate culture per se, they have made adaptations to their 

circumstances that may affect the choices they make (Milstrey, 1994). For 

example, behavior that may appear dysfunctional to the clinician may be adaptive 

for life on the streets. 

Agencies that offer culturally adapted services share common strategies. They 

match clients with providers who have the same language and culture; provide 

services in minority communities; offer flexible hours and walk-in services; 

include families in treatment, where appropriate; and allow clergy and traditional 

healers to participate in the treatment process if the client desires (Flaskerud, 

1986; Dana et al., 1992). 

Criminal Justice System Initiatives 

People with serious mental illnesses and/or co-occurring substance use disorders 

who are homeless have frequent contact with the legal system, both as offenders 

and as victims. There are a number of points at which the mental health, 

substance abuse, and criminal justice systems can work together more effectively 

to address the multiple needs of people with serious mental illnesses and/or cooccurring substance use disorders in the criminal justice system. 

For example, the Sequential Intercept Model, developed by Steadman et al. (The 

National GAINS Center, unpublished paper) is based on the idea that people 

move through the criminal justice system in reasonably predictable ways. The 

five points of interception are: (1) law enforcement/emergency services; (2) 

initial detention/initial hearings; (3) jails, courts, forensic evaluations, and 

hospitalization; (4) re-entry; and (5) community corrections and community 

support. Use of the model helps communities visualize how the local mental 

health, substance abuse, and criminal justice systems intersect as they serve 

individuals with mental illnesses and substance use disorders. Interventions at 

several of these points are described below. 

Diversion 

Individuals with serious mental illnesses or co-occurring disorders who are 

homeless can be diverted from the criminal justice system either before or after 

charges have been filed (pre-booking and post-booking, respectively). Drug, 

mental health, and homeless courts—sometimes referred to as problem-solving 
76 B LUEPRINT FOR C HANGE

or collaborative justice courts—are one model of diversion that shows increasing 

promise for keeping nonviolent offenders with serious mental illnesses and/or cooccurring substance use disorders from cycling in and out of jails and prisons. 

Drug courts combine treatment with intensive judicial supervision, mandatory 

drug testing, and escalating sanctions to help people break the cycle of addiction 

and the crime that often accompanies it. Individuals also receive such necessary 

services as education or job skills training. 

Research shows that drug courts have an impact on both drug use and recidivism. 

A National Institute of Justice evaluation of the Nation’s first drug court in 

Miami showed a 33 percent reduction for re-arrests for drug court graduates, 

compared to other offenders with substance use disorders. Fifty to 65 percent of 

drug court graduates stopped using drugs (Curie, 2002). 

Jurisdictions with drug courts also report savings in jail/prison costs as a result of 

drug court programs. In 2001, the Drug Court Clearinghouse reported that the 

average annual number of jail/prison days saved per drug court program was 

10,113, for a per program cost savings of $667,694 (DOJ, 2001). 

Mental health courts based on this model are being developed to divert people 

with serious mental illnesses into treatment. An evaluation of the first two years 

of the Seattle Mental Health Court found that the target population experienced a 

decrease in criminal justice involvement and an increase in mental health 

treatment engagement (Haimowitz, 2002). 

More recently, communities have begun to adapt this model to help homeless 

people resolve misdemeanor cases, with the added twist that the court goes to the 

defendant. “The Homeless Court program brings the law to the streets, the court 

to the shelters, and the homeless back into society,” notes the American Bar 

Association (Binder, 2002). Participation is voluntary, and “sentences” include 

life-skills training, 12-step meetings, computer training or literacy classes, job 

training, counseling, or volunteer work. 

The homeless court program began in San Diego in the late 1980s as part of a 

“stand down” to provide multiple services to homeless veterans. In 1999, the 

San Diego Public Defender’s Office began holding a monthly homeless court at 

local shelters, which removes barriers to participation for individuals whose days 

are spent looking for shelter, income, and food. In addition, helping homeless 

people resolve outstanding warrants and criminal misdemeanor cases paves the 

way for receipt of such vital services as housing, mental health and/or substance 

abuse treatment, public benefits, and job training and employment (Binder, 

2002). 

Comprehensive Services 

Diversion programs cannot exist in isolation. They must be part of a 

comprehensive array of other jail services—including screening, evaluation, 

short-term treatment, and discharge planning—and must be integrated with 

community-based mental health and substance abuse treatment, housing, and 

social services (CMHS, 1995). So-called “boundary spanners” can bridge the 
 C HAPTER 6 : U SE E VIDENCE - B ASED AND P ROMISING P RACTICES 77 

two systems and serve as a liaison among mental health and drug courts, local 

police, and treatment providers (Steadman, 1992). 

Treatment for people in jails and prisons improves justice operations and 

increases the likelihood that individuals will make a successful return to the 

community. In her review of effective treatment programs for people with cooccurring mental illnesses and substance use disorders in the justice system, Hills 

defines a set of program principles for successful outcomes: 

 Services for people with co-occurring disorders must focus on the 

integration of treatment programming; 

 Both disorders should be treated as primary; 

 Services should be individualized and address symptom severity and skill 

deficits; 

 Psychopharmacological interventions should be used when appropriate; 

 Phases of intervention must be tailored to the setting; 

 The treatment continuum must extend into the community; and 

 Support and self-help groups are critical in successful reintegration to the 

community (2000). 

Re-Entry Planning 

Jail stays are frequently short, and some individuals cycle through jails dozen or 

even hundreds of times without ever being connected to community services. 

Re-entry planning must begin at admission; otherwise a person with a mental or 

substance use disorder who enters jail in a state of crisis may leave before the 

crisis can be addressed. This places individuals at risk of relapse, re-arrest, 

homelessness, and suicide. 

Numerous multisite studies of jail mental health programs suggest best practices 

for people with co-occurring mental illnesses and substance use disorders who 

are released from jail. Osher et al. (2002) propose one such model called APIC, 

which includes the following components: 

 Assess the inmate’s clinical and social needs and public safety risks; 

 Plan for the treatment and services required to address the inmate’s 

needs; 

 Identify required community and correctional programs responsible for 

post-release services; and 

 Coordinate the transition plan to ensure implementation and avoid gaps 

in care with community-based services. 

Jails legally are required to screen and identify inmates with co-occurring 

disorders and provide crisis intervention and psychiatric stabilization. Successful 

transition to community services can occur only if the justice, mental health, and 

substance abuse systems have a capacity and a commitment to work together on 

behalf of the individuals they serve (Osher et al., 2002). 

