Department of Health and Human Servces 

OFFICE OF


INSPECTOR GENERAL


ALCOHOL, DRUG, AND MENTAL HEALTH


SERVICES FOR HOMELESS INDIVIDUALS


Richard P. Kusserow


INSPECfOR GENERA


MACH 199 
OFFCE OF INSPECfOR GENRA


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

amended, is to protect the integrty of the Department of Health and Human Servce' (HHS) 

programs as well as the health and welfare of beneficiaries selVed by those programs. Th statutory 

mission is carred out through a nationwide network of audits, investigations, and inspections

conducted by three OIG operating components: the Offce of Audit Servce, the Office of 

Investigations, and the Offce of Evaluation and Inpections. The OIG also inorm the Secretary 

of HHS of program, and management problems, and recommends courses to correct them. 

OFFCE OF AUDIT SERVICE 

The OIG's Offce of Audit Servce (OAS) provides all auditing servce for HHS, either by 

conducting audits with its own audit resources or by overseeing audit work done by others. Audits 

examine the performance of HHS programs and/or its grantees and contractors in carrng out their respective responsibilities and are intended tp provide independent assessments of HHS programs 

and operations in order to reduce waste, abuse, and mismanagement and to promote economy and 

efficiency throughout the Department. 

OFFCE OF INTIGATIONS 

The OIG's Offce of Investigations (01) conducts criminal, civil, and administrative investigations of 

allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrchment by 

providers. The investigative effort of 01 lead to criminal convictions, adminitrative sanctions, or 

civi money penalties. The 01 also oversees State Medicaid fraud control units which investigate and 

prosecute fraud and patient abuse in the Medicaid program. 

OFFCE OF EVALUATION AN INSPECTONS 

The OIG' s Offce of Evaluation .and Inspections (OEI) conducts short-term management and program 

evaluations (called inspections) that focus on issues of concern to the Department, the Congress, and 

the public. The fidigs and recommendations contained in these inpection report generate rapid 

accurate, and up-to-date information on the efficiency, vulnerabilty, and effectiveness of departmental 

programs. 

This report was prepared under the direction of Wiliam C. Moran, Regional Inspector General 

Offce of Evaluation and Inpections and Natalie Coen, Deputy Regional Inspector General, Offce 

of Evaluation and Inpections, Region V. Participating in this project were the following people: 

Chcago. II Heaquars 

Barbara Butz (Project Leader) Emilie M. Baebel 

Jenner Antico Susan E. Hardwick 

Pamela S. May W. Mark Krhat 

Kate McFadden 

Emil J. Posavac 
Department of Health and Human Servces 

OFFICE OF


INSPECTOR GENERAL


ALCOHOL, DRUG, AND MENTAL HEALTH


SERVICES FOR HOMELESS INDIVIDUALS


Richard P. Kusserow


INSPECfOR GENERA


OEI-05-91-002 
EXECUTIVE SUMMARY


PUROSE 

This inspection examined how States use the Alcohol, Drug Abuse and Mental Health 

Servces (ADMS) block grant to serve homeless individuals with mental health, alcohol 

or other drug problems.


BACKGROUN 

Recent research suggests that approximately one-third of an estimated 600 000 homeless 

population are severely mentally il, at least 40 percent have problems with alcohol, and 

an additional 10 percent abuse other drugs. In addition, it is estimated that at least 

one-half of the homeless mentally il population also have alcohol or other drug 

problems. 

The Department's response to homelessness is two-pronged: (1) specially targeted 

programs for homeless persons and (2) mainstream programs that serve them as part of 

their servce population. The 1987 Stewart B. McKinney Act is the government s major 

targeted response to the problem of homelessness; the McKinney Projects for 

Assistance in Transition from Homelessness (PATH) program targets the homeless 

population with dual diagnosis of serious mental ilness and substance abuse disorders. 

In terms of mainstream programs, the ADMS block grant is one of the Department's 

largest programs that could serve homeless persons. 

The ADMS block grant is administered by the Public Health Servce (PHS). States 

may use ADMS funds for grants to community mental health centers and for substance 

abuse prevention, treatment, and rehabiltation programs and activities. States are not 

mandated to serve the homeless population with ADMS monies; however, they may 

choose them as a special target population. 

ADMS funding for fiscal year (FY) 1991 is $1.33 bilion; nationally, 20 percent is being 

spent for mental health servces, and 80 percent for substance abuse treatment and 

prevention. ADMS dollars represent a small portion of total State mental health 

expenditures; in 1987, they accounted for only 2.3 percent of $9.3 bilion spent for 

mental health nationally. According to the 1990 State Alcohol and Drug Abuse Profie 

ADMS dollars represent about 20 percent of all funding for public sector alcohol and 

drug abuse treatment servces. 

SCOPE AN METHODOLOY 

Besides the ADMS block grant, this study looked at Medicaid and Supplemental 

Security Income (SSI). We examined the availability, accessibilty and appropriateness 
of these mainstream programs for homeless individuals. This report presents findings 

concerning the ADMS block grant; two other reports present findings related to 

Medicaid and SSI. 

We spoke with 224 ADMS grantees in 10 States: California, Hawaii, Illnois, Ohio 

Oregon, Maryland, Missouri, New Jersey, New York, and Texas. A description of the 

methodology for this inspection is in Appendix A. 

FIINGS 

Many provi who receie ADMS dollrs say th sere homele inviLr but lack 

data on nuer sered and seres provi 

Homele inls have proble tht are more depete sever and diff to treat 

thn thoe of othe clits. 

For the mot part grantees provi the same seres to homele inivils as to othe cli. Some provi specil seres. 

Respondts say th seres are approprite for homele inls but inomplete. 

freqtly Th refer th elsewhee for serces the do not provi but referals ma not

be efectie.


Respondts strngly agree that spcil approache are need to sere homele peons. 

RECOMMNDATIONS 

We conclude that it is critical for agencies to work together to develop the expertise 

needed to serve homeless individuals and to ensure comprehensive servces for them. 

Our recommendations emphasize the ideas of linkage and coordination among different 

levels of government, between government agencies, and within local servce systems. 

Th PHS shoul provi technal astance to States and othe PHS-f grntees who sere homele inLr. 

Th Alcoho Drg Abuse, and Mental Health Admtratin shoul is an adviory letter 

to all State wi th ne roun of fug. Th letter shoul uncore th importnce

for ADMS gr to inlu the follwig compone in serg homele inivls: 

Specialized training for servce providers, shelter personnel, and volunteers, for 

dealing with the unique problems of this population. 

Developing Memoranda of Understanding or other tyes of formal agreements 

with other servce providers. Agreements would include information-sharing, 

cross-training, technical assistance, development of model programs (including 
outreach, application procedures, resource referral, and coordination with the 

broader servce community), and model release plans (including housing) for 

institutionalized persons (Le. in jails or hospitals). 

COMM 

We received comments from PHS and the Assistant Secretary for Planning and 

Evaluation (ASPE). We wish to thank those who commented on this report. The text 

of their comments is in Appendix C. 

Although PHS concurs with the principles underlying our recommendations, they do not 

agree with us that the ADMS block grant is an appropriate mechanism to implement 

them. Instead, they propose to rely on their current McKinney-funded programs. 

