U.S. Department of Housing

and Urban Development

STRATEGIES

for Preventing Homelessness

U.S. Department of Housing and Urban Development 

Office of Policy Development and Research

U.S. Department of Housing and Urban Development

Office of Policy Development and Research Strateges for Preventing H

o

melessness 
Visit PD&R’s Web Site

www.huduser.org

to find this report and others sponsored by

HUD’s Office of Policy Development and Research (PD&R).

Other services of HUD USER, PD&R’s Research Information Service, include listservs; 

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Prepared for:

Office of Policy Development and Research

U.S. Department of Housing and Urban Development

Prepared by:

Martha R. Burt

The Urban Institute

Washington, DC

Carol L. Pearson

Ann Elizabeth Montgomery

Walter R. McDonald & Associates, Inc.

Rockville, MD

May 2005

STRATEGIES

for Preventing Homelessness

U.S. Department of Housing and Urban Development 

Office of Policy Development and Research
ACKNOWLEDGEMENTS 

Many individuals have assisted us on this project; we would especially like to thank the 

following: 

• The researchers and program administrators who nominated potential sites. 

• The people we interviewed individually and in on-site meetings, who shared their time, 

information, and insights with us. We would particularly like to thank our primary 

contacts at each of the study communities: 

Shirley Hendrickson in Hennepin County; 

Walter Jabzanka at the Massachusetts Department of Mental Health; 

Jan Marcason at the Mid America Assistance Coalition; 

Corinne Stevens in Montgomery County, MD; 

Marcella Maguire and Rob Hess in Philadelphia, PA; and 

Jerene Petersen at Urban Peak. 

• Marina Myhre, our Government Technical Representative from the U.S. Department of 

Housing and Urban Development (HUD), who has provided us with thoughtful feedback 

and guidance throughout the study. Other HUD staff members who provided helpful 

comments throughout the study include Paul Dornan, Marge Martin, and Kevin Neary 

from the Office of Policy Development and Research, and Velma Simpson from the 

Office of Special Needs Assistance Programs. 

In addition, we would like to acknowledge Anja Maguire and Madonna Aveni of Walter R. 

McDonald & Associates, Inc., who provided editorial assistance. 

We appreciate the significant contributions that the above individuals made to carrying out the 

research and writing of this report. They are not responsible for any remaining errors or 

omissions. The findings and views herein are those of the contractors and authors. 

The contents of this report are the views of the contractors and do not necessarily reflect the 

views or policies of the U.S. Department of Housing and Urban Development or the U.S. 

Government.
Within the context of the aforementioned elements, the study identified four 

promising homelessness prevention activities that may be used alone or in combination as 

part of a coherent community-wide strategy: (1) supportive services coupled with 

permanent housing, particularly when combined with effective discharge from 

institutions, especially mental hospitals; (2) mediation in Housing Courts; (3) cash 

assistance for rent or mortgage arrears; and (4) rapid exit from shelter. 

This study provides insight into approaches that will help prevent homelessness. 

It is an important contribution to our understanding of how to help homeless Americans. 

' Secretary 
TABLE OF CONTENTS

v

EXECUTIVE SUMMARY xi

Why Homelessness Prevention? xi

What Makes A Good Prevention Intervention? xii

The Challenge of Creating Effective Prevention Strategies xiii

The Focus of This Study xiv

 Common Prevention Activities xiv

 Selecting Communities to Study xv

 Prevention Activities in the Six Study Communities xvi

Promising Homelessness Prevention Activities xvii

Documenting Prevention Effectiveness xviii

Key Elements of Prevention Strategies xix

Implications for Policy and Practice xxiii

 The Role of Funding Agencies xxiii

Implications for Future Research xxiv

Conclusions xxiv

 Maximizing Effectiveness xxv

 Planning and Organizing for Prevention xxv

CHAPTER ONE INTRODUCTION 1

Understanding Prevention 2

Targeting Efficiency—The Key to Prevention Effectiveness 3

What “Prevention” Looks Like in American Communities 3

Identifying Communities to Study 6

Study Domains 8

Report Organization 9

CHAPTER TWO SUMMARY DESCRIPTIONS OF SITES 11

Hennepin County, Minnesota 12

 Developing the Commitment to Prevention 12

 Population Served, Targeting Practices 13

 Components and Organization of the Community Strategy 14

 Data Collection and Use 15

 Relationship to CoC Process and HMIS 16

Montgomery County, Maryland 16

 Developing the Commitment to Prevention 16

 Population Served, Targeting Practices 17

 Components and Organization of the Community Strategy 18

 Data Collection and Use 18

 Relationship to CoC Process and HMIS 19

Mid America Assistance Coalition 19

 Developing the Commitment to Prevention 19

 Population Served, Targeting Practices 20

 Components and Organization of the Community Strategy 20

 Data Collection and Use 20

 Relationship to CoC Process and HMIS 21

Massachusetts Department of Mental Health 21

 Developing the Commitment to Prevention 21

 Population Served, Targeting Practices 23

 Components and Organization of the Community Strategy 24

 Data Collection and Use 25

 Relationship to CoC Process and HMIS 26
Table of Contents

vi

Philadelphia, Pennsylvania 26

 Developing the Commitment to Prevention 26

 Population Served, Targeting Practices 27

 Components and Organization of the Community Strategy 28

 Data Collection and Use 28

 Relationship to CoC Process and HMIS 29

Urban Peak 29

 Developing the Commitment to Prevention 29

 Population Served, Targeting Practices 30

 Components and Organization of the Community Strategy 30

 Data Collection and Use 31

 Relationship to CoC Process and HMIS 31

Summary 32

CHAPTER THREE USING DATA TO DOCUMENT PREVENTION EFFECTIVENESS 35

Documenting Prevention Effectiveness 35

 Proportion of Families Served Who Became Homeless 35

 Changes Over Time 37

Common Measures of Prevention Among Study Communities 40

 Data Elements Key to Outcome Measurement 40

 Developing Outcome Measures and Collecting Outcome Data 40

 Additional Outcome Measures to Consider 41

Additional Research Efforts 42

 Tracking Changes Over Time 42

 Program Evaluation Designs 42

Conclusions 45

CHAPTER FOUR KEY ELEMENTS OF PREVENTION STRATEGIES 47

What It Takes—Effective Prevention Activities 47

What It Takes—Organizing For Preventing Homelessness 49

 Elements Affecting Ability to Target Well 53

 Elements Reflecting Community Motivation 57

 Elements That Maximize Resources 58

 Elements Affecting Direction, Sustainability, Control, and Feedback 60

Conclusions 62

CHAPTER FIVE POLICY, PRACTICE, AND RESEARCH IMPLICATIONS 65

Implications for Policy and Practice 65

 Select Effective Prevention Activities 65

 Develop an Efficient Community-Wide Prevention System 66

 The Role of Federal Agencies 69

Implications for Future Research 70

 Control or Comparison Groups 70

 Comparison Groups 71

 Longitudinal Tracking 72

 Targeting 72

Conclusions 72

REFERENCES 75
Table of Contents

vii

APPENDICES 77

APPENDIX A HENNEPIN COUNTY, MINNESOTA A–1

Practices of Potential Interest to Other Jurisdictions A–2

Developing the Commitment to Prevention A–2

Components and Organization of the Community Strategy A–5

 FHPAP and Preventing Housing Loss A–11

 Rapid Exit A–13

 Staffing and Caseloads A–16

 Funding Sources A–16

Data Collection and Use A–16

 Access to the Data A–17

 Data Elements A–17

 Outcomes—Success at Preventing Shelter Use or Return to Shelter A–18

Hennepin County Site Visit Participants A–19

Hennepin County Acronyms A–20

APPENDIX B MONTGOMERY COUNTY, MARYLAND B–1

Practices of Potential Interest to Other Jurisdictions B–2

Developing the Commitment to Prevention B–2

Components and Organization of the Community Strategy B–3

 Accessing MCDHHS Emergency Services B–3

 Eligibility Criteria for MCDHHS Emergency Services B–4

 Eligibility Determination for MCDHHS Emergency Services B–4

 Approach with Landlords B–5

 Approach with Tenants in Subsidized Housing B–5

 Staffing and Caseloads B–5

 Funding Sources and Arrangements B–5

 Approach with Transitional Housing B–6

 Approach with the Larger Community B–7

 Approach with Tenants with Special Needs B–7

 Promising New Strategies B–7

Data Collection and Use B–8

 Analysis B–9

 Initial Findings B–9

 Future Analyses B–10

 Caveats and Limitations of Outcomes Data B–10

 Documentation of Reduction in Family Homelessness B–10

Montgomery County Site Visit Participants B–10

Montgomery County Acronyms B–11

APPENDIX C MID AMERICA ASSISTANCE COALITION C–1

Practice of Potential Interest to Other Jurisdictions C–1

Developing the Commitment to Prevention C–2

Components and Organization of the Community Strategy C–3

 Services C–3

 Screening and Eligibility Issues C–4

 Selected System Components C–5

 Mainstream Agency Involvement C–6
Table of Contents

viii

 Funding C–7

 Community Relations and Advocacy C–7

Data Collection and Use C–7

 Analysis C–7

 Initial Findings C–8

 Future Analyses C–8

 Limitations of Data and Outcomes C–9

Mid America Assistance Coalition Site Visit Participants C–9

Mid America Assistance Coalition Acronyms C–9

APPENDIX D MASSACHUSETTS DEPARTMENT OF MENTAL HEALTH D–1

Practices of Potential Interest to Other Jurisdictions D–2

Developing the Commitment to Prevention D–3

Components and Organization of the Community Strategy D–4

 Mental Health Services D–5

 Discharge Planning D–6

 Housing Supply and Development D–6

 Residential Services Other than Permanent Housing D–8

 Services in Support of Stable Housing D–9

 Programs of Assertive Community Treatment D–9

 MBHP’s Behavioral Health Care Services D–9

 Employment Services D–10

 Specialized Services D–10

 Outreach and Referral D–11

 Department-Wide Emphasis on the Importance of Housing D–11

 Outreach to Inpatient Psychiatric Units D–13

 Springfield/Hamden County Tenancy Preservation Project D–14

Data Collection and Use D–14

 Statewide Changes, 1992–2003, Excluding Metro Boston D–15

 Metro Boston D–17

 Effectiveness of Western Massachusetts’ TPP D–19

Massachusetts Site Visit Participants D–20

Massachusetts Acronyms D–22

APPENDIX E PHILADELPHIA, PENNSYLVANIA E–1

Practices of Potential Interest to Other Jurisdictions E–2

Developing the Commitment to Prevention E–3

Components and Organization of the Community Strategy E–4

 Philadelphia’s Behavioral Health Care System E–4

 The System for Adults in Adult Inpatient Care E–6

 Special Projects for Corrections Discharges of Inmates with Serious Mental Illness E–9

 Funding for Casework and Prevention Services E–12

 Who is Served? E–12

Data Collection and Use E–13

Philadelphia Site Visit Participants E–14

Philadelphia Acronyms E–15
Table of Contents

ix

APPENDIX F URBAN PEAK F–1

Practices of Potential Interest to Other Jurisdictions F–2

Developing the Commitment to Prevention F–2

Components and Organization of the Community Strategy F–4

 Outreach F–4

 Drop-In Services F–6

 Emergency Shelter and Support Services F–6

 Permanent Supportive Housing F–8

 Community Advocacy and Collaboration F–8

Data Collection and Use F–9

 Innovative Data Collection Methods F–10

 Recommended Data Analyses F–10

 Next Steps F–11

Urban Peak Site Visit Participants F–12

Urban Peak Acronyms F–12

 

APPENDIX G METHODS G–1

Site Selection G–1

Site Visits G–3

Data Analysis Plans G–5

APPENDIX H GLOSSARY H–1
Table of Contents

x

Exhibits

Exhibit ES.1. Organizing for Community-Wide Homelessness Prevention xxi

Exhibit 1. Homelessness Prevention Activities 4

Exhibit 2. Study Sites 7

Exhibit 3. Homelessness Prevention and Intervention Options 33

Exhibit 4. Proportion of Families Entering a Homeless Shelter Within 12 Months 

Following Receipt of Rent or Mortgage Assistance or Rapid Exit Services 

36

Exhibit 5. Change in Housing Barriers of Sheltered Families in Hennepin County 38

Exhibit 6. Changes in Massachusetts DMH Community Residential Capacity and Changes 

in Proportion of Homeless Admissions and Discharges 

39

Exhibit 7. Outcome Measures for Urban Peak, 2000–2004 39

Exhibit 8. Outcome Status of Closed Cases at the Tenancy Preservation Project of the 

Mental Health Association, Inc., of Springfield, MA 

44

Exhibit 9. Organizing for Community-Wide Homelessness Prevention 51

Exhibit 10. Hennepin County Housing Barrier Screen 55

Exhibit A.1. Hennepin County Housing Barrier Screen A–7

Exhibit A.2. Change in Housing Barriers of Sheltered Families A–18

Exhibit B.1. Outcome Measures for Families B–9

Exhibit C.1. Recipients of Rent and Mortgage Assistance Who Became Homeless the 

Following Year 

C–8

Exhibit D.1. Growth in DMH Residential Housing Capacity, Affiliated Housing Statewide, 

and Metro Boston Capacity, 1991–2004 

D–7

Exhibit D.2. DMH Funding for Community-Based Housing and Services, 1999–2004 D–7

Exhibit D.3. Changes in Homeless and Total Admissions to DMH Continuing Care Units, 

Excluding Metro Boston, 1993–2003 

D–16

Exhibit D.4. Changes in Homeless Admissions and Discharges in DMH Continuing Care 

Units, Excluding Metro Boston, 1993–2003 

D–16

Exhibit D.5. Changes in Proportions of Homeless Admissions and Discharges to All 

Admissions in DMH Continuing Care Units, Excluding Metro Boston, 

1993–2003 

D–17

Exhibit D.6. Discharge Destinations of People Leaving Private Acute Psychiatric Care, Metro 

Boston, SFY 2002–2004 

D–19

Exhibit D.7. TPP Case Status, Total Closed, by Diagnosis, and Comparison Cases D–20

Exhibit F.1. Outcome Measures for Urban Peak Denver, 2000–2004 F–10

Exhibit G.1. Canvass Discussion Guide G–2

Exhibit G.2. Study Sites G–3

Exhibit G.3. Site Visit Protocol G–6
xi

EXECUTIVE SUMMARY 

WHY HOMELESSNESS PREVENTION? 

Every day in the United States, families and single adults who have never been homeless lose 

their housing and enter a shelter or find themselves on the streets. No matter how effective 

services are to help people leave homelessness, reducing homelessness or ending it completely 

requires stopping these families and individuals from becoming homeless. Policies and activities 

capable of preventing new cases, often described as “closing the front door” to homelessness, are 

as important to ending homelessness as services that help those who are already homeless to 

reenter housing (National Alliance to End Homelessness, 2000). 

Most communities in the United States offer a range of activities to prevent homelessness. The 

most widespread activities provide assistance to avert housing loss for households facing 

eviction. Other activities focus on moments when people are particularly vulnerable to 

homelessness, such as at discharge from institutional settings (e.g., mental hospitals, jails, and 

prisons). Given that the causes and conditions of becoming homeless are often multifaceted, 

communities use a variety of strategies to prevent homelessness. 

By definition, the intent of prevention is to stop something from happening. The worse the 

effects of what one is trying to prevent, the more important it is to develop effective prevention 

strategies, and the more one is willing to accept partial prevention if complete prevention is not 

possible. 

Homelessness is a very undesirable condition, both for the people it affects and for society in 

general. The effects of homelessness on children, for example, make it easy to see why many 

communities offer interventions to help keep families with children in housing. Compared to 

poor, housed children, homeless children have worse health (more asthma, upper respiratory 

infections, minor skin ailments, gastrointestinal ailments, parasites, and chronic physical 

disorders), more developmental delays, more anxiety, depression and behavior problems, poorer 

school attendance and performance, and other negative conditions (Buckner, 2004; Shinn and 

Weitzman, 1996). There are also indications that negative effects increase the longer 

homelessness continues, including more health problems (possibly from living in congregate 

shelters or in cars and other places not meant for habitation) and more mental health symptoms 

of anxiety, depression, and acting out brought about by the disruptions in routines, relationships, 

and environments that homelessness entails (Buckner, 2004). 

Even housing instability negatively impacts children. Analyses of the National Health Interview 

Survey show strong associations between moving three or more times and increased behavioral, 

emotional, and school problems (Shinn and Weitzman, 1996), even when poverty does not 

complicate the picture. These findings suggest that even if families receiving prevention 

assistance would not become literally homeless without assistance, reducing the number of times 

they move may be worth the investment of paying rent, mortgage, or utility arrearages. 

Effects of homelessness on parents in homeless families are similar to those of their children, 

with the exception of school-related problems (Shinn and Weitzman, 1996). The effects of 

homelessness on single adults are also grim. Homeless individuals report poor health (37 percent 
Executive Summary 

xii

versus 21 percent for poor housed adults), and are more likely to have life-threatening contagious 

diseases such as tuberculosis and HIV/AIDS (Weinreb, Gelberg, Arangua, and Sullivan, 2004). 

The risk of homelessness is relatively high among poor households in the United States. About 

one in 10 poor adults and children experience homelessness every year (Burt, Aron, and Lee, 

2001; Culhane, Dejowski, Ibanez, Needham and Maccia, 1994; Link, Susser, Stueve, Phelan, 

Moore, and Struening. 1994, 1995). Homelessness exacerbates the negative effects of extreme 

poverty on families and individuals. 

The litany of negative effects of homelessness makes it easy to see why a community would 

want to prevent it. But being convinced that action is needed and knowing what action to take are 

two different things. Despite the theoretical importance of prevention as the only intentional 

practice that will reduce the number of new cases of homelessness, public funders are often 

reluctant to invest in homelessness prevention strategies. In part, this reluctance stems from fear 

that funds could benefit people other than those likely to become homeless, thereby diluting the 

already limited public resources committed to homeless people, or invested in activities that have 

not been proven effective to prevent homelessness. 

WHAT MAKES A GOOD PREVENTION INTERVENTION? 

To prevent something from happening, ideally one would know what causes it. The next best 

thing is to be able to predict in advance when, or to whom, it will happen. Knowing causes or 

having the ability to predict causes improves the odds of being able to design effective 

interventions. 

The causes of some undesirable things are clear and the solutions obvious, if not always simple 

or inexpensive. Bacteria cause some diseases, so to prevent these diseases one must do 

something about the bacteria.1

 One can kill the bacteria in a number of ways, by washing or 

using antibacterial agents on one’s hands, by using sterile procedures in operating rooms, or by 

assuring that the water in dishwashers reaches 180 degrees. Other approaches seek to prevent the 

bacteria from reaching people, including killing mosquitoes that carry malaria or yellow fever, 

fleas that carry typhus, or ticks that spread Lyme disease. Still other approaches (vaccines) make 

people more resistant to the bacteria. 

Unfortunately, the causes of homelessness are not as clear as is true for many diseases, and 

prediction is thus less certain. Research has identified many antecedents of homelessness that can 

serve as predictors. But knowing such factors about a set of people will not predict homelessness 

with certainty. For example, in their groundbreaking study comparing poor housed and homeless 

families in New York City the best that Shinn and her colleagues were able to do was correctly 

 

1

 Even this example is not so simple, as some people will not get a disease even if infected with the relevant 

bacteria. As with homelessness, the presence of risk factors does not guarantee that the outcome will follow. 
Executive Summary 

xiii

classify a family as homeless or not homeless 66 percent of the time (Shinn et al., 1998). The 

prediction equation used 10 factors, including race and ethnicity, childhood poverty, being 

pregnant or having an infant, being married or living with a partner, current domestic violence, 

childhood disruption, and four housing factors—overcrowding, doubling up, not having a 

housing subsidy, and frequent moves. The single factor “facing eviction” predicted homelessness 

only 20 percent of the time (that is, 20 percent of families facing eviction eventually became 

homeless). 

Few communities desiring to prevent homelessness among families will be able to eliminate 

these risk factors, at least in the short run. That is, they cannot do the equivalent of killing the 

bacteria. But communities can use knowledge of these factors to increase the odds that they are 

delivering homeless prevention services to families who would very likely become homeless 

without it, and would be well advised to use more factors than just “threat of eviction.” 

Communities can use the identified predictive factors mentioned above to screen families for 

high homelessness risk and then target their resources toward the highest-risk families. 

Factors differentiating adults who have experienced homelessness from those who have not 

include having an income less than 50 percent of poverty level; the presence of mental health, 

substance abuse, and chronic physical health problems; and a history of incarceration. Adverse 

childhood experiences including physical and sexual abuse and out-of-home placement also 

predicted the likelihood that an adult had experienced homelessness (Burt, Aron, and Lee, 2001). 

THE CHALLENGE OF CREATING EFFECTIVE PREVENTION STRATEGIES 

This study concentrated on the primary prevention of homelessness—that is, on preventing new 

cases of homelessness and stopping people from ever becoming homeless. It also examined 

secondary and tertiary prevention activities, but only as part of a community’s comprehensive 

prevention strategy. Secondary prevention focuses on intervening early during a first spell of 

homelessness to help the person leave homelessness and not return. Tertiary prevention activities 

seek to end long-term homelessness, thus preventing continued homelessness, and were the focus 

of an earlier HUD study (Burt et al., 2004). 

It is relatively easy to offer prevention activities but difficult to develop an effective communitywide prevention strategy. Such a prevention strategy needs to offer effective prevention activities 

and do so efficiently. Effective activities must be capable of stopping someone from becoming 

homeless (primary prevention) or ending their homelessness quickly (secondary prevention). An 

efficient system must target well, delivering its effective activities to people who are very likely 

to become homeless unless they receive help. 

Inefficiency is widely considered to be the common failing of local prevention strategies and 

activities; they simply target too broadly. The people receiving the intervention are not uniformly 

at very high risk of homelessness, so relatively few would actually become homeless even 

without the intervention. Based on the goal of prevention, a prevention strategy is not efficient 

and “wastes” resources if it uses them to assist people who would not have become homeless 

without the service. Briefly stated, poor targeting leads to an inefficient strategy and inefficient 

strategies are rarely effective. This study sought evidence that particular prevention activities 
Executive Summary 

xiv

were effective, and also sought to understand what makes a community’s homelessness 

prevention strategy efficient.

By what standard should one judge the effectiveness of a prevention activity? The answer to this 

question depends on the type of prevention one attempts. The Centers for Disease Control and 

Prevention of the U.S. Department of Health and Human Services maintains a Web site called 

“The Guide to Community Prevention Services” (www.thecommunityguide.org), through which 

it recommends activities whose effectiveness is considered proven for preventing health 

problems as diverse as suicide, youth violence, and smoking. Rates of change achieved by 

prevention activities that this guide describes as having strong evidence of effectiveness range 

from very low for primary prevention activities to very high for tertiary interventions. For 

instance, raising the price of cigarettes reduces smoking initiation by about 4 percent, and, when 

combined with extensive media campaigns, by about 8 percent. At the other extreme, therapeutic 

foster care for chronically delinquent violent youth—a tertiary intervention—produces a 

70 percent reduction in violence compared to regular group home treatment. 

The lesson for homelessness prevention efforts is that sometimes even relatively small 

percentage changes may be judged effective when the issue is primary prevention, both because 

the target population is so large and diverse, and therefore difficult to influence, and also because 

the consequences of failure are many and costly. When looking at the impacts of interventions 

designed for secondary and tertiary prevention, however, one should look for somewhat stronger 

effects because the target population is well-defined and interventions can be more precisely 

tailored. 

THE FOCUS OF THIS STUDY 

To learn more about effective prevention strategies, the U.S. Department of Housing and Urban 

Development (HUD) contracted in 2003 with Walter R. McDonald & Associates, Inc. (WRMA) 

and its partner, Urban Institute (UI), to conduct this study. Specifically, the study’s objectives 

were to: 

• Identify communities that have implemented community-wide strategies to prevent 

homelessness and can document their effectiveness; 

• Describe these strategies and their component activities for other communities and the 

field at large; and 

• Review community data that measure achievements in preventing homelessness and 

provide evidence that the prevention activities were effective. 

Common Prevention Activities 

To give the concept of “homelessness prevention” some concreteness, the study team examined 

Continuum of Care (CoC) applications for 2004 to identify the activities that communities 
Executive Summary 

xv

include in the prevention component of their CoCs.2 One cluster of activities was found in 

almost every application. It included counseling and advocacy to help households connect to 

resources and housing, as well as budget and credit counseling. It also included in-kind 

emergency assistance (food, clothing, transportation vouchers, and occasionally furniture and 

medical care); and cash assistance with rent, mortgage, or utility payments to avert eviction. 

A smaller proportion of communities also offered a second set of activities aimed at preventing 

homelessness. These activities included the following: legal and other assistance to retain 

housing; mental health, corrections, child welfare, and Temporary Assistance for Needy Families 

(TANF) agencies making commitments to house their clients as part of their service obligation; 

and strategies that involve more than one public agency working together to prevent 

homelessness. An example of the latter is mental health and corrections agencies collaborating to 

prevent homelessness at institutional release for mentally ill inmates. 

Selecting Communities to Study 

Armed with a general knowledge of prevention activities and target populations (e.g., families, 

people leaving institutions), the study team sought communities to include in this study that 

represented a range of approaches and focal populations, and also met two criteria specified by 

HUD. 

• Community-wide strategy: Primary prevention activities that represent a conscious 

commitment of the community to prevent homelessness. They go beyond the activities 

of a single agency to encompass the whole community in a structured and coordinated 

way, although they may have a specific population focus.

• Data documenting effectiveness: The community collects and analyzes data capable of 

showing that its prevention efforts do or do not prevent homelessness.

To identify appropriate communities, the study team started by contacting national experts on 

homelessness, who suggested 45 points of contact in 28 communities. A canvass of these 

communities eventually identified six communities that met both HUD criteria reasonably well. 

If the only criterion had been “community-wide,” more communities would have been included. 

However, most communities with community-wide prevention strategies did not maintain data 

on program effectiveness. The lead agencies in the six communities selected for further study 

were: 

• Hennepin County Human Services Department in Minnesota; 

• Montgomery County Department of Health and Human Services in Maryland; 

• Mid America Assistance Coalition (MAAC) in Kansas City, Kansas and Missouri; 

 

2

 “Continuum of Care” is a concept HUD has used since 1994 to describe the full range of a community’s response 

to homelessness. It spans activities from prevention through emergency shelter to supportive housing and permanent 

affordable housing without supportive services. In applications for funding under HUD’s Supportive Housing 

Program, communities are asked to describe their Continuums of Care; the study team examined the prevention 

components of these descriptions.
xvi

• Department of Mental Health (DMH) serving the Commonwealth of Massachusetts; 

• Office of Behavioral Health (OBH) in Philadelphia, Pennsylvania; and 

• Urban Peak, a private nonprofit agency in Denver, Colorado. 

Prevention Activities in the Six Study Communities 

Among these six study communities, one can find virtually every type of prevention activity, 

although they varied in their combinations and population focus. The first three communities 

were included to examine their strategies for primary homelessness prevention for families. The 

next two were included to examine their strategies for primary and secondary prevention with 

people with serious mental illness. The sixth site was selected because it served homeless youth, 

which is an important population to understand from a prevention perspective. 

The key to understanding homelessness prevention in the study communities lies in 

understanding what each community was trying to do. Differences in their prevention strategies 

and activities flowed from differences in their target populations and goals. 

The communities that aimed at primary homelessness prevention for families—Hennepin County 

Montgomery County and MAAC—selected families with short-term problems. Although they 

often discovered family issues that could not be resolved with one month of cash assistance, for 

primary prevention they selected the families whose housing problems could be resolved with 

the resources that were available. These communities offered families cash assistance to prevent 

eviction and cover rent, mortgage, or utility arrears, along with other prevention activities such 

as in-kind assistance and budget counseling. 

The other communities—Massachusetts, Philadelphia, and Urban Peak—focused their attention 

on people who would need long-term help. Of course, these communities found less severely 

disabled people during screenings, but they selected the ones who needed the most help. The 

help these communities offered was generally more intense, more expensive, and longer-term 

than that offered by the family-focused communities, in keeping with the nature and needs of the 

population being served. Permanent housing and supportive services to remain in housing were 

key activities, and collaborations among two or more mainstream agencies to make these 

approaches work were common. 

It is also important to recognize that some of the more intensive prevention activities serve 

multiple purposes. For example, Massachusetts DMH uses four interventions—mental health 

services, supportive services to maintain housing, rent subsidies, and permanent supportive 

housing—to accomplish both primary and secondary prevention and also to end chronic 

homelessness. Supportive and mental health services help keep never-homeless people with 

serious mental illness in housing and also help formerly homeless people stay in their new 

homes. Secondly, the same intervention can be used with different populations. For example, 

Hennepin County has a well-developed rapid exit program to assist families with multiple 
Executive Summary 

xvii

housing barriers to leave shelter and sustain their new housing. Massachusetts DMH also has a 

rapid exit strategy to assist homeless people with serious mental illness to leave shelters and the 

streets. 

PROMISING HOMELESSNESS PREVENTION ACTIVITIES 

This study identified five effective prevention activities that may be implemented at all levels of 

prevention: primary, secondary, and tertiary. These activities may be used alone or in 

combination as part of a coherent community-wide strategy. 

• Housing subsidies. Evidence for housing subsidies as a very effective prevention activity 

comes from studies other than the present one. Shinn and colleagues (Shinn et al., 2001; 

Stojanovic et al., 1999) documented the effectiveness of housing subsidies at keeping at 

least 80 percent of first-time homeless families housed for a minimum of two years. Rog, 

McCombs-Thornton, Gilbert-Mongelli, Brito, and Holupka (1995) demonstrated similar 

success (80–85 percent retention over at least 18 months) for homeless families in which 

a parent’s mental illness complicated housing stability. Evidence from simulations 

(Quigley, Raphael, and Smolensky, 2001) indicates that subsidizing housing costs for 

extremely low-income people has the strongest effect on lowering homelessness rates 

compared to several other interventions tested. Thus when used as secondary and tertiary 

prevention, housing subsidies help 80–85 percent of homeless families or chronically 

homeless single adults to achieve housing stability. 

• Supportive services coupled with permanent housing. For people with serious mental 

illness, with or without co-occurring substance abuse, permanent supportive housing 

works to prevent initial homelessness, to rehouse people quickly if they become 

homeless, and to help chronically homeless people leave the streets (Burt et al., 2004; 

Shern et al., 1997; Tsemberis and Eisenberg, 2000). Evidence collected in Massachusetts 

for the present study indicates declining rates of homelessness among people with serious 

mental illness admitted to state psychiatric hospitals over the 10-year period during which 

the DMH was expanding housing with supportive services.3

• Mediation in Housing Courts. Evidence collected in the present study on the 

effectiveness of mediation under the auspices of Housing Courts shows the ability to 

preserve tenancy, even after the landlord has filed for eviction. Sixty-nine percent of 

cases filed against families in the Hennepin County Housing Court were settled without 

eviction and the family retained housing. Mediation preserved housing for up to 

85 percent of people with serious mental illness facing eviction in the Western 

Massachusetts Tenancy Preservation Project and cut the proportion becoming homeless 

by at least one-third. 

 

3

 Some cost-conscious state corrections departments are recognizing that lack of housing and employment at release 

are two very strong predictors of renewed criminal activity and return to prison—two-thirds of prison inmates return 

within three years. These factors also predict homelessness, often within one or two months after release. These 

departments are experimenting with transitional housing with employment services for the highest-risk releasees, 

which should prevent both reincarceration and homelessness. 
xviii

• Cash assistance for rent or mortgage arrears. This commonly used primary prevention 

activity for households still in housing but threatened with housing loss can be 

effective—the challenge is to administer it in a way that makes it well-targeted and, 

therefore, efficient. In the study communities, 2–5 percent of families receiving 

assistance became homeless during the following year, which is an improvement over the 

20 percent that might have become homeless when facing eviction without the 

intervention. 

• Rapid exit from shelter. These secondary prevention activities are directed toward 

families just entering shelter, to ensure that they quickly leave shelter and stay housed 

thereafter. Using this innovative strategy, Hennepin County halved the average length of 

shelter stay (from 60 to 30 days) and achieved an 88 percent success rate in keeping 

formerly homeless families from returning to shelter over the next year. 

DOCUMENTING PREVENTION EFFECTIVENESS 

A community that wants to offer the most effective prevention activities in a manner that directs 

the most resources to those most likely to become homeless would be well advised to monitor 

performance. The community should establish systems to assess both the effectiveness and 

efficiency of its prevention efforts on a regular basis and use the resulting feedback to improve 

its targeting and balance among prevention activities. However, commitment to such 

performance monitoring is rare, as this study’s search for communities with performance data 

indicated. 

Each of the study communities collected basic data and could describe who they served and what 

services they provided. Some communities had sophisticated linkages among service providers, 

while others had more centralized databases. For most, sharing data among various systems 

remained a challenge, even though most study communities had developed innovative strategies 

to meet these challenges. Yet the communities had taken considerable strides in developing 

systems that could document primary and secondary prevention of homelessness. 

• Matching against emergency shelter records. This performance monitoring approach 

requires a prevention database and a shelter database, each of which should cover all or 

most of the relevant services. Each database must have a field or fields that permits 

matching a household in one database with the same household in the other database. The 

database containing information about which households received a prevention 

intervention is matched to a database such as a homeless management information system 

showing which households used shelter. Knowing when a household received prevention 

assistance, the shelter database is queried to learn whether that household used shelter at 

any time during the following 12 months. One database could contain all of the needed 

data. 