Supportive housing may be an appropriate adjunct to re-entry planning, 

according to the Corporation for Supportive Housing, which has prepared a guide 

to re-entry supportive housing for former inmates (CSH, 2002b). Many of the 
78 B LUEPRINT FOR C HANGE

individuals who leave jails and prisons are the very same individuals served by 

supportive housing, including those who face persistent mental health, substance 

use, and other chronic health challenges, and are at risk of homelessness, the 

CSH report notes. Again, such an approach requires collaboration and 

commitment among the housing, health care, social services, and justice systems. 

SAMHSA’ S L EADERSHIP 

IN E VIDENCE - B ASED 

P RACTICES

SAMHSA has been a leader in the development of evidence-based practices for 

people with serious mental illnesses and substance use disorders, including those 

who are homeless. SAMHSA develops technical assistance materials to help 

providers adapt and adopt evidence-based practices and sponsors grant programs 

that develop and evaluate science-based interventions for people with mental 

illnesses and substance use disorders. Some of these programs were described in 

Chapter 1. Information on additional resources follows. More information on 

these programs and services is available on the SAMHSA web site at 

www.samhsa.gov. 

The Evidence-Based Practices Project 

SAMHSA is a sponsor of the Implementing Evidence-Based Practices for Severe 

Mental Illness Project, a joint effort of SAMHSA and the Robert Wood Johnson 

Foundation, the National Alliance for the Mentally Ill (NAMI), and state and 

local mental health organizations in New Hampshire, Maryland, and Ohio. The 

project’s goal is to develop implementation toolkits to promote the delivery of 

effective practices for people with serious mental illnesses and/or co-occurring 

substance use disorders, including those who are homeless. 

Each toolkit includes specific information for funders, administrators, clinicians, 

consumers and recovering persons, and their families. Current toolkit topics 

include medication management, family psychoeducation, ACT, co-occurring 

disorders, supported employment, and illness management and recovery. 

Community Action Grants for Service System Change 

The Community Action Grant for Service System Change program, administered 

by SAMHSA’s CMHS, supports the adoption and implementation of exemplary 

practices for children with serious emotional disturbances or adults with serious 

mental illnesses, including those with co-occurring substance use disorders. 

Phase I grants support consensus-building among key stakeholders to adopt an 

exemplary practice in their community or state. Phase II grants support 

implementation of the practice with funds for training and other nondirect 

services. Both phases of the program include process evaluations. 
 C HAPTER 6 : U SE E VIDENCE - B ASED AND P ROMISING P RACTICES 79 

SAMHSA’s CSAT Targeted Capacity Expansion Program 

CSAT’s Targeted Capacity Expansion (TCE) program helps communities 

address gaps in treatment capacity. The TCE program supports rapid and 

strategic responses to demands for substance abuse treatment, including alcohol 

and drug use services. Grantees may include communities with serious, 

emerging drug problems, as well as communities with innovative solutions to 

unmet needs. 

Addiction Technology Transfer Centers (ATTCs) and Centers for 

the Application of Prevention Technology (CAPTs) 

SAMHSA uses regionally based centers to help communities adopt evidencebased practices in the prevention and treatment fields. Addiction Technology 

Transfer Centers (ATTCs) are a nationwide, multidisciplinary resource that 

transmits the latest knowledge, skills, and attitudes of professional addiction 

treatment practice. Launched by CSAT in 1993, the ATTC network comprises 

14 regional centers and a national office that help treatment systems adopt or 

adapt evidence-based practices for people with substance use disorders, including 

those with co-occurring mental illnesses. CAPTs are structured similarly and 

perform the same function for evidence-based substance use prevention 

strategies. 

Treatment Improvement Protocols (TIPS) 

SAMHSA’s Treatment Improvement Protocol (TIP) series for substance abuse 

treatment professionals translates evidence-based research findings in substance 

abuse treatment to the clinical setting. Each TIP focuses on a specific age group 

(e.g., adolescents, older adults), a group with special needs (e.g., people with cooccurring disorders, individuals impacted by domestic violence), or a particular 

clinical practice (e.g., motivational enhancement, brief interventions). TIPs are 

available at www.SAMHSA.gov/centers/CSAT2002

D EVELOPING S ERVICES 

T HAT W ILL L AST

Programs that use evidence-based and promising practices can produce positive 

outcomes for people with serious mental illnesses or co-occurring disorders who 

are homeless. The ability to show that these services produce measurable results 

will help sustain programs that are competing for limited funds, often in a 

managed care environment. 

The final two chapters of this report comprise Section IV: Sustain Services. 

Chapter 7 examines the types of outcomes that can and should be measured and 

the use of management information systems to track client data. Chapter 8 looks 

at ways to improve the availability and accessibility of mainstream resources for 

people with serious mental illnesses and/or co-occurring substance use disorders 

who are homeless. 
80 B LUEPRINT FOR C HANGE

Table 6.1 

Essential Service System Components 

Evidence-Based and Promising Practices 

Outreach and Engagement 

 Meets immediate and basic needs for food, clothing, and shelter. 

 Nonthreatening, flexible approach to engage and connect people to needed services. 

Housing with Appropriate Supports 

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

 Combines affordable, independent housing with flexible, supportive services. 

Multidisciplinary Treatment Teams/Intensive Case Management 

 Provides or arranges for an individual’s clinical, housing, and other rehabilitation needs. 

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

Integrated Treatment for Co-occurring Disorders 

 Features coordinated clinical treatment of both mental illnesses and substance use disorders. 

 Reduces alcohol and drug use, homelessness, and the severity of mental health problems. 

Motivational Interventions/Stages of Change 

 Helps prepare individuals for active treatment; incorporates relapse prevention strategies. 

 Must be matched to an individual’s stage of recovery. 

Modified Therapeutic Communities 

 Views the community as the therapeutic method for recovery from substance use. 

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

Self-Help Programs 

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

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

Involvement of Consumers and Recovering Persons 

 Can serve as positive role models, help reduce stigma, and make good team members. 

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

Prevention Services 

 Reduces risk factors and enhance protective factors. 

 Includes supportive services in housing, discharge planning, and additional support during transition 

periods. 

Other Essential Services 

Primary Health Care 

 Includes outreach and case management to provide access to a range of comprehensive health services. 