We believe that both the McKinney Act and the ADMS block grant are valuable 

resources for improving servces to this population. A previous OIG study on the 

McKinney Act revealed widespread agreement among respondents that McKinney alone 

is not the solution to homelessness, and that greater efforts should be made by 

mainstream Federal programs to serve the homeless. The ADMS grantees in this study 

represent an extremely broad and diverse national network of providers, a large 

majority of whom are providing some level of servce to homeless individuals. We do 

not think that such a broad mainstream program, funded at $1.33 bilion, should be 

overlooked as a mechanism to address the problems identified in this study. We think 

that PHS, in bringing its resources to bear on this network, can help improve 

considerably the response of these providers to homeless individuals. 

We continue to recommend a strong technical assistance role for PHS. However we 

have modified our language in the recommendation slightly. We recognize that PHS' 

primary responsibilty is to States for the block grant, and to their local McKinney 

grantees, who in turn can work - and, we hope, would take every opportunity to do so ­

with local ADMS grantees. 

We revised the first finding and made some editorial changes elsewhere in the report 

accommodate concerns raised by PHS and ASPE. 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . .. . . . . . . . . . . . . . .. . . . . . . . . . . . . .. . . .

TABLE OF CONTENTS


PAGE


EXCU SUMY


INODUCfON . 

Purpose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Scope


Background


Methodology


FIINGS 

Many providers who receive ADMS dollars say they serve homeless 

individuals but lack data on numbers served and servces 

provided 

Homeless individuals have problems that are more desperate, severe 

and dicult to treat than those of other clients. . . . . . . . . . . . . . . . . . . . . . . . . .. 5 

For the most part, grantees provide the same servces to homeless 

individuals as to other clients. Some provide special servces 

Respondents say their servces are appropriate for homeless individuals 

but incomplete. They frequently refer them elsewhere for servces they 

do not provide, but referrals may not be effective. ........................ 7 

Respondents strongly agree that special approaches are needed to serve 

homeless individuals effectively. ...................................... 8 

REcx i\110NS .......................................... 

APPENIX A: Methodology 

APPENIX B: Data Verication Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. BAPPENIX C: Agency Comments. . . . . . . . . . . . . 
INTRODUCTION


PUROSE 

This inspection examined how States use the Alcohol, Drug Abuse and Mental Health 

Servces (ADMS) block grant to serve homeless individuals with mental health, alcohol 

or other drug problems.


SCOPE 

There is no definitive count of the number of homeless people in the United States 

(U. ). The Urban Institute estimated in 1988 that between 567 000 and 600 000 are 

homeless in the U.S. on any given night. In March 1991, the U.S. Census Bureau 

counted 178 828 persons in emergency shelters and 49 793 persons at pre-identified 

street locations; however, they acknowledge that this is an undercount. 

Recent research suggests that approximately one-third of the homeless population are 

severely mentally il, at least 40 percent have problems with alcohol, and an additional 

10 percent abuse other drugs. In addition, it is estimated that at least one-half of the 

homeless mentally il population also have alcohol or other drug problems; we refer to 

such persons as the "dually diagnosed" in this report. This study focused on homeless 

individuals (as opposed to familes) with these problems; the ' terms "the homeless" or 

homeless individuals" in the report refer strictly to this population. 

Federal efforts to assist homeless persons are two-pronged: (1) specially targeted 

programs directed at the homeless population, and (2) mainstream programs that serve 

homeless clients as a portion of their servce population. The major Federal targeted 

response is the 1987 Stewart B. McKinney Act (hereafter referred to as McKinney), 

funded for fiscal year (FY) 1991 at $682.3 milion. The McKinney Projects for 

Assistance in Transition from Homelessness (PATH) program, funded at $30 milion for 

FY 1992, targets the homeless population with dual diagnosis. A 1990 study by the 

Office of Inspector General found that while McKinney programs have helped meet 

emergency needs, respondents did not view McKinney as the long-term solution to 

homelessness; rather, they advocated greater Federal and State efforts through ongoing, mainstream programs. 

This inspection looked at three major mainstream programs in the Department which 

could serve homeless individuals: the ADMS block grant, Medicaid, and Supplemental 

Security Income (SSI). This report presents findings concerning the ADMS block grant. 

Two separate reports present findings related to Medicaid and SSI. 

We examined the availabilty, accessibilty and appropriateness of each of these 

mainstream programs for homeless individuals. "Availabilty" means whether a program 
or servce exists in an agency or community and homeless individuals are eligible for it. 

Accessibilty" refers to the ease or diffculty homeless individuals have in finding and 

utilizing available servces. "Appropriateness" refers to whether available, accessible 

servces match the homeless client's needs in a broad sense. 

BACKGROUN 

The ADMS block grant, funded by the Public Health Servce (PHS) through the 

Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) was created 

under the Omnibus Budget Reconciliation Act of 1981. The block grant is currently 

administered by the Office for Treatment Improvement (OTI) in ADAMHA. A 

proposed reorganization plan for ADAMHA could affect the administration of this 

program. 

States may use ADMS block grant funds for grants to community mental health centers 

and for substance abuse prevention, treatment, and rehabiltation programs and 

activities. States are not mandated to serve the homeless population with ADMS 

monies; however, States may choose homeless persons as a special target population. 

ADMS funding for FY 1991 was $1.33 billon. Nationally, 20 percent was being spent 

for mental health servces and 80 percent for substance abuse treatment and 

prevention. However, this ratio varies significantly across States. In recent years 

substance abuse dollars have risen dramatically. In contrast, mental health dollars have 

remained stable or, in some years, even declined. Recently, there has been growing 

Congressional interest in how ADMS funds are being used, as well as some interest in 

separating the mental health from the substance abuse portion of the block grant. 

ADMS dollars represent a small portion of total State mental health expenditures. In 

1987, ADMS dollars accounted for only 2.3 percent of $9.3 bilion spent for mental 

health nationally. According to the 1990 State Alcohol and Drug Abuse Profie ADMS 

dollars represent about 20 percent of all funding for public sector alcohol and drug 

abuse treatment servces. 

Several Departmental initiatives impact the homeless population. Two of Secretary 

Sullvan s 1990 Program Directives relate to this study: 1) Expand the use of costeffective human servces to ensure the quality and availabilty of effective assistance; 

and, 2) Improve the health status of minority and low-income persons. Also, the 

Secretary has created a task force, chaired by the Director of the National Institute of 

Mental Health, which is charged with identifyng barriers to servce for severely mentally

il homeless persons. 
METHODOLOY 

During pre-inspection we conducted an extensive review of literature, including program 

descriptions, Federal legislation and regulations, and articles, reports and research 

papers of all kinds. We also talked with persons at PHS, the Social Security 

Administration, Health Care Financing Administration; the National Association of 

State Alcohol and Drug Abuse Directors, the National Association of State Mental 

Health Program Directors and other related associations; foundations; and experts. 

spent two days with a special mobile assessment unit in Chicago. 

For the inspection on ADMS, we reviewed portions of the ADMS 1989 State reports 

and 1990 State plans. We collected additional data from 224 ADMS mental health and 

substance abuse grantees in 10 States: California, Hawaii, Ilinois, Ohio, Oregon 

Maryland, Missouri, New Jersey, New York, Texas. We spoke by telephone with the 

executive directors or program directors of these agencies about the inspection issues 

related to ADMS. With those who said they serve homeless individuals, we also 

discussed issues related to Medicaid and SSI. 

Our review was conducted in accordance with the Interim Standards for Inspections


issued by the President s Council on Integrity and Efficiency. A detailed description of 

the methodology for this inspection is in Appendix A. 
FINDINGS


Findig #1: May provders who receive ADMS dollar say they serve homeless 

indidua but lack data on numbers served and servces provided. 