• Changes over time documented within a single database. Evidence over time that 

fewer people who received homelessness prevention services are becoming homeless 

increases the confidence that a system is moving toward greater prevention. This 

movement could reflect several changes that would indicate that prevention is occurring: 

decreasing numbers of households are requesting shelter, only households with the most 
xix

complex problems are requesting shelter, or decreasing proportions of people are 

homeless at psychiatric facility intake and discharge. The study communities of Hennepin 

County and Massachusetts DMH documented outcomes of this type. 

• Special data collection. Even in the absence of formal databases or the ability to match 

across databases, specific prevention interventions can maintain records to document 

prevention effectiveness. The Tenancy Preservation Project in Massachusetts is one 

example. It maintained records on all people assisted and tracked housing outcomes. As it 

had a waitlist and some people never received services, it was also able to construct a 

small comparison group of people similar to those receiving services, and was able to 

show substantial differences in outcomes between the two.4

 

KEY ELEMENTS OF PREVENTION STRATEGIES 

Any agency may use effective prevention activities, alone or in combination, and will probably 

prevent some homelessness. But prevention resources are unlikely to be used efficiently unless 

they are part of a larger structure of planning and organization that addresses the issue of 

targeting. A single agency can target and do it well. But to get the most from a community’s 

prevention dollar, indications from this study are that one needs a community-wide system. The 

system would have a carefully articulated targeting strategy and mechanisms to assure that funds 

allocated to prevention are used in ways likely to reach the people at greatest risk of 

homelessness. The communities in this study each had some elements of such a system, and 

several had many. From the evidence we have, the study communities with the most elements, 

Hennepin County and Massachusetts, were more likely to prevent homelessness and were best 

able to document achievements in homelessness prevention. 

The elements found in the study communities that appear to contribute to homelessness 

prevention all concern community organization of one type or another. The more comprehensive 

and sustained they are, the more they are likely to contribute to developing a system of 

homelessness prevention. The elements include: 

• Elements affecting ability to target well: 

- Agencies and systems sharing information, through a single unifying data system 

or with the capacity to track clients across different data systems; and 

- A single agency or system controlling the eligibility determination process, 

including agreed-upon criteria combined with housing barrier screening and 

triage. 

• Elements reflecting community motivation: 

- Community accepts an obligation to shelter one or more at-risk populations—the 

obligation may come as county council policy, as statutory requirement, as a 

governor’s commitment, or through other mechanisms; and 

- Given the obligation, the jurisdiction accepts that it must provide funds to fulfill 

it. As these funds are usually substantial, the community is motivated to use them 

wisely. 

 

4

 The small numbers of the comparison group provide tentative rather than conclusive results. 
xx

• Elements that maximize resources: 

- Collaboration among public and private agencies helps stretch resources through 

referrals to appropriate agencies and creates new resources when two or more 

organizations work together to identify a need and then develop a service that did 

not previously exist (e.g., mediation in Housing Courts); and 

- Nonhousing mainstream agencies accepting their clients’ housing stability as one 

of their responsibilities. For example, child welfare departments fund housing 

options for families in which mental illness is an issue (Philadelphia) and for 

youth aging out of foster care (Denver). 

• Elements affecting direction, sustainability, control, and the use of data to guide future 

development: Leadership is essential at two levels. Agency heads and public figures must 

commit to developing and sustaining a community-wide prevention strategy. To make 

such a strategy work, it has to be someone’s job to “mind the store,” manage the strategy, 

analyze performance, promote collaboration, and all the other activities that make a 

system work well. Several elements are involved in making this happen, including: 

- Having a clear goal of preventing homelessness; 

- Developing a strategy to reach the goal; 

- Having mechanisms that provide feedback on progress, stimulate new thinking 

and innovation, identify gaps and next steps; and 

- Knowing what is needed and making sure contract agencies are committed to 

providing it. 

With respect to organizing a community for prevention, the study team identified two overall 

strategies—short-term assistance and long-term support. The first strategy, most commonly 

applied to families threatened with housing loss, screens for short-term problems that 

nonetheless constitute crises for particular families, and applies short-term solutions. The latter 

seeks people whose disabilities or other circumstances indicate chronic problems, and applies the 

long-term solutions of housing with supportive services. When these solutions are made 

available before homelessness occurs, they have a stabilizing and preventive effect similar to 

what happens when they are offered to chronically homeless people with disabilities. (See 

Exhibit ES.1 for a complete list of organizing elements by population type.) 

These two community-wide prevention strategies, focusing on populations needing short-term or 

long-term assistance, respectively, operate through several mechanisms that other communities 

could begin to develop. These include careful targeting toward populations at very high risk of 

homelessness, and organizing and controlling access to preventive services to maximize 

targeting. The best organized among the study communities reached their present situation 

deliberately and over time, in a process that involved leadership, analytic thinking, strategic 

planning, alliance building, and collaboration. Developing better data and using existing data 

more strategically can improve performance, identify and fill gaps, and further the development 

of a community’s approach to homelessness prevention. 
Exhibit ES.1. Organizing for Community-Wide Homelessness Prevention 

Community-Wide Strategies with 

Community-Wide Strategies with Families People with Serious Mental Illne

Element 

Hennepin County Montgomery County MAAC Massachusetts P

Information sharing across agencies and systems 

All prevention and rapid exit agencies share a data system 

Prevention and shelter services through one agency, with common database 

All private agencies handling prevention funds share common database, which also tracks shelter referral and usage 

Acute inpatient, shelter, DMH transitional programs share information through outreach; courts and DMH contract agencies share information through Tenancy Preservation Projects; working with Medicaid and TANF agencies 

OBH shchild wesysteminternalmental substanagencie

Targeting Aids Housing barrier screening and triage Yes, measure via scale Yes, though no formal measurement No Formally, to become DMH client (must meet diagnostic and disability criteria); informally for housing (related to level 

of need, absence of alternatives) 

Formallclient (mdiagnoscriteria)housing need, aalternat

Public jurisdiction recognizes a legal or moral obligation to shelter 

Yes, moral, from County Council 

Yes, moral, from County Council 

No Yes, part of legislative and DMH 

commitments 

Some, f

Motivators Significant mainstream resources are invested 

(other than Federal) 

Yes, state and local Yes, mostly local No Yes, mostly state Yes, mo

Collaboration among public and private agencies 

Public and private, extensive 

Public and private, extensive 

Private only Public and private, extensive Public a

Maximizing Resources Nonhousing mainstream agencies accepting housing their clients as one of their responsibilities Yes, child welfare, TANF, mental health caseworkers included in rapid exit case planning for families Yes, child welfare, behavioral health, and domestic violence case workers coordinate housing 

services 

No Yes, DMH itself and to some extent 

corrections, for people with serious mental illness 

Yes, OBserious 

xxi 
Exhibit ES.1. Organizing for Community-Wide Homelessness Prevention (continued) 

Community-Wide Strategies with 

Community-Wide Strategies with Families People with Serious Mental Illne

Element 

Hennepin County Montgomery County MAAC Massachusetts P

Leadership Yes, strong, 

sustained, for both prevention and rapid exit 

More coordinating than leadership 

Coordinating function, but not for new or developing prevention strategies 

Yes, strong, sustained, for prevention, rapid exit, and community-based housing for people with serious mental illness 

Just beprevenpresenbased people mental 

Clear goal of preventing homelessness among target population(s) 

Yes Yes Yes Yes Just be

Clear strategy with ways to track success and progress 

Have strategy, track progress, use feedback to adjust system; prevention success tested against shelter database 

Only beginning to develop a strategy; prevention success tested internally and against Sheriff's eviction database; have data to do more 

Do not have a strategy for system development; have data to track progress but have not to date 

Have strategy, track some kinds of progress, but not yet specifically for prevention 

Just bedevelotracking 

Lead agency has control of funding and contracting for all or most of system 

Yes Yes No Yes Yes 

Direction, Sustainability, Control, and Feedback Uses outcomes-based 

contracting with adjustments based on performance 

Contracts specify outcomes, not process or services; contractors have been terminated or not renewed for not meeting outcome commitments 

No No No No 

xxii 
Executive Summary 

xxiii

IMPLICATIONS FOR POLICY AND PRACTICE 

The implications of study findings are clear for communities desiring to mount effective and 

efficient homelessness prevention strategies and for funders desiring to support effective efforts. 

• First, offer only prevention activities for which some research has indicated at least a 

minimal level of effectiveness. 

• Second, recognize that the effectiveness of any activity is only as good as the efficiency 

with which it is targeted to the families and individuals most likely to become or remain 

homeless if they do not receive help. 

• Third, organize the community to improve targeting, develop strong collaborations, and 

involve mainstream agencies. 

• Fourth, develop useful data systems and use the resulting data to reflect and improve 

system performance. Important data elements and outcome measures were identified in 

the study communities. 

The Role of Funding Agencies 

Funders considering support for homelessness prevention, including governments at any level, 

foundations, or even service agencies using charitable donations, should pay attention to the 

effectiveness of prevention activities and the likelihood that community organization is adequate 

to assure careful targeting before making significant investments in prevention activities. They 

should also consider funding the organizational capacity itself, as having staff responsible for 

seeing that the system works well is an important element in developing into a well-functioning 

system. 

In addition, state and local governments and private funders may accept multiple goals for an 

activity, of which homelessness prevention would be one. Paying rent, mortgage, and utility 

arrearages or offering in-kind assistance and budget counseling may serve more than one 

purpose, and funder goals may include providing crisis relief to extremely poor households 

whether or not they face a high homelessness risk. If this is the case in a community, 

performance monitoring will need to reflect the success of several outcomes that an intervention 

is expected to achieve, not only homelessness prevention. 

Federal, state, and local government resources are being used extensively to support 

homelessness prevention. Federal resources include the Supportive Housing Program, 

Emergency Shelter Grants, Emergency Food and Shelter Program, Projects for Assistance in 

Transition from Homelessness, and several block grants. In the case of the Supportive Housing 

Program, this support is for secondary and tertiary prevention. Although secondary and tertiary 

prevention activities are called prevention in this report, they actually involve interventions for 

people who are already homeless, such as rapid exit from emergency shelters and other activities 

that reduce the time a person spends homeless and assure that homelessness does not reoccur or 

act to end a person’s chronic homelessness. Significant state and local commitments were 

obvious in several study communities. The government agencies responsible for these funding 
Executive Summary 

xxiv

streams emphasize community-wide strategic planning, integrated approaches to homelessness 

prevention, and the importance of reducing homelessness for those at greatest risk. HUD in 

particular can stress the need for a systematic approach to prevention in its annual CoC 

applications. Funding agencies should assemble and disseminate information about prevention 

activities, the circumstances under which they are most likely to be effective, and how they can 

be integrated into a community-wide strategy. Federal and possibly state agencies should make 

technical assistance to improve targeting and the measurement of outcomes widely available to 

communities to use in their strategic planning to prevent and end homelessness. 

IMPLICATIONS FOR FUTURE RESEARCH 

This study has only scratched the surface of homelessness prevention—assembling data from a 

few communities that could begin to reflect the effectiveness of prevention. Other researchers 

(Lindblom, 1997; Shinn, Baumohl, and Hopper, 2001) have concluded that strong evidence is 

still lacking that homelessness prevention efforts are effective, but the bulk of their criticism has 

to do with targeting and inefficiency, not with the underlying effectiveness of different activities. 

Developing powerful evidence on the effectiveness of prevention activities requires sophisticated 

and usually expensive research designed to assess what would have happened if particular 

families or disabled people were not assisted. For this, controlled experiments or at least quasiexperimental designs are essential. Minimally, research needs to compare over time persons who 

receive prevention assistance with those who do not where those households are carefully 

assessed so that they differ only on receipt of such assistance. Federal government agencies are 

in the best position to support such research, as it is usually beyond the means of local actors. 

CONCLUSIONS 

Community-wide approaches to prevent homelessness have an essential role to play in ending 

homelessness, as reaching this goal will require communities to stop the flow of new households 

into homelessness as well as assisting those already homeless to return to housing. Many 

communities offer a wide range of activities intended to prevent homelessness. This study found 

examples of promising policies and practices that could be adapted to local circumstances and 

applied by other communities. 

This study identified two issues confronting communities desiring to prevent homelessness: 

knowing what prevention activities are effective and developing a system to deliver them 

efficiently (i.e., to the households with a very high risk of becoming homeless if they do not 

receive help). Many activities and interventions may succeed in preventing first-time 

homelessness for some, or helping newly homeless people return to and retain housing. 

However, many resources might be expended if such activities were offered to households that 

did not have a significant risk of becoming homeless. That is, the intervention might help a 

particular household avoid homelessness, but a program offering the intervention would be very 

inefficient if it did not take steps to assure that very high proportions of the people receiving the 

intervention really would have become homeless without it. In common parlance, an intervention 

is considered to be effective if it meets two tests—the intervention itself prevents homelessness, 

and it selects recipients with a very high risk of homelessness. 
Executive Summary 

xxv

Maximizing Effectiveness 

Several effective prevention strategies were identified, including some that are most likely to be 

used for primary prevention and others that are more likely to be used for secondary prevention 

or even tertiary intervention. 

For a community looking for the most effective and efficient approaches, the evidence suggests 

two places to concentrate: 

• Intervening to promote rapid exit from shelter and prevent renewed homelessness is a 

secondary prevention activity. Intervention with newly homeless people should be quick, 

and seek to prevent lengthy or repeated homeless spells and their negative consequences. 

Rapid exit has the advantage of potentially being able to target very accurately, as 

households in shelter clearly have become homeless at least once. Screening is still 

necessary, however, to select for the intervention households likely to return to 

homelessness if they do not receive help, as even with currently homeless households, 

evidence suggests that about two-thirds exit homelessness and do not have additional 

episodes. 

• People with disabilities leaving psychiatric and correctional institutions have a very high 

risk of homelessness if they do not receive assistance to find and keep stable housing. 

Their risk level for homelessness makes them an ideal target population for prevention 

activities, which may be primary or secondary depending on whether the people in 

question were ever homeless prior to institutionalization. Having or developing 

community-based housing and supportive services for people with serious mental illness 

exiting these facilities, coupled with discharge planning that links people in need with the 

housing and services, can be both effective and efficient, preventing both homelessness 

and a return to costly institutional settings. 

Cash assistance to prevent housing loss is a primary prevention strategy, and as such joins 

primary prevention in other fields in being held to a lower standard of impact than would be 

expected of secondary or tertiary prevention strategies because the intervention is applied to 

people with a relatively broad range of risk. Communities may still be interested in offering this 

activity with multiple goals, of which primary homelessness prevention will be only one. 

Planning and Organizing for Prevention 

Any homelessness prevention activities will have the greatest chance of success if they are part 

of a coherent, multiyear approach supported by strong leadership, adequate resources, and 

mainstream agency commitments, particularly for the policies involving populations with 

chronically disabling conditions. Communities could also begin to improve their prevention 

targeting and establish one or more of the innovative strategies described in this report. The CoC 

planning process occurring in many communities is an appropriate vehicle for implementing 

many of this report’s suggestions. Federal and state programs, as well as national organizations 

that encourage community-wide, collaborative thinking and help fund such efforts, would 

contribute significantly to their success. 
xxvi
1

CHAPTER ONE 

INTRODUCTION 

Every day in the United States, families and single adults who have never been homeless lose 

their housing and enter a shelter or find themselves on the streets. No matter how effective 

services are to help people leave homelessness once they lose housing, reducing the level of 

homelessness or ending it completely requires stopping these households from becoming new 

cases of homelessness. Policies and activities capable of preventing new cases, described in the 

memorable phrase of the National Alliance to End Homelessness as “closing the front door” to 

homelessness, are as important to ending homelessness as are services that help those who are 

already homeless to reenter housing (National Alliance to End Homelessness, 2000). 

Virtually every community in the United States pursues some activities that it considers 

homelessness prevention. The most widespread of these activities is to provide cash assistance to 

cover rental, mortgage, and utility payments to avert housing loss, often for households facing 

eviction. Other activities focus on moments when people are particularly vulnerable to 

homelessness, such as at discharge from institutional settings (e.g., mental hospitals, jails, and 

prisons). Given that the causes and conditions of becoming homeless are complex, it is not 

surprising that communities have developed a range of activities to prevent first-time 

homelessness and keep homeless spells as short as possible. 

Despite the theoretical importance of prevention as the only practice that will reduce the number 

of new cases of homelessness, public funders are often reluctant to invest in homelessness 

prevention. In part, this reluctance stems from fear that funds could be used to help broader 

populations, losing focus on those very likely to become homeless, or be invested in activities 

that have not been proven to prevent homelessness. Further, the most widespread prevention 

strategies remain loosely organized and untested. 

To learn more about effective prevention strategies, the U.S. Department of Housing and Urban 

Development (HUD) contracted in 2003 with Walter R. McDonald & Associates, Inc. (WRMA), 

and its partner, Urban Institute (UI), to conduct this study. The purpose of this study was to 

identify and learn from communities that had a systematic, community-wide strategy to address 

homelessness prevention and were able to demonstrate with data that the strategy actually 

prevented homelessness. Specifically, the study’s objectives were to: 

• Identify communities that have implemented community-wide strategies to prevent 

homelessness and can document their effectiveness; 

• Describe these strategies and their component activities for other communities and the 

field at large; and 

• Review community data that measure achievements with preventing homelessness and 

provide evidence that the prevention activities were successful. 
Chapter One Introduction 

2

UNDERSTANDING PREVENTION 

The challenges involved in any attempt to document the effectiveness of prevention activities are 

twofold: (1) specifying what one is trying to prevent, and (2) demonstrating that one’s efforts 

have actually stopped or reduced the occurrence of the event. 

The study team adopted one of the most enduring approaches to prevention to guide the selection 

of prevention activities to examine for this study—the public health model (Klein & Goldston, 

1977; Mace, 1983). This model identifies three types of prevention: primary, secondary, and 

tertiary intervention. This study concentrated on primary prevention and examined approaches to 

secondary and tertiary prevention only when these activities were part of a community’s 

comprehensive prevention strategy.5

• Primary prevention strategies take proactive steps to keep a particular event or behavior 

from occurring for the first time. For purposes of this study, primary prevention refers to 

preventing homelessness before it occurs for the first time. Various factors may 

contribute to one’s risk of homelessness, and several of these factors may be involved in 

a community’s decisions about whom to target for prevention activities. These factors 

include income loss, release from institutions or transitions out of social service 

programs, family violence, and mental health or substance abuse issues. 

• Secondary prevention efforts focus on early intervention after risks are identified, but 

before severe problems arise. In the case of homelessness, secondary prevention targets 

those who have recently become homeless to curtail the time spent homeless and assure 

that homelessness does not recur. The goal of secondary prevention would be to prevent 

first-time homelessness from becoming episodic or chronic and spanning many years. 

• Tertiary intervention is not always considered prevention because it addresses 

situations in which people have had extensive experience with homelessness. Yet 

interventions at this advanced stage can be successful at ending chronic homelessness, 

thus preventing continued homelessness. 

The public health framework helps to place homelessness prevention strategies and activities in a 

context used by practitioners and policymakers working in a number of areas, including disease 

prevention, drunk driving, and youth violence. This framework may also help readers to 

understand where the homelessness prevention activities in their own community fit in a larger 

conceptual framework and aid future planning. Decisions about whether to invest resources in 

prevention may be influenced by a clear understanding of the types of prevention that are most 

likely to be effective, as well as the types of prevention that a community identifies as being 

most important. 

 

5

 This study was deliberately oriented toward the primary end of the prevention continuum because several other 

HUD-sponsored studies had focused on tertiary intervention strategies (ending street homelessness, Housing First 

approaches to permanent housing for chronically homeless people). 
Chapter One Introduction 

3

TARGETING EFFICIENCY—THE KEY TO PREVENTION EFFECTIVENESS 

Showing that a prevention activity “works” is a challenge. Prevention targets people at risk. 

However, risk is not reality; the risk will only materialize for some, even without the 

intervention. The objective of the intervention is to reduce the probability that the risk will 

become reality. A common failing of many prevention efforts is that they target their 

interventions too broadly. Those receiving the intervention are not uniformly at very high risk, so 

relatively few would actually experience what the intervention is intended to prevent (in this 

case, homelessness) even without the intervention. Briefly stated, poor targeting leads to an 

inefficient program, and inefficient programs are rarely effective. 

For instance, threatened eviction is a common targeting criterion for homelessness prevention 

programs, but by itself it is a poor predictor of becoming homeless. Analyses in New York City 

showed that only one in five (20 percent) welfare families facing eviction actually became 

homeless (Shinn, Baumohl, and Hopper, 2001). Without an intervention, 80 percent of the 

families were “successes.” The intervention would have to improve those odds and would 

attempt to do so by assisting both the 80 percent who did not need it as well as the 20 percent 

who did. Using only this criterion, the program would be very inefficient. Clearly, excellent 

targeting procedures capable of identifying the people at highest risk are necessary for 

prevention activities to be both efficient and effective. 

In addition to good targeting, a prevention intervention also has to be able, at least in theory, to 

affect a person’s housing status. The link to housing retention and stability is more robust for 

some interventions than others. For instance, providing housing is one of the strongest 

interventions, but also probably the most costly and therefore, not to be used unless necessary. 

Instructing a family in budgeting is much less expensive, but also more tenuously linked, 

because the family would need to follow the budget over many months and also have the 

resources to pay for the budgeted items. All other circumstances being equal, one would expect 

stronger, more intense, and long-term interventions to be more effective in preventing 

homelessness. 

WHAT “PREVENTION” LOOKS LIKE IN AMERICAN COMMUNITIES 

To give the idea of “prevention” some concreteness, the study team identified 13 Continuum of 

Care (CoC) applications for fiscal year 2004 through a Web search and scanned their Services 

Activity Chart, Ending Chronic Homelessness, and Discharge Planning sections for prevention 

activities.6

 Exhibit 1 displays the activities that various communities around the United States 

include in the prevention component of their CoCs. The first cluster of activities is found most 

commonly, described in almost every Services Activity Chart consulted. These activities include 

counseling and advocacy to help households connect to resources and housing. Budget and credit 

 

6

 “Continuum of Care” is a concept HUD has used since 1994 to describe the full range of a community’s response 

to homelessness. It spans activities from prevention through emergency shelter to supportive housing and permanent 

affordable housing without supportive services. In applications for funding under HUD’s Supportive Housing 

Program, communities are asked to describe their Continuums of Care; the study team examined the prevention 

components of these descriptions. 
Chapter One Introduction 

4

counseling is also very common, in part as a prelude to assessing whether the household should 

receive cash assistance with rent, mortgage, or utility payments and in part to prepare the 

household to avoid future financial crises. In-kind emergency assistance in the form of food, 

clothing, and transportation vouchers is also widespread; the offer of furniture and medical care 

somewhat less so, but still fairly common. 

Exhibit 1. Homelessness Prevention Activities7

I. Most Commonly Offered Activities 

Counseling and advocacy 1. Information and referral about available resources 

2. Budgeting and debt reduction, handling credit and improving credit rating/history 

3. Links to entitlements and community resources 

4. Housing search assistance 

In-kind emergency assistance Food, clothing, transportation, furniture, medical care 

Cash assistance to maintain 

or obtain housing 

1. Deposits (first month's rent, last month's rent, security) 

2. Arrearages (rent, mortgage, utilities) to prevent eviction or foreclosure 

3. Moving costs 

Links to more sustained help 1. Mental health treatment 

2. Substance abuse treatment 

3. Training and employment assistance and support, job search 

4. Links to benefits: Temporary Assistance for Needy Families (TANF), Supplemental Security Income 

(SSI), food stamps, housing subsidies, local programs 

II. Less Commonly Offered Activities 

Other cash assistance 1. Automobile loan or repair 

2. Short-term rental payments for people with disabilities while waiting for SSI 

3. Special funds associated with Memoranda of Understanding arrangements, described below 

Legal and other assistance to 

retain housing 

1. Mediation with landlords around rents, heat or utilities, repairs, hazardous conditions 

2. Arrangements through Housing Courts, including mediation, provision of counselor, fee return to 

landlords, special funds 

3. Supportive services to assure housing retention once families or singles move to housing (e.g., 

Assertive Community Treatment for people with serious mental illness) 

Mainstream agencies 

assuming prevention 

responsibilities for own 

clients, inmates, or consumers 

1. Develop specialized housing (various forms for people with serious mental illness, halfway house for 

corrections) 

2. Supportive services to assure housing retention 

3. Employment links and supports 

4. Discharge planning, especially linked to housing, services, and employment 

5. Specialized units, trained staff 

Memoranda of Understanding 

or other formal interagency 

arrangements to prevent 

homelessness for vulnerable 

populations 

Strategies 

1. Special funds for cash assistance 

2. Hotlines and other mechanisms to alert agencies to risk situations 

3. Special training and staffing 

4. Centralized resources to resolve housing emergencies 

5. Mental Health Courts (prevent people with serious mental illness cycling through jails, shelters) 

6. Planning and coordination so code enforcement (condemning or otherwise closing housing, temporarily 

or permanently) does not produce homelessness 

Agencies involved (with each other, public agency responsible for homeless programs, CoC, or in 10-year 

plan process as partner): Corrections, Mental Health, Child Welfare, TANF 

III. Sometimes Mentioned as Deep or Long-Term Prevention Strategies 

Antipoverty activities 1. Job training, continuing education, skill development 

2. Literacy, adult basic education, English as a second language 

3. Affordable housing development 

 

7 Sources: (1) Canvass of the 28 candidate communities for this study and in-depth examination of six of them; (2) 

Web search for “2004+application+continuum of care” and a review of 13 CoC applications: Very large—New 

York City, NY; Los Angeles County, CA; Medium—Bridgeport, CT, Columbus/Franklin County, OH, Dakota 

County Knoxville/Knox County, TN, Santa Clara County, CA, Washington, DC; Small and/or largely rural—

Burlington, VT, Delaware, Frederick City and County, MD, Iowa balance-of-state, and West Memphis, AR. 
Chapter One Introduction 

5

The most commonly offered homelessness prevention activity, especially for families, is shortterm (usually one month) cash assistance to obtain or retain housing. Two McKinney-Vento 

programs, the Emergency Food and Shelter Program and the Emergency Shelter Grants Program, 

are important funders of these activities. Local decisionmakers allocate approximately $25–$30 

million of these funds each year for rent, mortgage, and utility cash assistance. This sum 

comprises about 10–15 percent of the resources in these two programs, but is swamped by the 

total McKinney-Vento budget of over $1 billion per year in Federal funding for homeless 

services. Federal resources used for prevention are widespread. The Emergency Food and Shelter 

Program funds ($153 million during the most recent year), for example, are distributed through 

11,000 agencies in 2,500 jurisdictions across the country. State and local funding streams are 

also used, as are charitable donations. In most communities, many social service agencies have 

some access to these resources and offer these prevention activities. These activities may be 

organized into a linked network, but more often are not. 

The second set of activities, identified in Exhibit 1 as “Less Commonly Offered,”include the 

following: legal and other assistance to retain housing; mainstream agencies such as mental 

health, corrections, child welfare, and Temporary Assistance for Needy Families (TANF) 

agencies accepting their clients’ housing stability as one of their responsibilities; and various 

strategies to prevent homelessness that involve more than one public agency. These activities 

require more organizational commitment and a longer time perspective on the part of leadership. 

They are most commonly undertaken by mainstream agencies, alone or in collaboration with 

others, whose clients risk homelessness due to institutional discharge or the periodically 

disruptive nature of their conditions (e.g., serious mental illness). In general, CoCs offering the 

second set of activities reflect a high degree of investment by mainstream agencies, as well as 

homeless-specific agencies, to develop effective community-wide prevention strategies. 

Finally, some CoCs mention some generic, antipoverty activities that seek to give people the 

skills to generate incomes sufficient to afford housing as homelessness prevention. Development 

of affordable housing is also an obvious, if expensive, long-term anti-homelessness strategy. 

There is no simple correspondence between the prevention activities in Exhibit 1 and the 

primary-secondary-tertiary prevention framework introduced above. Many prevention activities 

can serve multiple purposes. For instance, budget counseling would be relevant for never, newly, 

and chronically homeless people. Likewise, permanent housing with supportive services may be 

used to keep someone with serious mental illness from ever becoming homeless (primary), as a 

way to move a newly homeless person with serious mental illness out of homelessness quickly 

(secondary), or for ending a 20-year spell of homelessness (tertiary). 

That being said, most communities perceive the following activities as contributing mostly to 

primary prevention: counseling and advocacy; in-kind emergency assistance; and rent, mortgage, 

and utility cash payments. This perception arises largely because these are the activities most 

common in strategies targeting families and single individuals who are still in housing, but 

threatened with housing loss. In addition, discharge planning involving housing, often combined 

with supportive services to help maintain tenancy, tends to be associated with secondary and 

tertiary prevention efforts. 
Chapter One Introduction 

6

IDENTIFYING COMMUNITIES TO STUDY 

Given the wide array of activities undertaken in the name of homelessness prevention, the study 

team had to narrow the field to select communities to visit. Two criteria were specified by HUD: 

the prevention strategy had to be community-wide and have data to document prevention 

effectiveness. 

• Community-wide: Primary prevention activities represent a conscious commitment of 

the community to do primary prevention. They go beyond the activities of a single 

agency to encompass the whole community in a structured and coordinated way, 

although they may have a specific population focus.

• Data documenting effectiveness: The community collected and analyzed data capable 

of showing that its prevention efforts did or did not prevent homelessness.

The study team sought to include prevention strategies that represented the full range of 

activities, and selected some that attempted to prevent first-time homelessness among families—

using primarily the first four activities in Exhibit 1—and others that attempted to prevent 

homelessness among populations at high risk due to mental illness or institutionalization. Finally, 

with knowledge based on extensive prevention research literature that appropriate targeting is the 

key to efficient and therefore, effective prevention, the study team looked for communities with 

systematic strategies to determine the homelessness risk level of the people the community might 

potentially serve.8 

The study team’s canvass to identify relevant communities began by contacting sources 

identified in WRMA’s and UI’s previous studies of homelessness, as well as national experts on 

homelessness, state and local agencies, and mental health and homelessness consortia. Requests 

for candidates stressed the requirement that the communities have data because experience 

indicated that requirement would be the hardest to meet. This indeed proved to be the case. The 

“community-wide” criterion also posed challenges, as key informants sometimes knew contacts 

at individual programs pursuing prevention activities but, upon further inspection, these 

programs were not part of community-wide efforts. 

The canvassed communities were neither a comprehensive nor random sample of what 

communities in the United States are doing to prevent homelessness. Rather, the study team used 

knowledgeable people to identify potential communities to include in the study. The various key 

informants were able to suggest 45 points of contact at various agencies in 28 communities. 

More communities might have been included if the only criterion had been “community-wide,” 

but the requirement that the community have relevant data narrowed the selection. 

Contacts in all 28 communities were interviewed by phone to determine whether their 

communities met the study criteria. Even among these 28 that had been specifically 

recommended by people aware of the selection criteria: 

 

8

 For homelessness prevention, the best summary is Shinn et al., 2001. 
Chapter One Introduction 

7

• Nine were found to be single programs that were not part of a community-wide strategy 

and were dropped from further consideration; 

• Ten had strategies for preventing homelessness among families; 

• Nine served specialized populations, such as people with serious mental illness, exoffenders, and youth; and 

• Most communities did not have data capable of assessing effectiveness at preventing 

future homelessness among families and individuals receiving prevention assistance. 

Among the communities with community-wide strategies, the study team selected six sites for 

further study. These sites had relevant data and the promise of being able to assess future 

homelessness among people receiving prevention aid. The lead agencies in these communities 

were:9

• Hennepin County Human Services Department in Minnesota; 

• Montgomery County Department of Health and Human Services in Maryland; 

• Mid America Assistance Coalition in Kansas City, Kansas and Missouri; 

• Department of Mental Health serving the Commonwealth of Massachusetts; 

• Office of Behavioral Health in Philadelphia, Pennsylvania; and 

• Urban Peak, a private nonprofit agency in Denver, Colorado.10

Among these six study communities, one can find virtually every prevention activity identified in 

Exhibit 1, although they varied in their combinations and population focus. The first three 

communities listed above were included to examine their strategies for primary homelessness 

prevention for families. The next two were included to examine their strategies for primary and 

secondary prevention with people with serious mental illness. The sixth site (Urban Peak) was 

selected because it served homeless youth—an important population to understand from a 

prevention perspective. Exhibit 2 shows the sites and the types of systems they represent. 

Exhibit 2. Study Sites 

Community-Wide Strategies with 

Specialized Populations Site 

Community-Wide 

Strategies with 

Families and 

Individuals 

People with Serious 

Mental Illness 

Homeless and 

Runaway Youth 

Hennepin County X 

Montgomery County X 

Mid America Assistance Coalition X 

Massachusetts Department of Mental Health X 

Philadelphia X 

Urban Peak X 

 

9

 Appendices A–F present the findings from the in-depth reviews of the six communities. 

10 Throughout this report, public agencies are designated by the name of the community they serve, e.g., Hennepin 

County ; Montgomery County; Philadelphia; and Massachusetts. The two remaining sites are referred to by their 

names: Mid America Assistance Coalition (MAAC) and Urban Peak. 
Chapter One Introduction 

8

STUDY DOMAINS 

The difficulties noted above in targeting prevention to those at highest risk—identifying and 

implementing effective strategies, stimulating investment in prevention, and documenting 

effectiveness—drove the study’s exploration of homelessness prevention in the six communities. 