Mental Health and Substance Abuse Treatment 

 Provides access to a full range of outpatient and inpatient services (e.g., counseling, detox, selfhelp/peer support). 

Psychosocial Rehabilitation 

 Helps individuals recover functioning and integrate or re-integrate into their communities. 

Income Support and Entitlement Assistance 

 Outreach and case management to help people obtain, maintain, and manage their benefits. 

Employment, Education, and Training 

 Requires assessment, case management, housing, supportive services, job training and placement, and 

follow-up.

Services for Women 

 Programs focus on women’s specific needs, e.g., trauma, childcare, parenting, ongoing domestic 

violence, etc. 
 C HAPTER 6 : U SE E VIDENCE - B ASED AND P ROMISING P RACTICES 81 

Table 6.1 

Essential Service System Components (continued) 

Other Essential Services (continued) 

Low-Demand Services 

 Helps engage individuals who initially are unwilling or unable to engage in more formal treatment. 

Crisis Care 

 Responds quickly with services needed to avoid hospitalization and homelessness.

Family Self-Help/Advocacy 

 Helps families cope with family members’ illnesses and addictions to prevent homelessness.

Cultural Competence 

 Accepts differences, recognizes strengths, and respects choices through culturally adapted services. 

Criminal Justice System Initiatives 

 Features diversion, treatment, and re-entry strategies to help people remain in or re-enter the 

community. 
82 B LUEPRINT FOR C HANGE
S ECTION IV 

SUSTAIN SERVICES 

Often, establishing a new program or service for people with serious mental 

illnesses and/or co-occurring substance use disorders who are homeless is easier 

than sustaining it once initial funds run out. Most government and private funders 

want to see a plan for sustainability built into funding applications so they know 

that, when their support ends, vital services won’t be discontinued. Measuring 

outcomes is critical to show potential supporters that your program achieves its 

goals and objectives. Planning for sustainability also requires that mainstream 

resources be available and accessible to homeless people. 

The next two chapters—Measure Results and Use Mainstream Resources to Serve 

People Who Are Homeless—address these critical areas. These chapters discuss 

the need to: 

 Measure client-level outcomes; 

 Measure system-level outcomes; 

 Use management information systems; 

 Use mainstream resources to prevent homelessness; 

 Improve access to mainstream programs; 

 Expand the capacity of mainstream programs; 

 Promote coordination and collaboration among mainstream programs; 

 Build the infrastructure of housing and services; and 

 Create public awareness. 

Additional information on the materials cited in these chapters can be found in the 

References. Organizations that offer technical assistance in these areas are listed in 

the Resources section. 

 

I N THIS

S ECTION

■ ■ ■ ■ ■ ■ ■ ■

Measure Results 

■ ■ ■ ■ ■ ■ ■ ■

Use Mainstream 

Resources to Serve 

People Who Are 

Homeless 

83
84 B LUEPRINT FOR C HANGE
 C HAPTER 7 : M EASURE R ESULTS 85 

■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ 7

Measure Results 

Significant changes in the financing and delivery of health care, including the 

rapid development of managed care, have increased the need to monitor and 

evaluate costs, quality, and access (Kamis-Gould and Hadley, 1996). In the 

same vein, the Federal, state, and local agencies that fund services for people 

who are homeless increasingly are using outcome measures to balance service 

quality and effectiveness with limited resources. 

Many states and localities have been influenced by the Government Performance 

and Results Act of 1993 (P.L. 103-62), which requires Federal agencies to set 

specific performance goals and to measure outcomes for Federal programs 

(GAO, 1999b). SAMHSA’s new Performance Partnership grants will give states 

more flexibility in how they spend their Federal mental health and substance 

abuse block grant funds, and, in turn, the states will have to show that they have 

been effective in meeting the goals they’ve set. 

For programs that serve homeless people, a General Accounting Office report 

notes, “The use of outcome measures shifts the focus from outputs, such as the 

types and numbers of activities performed, to the outcomes, or results achieved” 

(GAO, 1999b). This means, for example, that a provider should include a 

measure of the number of people who become permanently housed, along with 

the number of people the program serves. 

This chapter examines (1) the rationale for measuring outcomes, (2) the type of 

outcomes that should be measured, (3) the barriers to measuring outcomes for 

people with serious mental illnesses and/or co-occurring substance use disorders 

who are homeless, and (4) the use of management information systems to track 

client data. 

States will have to show that 

they have been effective in 

meeting the goals they’ve set. 

C HAPTER
86 B LUEPRINT FOR C HANGE

W HY M EASURE 

O UTCOMES ? 

Measuring outcomes, first and foremost, is a way to ensure accountability. 

Positive outcomes provide justification for continued services, which may help 

programs sustain activities in difficult fiscal environments and/or when start-up 

funding ends. Agencies also use outcome measures to evaluate their progress in 

meeting strategic goals and objectives. Beyond these broader aims, some 

specific reasons to measure outcomes of services for people who are homeless 

include (HRSA BPHC, 1996): 

 To demonstrate improvements in clients’ health status, level of 

functioning, and quality of life. Residential stability also is a key 

indicator that a program has met its goal of helping individuals exit 

homelessness. 

 To know what works and what doesn’t, and to be able to make 

appropriate interventions more effective. People with serious mental 

illnesses and/or co-occurring substance use disorders who are homeless 

are a heterogeneous group. Measuring the effectiveness of specific 

interventions helps clinicians know what works for whom, and at what 

cost. 

 To assist with and assess internal quality improvement efforts. Agencies 

can use outcome measures to make internal course corrections that 

improve the quality of services they offer. 

 To assess cost-effectiveness. Resources available to serve people who are 

homeless and people who have serious mental illnesses and/or cooccurring substance use disorders are limited. Providers can demonstrate 

that timely and appropriate interventions result in cost savings. 

 To assist in resource allocation. Limited resources necessitate difficult 

decisions about how to allocate funds among providers and services. 

Outcome measures can be used to help determine which providers and 

which interventions are best able to meet clients’ needs. 

 To exchange successful strategies. There is no need for programs that 

serve people who are homeless to reinvent the wheel. As noted 

previously in this report, states, communities, and individual agencies 

can adopt or adapt practices that prove promising, as indicated by the 

outcomes they achieve. 

 To build support for specific interventions that are effective with people 

who are homeless. Showing positive results with vulnerable, high-need 

individuals can help justify the expenditure of resources for a particular 

program or approach. 