We contacted 224 mental health and substance providers who States identified as 

recipients of ADMS funds. Our first goal was to learn whether these providers serve 

homeless individuals at all, regardless of how many they serve or the extent of servces. 

On the basis of this very broad criterion, 168 of the 224 told us that they provide 

servces of some sort to homeless individuals. 

For many of these 168 grantees, ADMS dollars are a small portion of the budget. 

When we compared the ADMS grants of these 168 agencies (reported by States) with 

their annual budgets (reported by the agencies), we found that for roughly 60 percent 

ADMS dollars were only 10 percent or less of the annual budget. 

While we recognize that ADMS funds may be a small part of their budgets in some 

cases, we nevertheless believe that these agencies represent a broad and diverse 

network of mainstream providers whose servces can be important in a solution to


homelessness. They include community mental health centers, community health 

centers, cities and counties, regional boards, public and private not-for-profit agencies of 

all tyes, hospitals, school boards, and others. 

Whether ADMS dollars were a small proportion of their budget or not, we were 

interested in (1) whether these providers use ADMS funds, specifically, to serve 

homeless individuals, and (2) what ADMS-funded servces they provide to them. 

Unfortunately, few respondents were able to answer these questions. Some did not 

realize that their agency received ADMS funds; others knew but said that their agency 

does not track these dollars separately. And, we learned that few of these agencies are 

tracking homeless clients or the servces they receive, whether ADMS-funded or not. 

We then asked these respondents how many homeless individuals their agency served in 

the previous program year. Again, many did not know because they lack data. Fifteen 

percent did not answer the question at all and half only gave a ball-park estimate. For 

the few who did give a hard number, we were not always confident of its reliability. 

Sometimes we suspected that it represented a duplicated count or included all homeless 

clients served, including familes, rather than solely individuals with mental health 

alcohol or other drug problems.


The servces these respondents most often said their agencies provide - to all clients in 

general, and whatever the funding source - are: outpatient mental health and outpatient 

substance abuse servces. Half provide both of these servces, with mental health 

grantees far more likely to provide both than substance abuse grantees. Smaller 
proportions provide inpatient mental health or substance abuse servces, or detox 

servces. A few grantees offer none of these servces but rather case management information and referral, education, or prevention servces instead. 

The rest of this report presents what these 168 respondents said about the homeless 

individuals they serve and the servces they provide to them. We refer to these 

respondents subsequently in this report as "ADMS grantees. 

Findig #2: Homeless indidua have problems that are more desperate, severe, and difcut to treat than those of other clients. 

As a backdrop to any discussion of the availability, accessibilty and appropriateness 

the servces of ADMS grantees for homeless individuals with alcohol, drug or mental 

health problems, it is important to note that this is a very needy population. Over fourfifths of our respondents said that the needs of the homeless clients they serve differ 

significantly from the needs of their other clients. 

Of the 293 comments they made about the differences between homeless individuals 

and other clients, 290 referred to the severity of the problems of the homeless. Only 

three respondents said that homeless people respond more positively to assistance 

compared to other clients; however, the reason given was that homeless clients "are 

more desperate." 

The overwhelming impression made by these respondents is that homeless persons are 

indeed more desperate. In Figure 1 is a list of some of the many ways in which they 

said the needs of homeless clients differ from those of their other clients. 

The most frequent comments emphasized 

that homeless individuals need more 

comprehensive servces, stable homes How Homeles Clients DUrer
 more social supports, and basic medical from Other Cl1ents 

care. Person after person stressed that 

their homeless clients were the neediest . Lak boe/J1le or drag-tre env1enl 

among the needy, that being homeless . Lack lupport networlttamlly/frlendl 

exacerbates all other physical or . Prblema ar more cb1D1c 

emotional problems while at the same . Ar more 11 than other cUen" time creating new problems. One 

respondent summaried the sense of 

. Have concurrnt medica nee 

many other comments: "They re at the 

. Nee mor comprehensi'9 I8Mce 

absolute bottom when they get to us." . Need baic nee met lor trent to lucced 

Respondents also pointed out that 

homelessness increases the difficulty of Figure 1 

treating mental ilness and substance 

abuse. Many said that homeless people often require long-term treatment yet live day­
to-day; display a very short time perspective, thinking of only the immediate future; 

need mental health treatment, but distrust, resist, and fear those who try to help; or are 

transient - "a moving target " as one respondent called them. 

Respondents reported that it can be too difficult to provide long-term treatment, even 

when a homeless person requests help. Some said that it is necessary to stabilze these 

clients with temporary housing, food or medical care for treatment to be effective. 

Others said that when homeless people seek servce, it may well be during an acute 

crisis; they may demand immediate attention when they approach an agency, wanting 

only a "quick fix." They may approach an agency numerous times for such help, cycling 

in and out for short periods rather than remaining for long-term treatment. 

Given their many needs, homeless clients must seek out help from . a vast array of 

servce providers: welfare agencies, Social Security district offices, community mental 

health centers, community health centers, clinics, emergency rooms, alcohol or drug 

programs, shelters and food pantries, and others. The severity of their problems may 

make it difficult for them to find appropriate help on their own. 

Findig #3: For the most par grantees provide the sae servces to homeless 

indidua as to other clients. Some provide special servces. 

Less than one-quarter of the ADMS grantees who serve homeless individuals do any 

outreach targeted specifically at them. Rather, homeless individuals come to them in 

variety of ways. The most frequently mentioned is "walk-ins;" nearly 70 percent 

mentioned this. However, they are also referred by social servce agencies, shelters or 

missions, police, and the courts. Substance abuse grantees were more likely than 

mental health grantees to report walk-ins (73 vs 60 percent) and court referrals (48 

19 percent); mental health grantees were more likely to mention hospital referrals (32 

vs 18 percent) and general, non-targeted outreach (30 vs 16 percent). 

Once they make their way into these agencies, homeless individuals are most likely to 

receive the same servces as non-homeless clients. The most frequently mentioned 

servces which they share with other clients are residential treatment, outpatient mental 

health counselig, outpatient substance abuse counseling, and case management. 

addition, 20-25 percent of our respondents mentioned that their agency provides other 

servces such as psychotropic medication, information and referral, medical care 

vocational rehabiltation, or job placement. 

Forty-five ADMS grantees (29 percent) also make special servces of some sort 

available to homeless individuals: 35 percent of the mental health grantees and 25 

percent of the substance abuse grantees. These servces differ primarily by being more 

intensive and beginning to address fundamental needs for housing, food, and medical 

care. Many of these respondents also said they use special servce-delivery approaches 

such as outreach, drop-in centers, or case management to serve homeless individuals. 
Seventeen of these 45 grantees receive McKinney funding of some sort for these special 

servces. Three-quarters of them said they had developed these servces in response to 

a Federal or State initiative; 40 percent specifically mentioned McKinney. This was the 

only evidence we found that of a specific Federal initiative that had influenced ADMS 

grantees to develop servces specifically for homeless individuals. The majority of 

ADMS respondents we spoke with - most of them agency directors or program 

directors - knew little about McKinney programs or Federal policies on homelessness in 

general. 

Findig #4: Respondents say their servces are appropriate for homeles indivdua 

but incomplete. They frequentl refer them elsewhere for servces they do not provde 

but referral may not be effece. 