The study team examined the following domains of inquiry, for which examples of questions 

posed during site visits are provided. 

• How the Strategy Evolved and Why It Took the Form It Did 

- What was the context and history under which the prevention policies or 

programs were established? 

- If alternative strategies or activities were considered, how were the current ones 

decided upon? 

- How did the community define the at-risk population? Why that population and 

not others? 

- How much multiagency coordination was involved in developing the strategy? 

• Who the Strategy Served and How They Were Identified 

- Who did the strategy serve? How were they found? How was risk assessed? How 

was eligibility restricted to those at highest risk? To what extent could the strategy 

successfully target its services to the at-risk population? 

- How did the community decide what prevention activities were likely to be most 

effective for the target population? 

- If one subset of the at-risk homeless population was targeted, were there other 

policies or programs to respond to the needs of other at-risk populations in the 

community? How did the strategy fit into the broader local effort to aid homeless 

people, frequently called the “Continuum of Care?” 

• What Prevention Activities Were Offered and How They Were Organized 

- What programs, services, and activities were offered? 

- How was the strategy administered? How much multiagency cooperation was 

involved in implementing the strategy? 

- What changes in policy were required to establish the strategy to preventing 

homelessness? 

- Did the community consider any aspects of the program to be controversial? 

• How the Strategy Was Funded 

- What funding sources were used for the strategy? 

- How was the community induced to invest resources in the prevention strategy? 

• Available Evidence of Effectiveness 

- What outcomes were achieved? 

- Was the agency able to document these outcomes? What types of evidence were 

available? 

- What additional quantitative and qualitative measures might be used by 

community-wide homelessness prevention programs to determine their 
Chapter One Introduction 

9

effectiveness, and how could these measures be incorporated into the Homeless 

Management Information System? 

The study team conducted site visits to the six communities to collect qualitative information 

pertaining to the above domains. Study team members interviewed the people who designed the 

community’s strategy, supervisors, front-line staff, contract agency staff, and collaborators. 

Between 11 and 74 people were involved per site, depending on the complexity of the prevention 

strategy. Meetings with information technology staff provided specific information about the 

relevant data systems, the data collected, and how sites could analyze these data to assess the 

effectiveness of their homelessness prevention programs. Representatives at each site reviewed 

for accuracy what this report says about their community and its activities for preventing 

homelessness. 

REPORT ORGANIZATION 

The four remaining chapters report the study’s findings and implications: 

• Chapter Two: A summary description of each site including how the community 

developed its commitment to prevention; the population served and targeting strategies; 

components and organization of the community strategy; data collection and use; and the 

strategies’ relationship to the CoC and Homeless Management Information System 

within the jurisdiction.

• Chapter Three: A description of the study communities’ data systems, current use of 

outcome measures, the outcomes the communities have been able to measure, as well as 

recommendations for additional data collection and analysis of homelessness prevention 

programs. 

• Chapter Four: A cross-site analysis of the common themes that appear to be salient to 

the development and implementation of a community-wide homelessness prevention 

program, differences depending on the populations served and the level of prevention 

attempted, ways the communities developed commitments, and useful tactics.

• Chapter Five: The implications of these findings for local communities in terms of 

policy, practice, and future research. 

Appendices follow, describing the six study communities’ prevention strategies in detail 

(Appendices A–F). Each site appendix includes: 

• A brief description of the jurisdiction and a list of practices of potential interest to other 

jurisdictions; 

• The history and context of the strategy for preventing homelessness in the community 

and gaining organizational and funding commitments and collaborations; 
Chapter One Introduction 

10

• Information on the administration and organization of services and targeting strategies; 

and 

• A description of the data collection and documentation processes. Also identified are 

potential future analyses. 

Appendix G provides additional information on the study methods, including the initial canvass 

of the 28 communities. Finally, Appendix H supplies a glossary of acronyms used in the report. 
11

CHAPTER TWO 

SUMMARY DESCRIPTIONS OF SITES

This chapter provides a summary overview of each of the six communities selected for this 

study, and places their prevention activities in the context of the prevention activities identified 

in Exhibit 1. Each community is described in terms of five main topics: 

• Developing the Commitment to Prevention—how the community developed its strategy 

and made and sustained commitments with community partners; 

• Population Served, Targeting Strategies—how and why the community selected its target 

population, a description of the target population, and techniques for improving the odds 

of serving only those at highest risk of homelessness; 

• Components and Organization of the Community Strategy—programs and services, and 

how the community organizes and administers them; 

• Data Collection and Use—the data the community collects, by whom, and how they are 

used, e.g., for monitoring, feedback on goal achievement, quality control, and advocacy 

(examples of documentation for specific outcomes are discussed in Chapter Three); and

• Relationship to Continuum of Care (CoC) Process and Homeless Management 

Information System (HMIS)—the role that prevention plays within the larger homeless 

assistance system and how it is integrated into the local HMIS. 

The three sites we visited to examine their homelessness prevention strategies for families are 

described first and include Hennepin County, Montgomery County, and the Mid America 

Assistance Coalition serving Kansas City. The three sites that focused on longer-term, more 

intensive interventions with persons who were seriously mentally ill and with homeless youth are 

summarized next. These sites include the Massachusetts Department of Mental Health and the 

Philadelphia Office of Behavioral Health, followed by Urban Peak. 

Descriptions of the Hennepin County strategy for family homelessness prevention and the 

Massachusetts Department of Mental Health’s strategy for preventing homelessness among 

people who are seriously mentally ill are described at greater length than other community 

approaches because these two communities represent the most fully developed and 

systematically implemented strategies found among the six study sites. A more detailed 

description of each of the study sites can be found in Appendices A–F. 
Chapter Two Summary Descriptions of Sites 

12

HENNEPIN COUNTY, MINNESOTA 

In Hennepin County, the Human Services Department administers the Family Homeless 

Prevention and Assistance Program (FHPAP), which is an umbrella program with components 

focused on homelessness prevention for families and adults, rapid exit from shelter for families 

and adults, transitional housing for families, and programs for youth. The study team focused on 

the components of homelessness prevention and rapid exit for families. Private nonprofit 

agencies, under contract to the Department, provide most of the services. Agencies may 

participate in any or all of the FHPAP components, depending on their areas of competence. 

Federal, state, and county monies fund the program, with the bulk of the money coming from the 

state FHPAP. 

Developing the Commitment to Prevention 

Hennepin County has traditionally been a jurisdiction that takes seriously its responsibility “to 

promote the general welfare.” With respect to family homelessness, the County Board of 

Commissioners has a long-standing policy that the county will do what it takes to assure that no 

family spends the night on the streets. Several factors help explain why the county was motivated 

to create its current system of homelessness prevention, why families are the primary target 

population, and why it has succeeded to a considerable extent. These factors are: 

• The county’s commitment to prevent all family “street” homelessness; 

• The county’s investment in sheltering families—the county pays for this shelter through 

contracts with shelter providers; 

• The county’s ability to shape and control the various parts of the system through 

contractual arrangements; 

• The county’s facilitation of extensive collaborative networks of providers and inclusion 

of many influential stakeholders on the FHPAP Advisory Committee; and 

• The county’s use of data to facilitate daily assistance to clients and to provide daily, 

monthly, and annual feedback to improve the system, including contract monitoring and 

nonrenewal of poorly performing contractors. 

The first critical year for family homelessness prevention and sheltering in Hennepin County and 

the state as a whole was 1993. Facing the reality that the system could no longer adequately 

serve the increasing number of homeless families, county officials in the Human Services 

Department decided that they needed to do something very different. In addition to beginning to 

charge families for shelter, the county looked for a way to stem the tide of family homelessness. 

The county’s Human Services Department worked with the Minnesota Housing Finance Agency 

to draft creative legislation that authorized FHPAP, and the Minnesota Housing Finance Agency 

administers the program at the state level. The FHPAP legislation established a set of outcomes 

related to preventing family homelessness, including shortening lengths of stay in shelter, 

preventing first-time entry into shelter, and eliminating shelter re-entry. FHPAP is a statewide 
Chapter Two Summary Descriptions of Sites 

13

program, with Hennepin County receiving the most funding because it serves about one-half the 

state’s known homeless population. 

FHPAP provides flexible outcome-based funding, which is an extremely valuable commodity. It 

allows grantees to do “whatever it takes” to prevent homelessness, with the exception of paying 

for shelters, building housing, or subsidizing housing for more than 24 months. Contractors 

apply for funds every biennium and are awarded funding based on outcomes accomplished, or on 

outcomes proposed if they are new contractors. Initially designed for families and youth, the 

state added single adults to the program in 1998. However, the county uses the bulk of its 

FHPAP funding to prevent family homelessness. 

Even with FHPAP resources, the number of sheltered families did not decrease in Hennepin 

County and indeed began to grow. A second crisis year was 2001, during which homeless 

families overflowed available shelter and hundreds were placed in motels without significant 

services to help them leave shelter. Managers from the Human Services Department realized that 

they had to use their resources “smarter,” as the resources were not going to increase. To cope 

with not having a system that could ensure that shelter resources would be used for the families 

with the most barriers to housing, and who needed the most help, the county began to develop a 

shelter screening and admission system to control access to only those families. This process 

required several iterations, trying different things, assessing their effects, and revising. The 

resulting screening and admission system cut shelter length-of-stay by one-half (to just under 30 

days, on average), reduced the number of families in shelter on any day by 63 percent, and 

assured that only families with serious and multiple barriers to housing receive shelter services 

(with the remainder receiving referral to the prevention component of FHPAP). The system is 

structured around two essential components, a precise and demanding screening tool and strong 

casework supports to help families leave shelter and keep them in housing thereafter. 

Population Served, Targeting Practices 

This study looked at two FHPAP components, both focused on families. The first is primary 

prevention for families still in housing; the second is secondary prevention for families in shelter. 

Homelessness Prevention 

The family homelessness prevention component of FHPAP operates through 17 nonprofit 

agencies that offer a variety of emergency assistance and other social services. All roads lead to 

one of these agencies; they are well known and highly publicized as the source of emergency 

assistance and receive referrals from many sources, including 211 (the local information and 

referral hotline), churches, schools, city and county agencies, and other nonprofit service 

agencies. Each agency has its own screening procedures, but criteria for receiving help paid for 

by FHPAP are uniform. The family must be threatened with housing loss from past failures to 

pay rent or other situations leading to eviction, and resolution of the crisis situation must be in 

sight. These criteria usually mean that past nonpayment of rent has been due to illness or job loss 

but that someone in the family will soon have an income sufficient to cover future housing costs. 
Chapter Two Summary Descriptions of Sites 

14

In addition to assessing the amount of arrearages or danger of housing loss and the promise of 

future relief, FHPAP prevention agencies also examine the family’s personal resources and 

savings, those of relatives or friends, budgets and spending habits, credit history, rental history, 

and other factors. This information is used to determine how desperate and lacking resources the 

family truly is, and what the family might be able to do for itself. It is rare that a family receives 

full payment from an FHPAP provider; providers insist that the family contribute something to 

resolve its immediate difficulties. How much the family is asked to contribute depends on the 

caseworker’s judgment about available resources. These probes and other practices (e.g., 

working with the family to develop a realistic budget, including helping them move to a smaller 

apartment if necessary) are the FHPAP providers’ way of assuring that the most resources go to 

the families who need them the most and who have the highest risk of homelessness if they do 

not receive assistance. 

Shelter and Rapid Exit 

Families without housing and who are seeking shelter do so through the Human Services 

Department Shelter Team. At first contact with a family, a Shelter Team worker probes to 

determine if the family has any alternatives to entering shelter, including family or friends with 

whom they could stay. If not, the family receives a voucher for shelter, but only for the number 

of days (usually one to three) that it takes for the family to meet with the rapid exit coordinator 

for screening. This is a very thorough screening that requires about one hour and covers a wide 

range of housing barriers. (This housing barrier screening is more fully described in Chapter 

Four.) The county has established four levels of housing barriers and tries to reserve emergency 

shelter only for families at the two highest levels. Since instituting rapid exit screening 

procedures in 2001, representation of the two lowest levels has decreased from 55 percent in 

1995 and 43 percent in 1998 (before the procedures began) to 2 percent in 2003. 

Components and Organization of the Community Strategy 

Family homelessness prevention services are organized separately from family shelter services. 

All are funded through county contracts and managed and monitored by the FHPAP Umbrella 

Program manager. The Umbrella Program is also overseen by an Advisory Committee that 

serves many useful functions, from reviewing proposals and contract performance, to lobbying 

the legislature, to participating in strategic planning for the county’s FHPAP. 

Seventeen nonprofit agencies run the prevention services. They are organized by geographical 

catchment areas, with families being served only by the agency covering the area of its current or 

most recent address. These agencies screen families and decide which families should receive 

prevention assistance, and what types of assistance they should get. Contact between FHPAP 

prevention providers and families around a threat of housing loss is usually relatively short 

(several months at the most, and usually less), although families may use other services of the 

same agency (e.g., food, clothing, and transportation assistance) at other times. If a family needs 

a service that a particular FHPAP provider does not offer (e.g., car repairs, certain types of job 

training, or adult basic education), the providers refer among themselves to an agency that does 

have that service. FHPAP providers try not to duplicate these specialized services, and each has 
Chapter Two Summary Descriptions of Sites 

15

its specialties. In Minneapolis, FHPAP cash assistance is a grant; in the suburbs the prevention 

providers decided it should be a loan. Suburban families who received assistance are now 

repaying about $40,000 each year to the program, and many say they are happy to be able to help 

other families in trouble as they once were. 

All families receiving county-vouchered shelter go to one 116-unit facility in Minneapolis. The 

county pays this facility for sleeping accommodations and three meals a day, but not for services. 

All services to homeless families are contracted to nonprofit agencies offering rapid exit 

services. The rapid exit coordinator, who did the intensive screening, will refer the family to a 

rapid exit program that does all services. This structure evolved from the county’s belief that it 

was smarter, and avoided even an apparent conflict of interest—to separate the work of 

providing shelter from the work of helping people leave shelter. The rapid exit agency assigns a 

caseworker to work with the family to develop a housing stabilization plan. The plan includes 

action steps and timetables; continued shelter stay is contingent on the family cooperating with 

the rapid exit caseworker and the plan. 

The rapid exit caseworker attends mostly to the housing portion of the plan and uses community 

resources for additional services. Ongoing services are coordinated by a Shelter Team worker 

who is responsible for identifying other county services with which the family is involved (e.g., 

public assistance, employment services, child welfare, and services to the disabled), notifying 

county caseworkers that the family is in shelter and is receiving housing services, and 

coordinating the family’s various service requirements. The rapid exit caseworker helps the 

family find housing, leave shelter, and stabilize and sustain housing through six months after the 

family leaves shelter. 

All FHPAP contracts are awarded annually based on responses to a very carefully worded 

request for proposals (RFP). Numbers of families to serve and expected outcomes are specified. 

Agencies may “do what it takes” with FHPAP resources to achieve those outcomes. FHPAP 

does not monitor types and amounts of services delivered, only outcomes. Some agencies thrive 

in this environment, while others do not. The FHPAP manager uses performance data to identify 

successful agencies and reward them with continued contracts. Agencies that do not achieve the 

required outcomes receive assistance to correct their performance. If performance does not 

improve, the contract is not renewed. The Advisory Committee’s involvement with this process 

helps to keep it as peaceful as possible. 

Data Collection and Use 

The Human Services Department contracted with the Wilder Foundation, a local research 

organization, to develop and maintain an automated client database to meet FHPAP program 

needs. All FHPAP providers currently use this database. Agencies maintain current and historical 

data on the characteristics of the client families and the services they receive. Caseworkers can 

see the service history of their clients, and can also check to see if the client has received services 

from other FHPAP providers. FHPAP agency managers track their own agency performance for 

clients served, service history, resource use by funding source and month, client flow from 

month to month, outcomes achieved (for rapid exit providers, these include shelter exit and 

months of maintaining housing), and other managerial issues. 
Chapter Two Summary Descriptions of Sites 

16

Every month, FHPAP agencies copy their databases and send them to the Wilder Foundation, 

where the database manager assembles them into a system-wide database. The system manager 

routinely uses this system-wide database to assess program performance, both overall and for 

each agency. She checks for possible duplication of services, funding drawdowns, and client 

outcomes, among other things. Each year, FHPAP data are compared to the county’s records of 

families using emergency shelter to determine if families who received prevention or rapid exit 

services had a shelter episode during the 12-month period following their receipt of assistance. 

The system manager also uses FHPAP data to monitor if the provider agencies achieved the 

outcomes specified in their contracts for services. 

 

Relationship to CoC Process and HMIS 

Individual FHPAP providers and the Umbrella Program manager participate in the CoC planning 

and application process, but another agency has the lead. The FHPAP data system was developed 

before the advent of HMIS. The data system contains the data elements required for HMIS, but 

also contains other data elements that are useful to FHPAP. The program was told to use HMIS, 

rather than uploading relevant data from its own system. To maintain its own operation, which 

depends on using its own data system, FHPAP is now doing double data entry to retain its own 

system while complying with HMIS demands. 

MONTGOMERY COUNTY, MARYLAND 

For more than 20 years, Montgomery County government, in partnership with the nonprofit 

community, has provided funds and services to prevent evictions for those at risk of 

homelessness. With respect to family homelessness, the County Council has a long-standing 

policy (since 1987) that no family spends a night on the streets; it supports this policy by paying 

for shelter. The extreme pressure of housing costs in the county, and the commitment to shelter 

every family who applies for assistance, drives the response to families in crisis in Montgomery 

County. The county has a unified system for access to homelessness prevention, emergency 

shelter, and transitional housing for families. The lead agency is the Montgomery County 

Department of Health and Human Services (MCDHHS), which is also the lead agency for the 

county’s CoC. 

Developing the Commitment to Prevention 

Montgomery County began serving families and individuals at risk of homelessness during the 

early 1970s, but these services took several years to evolve into a community-wide approach to 

homelessness prevention. Early on, responsibilities were split between a state and a county 

agency. The state Department of Social Services provided eviction prevention services to help 

families and individuals with past due rents and utility bills, while the county’s Department of 

Family Resources partnered with the nonprofit community to develop and provide emergency 

shelter. In 1987, new leadership at the Department of Social Services recognized that prevention 

was an essential part of a continuum of services to address the growing problem of 

homelessness. The local office of the Department of Social Services assumed leadership for both 
Chapter Two Summary Descriptions of Sites 

17

the prevention services and the contractors providing emergency shelter services, but initially 

only for families. This was the genesis of the unified entry system for homelessness prevention, 

placed in the new Department of Social Services, Division of Emergency Services. 

During 1995, the nonprofit community organized the Emergency Assistance Coalition. This 

coalition coordinates a regional network of 40 nonprofit agencies that work with the county to 

distribute public and private resources to prevent eviction. This public-private partnership is the 

basic structure of family homelessness prevention activities in Montgomery County today. 

Also during 1995, another public agency reorganization occurred, bringing what had been a state 

agency’s local office for social services together with three county human services agencies 

(health, mental health, and family resources) to form the MCDHHS. This move officially united 

homelessness and other social services, which improved the access of families and individuals to 

an array of important services. The move also brought together agency directors and staffs that 

often had their own ideas. No single leadership structure has yet emerged to make system-wide 

assessments of resource availability, identify the points of maximum payoff for investing those 

resources, and orchestrate the changes that would be needed to shape a more efficient primary 

and secondary prevention system. 

Population Served, Targeting Practices 

MCDHHS provides emergency services to any family or individual who requires financial 

assistance to remedy an eviction, foreclosure, or utility disconnection. When the system 

combining family prevention and shelter began in 1987, the first and most important change 

involved establishing triage, screening criteria, and priorities for which families would be 

sheltered and which would receive prevention assistance. The county established standardized 

procedures to assess level of need and develop a service plan, placing the responsibility on the 

family to address the issues that led to its homelessness. 

Screening criteria include having a verifiable county address and being in a short-term financial 

crisis rather than an ongoing condition. Prevention efforts focus on families or individuals whose 

inability to pay rent stems from a temporary illness, job loss, or other short-term problem, and 

for which returning to work or a new job or income source is verified. The MCDHHS 

Emergency Services worker determines that the family will be able to maintain housing 

following receipt of the cash payment and other assistance for one month. The worker assesses 

the precipitating factors that led to the housing crisis and reviews the family’s income sources 

and budget to determine the feasibility of paying housing costs in the future. The family develops 

a service plan and agreement with the worker to resolve the housing crisis and must complete 

required action steps of the service plan before payment is authorized to the landlord or utility 

company. For example, a family member may be required to attend drug screening or treatment, 

obtain credit counseling, or apply for income supports and entitlements. 

The screening process for access to congregate shelter services is more comprehensive than the 

screening process for eviction prevention assistance, to ensure that emergency shelter is offered 

only as a last resort to those families with the most serious barriers to housing. MCDHHS will 

not provide financial assistance if a client at risk of eviction or foreclosure has arrears in excess 
Chapter Two Summary Descriptions of Sites 

18

of several thousand dollars. Further, if the client or family is involved in a recidivist situation and 

has never followed through on a service plan to resolve the crisis, MCDHHS may deny 

assistance. Households with financial crises that exceed the department’s guidelines receive a 

referral to the nonprofit Emergency Assistance Coalition, which is a group of nonprofit agencies 

that may provide eviction prevention funds, utility assistance, food, clothing, transportation, and 

other goods and services. 

Components and Organization of the Community Strategy 

Families must apply in person for emergency assistance or shelter at one of the three regional 

county centers. Social workers screen clients, determine needs, enter relevant data into the 

MCDHHS client database, and make the relevant referrals or service linkages. Access to 

homelessness prevention services is co-located with assessment for shelter services. In addition, 

co-locating homeless prevention services with mainstream services provides access to screening, 

history, and eligibility determination information not only for emergency assistance but also for 

mainstream resources such as Temporary Assistance for Needy Families (TANF), medical 

assistance, and food stamps. 

Most of the actual services and supports available to families facing housing loss in Montgomery 

County are provided by a network of nonprofit agencies organized through the Emergency 

Assistance Coalition. In addition to the usual range of services, MCDHHS works extensively 

with landlords and with the Housing Opportunities Commission (the county’s public housing 

authority) to negotiate accommodations on the part of both landlords and tenants to prevent 

eviction. 

Data Collection and Use 

The county collects data on recipients of emergency housing assistance using three automated 

systems. One system tracks clients, a second distributes payments, and a third manages shelter 

and other contracted services. The nonprofit agencies do not have access to the county systems, 

but the county uses them for a variety of management functions. MCDHHS also routinely checks 

against the Sheriff’s eviction database to see if households that received prevention assistance 

were able to retain their housing. 

For the past five years, the department has used a manual process to track the outcomes of 

emergency assistance recipients. Client data are obtained from several systems to determine the 

outcomes for those who have used shelter. As part of this study, data sets were merged to 

determine the percentage of people who entered emergency shelter within 12 months following 

the prevention intervention. 
Chapter Two Summary Descriptions of Sites 

19

Relationship to CoC Process and HMIS 

MCDHHS is the lead agency for the unified system for access to homelessness prevention, 

emergency shelter, and transitional housing for families and is also the lead agency for the 

county’s CoC. The Homeless Tracking System for Montgomery County does not include data on 

clients receiving emergency assistance or prevention services. 

MID AMERICA ASSISTANCE COALITION 

The Mid America Assistance Coalition (MAAC) includes more than 175 nonprofit agencies that 

share the goal of improving emergency assistance services for low-income and homeless 

individuals in the greater Kansas City metropolitan area. Each of the social service agencies 

associated with MAAC provides a variety of services under its own budget. All agencies provide 

assistance with utilities payments as the primary homelessness prevention intervention. Services 

are coordinated using a shared information system. The goals and prevention strategies of 

MAAC have remained stable over the years of its existence, with the major change being the 

increasing number of agencies that have joined the network. The nonprofit agencies in MAAC 

do not have any significant public allies in pursuing their goal of preventing homelessness. 

Developing the Commitment to Prevention 

As early as 1974, nonprofit agencies in the Kansas City metropolitan area that were offering 

emergency assistance services saw the need to organize among themselves to prevent clients 

from bouncing among providers and to assure nonduplication and efficient use of shrinking 

resources. During 1975, the first alliance of 21 agencies convened, with increasing numbers 

joining over the years until they created a new nonprofit, the Mid America Assistance Coalition, 

in 1984. MAAC’s goal, shared by member agencies, was to improve emergency assistance 

provision to low-income and homeless individuals. To this end, MAAC merged centralized 

client tracking and information and referral services to improve accounting for services and 

payments, creating the data system known as MAACLink. 

 

Funding agencies applauded this move, which they saw as helping to avoid duplication of 

services and track case management and funding accountability. Agencies participated in 

defining data system elements and information to track as well as management outcomes to 

report. This data system is the heart of MAAC and also defines the scope of collaboration. The 

data system has been upgraded numerous times, and new agencies have joined MAAC. Both the 

goal and the activities offered to reach it have remained consistent over the years. MAAC, and 

the homelessness prevention efforts in the greater Kansas City area, have not enjoyed significant 

participation or leadership from any public agency. 
Chapter Two Summary Descriptions of Sites 

20

Population Served, Targeting Practices 

This study concentrated on MAAC’s efforts to prevent homelessness among families, although 

single individuals are also eligible for the services of network agencies. There is no single point 

of entry for MAAC clients, but neither is there any wrong door. MAACLink allows a family to 

walk into any agency and either receive services or a referral to another agency that can provide 

services. 

When a client enters a MAACLink agency, a staff person conducts a standard intake of basic 

client demographics. The major reason for screening someone out is too high an income (usually, 

above 150 percent of the poverty level) or too frequent or too recent use of a service similar to 

what is being sought. The agency also assesses the match between need and available assistance; 

if a client’s need is more than the rent, mortgage, or utility payment the MAAC agency is 

authorized to make, referrals to more sustained help may be made instead of giving cash 

assistance. As is the case in Hennepin County and Montgomery County, MAAC agencies are 

looking for families with relatively short-term and limited need, albeit also those facing a crisis 

such as utility shutoff or eviction for nonpayment. 

Components and Organization of the Community Strategy 

MAAC’s nonprofit social service and emergency assistance agencies operate independently but 

are linked through the MAACLink data system. Services offered within the system include 

counseling and advocacy, in-kind assistance, and cash assistance for rent, mortgage, or utility 

payments (the activities listed in the first four rows of Exhibit 1). Some MAAC agencies also 

offer emergency shelter. 

In addition to using MAACLink for screening, workers also use MAACLink to identify other 

pertinent service agencies that can provide services (within certain confidentiality restrictions). If 

a family’s situation is beyond prevention, agencies can check shelter availability on MAACLink 

and refer the family to the appropriate shelter facility. MAACLink is thus the primary form of 

organization for member agencies. Although member agencies occasionally participate in 

collective advocacy for more resources, no system-level planning or strategy development 

activities are a significant part of MAAC. 

Data Collection and Use 

The MAACLink data system is MAAC’s main contribution to preventing homelessness. The 

system’s capacity for data collection and analysis is broad. Any MAAC agency can see a client’s 

service history including rental, mortgage, or utility assistance, as well as other services such as 

food, transportation, case management, or bed nights at a homeless shelter. Any service provided 

by any MAAC agency is recorded, making it easy to determine how frequently and recently a 

family received assistance as well as if the family has sought help from different agencies. Other 

unique aspects of the system include the ability to manage eviction prevention funds across the 

system so that workers can accurately refer clients; and the ability to view homelessness 

prevention and homeless shelter use in the same data system. 
Chapter Two Summary Descriptions of Sites 

21

MAAC produces many routine reports in two major areas: services and fund utilization. Some 

reports describe clients, by demographics and service use. Others describe fund utilization, by 

fund (MAAC agencies manage more than 20 different emergency assistance funds) and the type 

of services it paid for, by agency, and many other breakouts. These reports are used by program 

managers to monitor and control expenditures, prevent duplication of services, and report to 

funders. Until the study team visited this community, however, the MAACLink data had never 

been used to see if families receiving assistance to prevent homelessness actually stayed out of 

emergency shelters for the 12 months after they received aid. 

Relationship to CoC Process and HMIS 

The Homeless Services Coalition, an organization of homeless service providers, coordinates the 

greater Kansas City region’s response to homelessness. Each county in the region pursues its 

own CoC planning and application process, and all adopted the MAACLink system as its HMIS 

in 2002. Of the six study communities, only MAACLink tracks both prevention and homeless 

services in the same HMIS. Sharing these data and the interagency communication channels 

have become the foundation for the region’s CoC planning process. 

MASSACHUSETTS DEPARTMENT OF MENTAL HEALTH 

The Massachusetts Department of Mental Health (DMH) has invested heavily, both directly and 

indirectly, in addressing homelessness among persons with serious mental illness. Elements of 

homelessness prevention are present throughout the department’s multifaceted system of 

inpatient and outpatient continuing care. Most of the department’s core services are relevant to 

homelessness associated with serious mental illness. In addition, the department sponsors various 

initiatives to prevent first-time homelessness, to identify and move newly homeless clients or 

potential clients quickly out of homelessness, and to avoid chronic homelessness. The 

department’s prevention efforts are supported primarily with state-appropriated funds, which the 

department uses to leverage the U.S. Department of Housing and Urban Development (HUD) 

and the U.S. Department of Health and Human Services (HHS) resources in its role as the lead 

agency for the CoC covering all areas of the state not included in city CoCs. Many of the 

department’s prevention efforts are conducted through contractual arrangements with nonprofit 

and for-profit providers. 

Developing the Commitment to Prevention 

DMH began to focus on homelessness among its clients during the early 1990s, recognizing that 

people were leaving state hospitals without adequate housing arrangements. In 1991, advocates 

and shelter operators in the Boston area documented a surprisingly high number of people in 

shelter who had come directly from mental hospitals. Strong advocacy parlayed this information 

into the first Homeless Initiative, providing DMH with $1 million in 1992 to “do what it takes” 

to prevent or end homelessness for people with serious mental illness. Advocacy, coupled with 

DMH leadership and positive results from DMH activities, has sustained state commitment. 

DMH has been rewarded with steadily increasing state appropriations for the Homeless 
Chapter Two Summary Descriptions of Sites 

22

Initiative, reaching $22 million in recent years. DMH has additional service resources as part of 

its regular budget as well as access to capital resources for housing development from state 

funds. The capital resources are designed to move the investments once made in state mental 

hospitals into the community. 

The department established homelessness prevention as a legitimate and important goal, which 

makes it one of only a few state mental health agencies to do so. It undertakes regular staff 

training to reinforce the attitude that “housing is a clinical issue,” meaning that appropriate 

clinical treatment cannot happen when clients are homeless or insecure in their housing. Over 

several years, the high risk of homelessness among people with serious mental illness and the 

need for a coordinated and strategic prevention approach were identified as critical issues. 

Closings of state hospitals, the continued pressure of advocates, and ongoing negotiations among 

various agencies maintained the issue in the public agenda. 

DMH’s strategy for homelessness prevention is multifaceted, based on the recognition that 

people with serious mental illness may face the risk of homelessness from various causes. 

Supportive services to keep people in housing, respite beds to relieve caretakers, caseworkers to 

monitor stability and identify problems early, and providing housing are all activities that may 

keep people from becoming homeless for the first time or a subsequent episode. Discharge 

planning, coupled with developing housing to provide discharge options, prevents homelessness 

for people who were homeless at hospital admission or who lost their housing while hospitalized 

for an extended period of time. Outreach to find homeless people with serious mental illness who 

are not yet DMH clients shortens homeless spells for both first-time and chronically homeless 

people. DMH has pursued all of these activities. Most importantly, it has systematically 

developed an extensive network of housing options, leaning heavily toward the independent and 

semi-independent living situations that clients prefer and away from group homes. 

DMH has used its extensive funding and strong leadership to pursue a long-term strategy of 

system development that has been sustained through three commissioners, as many governors, 

changes of political party, and state budget crises. Its strategy involves leveraging Federal 

funding with its own resources; the Homeless Initiative’s $22 million annually of state funding 

leverages about $85 million in Federal funding each year. DMH also has strong collaborative 

relationships with other state agencies that control additional resources (e.g., health, community 

development, housing finance, public housing authorities, employment and training, corrections). 

Some examples of these collaborations are listed below. 

• An agreement with MassHousing, the state’s housing finance agency, ensures that 3 

percent of all units developed with MassHousing financing are directed to DMH and the 

Department of Mental Retardation to house people with serious mental illness or mental 

retardation. DMH clients now lease more than 400 such self-contained, scattered-site 

units. 

• An agreement is in place with the Massachusetts Department of Housing and Community 

Development to operate several state-funded programs. Among these are a rental 

assistance program serving more than 600 DMH clients, a bricks and mortar housing 

development program through statewide Department of Housing and Community 

Development grants to local housing authorities for DMH and Department of Mental 
Chapter Two Summary Descriptions of Sites 

23

Retardation clients with a DMH capacity of more than 600 clients, and special projectbased voucher allocations to DMH housing development projects. 