 To increase client satisfaction. Though client satisfaction measures may 

not always relate to successful clinical outcomes, individuals who are 

satisfied with the type of services offered and the way in which services 

are delivered may be more likely to complete treatment. For example, 

offering people a choice in housing relates directly to their success in 

remaining housed (Srebnik et al., 1995). 

 To demonstrate positive impact on public health and social issues. 

Ending homelessness for people with serious mental illnesses and/or cooccurring substance use disorders reduces human suffering; it also 

reduces the burden on the broader service system. For example, outcome 
 C HAPTER 7 : M EASURE R ESULTS 87 

measures show that people who are housed and receiving appropriate 

treatment have less contact with the criminal justice system and make 

less use of emergency room and inpatient care. 

Population-specific outcome measures also can help gauge the appropriateness 

and effectiveness of managed care contracts. In an effort to improve quality and 

contain costs, many states contract with managed behavioral health care 

companies to provide mental health and substance abuse treatment to Medicaid 

recipients. Serious questions have been raised about the ability of managed care 

companies to respond appropriately to the needs of people with serious mental 

illnesses or co-occurring disorders who are homeless. State agencies that 

contract with these organizations can build in specific quality assurance activities 

and outcome measures relevant to people who are homeless, as well as incentives 

and sanctions to ensure compliance (Wunsch, 1998). 

T HE T YPES OF O UTCOMES 

T HAT S HOULD B E M EASURED

Providers who work with people who are homeless and have serious mental 

illnesses and/or co-occurring substance use disorders agree on the need to 

measure positive changes in both the client and in the service system. Outcome 

assessment requires a thorough planning process and the involvement of key 

stakeholders, including consumers (HRSA BPHC, 1998a). 

Programs will measure different client-level and system-level outcomes 

depending on a number of factors: 

 Population they serve; 

 Specific services they offer; 

 Overall goals and objectives of the organization; 

 Requirements of their primary funding source(s); 

 Role they play in their community’s Continuum of Care for people who 

are homeless; and 

 Political climate in their state or community. 

Outcomes measures frequently are expressed in broad terms such as “reduction 

of barriers” (system-level outcome) or “mental health or substance use status” 

(client-level outcome). Data collected to support the outcomes typically are 

articulated as a series of specific measures, often called performance indicators. 

For example, “the number of access points to the system” is a performance 

indicator for reduction of barriers. Similarly, “the number of psychiatric 

emergency admissions” is a performance indicator for mental health status. 

Some organizations compile outcomes and performance indicators in a document 

called a report card. Report cards have been developed by national oversight 

organizations, such as the National Committee on Quality Assurance (NCQA) 

and the Joint Commission on Accreditation of Health Care Organizations 

(JCAHO); by the insurance industry; and by large corporations. The SAMHSA 
88 B LUEPRINT FOR C HANGE

Center for Mental Health Services’ Mental Health Statistics Improvement 

Program (MHSIP) has developed the MHSIP Consumer-Oriented Mental Health 

Report Card (MHSIP, 1996). A report card informs key stakeholders, including 

policymakers, payers, providers, and consumers, whether the agency or health 

care system does what is expected and whether it does it well (MHSIP, 1996). 

Client-Level Outcomes 

Ultimately, the goal of an integrated system of care is to improve client 

outcomes. For people with serious mental illnesses and/or co-occurring 

substance use disorders who are homeless, this means improvements in mental 

symptoms, substance use, housing status, and quality of life. Measures of 

improved functioning for people with serious mental illnesses or co-occurring 

disorders who are homeless may include the following outcomes (in bold) and 

suggested performance indicators (in italics). Although some of these results are 

difficult to quantify, they are a clear indication that all the preparatory work has 

been successful (NASMHPD, 1995). 

 Housing status: Number of days homeless; number of days in housing; 

length of time in most recent housing placement; possession of housing 

subsidy; 

 Mental health status: Number of psychiatric emergency admissions; 

number of days in inpatient treatment; self-report of mental health status; 

 Substance use status: Number of days drinking and/or using drugs; 

number or severity of problems associated with substance use; self-report 

of substance use; 

 Employment: Number of days employed; number of work days lost to 

mental symptoms or substance use; 

 Income: Average monthly income; receipt of SSI/SSDI or other public 

benefits; 

 Health status: Number of acute illnesses; number of inpatient days; 

self-report of health status; has private or public health insurance; 

 Family relationships: Self-report of quality of family relationships; 

 Criminal justice involvement: Number of arrests; number of days 

incarcerated; 

 Social supports: Self-report of degree of social support; 

 Consumer satisfaction: Self-report of satisfaction with a broad range of 

variables, including housing, mental health, substance use, health status, 

and degree of social support; and 

 Quality of life: Measurable improvements in the expected direction in 

the areas noted above; self-report of perceived quality of life. 

System-Level Outcomes 

At the system-level, most programs that serve people with serious mental 

illnesses and/or co-occurring substance use disorders who are homeless will 

measure access to services, quality of care, and cost-effectiveness. Other systemlevel outcomes for programs that provide health care services to people who are 

homeless may include availability of comprehensive services, continuity of care, 

prevention activities, and degree of client involvement (HRSA BPHC, 1996). 
 C HAPTER 7 : M EASURE R ESULTS 89 

Some specific system-level outcomes for programs that serve people with serious 

mental illnesses and/or co-occurring substance use disorders who are homeless 

also might include (NASMHPD, 1995): 

 Attention to those not in the system; 

 Degree of choice; 

 Cultural competence; 

 Reduction of barriers; 

 Affordable housing options; 

 Array of service options; 

 Access to services clients want and need; 

 Degree to which the mainstream system is responsive; and 

 Level of support to maintain progress. 

It also is possible to measure the level of systems integration. Measures of 

improved system performance, designed to gauge the extent to which agencies 

share information, resources, and clients, include the following performance 

indicators (HRSA BPHC, 1996; Glover and Gustafson, 1999): 

 Number and type of formal interagency agreements; 

 Degree of blended funding; 

 Number of joint activities between and among providers; 

 Extent to which staff from participating agencies are trained in each 

other’s disciplines; 

 Degree to which application procedures have been streamlined and 

exclusionary program rules have been waived; 

 Extent to which the system offers “no wrong door” access; and 

 Degree to which program planning and development incorporates the 

participation of key community stakeholders, including consumers. 