Respond belie tht the agen' seres are genll apprprite for homele invils. 

Despite differing perceptions of the homeless population and their needs, most 

respondents described their agencies' servces , in a general sense, as appropriate for 

them. However they express a sense of frustration at not being able to provide a 

sufficiently broad range of servces for homeless people, sufficiently flexible servces to 

engage them in treatment, and sufficiently intensive servces to meet their needs for for 

stability, structure, and social support. 

Comments about the appropriateness of servces reflect the fact that this is not a 

homogeneous population. Respondents did not agree about the best way to approach 

treatment for homeless individuals, nor did they recommend any single approach as the 

most appropriate. Indeed, their comments reveal that they feel pulled in conflcting 

directions in working with them. 

Almt aU resndts refer homele inls to othe agenc for seres 

theelves do not offer However clits ma not follw though, or ma not be able to 

acces seres eLrewhee. 

Ninety-six percent of respondents report making referrals; over 80 percent report 

making "frequent" referrals. The most common referrals are for: emergency, 

permanent, or transitional housing; primary medical or dental care; and vocational 

rehabiltation or training. More referrals are made to social servce agencies and 

emergency shelters than to other tyes of servce providers. A number of respondents 

commented that some of their homeless clients need vocational training but there is no 

vocational program to refer them to. 

Referral may not be effective. A number of respondents said homeless people will 

often not continue to search for an agency even upon referral. Follow-through may 

take more persistence or resources than the life circumstances of homeless persons 

allow. Lacking a watch or money for transportation, for example, can make it difficult 
to follow through. Or, sometimes homeless persons may not follow through because, as 

one respondent noted, they "have lost hope. 

Referral may also not succeed because access to the servces where homeless clients are 

referred is limited. We asked respondents whether homeless individuals have problems 

accessing servces from other mental health or substance abuse providers in their 

communities. Over 80 percent of them said there were problems; two-thirds mentioned 

multiple problems. 

As ilustrated in Figure 2, some of these 

problems relate to the instability of 

homeless individuals and their transient Problems the Homeles Pace lifestyle, and others to the servce system in Accesing Trment itself. The most frequently mentioned is 

that other servce providers see homeless ./Provid8r1 le8 them CD undesirable clients 

individuals as undesirable clients, either ./ Be/Ilots nol available; wa1tng lilts because they look or act strange, are 

dirty or unkempt, resist treatment, don ./Ho appropriat proiders to reler to 

follow through with appointments, don ./Homeleu ca t pa; put at bottom 01111 

conform to agency procedures or rules ./Homelea CD Iralient/hCl 10 contact 

or "agencies know that treatment of the ./ Homeles lack IrclJrtal.oD 

homeless is a lot of work, so they don 

encourage them." Other frequently 

mentioned barrers were: waiting lists or 

lack of openings in a program, lack of Figure 2 

transportation, and a lack of health insurance or funds to pay for servces. 

Nearly one-fifth of our respondents said there are no appropriate servce providers 

available to which to refer homeless individuals; a few specifically mentioned a lack of 

programs for the dually diagnosed. And, some respondents commented generally that 

there is community resistance towards developing programs because residents fear 

homeless people. 

Findig #5: Respondents strongl agree that speal approaches are neeed to serve 

homeles indidua effectely. 

Respondents were in marked agreement that, in terms of reaching a long-term solution 

to homelessness for this population, servces must be modified in some way to serve 

them effectively. 

Some of the more general suggestions made were: (1) homeless individuals need to be 

approached in ways that engage them in treatment; (2) comprehensive servces are 

needed to stabilze these clients, since treatment cannot be expected to be helpful with 

people who return to parks or metal grates to sleep at night; and, (3) servce providers 

should offer less compartmentalized, more flexible servces. The picture that emerges 
of an "ideal" servce provider is one that reaches out to homeless clients and, at a single 

location, meets all their needs - not only those most immediately evident (such as food 

shelter, and medical care) but those related to alcohol or drug dependence, mental 

ilness, lack of housing, and joblessness. 

Respondents made many other more specific suggestions on how servces to this 

population could be enhanced: special outreach; a housing component of some kind; 

medical servces; specially-trained staff; better coordinated programs to overcome the 

fragmentation of the social welfare system; and, special programs for the dually 

diagnosed. 

On a related issue, we asked respondents whether they thought that homeless 

individuals need separate mental health or substance abuse programs designed 

specifically for them, that is, programs set apart from the traditional treatment system. 

We found that opinion was split on this issue: 54 percent favored separate programs 

and 42 percent felt that they were neither needed or desirable. Significantly, however 

almost three-quarters of those opposed to separate programs, stil felt that traditional 

servces should incorporate different approaches of some kind - special outreach, for 

example - to reach this population. 
RECOMMENDATIONS


Ths study confirmed earlier findings that homeless individuals have severe, multifaceted problems. Their many needs range from the basics of food and shelter to more 

complex needs for mental health and substance abuse treatment. Agencies try to meet 

these many needs, but experience great difficulty in doing so - often due to lack of 

resources. 

As stated in our findings, 96 percent of ADMS respondents told us that they must refer 

clients to other providers for servces they are unable to provide. Yet the referral 

process is often an obstacle for homeless people seeking help. Some lack the skills to 

follow through; others may not have transportation to the assortment of agencies they 

must visit for servces. The result is that many homeless individuals fall through the 

cracks and go unserved. This, combined with various obstacles inherent in the servce 

system itself that limit the availabilty or accessibility of servces, may limit access to 

servces for them.


We conclude that it is critical for agencies to work together to develop the expertise 

needed to serve homeless individuals and to ensure comprehensive servces for this 

population. Our recommendations emphasize the ideas of linkage and coordination 

among different levels of government, between government agencies, and within local 

servce systems. The themes of linkage and coordination are stressed in all three 

reports related to this inspection (see separate reports on SSI and Medicaid). We 

should also note that the Secretary named servce integration a priority for the 

homeless population in a speech in the spring of 1991. 

In many States, linkage and coordination are already priorities, while in others they 

have yet to be developed. At the end of our study, we spoke with the coordinators for 

the McKinney-funded Projects for Assistance in Transition from Homelessness (PATH) 

programs in the 10 sample States to generally discuss potential recommendations arising 

from this study. They agreed that linkage and coordination are critical elements for 

servng such a needy population. 

Constructing recommendations that will have widespread impact is difficult, since there 

is such a large variety of servce providers and funding streams. Furthermore, the 

scope of our recommendations is limited by the nature of ADMS as a block grant 

program. Also, we are mindful that ADMS grantees are only one group of providers 

among many who serve homeless individuals, and that ADMS dollars are only one 

piece of the funding pie. 

Nevertheless, we do consider ADMS a valuable resource for homeless individuals. 

ADMS grantees represent a large network of servce providers nationally who can 

supply both treatment and other needed servces. It appears that the majority are 
already servg homeless individuals, albeit in a limited way for the most part. We 

believe, therefore, that the ADMS block grant should not be overlooked as a resource

for homeless individuals. 

Our goal in these recommendations is to faciltate a first step toward a long-term 

solution for homeless individuals who are mentally il or have alcohol or other drug 

problems. They are designed to help reduce the number of homeless individuals who 

go unserved and to ensure comprehensive servces that are accessible and appropriate 

for this population. 

Recommendation #1: The PHS should provide technca asistace to States and other 

PHS-fuded grtees who serve homeless indidua. 