• The Massachusetts Department of Housing and Community Development operates the 

Facilities Consolidation Fund bond program, providing grants and loans to nonprofit 

developers to develop DMH and Department of Mental Retardation housing and to house 

homeless persons with serious mental illness. The Fund was established in 1992 with 

bonding authority to invest capital into community-based housing instead of state 

hospital campuses. DMH has used the Fund to help develop 83 housing projects for 658 

of its clients. 

• Agreements with the state’s Department of Capital Asset Management ensure housing for 

DMH clients as part of rental housing projects being developed on five former DMH 

state hospital campuses. 

• Area housing coordinators for local Continuums and DMH central office staff participate 

in the CoC application process through DMH. 

• DMH collaborations with Housing Courts, MassHousing, and some local housing 

authorities have created several Tenancy Preservation Projects throughout the state. 

Tenancy Preservation Projects mediate in landlord-tenant conflicts in which tenants with 

serious mental illness or substance abuse issues are threatened with eviction. 

DMH’s funding has helped to create partnerships with nonprofits to develop permanent housing 

with supportive services, supports for community living such as Assertive Community Treatment 

teams and Clubhouses, and employment and training opportunities. It also contracts for health, 

mental health, and substance abuse services with a for-profit managed behavioral health care 

organization, leveraging Medicaid dollars with its own resources for those who do not qualify for 

Medicaid. 

Population Served, Targeting Practices 

DMH estimates that approximately 48,000 adults in the state have serious mental illness—the 

department serves the most disabled and the poorest. Its clients’ incomes hover around 

15 percent of the area median income and most clients are not employed. These circumstances 

leave them vulnerable to homelessness should hospitalization or loss of a caretaker disrupt their 

housing arrangements. Targeting is a matter of clinical assessment to determine if a person’s 

mental illness meets state and Federal criteria for becoming a DMH client. DMH outreach teams 

actively look for clients and potential clients among homeless people on the streets and in 

shelters. Identification of potential clients triggers further assessment, formal enrollment as a 

DMH client, and efforts to help the person move to safe and stable housing. The characteristics 

that make a person DMH-eligible signify a level of disability indicating a high risk of 

homelessness if the person has no family or obvious means of support. 
Chapter Two Summary Descriptions of Sites 

24

To reach homeless people, DMH locates mental health services at the four largest traditional 

shelters in the state, all operated in Boston by private agencies. These services help shelter guests 

directly, but also make referrals to other services to help guests determine if they are eligible for 

DMH continuing care services. If eligible, their prospects for ultimately becoming housed and 

receiving ongoing community supports through DMH increase substantially. 

DMH also has developed transitional shelters affiliated with Metro Boston’s mental health 

centers. These transitional shelters are better prepared than generic shelters to keep people with 

serious mental illness safe and help them handle their mental health and other issues. Every 

effort is made to move homeless people with serious mental illness from traditional emergency 

shelters and the streets to more appropriate settings such as these transitional shelter facilities 

and, ultimately, into permanent housing. 

Components and Organization of the Community Strategy 

Since this “community” is an entire state and DMH has responsibility for all of it (counties have 

little effective role in Massachusetts), its structure of services and oversight is more complex 

than the other communities included in this study. 

The importance DMH places on housing is signified by having a Housing Coordinator in all six 

of the state’s Service Areas, as well as three staff at the state level focused on housing. All 

participate in the CoC planning and application process, which DMH leads for the balance-ofstate application. DMH-affiliated housing has grown from about 2,750 units in 1991 to about 

7,650 units in 2004, while changing the mix from mostly group homes to mostly independent 

and semi-independent living, which clients greatly prefer. DMH uses its housing options at every 

level of prevention, and provides supportive services in the community to help people maintain 

their current housing. Secondary prevention efforts are coordinated through outreach to people 

on the streets and in shelters. People with serious mental illness are identified when they first 

become homeless and become DMH clients if they are not currently being served. The agency 

helps these individuals to move to safer and more appropriate accommodations, including 

permanent housing with supportive services. 

DMH interventions span the entire range of primary, secondary, and tertiary homelessness 

prevention services. Specialized DMH shelters offer short-term solutions that are safer and more 

appropriate than ordinary shelters for people with serious mental illness. Discharge planning and 

housing assistance are offered to individuals leaving inpatient care or people with serious mental 

illness leaving correctional facilities who are at imminent risk of homelessness, are currently 

homeless, or have been homeless. Community supportive services help people maintain housing 

regardless of their history of homelessness. Housing Courts work with DMH-funded local 

mediators to seek solutions with tenants and landlords to prevent eviction and subsequent 

homelessness. Evidence analyzed for this study indicates that these tenancy preservation 

activities do reduce the incidence of homelessness. 
Chapter Two Summary Descriptions of Sites 

25

Data Collection and Use 

DMH maintains extensive data in multiple databases and case records. Its commitment to 

resolving homelessness among its clients is attested to by the modification of its statewide client 

database during the early 1990s. At the time, DMH added fields for recording homelessness at 

admission and at discharge. In a system as large as DMH, it was no surprise that the pertinent 

data for this study’s purposes was dispersed among various information systems and various 

locations. One analysis for the current study tracked the number of homeless admissions and 

discharges from continuing care facilities. The analysis found reductions in homelessness at 

admission and even greater reductions in discharges to homelessness between 1991 and 2004. 

DMH staff working with clients have always had access to client records for treatment purposes, 

but until recently the department had not systematically documented its success at preventing 

homelessness or used data for system improvements. DMH uses discharge and related data to 

focus on several fronts. The Metro Boston area office uses its discharge data to assess how well 

its current system is performing, and to identify gaps in resources as well as populations not 

currently served that need assistance. Results lead to efforts to fill gaps. Data from the Western 

Massachusetts Tenancy Preservation Project has been used to argue for more interagency 

recognition and support for expanding that program and related Tenancy Preservation Projects 

throughout the state. 

Some new data uses emerged following work on this project, including: 

• DMH has made major changes and updates to its overall client enrollment and services 

tracking data system, including new and revised definitions for homelessness, at risk 

homelessness, former homelessness, and discharge destinations. 

• DMH has made arrangements with its central information system director to get routine 

reports on clients who are homeless upon application for eligibility for DMH services. 

These people will be tracked to learn how effectively DMH can house them, what 

services work best, if they are rehospitalized, and the like. 

• Another direct outcome of working with the study team is that DMH is working with 

DMH Area Offices to confirm that DMH clients who were reported as discharged to 

homelessness actually were and, if so, to explain how this happened. DMH has never 

done this before and expects to make it a regular practice. The central office monitors 

local DMH discharges to homelessness; learns about the situations that might lead to 

these discharges; and highlights gaps in local use of the statewide information system, 

which could lead to misinterpretation and miscoding of discharges. 

• Data on homelessness prevention are also being used to inform workshops and 

workgroups associated with Boston’s project under the HUD/HHS/Veterans 

Administration Chronic Homelessness Initiative and to stimulate improved data sharing 

and client tracking across public systems. 
Chapter Two Summary Descriptions of Sites 

26

Relationship to CoC Process and HMIS 

DMH staff in all areas have participated in local CoC processes since their inception; DMH 

participates at the state level in the balance-of-state application, for which the Department of 

Transitional Assistance is the lead agency. Much of DMH’s permanent supportive housing is 

financed in part through McKinney-Vento funds. The Department of Transitional Assistance 

runs the state’s HMIS. DMH data systems run independently of HMIS, although any housing 

projects funded with Supportive Housing Program dollars contribute data to HMIS. 

PHILADELPHIA, PENNSYLVANIA 

Philadelphia has a long history of organizing to address homelessness, and an even longer 

history of organizing to address the needs of people with serious mental illness and other 

behavioral health issues. Strategies, programs, and services in the homelessness and behavioral 

health systems often overlap, in recognition that the same people are often clients of both 

systems. For this study, the study team concentrated on the role of the city’s Office of Behavioral 

Health (OBH) in developing and implementing homelessness prevention activities for its 

clients.11 

Developing the Commitment to Prevention 

Preventing and alleviating homelessness among people with serious mental illness has been on 

the agenda in Philadelphia for a very long time. Several mayors have supported strong city 

investment in social services and behavioral health services, and have appointed dynamic staff to 

make these services work. Respondents frequently mentioned the influence of Estelle Richman, 

who for at least 10 years increased her breadth of control until she became the Deputy Managing 

Director for Social Services before moving to the state level when the mayor who appointed her 

became governor. 

Richman’s creative bureaucratic negotiations during the mid-1990s established the city’s 

Behavioral Health System, which is now formalized as OBH. OBH comprises the Office of 

Mental Health, the Coordinating Office of Drug and Alcohol Abuse Programs, and Community 

Behavioral Health, the city’s own Medicaid managed behavioral health care system. Together, 

these agencies offer prevention, outreach, substance abuse, and mental health services for people 

with serious mental illness or substance abuse problems. Services are delivered largely through 

contracts with nonprofit agencies. 

Richman saw from the beginning that housing was part of the solution to preventing 

homelessness among people with severe behavioral health problems. The directors of the Office 

of Mental Health and Coordinating Office of Drug and Alcohol Abuse Programs, who ultimately 

answered to her, supported development of housing and service options that continue to play 

preventive roles in keeping disabled people off the streets. Many city officials interviewed by the 

 

11 The history, structure, and accomplishments of the homeless assistance system in Philadelphia, especially in 

reducing chronic street homelessness, were examined in a previous study (Burt et al., 2004). 
Chapter Two Summary Descriptions of Sites 

27

study team considered themselves to be following Richman’s example, “doing the right thing” 

first and handling bureaucratic consequences if and when they arise. 

Outreach efforts to assist mentally ill homeless people on Philadelphia’s streets, especially 

women, began during the early 1980s and expanded significantly during the late 1990s with the 

strong support of OBH. In the last five or six years, outreach has been combined with Safe 

Havens, permanent supportive housing, and other supports to create a complex system. Recent 

efforts under OBH guidance focus on preparing for an individual’s moment of release from an 

institution such as jail or a psychiatric inpatient setting. They attempt to build supports, including 

housing, that will prevent entry or re-entry into homelessness. 

During May 2004, Community Behavioral Health was in the final stages of developing standards 

for discharge planning that will span several agencies. These agencies will include the OBH 

agencies (covering people with mental illness, mental retardation, developmental disabilities, and 

substance abuse), homeless services, child welfare, and the county jail. The process of 

integrating services began in 2002, following the recognition that many clients had serious 

mental illnesses in addition to the problems that brought them to the attention of the various 

agencies. When the study team visited Philadelphia most of the envisioned prevention efforts had 

been implemented only recently or were just getting started. 

Population Served, Targeting Practices 

Eligibility for OBH services is determined through detailed screening and assessment 

procedures. For people with serious mental illness, these procedures are geared toward 

identifying a level of mental illness that meets carefully defined criteria established by Federal 

and state standards for reimbursement under Medicaid and several additional funding streams. 

One does not have to be an OBH client at first contact to access OBH services, but one does have 

to meet eligibility criteria eventually. As these criteria include establishing a significant level of 

disability, they also serve to screen in people whose risk of homelessness, if left to them, is likely 

to be high. 

Working with agencies that were involved in developing the discharge planning standards, OBH 

is beginning to develop strategies to prevent homelessness. A first step, data sharing to identify 

people at risk of homelessness, is happening between OBH and child welfare, the county jail, 

and homeless system intake. Clients identified through these mechanisms are connected to case 

workers. For child welfare this means learning that a parent’s or child’s serious mental illness is 

part of the reality of resolving a family’s problems, so more appropriate solutions can be 

developed. For people with serious mental illness leaving jail or prison, OBH caseworkers help 

to find housing and assure some support in the community. 

Another access point is at shelter intake, where OBH’s efforts involve secondary prevention. A 

person seeking shelter who appears to be mentally ill may be referred to special psychiatric 

shelter intake units operated by the Office of Mental Health. In addition, OBH is starting to place 

triage staff at shelters to increase identification of persons with psychiatric impairments. The 

objective is to divert such persons to specialized shelter environments, where they can receive 
Chapter Two Summary Descriptions of Sites 

28

assessments and services from OBH. This activity is designed to offer secondary prevention—

keeping the period of homelessness as short as possible. 

Components and Organization of the Community Strategy 

OBH serves individuals with serious mental illness whether or not they have had prior episodes 

of homelessness. Residential options and assistance to find stable housing are part of the service 

package, based on the belief that if OBH did not offer these types of support, these individuals 

would be homeless or very likely to become homeless, since they are both sick and very poor. 

Within OBH, the Office of Mental Health and the Coordinating Office of Drug and Alcohol 

Abuse Programs participate in both the regular behavioral health system and the homeless 

continuum of care for people with serious mental illness. 

OBH agencies offer, usually through contracts with nonprofit agencies, the entire range of 

services one would expect of a public behavioral health agency. These include specialized 

emergency rooms; a variety of acute and extended inpatient settings; detoxification, hospitalbased rehabilitation, and residential rehabilitation programs for substance abusers; respite and 

crisis beds and residences; outreach; Safe Havens; and nearly 3,000 residential beds in a variety 

of settings from no-demand to locked facilities. 

For at least the past year, OBH and its component offices have been engaged in efforts to prevent 

homelessness among its clients with serious mental illness who are in the city jail or a state 

prison. Case management and other services are designed to connect people to appropriate 

housing in the very likely event that they will not be able to return to a previous residence. 

Linkages with other city agencies (child welfare, homeless assistance) to identify and intervene 

with people at risk of homelessness are also part of the organized community approach under the 

general leadership of OBH. They were described above. 

Data Collection and Use 

Philadelphia is well known for its long-standing database with information regarding people 

using public shelters. Researchers at the University of Pennsylvania work with the city to link 

shelter, behavioral health, welfare, and corrections databases, and answer questions that are 

important for shaping public policy. Several public information systems contain data pertinent to 

the issue of primary and secondary prevention of homelessness among people with serious 

mental illness. These include databases on people leaving hospitals, people receiving housing 

through OBH agencies, people using shelters, and people being contacted by street outreach. 

At present, staff working with households using any one of these systems may use their own 

system to assess the household’s current status, receipt of services, place of residence, and other 

matters important to case management. OBH managers use the OBH database to decide whether 

to authorize additional services, analyze service use by individuals and for the client base as a 

whole, and in many other ways. OBH and child welfare caseworkers have recently gained the 

ability to check each other’s data systems to determine if the client of one agency is also the 

client of the other, and to alter case plans accordingly. OBH also has the capacity to check the 
Chapter Two Summary Descriptions of Sites 

29

homeless shelter database to ascertain homeless status or history for its clients. There is potential 

for increased use of these integrated data. Especially relevant for homelessness prevention would 

be the ability to match to the shelter database to determine if, after intervention, people 

experience homelessness and apply for shelter. However, this type of outcomes analysis is not 

happening routinely, and city analysts were unable to conduct these cross-system analyses for 

this study. 

Relationship to CoC Process and HMIS 

OBH staff participate in Philadelphia’s CoC process. Much permanent supportive housing in 

Philadelphia is financed in part through McKinney-Vento funds, including some affiliated with 

OBH. The Office of Adult Services is the lead agency for HMIS. OBH data systems run 

independently of HMIS, although any housing projects funded with Supportive Housing 

Program dollars already do, or will, contribute data to HMIS. 

URBAN PEAK

Urban Peak is a private nonprofit agency in Denver and Colorado Springs serving homeless and 

runaway youth as well as other youth who do not have stable or reliable housing. It provides a 

full continuum of services for homeless youth, and owns and operates permanent supportive 

housing for youth who want to leave homelessness. Urban Peak started as a small agency in 

1988. Over the years, it has established collaborations with other service providers and gained a 

reputation through advocacy and persistence as the cornerstone and organizational heart of the 

Denver area’s efforts to end youth homelessness. It is an example of what can be accomplished 

by way of secondary and tertiary homelessness prevention without the significant involvement of 

public agencies that four of the other communities in this study enjoyed. 

Developing the Commitment to Prevention 

In response to the increasing number of homeless youth gathering in the Denver area, Urban 

Peak opened during 1988 with a small annual budget provided by the Capital Hill United 

Neighborhood Association. At that time, the agency provided only food and basic counseling 

services. During 1992, the agency incorporated and expanded services to include a 20-bed youth 

shelter. Its focus from the beginning has been the population of street youth and other youth with 

no stable or reliable housing visible on the streets of Denver. 

The story of Denver’s strategy for youth homelessness is really the story of how a nonprofit 

agency, Urban Peak, strategized its way from its own tiny beginnings to today’s complex of 

services for homeless youth offered through its own programs and those of its collaborators 

throughout the Denver area and extending to Colorado Springs. During 2002, the General 

Assembly of the State of Colorado established an Office of Homeless Youth Services. One of the 

architects of Urban Peak’s community collaboration moved into city government as manager of 

the Denver Department of Human Services, reporting to the Mayor of Denver. This department 

has established the Mayor’s Commission to End Homelessness and is working diligently toward 
Chapter Two Summary Descriptions of Sites 

30

this objective; Urban Peak serves on this commission. Urban Peak receives funding from the 

Denver Department of Human Services to operate the emergency shelter, provide street outreach, 

and provide drug and alcohol intervention services. 

Urban Peak uses a strategic planning process to make decisions about its direction, approach, and 

strategies. Leadership and a commitment to intensive planning have provided a blueprint for the 

agency to respond flexibly to new opportunities, the changing needs of youth, budget realities, 

and necessary changes in organizational structure. The clarity of vision also helped identify areas 

where allies and collaborators were needed. Urban Peak has been a leader in assembling Denverarea nonprofit agencies serving youth into a supportive collaboration. In the process, one 

agency—The Spot, a drop-in center—merged with Urban Peak and Urban Peak developed two 

other agencies. Its presence in Colorado Springs grew out of an appeal by an already-interested 

group of service providers, who helped raise money locally to start outreach and a drop-in center. 

Population Served, Targeting Practices 

Urban Peak serves street youth and other youth without stable or reliable housing such as those 

who spend a night or two with different friends or relatives. Since the large majority of the youth 

involved with Urban Peak are already homeless, the activities directed toward them fall into the 

categories of secondary prevention (for those who have not been homeless long) and tertiary 

intervention (for those who have already been homeless for years).12 The study team 

concentrated on these activities. 

Targeting well for secondary and tertiary prevention is much easier than targeting for primary 

prevention. The first criterion is if the person is already homeless; the second criterion is a high 

probability that she or he will remain so without intervention. The homelessness of the youth 

served by Urban Peak is easy to document, and their continued homelessness in the absence of 

intervention is highly likely (especially for the street youth whose homeless spells are already 

long). Street youth typically enter the Urban Peak service system through street outreach 

services, while the “hidden” homeless youth are more likely to enter through The Spot or the 

agency’s shelter facilities. Intake and assessment procedures document homeless history, 

resources, housing barriers, and what would be needed for the youth to leave homelessness. 

Components and Organization of the Community Strategy 

Urban Peak is command central for activities to help homeless youth and those at high risk of 

homelessness in the Denver area. It offers many services itself, links with other agencies to 

augment its own capacity, and receives referrals from its many collaborators. Activities directed 

toward ending homelessness for youth ages 14–24 years are described below. 

 

12 The Spot, a drop-in center founded in 1994, became part of Urban Peak in 2003. It serves a broader clientele than 

Urban Peak’s other services: 46 percent of its youth (ages 14–24) live in temporary situations, but the remainder 

(who are mostly 18 years and older) live with parents, in their own place, or stably with friends. 
Chapter Two Summary Descriptions of Sites 

31

• The Spot offers a full range of drop-in services for homeless and at-risk youth between 

the ages of 14 and 24 years, aimed at improving their quality of life and linking them 

with needed resources. 

• The Urban Peak Outreach Team works throughout metropolitan Denver to build 

relationships with homeless youth to remove barriers that inhibit them from accessing 

services through Urban Peak and other agencies. 

• The emergency shelter and support services at Urban Peak are directed toward youth 

between the ages of 15 and 21 years. Services include overnight shelter, meals, case 

management, education and employment resources, medical and behavioral health 

services, and general drop-in services. 

• The Urban Peak Housing Corporation owns two multiunit buildings and manages another 

for the city of Denver. Two programs that serve eligible youth with disabilities occupy 

multiunit buildings and receive operating support through their tenants’ Shelter+Care 

grants. A third building was developed and is run collaboratively by Urban Peak and the 

Denver Department of Human Services. It houses homeless and runaway youth and is 

subsidized by an HHS Transitional Living Program grant and the state of Colorado’s 

HUD-funded Family Unification Program, which provides Section 8 vouchers for young 

people aging out of foster care. 

• A network of collaborating agencies makes possible many of the services at The Spot and 

Urban Peak. Six agencies offer on-site medical and mental health care, and services 

related to pregnancy and sexually transmitted infections. The Denver Public Schools 

offer General Educational Development (GED) and other educational services. Three 

additional agencies offer transitional housing opportunities to Urban Peak clients. 

Data Collection and Use 

For the past five years, the Urban Peak Client Database has been used to collect and store 

information on the youth who receive services, the services provided, and the costs of services. 

The program also tracks “positive outcomes,” which include leaving homelessness for a variety 

of housing settings from stable arrangements with family to permanent supportive housing. 

Urban Peak case managers and counselors use the data daily to help youth; the executive director 

also uses data to document program outcomes. In addition, Urban Peak has participated in 

several point-in-time surveys to gather information about drop-in clients’ experiences and needs. 

Urban Peak is currently developing a follow-along, Web-based system for youth to report back 

regularly to Urban Peak about their current life situations. 

Relationship to CoC Process and HMIS 

Urban Peak in Denver and Colorado Springs participate in local CoC processes, both for the 

Metropolitan Denver Homeless Initiative and the Colorado Springs/El Paso County CoC. Most 

of Urban Peak Housing Corporation’s permanent supportive housing is financed in part through 
Chapter Two Summary Descriptions of Sites 

32

McKinney-Vento funds. Urban Peak’s data systems will run independently of Denver’s HMIS, 

which has not yet been fully developed. Urban Peak participates in all coordination and planning 

meetings for development of the Denver HMIS. 

SUMMARY 

The six communities selected for this study vary in population focus, size, organization, lead 

agency, and the types and range of prevention activities they offer. They also vary in the degree 

to which they use data to support program planning and evaluation. It is now possible to relate 

the prevention activities of the six communities to the range of prevention activities found 

throughout the United States and displayed in Exhibit 1. This information is summarized in 

Exhibit 3, which occasionally collapses some of the Exhibit 1 categories for ease of presentation. 

Exhibit 3 also categorizes the screening approaches used in the study communities. 

The key to understanding the prevention activities available in each community lies in 

understanding what the different sites are trying to do. The first three rows of Exhibit 3, 

depicting screening activities, reveal the primary differences. The communities aimed at primary 

homelessness prevention for families—Hennepin County, Montgomery County, and MAAC—

are screening to find short-term problems. Although they often discover family issues that cannot 

be resolved with one month of cash assistance, for primary prevention they select the families 

whose housing problems can be resolved with the resources they have available. The other 

communities—Massachusetts, Philadelphia, and Urban Peak—are screening to find the people 

who will need long-term help. They may identify less severely needy people during screenings, 

but they select the ones who need the most help. All other service provision follows from this 

difference, as is obvious from the pattern indicated in Exhibit 3. 

• The communities geared toward primary prevention for families (first three columns of 

Exhibit 3) tend to offer the time-limited crisis intervention services including cash and 

noncash assistance located at the shorter, less-intensive, and less-expensive end of the 

array of prevention activities. The preponderance of blank cells in the last five rows of 

these columns indicates avoidance of the most-intensive prevention activities. 

• The communities targeting persons with serious mental illness and homeless youth (last 

three columns of Exhibit 3) concentrate their resources to offer the long-term, intensive 

interventions that involve permanent supportive housing and housing assistance, located 

at the more-expensive end of the array of options. It is important to note that they also

offer their carefully defined target population virtually all of the prevention activities 

available through the family homelessness prevention approaches. 

It is also important to recognize that some of the more intensive prevention activities serve 

multiple purposes. For example, Massachusetts DMH uses four interventions—mental health 

services, supportive services to maintain housing, rental subsidies, and permanent supportive 

housing—to accomplish both primary and secondary prevention and also to end chronic 

homelessness. That is, supportive and mental health services help keep never-homeless people 

with serious mental illness in housing and also help formerly homeless people stay in their new 

homes. Secondly, the same intervention can be used with different populations. For example, 
Chapter Two Summary Descriptions of Sites 

33

Hennepin County has a well-developed rapid exit program to assist families with multiple 

housing barriers to leave shelter and sustain their new housing. Massachusetts DMH also has a 

rapid exit strategy for people with serious mental illness, whom it identifies among homeless 

people in shelters and on the streets. 

Another important insight one can derive from Exhibit 3 is the relationship between common 

prevention activities and programs that HUD funds within the CoC. Communities already must 

include prevention activities in the continuum they describe in their annual SuperNOFA 

application. However, it is not entirely clear how well integrated local prevention activities are 

with homeless assistance programs funded through the SuperNOFA process. 

Exhibit 3. Homelessness Prevention and Intervention Options 

Prevention Strategies with Families Prevention Strategies with Specialized 

Array of Preventive Populations 

Interventions Hennepin 

County 

Montgomery 

County MAAC Massachusetts Philadelphia Urban Peak 

Screening to Select For: 

 Short-term issues Yes Yes Yes 

 Multiple barriers to housing Yes Yes Yes Yes 

 Chronic homelessness Yes Yes Yes 

Noncash Assistance 

 Counseling and advocacy Yes Yes Yes Yes Yes Yes 

In-kind emergency 

assistance Yes Yes Yes Yes Yes Yes 

Short-Term Cash Assistance for Payments to Obtain or Maintain Housing 

Deposits, arrearages, 

moving costs Yes Yes Yes Yes Yes Yes 

Legal and Other Assistance to Retain Housing 

 Negotiating with landlords Yes Yes Yes Yes Yes 

Housing Court 

interventions Yes Yes 

Training and employment 

assistance and support Yes Yes Yes Yes Yes Yes 

Assistance to get 

entitlements Yes Yes Yes Yes Yes Yes 

Special funds for disabled 

target populations Yes Yes Yes 

Long-Term Intensive Interventions 

 Rapid exit strategies Yes Yes Yes 

Supportive services to 

maintain housing before or 

after homelessness 

Yes Yes Yes Yes 

Mental health and 

substance abuse treatment Yes Yes Yes 

Permanent supportive 

housing Yes Yes Yes 

Mainstream agencies 

assuming housing 

responsibilities for their 

clients 

 Yes Yes 

Affordable housing, 

preferences for subsidies Yes 
Chapter Two Summary Descriptions of Sites 

34

Looking at the array of interventions in Exhibit 3 that are used to prevent homelessness, one can 

see that the McKinney-Vento Supportive Housing Program is most likely to be contributing to 

interventions at the more intensive end (the bottom of the exhibit). Hennepin County has a 

Supportive Housing Program services-only grant to support its rapid exit services. A good deal 

of permanent supportive housing in Massachusetts, Philadelphia, and Denver (for youth) is 

supported in part through Supportive Housing Program funding. Other HUD-controlled funds 

help to make housing affordable through Section 8 and Shelter+Care. Public Housing Authorities 

in Massachusetts, for example, work with DMH to establish priorities for subsidies to DMH 

clients. Other McKinney-Vento programs (Emergency Food and Shelter Program, Emergency 

Shelter Grants) are major contributors to the short-term cash assistance activities of the family 

homelessness prevention sites in this study. Further, in Montgomery County and Massachusetts, 

the agencies visited for this study are the lead agencies for their communities’ annual CoC 

applications to HUD (for the balance-of-state application in Massachusetts), so they are in an 

excellent position to assure that CoC plans attend to the needs of homelessness prevention. 

Chapter Three describes ways that the study communities collected and analyzed data and used 

these data to evaluate their strategies for preventing homelessness. 
35

CHAPTER THREE 

USING DATA TO DOCUMENT PREVENTION EFFECTIVENESS 

A critical part of service management is the collection and analysis of data. Normally one might 

expect a discussion of data and results to follow a discussion of strategies. However, use of data 

is one of the strategies for creating an effective prevention strategy. In addition, a discussion of 

strategies involves recommendations for effective interventions, and one needs data to determine 

which prevention activities are effective. Therefore this report discusses documentation before 

discussing strategies. 

Each of the study communities collected basic data and could report on the population they 

served and the services they provided. Some communities had sophisticated linkages among 

service providers, while others had more centralized databases. For most, the sharing of data 

among various systems remained a challenge, even though many communities had developed 

innovative strategies to meet these challenges. 

Many communities do not routinely assess the effectiveness of their homelessness prevention 

strategies. As the study team discovered when canvassing prevention programs for inclusion in 

this study, very few homelessness prevention efforts in this country have the ability to assess 

whether or not the households receiving assistance subsequently became homeless. The 

communities in this study have made considerable strides in developing systems that could 

document primary and secondary prevention of homelessness, although most of them were not 

systematically using available data to get feedback on their prevention efforts. 

This chapter describes the study communities’ ability to use their data and the implications for 

evaluating their programs. Suggestions for additional research efforts are included in the 

Conclusions section at the end of this chapter. 

DOCUMENTING PREVENTION EFFECTIVENESS 

The evidence for homelessness prevention assembled in each of the study communities is based 

on two types of analyses: tracking whether recipients of homelessness prevention services 

became homeless (i.e., entered shelter) and constructing time-series analyses of prevention 

outcomes. Findings from these analyses are discussed below. 

Proportion of Families Served Who Became Homeless 

Exhibit 4 lists the proportion of families from Hennepin County, Montgomery County, and the 

Mid America Assistance Coalition (MAAC) in Kansas City who entered a homeless shelter for 

at least one night within 12 months following receipt of rent or mortgage assistance. Data for 

families from these communities’ primary homelessness prevention components indicate that 

very few families receiving prevention services entered shelter during the followup period—only 

2–5 percent. The rapid exit program in Hennepin County found that 12 percent became homeless 

again within 12 months of leaving shelter. 
Chapter Three Using Data to Document Prevention Effectiveness 

36

Exhibit 4. Proportion of Families Entering a Homeless Shelter Within 12 Months 

Following Receipt of Rent or Mortgage Assistance or Rapid Exit Services 

COMMUNITY Proportion of Families 

Hennepin County 

FHPAP prevention 

Rapid exit 

Transitional housing 

5% 

12% 

4% 

Montgomery County 2% 

MAAC 3% 

Rent and Mortgage Assistance for Primary Prevention 

For these analyses, the outcome measure that the study communities documented was the 

proportion of families served who subsequently became homeless. This measure has several 

limitations. For example, a family could have avoided shelter entry but experienced 

homelessness by losing its housing, or living in its car. Without case-specific followup or 

tracking of families’ post-prevention experiences, agencies cannot conclusively determine that 

homelessness was prevented. 

A study in New York City that used a comparison group of families facing imminent eviction 

who did not receive an intervention to prevent homelessness determined that 20 percent of the 

families became homeless (Shinn et al., 2001; Stojanovic, Weitzman, Shinn, Labay, and 

Williams, 1999). Comparing the outcomes listed in Exhibit 4 with the finding from the New 

York City study demonstrates that the study communities’ outcomes of primary prevention 

activities are “better.” Without an intervention, 20 percent of the New York City comparison 

group became homeless; 80 percent did not. With an intervention, 2–5 percent of the families 

receiving prevention assistance from Hennepin County, Montgomery County, and MAAC 

became homeless; 95–98 percent did not. Based on these data, it could be determined that 19–23 

percent more families avoided homelessness following receipt of a prevention intervention in 

these study communities than without an intervention in New York City.13

This comparison also illustrates the serious inefficiency of this common approach to 

homelessness prevention. At least 80 percent of the resources disbursed in the name of 

prevention go to families who would not have become homeless even if they did not receive help 

from prevention programs. 

 

13 New York City is one of the tightest and most expensive housing markets in the United States. It is possible that 

families find it more difficult to avoid homelessness than they might in other communities, and that the odds of 

becoming homeless without an intervention are lower elsewhere. On the other hand, tenant protection laws in New 

York City make eviction extremely difficult—a household must be at least three months behind in rent and the 

landlord faces a long court process—suggesting that families facing eviction in New York City are in more serious 

trouble than families in the same situation elsewhere. These conflicting realities of tenancy in New York City may 

cancel each other out, leaving the 20 percent statistic as a reasonable benchmark to use for assessing the 

effectiveness of primary prevention for families in this study. 
Chapter Three Using Data to Document Prevention Effectiveness 

37

Secondary Prevention—Rapid Exit 

The FHPAP program in Hennepin County offers rapid exit services to families with multiple 

barriers to housing who are in emergency shelter. In most communities, these families would be 

candidates for transitional housing, where programs would have several months to work with 

them to obtain permanent housing. However, rapid exit moves these families into housing in an 

average of 30 days, and keeps most of them in housing for one year with the support of followup 

services. Only 12 percent of these families return to shelter within one year. Given that these 

families have already been homeless once, and thus could be considered at higher risk of a repeat 

than the primary prevention families might be of actually becoming literally homeless, holding 

these families to only 12 percent recidivism is a more remarkable achievement than the finding 

that only 5 percent of the primary prevention families enter shelter within one year. 

Since Hennepin County was not able to construct a relevant comparison group from among its 

own families, the study team used reports of shelter readmission rates in Philadelphia and New 

York City to assess whether this 12 percent readmission rate represents an accomplishment 

significantly greater than would have happened without the rapid exit intervention. The 

Philadelphia and New York City figures range from 19 percent to approximately 36 percent of 

families who return to shelter within one year (Culhane, Dejowski, Ibanez, Needham and 

Maccia, 1994).14 Compared with these sites, the rapid exit results for Hennepin County represent 

at least one-third, and possibly as many as two-thirds, fewer families returning to shelter. 