The Massachusetts Division of Medical Assistance has set certain 

performance standards related to people who are homeless in its 

contract with the company that provides mental health and substance 

abuse services for many of the State’s Medicaid recipients. For 

example, one performance standard requires the company to 

implement measures that will reduce the inappropriate discharge of 

people from psychiatric facilities to shelters or the streets. Another 

provides incentives to the company for increasing enrollment of 

Medicaid-eligible individuals who are homeless (GAO, 1999b). 

B ARRIERS TO 

M EASURING O UTCOMES

There are numerous barriers to measuring outcomes for people with serious 

mental illnesses and/or co-occurring substance use disorders who are homeless. 

Indeed, mental illness, substance use, and homelessness each pose special 

problems in valid and reliable assessment (Mercer-McFadden and Drake, 1992). 
90 B LUEPRINT FOR C HANGE

These problems are further complicated by the interaction of these conditions, 

which makes categorizing their progress challenging at best. 

If progress is difficult to measure, measuring “success” is even more challenging. 

Much depends on how success is defined. For people with serious mental 

illnesses and/or co-occurring substance use disorders, recovery may be 

incremental and long term, often marked by numerous flare-ups and relapses. 

Outcome measures therefore, must reflect the intensity of services required to 

serve people with serious mental illnesses or co-occurring disorders who are 

homeless, and must recognize the small steps that constitute success (HRSA 

BPHC, 1996). 

Further, the availability of many services that individuals require to exit 

homelessness, such as supportive housing, may be beyond the ability of 

individual programs to control. Also, some outcome measures, such as “quality 

of life,” are difficult to quantify, especially when they rely on individual selfreports. 

In addition, data collected on program clients cannot capture information on the 

individuals who are not in the system but whose needs may be just as great, if not 

greater, than those of the individuals being served. Finally, measuring outcomes 

requires development and implementation of data systems that are sophisticated 

and user-friendly, as well as staff trained in the use of these tools. Even when the 

systems and personnel are in place, however, fragmented, duplicative, and 

inconsistent reporting and evaluation requirements attached to different funding 

streams pose an ongoing challenge for many providers. 

U SE OF M ANAGEMENT 

I NFORMATION S YSTEMS 

Collecting client-level information can help streamline services, reduce 

duplication of effort, improve access, and inform public policy. Beginning in 

2004, the U.S. Department of Housing and Urban Development will require all 

government and nonprofit agencies receiving McKinney-Vento Homeless 

Assistance funds to implement homeless information management systems 

(HMIS) (University of Massachusetts, 2001). 

HMIS have already been implemented in 20 to 25 jurisdictions, including several 

statewide plans and a handful of communities that are pooling resources to build 

local tracking networks. In other jurisdictions, State and local HMIS efforts are in 

various stages of planning, pilot testing, and implementation. 

The benefits of such systems to individuals who are homeless include 

streamlined referrals, coordinated case management, and reduction of duplicative 

intakes and assessments. Service agencies gain reporting tools, mechanisms for 

internal and external service coordination, and information that can inform 

service and systems planning and advocacy. Policymakers benefit from data that 

can include the types and number of services provided, an unduplicated count of 
 C HAPTER 7 : M EASURE R ESULTS 91 

individuals being served, population characteristics and service needs, and trends 

over time. 

States and local jurisdictions implementing HMIS must ensure this data 

collection is done in compliance with the Health Insurance Portability and 

Accountability Act of 1996 (HIPAA). HUD is preparing security and data 

element guidelines for compliance with HIPAA. Under the guidelines, 

jurisdictions will be able to decide what information can be shared. To be 

compliant with HIPAA, any sharing of health information must be done with 

client consent, and individuals must be informed of what information is being 

shared and why (NAEH, 2003). 

In December 2000, the Wisconsin Division of Housing and 

Intergovernmental Relations purchased a commercial software 

package to implement a statewide system using a central database, 

and offered bonus points to agencies applying for funds as an 

incentive to participate. To date, 84 agencies representing 68 counties 

participate in the statewide HMIS. The system is designed to protect 

confidential data and allow clients to determine which records are 

shared. The HMIS system has reduced or eliminated monthly or 

quarterly reporting requirements for many agencies, decreased 

duplicative client intakes, helped coordinate services and streamline 

referrals, provided better access to data for funders and other 

stakeholders, and offered on-line access to a statewide database of 

service providers (University of Massachusetts, 2001). 

C ONNECTING TO 

M AINSTREAM R ESOURCES

Weaving best practices for people with serious mental illnesses and/or cooccurring substance use disorders who are homeless into a seamless system of 

care and measuring the results is a tall order indeed. In the last decade, the 

homeless service system has created a wealth of programs and services that show 

positive results for this very vulnerable group. However, the homeless service 

system does not have the human or financial resources to address this problem 

fully. The final chapter of this report examines some ways in which mainstream 

resources can play a vital role in ending homelessness among people with serious 

mental illnesses or co-occurring disorders. 
92 B LUEPRINT FOR C HANGE
 C HAPTER 8 : U SE M AINSTREAM R ESOURCES TO S ERVE P EOPLE W HO A RE H OMELESS 93 

■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ 8

Use Mainstream Resources to 

Serve People Who Are Homeless 

Homeless assistance programs alone cannot prevent or end homelessness 

(NAEH, 2000). Because most people who are homeless are eligible for, and 

many already are clients of, mainstream service programs, Federal agencies, 

states, and communities are actively pursuing ways to make mainstream 

services more accessible, relevant, and appropriate for people who are 

homeless. This has taken on new urgency with the Administration’s goal to end 

chronic homelessness. 

As noted previously in this report, people with serious mental illnesses and/or cooccurring substance use disorders who are homeless are eligible for a host of 

mainstream health, social service, and income support programs that are intended 

to meet the needs of all low-income people, though many are not receiving them. 

These resources are vital to provide needed services and supports that will 

prevent people from becoming homeless or help them exit homelessness. This 

chapter examines (1) the type of mainstream benefits for which homeless people 

with serious mental illnesses and/or co-occurring substance use disorders are 

eligible and (2) strategies for making mainstream programs available and 

accessible to homeless people. 

A W IDE R ANGE OF 

A VAILABLE R ESOURCES

The scope of “mainstream” resources varies depending on the agency or group 

examining them. In a 1999 report, the GAO identified 50 Federal programs 

administered by eight Federal agencies that can provide services to homeless 

people. Of these 50 programs, 16 were targeted for homeless people, and the 

remaining 34 were nontargeted, or were available to low-income people 

generally (GAO, 1999a). These nontargeted resources are generally referred to 

as “mainstream” programs. 