The technical assistance provided should include, but not be limited to, the two items 

specified in Recommendation #2 below. 

Recommendation #2: The ADAM should isue an advory letter to al States with 

the nex round of fudig. The letter should undersre the importce for ADMS 

grantees to include the followig components in servg homeless indidua with 

menta heath, alcohol, or drg problems: 

Specialized training for servce providers, shelter personnel, and volunteers for 

dealing with the unique problems of this population. For example, agency 

personnel should be trained to work with staff from State mental institutions 

jails, nursing homes, and other residential settings to develop release plans for 

individuals coming out of these institutions. 

Memoranda of Understanding or other formal agreements with other agencies in 

the community. These would address information sharing, cross-training, 

technical assistance, development of model programs (including outreach 

application procedures, resource referral, and coordination with the broader 

servce community), and model release plans (including housing) for 

institutionalized persons. 

Other agencies would include, but not be limited to, Social Security district 

offces, McKinney-funded providers, local mental health and substance abuse 

authorities and departments, and local welfare offices. 

COMM 

We received comments from PHS and the Assistant Secretary for Planning and 

Evaluation (ASPE). We wish to thank those who commented on this report. The text 

of their comments is in Appendix C. 

Although PHS concurs with the principles underlying our recommendations, they do not 
agree with us that the ADMS block grant is an appropriate mechanism to implement 

them. Instead, they propose to rely on their current McKinney-funded programs. 

We believe that both the McKinney Act and the ADMS block grant are valuable 

resources for improving servces to this population. A previous OIG study on the 

McKinney Act revealed widespread agreement among respondents that McKinney alone 

is not the solution to homeless ness, and that greater efforts should be made by 

mainstream Federal programs to serve the homeless. The ADMS grantees in this study represent an extremely broad and diverse national network of providers, a large 

majority of whom are providing some level of servce to homeless individuals. We do 

not think that such a broad mainstream program, funded at $1.33 bilion, should be 

overlooked as a mechanism to address the problems identified in this study. We think 

that PHS, in bringing its resources to bear on this network, can help improve 

considerably the response of these providers to homeless individuals. 

We continue to recommend a strong technical assistance role for PHS. However we 

have modified our language in the recommendation slightly. We recognize that PHS' 

primary responsibilty is to States for the block grant, and to their local McKinney 

grantees, who in turn can work - and, we hope, would take every opportunity to do so ­

with local ADMS grantees. 

We revised the first finding and made some editorial changes elsewhere in the report 

accommodate concerns raised by PHS and ASPE. 
APPENDIX A


GEN COMM REGARING TH DATA 

We collected both qualitative and quantitative data for this inspection. The qualitative data presented in the reports is not weighted. Quantitative ADMS data 

was used to make national projections (described later in this Appendix) based on 

weighted State averages for our sample States. For the most part, data collected 

from ADAM States and respondents was for 12 month periods representing 

fiscal years 1989 or 199. 

In general, data from States and respondents regarding ADMS expenditures was very 

difcult to obtain as well as extremely variable. They rarely kept this data in a complete or uniorm manner. Also, State fiscal years varied, as did those of 

respondents. 

STATE SAMLE SELCTON 

We used a stratified, multi-stage methodology in choosing States, since we intended 

to make national projections with the quantitative data. We wanted to talk to 

ADMS grantees and certain McKinney-funded grantees (descnbed later in the 

Appendix), who could discuss Medicaid and SSI. Thus we divided the 50 States into 

two categories: those with both ADMS grantees and more than one McKinney 

grantee, and those with ADMS grantees and one or no McKiney grantees. (As noted in the Methodology section, McKinney respondents were Health Care for the 

Homeless grantees or grantees of research and demonstration projects funded by 

ADAMHA.) We selected six States from the first category and four States from the

latter. The sample States from each category were selected, with replacement, based on probabilty proportional to the estimated FY 1991 ADMS funding. 

The table lists the sample States, estimated amount of ADMS 1991 funding, and the 

States' percent of total ADMS funding. The sample represents a significant portion 

of total ADMS funds. 

ESTIMTED ADMS PERCENT OF TOTAL 

STATE FUS FOR FY 1991 ADMS FUS 

California $151 048,450 13% 

Hawaii 077 746 

Ilinois 484 994 

Maryland 274 979 

Missouri 789,494 
New Jersey 169 435 

New York 103 642, 170 

Ohio 814 

Oregon 12,583 566 

Texas 804 

Total $559 530 452 47% 

Total FY 1991 

Estimated 

ADMS Funding 187 357 962 

SAMLIG MEODOLOY FOR ADMS REPONDEN 

We intended to sample 30 grantees from each State which would represent a 

proportional mix of mental health and substance abuse grantees. Respondents were 

program directors or managers. The number of grantees sampled in each of these two categories was determed by the proportion of FY 89 mental health ADMS 

funding to substance abuse funding in each State. This was the most recent year for 

which States had this inormation. We contacted the 10 States and asked for the 

amount of ADMS funds they received in FY 1989, and the total amount that went to 

mental health grantees and substance abuse grantees. In addition, we asked for a 

listing of the mental health grantees and substance abuse grantees and the amount of 

ADMS funding each received. 

In most States, mental health and substance abuse grantees were then selected with 

probabilty proportional to the amount of the ADMS grant received. In instances 

where the grant money was given to counties, we selected six counties proportional 

to mental health and substance abuse funding. We then selected five grantees within each county with probabilty proportional to the amount of the ADMS grant 

received. 

There were some exceptions to these two basic methodologies. In those States 

where the amount of ADMS grant money for 1989 was not readily available, we 

chose a simple random sample of grantees. In instances where a grantee 

subcontracted over 50 percent of its ADMS funds, we asked the grantee to identify 

the two subgrantees who received the largest proportion of grant funds, whom we 

then intervewed. 

Several grantees were dropped because they were no longer receiving ADMS funds 

in FY 1991. Our final sample consisted of 224 grantees in 10 States. There were 95 

mental health and 129 substance abuse grantees. The subsampling in each State was 

independent of that conducted in any other State. 

A ­

Ths methodology enabled us to capture, in most cases, a signficant portion of States' ADMS funds in our sample. The following table gives the percent of ADMS 

mental health and substance abuse FY 1989 funds sampled in each State. 

PERCENT OF SAMLED PERCENT OF SAMLED 

ADMS MENTAL HEALTH FUS TO TOTAL STATE 

ADMS SUBSTANCE ABUSE 

FUNDS TO TOTAL STATE 

STATE 

ADMS MENTAL HEALTH FUS ADMS SUBSTANCE ABUSE FUS 

California 24% 12% 

Hawaii 82% 54% 

ilinois 62% 46% 

Maryland 41% 35% 

Missouri 77% 39% 

New Jersey 45% 22% 

New York 12% 28% 

Ohio 12% 44% 

Oregon 68% 39% 

Texas 78% 14% 

We spoke with sampled respondents by telephone. Our first objective was to learn if the grantees served homeless individuals. We did not pursue further questions with 

the 56 grantees who said they do not serve the homeless. We discussed the 

availabilty, accessibilty and appropriateness of their servces and Medicaid and SSI 

for this homeless population, with 168 grantees who did serve them. We also asked 

respondents to provide basic data on their total agency budget and ADMS grant 

clients served, including homeless clients, and Medicaid reimbursement. 