Further, this result was achieved after an average shelter stay of 30 days (compared with 60 days 

in Philadelphia and 120 days in New York City), and with families who were admitted to shelter 

after determining that they face multiple barriers to housing. 

Changes Over Time 

A system that can demonstrate a decrease over time in the number of people receiving 

homelessness prevention services who later became homeless confidently claim the effectiveness 

of its prevention services. Several changes indicate that prevention is occurring: decreasing 

numbers of households requesting shelter, only households with the most complex problems 

requesting shelter, decreasing proportions of people who are homeless at psychiatric facility 

intake and discharge, or increasing proportions of homeless youth exiting the street. Three study 

communities, Hennepin County, Massachusetts Department of Mental Health; and Urban Peak, 

documented outcomes of this type. 

 

14 In this article, the authors did not calculate readmissions in the 12 months following each family’s exit from 

shelter. Rather, they examined how many families with a homeless spell in one 12-month period (June 1, 1990–May 

31, 1991) had another spell during (a) the next 12-month period (June 1, 1991–May 31, 1992), or (b) either the same 

12-month period of their first spell or the next one. For Philadelphia those figures are, respectively, 12 and 27 

percent. For New York City the respective figures are 27 and 65 percent. To calculate the range of families with a 

return to shelter within 12 months of leaving (19–36 percent), one could: (1) take the difference in the two figures 

(16 percent for Philadelphia and 38 percent for New York City) and assume this is the rate of recurrence during the 

same 12-month period as the first spell; (2) take one-third of the recurrences in the second 12-month period (4 

percent for Philadelphia and 9 percent for New York City) and assume they happened within 12 months of the end 

of the first spell); and (3) add those two figures. 
Chapter Three Using Data to Document Prevention Effectiveness 

38

Hennepin County used client screening to direct scarce emergency services resources toward 

those who needed them the most, and tracked changes over time in the targeting of shelter 

services. The Human Services Department in Hennepin County analyzed its data to demonstrate 

the impact of its screening and prevention practices. These practices significantly altered the 

population and reduced the number of families receiving shelter services in the county. Since 

2001, Hennepin County has cut its average length of shelter stay by one-half (from 60 to 30 

days), eliminated the need for motels, and reduced the number of families in shelter at any given 

time from 317 to fewer than 116. It also succeeded in reserving shelter resources for families 

with the higher levels of housing barriers, whom county administrators believe need the most 

assistance. 

Hennepin County operates under the assumption that the most appropriate and efficient use of its 

scarce resources is to limit the type of intensive help that families receive in shelter to the 

neediest families, those who are likely to be the greatest burden on the system if their 

homelessness is not mitigated. (See Exhibit 5.) 

Exhibit 5. Change in Housing Barriers of Sheltered Families 

in Hennepin County15

Barrier Level 1995 1998 2003 

Level 1—No or few barriers 15% 0% 0% 

Level 2a—Few barriers 40% 43% 2% 

Level 2b—Many barriers 40% 44% 70% 

Level 3—Most serious barriers 5% 13% 28% 

Using data that it currently collects, Massachusetts DMH analyzed changes in homelessness over 

time among its clients with serious mental illness as they were admitted to and discharged from 

inpatient psychiatric facilities operated by the department. Since 1992, Massachusetts DMH has 

developed community-based housing options and supportive services to help people retain 

housing and to reduce hospitalizations and homelessness. Since 1993, hospitals have recorded 

whether patients were homeless at admission or discharge. If the increase in community-based 

housing and supports was preventing homelessness, one would see the rate of homelessness 

decreasing at both admission and discharge. Either change could represent primary or secondary 

prevention, depending on client homeless histories.16

Findings from these data are illustrated in Exhibit 6, which indicates that: 

• DMH residential community housing capacity in thousands (illustrated by triangles) 

increased from 2,750 in 1991 to 7,090 in 2003; 

 

15 Hennepin County FHPAP Annual Report for SFY 2003, page 14. 

16 These changes occurred during a time when state hospitals were being closed. These closures accounted for a 

significant drop in hospital admissions (not shown), but these changes do not wholly account for the drop in 

homeless admissions. While overall admissions dropped by two-thirds, the proportion of people homeless at 

admission dropped by almost 90 percent (not shown). A combination of housing and community services to stabilize 

persons with serious mental illness at risk of homelessness may account for much of this impact. Intensive discharge 

planning coupled with the existence of housing options developed by the department helps to explain the drop in 

homelessness at discharge, which affects both people homeless at admission and those who lost their housing while 

hospitalized. 
Chapter Three Using Data to Document Prevention Effectiveness 

39

• The proportion of people entering hospitals who were homeless at admission (illustrated 

by squares) decreased from 8.9 percent in 1993 to 1.9 percent in 2003; and 

• The proportion of people leaving hospitals without housing arrangements or homeless 

(illustrated by diamonds) decreased from about 1.7 percent in 1993 to about 0.7 percent 

in 2003. 

Exhibit 6. Changes in Massachusetts DMH Community Residential Capacity and 

Changes in Proportion of Homeless Admissions and Discharges 

0

2

4

6

8

10

12

Proportion Homeless

and

Capacity in Thousands

Proportion homeless at admissions 8.9 9.9 9.8 7.9 7.5 7.7 7.1 8.5 6.0 3.7 1.9

Proportion homeless at discharge 1.7 2.5 1.3 2.2 0.4 0.6 0.3 1.4 1.0 0.6 0.7

DMH residential housing capacity 2.75 3.39 3.65 4.29 4.89 5.18 5.45 5.63 5.77 6.11 6.39 6.82 7.09

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Urban Peak maintains a single database that includes unduplicated counts of the youth served 

and tracks daily service use. Urban Peak’s data from 1996 to 2004 illustrate its ability to move 

increasing proportions of the youth served into permanent housing or other positive housing 

outcomes. Along with moving into permanent supportive housing, positive outcomes for youth 

served by Urban Peak include returning home, entering an appropriate placement, or securing 

one’s own apartment. Exhibit 7 shows the total number of youth served per year by Urban Peak 

and the number and percent of those with successful housing outcomes. 

 

Exhibit 7. Outcome Measures for Urban Peak, 2000–2004 

Measure 2000 2001 2002 2003 2004 

Total number of youth served 642 660 694 655 690 

Number of youth with successful housing outcomes 308 343 368 426 435 

Percentage of youth with successful housing outcomes 48% 52% 53% 65% 63% 

While these findings do not document an overall reduction of homelessness among youth in 

Denver, they do represent a useful way to assess whether interventions are making a difference. 

As the findings clearly document an end to homelessness for the youth served, who would have 

been unlikely to leave homelessness without these interventions, they are valid indicators of 

secondary and tertiary prevention. Urban Peak is currently developing methods to strengthen 

these data such as tracking outcomes of all youth served through innovative followup tracking 
Chapter Three Using Data to Document Prevention Effectiveness 

40

methods and obtaining improved data on targeting, including prior homelessness of youth 

served. 

COMMON MEASURES OF PREVENTION AMONG STUDY COMMUNITIES 

All communities in this study expressed interest in improving the use of data to document 

prevention. The data that are currently being used, the outcome measures that have been defined 

or are under definition, and suggestions for additional measures, are discussed below. 

Data Elements Key to Outcome Measurement 

The following list includes categories of key data elements that appeared to be important for 

outcome measurement in the study communities: 

• Demographic characteristics of recipients of primary (or any other) prevention services; 

• Eligibility for homelessness prevention services criteria; 

• Start and end dates of primary or secondary prevention services; 

• Reason for ending primary or secondary prevention services; 

• Receipt of primary or secondary prevention services; 

• Receipt of shelter services; and 

• Followup data. 

Developing Outcome Measures and Collecting Outcome Data 

The study communities have developed, or could develop, several outcome measures to assess 

the effectiveness of homelessness prevention interventions. Most of these measures are 

multipurpose and can measure either primary or secondary prevention, depending on the context 

in which they are used. For example, Montgomery County and Hennepin County tracked the 

number of people becoming homeless within 12 months following receipt of prevention services. 

This measure could address both primary and secondary prevention. As a measure of primary 

prevention, one would identify people who received the intervention before they were ever 

homeless. As a measure of secondary prevention, one would identify people who had become 

homeless for the first time and then received the intervention. 

Tracking housing tenure for formerly homeless persons can also serve as an indicator of the 

long-term effectiveness of some rent or mortgage assistance interventions. Hennepin County 

measures the length of housing tenure to illustrate the effectiveness of rapid placement in 

housing following a first shelter stay. 

Communities can also develop measures for mainstream agencies that have responsibility for 

populations with chronic problems and a heightened vulnerability to homelessness. This is a 

timely issue as many cities, counties, and states have developed plans to end long-term 

homelessness. These plans include mainstream agencies as the major arenas where primary 
Chapter Three Using Data to Document Prevention Effectiveness 

41

homelessness prevention will take place if the front door to homelessness is to be closed. 

Examples of these types of measures include the following. 

• To gauge if community-based housing options and supportive services help people retain 

housing and reduce hospitalizations, Massachusetts DMH used hospital records of 

homeless status at admission and discharge. DMH can track changes in the proportion of 

people homeless at admission and at discharge over 12 years, and determine that both 

have decreased over time. 

• Child welfare agencies that provide followup services to youth exiting foster care could 

include housing retention measures to determine the effectiveness of housing policies for 

youth. Urban Peak tracks housing tenure where the measure of success is youth exiting 

the streets. 

Additional Outcome Measures to Consider 

Communities may be able to develop and analyze additional outcome measures. Measures to 

consider include the following. 

• Reduction in the number of people who enter shelter for the first time (to measure 

primary prevention) and reduction in the number of people who enter shelter from mental 

health agencies or jails (to measure discharge policies). Data may be gathered from local 

homelessness information system or some other central intake. This measure requires that 

the data source contain information about the number of times the person has been 

homeless and where the person lived prior to becoming homeless or entering shelter. 

• Improved targeting of persons to be served. The homelessness information system or 

other applicable data system could be structured to record a variety of barriers to 

obtaining and keeping housing, such as poor credit history, housing violations, and 

substance abuse issues. Such data could be used to establish homelessness rates for 

different populations. 

• Agencies, such as mental health departments, with responsibilities for chronic 

populations could track the number of people who are homeless at admission and if fewer 

people are homeless at discharge. The intake data system should be structured to record 

homeless status at intake. Case records could also record the housing circumstances of 

people being discharged. Specific periodic studies could be undertaken to attempt to track 

persons who have been discharged from mental health facilities. 

• Social service agencies could include the systematic data collection of the homeless 

status of clients and whether the situation was alleviated. Child welfare services could 

monitor whether children are being removed from their homes due to unstable housing. 

An agency could develop a homelessness risk assessment procedure to alert caseworkers 

to the risk of housing loss; it could also track or followup with clients to determine if 

their housing status has remained stable. 
Chapter Three Using Data to Document Prevention Effectiveness 

42

ADDITIONAL RESEARCH EFFORTS 

This section suggests additional approaches that could be used by communities to determine the 

effectiveness of homelessness prevention interventions. These measures focus on analytical 

approaches to tracking changes over time, developing evaluation studies using control and 

comparison groups, and using multivariate approaches to determine which client characteristics 

warrant targeting. 

Tracking Changes Over Time 

Tracking changes over time is one way to assess if interventions make a difference. Several of 

the communities in the study tracked changes over time and most communities have the data 

available to construct such an analysis. This approach merits consideration as it is possible 

within most systems and provides useful feedback to guide system change. 

This approach is most relevant if a community has made some substantial changes in its 

prevention activities. One working hypothesis might be that as prevention efforts increased over 

time, there would be a decrease in the incidence of homelessness. Massachusetts has presented 

results illustrating how housing development affected homelessness at admission for people with 

serious mental illness. In addition, Urban Peak was able to illustrate the increased placement of 

youth into positive housing situations. This type of finding can be presented as a “before and 

after” picture, illustrating that a situation has improved over the given period of time. On the 

other hand, the data may show that the problem has not improved. Such information would help 

programs reassess their priorities and their service designs. 

This type of analysis can be conducted prospectively and retrospectively. The choice depends 

upon the specific research question and the availability of data. With sufficient data points and 

quality data, it is also possible to use other analytic techniques, such as regression. These 

techniques can be used to compare statistically the actual outcomes associated with the 

intervention to a future or forecasted baseline. 

Program Evaluation Designs 

The fundamental goal of homelessness prevention programs is to provide services that 

effectively reduce first time homelessness or avoid repeat episodes of homelessness. Many 

different indictors might be used to measure “effective homelessness prevention,” including: 

• Providing emergency services so that people who will be homeless within 24–48 hours 

receive immediate shelter or other services; 

• Providing services to those who are at risk of becoming homeless, perhaps not 

imminently but in the near future; 

• Providing emergency services so that people who become homeless are only homeless 

for a short period of time; 

• Avoiding any need for shelter facilities; 

• Avoiding long-term usage of shelter facilities; 
Chapter Three Using Data to Document Prevention Effectiveness 

43

• Avoiding repeat occasions of shelter use or other near homeless situations; and 

• Reducing shelter costs, possibly other reduced costs for crisis services. 

The variation in definitions of effective homelessness prevention raises the question of how best 

to evaluate the effectiveness of services. Each community and its agencies may determine how to 

evaluate prevention effectiveness by using the following three steps. 

• The first step would be to identify the critical outcome or outcomes that the community 

desires. 

• The second step would be to define the components for measuring that outcome. For 

example, many programs consider a service effective if a person remains in housing for 

12 months or longer. Other programs might set different timeframes. This step also 

includes defining the study population (e.g., youth) and the service intervention (e.g., 

outreach) to be measured. 

• The third step would be to identify the research strategy best suited to the research 

question, the needs of the decisionmakers, and the resources of the agency. For example, 

one way to evaluate a program is to consider the trends in community statistics, as 

illustrated by some of the communities in this study. 

Experimental or Quasi-Experimental Approach 

From a research perspective, a controlled experiment with random assignment is the most 

rigorous evaluation design. However, such designs are not always feasible due to many concerns 

including the program design and the operating conditions of service provision and availability 

of data, research staff, and resources to conduct a rigorous study. 

Random assignment means that persons are selected and assigned by chance to various 

experimental conditions. In other words, neither the potential client nor the service provider 

determines which service option will be offered or received. Indeed, in a control group study, 

one group of persons will have been randomly assigned to receive “no service,” and the other 

group will have been assigned to receive the service being studied. The hypothesis being tested is 

that those who received the service would have better outcomes than those that received “no 

service.” 

Short of random assignment, communities could use several approaches to create useful 

comparison groups. It is sometimes possible to create “naturally occurring” comparison groups 

to use in this type of design. Such comparison groups may be approximations of control groups. 

For example, there may be “random” (unbiased) reasons why an agency might not serve a family 

or individual. Such reasons might include: 

• The agency placed the family or individual on a waiting list for services, and the family 

or individual either left before the agency offered services or was still on the list; and 

• The agency did not have resources when the family or individual applied for help. 
Chapter Three Using Data to Document Prevention Effectiveness 

44

If a prevention program has not provided services to clients for “random” (unbiased) reasons and 

is able to record information about such persons, it could create a control-group-like comparison 

group. This group would be useful to determine whether its membership experienced a 

significantly higher likelihood of becoming homeless than the people who did receive services. 

One difficulty in using such comparison groups is that the program must at the same time guard 

against “creaming.”17 

To consider the real world implications of using a comparison group methodology to evaluate 

homelessness prevention services, the study team used a comparison group to gauge the impact 

of program services on housing retention in the Western Massachusetts Tenancy Preservation 

Project. This project involves an alliance among local Housing Courts, MassHousing, DMH, 

Department of Mental Retardation, Department of Public Health, several local housing 

authorities, and local service providers. The study team visited one such service provider, the 

Mental Health Association, Inc., of Springfield, MA. The program was established to help 

tenants threatened with eviction because of their mental illness, substance abuse, or cognitive 

disability. The goals of the program were to preserve existing tenancies or connect households to 

alternate housing. 

The Tenancy Preservation Project began in 1998, and since that time has opened 441 cases and 

closed 366, with 23 households refusing services. Outcomes of cases closed between July 1, 

1998 and June 30, 2004 are displayed in Exhibit 8. The top row of the table shows the results for 

the entire Tenancy Preservation Project caseload. About one-half (51 percent) stayed in their 

original housing, 34 percent moved to alternative housing arranged through the Tenancy 

Preservation Project, and 15 percent became homeless. Outcomes differed substantially by 

diagnoses, as indicated in the table. The Tenancy Preservation Project had the greatest success 

with elderly and cognitively impaired tenants and the least success with tenants who were both 

mentally ill and substance abusers. 

 

Exhibit 8. Outcome Status of Closed Cases at the Tenancy Preservation Project 

of the Mental Health Association, Inc., of Springfield, MA 

Tenancy 

Preserved 

Moved to Alternative 

Housing 

Became 

Homeless All cases served and closed by The 

Tenancy Preservation Project (n=366) 51% 34% 15% 

By Diagnosis 

Mental health (n=202) 

Substance abuse (n=43) 

Dual diagnosis (n=83) 

Elder/senility/Alzheimer’s (n=24) 

Other (n=13) 

55% 

51% 

37% 

71% 

38% 

32% 

37% 

35% 

21% 

62% 

13% 

12% 

28% 

8% 

0% 

These outcomes can be compared to cases that were wait-listed by the Tenancy Preservation 

Project and never served. These cases had similar issues and difficulties and comprise a 

reasonable comparison group to those served by the Tenancy Preservation Project. There were 

 

17 Creaming refers to the sometimes inadvertent tendency to provide services to persons who are perceived to be 

more likely to succeed and not to provide services to those who are expected not to succeed. As creaming is what 

many rent/mortgage/utility assistance activities do, a control or comparison group is especially important to be sure 

that the prevention activities really do improve on the outcomes that would have happened without them. 
Chapter Three Using Data to Document Prevention Effectiveness 

45

21 such cases, for which outcomes were retrieved from court records. The outcomes for this 

comparison group were: 

• Twenty-four percent were resolved favorably for the tenant without the help of the 

project and these people were able to remain in their housing; and 

• Subsequent location is unknown for the remaining 76 percent. 

This simple comparison indicates that the Tenancy Preservation Project may have been able to 

preserve original housing for slightly more than twice as many people as would have kept their 

housing without Tenancy Preservation Project services—51 percent versus 24 percent.18 

Multivariate Approach 

Analyses using covariates may help a community determine who is at highest risk of 

homelessness and to plan and adjust a prevention strategy. Covariates are variables that may 

affect the risk of homelessness or level of housing stability. Most prevention program screening 

systems make assumptions about applicant characteristics that indicate a higher risk of becoming 

homeless. A community could combine this information with outcome measures to conduct two 

analyses: 

• Test assumptions about recognized risk factors; and 

• Determine whether some interventions work especially well (or not well) with 

households that have a particular type or set of risk factors. 

The data of those who received prevention assistance could be analyzed to determine whether 

those judged to be at higher risk were more likely to become homeless. Communities may find 

that some characteristics pose fewer problems than previously thought for attaining and keeping 

housing. The agency might decide to modify selection criteria to improve the program’s ability 

to target the people who need help the most. Further, communities could test assumptions about 

the types of services that work best for people with particular types of barriers. 

CONCLUSIONS 

Comprised of agencies often working with limited staff, facility, and financial resources, the 

homelessness prevention field has focused primarily on providing services to the most needy or 

visible populations. Given the size, experience, and diversity of the community agencies that 

provide these services, many have faced, and continue to face, formidable challenges to 

recording, collecting, reporting, and analyzing data on clients and their outcomes. Nevertheless, 

as shown in this chapter, agencies are making progress to develop relevant databases and 

 

18 The small numbers of the comparison group provide tentative, rather than conclusive, results. 
Chapter Three Using Data to Document Prevention Effectiveness 

46

coordinate with other agencies in the use of data. The experiences of the six study communities 

can help other agencies to progress in their systematic collection and use of data. 

Many prevention approaches already report data describing the households they serve, but very 

few have the capacity to assess the effectiveness in terms of those households’ successes in 

avoiding future homelessness. Evaluation of homelessness prevention programs joins the 

evaluation of other social service prevention programs in being in the early stages of 

development. As data systems are developed and used for program monitoring and service 

delivery, the likelihood of being able to develop research strategies that address fundamental 

questions of effectiveness and efficiency will increase. Agencies and communities will need to 

work with their local universities and others to develop strategies that can be implemented with 

sometimes restricted resources and that can be meaningful to all stakeholders. 
47

CHAPTER FOUR 

KEY ELEMENTS OF PREVENTION STRATEGIES 

Each study community offered several activities aimed at preventing homelessness, or quickly 

rehousing those who have already become homeless. Some also developed a coherent 

community-wide strategy through which they linked services to people who faced homelessness 

or who recently became homeless. This chapter integrates study findings related to preventing 

homelessness among families and populations with disabling conditions, with the intent of 

answering the following two questions. 

• What does it take to prevent homelessness or end it quickly for newly homeless 

individuals and families? To answer this question, one needs to know which particular 

activities are effective to prevent homelessness. Independent of targeting, system 

development, and the activities’ acceptability to the population at risk, the issue is, does 

this activity work? Does it keep people in housing, or get them back into housing quickly?

• What does it take to organize a community so activities that are effective at 

preventing homelessness are applied where they will do the most good? To answer 

this question, one needs to be aware of the issues and problems that can make it difficult 

to apply prevention activities, and to do so efficiently, and how communities overcome 

these difficulties. 

 

The following sections examine each of these issues. 

WHAT IT TAKES—EFFECTIVE PREVENTION ACTIVITIES 

To date, evaluation evidence indicates that “housing” prevents homelessness more effectively 

than any other strategy (Shinn et al., 2001). The communities in this study are trying, through 

many activities, to preserve housing for people facing homelessness, or to supply housing when 

it is needed. This chapter summarizes the evidence that exists from evaluation studies, as well as 

the current study on effective housing strategies, to prevent homelessness. 

• Housing subsidies. Evidence for housing subsidies as a very effective prevention activity 

comes from studies other than the present one. Shinn and colleagues (Shinn et al., 2001; 

Stojanovic et al., 1999) documented the effectiveness of housing subsidies at keeping at 

least 80 percent of first-time homeless families housed for a minimum of two years. Rog, 

McCombs-Thornton, Gilbert-Mongelli, Brito, and Holupka (1995) demonstrated similar 

success (80–85 percent retention over at least 18 months) for homeless families in which 

a parent’s mental illness complicated housing stability. Evidence from simulations 

(Quigley, Raphael, and Smolensky, 2001) indicates that subsidizing housing costs for 

extremely low-income people has the strongest effect on lowering homelessness rates 

compared to several other interventions tested. Thus when used as secondary and tertiary 

prevention, housing subsidies help 80–85 percent of homeless families or chronically 

homeless single adults to achieve housing stability.
Chapter Four Key Elements of Prevention Strategies 

48

• Supportive services coupled with permanent housing: Studies summarizing the first 

round of McKinney demonstrations for people with serious mental illness (and often cooccurring substance abuse) show that permanent supportive housing works even for the 

chronically homeless people targeted by those demonstrations. These programs achieved 

approximately 80–85 percent housing retention at 18 months (Shern et al., 1997). Burt et 

al. (2004) collected evidence from seven communities engaged in efforts to end chronic 

homelessness that showed that permanent supportive housing is effective. (See also 

Tsemberis and Eisenberg, 2000, for the success of the Pathways to Housing program in 

New York City.) 

It follows that if housing, with supportive services, works to sustain tenancy for people 

with long histories of homelessness, serious mental illness, and co-occurring substance 

abuse, it should also be effective with the less-severely affected clients of mental health 

agencies. The housing options developed by the Massachusetts Department of Mental 

Health (DMH) and the Philadelphia Office of Behavioral Health (OBH)—coupled with 

the supportive services they offer to avert a worsening of clients’ mental illness and to 

address other issues that might affect housing tenure—provide both primary and 

secondary homelessness prevention. Evidence from Massachusetts indicates declining 

rates of homelessness among admissions to psychiatric inpatient care over the course of 

more than a decade, supporting this conclusion for primary prevention. Declining rates of 

discharges to homelessness from psychiatric inpatient care show the effects of secondary 

prevention efforts involving housing and supportive services. 

• Mediation in Housing Courts: Evidence collected in the present study on the 

effectiveness of mediation under the auspices of Housing Courts shows the ability to 

preserve tenancy, even after a landlord has filed for eviction. 

- Hennepin County: 69 percent of cases filed against families in the Hennepin 

County Housing Court were settled without eviction, and the family retained 

housing. If 20 percent of these families would have become homeless if evicted 

(based on New York City estimates discussed in Chapters One and Three), 

mediation has successfully prevented homelessness among these families. 

- Massachusetts: Evidence presented in Chapter Three on the Western 

Massachusetts Tenancy Preservation Project showed that mediation preserved 

tenancy for 85 percent of seriously mentally ill tenants facing eviction, and 

reduced the probability of becoming homeless by about one-third. 

• Cash assistance for rent or mortgage arrears: Compared to the finding in New York 

City that 20 percent of families facing eviction will become homeless if they do not 

receive assistance, the commonly used interventions offered by the study communities 

for families facing housing loss were effective. Cash assistance to cover arrears in rent, 

mortgage, or utility payments to avert eviction, as used in Hennepin County, 

Montgomery County, and the Mid America Assistance Coalition (MAAC), resulted in 

only 2–5 percent of assisted families experiencing homelessness in the 12 months 

following receipt of help. This is a substantial improvement over the 20 percent 

becoming homeless without assistance. The difference between the results in this study’s 
Chapter Four Key Elements of Prevention Strategies 

49

communities and those from New York City used as a comparison are probably 

attributable at least in part to screening that improves targeting—that is, an effective 

strategy is being used efficiently. 

• Rapid exit from shelter: Hennepin County supports a program to move families who 

enter emergency shelter into housing rapidly, and to promote their housing tenure for at 

least six months after they leave shelter. Returns to shelter within 12 months were 

assessed against the county’s Homeless Management Information System (HMIS)— 

12 percent of the families served experienced a return to shelter. Compared to family 

shelter readmission rates in Philadelphia and New York City—which ranged from a low 

of 19 percent to possibly as much as approximately 36 percent of families who return to 

shelter within one year—the rapid exit results in Hennepin County represented at least 

one-third, and possibly as many as two-thirds, fewer families returning to shelter 

(Culhane et al., 1994). 

The activities described above may be used for all levels of prevention: primary, secondary, and 

tertiary. Further, they may be used in combination, and in a variety of settings. For example, Los 

Angeles has several programs that work with jail inmates with serious mental illness to prevent 

homelessness at release. These programs have flexible state funding that they may use to offer 

supportive services in the community, assistance to obtain housing, and short- or long-term 

rental assistance. The programs have successfully reduced the amount of time this population 

spends homeless or incarcerated and have increased the amount of time spent housed (Mayberg, 

2003). 

WHAT IT TAKES—ORGANIZING FOR PREVENTING HOMELESSNESS 

Any agency could use these prevention activities, alone or in combination, and they would 

probably prevent some homelessness. But an agency is unlikely to use prevention resources 

efficiently unless the strategies are part of a larger structure of planning and organization that 

addresses the issue of targeting, as discussed in Chapter One. A single agency can target and, to 

some extent, do it well. To get the most from a community’s prevention dollar, indications are 

that one would need a community-wide system. The system would have a carefully articulated 

targeting strategy and mechanisms to assure that funds allocated to prevention are used to reach 

the people at greatest risk of homelessness. The communities in this study each had some 

elements of such a system, and several had many. The study communities with the most 

elements, Hennepin County and Massachusetts, were best at preventing homelessness and were 

certainly best able to document their achievements in homelessness prevention. 

The ability to contrast and compare across sites and observe how different communities conduct 

prevention is central to this type of study—learning happens by observing what is not present, as 

well as what is. The differences apparent among communities allow one to identify the elements 

that are relevant to developing and sustaining homelessness prevention efforts, from both 

practice and policy perspectives. From the site visits and other information gathered about the 

study communities, the study team identified elements of community organization that helped 

focus homelessness prevention efforts and influenced their greater likelihood of success. 
Chapter Four Key Elements of Prevention Strategies 

50

Chapter Two described each study community on a number of dimensions, and the Appendices 

provide even more detail. Without repeating much of that material here, this section analyzes the 

elements found in the study communities that appear to contribute to homelessness prevention—

the elements all concern community organization of one type or another. The more 

comprehensive and sustained these elements are, the more likely they are to contribute to 

developing a system of homelessness prevention. A list of key elements by domain follows; 

Exhibit 9 summarizes the elements. 

• Elements Affecting Ability to Target Well: 

- Information sharing across agencies and systems; and 

- Control over the eligibility determination process, including agreed-upon criteria, 

combined with housing barrier screening and triage. 

• Elements Reflecting Community Motivation 

- Community accepts a legal or moral obligation to shelter; and 

- Fulfilling this obligation costs a lot of money, and the community is motivated to 

use it wisely. 

• Elements that Maximize Resources 

- Collaboration among public and private agencies; and 

- Nonhousing mainstream agencies accepting their clients’ housing stability as one 

of their responsibilities. 

• Elements Affecting Direction, Sustainability, Control, and the Use of Data to Guide 

Future Development: 

- Leadership; 

- Having a clear goal of preventing homelessness; 

- Developing a strategy to reach the goal; 

- Having mechanisms that provide feedback on progress, stimulate new thinking 

and innovation, identify gaps and next steps; and 

- Knowing what is needed and making sure contract agencies are committed to 

providing it. 
Exhibit 9. Organizing for Community-Wide Homelessness Prevention 

Community-Wide Strategies with S

Community-Wide Strategies with Families People with Serious Mental Illne

Element 

Hennepin County Montgomery County MAAC Massachusetts P

Information sharing across agencies and systems 

All prevention and rapid exit agencies share a data system 

Prevention and shelter services through one agency, with common database 

All private agencies handling prevention funds share common database, which also tracks shelter referral and usage 

Acute inpatient, shelter, DMH transitional programs share information through outreach; courts and DMH contract agencies share information through Tenancy Preservation Projects; working with Medicaid and TANF agencies 

OBH shachild wehomelesjails/prisamong iand subservice a

Targeting Aids Housing barrier screening and triage Yes, measure via scale Yes, though no formal measurement No Formally, to become DMH client (must meet diagnostic and disability criteria); informally for housing (related to level 

of need, absence of alternatives) 

Formallyclient (mdiagnostcriteria); housing need, abalternati

Public jurisdiction recognizes a legal or moral obligation to shelter 

Yes, moral, from County Council 

Yes, moral, from County Council 

No Yes, part of legislative and DMH 

commitments 

Some, fr

Motivators Significant mainstream resources are invested 

(other than Federal) 

Yes, state and local Yes, mostly local No Yes, mostly state Yes, mo

Collaboration among public and private agencies 

Public and private, extensive 

Public and private, extensive 

Private only Public and private, extensive Public a

Maximizing Resources Nonhousing mainstream agencies accepting housing their clients as one of their responsibilities Yes, child welfare, TANF, mental health caseworkers included in rapid exit case planning for families Yes, child welfare, behavioral health, and domestic violence case workers coordinate housing 

services 

No Yes, DMH itself and to some extent 

corrections, for people with serious mental illness 

Yes, OBserious 

51
Exhibit 9. Organizing for Community-Wide Homelessness Prevention (continued) 

Community-Wide Strategies with S

Community-Wide Strategies with Families People with Serious Mental Illnes

Element 

Hennepin County Montgomery County MAAC Massachusetts P

Leadership Yes, strong, 

sustained, for both prevention and rapid exit 

More coordination than leadership 

Coordinating function, but not for new or developing prevention strategies 

Yes, strong, sustained, for prevention, rapid exit, and community-based housing for people with serious mental illness 

Just begpreventpresent based hpeople wmental 

Clear goal of preventing homelessness among target population(s) 

Yes Yes Yes Yes Just beg

Clear strategy with ways to track success and progress 

Have strategy, track progress, use feedback to adjust system; prevention success tested against shelter database 

Only beginning to develop a strategy; prevention success tested internally and against Sheriff's eviction database; have data to do more 

Do not have a strategy for system development; have data to track progress but have not to date 

Have strategy, track some kinds of progress, but not yet specifically for prevention 

Just begdevelop tracking 

Lead agency has control of funding and contracting for all or most of system 

Yes Yes No Yes Yes 

Direction, Sustainability, Control, and Feedback Uses outcomes-based 

contracting with adjustments based on performance 

Contracts specify outcomes, not process or services; contractors have been terminated or not renewed for not meeting outcome commitments 

No No No No 

52 
Chapter Four Key Elements of Prevention Strategies 

53

Elements Affecting Ability to Target Well 

System efficiency depends on targeting well. The study communities used several strategies to 

improve targeting and ensure that prevention resources go to the people at highest risk of 

homelessness. These strategies are discussed below. 

Information Sharing Across Agencies and Systems 

The lead agencies in the six study communities had a single data system, some of which could 

link to other relevant agencies and offices. These data systems were essential for unifying the 

community’s prevention strategy. No community had a true “single point of entry,” if by that one 

means all people seeking services enter through a single location to get help. But the agencies 

offering prevention in each community were all linked to a shared, real-time data system, and 

therefore enjoyed and continue to enjoy such advantages as those listed below. 