Mainstream services are vital 

to provide needed services and 

supports. 

C HAPTER
94 B LUEPRINT FOR C HANGE

In its report on mainstream systems and homelessness, the Charles and Helen 

Schwab Foundation (2003) defined mainstream resources as: 

...publicly funded programs which provide services, housing and 

income supports to poor persons whether they are homeless or not. 

They include programs providing welfare, health care, mental health 

care, substance abuse treatment and veterans’ assistance (p. i). 

Using this definition, the Foundation report cites the following mainstream 

services as being critical for people who are homeless (CHSF, 2003, p. 2): 

 Income support programs such as SSI and TANF and supplements such 

as Food Stamps; 

 Medicaid and other health insurance programs, including Community 

Health Centers and health assistance through the VA; 

 Mental health and substance abuse services funded through a variety of 

Federal block grant programs; 

 Workforce Initiative Act (WIA) programs designed to provide training 

and secure employment for low-income workers receiving benefits; and 

 Housing subsidy programs, such as Federal Housing Choice and public 

housing. 

Additional services that affect low-income people include public schools, jails 

and prisons, child protective services, and foster care. 

HHS Mainstream Programs 

Of the 34 mainstream programs the GAO identified in 1999, 12 programs are 

administered by HHS, the parent agency of SAMHSA. The HHS Secretary’s 

Workgroup on Ending Chronic Homelessness identified eight of these programs 

as relevant to meet the needs of disabled adults who make up the chronically 

homeless population (HHS, 2003): 

 Medicaid; 

 TANF; 

 Social Services Block Grant; 

 Community Services Block Grant; 

 Community Health Centers (including Migrant Health Centers); 

 Ryan White Programs; 

 Substance Abuse Prevention and Treatment Block Grant; and 

 Community Mental Health Services Block Grant. 

Within these programs, the workgroup found considerable opportunity for the 

state or grant recipient to tailor service responses to the unique needs of 
 C HAPTER 8 : U SE M AINSTREAM R ESOURCES TO S ERVE P EOPLE W HO A RE H OMELESS 95 

beneficiaries, including people who are homeless. However, the group also 

noted (HHS, 2003) that: 

 All programs include restrictions on offering certain services. For 

example, of the eight programs, only Medicaid is authorized to pay for 

inpatient services. 

 The most frequently offered core services (defined as those that are 

needed to move people from the streets into housing and stabilize their 

conditions) include information and referral, offered by all eight 

programs, followed by outreach, supportive case management, and 

substance abuse services, offered by seven programs. 

 Of six supportive services identified as necessary to re-integrate 

individuals into the community, only one—transportation—is offered by 

all eight programs. Five of the programs provide all of the supportive 

services. 

 None of the eight programs offer the entire group of core and supportive 

services the workgroup identified as necessary to prevent and end 

homelessness among people with serious health and behavioral health 

disorders. 

M AKING M AINSTREAM 

S ERVICES W ORK FOR 

H OMELESS P EOPLE

Researchers, policymakers, and advocates who have examined the issue of using 

mainstream resources to prevent and end homelessness have developed a set of 

strategies useful both to homeless service providers and to those who administer 

and fund mainstream programs. Generally, these strategies fall into six main 

areas, including: 

 Preventing homelessness among clients of mainstream programs; 

 Improving access to mainstream resources for people who are homeless; 

 Expanding the capacity of mainstream programs to serve people who are 

homeless; 

 Promoting coordination and collaboration among mainstream programs; 

 Building the infrastructure of housing and services that homeless people 

need; and 

 Creating public awareness about mental illnesses, substance use 

disorders, and homelessness. 

Each of these strategies is discussed in brief below. 

Prevent Homelessness 

Homelessness prevention activities within mainstream programs hinge on the 

fact that most people who become homeless already are clients of publicly 

funded programs. If these programs don’t serve them appropriately, they are at 

greater risk of homelessness. This is especially true for people with serious 

mental illnesses and/or co-occurring substance use disorders. 
96 B LUEPRINT FOR C HANGE

Prevention activities may be as simple as the use of funds to prevent eviction or 

to help an individual maintain his or her housing. For example, the 

Massachusetts Public Housing Authority gives preference for Housing Choice 

vouchers to applicants who are subject to a court-ordered eviction when the 

applicant’s rent exceeds 40 percent of his or her income (CHSF, 2003). In 

Minnesota, the state pays for up to 90 days of rental housing while an individual 

with a serious mental illness receives inpatient treatment. 

Improving discharge planning is a system-wide effort to prevent homelessness 

for individuals being released from temporary housing, such as foster care, jails, 

and psychiatric hospitals. The Massachusetts Housing and Shelter Alliance 

(MHSA) discovered that many of its clients had been recently released from 

institutional care. To improve discharge planning, the MHSA advocated for the 

use of mainstream resources with the mental health, substance abuse treatment, 

corrections, and foster care systems. The group’s success rests in part with its 

ability to convince the state to evaluate agencies on new performance measures 

that make homelessness a bad performance outcome (CHSF, 2003). For more 

information, see http://www.nhchc.org/discharge/discharge_planning_main.htm. 

Improve Access to Mainstream Programs 

Homeless people face numerous barriers to the receipt of mainstream resources, 

including barriers that result from the condition of homelessness itself, such as 

the lack of stable housing from which to receive services (CHSF, 2003). Further, 

the structure and operations of Federal mainstream programs themselves create 

additional barriers to serving homeless people (GAO, 2000a). 

In its recent report Ending Chronic Homelessness: Strategies for Action, HHS 

proposed several approaches to improve access to mainstream housing and 

supports for people who are chronically homeless (HHS, 2003). They include: 

 Strengthening outreach and engagement activities. Mainstream 

programs that support outreach and case management should be 

encouraged to identify chronically homeless people as potentially eligible 

for these services. This can be accomplished by out-stationing or colocating staff from mainstream programs in homeless service settings. 

For example, staff of the SSI Outreach Project in Baltimore provide 

outreach to homeless people who are eligible for SSI and help them 

through the application process. This began as a demonstration program 

of SSA and continues today as its own program (CHSF, 2003). 

 Simplifying application procedures. Complicated, redundant 

applications for mainstream services pose a significant barrier to people 

with serious mental illnesses or co-occurring disorders who are homeless. 