ADMS PROJECTONS


We made two national projections in this inspection: (1) the percent of ADMS going to grantees that told us that homeless individuals were among their served 

population, and (2) Medicaid funds as a percent of total budget of the grantees. The projections are based on what these ADMS respondents told us. In some cases 

they could not give us numbers, or could only give estimates. The Data Verification 

Sheet we sent to respondents prior to callng them is in Appendix B. 

The definition of "homeless" we asked respondents to use in providing this information was: "A person who is not a member of a homeless family, and who 

lacks stable housing (including a person whose primary residence during the night is 

a supervsed public or priate facilty that provides temporary ling accommodations

or a person who is a resident in transitional housing. 

A ­

These projections are based upon unbiased estimates derived from the sample of withi each State. Estimates of the totals, and the variance associated with 

each total, accounting for the sub-samplig within each State, were calculated using 

methods described by Cochran . Given these totals, the percentages, as ratios, were 

easily derived. 

grantees 

The results of these estimates are presented, by State and overall, in the following tables. 

1 Cochran, William G., (1977) Sampling Techniques. John Wiley & Sons, New 

York, Sec. 11.9, pg. 306. 

A ­
Percent of ADMS Money Associated with 

Grantees Servng Homeless 

Mental Health Substance 

NEW JERSEY 

MISSOURI 

CALIFORNIA 

OHIO 

ILLINOIS 

NEW YORK 

Strata Avg 

TEXA Mi 

OREGON 

HA WAIl 

Strata Avg 

Overall Avg 

Std. Err.


Precision 

L 90% CI


U 90% CI 

Grantees 

100. 

92. 

45. 

75. 

66. 

71.5% 

82.4% 

87. 

98. 

38. 

72.4% 

71.8% 

21.8% 

49. 

35. 

107. 

i\buse CJrantees


64. 

91. 7% 

77. 

83. 

93. 

64. 

72.4% 

75. 

100. 

84. 

60. 

74. 

75. 

21.8% 

47. 

39. 

111.6% 

Because of the extreme variabilty in the data, the upper 90 percent confidence limit 

exceeds 100 percent. Logically, the upper limit should be truncated at 100 percent. 

The coefficient of variation for Mental Health programs is 30 percent and that for 

Substance Abuse programs is 29 percent. 

2 The precision is defied as the semi-width of the confidence interval as a 

percent of the estimated mean. 

i\ ­

Medicaid Funds as a Percent of Total Budget 

by Type of ADMS Grantee 

NEW JERSEY 

MISSOURI 

CALIFORNIA 

OHIO 

ILLINOIS 

NEW YORK 

TEXA 

MAYLD


OREGON 

HAWAII 

Weighted Avg 

Std Err 

Precision 

ev. 

L 90% CI


U 90% CI 

18. 

13. 

16. 

25. 12. 

35. 

13. 13. 

1.6% 1.8% 

15. 

28. 

1.7% 

82% 87% 

33. 25. 

20. 15. 

12. 

This data demonstrates less variabilty than that in the ADMS funds data. However 

the coefficient of variation is below 10 percent for only one of the estimates, the 

percent homeless among Mental Health grantees. 

3 The precision is defined as the semi-width of the confidence interval as a 

percent of the estimated mean. 

A ­
SAMLIG MEODOLOY FOR OT REPONDEN 

McKi Gra 

The 33 McKinney grantees in our sampled States included 25 Health Care for the 

Homeless grantees and 8 other providers who have received McKiney research 

demonstration grants from either the National Institute for Mental Health or the 

National Institute on Alcohol Abuse and Alcoholism. We spoke by telephone or in 

person with these respondents. The focus of our discussions was the availabilty, 

accessibilty and appropriateness of Medicaid and SSI. We were especially interested

in comparig their perspectives - as providers whose mandate is to serve the 

homeless - with those of ADMS grantees, who have a much broader mandate. 

Soc Secu Ditrt Ofe Respond 

These 25 respondents included district managers, assistant district managers and 

claims and servce representatives in district offces near the McKinney grantees in 

the sample. We discussed their experiences servng this population, their opinions about how to enhance access to SSI for them, and their views on the role of SSI in a 

long-term solution to homelessness. 

State Medaid Staff 

For background, we reviewed portions of the Medicaid plan for each of the 

sample States, looking at eligibilty criteria and servces relevant to homeless mentally 

il or substance abusing individuals. We then talked by telephone with 16 Medicaid 

staff in the 10 States to clarify our understanding of eligibilty and servces, and to 

ask if there were any special State Medicaid policies, procedures or special initiatives 

which affect this population. 

A ­

APPENDIX 


DATA VERICATION SHEET 

Please have the following background information available for our telephone 

discussion; do not return it to us by mail. If possible, we want this data for Federal 

Fiscal year (FFY) 1990. However, if you maintain data on a State fiscal year (SFY) 

or calendar year instead, please tell us when we call. 

Please provide only the information that you maintain in your existing management 

information system; otherwse, do not generate it specifically for us. We realize that 

you may not know or keep some of this information. In this case, we ask that you 

provide your best estimate, if you are comfortable with doing so. If not, just tell us 

you don t know. 

For FFY. SFY or Calendar 1990 ACTUAL or ESTIMATED 

1. Total agency budget: 

2. Total ADMS block grant 

funds received: 

3. Total McKinney funds 

received: 

4. Total clients served by your 

agency (unduplicated count; all 

programs or servces): 

5. Total clients served by your 

agency (unduplicated count) 

with ADMS dollars: 

1 Alcohol, Drug Abuse and Mental Health Servces Block Grant 
........................

DATA VERICATION SHEET 

PAGE TWO 

6. Total 
 homeless individuals 

over 18 served by your agency


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


a. # mentally il (no


substance abuse problem):


b. # substance abusers (not


mentally il): 

c. # dually diagnosed


(both problems)


7. Total 
 homeless individuals over 

served by your agency


with ADMS dollars (unduplicated 

count) 

a. # mentally il (no


substance abuse problem):


b. # substance abusers (not


mentally il): 

c. # dually diagnosed


(mentally il and


substance abusing) 

8. Total Medicaid reimbursement 

OR percent of total agency budget 

that was Medicaid reimbursement 

9. Number OR percent of total 

clients served by your agency 

who were on Medicaid 

10. Number OR percent of total 
 homeless 

individuals over 18 served by 

your agency who were: 

on Medicaid:


on SSI:


2Person who is not a member of a homeless family, and who lacks stable housing 

(including a person whose primary residence during the night is a supervsed public 

or private facilty that provides temporary living accommodations, or a person who is 

a resident in transitional housing. 
APPENDIX C


AGENCY COMMNT


C - 1

. 

DEPARTMENT OF HEALTH &. HUMAN SERY-ICES PubliC Health Service 

Date


From


S ub,eCt 

Memorandum FEB -7 199


Assistant SecreL3ry for Health


Office of Insrector General (OIG) Draft Report " Alcohol and Ment.-l Health Services for Homeless Individuals Drug, 

Inspector General , OS 

At t a c he d are the Pub 1 i c He a I t h S e r vi c e ' s (p H S) co mm en t s on the subject OIG draft report. The report recommends that PHS: (1) provide technical assistance to State and local Alcohol


Drug Abuse , and Mental Health Services (ADMS) Block Grant recipients and other PHS-funded grantees who serve homeless individuals , and (2) issue an advisory letter to all States underscoring the importance for ADMS grantees to include specialized training and formal agreements with other community social services agencies in serving homeless individuals with alcohol , drug abuse , or mental health (ADM) problems. 