• Agencies are able to view service histories, client characteristics, and diagnoses and 

treatments to determine client eligibility and what services to offer. 

• In cases where a client needs a service that an agency does not offer, the agency can 

search the data system for an appropriate provider and help the client make arrangements 

to get the service. In some communities, agencies may find other agencies with 

remaining funds if their own have run out. 

• Agencies collect client descriptors for identical fields and code them in identical ways. 

As a result, information is comparable across and within agencies, offices, and regions. 

Each user knows what another agency’s data mean, and can share screening criteria and 

make similar decisions based on similar evidence. 

• MAAC has the advantage of having both prevention and shelter services recorded in the 

same database. MAAC can regularly check its own database for evidence that families 

who received homelessness prevention assistance do not become homeless. 

Several communities also had arrangements to share or compare data with other systems for 

purposes of service delivery, as well as to assess prevention success. These arrangements 

evolved over several years and were motivated by leaders and planners who saw the system 

advantages, as well as the advantages for serving clients better. Examples of these ongoing 

arrangements are listed below. 

• To evaluate its primary prevention efforts with families, Hennepin County compares the 

families who received prevention assistance and rapid exit services through the Family 

Homeless Prevention and Assistance Program (FHPAP) with the county’s HMIS to 

determine if families who were served enter shelter. To offer the most appropriate 

services, its rapid exit screening process accesses county Housing Court and police 

systems to search for barriers related to housing or criminal history, and uses the 

information to design better service plans for families. 
Chapter Four Key Elements of Prevention Strategies 

54

• To evaluate primary prevention, Montgomery County checks families who received 

prevention assistance against the Sheriff’s eviction records. Because Montgomery County 

Department of Health and Human Services is an umbrella agency incorporating many 

services, its integrated agency-wide data system contains information on health, mental 

health, and family services that in another county might require interagency arrangements 

to access. 

• Philadelphia’s OBH can access the HMIS and child welfare’s data system to determine a 

family’s multisystem involvement to develop the most appropriate service plans. OBH 

also receives information on jail inmates, allowing OBH to identify its own clients and 

see that they receive casework services to, among other things, avoid homelessness upon 

release. 

Control Over the Eligibility Determination Process 

Chapter One identified careful targeting as the key to an efficient use of resources for 

homelessness prevention. Shared data systems, such as the ones these communities maintain, are 

vital tools for any community that is serious about targeting resources to those most in need. 

Once targeting criteria are developed and agreed upon, system managers can use system data to 

assess whether the criteria are being used correctly and provide feedback to improve targeting. 

All study communities exercised some degree of control over which families received prevention 

assistance. But some communities maintained significantly more control than others and targeted 

the most intensive interventions toward the families who experienced the most barriers to 

housing. The Hennepin County system of screening and triage for families seeking shelter was 

the most carefully articulated targeting procedure among the study communities. It is described 

below as an example of a strategy that developed through several iterations. Equally important, it 

would never have happened without strong managers who had a vision of how they wanted the 

system to operate, as well as knowledge of what was going wrong based on careful monitoring 

of system performance. 

Any family seeking shelter in Hennepin County is screened by the rapid exit coordinator, as 

explained in Chapter Two. The rapid exit coordinator checks for the existence of housing 

barriers against a formal screening tool, shown in Exhibit 10. Any barriers identified are 

discussed with the family to learn more about them, and entered onto the screening sheet, which 

also contains columns for a family’s service plan. The rapid exit coordinator refers the family to 

a rapid exit provider, and sends the screening sheet along so the provider has full information as 

work with the family begins. The county exercises additional control over the rapid exit process 

by linking approval for continued shelter stay to progress on the plan developed between the 

family and rapid exit provider. The system leaves very little room for a family to drift along 

without taking steps to return to housing quickly. 

Montgomery County has a screening process that resembles that of Hennepin County in terms of 

types of identified barriers. The county does everything it can to divert the families with fewer 

barriers away from shelter by supplying appropriate cash and in-kind assistance. But it does not 
Chapter Four Key Elements of Prevention Strategies 

55

use effective strategies for shortening the length of shelter stays, such as Hennepin County’s 

rapid exit services, when it makes a shelter referral. 

Exhibit 10. Hennepin County Housing Barrier Screen 

ASSESSING HOUSING BARRIER LEVELS When screening (Rapid Exit) families for referrals for housing assistance, the following are 

guidelines for assessing a family’s housing barriers and categorizing the barriers into three levels: 

Level 1: No barriers. Family has a good rental history, no UDs (unlawful detainer/eviction), no criminal history, and no active chemical dependency 

or abuse issues. Families would be given an information packet and a sample rental application form. No FHPAP/RE referrals will be made. Family 

may return to RE Coordinator for help with application fees. 

Level 2a: Has some of the following barriers: 

• No rental history • No high school diploma 

• New to the area • Physical disabilities that affect housing 

• Large family • One parent/child household 

• One easily explained UD • Needs financial help with moving, furniture, misc. services 

• History of battery but abuser not in the area • Head of household under 18 years of age 

• Non-English speaking 

Does NOT have the following barriers: Criminal record, active CD/alcohol issues, more than one UD. 

Families would be given the information packet, a sample rental application, and referral to a FHPAP/RE or short-term provider.

Level 2b: Family has some of the following barriers: 

• Poor rental history (up to three UDs or evictions) • Recent domestic abuse with the abuser in the area 

• Recent minor drug or criminal history • Just released from jail 

• Mild behavior problems-adult • Not currently abusing drugs 

• Mild behavior problems—child(ren) • May also have some of the barriers from Level 2a 

• Male teenager in the home • Open child protection case 

Does NOT have any Level 3 barriers. Families would be given the information packet, a sample rental application and be referred for longer term 

case management services to a FHPAP/RE or other provider who provides such services. Transitional housing services may also serve 2bs. 

Level 3: Has some of the following barriers: 

• Actively using drugs • Recent serious criminal history 

• Adult with severe behavior problems • Current sexual abuse in the family unit 

• 4 or more UDs • Current battering with the abuser in the family unit 

• Children with severe behavior problems • Has recent record of property damage to rental housing 

Families may be referred to Project Connect or a similar service. The difficulties in obtaining housing will be explained to families along with 

alternatives. They may be referred to non-FHPAP housing search options and FHPAP/RE providers, including transitional housing. 

SERVICE REFERRALS TO FHPAP RAPID EXIT & TRANSITIONAL HOUSING PROVIDERS Referrals for each barrier level are summarized 

above. Since FHPAP/RE services are directed to Level 2 and lower Level 3 families, referrals of Level 1 and high barrier Level 3 will not be made to 

FHPAP/RE providers. Referrals to other services such as Project Connect (transitional housing) can be made for Level 3. 

FHPAP RAPID EXIT ELIGIBLE FAMILIES As of 7/1/95, FHPAP rapid exit providers are to serve Level 2 and lower Level 3 families referred by the 

FHPAP Rapid Exit Coordinator (REC). This will assure that FHPAP providers serve the target group and that the appropriate families reach services 

soon after shelter entry. 

AVAILABILITY OF RAPID EXIT & TRANSITIONAL HOUSING SERVICES Rapid exit providers are to communicate with the FHPAP REC what 

their current capacity is and how many referrals they are ready to accept. This communication is essential to facilitating services for families. 

REC SCREENING GOAL The target goal is for families to be screened and referred within 5 days of their first voucher into shelter. 

APPLICABILITY OF POLICY These guidelines will be used not only by the FHPAP Screener/REC but by all FHPAP service providers, including 

SHP and ESG, who are assessing housing barrier levels for a family under the FHPAP Umbrella Program. 

(modified version of County form: SJH 04 RECBarrierLevels04) 

MAAC is an example of an excellent data system that links many agencies and supplies 

providers with much-needed information. It promotes targeting by facilitating the use of shared 

eligibility criteria by all prevention providers. However, the system stops there because MAAC 
Chapter Four Key Elements of Prevention Strategies 

56

does not have any mechanisms of control, or any right to exercise control, over which families its 

member agencies serve. To the extent that efficient targeting of prevention resources happens 

among MAAC agencies, it arises from voluntary agreements and the requirements of the funding 

streams that supply the money for prevention assistance. MAAC thus represents the probable 

limits of targeting efficiency in communities without an overall strategic plan that includes 

continuous efforts to improve efficiency and effectiveness. 

The remaining study communities had a targeting challenge that is quite different from that faced 

by the strategies focused on helping high-risk families. Massachusetts, Philadelphia, and Urban 

Peak serve individuals whose history and disabilities already put them at high risk for 

homelessness. In addition, much of the population they serve has already had at least some 

experience of homelessness, making their future risk that much more obvious. Each of these sites 

applies assessment procedures to judge homelessness risk, and all offer remedies commensurate 

with the risk level observed. Often, this means the relevant agencies supply actual housing after 

determining that, without it, a client faces a very high risk of homelessness. With or without the 

housing, these sites are most likely to offer ongoing community-based supportive services to 

keep clients in housing and, for the mental health agencies, to keep mentally and emotionally 

stable people in the community rather than in hospitals.

Rationale for Screening Criteria 

The communities selected for this study represented two targeting strategies. One strategy, 

usually employed by communities seeking to prevent family homelessness, targets the families 

best able to resolve their current housing problems. Among the study communities, Hennepin 

County, Montgomery County, and MAAC follow this strategy for primary prevention—selecting 

families who do not appear to have chronic problems and helping them with a temporary 

problem. 

The second strategy, usually employed by communities seeking to prevent homelessness among 

populations with chronic disabilities (such as people with serious mental illness) or severe 

situational disadvantages (such as those exiting correctional facilities, foster care, or who are 

already on the streets) targets people with multiple and complex problems. In this study, these 

communities include Massachusetts, Philadelphia, and Urban Peak. These communities first 

screen for agency eligibility, which addresses psychiatric diagnosis, disability, and duration. 

Once eligibility is determined and the person becomes an agency client, screening for various 

needs and services is ongoing. Income is not a criterion for agency eligibility; however, the 

majority of public mental health agency clients is extremely poor and experience difficulty 

finding, affording, and keeping housing without agency assistance. 

Of the two targeting strategies, the second is more likely to be efficient in selecting people who 

are demonstrably at higher risk than the families helped through the first strategy. The family 

prevention agencies’ task is difficult because they are seeking those who are in real trouble, but 

who are close to having their difficulties resolved. Relatively few of these families are likely to 

become homeless, even without the help of prevention agencies or when they can prove to the 
Chapter Four Key Elements of Prevention Strategies 

57

agency that they are facing eviction. These agencies must be rigorous in their screening 

procedures to determine that the risk of homelessness is reasonably high. 

Elements Reflecting Community Motivation 

In this study, the communities with the strongest publicly held motivation to prevent 

homelessness did the most to develop community-wide prevention strategies. Legal or moral 

obligation to act was part of this motivation, but so was a concern with cost, and wanting public 

dollars to be used most effectively. These elements are discussed below. 

Obligation to Shelter 

Two study communities took on a moral obligation to help families avoid homelessness. County 

Councils in Hennepin County and Montgomery County had long-standing policies that no family 

would spend the night on county streets. The study team did not ascertain the origins of these 

policies, which went back at least a decade. One clear consequence of these policies, and a 

measure of the Councils’ commitment to them, was that both counties paid for shelter for 

families. 

Two study communities—Massachusetts and Philadelphia—have a legal obligation to care for 

people with serious mental illness, as well as the responsibility for allocating public funds to this 

end.19 Both communities recognized the importance of housing as a necessary component of that 

responsibility. 

Significant Investment of Public Funds 

These four jurisdictions (County Councils in Hennepin County, Montgomery County, 

Massachusetts, and Philadelphia) invested significant state or local monies in homelessness 

prevention. This investment, coupled with their policy commitment, has motivated them to 

develop systems that offer effective prevention activities efficiently. Massachusetts DMH has 

focused on preventing homelessness among its clients for more years than OBH in Philadelphia. 

In part, the difference arises because DMH as a state agency simply has more resources. The 

Special Homeless Initiative appropriation that began in 1992 resulted from the combined efforts 

of the Massachusetts Housing and Shelter Alliance (Boston’s largest shelter providers) and 

DMH, working with the governor and legislature to make the case for investment and to shape 

the legislation.20 Legislative directives also charge the department with preventing 

Commonwealth citizens with serious mental illness from becoming or remaining homeless, and 

 

19 All state mental health systems have similar obligations, although not all states invest the resources that 

Massachusetts does in fulfilling these obligations. As a city, Philadelphia has taken on more extensive commitments 

to assist people with serious mental illness than would be mandatory under state law. 20 Money has been appropriated for the Homeless Initiative every year since 1991 in the governor’s annual budget 

proposal to the legislature, which is always House Bill 1. The Homeless Initiative has never been authorized as a 

program. 
Chapter Four Key Elements of Prevention Strategies 

58

the Homeless Initiative money is extremely flexible, permitting DMH to “do what it takes” to 

prevent homelessness. Over the years, advocacy and provider pressures, coupled with its own 

commitments, have pushed DMH to develop a long-term strategy and provide the leadership to 

carry it out. 

Elements That Maximize Resources 

No single agency or program has the resources needed to prevent homelessness. Every study 

community recognized the need for collaboration among key players to bring more resources to 

the table. The primary differences among the communities were in the nature of the players and 

the resources they commanded. Where public agencies lead or shape prevention strategies, the 

resultant activities command many more resources and offer more comprehensive approaches. 

Collaboration Among Public and Private Agencies 

Two study organizations—MAAC and Urban Peak— illustrate collaborations of private 

nonprofit agencies without much public contribution of ideas, resources, or power. MAAC 

boasts many member agencies that work together to share resources and maximize appropriate 

use within the bounds of its network. However, it has not succeeded in recruiting significant 

public involvement, nor does it strategically plan to develop new and more effective approaches 

to homelessness prevention. Conversely, Urban Peak has thought strategically about preventing 

and ending youth homelessness and has greatly expanded its collaborative network since it began 

17 years ago. It is an example of how far a nonprofit agency can go toward organizing a 

community strategy without the participation of mainstream agencies. 

The FHPAP Advisory Committee in Hennepin County is an interesting example of how 

collaborative relationships can help a community strategy focus and expand.21 The Committee’s 

membership includes: shelter operators; providers with and without FHPAP contracts; advocates; 

formerly homeless people; representatives of legal services; Minnesota Housing Finance 

Agency; Twin Cities Voicemail (a company that provides free voicemail for homeless people); 

the Minneapolis Public Schools homeless programs; Minnesota Coalition for the Homeless; and 

other homeless planning groups such as the Continuum of Care. In addition, supervisors of direct 

service units in county departments—who have responsibilities for homeless-related services—

attend meetings and provide input. 

The FHPAP Advisory Committee is essential to smooth program operation. The committee 

establishes outcome goals; assesses service gaps and recommends services for funding; designs 

requests for proposals and reviews proposals; seeks new providers; provides cross-fertilization 

through members who serve on other committees; promotes new partnerships; and reviews 

contract performance. The makeup of the Advisory Committee is especially important for 

establishing and maintaining standards of performance. Members are knowledgeable about the 

 

21 FHPAP providers also operate in a strong collaborative network similar to MAAC, as does the Emergency 

Assistance Coalition in Montgomery County. 
Chapter Four Key Elements of Prevention Strategies 

59

population to be served, as well as the options for helping them, and are supportive of the use of 

outcomes-based contracting. If a provider’s performance is unsatisfactory, it must appear before 

the Advisory Committee to explain what happened and how it will improve its performance. If 

the provider is unable to improve its performance, the FHPAP Advisory Committee will suggest 

that it not be refunded. Under such scrutiny, nonperforming providers usually agree to drop the 

contract rather than have the county terminate it. This process of winnowing and sifting to 

engage the most effective providers is essential to improve overall system performance. 

Massachusetts offers the best example of leveraging resources controlled by other public 

agencies in pursuit of its homelessness prevention goals. As detailed in Chapter Two, DMH 

leverages its own resources to obtain housing investments from the state housing finance agency, 

state agency for community development, the state property management agency, and several 

local public housing authorities. It works with the state health department to leverage Medicaid 

dollars for its clients and with the state’s labor department to obtain employment and training 

resources. DMH also works with the state welfare agency to coordinate the state’s overall 

strategy for addressing homelessness, and with Housing Courts in several parts of the state. In 

addition to these public collaborators, DMH works and contracts with a host of nonprofit 

providers and the for-profit agency that manages behavioral health care for its clients. 

The Role of Nonhousing Public Agencies 

A final issue related to maximizing resources for prevention is the involvement of public 

agencies whose mandate includes assistance to vulnerable individuals and families. Examples 

include child welfare, corrections, Temporary Assistance for Needy Families (TANF), and 

mental health agencies. Agencies of this type often have not recognized a housing component as 

part of their responsibilities, but in some communities their understanding is changing, and with 

it their investments. The lead prevention agencies in four of the study communities provide 

obvious examples. 

For families, these agencies include the Human Services Department in Hennepin County and 

the Department of Health and Human Services in Montgomery County, both of which combine 

responsibilities for TANF, child welfare, and mental health. Not only have these agencies taken 

the lead on homelessness prevention, they have also assured that families involved in any of their 

agency’s services will receive coordinated case management and shared agency resources. 

The public mental health agencies in Massachusetts and Philadelphia have long recognized the 

importance of stable housing for their clients’ well-being. Both have involved corrections 

agencies in their efforts. Philadelphia has also been working with the child welfare and TANF 

agencies to develop a system that alerts caseworkers quickly to a family’s impending housing 

crisis so that timely intervention and assistance may prevent homelessness. In Massachusetts, 

DMH works closely with the Department of Transitional Assistance, which is the lead agency 

for addressing homelessness in the state. 
Chapter Four Key Elements of Prevention Strategies 

60

Elements Affecting Direction, Sustainability, Control, and Feedback 

Many of the elements falling under this heading—leadership, having clear prevention goals, and 

having a strategic multiyear plan for achieving the goals—are so interdependent that they cannot 

be discussed separately. It is also impossible to say “which came first,” as they often evolve 

together. 

The three study communities with the best-developed multiyear approaches were Hennepin 

County, Massachusetts DMH, and Urban Peak. (Urban Peak differs from Hennepin County and 

Massachusetts DMH in the absence of public agency investment and commitment.) Each 

community had a different goal: preventing family homelessness within one urban county for 

Hennepin County; preventing first-time and subsequent homelessness by providing stable 

housing and community supports for people with serious mental illness for Massachusetts DMH; 

and helping already-homeless youth gain housing and stability for Urban Peak. The remaining 

three study communities had some aspects of a coherent approach, but lacked others. These 

differences allowed the study team to identify the aspects of prevention approaches that appear to 

be most important to developing a coherent, multiyear strategy for homelessness prevention. 

Leadership, Goal Orientation, and Planning 

The three communities with multiyear strategies had leaders who were committed to the goal of 

prevention. In two of the communities (Hennepin County and Massachusetts), public agencies 

had the authority and responsibility to set goals and develop plans. In the third, a nonprofit 

agency developed into a leader over time even without the backup of public authority. These 

leaders, knowing that implementing their overall strategies would take years, pursued many 

activities at once. A clear goal and sustained leadership has enabled them to take advantage of 

many opportunities for joint funding from the U.S. Department of Housing and Urban 

Development and other Federal, state, and local agencies. Leadership in each of these 

communities worked with local legislatures over the years to obtain enabling legislation, 

funding, and waivers; add eligible populations to their funding streams; and create new programs 

based on their experience of what was necessary to prevent homelessness. Alliances and 

collaboration with the sources of capital and operating funds for housing have been essential to 

prevent homelessness among people with chronic conditions. 

Centralized control of much funding for prevention makes it easier to establish an efficient 

system to handle both primary and secondary prevention. This control can also provide leverage 

to establish systematic monitoring to determine what works at the various stages of the 

prevention and emergency shelter phases. This knowledge enables agencies and communities to 

buy effective services and achieve desired objectives. If exercised in a spirit of collaboration and 

collective system-building, centralized control of funding encourages community-wide support 

of prevention and creative problem solving to reach the goal of preventing homelessness. 

For example, Massachusetts DMH has consciously directed its funding toward meeting strategic 

prevention objectives. Since 1992, the department has developed independent and semiindependent housing options, as well as an extensive array of community-based supportive 
Chapter Four Key Elements of Prevention Strategies 

61

services for its clients. Homelessness prevention and rapid exit have been one theme in a broader 

agenda of developing a community-based service structure to maintain DMH clients in stable 

housing in the community, thus avoiding rehospitalization and homelessness. DMH establishes 

partnerships and collaborative arrangements with other funders and with providers, seeking 

contracts for specific supports to advance the department’s overall strategy. 

Feedback for System Improvements 

Of the four study communities with high levels of funding control (Hennepin County, 

Montgomery County, Massachusetts DMH, and Philadelphia), Hennepin County is the most 

advanced in its conscious use of the contracting process to obtain specific outcomes that reflect 

progress toward goals. FHPAP managers routinely solicit proposals to achieve explicit outcomes 

for families with specified housing barriers. This method of contracting enables providers to do 

“whatever it takes” (with the exception of paying for shelters, building housing, or subsidizing 

housing for more than 24 months) to prevent homelessness or assure rapid exit from shelter. 

Hennepin County staff track outcomes and, together with a broadly representative Advisory 

Committee, make contract renewal decisions based on providers’ abilities to achieve the 

promised outcomes. Because these activities uniquely maximize investment in prevention, they 

warrant a detailed presentation. 

• Controlling the whole system: When FHPAP was established, program managers 

reasoned that pressure on one service component would merely push families into 

another service component unless the county controlled access to the entire system. For 

example, refusing prevention assistance might push a family into emergency shelter. The 

county created the primary prevention and rapid exit components of its system together to 

ensure that family housing crises must be addressed. 

• Using its data to create a feedback loop for monitoring and system improvement: The 

FHPAP program manager was the moving force behind the FHPAP data system. She 

uses it routinely to monitor the system and check on performance. Issues she looks for 

include the housing barrier levels of families being admitted to shelter, the speed of exit 

from shelter, and smooth operation of the primary prevention component. Targeted 

screening combined with careful monitoring has succeeded in reserving scarce shelter 

resources for the hardest-to-house families. Other study communities have not been as 

focused on control through feedback and adjustment, although some communities could 

do so with data they have on hand. Massachusetts, Philadelphia, and Montgomery 

County use data to inform and guide their approaches to preventing homelessness. These 

jurisdictions are beginning to think strategically about homelessness prevention and the 

use of data to guide system development. 

• Using outcomes-based contracting: Because it has a comprehensive strategy with clear 

goals, the FHPAP is able to document outcomes of service receipt. In its Request for 

Proposals seeking prevention and rapid exit providers, it specifies the level of 

performance it wants to purchase. Specifications are stated in terms of outcomes, not 

persons served or services delivered. Bids must also be clear as to the outcomes being 
Chapter Four Key Elements of Prevention Strategies 

62

promised, and expected outcomes are clearly stated in county contracts. FHPAP 

managers generally receive 30–40 proposals in response to each RFP, of which 10–15 

percent receive funding. Due to a high level of choice, FHPAP is able to select providers 

that best understand its outcomes-based approach and provide evidence that they will 

fulfill the performance commitments. FHPAP monitors and evaluates providers based on 

outcomes. Providers that do not fulfill these contract obligations may be terminated. 

Montgomery County and OBH in Philadelphia control many of the resources that could be 

devoted to homelessness prevention and rapid exit. They also have data systems that could 

provide feedback to guide the contracting process toward using outcomes as the basis of 

awarding and renewing funding. Both jurisdictions also have control over who receives 

prevention services, and Montgomery County controls access to shelter as well. In both 

communities, the payment structure could, in the abstract, establish the types of performance 

feedback mechanisms that Hennepin County uses to ensure that resources are expended in the 

most effective and efficient manner. 

CONCLUSIONS 

This chapter identified two issues confronting communities desiring to prevent homelessness: 

knowing what prevention activities are effective and developing a system to deliver them 

efficiently (i.e., to the families with a very high risk of becoming homeless if they do not receive 

help). Several effective prevention strategies were identified, including some that are most likely 

to be used for primary prevention and others that are more likely to be used for secondary 

prevention or even tertiary intervention. 

With respect to organizing a community for prevention, the study team identified two overall 

strategies. The first—most commonly applied to families threatened with housing loss—screens 

for short-term problems that nonetheless constitute crises for particular families, and applies 

short-term solutions. The second seeks people whose disabilities or other circumstances indicate 

chronic problems, and applies the long-term solutions of housing with supportive services. When 

these solutions are made available before homelessness occurs, they have a stabilizing and 

preventive effect similar to what happens when they are offered to chronically homeless people 

with disabilities. 

These two strategies operate through several mechanisms that other communities could begin to 

develop. These include careful targeting toward populations at very high risk of homelessness, 

and organizing and controlling access to preventive services to maximize targeting. The best 

organized among the study communities reached their present situation deliberately and over 

time, in a process that involved leadership, analytic thinking, strategic planning, alliance 

building, and collaboration. Developing better data and using existing data more strategically can 

improve performance, identify and fill gaps, and further the development of a community’s 

approach to homelessness prevention. 

This study has not found definitive proof that these prevention efforts work, as it has not been 

able to identify or construct control or comparison groups from the study communities to assess 
Chapter Four Key Elements of Prevention Strategies 

63

how much homelessness would have occurred without the interventions. It did, however, identify 

some comparative data, in light of which one can make some claim to the effectiveness of 

homelessness prevention activities described in this chapter. The study has also helped to 

identify circumstances under which activities designed to prevent homelessness have the greatest 

chance of actually doing so. 

Communities interested in supporting homelessness prevention activities should think very 

carefully about targeting, how and toward what ends it is allocating prevention resources, and 

how it could obtain feedback to assess effectiveness and improve system performance. 

Communities should also identify a person to lead the effort to organize for prevention, and give 

that person the authority to plan and make things happen over the long term. It is impossible to 

say how much each element identified during this study contributes to effective and efficient 

prevention. However, one can conclude that the communities whose prevention efforts include 

the most elements seem to be making the most difference, and are certainly able to supply the 

best documentation that their activities have prevented some homelessness. 
64
65

CHAPTER FIVE 

POLICY, PRACTICE, AND RESEARCH IMPLICATIONS 

Chapter Four identified two issues for prevention: the effectiveness of any particular activity, and 

the efficiency with which that activity could be delivered. Effective activities are those that avert 

initial homelessness (primary prevention), or end a homeless experience quickly (secondary 

prevention). Efficient systems are those that target well, delivering effective activities to people 

who are very likely to become homeless unless they receive help. 

Policymakers intending to prevent homelessness will want to support effective activities. 

However, this will not be sufficient for most communities. Policymakers and administrators will 

also need to consider the elements that comprise an efficient community-wide prevention 

strategy if they want to assure that resources are used wisely. This study identified several 

prevention activities that have some evidence to support their effectiveness, as well as elements 

of community systems that appear to be important in making a prevention strategy efficient. 

Findings from this study, combined with updated summary of prevention effectiveness research 

(Shinn et al., 2001), point toward some new directions for policy and practice. Implications for 

future research are apparent, given the paucity of adequate documentation that exists regarding 

prevention effectiveness. 

IMPLICATIONS FOR POLICY AND PRACTICE 

Some communities in the United States have committed to ending all homelessness in 10 years. 

Many communities have committed to ending chronic homelessness in that timeframe. 

Communities are not likely to succeed in either endeavor without preventing new entries into 

homelessness and quickly resolving any homeless episodes that occur. 

Select Effective Prevention Activities 

The following prevention activities may be implemented at all levels of prevention: primary, 

secondary, and tertiary. These activities may be used alone or in combination as part of a 

coherent community-wide strategy. Any funder considering an investment in homelessness 

prevention—whether nonprofit, for-profit, or government at any level—would do well to 

concentrate its support on one or more of the following activities. 

• Housing subsidies. Evidence for housing subsidies as a very effective prevention activity 

comes from studies other than the present one. Shinn and colleagues (Shinn et al., 2001; 

Stojanovic et al., 1999) documented the effectiveness of housing subsidies at keeping at 

least 80 percent of first-time homeless families housed for a minimum of two years. Rog, 

McCombs-Thornton, Gilbert-Mongelli, Brito, and Holupka (1995) demonstrated similar 

success (80–85 percent retention over at least 18 months) for homeless families in which 

a parent’s mental illness complicated housing stability. Evidence from simulations
Chapter Five Policy, Practice, and Research Implications 

66

(Quigley, Raphael, and Smolensky, 2001) indicates that subsidizing housing costs for 

extremely low-income people has the strongest effect on lowering homelessness rates 

compared to several other interventions tested. Thus when used as secondary and tertiary 

prevention, housing subsidies help 80–85 percent of homeless families or chronically 

homeless single adults to achieve housing stability. 

• Supportive services coupled with permanent housing. For people with serious mental 

illness, with or without co-occurring substance abuse, permanent supportive housing 

works to prevent initial homelessness, to rehouse people quickly if they become 

homeless, and to help chronically homeless people leave the streets (Burt et al., 2004; 

Shern et al., 1997; Tsemberis and Eisenberg, 2000). 

• Mediation in Housing Courts. This study collected evidence indicating that mediation 

succeeds in maintaining housing for about 69 percent of families and up to 85 percent of 

people with serious mental illness, even when their landlords have filed a formal eviction. 

• Cash assistance for rent or mortgage arrears. This commonly used prevention activity 

can be effective—the challenge is to administer it in a way that makes it well targeted and 

therefore efficient. 

• Rapid exit from shelter. These secondary prevention activities are directed toward 

families just entering shelter to ensure that they quickly leave shelter and stay housed 

thereafter. Using this innovative strategy, Hennepin County halved the average length of 

a shelter stay (from 60 to 30 days) and achieved an 88 percent success rate in keeping 

formerly homeless families from returning to shelter. 

In addition to selecting effective prevention activities, a community’s prevention strategy must 

offer activities that are accessible and acceptable to all, or some significant subgroups, of the 

target population. In developing any system of homelessness prevention, consultation with 

consumers assures investment in acceptable housing options. Offering consumers a role in 

selecting among housing options for themselves will increase the likelihood of satisfaction with 

housing and willingness to stay in that housing (Tsemberis, Gulchar, and Nakae, 2004). 

Develop an Efficient Community-Wide Prevention System 

Whether a community chooses to concentrate on preventing homelessness among people with 

short-term risk, people who require long-term support, or both, its prevention strategy should 

strive for maximum efficiency. The short-term solutions would be similar to current practices, 

but with increased and more accurate targeting to prevent homelessness. Strategies for 

populations with chronic conditions, which make them vulnerable to homelessness, should 

identify and serve these persons with housing and support options that are acceptable to them.

Critical to efficiency is community-wide collaboration in all aspects of system organization and 

development. Mainstream agencies such as those focusing on mental health and corrections 

should be involved in developing these strategies, developing mechanisms to assure appropriate 

housing for people leaving institutional settings, foster care, and other venues. Communities 
Chapter Five Policy, Practice, and Research Implications 

67

should also consider developing community supports for people at high risk of repeated 

homelessness, to keep them in housing. Consumer input should be valuable in these efforts, 

identifying the factors that cause people to leave housing when they have nowhere else to go. 

The Continuum of Care (CoC) planning process helps ensure that communities pay attention to 

homelessness prevention, in that CoC applications for HUD funding must describe prevention 

offerings as part of their community continuum. The CoC process is a reasonable mechanism for 

developing more comprehensive prevention plans, as many community stakeholders are 

typically involved. Incorporating data collection through a local Homeless Management 

Information System (HMIS) and other approaches would also be appropriate for a CoC, and the 

resulting feedback could be used to shape responses to fill the gaps in primary and secondary 

prevention in the jurisdiction’s CoC. 

Improve Targeting 

For investments in homelessness prevention to be used efficiently, they must target the people 

with the highest risk of homelessness. Regardless of the specific activities adopted, the 

importance of appropriately targeting prevention activities suggests that certain elements should 

be established to increase the likelihood of prevention efficiency.22 These elements include: 

• Determination to target prevention resources to those at highest risk, occurring at several 

levels—policy, program management, and direct service worker; and 

• Mechanisms to assist with identifying the high-risk people and households, including: 

- Knowledge of risk factors and agreement on those that, alone or in combination, 

comprise very high risk; 

- Adequate screening procedures to identify people and households that exhibit the 

risk factors; and 

- Community-wide consistency with applying screening procedures and eligibility 

standards. 

 

22 This chapter has separated the issues of effectiveness and efficiency to make the point that many different 

activities may prevent some homelessness, but that a great deal depends on the system that delivers them. An 

evaluation researcher would say that an inefficient prevention system could not be effective. That is, if one compared 

a treatment and control group drawn from a poorly targeted population (one that was very unlikely to experience 

homelessness even without an intervention), one would find “no difference.” A statistical finding of “no difference” 

is usually interpreted to mean that the intervention is not effective. But with respect to prevention interventions it 

probably means that the population had such a low risk of homelessness initially that the intervention could not 

make enough difference to be statistically significant. 
Chapter Five Policy, Practice, and Research Implications 

68

Develop Strong Collaborations 

For homelessness prevention to work, a community will need to make available a range of 

prevention activities—from counseling to housing—that is acceptable to the target population(s), 

or commit to identifying and creating such options. To this end, it is useful to engage many 

stakeholders and establish collaborations within the community. Allies are needed to prevent 

homelessness, as no single agency has the resources or the responsibility to do it alone. 