An expert panel convened to advise the GAO on barriers to mainstream 

resources for homeless people suggested the use of a single application 

form to gather basic information required for most Federal programs 

(GAO, 2000a). 

 Improving the eligibility review process. Lengthy application and 

appeals processes increase the risk that an individual with a serious 
 C HAPTER 8 : U SE M AINSTREAM R ESOURCES TO S ERVE P EOPLE W HO A RE H OMELESS 97 

mental illness or co-occurring substance use disorder will become or 

remain homeless. The HHS report suggests that its Operating Divisions 

could establish an interagency agreement with SSA to provide crosstraining for people who work with homeless individuals on appropriate 

medical documentation needed to determine disability.

 Exploring ways to maintain program eligibility. Individuals with mental 

illnesses and/or co-occurring substance use disorders may lose their 

benefits when institutionalized in a hospital or jail, which makes them 

vulnerable to homelessness when they leave the facility. HHS 

encourages states to not terminate Medicaid eligibility for individuals 

who are institutionalized (HHS, 2003). In Massachusetts, prisoners can 

be deemed eligible for Medicaid while still in prison and be 

automatically enrolled on the day of their release (CHSF, 2003).

Expand the Capacity of Mainstream Programs 

The homeless service system that has emerged in the 16 years since the original 

McKinney Act was enacted has compiled an impressive array of evidence-based 

and promising practices to serve people with serious mental illnesses and/or cooccurring substance use disorders who are homeless. The GAO expert panel 

noted that Federal agencies could do more to incorporate into mainstream 

programs the various lessons learned from McKinney-Vento Act programs and 

demonstration projects targeted to homeless people (GAO, 2000a). 

These lessons include the need to (1) integrate services, treatment, income, and 

housing; (2) link to needed supports; (3) support access to a range of housing 

options; (4) make services continuously available; and (5) involve consumers in 

program design and evaluation (HomeBase, 2003). One way to increase the 

capacity of the mainstream system to provide these services is through the use of 

training and technical assistance. 

For example, HHS recommends training and technical assistance for mainstream 

service providers on steps that can be taken to end chronic homelessness (HHS, 

2003). The State Policy Academies sponsored by HHS and HUD are another 

example of capacity building. The Policy Academies are designed to help States 

develop and implement State-specific action plans to identify and address chronic 

homelessness. 

HHS also recommends the use of toolkits and blueprints as technical assistance 

aids. To this end, HHS and HUD are developing a comprehensive tool to 

educate and raise awareness among homeless service providers and homeless 

individuals about various Federal mainstream benefit programs that homeless 

individuals are eligible for. 

Finally, the GAO expert panel called for mainstream providers at the Federal, 

state, and local levels to be held accountable for serving homeless people, 

including the development of a set of minimum standards for using program 

funds (GAO, 2000a). The development and use of homeless-specific outcome 

measures by mainstream programs will allow the agencies that fund these 
98 B LUEPRINT FOR C HANGE

services to determine how well they serve people with serious mental illnesses 

and/or co-occurring substance use disorders who are homeless. 

Promote Coordination and Collaboration 

The need for greater collaboration among mainstream services on behalf of 

people who are homeless was one of three top goals cited by HHS in its report on 

ending chronic homelessness (HHS, 2003). The workgroup that prepared the 

report recommended, among other strategies that HHS: 

 Provide incentives for states and localities to coordinate services and 

housing. One such incentive, for example, might be the ability to use 

grant funds to support interagency efforts that address chronic 

homelessness. 

 Reward coordination across HHS assistance programs to address 

chronic homelessness. The HHS workgroup proposed, as an example, an 

incentive program in which States submitting block grant applications 

that demonstrate a coordinated set of activities across mainstream 

programs to address chronic homelessness would be eligible for a partial 

bonus payment up front, with the balance of the bonus based on the 

achievement of selected performance goals. 

 Permit flexibility in paying for services to individuals experiencing 

chronic homelessness. This might be accomplished by allowing states to 

blend a portion of funds from multiple, relevant HHS assistance 

programs to target homelessness. 

Public systems currently are overburdened and underfunded, making it difficult 

for them to serve current clients, much less meet increased demands (CHSF, 

2003). In the absence of incentives such as those recommended by the HHS 

workgroup, they rely on the homeless service system to meet the needs of those 

individuals who have complex problems (NAEH, 2000). 

In addition, restrictive eligibility criteria and separate funding streams make it 

difficult for mainstream programs to cooperate with one another on behalf of 

people with multiple conditions. However, numerous reports cite examples of 

innovative financing and program models that serve individuals whose problems 

cross service system boundaries (e.g., SAMHSA, 2002b; NASMHPD and 

NASADAD, 2002). 

As an outgrowth of its report to Congress on the prevention and treatment of cooccurring mental illnesses and substance use disorders, SAMHSA will 

disseminate strategies that States and communities have used to address this 

growing problem. These include strategies to build consensus around the need 

for an integrated response to the prevention and treatment of co-occurring 

disorders; to develop aggregated funding mechanisms; to cross-train staff; and to 

measure success by improvements in client functioning and quality of life. 
 C HAPTER 8 : U SE M AINSTREAM R ESOURCES TO S ERVE P EOPLE W HO A RE H OMELESS 99 

Build the Infrastructure of Housing and Services 

Improving access and coordinating services will be of little use unless there is a 

full range of housing and services available to which homeless people can be 

referred. The National Alliance to End Homelessness makes this clear in its 

report A Plan: Not a Dream. How to End Homelessness in Ten Years (NAEH, 

2000). “Attempts to change the homeless assistance system must take place 

within the context of larger efforts to help very poor people,” the report notes (p. 

2). 

In particular, the National Alliance calls for an increase in affordable housing 

units, an increase in wages that will allow workers to afford housing and needed 

services, and increases in the availability of such services as mental health and 

substance abuse treatment and child care. Some additional suggestion follow. 

 Increased entitlements and health insurance benefits. Many people with 

serious mental illnesses and/or co-occurring substance use disorders 

depend on SSI and/or SSDI, and the corresponding health insurance 

programs, Medicaid and Medicare, respectively. Any increases in these 

vital benefit programs will help lift these individuals out of poverty and 

improve their chances of maintaining residential and psychiatric stability. 