We concur with the principles underlying these recommendations and explain that the ADMS Block Grant may not be the most 

a p pro p ria t e me c h ani s m t 0 imp 1 e men t the r e c 0 mm end a t ion s . Congress chose to target the problems of the homeless population through the McKinney Act. The McKinney Projects for Assistance in Transition from Homelessness is the program that targets the homeless population with dual diagnoses of serious mental illness and substance abuse disorders. 

In our comments , we note that PHS has provided and will continue to provide a variety of technical assistance to the
 States and its other grant recipients. We highlight activities undertaken by the Alcohol , Drug Abuse , and Mental Health Administration to address the programmatic needs of homeless individuals with ADM disorders. We identify activities
 administered by the National Institute on Alcohol Abuse and
 Alcoholism that evaluate the effectiveness of comprehensive
 service interventions designed to meet the special needs of various subgroups of homeless individuals. Lastly, we mention research and demonstration programs administered by the National Institute of Mental Health for homeless mentally ill individuals. 

Tho ugh we d 0 not s p e c i f i call y co mm e n t on the r e co mm end a t ion s the companion OIG draft reports on Medicaid and Supplemental

Security Income (551) for homeless individuals, we see these programs as essential components of an overall strategy for meeting the needs of homeless individuals with ADM disorders. We are pre par e d to t a k e a p pro p ria te a c t ion s t 0 b ring a b 0 u t 
g rea t e r coo per at ion and co 11 a b 0 rat i n bet ween PHS pro g r ams and 

Medicaid and 551. 

We include also a series of te hnical comments for your 

c;o'1sideracion. 

o.lh 

Mason , Dr. 

achClent 
PUBLIC HEALTH SERVICE (PHS) COMMENTS ON THE OFFICE OF INSPECTOR 

GENERA (OIG) DRAFT REPORTS " ALCOHOL, DRUG, AND MENTAL 

HEALTH SERVICES FOR HOMELESS INDIVIDUALS: MEDICAID


AND HOMELESS INDIVIDUALS: " AND " SUPPLEMENTAL


SECURITY INCOME AND HOMELESS INDIVIDUALS"


Genera 1 Commen ts


These three reports present the findings and recommendations of a
 study looking at three large , main-stream programs that could
 serve homeless individuals as part of their service population: the Alcohol, Drug Abuse , and Mental Health Services (ADMS) Block
 Grant; Medicaid; and Supplemental Security Income. All three 

reports rely on the same methodology: interviews with Federal
 program staff and national organization representatives; and
 telephone surveys of a sample of local ADMS grantees in ten


randomly selected States , McKinney Mental Health Care for the
 Homeless Block Grant and research demonstration grantees in those States, as well as staff in the State Medicaid and Social 

Securi ty district of fice in the same areas as the McKinney responden ts . 

The general findings across the three studies agree with
 inforra tion from other sources. For example , these studies document the extensive service needs of homeless individuals and
 the difficulties they face in accessing and maintaining eligibili ty for these services. Enhanced coordination of the 

many programs that provided services to the homeless population


is generally a common theme in many studies. The divergence of opinion between service providers and mainstream program 

officials over the role of those programs in providing assistance to homeless individuals has also been frequently discussed. 

However, much of this information is anecdotal; very little systematic data is available with the exception of a few studies 

in individual localities or treatment settings. 

We also want to emphasize two general issues which are of concern to us. The first issue concerns the use of language. Using " the homeless " to refer to individuals is depersonalizing; being 

homeless is difficult enough without also losing a sense identity. The substitution of " homeless persons, homeless individuals, " or even the homeless population" would help considerably. Secondly, we want to re-emphasize that, despite the careful wording around the estimates, the report will leave


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


are being spent on services to homeless individuals with alcohol


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


roughly 75 percent of local providers receiving ADMS funding


provide some level of service to homeless individuals. However, the level of service , and the numer of homeless individuals receiving it, could be as little as one outpatient visit to one 

homeless person in the past year. 

C-4

... ...

We have no specific comments on the recommendations contained in 

the reports on Medicaid and Supplemental Security Income. We do, however, see these programs as essential components of an overall 

national strategy for meeting the needs of homeless individuals 

wi th ADM disorders. We are prepared to take whatever actions are 

appropriate to bring about greater cooperation and collaboration 

between PHS programs serving the target population and Medicaid 

and Supplemental Security Income. 

OIG Recommendations 

The PHS should provide technical assistance to State and


local ADMS grantees and other PHS funded grantees who serve 

homeless individuals. (The technical assistance provided should include , but not be limited to, the two items 

specified in Recommendation No. 2 below. 

The ADAM should issue an advisory letter to all States 

wi th the next round of funding. The letter should underscore the importance for ADMS grantees to include the 

following components in serving homeless individuals with

mental health , alcohol, or drug problems: 

Specialized training 

Memoranda of Understanding or other formal agreements


with other agencies in the community. 


PHS Comment


We concur with the principles underlying these two


recommenda tions However, we do not believe that the ADMS Block 

Grant is the appropriate mechanism with which to implement the

recommendations. Congress has chosen to target the problems of 

the homeless population by the passage of the MCKinney Act. The 

McKinney Projects for Assistance in Transition from Homelessness 

(PATH) is the program which targets the homeless population with 

dual diagnosis of serious mental illness and substance abuse disorders. The PATH program specifically provides for staff 

training, including training of individuals who work in shelter, mental health clinics , substance abuse programs and other sites 

where homeless individuals require services.


In addition, PHS has provided and will continue to provide a wide 

variety of technical assistance to recipients of its grants. For example, ADAM currently funds several specialized 

clearinghouses and technical assistance centers dealing with the 

programmatic needs of homeless individuals with ADM disorders. 

Also, the National Institute on Alcohol Abuse and Alcoholism (NIAA) currently administers the Community Demonstration Grant 

Program for Alcohol and Other Drug Treatment for Homeless 
Individuals, and the Cooperative Agreements for Research


Demonstration Projects on Alcohol and Other Drug Abuse Treatment


for Homeless Persons. These two programs are evaluating the


effectiveness of comprehensive service interventions designed to
 meet the special needs of various subgroups of the homeless
 popula tion. In addition, the NIAA supports a numer of other research grants that are looking at the relationship of alcohol
 use and homelessness. These research and research demonstration


projects will provide the basis for this technical assistance. 

The National Institute of Mental Health also administers the 

McKinney Research Demonstration Program for Homeless Mentally III 

Adul ts and the Mental Health Research Program on Homeless Individuals. 

However, PHS is unable to directly provide technical assistance to local ADMS grantees. We believe that the States are in a 

better position to develop training for local grantees and to

encourage the development of agreements among providers.

Technical Comments


Page i, first paragraph under " BACKGROUND" The figures given


in this paragraph do not reflect the mo recent research. The 

paragraph should be rewritten as follows: 

Recent research suggests that approximately one-third 

of the homeless are severely mentally ill, at least 40 

percent have problems with alcohol, and an additional 

10 percent abuse other drugs. In addition, it is 

estimated that at least one-half of the homeless 

mentally ill population also have alcohol or other drug

problems. 

This is also true on page 1 of the introduction, in the second


paragraph under " Scope. "


Page i, 4th paragraph, last sentence It is fairly well
 established State Alcohol and Drua Abuse Profile , National Association of State Alcohol and Drug Abuse Directors, 1990) that the ADMS Block Grant, nationally, represents approximately 

20 percent of all funding for public sector alcohol and drug 

abuse treatment services. Accordingly, this information should


be used in lieu of the last sentence as it currently reads. 