Communities or entire states should conduct the following activities. 

• Fund the mainstream agencies responsible for people with chronic disabilities (e.g., 

mental health, mental retardation, and substance abuse agencies) and direct them to 

identify households at risk of losing housing. These agencies should take responsibility 

for helping at-risk households to prevent housing loss by providing supportive services 

coupled with community-based housing. Examples in this study include Massachusetts 

and Philadelphia. 

• Engage mainstream child welfare and welfare (Temporary Assistance to Needy Families, 

or TANF) agencies in homelessness prevention. These agencies also need to develop 

mechanisms to recognize risk of housing loss among their clients and act to prevent it. 

The communities in this study provided several examples of how these agencies can be 

involved in homelessness prevention, including the child welfare agency in Philadelphia, 

and TANF agencies in Hennepin County, Montgomery County, and Massachusetts. 

• Enlist corrections agencies, which are beginning to realize that it is in their own financial 

interest to offer short-term (e.g., six months) housing, links to employment, and 

supportive services to reduce the odds that recently released prisoners will return to very 

expensive correctional settings. (At present, about two-thirds of released prisoners return 

within three years, and many return much sooner.) Examples in this study include 

Massachusetts and Philadelphia. 

• Fulfill the promise of developing community-based housing following state hospital 

closings. Jurisdictions can reinvest into the community the capital and operating 

resources previously used to fund state hospitals. An example from this study is the 

Facilities Consolidation Fund bond financing in Massachusetts, which was recently 

renewed for an additional 10 years. This fund provides capital resources for communitybased housing for people with serious mental illness and mental retardation who 

previously might have been housed in state institutions. 

Develop and Use Data Systems 

Data systems are needed to record homelessness risk factors for households, as well as previous, 

current, and subsequent homeless status, either at the time a household applies for assistance or 

at high-risk moments such as institutional entry and discharge. In addition to collecting 

information to conduct the risk assessments and targeting activities described above, 

communities or entire states should conduct the following activities. 
Chapter Five Policy, Practice, and Research Implications 

69

• Adopt one or more of the outcome measures described in Chapter Three. Communities 

could use their HMIS, modify existing systems, or create new data systems to include 

information about homelessness or housing status and barriers. Determining the data 

needed to make informed decisions about system improvements should be part of a 

CoC’s planning process, just as using the data to assess effectiveness and make 

investment decisions should be part of regular system reviews. Communities should be 

able to adapt their HMIS to assist in this effort. 

• Collect data on the selected outcome and explanatory variables for people served by 

prevention interventions. 

• Train staff throughout the system to use the new fields or new data system, and introduce 

quality control to ensure the system is accurately recording the information. 

• Collect equivalent data on one or more of the groups identified in Chapter Three to 

provide comparison data (e.g., people on waiting lists who are never served or not served 

for long periods of time, or people turned away because resources are not available). 

Examine outcome measures for both groups to assess progress or success. 

• Adjust practice according to progress or successes. Disseminate results demonstrating 

success to build confidence in the approach and bolster support for sustained funding and 

participation. 

Leadership 

Designating someone with the primary responsibility of “minding the store” is essential if 

communities expect to improve their ability to prevent homelessness. An organized, persistent 

effort is required. The resulting strategy has to include feedback capable of revealing that midcourse corrections are needed, the ability and authority to make mid-course corrections, and the 

information to demonstrate that the strategy operates better following such corrections. These 

requirements imply active leadership committed over the period of years it takes to develop and 

sustain a comprehensive community-wide strategy. It is also highly desirable that the strategy 

provides the opportunity for creativity, serendipity, and synergy, which flourish when partners 

bringing a wide range of resources and skills to the table work collaboratively toward common 

goals. The best strategies identified in this study have these characteristics. 

The Role of Federal Agencies 

Federal agencies can promote adoption of more effective prevention strategies through their 

policy positions and by the way they structure funding opportunities. Federal agencies need to 

continue to emphasize the role of prevention in community-wide strategic planning and 

integrated approaches for reducing homelessness for those at greatest risk. Federal agencies in 

charge of block grants and formula grants with potential for use to prevent homelessness should 

emphasize the importance of improved targeting and measurement of outcomes. These agencies 
Chapter Five Policy, Practice, and Research Implications 

70

should also and encourage the local agencies controlling the funds to incorporate more strategic 

and community-wide planning as they distribute these resources. Relevant programs include 

Emergency Food and Shelter Grants, Emergency Shelter Grants, and the community support 

aspects of some programs and block grants from the U.S. Department of Health and Human 

Services (e.g., Projects for Assistance in Transition from Homelessness, Community Mental 

Health Services Block Grant, Substance Abuse Prevention and Treatment Block Grant). Finally, 

Federal agencies should continue to make technical assistance available to communities that are 

trying to improve targeting and measure outcomes as part of their strategic planning to prevent 

and end chronic homelessness. HUD’s technical assistance guide on using ESG for homelessness 

prevention is an excellent example of a resource that can benefit grantees as they incorporate a 

homelessness prevention component into their service delivery.

IMPLICATIONS FOR FUTURE RESEARCH 

The implications of this study’s findings for future research are formidable. They arise from the 

finding that even the few communities that systematically collect data on their prevention efforts 

are not able to provide solid evidence that activities intended to prevent homelessness actually do 

so. The role of Federal agencies in promoting and sponsoring the following research suggestions 

is vital, as there is little likelihood that local programs will mount extensive research efforts, or 

that they will establish the control or comparison groups that are so important for verifying that 

prevention really happened. State agencies or foundations might also sponsor evaluations of 

homelessness prevention activities, but HUD and other Federal agencies are in the best position 

to do so, and are most likely to have the necessary resources. 

For primary prevention, control groups are necessary to prove that significant levels of 

homelessness would have occurred if the intervention had not been offered. Comparison groups 

that approximate randomness would also contribute to these findings. In the absence of control 

or comparison groups, documenting changes over time in relation to significant changes in the 

intensity of interventions or precipitating factors (e.g., unemployment) may be convincing. The 

research suggestions presented below may help fill the most glaring gaps in current knowledge 

and indicate whether approaches to preventing homelessness are effective. 

Control or Comparison Groups 

For prevention interventions, conducting controlled experiments (with randomly assigned control 

groups) or quasi-experiments (with comparison groups that are matched as well as possible but 

are not randomly assigned) is the only sure way to assess effectiveness. The types of control or 

comparison groups may vary based on the population being studied. 
Chapter Five Policy, Practice, and Research Implications 

71

Families 

To demonstrate prevention effectiveness among families, control groups may be constructed by 

randomly assigning families to either the treatment or control group to perform a true 

experiment. Quasi-experimental designs may be used with comparison groups developed from 

waiting lists. Literal homelessness may be measured as an outcome, as well as more refined 

measures such as less stable housing and doubling up. These measures may help determine 

whether without rent, mortgage, and utility assistance and other short-term prevention activities, 

families begin the slippery slope to homelessness or manage to stabilize again after temporary 

economic setbacks. 

People with Chronic Disabling Conditions 

For people with chronic disabling conditions such as serious mental illness, HIV/AIDS, and 

chronic substance abuse, control groups may be constructed using random assignment and 

comparison groups may be constructed using waiting lists. If intervention levels vary 

significantly, one could track this variation over time against homelessness among people with 

the relevant disability. These data could be gathered at admission and discharge from institutions 

such as state hospitals, private psychiatric inpatient settings, substance abuse treatment settings, 

correctional institutions, and emergency shelters. 

For secondary prevention, one could track interventions and their success and speed at housing 

people as well as the length of time the interventions are able to keep people housed. Also, one 

could document the supportive services used to stabilize housing to determine what is required to 

keep people in the target populations housed. 

Comparison Groups 

Larger efforts that span over a number of jurisdictions could include supporting a reasonable 

sample of providers whose prevention efforts focus on distributing rent, mortgage, and utility 

payments to help people retain housing. This support would help these providers to collect and 

maintain better data on the families they do and do not assist. These providers could be 

concentrated in selected communities whose housing and employment opportunities varied 

systematically, to provide some level of contextual variation to help explain both demand for 

assistance and success in homelessness prevention. Required data elements for both categories of 

families include: 

• Family characteristics, housing barriers, and histories at intake; 

• Interventions provided; and 

• Followup for at least 12 months to assess levels of housing retention and various 

economic hardships. 
Chapter Five Policy, Practice, and Research Implications 

72

These data should be assembled at the national level. This approach would be less expensive 

than an ideal research design, but would still contribute significant new data on important issues, 

including the effectiveness of rent, mortgage, and utility assistance as homelessness prevention. 

To give this approach the greatest chance to contribute high quality information, a national 

research effort would have to be established to manage data collection within programs and 

conduct followup interviewing to assure acceptable completion levels. 

Longitudinal Tracking 

Longitudinal tracking studies should be funded to document housing retention and stability and 

to follow people after they receive a prevention intervention. A primary outcome to observe 

would be housing stability and the factors contributing to it. One could also observe the supports 

available to and used by households that do not receive prevention interventions. This 

information would add to the understanding of why households do or do not become homeless. 

Targeting 

Communities should identify and disseminate better targeting practices to help prevention 

programs determine those who are at high risk of becoming homeless without the intervention. 

This study described the targeting practices of Hennepin County in great detail. Even before the 

evidence from more controlled research is available, this and other targeting schemes for family 

homelessness prevention should be identified and assembled, compared, and disseminated. 

Detailed information should be assembled on mental health system practices for identifying 

clients who need housing to prevent homelessness or a slide into chronic homelessness. This 

process could start with the two mental health systems examined in this study. Any evidence 

available from system records for the success of this targeting should be extracted and analyzed, 

using information from all mentally ill clients to determine whether targeting has been accurate. 

Targeting information from these analyses should be assembled and disseminated to other mental 

health systems and to mental health advocacy organizations. 

Once results are known from one or more of the controlled research studies suggested above, the 

targeting schemes should be modified based on the results. 

CONCLUSIONS 

Community-wide approaches to prevent homelessness are an essential part of ending 

homelessness, because only prevention can reduce or eliminate new cases of homelessness. 

Many communities offer a wide range of activities intended to prevent homelessness. 

Researchers (Lindblom 1997, Shinn, Baumohl, and Hopper, 2001) have concluded that strong 

evidence is still lacking that homelessness prevention efforts are effective, but the bulk of their 

criticism has to do with targeting and inefficiency, not with the underlying effectiveness of 

different activities. This study found examples of promising policies and practices, including 
Chapter Five Policy, Practice, and Research Implications 

73

approaches to targeting that could be adapted to local circumstances and applied by other 

communities. 

These policies will have the greatest chance of success if they are part of a coherent, multiyear 

approach supported by strong leadership, adequate resources, and mainstream agency 

commitments, particularly for the policies involving populations with chronically disabling 

conditions. Communities could also begin to improve their prevention targeting and establish 

one or more of the innovative strategies described in this report. The CoC planning process that 

occurs in many communities is an appropriate vehicle for implementing many of this report’s 

suggestions. Federal and state programs, as well as national organizations, that encourage 

community-wide, collaborative thinking and help fund such efforts would contribute 

significantly to their success. 
74
75

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Housing Markets, and Homelessness in California. Research Brief: Public Policy Institute of 

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needs of participant families,” American Journal of Orthopsychiatry, 514–527. 

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Straw and P.A. Wood. 1997. “Housing outcomes for homeless adults with mental illness: 

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Shinn, M., J. Baumohl, and K. Hopper. 2001. “The prevention of homelessness revisited,” 

Analyses of Social Issues and Public Policy,” 95–127. 

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493. 

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Colorado,” Sexually Transmitted Infections, (78), 357–359. 

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77

APPENDICES 

This section of the report includes in-depth descriptions of each of the communities visited for 

this study, an expanded description of the study methodology, and a glossary of acronyms used 

throughout the report. The appendices are as follows: 

Appendix A Hennepin County, Minnesota 

Appendix B Montgomery County, Maryland 

Appendix C Mid America Assistance Coalition 

Appendix D Massachusetts 

Appendix E Philadelphia, Pennsylvania 

Appendix F Urban Peak 

Appendix G Methods 

Appendix H Glossary 

The three study sites that provide prevention strategies for families are described first and 

include Hennepin County; Montgomery County; and the Mid America Assistance Coalition 

serving Kansas City. The three study sites that focus on longer-term, more intensive 

interventions with persons who are seriously mentally ill or who are homeless youth are 

summarized next—Massachusetts Department of Mental Health, the Philadelphia Office of 

Behavioral Health, and Urban Peak. 

The information presented in each of the site appendices varies; however, each of the site 

appendices is organized in terms of four major headings: 

• Practices of Potential Interest to Other Jurisdictions; 

• Developing the Commitment to Prevention; 

• Components and Organization of the Community Strategy; and 

• Data Collection and Use.
78
A–1

APPENDIX A 

HENNEPIN COUNTY, MINNESOTA 

During 2003, the population of Hennepin County consisted of approximately 1.1 million people, 

383,000 of whom lived in Minneapolis, the county’s largest city. The county encompasses more 

than 20 suburban cities. The county is prosperous and its 1999 poverty rate was lower than for 

the nation as a whole (8.3 percent versus 11.3 percent).23 Although the local economy was 

affected by a recent recession, unemployment is lower than for the nation. Unemployment 

information was not available specifically for Hennepin County or Minneapolis, but the January 

2005 unemployment rate for the Minneapolis-St. Paul metropolitan area was 4.6 percent 

compared to the national rate of 5.2 percent.24 

The affordable rental housing market in Hennepin County has softened considerably since the 

late 1990s, when units were difficult to find, even with a subsidy. Reasons for the softening 

market include: new construction and increases in home ownership (abetted by low interest rates 

and the departure of many low-income working families when service sector employment, 

including the airlines and tourist industries, collapsed after September 11, 2001). As described 

below, the current availability of rental units helps many of the county’s prevention strategies to 

be more successful than they would have been in the tight market of only a few years ago. 

During the study team’s visit to Hennepin County during June 29–July 1, 2004, the team 

interviewed 12 people representing several offices of the county’s Human Services Department 

(HSD). The HSD oversees the Family Homeless Prevention and Assistance Program (FHPAP) 

and rapid exit system (nonprofit agencies providing prevention and rapid exit services under 

contract with the county) and a data analyst at the Wilder Foundation, who provides the system’s 

documentation. A complete listing of persons interviewed is located at the end of this appendix. 

Meetings with these persons provided information about the system and how it works, as well as 

how it fits into the larger scope of HSD responsibilities. The study team also learned about the 

reports currently used to document prevention effectiveness. Below is a description of the family 

homelessness prevention and rapid exit system in Hennepin County including the county’s 

documentation of program impact. 

 

23 Population data were obtained from the U.S. Census Bureau at: quickfacts.census.gov/qfd/states/27/27053/html 

and quickfacts.census.gov/states/00000.html (accessed 7/16/2004). 24 Unemployment data were obtained from the Bureau of Labor Statistics at: 

http://www.bls.gov/xg_shells/ro5xg02.htm#msa (accessed 3/29/2005). 
Appendix A Hennepin County, Minnesota 

A–2

PRACTICES OF POTENTIAL INTEREST TO OTHER JURISDICTIONS 

The contact for all Hennepin County practices discussed in this appendix is Shirley Hendrickson 

(Shirley.Hendrickson@co.hennepin.mn.us). Practices that are of potential interest to other 

jurisdictions are presented below. 

1. Data system shared by all FHPAP providers. Hennepin County and the Wilder 

Foundation developed a database that all FHPAP providers currently use. It is valuable to 

providers for helping clients, to the FHPAP manager for monitoring and assuring system 

performance, and to the county for documenting success that assists in sustaining 

funding. 

2. Outcomes-based contracting. Hennepin County uses FHPAP funds to support prevention 

and rapid exit services, and a services-only grant from the U.S. Department of Housing 

and Urban Development’s (HUD) Supported Housing Program (SHP) for rapid exit 

services. The county contracts with nonprofit agencies to deliver services. For more than 

a decade, requests for proposals (RFPs) have asked bids to produce outcomes (e.g., move 

four families into housing each month and keep them housed) rather than solely 

providing services to families (e.g., counseling, case management, and budgeting 

information). Only bids offering outcomes are funded, and providers are monitored and 

evaluated based on the outcomes they produce. Providers not fulfilling their contract 

obligations may be terminated if efforts to move them toward outcomes fail.

3. Control of the whole system—program concept and its execution. Prevention contracts 

use state money to do “whatever it takes,” within contract limits, to keep families at 

imminent risk of homelessness in housing. The county also pays for shelter for families 

and uses SHP and some FHPAP funds to contract for services to move families out of 

shelter into housing and keep them there. Some transitional housing is also under county 

control. The breadth of the FHPAP Umbrella Program gives the county the scope to 

analyze what works at the various stages and contract for such programs, without risking 

that controlling one part of the system will result in unintended consequences at another 

part. 

DEVELOPING THE COMMITMENT TO PREVENTION 

Hennepin County has traditionally been a jurisdiction that takes seriously its responsibility “to 

promote the general welfare.” With respect to family homelessness, the County Board of 

Commissioners has a long-standing policy that the county will do what it takes to assure that no 

family spends a night on the streets. Several factors help explain both why the county was 

motivated to create its current system of family homelessness prevention and why it has 

succeeded to a considerable extent. These factors are: 

• The county’s commitment to prevent all family “street” homelessness; 

• Traditions of activist local government; 
Appendix A Hennepin County, Minnesota 

A–3

• The county’s investment in sheltering families—the county pays for this shelter, through 

contracts with shelter providers; 

• The county’s ability to shape and control the various parts of the system through 

contractual arrangements; and 

• The county’s use of data to facilitate daily assistance to clients and to provide daily, 

monthly, and annual feedback to improve the system. 

A turning point for family homelessness prevention in Hennepin County and the state occurred 

during 1993. Facing the reality that the current system could no longer adequately serve the 

increasing number of homeless families, the county decided that it needed to do something very 

different. The county worked with the Minnesota Housing Finance Agency (MHFA) to draft 

creative legislation that addressed the increasing homeless problems of the state. The result was 

the FHPAP, which MHFA administers. The FHPAP legislation established a set of outcomes 

related to preventing family homelessness, including shortening lengths of stay in shelter, 

preventing first-time entry, and eliminating re-entry. 

In Hennepin County, FHPAP refers to the prevention funding, services for prevention and rapid 

exit from shelters, and to the FHPAP Umbrella Program that includes additional prevention and 

rapid exit programs funded through Federal and county dollars. FHPAP is flexible outcomesbased funding, allowing grantees to do “whatever it takes” to prevent homelessness. (Exceptions 

include paying for shelters, building housing, or subsidizing housing for more than 24 months.) 

Grantees apply for funds every biennium and are awarded funding based on outcomes 

accomplished—or on the initial plan to achieve the outcomes. Initially designed for families and 

youth, single adults were subsequently added as a target population and have been covered in the 

county since 1998. Nevertheless, the bulk of funding is committed to preventing family 

homelessness. 

The family rapid exit program began during 1993 as providers identified that shelter residents 

were in need of assistance to find housing. Analysis of the system found that the current methods 

were not identifying the neediest families. During 1995, the county introduced a centralized 

housing barrier screener, the rapid exit coordinator, and an assessment process for those entering 

shelter to target shelter services to those with moderate to great housing barriers. The rapid exit 

program evolved into a systematic process to review the barriers of each family entering countypaid shelter, and to connect them with the most effective housing placement agencies. 

Also during 1995, the county began expecting families to contribute toward their shelter stay 

costs. Prior to this time, families could stay in shelter, free of charge, and keep their entire 

welfare check, as well as gain access to many benefits including food stamps, Medicaid, and 

childcare. Since the county was providing all housing and food needs while the family retained 

its grant, there was little incentive to move quickly out of shelter. 

The cost for one night in shelter is approximately $30 per person (regardless of age) until the 

family’s money runs out, after which the county pays. The average state welfare check equals 

approximately five days of shelter. Having families contribute toward their shelter stay may 
Appendix A Hennepin County, Minnesota 

A–4

appear punitive; however, the county uses all funding sources—including FHPAP, Federal SHP, 

emergency assistance, and county taxpayer dollars—to help pay for costs associated with 

obtaining housing such as first and last months’ rent, security deposits, and moving expenses. 

Prior to when the county decided to charge for shelter, families could save their welfare checks 

to cover these costs. In addition, the county offers many supports, which keep families from 

needing to enter shelter and help them exit quickly. The operating assumption is that this use of 

resources is better for the family and for the county. The county does not have to pay for costly 

long shelter stays, which do little to move the family toward housing and stability. 

During 1995, HSD also recognized that FHPAP resources were not sufficient to address all the 

needs of the population. HSD was awarded two SHP grants to supplement services already 

provided. One grant supported Project Connect to serve the hardest to serve, multibarrier 

families. The second grant, awarded to the Homeless Outcome Project, increased the number of 

rapid exit services for the moderate- to high-barrier families. 

The present system evolved from a crisis moment during the fall of 2000, when HSD found itself 

with all (116) of its family shelter units full, an additional 201 families in motels funded by 

county vouchers, no systematic approach for moving families out of shelter or staunching the 

arrival of more, and no end in sight. HSD could not refuse shelter as a result of the Board of 

Commissioners’ policy of no street homelessness for families. Finding itself in an untenable 

situation, county staff sought to improve two dynamics—preventing families from needing 

shelter and working with those in shelter to shorten their stay and improve their circumstances 

upon exit from the shelter. 

The first change effort involved establishing priorities, namely: identifying families to be placed 

in shelter, and using the priorities to triage applicants for shelter. Pregnant or parenting teens, 

families with more than two children or infants, and families in which a parent or child received 

Supplemental Security Income (SSI) were given priority for available shelter space. Each family 

was interviewed and asked where they had spent the previous night and whether they could stay 

there one more night. They were informed of the shortage of shelter space and advised to try and 

make other arrangements for shelter for that night. Listings of community resources and private 

shelters were provided to each family. Sheltering assignments were delayed until mid-afternoon, 

when all of that day’s families had been screened. These procedural changes increased the 

number of families who were able to secure alternative housing and reduced the number of 

families entering shelter. 

The second change established a coordinated plan for each family to exit shelter more quickly. 

The HSD Shelter Team began a coordinated partnership with the FHPAP-funded rapid exit 

program and its advocates. As currently practiced, the rapid exit coordinator becomes involved 

within one to three working days of the family entering shelter. The rapid exit coordinator is colocated with the HSD Shelter Team and communication between the two supports a coordinated 

approach to assist families in exiting shelter. The HSD Shelter Team also established or 

improved relationships and communication with the employment services providers, legal aid, 

school social workers, and resources to address medical and health issues. This process 

succeeded, and still does, with most families. Those who do not want to comply with rapid exit 

activities or HSD Shelter Team plans sometimes leave shelter and do not return. 
Appendix A Hennepin County, Minnesota 

A–5

Within six months of implementing these changes, the county reduced the shelter population to a 

level the shelters could accommodate and eliminated the use of motels for supplemental shelter 

space. The county-supported system can now accommodate all homeless families with major 

housing barriers within its contracted 115 family shelter units, where the average length of stay is 

29.5 days. Since the peak during late 2000, the county has reduced shelter length of stay by onehalf and the number of families in shelter by 63 percent. Two practices contributed to the 

reduction in shelter use: diverting families with fewer barriers to prevention providers kept some 

families from entering the homeless system, and assigning rapid exit workers to families who did 

enter the system helped to shorten their lengths of stay and prevent their return.

Other opportunities for families seeking shelter in Minneapolis and neighboring cities include a 

50-unit downtown shelter that has a 30-day maximum length of stay, as well as an association of 

suburban churches through which families spend nights in a different church each week. 

Families accessing only these resources never enter the county-supported system. However, 

these additional family shelter programs do not have sufficient resources to assist very difficult 

families to find and sustain housing and typically refer families with multiple barriers to the 

county. 

COMPONENTS AND ORGANIZATION OF THE COMMUNITY STRATEGY 

The system in which prevention and rapid exit activities are embedded in Hennepin County 

makes prevention effective in the county. Hennepin County has found that it can bring people 

together, in part because funding is an incentive. Without funding, there is little incentive to keep 

people engaged for the length of time it takes to learn each other’s language and come to 

recognize common objectives. With the money, people communicate and can begin to construct 

a functional system. The county’s system for family homelessness prevention and services has 

changed a great deal since 1993. The change has been slow but steady, as the county continues to 

bring people together to make further improvements. The integral aspects of the system that 

contribute to success are discussed below. 

• The approach covers most parts of the system—from a family’s first contact with a 

contracted provider because of a housing crisis to providing shelter and rapid exit 

services. The approach also includes some transitional housing for families. 

• Families receive assistance in relation to their level of need, which for shelter is carefully 

determined through screening by the rapid exit coordinator. Rapid exit services are only 

available through referral by the screener. 

• A collaborative network of nonprofit agencies provides prevention and rapid exit 

services, with many agencies doing both. Each agency has a geographically-defined 

catchment area, and each family must go to the single provider covering the area where 

the family lives or most recently lived. 

• County requests for proposals (RFPs) for prevention and rapid exit services specify the 

families to be served, by numbers and level of difficulty, and the outcomes to be 
Appendix A Hennepin County, Minnesota 

A–6

achieved. Agencies that apply commit to meeting these goals, and outcomes-based 

contracts specify the goals to be met. Agencies that cannot produce the outcomes 

proposed in their contracts receive interventions and assistance to correct the situation. If 

the situation is not corrected, the contracts are not renewed. 

• All prevention and rapid exit agencies are linked with a custom-designed data system that 

allows access to real-time family service histories dating back to 1995. 

• An Advisory Committee with a carefully considered membership supports the system 

through a number of key roles to keep the system nimble and outcome oriented. 

• Creativity is encouraged; cross-agency cooperation is standard operating procedure; 

partnerships, collaborations, and new developments are commonplace. 

Respondents in Hennepin County consider it essential for the same system to coordinate 

families’ access to prevention, emergency shelter, and some transitional housing services. 

Further, they want this level of coordination to include all transitional housing and other services. 

Starting with four funding sources and proceeding to service components, the system includes: 

• State FHPAP funding for preventing eviction, sustaining housing, and some rapid exit 

services; 

• Federal SHP and Emergency Shelter Grant (ESG) funding for some rapid exit services, 

transitional housing for homeless people, and SHP Project Connect; 

• County Emergency Services Program prevention-services funding; 

• Emergency Services Program, through the Economic Assistance system, provides 

financial assistance using Federal, state, and county dollars to prevent the loss of housing; 

• The County Shelter System provides emergency shelter with intensive planning and 

assistance for exiting to housing and sustaining tenancy; and 

• Cooperating social services, education, and health programs, including: Health Care for 

the Homeless; ACCESS service for people with mental illness; City of Minneapolis 

Public Schools Homeless programs; and Twin Cities Voice Mail. 

Hennepin County contracts with a community agency to provide a screener (a rapid exit 

coordinator) to assess housing barrier levels for each family seeking shelter. The screening 

policy, which currently has four barrier levels, has been revised several times based on 

experience as to which barriers constitute the biggest challenges for obtaining and retaining 

housing. When the county first developed and contracted for the screening services, the system 

had three levels—no barriers (Level 1), some barriers (Level 2), and serious barriers (Level 3). 

After some experience, it became apparent that Level 2 was too big and should be split into 2a 

and 2b. The screener instructions are included in Exhibit A.1 (on the following page and 

modified slightly to explain some terms). The screener considers the criteria used to assess a 
Appendix A Hennepin County, Minnesota 

A–7

family, as well as the resources that may be most suitable for the family. The intensity and 

variety of assistance is related to the barrier level assessment. 

The screener has access to relevant county databases to check for barriers, including Housing 

Court (for previous evictions and eviction proceedings) and criminal court (for warrants, 

convictions, incarcerations, and restraining orders). No family gets more than seven nights in 

shelter, and most get only one to three nights, until this screening process is complete. Credit 

checks from credit bureaus can be run as needed. The rapid exit coordinator works with the 

County HSD Shelter Team to assure that families follow through with housing referrals. 

Exhibit A.1. Hennepin County Housing Barrier Screen 

HC POLICY FOR FHPAP RAPID EXIT COORDINATOR 

HOUSING BARRIER SCREEN AND REFER SERVICES 

AND RAPID EXIT SERVICES 

3-04 

ASSESSING HOUSING BARRIER LEVELS 

When screening (Rapid Exit Coordinator) families for referrals for housing assistance, the following guidelines for assessing a

family’s housing barriers and categorizing the barriers into three levels will be used: 

Level 1: No barriers. Family has a good rental history, no UDs (=unlawful detainer/eviction), no criminal history and no active 

chemical dependency or abuse issues. Families would be given an information packet and a sample rental application form. No 

FHPAP/Rapid Exit referrals will be made. Family may return to Rapid Exit Coordinator/Screener for help with application fees. 

Level 2a: Has some of the following barriers: 

• No rental history 

• No high school diploma 

• New to the area 

• Physical disabilities that effect housing 

• Large family 

• One parent/child household 

• One easily explained UD 

• Needs financial help with moving, furniture, misc. services 

• History of battery but abuser not in the area 

• Head of household under 18 years 

• Non-English speaking 

Does not have the following barriers: 

• Criminal record 

• Active CD/alcohol issues 

• More than one UD 

Families would be given the information packet, a sample rental application and be referred to a FHPAP/Rapid Exit Coordinator or 

other provider who has shorter term services (and subject to service availability). 

Level 2b: Family has some of the following barriers: 

• Poor rental history (up to three UDs or evictions) 

• Recent domestic abuse with the abuser in the area 

• Recent minor drug or criminal history 

• Just released from jail 

• Mild behavior problems—adult 

• Not currently abusing drugs 

• Mild behavior problems—child(ren) 
Appendix A Hennepin County, Minnesota 

A–8

• May also have some of the barriers from 2a. above 

• Male teenager in the home 

• Open Child Protection Case 

Families would be given the information packet and a sample rental application and be referred for longer term case management 

services to a FHPAP/rapid exit or other provider who provides such services (subject to service availability). Transitional housing 

services (which also have shelter stay requirements) would serve 2bs. 

Level 3: Has some of the following barriers: 

• Actively using drugs 

• Recent serious criminal history 

• Adult with severe behavior problems 

• Current sexual abuse in the family unit 

• 4 or more UDs 

• Current battering with the abuser in the family unit 

• Children with severe behavior problems 

• Has recent record of property damage to rental housing 

Families may be referred to Project Connect or any similar service. The difficulties in obtaining housing in this area will be explained 

to such families along with the alternatives they have including that they may be eligible for a bus ticket from their financial worker. 

They may be referred to non-FHPAP housing search options. Level 3 families will be referred to FHPAP/rapid exit providers, 

including transitional housing, as capacity allows and subject to the Provider’s assessment on whether they can adequately serve 

the family referred. 

SERVICE REFERRALS TO FHPAP RAPID EXIT & TRANSITIONAL HOUSING PROVIDERS 

Referrals for each barrier level are summarized above. Since FHPAP/Rapid Exit services are directed to Level 2 and lower Level 3 

families, referrals of Level 1 and high barrier level 3 will not be made to FHPAP/Rapid Exit providers. Referrals to other services such 

as Project Connect, if available, can be made for Level 3. 

FHPAP RAPID EXIT ELIGIBLE FAMILIES 

As of 7/1/95, FHPAP rapid exit providers are to serve Level 2 and lower Level 3 families referred by the FHPAP Rapid Exit 

Coordinator. This will assure that FHPAP providers serve the target group and that the appropriate target group of families reach 

services soon after shelter entry. 

AVAILABILITY OF RAPID EXIT & TRANSITIONAL HOUSING SERVICES 

Rapid exit providers (including transitional housing) are to communicate with the FHPAP rapid exit coordinator what their current 

capacity is and how many referrals they can accept/are ready to accept. Communication between the provider and the FHPAP rapid 

exit coordinator is essential to facilitating services for families. 

RAPID EXIT COORDINATOR SCREENING GOAL 

The target goal is for families to be screened and referred within 5 days of their first voucher into shelter. 

APPLICABILITY OF POLICY 

These guidelines will be used not only by the FHPAP Screener/Rapid Exit Coordinator but by all FHPAP service providers, including 

SHP and ESG, who are attempting to assess housing barrier levels for a family under the FHPAP Umbrella program. 

(modified version of County form: SJH 04 RECBarrierLevels04) 

For the purpose of delivering human services, including family homelessness prevention, 

Hennepin County is divided into geographic regions. Each region may have several providers 

with FHPAP contracts for prevention, but each provider has its own catchment area. Families 

seeking prevention services must go to the FHPAP provider that covers the location of the 

family’s current or most recent address. Providers know each other well and can access a shared 

database to find out what services the family has already received and by which agency. Families 

work with agencies that know their history, which assures that the family cannot apply for the 
Appendix A Hennepin County, Minnesota 

A–9

same assistance in different places. In contrast, rapid exit services are centrally controlled and all 

shelter is provided by one agency located in Minneapolis. Rapid exit service providers are 

assigned to families based on availability, geography, and specialized services. 

The contracting process to identify FHPAP and rapid exit providers begins with an RFP 

distributed widely in the community to encourage new providers to apply. On average, the 

county receives 30–40 proposals for each RFP, of which it usually funds 10–15 percent. The 

county selects the providers that appear to understand its outcomes-based approach and provide 

evidence that they will fulfill their performance commitments. Over the years, providers have 

come to understand the county’s “whatever it takes to achieve the goal” approach. 