 Improved work incentives. People with serious mental illnesses or cooccurring disorders who are homeless often are afraid to work for fear of 

losing public benefits, especially health insurance. Though the Ticket to 

Work and Work Incentives Improvement Act of 1999 addressed some of 

these issues, questions remain about the usefulness of these incentives for 

people who are homeless (HRSA BPHC, 2000). Advocates can monitor 

implementation of this legislation to be certain that people who are 

homeless are able to take full advantage of its provisions. 

 Increased housing subsidies. Housing subsidies alone won’t solve the 

problem of homelessness among people with serious mental illnesses 

and/or co-occurring substance use disorders, especially where affordable 

housing is in short supply. Yet research reveals that housing subsidies 

can help people with serious mental illnesses and/or co-occurring 

substance use disorders who are homeless find independent living 

arrangements (CMHS, 1994). 
100 B LUEPRINT FOR C HANGE

Create Public Awareness 

Individuals who understand that, with appropriate treatment and support, most 

people with serious mental illnesses or co-occurring disorders can and do recover 

may be less likely to discriminate against individuals who have these diseases. 

Some effective strategies include: 

 Education about the nature of serious mental illnesses and substance use 

disorders. Be certain to include the perspective of consumers and 

recovering persons in all written materials and public forums. Their 

stories provide powerful testimonies about the strength and resiliency of 

the human spirit. 

 Education about the causes of homelessness and ways to prevent and end 

homelessness. Get the word out to the public and your legislators that we 

know what works. This can be as simple, yet powerful, as inviting a 

lawmaker to spend a few hours in a shelter or drop-in center. Invite the 

media to record the event. 

 Community integration of all people with disabilities. This Nation is 

poised to improve the lives of all people with disabilities by redoubling 

its efforts to seek full community integration in housing, employment, 

and social activities. Take advantage of this momentum to be certain that 

people with serious mental illnesses and substance use disorders who are 

homeless benefit fully from these efforts. 

M OVING F ORWARD

Throughout this Blueprint, the message is clear: We know what works to end 

homelessness among people with serious mental illnesses and/or co-occurring 

substance use disorders. The time has come to put what we know to work. 

This Nation has learned much and accomplished much since publication in 1992 

of Outcasts on Main Street. However, the work is not done. There is an urgent 

need, through research and services, to continue to discover the most effective 

combination of treatment, housing, and supports that will end the cycle of 

homelessness for people who have serious mental illnesses and/or co-occurring 

substance use disorders. 

The guidance and action steps highlighted in this report are an important first 

step. 
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R ESOURCES 121 

R ESOURCES

The following organizations offer technical assistance and other information 

resources in many of the areas covered in this Blueprint. Brief descriptions of the 

services provided by each are offered below. 

F EDERAL R ESOURCES

HRSA’s Health Care for the Homeless Information Resource Center

345 Delaware Avenue 

Delmar, NY 12054 

(888) 439-3300 

hch@prainc.com 

www.hchirc.bphc.hrsa.gov

Offers front-line providers and program staff access to information regarding 

clinical practices and funding opportunities, also available are annotated 

bibliographies and a searchable database of resources on homeless health care 

issues, and clinical and administrative tools. 

SAMHSA’s National Clearinghouse for Alcohol and Drug Information 

PO Box 2345 

Rockville, MD 20847 

(800) 729-6686 

www.SAMHSA.gov

Collects, prepares, classifies and distributes information concerning alcohol, 

substance use, prevention strategies and materials, treatment approaches and 

resources, training programs for professionals and community education 

programs. 

SAMHSA’s National Resource Center on Homelessness and Mental Illness 

345 Delaware Avenue 

Delmar, NY 12054 

(800) 444-7415 

www.nrchmi.samhsa.gov

The National Resource Center provides technical assistance and comprehensive 

information concerning the treatment, service and housing needs of people who 

are homeless and have serious mental illnesses and/or co-occurring substance use 

disorders. 

SAMHSA’s National Mental Health Information Center 

PO Box 42490 

Washington, DC 20015 

(800) 789-2647 

www.mentalhealth.samhsa.gov

Information Specialists are available to assist with referrals and offer information 

concerning prevention, treatment and rehabilitation services for mental illnesses. 
122 B LUEPRINT FOR C HANGE

O THER R ESOURCES

Center for Urban Community Services 

120 Wall Street, 25th Floor 

New York, NY 10005 

(212) 801-3300 

cucshrc@cucs.org 

www.cucs.org

CUCS Housing Resource Center provides technical assistance and training to 

organizations to help build their capacity to people who are homeless, including 

supportive housing development and implementation, structuring partnerships, 

developing service programs and community need assessments. 

Corporation for Supportive Housing

50 Broadway, 17th Floor 

New York, NY 10004 

(212) 986-2966 

information@csh.org 

www.csh.org

Major repository and distributor of information concerning supportive housing in 

addition to promoting the expansion of permanent housing linked to services for 

persons with chronic medical, mental health, and other disabilities who are 

homeless or at risk of becoming homeless. 

National Alliance to End Homelessness 

1518 K Street, NW, Suite 206 

Washington, DC 20005 

(202) 638-1526 

naeh@naeh.org 

www.naeh.org

Provides assistance to service providers to develop and implement homeless 

prevention strategies, best practices and profiles, ending homelessness through 

the housing first approach, service delivery models and employment programs. 

National Law Center on Homelessness and Poverty 

1411 K Street, NW, Suite 1400 

Washington, DC 20005 

(202) 628-2535 

nlchp@nlchp.org 

www.nlchp.org

The Law Center works with groups to prevent and end homelessness by serving 

as the legal arm of the nationwide movement to end homelessness by addressing 

contributing factors such as the shortage of affordable housing, insufficient 

income, and inadequate social services. 
R ESOURCES 123 

Technical Assistance Collaborative 

535 Boylston Street, Suite 1301 

Boston, MA 02116 

(617) 266-5657 

info@tacinc.org

www.tacinc.org

Provides information on a full range of federal and mainstream housing programs 

and policies that can expand affordable housing for people with disabilities and 

who may be homeless. Also provides technical assistance regarding financing of 

services and healthcare delivery systems, program design and development, 

specializing in behavioral health and housing needs.

U.S. Interagency Council on Homelessness

451 Seventh Street, SW, Suite 2202 

Washington, DC 20410 

(202) 708-4663 

ich@hud.gov

www.ich.gov

Provides Federal leadership for activities assisting families and individuals who 

are homeless and technical assistance to community organizations regarding 

mainstream resources available to assist people who are homeless.