Page i, third paragraph under " BACKGROUND" Please change the


last sentence to read: " States are. not required to specifically serve the homeless population with ADMS monies; however, States may fund services for homeless mentally ill persons and homeless substance abusers. 

Page ii , second paragraph under " FINDINGS"
 Please change problems " to characteristics. The same sentence is in the Table 

of Contents.


Page ii, last sentence After institutionalized persons, please insert " (e. g., in jails and hospitals). 

Table of Contents. The last word of the third finding, servicese " should be corrected to read services. 

Page 1, second paragraph under " SCOPE" Plea:e add after 

dually diagnosed" a defining clause, " those individuals with cooccurring mental health and substance use disorders. 

Page 2, as noted in the comment for page i, please change the

last sentence in the second paragr ph to read: " States are not 

required to specifically serve the homeless population with ADMS 

monies; however, ' States may fund services for homeless mentally 

ill persons and homeless substance abusers.

, 

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


Severe Mental Illness is chaired by the Director of NIMH.


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


modified. We suspect that the first issue is that the counts
 were not unduplicated" and the second issue that respondents


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

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

Page 6, figure 1 -- Please insert " persons" after homeless.
 Also, the first bullet needs to be reworked. First, does
 stable" home mean permanent housing? Second, should " stable
 housing" be linked with "drug- free environment?"


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


sentences. The first of these sentences, " This was the only...
 is unclear , and the second sentence the majority of ADMS...
 is misleading. The interpretation of these statements could be


very different depending on who the actual respondents were. For example, why would line workers know about funding sources (e. g. , Federal legislation)? 

The final sentence on this page about homeless clients and job
 skills is too general and should be deleted unless there is more


tha t can be said.


Page 8, first paragraph -- As is, this paragraph has a victim
 blaming tone, and needs to be toned down. For example, " Follow- through may take more persistence or resources than the life 

circumstances of homeless persons allow. Consider the life 

circumstances of a homeless person, and the lack of resources


such as transportation or clocks. 

Page 8, figure 2 does not only address homeless persons with ADM disorders. These problems are, however, often particularly relevant to the homeless mentally ill population. 

Page 8, fourth paragraph, first sentence -- Please add after dually diagnosed" a defining clause, " those individuals with cooccurring mental health and substance abuse disorders. 

Page 10, first paragraph , first sentence -- This sentence should 

be revised to read: " This study confirmed earlier findings that 

homeless individuals... 

Page 10, fourth paragraph, second sentence -- The title for the


PATH program is the McKinney Pro jects for Assistance in


C-8 
Transition fI2 Homelessness (PATH) program. 

Page A2 , first sentence -- In the Sampling Methodology section, please clarify who , specifically, were the desired respondents


for the sampled " grantees. Were they program managers or clinicians? Did it vary among the 30 grantees? 

Page B2. The footnote on the data verification sheet contains a
 definition that differs from the one 

we suspect provided on page A­
3 and
 , the one that was actually used. The one on page A-is, 

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

, 

DEPARTMENT OF HEALTH a. HUMAN SERVICES	 \ Ofce of th Sec 

18'ashingon . D.C. 20201 

NO 2 2 199 

""0 

TO:	 Richard P. Kusserow , Inspector General 

FROM:	 Ass istant Secretary for Planning and

Evaluation 

SUBJECT :	 OIG Draft Reports: "Supplemental Income for Homeless Individuals" Alcohol, Drug Abuse and Mental Health 

Services for Homeless Individuals" , and "Medicaid and Homeless Individuals" 
 - 00(;&0
 (:V	 06"I-C - fl-Od6 

OtEl- os-- 9/- ooo 

This memorandum provides comments on the three subj ect draft 

inspection reports which examined the availability, accessibility 

and appropriateness of the Supplemental Security Income Program 

(SSI), the Alcohol, Drug and Mental Health Services (ADMS) block grant, and Medicaid programs for homeless individuals who have 

mental health, alcohol or other drug problems. 

In general, the assessments found that: 1) most ADMS grantees provide some, but usually not specialized, services to homeless people 2) the type and adequacy of those services are unclear 

due to the lack of data on the quantity of services or their

impact: 3) access to SSI and Medicaid programs is limited al though special efforts are now being made by most SSA Field 

offices to increase access to SSI. Another finding is that most 

program providers and SSA field office staff recognize that it 

especially difficult for the mentally ill or substance abusing population to access SSI and Medicaid programs. 

Overall, the findings in these assessments are consistent with 

what we are learning from other studies and program monitoring, particularly with respect to the need for improved linkage and coordination among different levels of governent, between government agencies, and wi thin local service systems.

Unfortunately, the data available for these assessments did not 

allow for more specific findings concerning numers served, the 

quality of services provided , or for descriptions of successful, generalizable models.


Nevertheless, the findings and recommendations from these three 

assessments will help shape a current initiative to simplify programs and make them more accessible to severely mentally ill homeless individuals. Your staff has already briefed the Federal 

Task Force on Homelessness and Severe Mental Illness and 

outside Advisory Committee regarding these assessments. The Task 

its 

Force will recommend a plan of action 	 th rP-ta the end

of January, 1992.

. .

Page 2 - Richard P. Kusserow


I have a few additional comments listed below and editorial 

comments written in the attached copies of these reports. 

Alcohol Drua and Mental Health Services for Homeless Individuals 

The background section on page i should include a sentence 

or two in the discussion of the McKinney Act programs, on the proj ects for Assistance in Transition from Homelessness 

(PATH) program, its purpose , and a clarification that while 

states award most of their PATH funds to ADMS grantees, those funds are not included by grantees that report 

providing services to the homeless mentally ill. 

A statement in the background section indicates that the 

ADMS dollars spent for substance abuse treatment as a 

portion of state expenditures for this purpose is unknown. 

We understand that as of 1990, there is an indicator in the 

National Drug and Alcohol Treatment Utilization Survey that 

provides this information. 

In the findings section on page 4, the third paragraph under finding #1, this statement should be reworded to clarify that the dollars referred to go to grantees that use an


unknown but crobablv small cortion of their grants to serve


this population. One could interpret the current statement


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

Appendix A, pages 4 and 5 contain very low percentages for 

New York state ADMS funds that go to grantees serving the 

homeless, and the extent to which ADMS grantees in New York 

state seek Medicaid reimbursement for services. These 

estimates are so at odds with those for other states in the 

sample and with New York' s usual participation in such 

programs that you may wish to re-check them. 

Succlemental Securitv Income and Medicaid for Homeless


Indi viduals 

The same data issue concerning New York state described 

above for Appendix A of the ADMS Report applies to Appendix 

A of the reports on SSI and Medicaid as well. 

On page iii of the Executive Sumary, we suggest adding a 

recommendation to ensure that a national survey of the 

homeless population being planned for 1992/1993 include the proportion receiving SSI benefits. 
Page 3 - Richard P. Kusserow


The description of the targeted federal response to 

homelessness on page 1 of all three reports would be more 

complete with the addition of the following sentence after 

the second sentence of the fourt paragraph: n An additional 

$200 million in non-McKinney federal funds is targeted at the homeless population. II Total spending in these targeted 

programs will rise to over $1 Billion in FY 1992. 

:' G