The Advisory Committee includes shelter operators; providers with FHPAP contracts; similar 

providers without FHPAP contracts; advocates; formerly homeless people; and representatives of 

legal services, MHFA, Twin Cities Voice Mail, the Minneapolis Public Schools homeless 

programs, Minnesota Coalition for the Homeless, and homeless planning groups, such as the 

Continuum of Care. In addition, supervisors of direct service units in county departments with 

responsibilities for homeless-related services attend meetings and provide input, but do not vote. 

The Advisory Committee is essential to the smooth operation of FHPAP in Hennepin County. It 

has many important duties, such as establishing outcome goals, assessing service gaps and 

recommending services for funding, designing RFPs and reviewing proposals, seeking new 

providers, providing cross-fertilization through members who also serve on other committees, 

promoting new partnerships, and reviewing contract performance. 

The Advisory Committee’s makeup is especially important for establishing and maintaining 

standards of performance. Members are knowledgeable about the population to be served and the 

options for helping them, and support the use of outcomes-based contracting. If providers’ 

performance is unsatisfactory, they come before the Advisory Committee to explain what 

happened and how they expect to improve their performance. If it appears that they cannot 

improve it, the Advisory Committee will suggest that they not be refunded. Under such scrutiny, 

nonperforming providers usually agree to drop the contract rather than have the county terminate 

it. This process is essential to improve overall system performance. 

The result is a very cooperative, collaborative, creative system. FHPAP and rapid exit providers 

are linked by a single data system. They refer back and forth, often exchanging resources when 

one provider is bereft of a particular resource (e.g., food, clothing, or funding) and another 

provider has the needed resource, thus avoiding duplication of services. For example, one 

provider offers a budgeting class while another offers a financial class that discusses credit and 

how to improve one’s credit record while still another offers no-interest loans for car purchase 

and emergency car repairs. Clients may use these services regardless of which provider offers 

them and which provider is helping the family. 

In addition to routine daily contacts, the suburban providers meet monthly, share resources and 

resource information, participate in training, and plan services for their area. Minneapolis 

providers have similar, but not as formalized, contact. In addition, all FHPAP providers meet 

every two months as a Provider Council, with additional service-specific coordination meetings 
Appendix A Hennepin County, Minnesota 

A–10

as needed. Several new services have emerged from provider and Advisory Committee 

interactions that promote the goal of preventing homelessness. Examples include: 

• Legal Aid and the Housing Court once had severely adversarial relationships. Through 

their interactions prompted by the FHPAP service delivery system, they recognized some 

common ground in keeping people housed and developed a mediation approach that is 

offered to landlords filing eviction papers. Mediation, with volunteers as mediators, is 

able to resolve 69 percent of the cases out of court, saving the landlord the filing fees and 

the family the disruption of moving and having an eviction on its public record. 

• One FHPAP and rapid exit provider has developed a basic training course to help people 

learn how to find housing. The provider holds classes in the local jail, and Legal Aid 

takes a similar curriculum to the high schools. Most people receiving the training have no 

idea how to find housing, so the course, however basic, provides new and important 

knowledge. Other materials that serve a training purpose are an illustrated booklet and a 

game, both called “Housing Challenge.” 

- The booklet was developed and written at an eighth-grade reading level. It uses a 

story format to show how different people in a shelter find housing despite 

various barriers (e.g., youth, unemployment, previous evictions, criminal record, 

many children, and racial or ethnic discrimination) and what they need to do to 

retain housing. The booklet is appropriate for high schools, service centers, social 

work offices, and other settings. 

- The game resembles “Family Feud.” It pits one-half of a class or group against 

the other to “build its community” by correctly answering questions about 

housing. Each correct answer earns the team a new house to put into its 

community, until the community is complete. The “Housing Challenge” game is 

intended for use by direct service workers, school teachers, and groups to teach 

about housing laws and how to retain housing. 

• A recent training session to teach caseworkers and counselors how to help clients with 

finding and keeping housing drew 65 attendees from community agencies. The demand 

suggests that another session would also be filled. 

• A housing “barrier” training video received a Telly Award for excellence. Like the 

booklet “Housing Challenge,” this video, “Shoe Box on the River,” follows three 

different housing situations that can cause housing loss and helps people learn the basics 

of how to retain housing. The video is shown at the shelters and used in housing training 

classes. 
Appendix A Hennepin County, Minnesota 

A–11

FHPAP and Preventing Housing Loss 

The prevention part of the FHPAP Umbrella Program serves Hennepin County families 

experiencing a housing crisis that threatens housing retention. All clients are currently in 

housing. For prevention families whose cases closed in State Fiscal Year (SFY) 2003, 72 percent 

were facing eviction, 14 percent had income loss that threatened housing, 4 percent were 

doubled-up in untenable situations, 7 percent faced a very hazardous situation in their housing or 

their housing was condemned, and 3 percent were in other situations. 

Getting to an FHPAP Prevention Provider 

A family in housing crisis may get to one of the 18 FHPAP prevention providers in several ways. 

The United Way’s First Call For Help (211) hotline has the providers’ numbers and confirms the 

family’s address before referring a family to assure it gets to the correct provider. Most 

prevention providers also offer other emergency and crisis services and are well known in their 

communities. Churches, schools, the police, community centers, Legal Aid, YM/WCAs, health 

care providers, and many landlords are familiar with FHPAP prevention as a consequence of 

good publicity, outreach, and past experience. A few FHPAP providers take only referrals but, 

for most, clients are primarily walk-ins. 

Eligibility Criteria for FHPAP Prevention 

In addition to being a county resident, a family must be verified to be in a short-term financial 

crisis, rather than an ongoing condition, to be eligible for FHPAP. Specifically, the FHPAP 

provider must see it as a reasonably “good bet” that the family will be able to sustain itself in 

housing after receiving one month of cash and other assistance from FHPAP. The assistance 

provided is for one month and the expectation is that the family can take over after that month. 

These are typically families whose inability to pay rent stems from a temporary illness, job loss, 

or other short-term problem, and relief in the form of returning to work, a new job, or a new 

income source is on the horizon. If a family needs a longer-term solution (e.g., a housing 

subsidy, a change to more affordable housing, a job), assistance is frequently offered in the form 

of “other then cash” services while the provider helps the family to obtain the longer-term 

subsidy or address working concerns. 

Eligibility Determination at an FHPAP Provider 

Preliminary screening may be done on the phone or in person. FHPAP providers determine if the 

family meets FHPAP eligibility criteria and ask about the cause of the present emergency, the 

length of residence, where the family is in the eviction process, what resources the family has 

and is likely to have in the near future, and similar issues. 

Completing an application requires in-person contact. An FHPAP worker reviews the family’s 

income sources and budget to determine the feasibility of covering housing costs in the future. 
Appendix A Hennepin County, Minnesota 

A–12

One recommendation might be to move to a smaller or cheaper apartment; others may involve 

giving up nonessentials on which the family currently spends money. The family must verify 

information with respect to residence, rent, employment, benefits, and other matters. Releases 

are requested for access to information related to benefits receipt and in order to contact 

landlords. Providers report that about two-thirds of the applicant families receive assistance. 

Failure to complete the application process is the main reason why a family does not receive 

assistance. Providers usually serve everyone they can, stretching the definition of a family being 

a “good bet” to its broadest possible interpretation. 

Approach with Families 

The type of assistance offered to a family depends on the family’s situation. A family suffering a 

short-term setback, but otherwise reasonably stable, might receive help with rent and perhaps 

budget counseling to establish a savings plan for emergencies, even if it is only a few dollars 

each week. Someone whose landlord is not making needed repairs may get legal help or help 

moving while they await return of their security deposit. A family who is experiencing greater 

difficulty might get more extensive help under a different program the agency offers, but may 

not receive prevention services because they are reserved for short-term needs. In this case, 

partnering services can be very effective. 

FHPAP providers describe their approach as “we’re here to help you; how are you planning to 

get out of this crisis situation?” Providers rarely offer a family the entire amount of cash 

assistance available through FHPAP; instead, they negotiate. If the family needs $500, a provider 

may offer $200 and ask if the family can produce the balance. Usually it can. FHPAP providers 

will require that families assess their eligibility for public benefits and help with applications. 

They will work with families to develop reasonable budgets given their circumstances. Providers 

also have many forms of non-cash assistance to offer families to tide them over through shortterm crises, including limited case management, legal services, volunteers, food banks, clothing 

shelves, advocacy, budgeting, furniture, car repairs, and even an occasional night in the basement 

of a church belonging to a suburban consortium of churches offering this type of emergency 

shelter. Once a family’s housing is secure, FHPAP prevention providers may hear from families 

again with respect to other assistance the family may need, but unlike rapid exit caseworkers, 

they do not necessarily provide systematic followup. 

Approach with Landlords 

An essential element contributing to FHPAP prevention providers’ success in keeping families 

housed is their highly developed cooperative relationships with landlords. Over the years, 

landlords have come to appreciate that FHPAP providers can help them retain tenants, thus 

saving re-rental costs. Landlords have been willing to negotiate payment plans for back rent, 

moving tenants to smaller and more affordable apartments, reducing the overall rent for a given 

apartment (especially for families with Section 8, for whom the landlord can anticipate steady 

payments from the housing authority), and making other accommodations. Some landlords are 

beginning to provide their own tenant services staff, having learned from FHPAP that preventive 
Appendix A Hennepin County, Minnesota 

A–13

steps are more cost-effective than evictions. Landlords also know they can call the prevention 

provider if a problem arises with the client. 

Staffing and Caseloads 

Staff providing FHPAP prevention have four-year degrees in a human services field or “decades 

of experience.” At any given time they are only working intensively with a few families for 

homelessness prevention, although they may have larger caseloads of less problematic clients. 

Funding Sources and Arrangements 

Several funds are available to assist families experiencing a housing crisis. HSD uses Federal, 

state, and county taxpayer dollars. Funds for family homelessness prevention come from 

FHPAP, county funds, and an array of smaller pots of money that individual providers have at 

their disposal. All these funds are for direct services; FHPAP providers shoulder most of the staff 

and administrative costs (10 percent is the standard amount provided from FHPAP), as does the 

county for its administrative work. Most providers match FHPAP with other funding so they can 

do this. 

FHPAP prevention providers have made some different local policies on a regional basis. Chief 

among their choices is whether FHPAP resources should be given as grants or loans. In 

Minneapolis the actual cash distributed for rent and other payments is given as a grant, but in the 

suburbs it is given as a voluntary loan. Suburban providers find their families appreciate the 

opportunity to repay the providers. The providers offer very flexible terms and can accommodate 

very low monthly payments (e.g., $5 per month) and gaps in payment if they are explained. 

Repayment can help a family establish a good credit history, and the agencies give credit 

referrals upon repayment. Families are not “hounded,” but providers have gotten more serious 

about following up on loan commitments. The only penalty for non-repayment is that future cash 

assistance may not be available, depending upon the circumstances of the non-repayment. 

Collectively, suburban FHPAP agencies have gone from getting back about $1,000 each year to 

receiving $30,000–$40,000 in loan repayments each year. 

Rapid Exit 

All families in rapid exit have housing barriers; most are Level 2b or lower Level 3 families (see 

pg. A–7 for definitions of the categories). Every homeless family seeking shelter is referred to 

the Shelter Team of the county’s HSD. This team of 23 staff and three supervisors is available 

from 7:00 a.m. to 3:00 a.m. weekdays and 5 p.m. through 3 a.m. on Saturday and Sunday, 
Appendix A Hennepin County, Minnesota 

A–14

leaving little uncovered time when a family might be in need of overnight shelter.25 Earlier in the 

shelter system development, coverage included regular working hours Monday–Friday, with 

United Way authorizing shelter on the weekends. United Way, however, did not assess need so 

having emergency assistance coverage extended was a positive step for both the family and the 

county. 

The HSD Shelter Team assesses whether any viable alternatives exist where the family could 

stay for the evening. This assessment usually takes about 15 minutes. If no alternatives exist, the 

family receives a shelter voucher for the number of days it will take to see the rapid exit 

coordinator—usually one to three days, sometimes up to seven days. 

Each family is screened by the rapid exit coordinator to determine barriers to housing and the 

most appropriate service to address its housing needs. One person, the rapid exit coordinator, 

does all the screening and referral (approximately 1,100 families each year) for rapid exit 

housing services. The rapid exit coordinator has a donated office and computer in the county’s 

HSD offices but actually is employed by a nonprofit rapid exit and transitional housing provider. 

This independence from the county often helps the rapid exit coordinator work with families who 

express concerns about telling the county some things about themselves and their histories. 

The screening process, which was described earlier in this appendix, takes about one hour. Seven 

slots each day are scheduled in advance, leaving the 11:00 a.m. hour available for quick access to 

reschedule missed appointments. 

The rapid exit coordinator uses a detailed interview format that is intended to facilitate both the 

screening process and the next step, which is determining eligibility for rapid exit housing 

services. The interview covers educational, vocational, housing, credit, chemical use, mental 

health, legal, physical health, relationships, and family of origin issues. The rapid exit 

coordinator also gathers facts, including checking both Housing Court and Criminal Court 

proceedings online, and completes a preliminary needs assessment. The assessment information 

is forwarded to the rapid exit agency assigned to help the family find housing. 

Families are assigned to rapid exit agencies on either a rotating basis, if there is more then one 

appropriate agency, or by agency service, if there is only one appropriate resource. Rapid exit 

providers can only accept referred families; they do not maintain waiting lists and must take the 

families that the county refers to them. However, if other barriers are found or if the client 

subsequently has needs the program is unable to fulfill, the client could be referred back to the 

rapid exit coordinator for a different referral. Once the family has been screened by the rapid exit 

coordinator, the HSD Shelter Team will extend the shelter voucher while the rapid exit agency 

assists the client to obtain permanent housing and the family begins to work on a plan with the 

Shelter Team to exit shelter. 

 

25 In 2000, the county consolidated its shelter vouchering, making it the sole province of this Shelter Team rather 

than having it spread among eight or nine teams that saw families with a variety of emergency needs, not just for 

shelter. The consolidation has meant that the Shelter Team staff that control access to shelter know the rules and 

procedures, know the families, know the resources, and are better able to allocate resources efficiently and 

appropriately. 
Appendix A Hennepin County, Minnesota 

A–15

The rapid exit agency receives the screening information and assigns a rapid exit caseworker to 

the family. Together, they develop a housing stabilization plan that looks at all aspects of the 

family’s need. The family signs and dates this plan, which includes action steps and timetables. 

The rapid exit caseworker attends mostly to the housing portion of the plan and uses mainstream 

resources for other family services. The HSD Shelter Team worker identifies any other county 

services with which the family is involved (e.g., public assistance, employment services, child 

welfare, services to the disabled). The Shelter Team notifies county caseworkers that the family 

is in shelter and is receiving housing services. The Shelter Team coordinates requirements the 

family may face from various county departments so that the family is not caught in demands 

that cannot be met simultaneously. The county also has certain priorities that are absolute—

school age children must be registered for and in school. 

The timetables attached to the action steps tell the family and rapid exit caseworker when each 

step should have been accomplished. These timeframes and tasks may be revisited if 

circumstances warrant. If a family fails to complete an action step on time it gets another chance. 

Repeated failure leads to a re-examination of the action step to ascertain why the family has not 

completed it and whether it is possible for the family to succeed. The more days a family has 

been in shelter, the more assistance it receives to complete action steps and move on to housing, 

aiming for the system average of no more than 30 days in shelter. Relatively few families fail in 

the process, but about 1 percent (16 of 1,463 families during 2003) receive an “involuntary 

discharge” from rapid exit services or leave shelter. 

The rapid exit caseworker will continue with needed supports to help the family stabilize and 

sustain housing through six months after the family moves to housing. Throughout this period, 

the caseworker is in regular contact with the Shelter Team and other relevant HSD staff involved 

with the family, to the extent that this involvement is required. Although rapid exit agencies and 

the FHPAP system administrator believe that six months of followup is sufficient for many 

families, a significant number of families require a longer period of support. 

The six-month restriction derives from a HUD decision to allow the same length of followup for 

rapid exit as it allows for transitional housing. From the perspective of the level of difficulty of 

the families involved, the rapid exit and transitional housing families may look fairly similar. But 

from the perspective of how much time a provider has had to work with the family before 

housing placement, the transitional housing provider has had up to 24 months, plus the six-month 

followup, while the rapid exit provider has had, on average, 30 days plus six months. 

The following is one rapid exit agency’s list of housing services—other providers offer similar 

services, also available to FHPAP prevention families since many providers offer both 

prevention and rapid exit services: 

• Co-sign leases; 

• Provide or assist in obtaining deposits, first month’s rent, and startup needs such as 

furniture and food packages; 

• Guarantee to cover eviction and damage costs; 

• Repair damage to apartments; 
Appendix A Hennepin County, Minnesota 

A–16

• Coordinate temporary funding for housing subsidy that supports a client through 

transition while avoiding a second move; 

• Serve as mediators in landlord disputes; 

• Offer extensive case management; 

• Teach responsible tenancy and money management; 

• Refer clients to and coordinate treatment for chemical dependency; 

• Refer clients to employment services; 

• Coordinate and assist in obtaining other needed services; and 

• Help ex-offenders. 

Staffing and Caseloads 

Rapid exit caseworkers have four-year degrees in a human service field plus training in their 

specific work. Some are formerly homeless people who have extensive experience in the field. 

Each caseworker handles between 30 and 40 rapid exit families at a time, some in the placement 

phase and some in followup. 

Funding Sources 

Rapid exit services are funded by a HUD SHP “Services Only” (SSO) grant to the county, which 

in turn contracts with nonprofit providers. This Federal funding is backed up by FHPAP for 

services and some placement costs that SHP will not cover. The county uses SHP resources 

exclusively for services. It coordinates the contracting and covers all county staff related to the 

project. Nonprofit organizations also “donate” much of their administrative time, as the SHP 

rapid exit funds are used exclusively for service costs. 

DATA COLLECTION AND USE 

The county designed its own FHPAP data system along with the Wilder Foundation staff who 

selected and modified the software. The Wilder Foundation is also under contract to the county 

to manage the data collection and produce requested reports, which the county uses to satisfy 

routine and special reporting requirements. One unique and significant feature of the software 

design is the number of controls built into the system to assure the accuracy of the data entered at 

provider sites. ZIP codes are used to enter city names to avoid misspellings (the system accepts 

only ZIP codes within the county), age range controls are on birth dates (no one younger than 16 

or older than 65 for the adults in a family), and cases cannot be saved unless all required data are 

entered. These controls circumvent incomplete data. 

The database administrator at the Wilder Foundation receives monthly backups of each FHPAP 

agency’s database, which she downloads and integrates to create both a complete longitudinal 

file and point-in-time files for the whole system. The database is kept in ACCESS, and the 

administrator keeps it current as new versions of ACCESS are issued. It fits the needs of the 

system very well, along three dimensions: 
Appendix A Hennepin County, Minnesota 

A–17

• Addressing FHPAP and rapid exit providers’ immediate needs as they serve families. 

The system’s fields contain the detail and family history that FHPAP and rapid exit 

providers need, when they need it. Service receipts are accessible dating back to 1995. 

The system administrator can make assessments of the overall program and performance 

of any provider on a longitudinal and immediate basis. 

• Monitoring the system. 

- Provider uses. Providers use their individual agency section of the database to 

track service delivery levels weekly or monthly. Providers may review cases 

opened, cases closed, payments made during the month, how much FHPAP 

money has been used during the month, and other issues. Providers can also 

answer special questions asked by the executive director by using the built-in 

reports or by downloading the data into ACCESS and doing their own reports. 

- Administrator uses. The system administrator uses the system to determine 

whether families are accessing services in more than one location, whether 

providers are meeting contracted obligations, and to provide reports from funders 

and agencies. Annual audits check such things as inappropriate spending patterns 

(e.g., erratic service patterns during the year) and outcomes (not saving people’s 

housing or stabilizing families in housing). Regular feedback to providers and to 

the Advisory Committee helps keep all parts of the system on their toes. 

• Reporting to the legislature, MHFA, the county, HUD, and other parties. Routine reports 

are generated for funders and other interested parties. Especially relevant to the purposes 

of the present study, the database is compared to county shelter data to assess whether 

recipients of FHPAP or rapid exit return to shelter within a 12-month period. The results 

of these analyses are reported below. 

Access to the Data 

FHPAP providers have access to both current and historic data from their own agency. They 

contact other providers based on the client’s former address to determine if services were 

provided in other areas. At this time, access to the complete database for all providers has not 

been shared due to data privacy concerns. The rapid exit coordinator has a full history of all 

clients served since 1995 to be used in screening for housing barriers. The database manager at 

the Wilder Foundation and the county’s FHPAP administrator have access to the entire system, 

both current and historic. 

Data Elements 

• Basic descriptive information includes social security number, name (first, last), birth 

date, gender, race, veteran status, ZIP code, city, county of residence, homeless status, 

citizenship, number of children by age group, and number of adults. 
Appendix A Hennepin County, Minnesota 

A–18

• Service data include date of intake, service type and date of receipt, housing placement 

date, referral source, shelter admit and discharge dates, voluntary discharge, discharge 

to, referral to, handicapping conditions, and other (non-financial) services. 

• Outcome data include intake status on outcome variables, annual declared income and 

income source at intake, income and income source at exit, barrier codes at intake and 

exit, and housing stability at three and six months. 

Outcomes—Success at Preventing Shelter Use or Return to Shelter 

Each year a report is prepared for MHFA with grant outcomes. As part of completing this report 

and analyzing contract and program-level performance, the FHPAP grant manager assesses 

whether the families who were served in the previous calendar year, in both prevention and rapid 

exit, have had a shelter episode in the 12 months since receiving FHPAP assistance. 

Three caveats are worth keeping in mind as one looks at the documentation of homelessness 

prevention in Hennepin County. First, there is no control or comparison group—virtually every 

family who approaches the system will receive some type of assistance. Second, due to the 

nature of the criteria used to accept families for prevention services—short-term economic crisis 

combined with the ability to pay for housing after the crisis month has passed—the families 

helped might not resort to shelter even if they do not receive the county’s help. However, all 

prevention families are screened to identify other resources (family, friends, savings, emergency 

assistance), and FHPAP is used only if no other resources exist. The funding available is not 

sufficient to meet the total community need for prevention services, so the county prioritizes its 

limited resources to prevent the loss of as much housing as possible among those most likely to 

succeed. 

Finally, some family shelters are not part of the data system the county uses to assess postFHPAP shelter use. The shelter stays tracked in this analysis are those for which the county pays 

(i.e., shelters that are vouchered through the HSD Shelter Team). As already noted, there are two 

other opportunities for a family to access shelter—one in Minneapolis and one through a network 

of suburban churches. Most families in need of more than a few nights of shelter will find their 

way to the county system in relatively short order. The county’s documentation of prevention 

will pick up shelter use by the families with the most barriers to housing, but perhaps not some 

with fewer issues. 

The county has succeeded in cutting its average length of shelter stay by one-half (from almost 

60 days to approximately 30 days), eliminating the need for motels, and reducing the number of 

families in shelter from 317 to fewer than 116 at any given time. It has also succeeded in 

reserving shelter resources for families with the most serious housing barriers (Level 2b and 

lower Level 3). 
Appendix A Hennepin County, Minnesota 

A–19

Exhibit A.2. Change in Housing Barriers of Sheltered Families 

Barrier Level 1995 1998 2003 

Level 1—No/few barriers 15% 0% 0% 

Level 2a—A few barriers 40% 43% 2% 

Level 2b—Many barriers 40% 44% 70% 

Level 3—Most serious barriers 5% 13% 28% 

Source: Hennepin County FHPAP Annual Report for SFY 2003, page 14 

In the recent FHPAP Annual Report, covering the period of July 1, 2002–June 30, 2003, 

Hennepin County reports the following rates of shelter use within the 12 months following 

receipt of FHPAP assistance: 

• Family prevention—95 percent of families did not use shelter within 12 months; 5 

percent did. This FHPAP component served 1,170 families (or approximately 4,149 

members), at an average cost to the county of $472 per family.26

• Family rapid exit from shelter—88 percent did not return to shelter within 12 months; 12 

percent did. This FHPAP component served 1,024 families (or approximately 3,573 

members), at an average cost to the county of $93 per family. Much of rapid exit is paid 

for through a Federal SHP SSO grant; including Federal funds, the average cost per 

family is still less than $800. 

• Family transitional housing—96 percent did not return to shelter within 12 months after 

their case was closed; 4 percent did. This FHPAP component served 47 families (or 

approximately 193 members), at an average cost to the county of $3,668 per family. 

HENNEPIN COUNTY SITE VISIT PARTICIPANTS 

Richard Amos, St. Stephen’s Housing Services, Program Manager 

Peg Douglass, Hennepin County Economic Assistance, Unit Supervisor 

Sara Frerotte, St. Stephen’s Housing Services, Case Manager/Family Advocate 

Shirley Hendrickson, Hennepin County Children, Family and Adult Services Department 

Housing Services, Coordinator 

Amanda Jackson, Person to Person, Homelessness Prevention Advocate 

Elizabeth M. Johnson, People Responding in Social Ministries, Executive Director 

Stephanie Miller, Community Emergency Assistance Program 

Annette Marie Poeschel, Intercongregation Communities Association, Executive Director 

Milton A. Schoen, Hennepin County Veterans Services, Area Director 

Lisa Sell, Wilder Research Center, Database Associate 

Anita L. Shoemaker, Northwest Hennepin Human Services Council, Senior Projects Coordinator 

Scheryl Wilson, Elim, Rapid Exit Coordinator

 

26 To estimate the number of family members served, Hennepin County assumes each family consists of four 

persons. 
Appendix A Hennepin County, Minnesota 

A–20

HENNEPIN COUNTY ACRONYMS 

ESG Emergency Shelter Grant 

FHPAP Family Homeless Prevention and Assistance Program 

HUD U.S. Department of Housing and Urban Development 

HSD Human Services Department, Hennepin County 

MHFA Minnesota Housing Finance Agency 

RFP Request for Proposal 

SFY State Fiscal Year 

SHP Supported Housing Program (HUD) 

SSI Supplemental Security Income 

SSO Supported Housing Program, Services Only grant 
B–1

APPENDIX B 

MONTGOMERY COUNTY, MARYLAND 

Montgomery County had a 2003 population of 909,411. This prosperous suburb of Washington, 

DC, has a median household income of $76,439 and ranked eighth highest of all U.S. counties. 

The high cost of housing poses serious problems for the almost 5.6 percent of individuals who 

live below the poverty level. The fair market rent for a two-bedroom unsubsidized unit in 

Montgomery County is $1,218 per month and the median rent ranked the 14th highest of all U.S. 

counties.27 Over the past several years, because less than 4 percent of housing units are vacant 

throughout the county, most of the jurisdiction’s low-wage earners struggle to afford or maintain 

housing.28 

To address these unique economic and housing challenges, Montgomery County government—

in partnership with the nonprofit community—has for longer than 20 years provided funds and 

services to prevent evictions for those at risk of homelessness. With respect to family 

homelessness, the county government has a longstanding policy that no family spends a night on 

the streets. 

During the study team’s visits to Montgomery County between June 19 and July 8, 2004, the 

study team interviewed 10 people representing several offices of the Montgomery County 

Department of Health and Human Services (MCDHHS), which oversees the single point of entry 

for families and individuals in need of homelessness prevention or shelter. MCDHHS also 

collaborates with local nonprofit agencies and the public housing authority to provide 

community-wide homelessness prevention coverage. The study team interviewed representatives 

from two nonprofit partners—Community Ministry of Montgomery County and Montgomery 

County Coalition for the Homeless—and the Housing Opportunities Commission (HOC), the 

county’s public housing authority. The study team learned about the various automated systems 

that collect data on families, services, and payments to document prevention effectiveness. The 

homelessness prevention program in Montgomery County is described below, including the 

county’s outcome measures and their use of data. 

 

27 Housing data were obtained from the U.S. Department of Housing and Urban Development at: 

http://www.huduser.org/datasets/FMR/FMR2004F/FMR2004F_County.xls (accessed on 11/9/04). 28 Income and housing statistics were obtained from the U.S. Census Bureau at: http://www.census.gov/acs/www/ 

(accessed on 11/9/04). 
Appendix B Montgomery County, Maryland 

B–2

PRACTICES OF POTENTIAL INTEREST TO OTHER JURISDICTIONS 

The contact for Montgomery County practices described in this report is Corinne Stevens 

(corinne.stevens@montgomerycountymd.gov). Practices that are of potential interest to other 

jurisdictions are presented below. 

• Single Point of Entry: In Montgomery County the same system controls families’ access 

to prevention, emergency shelter, and transitional housing. The advantage of a single 

point of entry to prevention services for families and individuals facing eviction or 

needing shelter is in standardized procedures that maximize use of all available resources 

in the community to prevent families from entering shelter. 

• Public-Private Partnership: The community-wide response to prevention involves a 

close working partnership with more than 40 nonprofit agencies, coordinated through the 

Emergency Assistance Coalition sponsored by the Community Ministry of Montgomery 

County. After public funding for an emergency financial situation has been exhausted, 

MCDHHS works with nonprofit agencies or faith communities that serve in a safety net 

support role. These agencies and communities are organized into a regionally based 

approach, along with MCDHHS, to serve people in designated ZIP codes. All families 

who seek emergency assistance receive help of some kind. 

• Outcomes Data Collection: The county collects data on recipients of emergency 

assistance and services using three different automated systems. These databases can be 

merged to document several prevention outcomes.

DEVELOPING THE COMMITMENT TO PREVENTION 

While Montgomery County began serving families and individuals at risk of homelessness 

during the early 1970s, these services took several years to evolve into a community-wide 

approach to homelessness prevention. Two county agencies provided services. The Department 

of Social Services provided eviction prevention services to help families and individuals with 

past due rents and utility bills, and the Department of Family Resources partnered with the 

nonprofit community to develop and provide emergency shelter. 

It was not until 1987 that the Department of Social Services had new leadership with the vision 

to realize that prevention was an essential part of a continuum of services to address the growing 

problem of homelessness. The Department of Social Services assumed leadership for both the 

prevention services and the contractors providing emergency shelter services, but initially served 

only for families. This was the genesis of the single point of entry for homelessness prevention. 

The Department of Social Services created the Division of Emergency Services, to prevent and 

remediate homelessness. The first and most important change involved establishing triage, 

screening criteria, and priorities for which families would be sheltered. Standardized procedures 

were established to assess level of need, coupled with a service plan that placed the responsibility 

on the family to address the issues that led to its homelessness. However, the county at this time 
Appendix B Montgomery County, Maryland 

B–3

determined that it would not allow a family to spend a night on the streets. Within six months of 

its inception, the Department of Social Services was more than $500,000 over budget, due 

mostly to the high costs of assistance with utilities and past due rents. 

Although prevention funds were originally designed for both at-risk families and individuals, 

when the demand exceeded the budgeted funds, the county-controlled funding for individuals 

was curtailed for a brief period. Prevention funding was reinstated for both families and 

individuals and remains so today; however, families constitute the highest proportion of 

households served. With respect to family homelessness prevention, one system controls the 

single point of entry. Individual prevention strategies are coordinated across several different 

access points. Therefore, the study team targeted the description to the family homelessness 

system in this report. 

Creating a single point of entry for family homelessness fostered a collaborative public-private 

partnership to reduce family homelessness. Key changes in both county government and the 

nonprofit sector further reinforced this collaboration. During 1995, county human services 

agencies—health, mental health, social services, and family resources—reorganized into one 

agency, MCDHHS. This move united homeless families with mainstream services, once 

dispensed by numerous agencies and divisions within agencies. Also during 1995, the nonprofit 

community, through the Community Ministry of Montgomery County, organized an Emergency 

Assistance Coalition. The Emergency Assistance Coalition coordinates a regional network of 

40 nonprofits that work with MCDHHS to coordinate public and private resources to prevent 

eviction. 

COMPONENTS AND ORGANIZATION OF THE COMMUNITY STRATEGY 

In Montgomery County, one system controls families’ access to homelessness prevention, 

emergency shelter, and transitional housing. Linking shelter access to homelessness prevention 

assures that shelter is only offered as a last resort and to those families with the most serious 

barriers. Coupling MCDHHS social work assessments and case management with shelter 

services is reducing numbers and length of stay for homeless families in shelter. The key 

elements of the approach to prevention and emergency shelter are discussed in the following 

section. 

Accessing MCDHHS Emergency Services 

MCDHHS emergency services are accessible to those in need via several options. Many 

landlords, community agencies, churches, schools, the police, community centers, Legal Aid, 

and healthcare providers know to refer to MCDHHS as a single point of entry for families facing 

a housing crisis. Community agencies and churches that also offer emergency services know to 

check the family’s address before referring to the appropriate regional office of MCDHHS. All 

crisis hotlines and the county information and referral numbers know the appropriate phone 

numbers and addresses to give families or individuals seeking help with a housing crisis. 
Appendix B Montgomery County, Maryland 

B–4

Any family or individual in need of emergency assistance must appear in person to one of three 

regional MCDHHS offices of Emergency Services in the county. The co-location of homeless 

prevention services with mainstream services provides access to screening, history, and 

eligibility determination not only for emergency assistance but also for mainstream resources 

such as Temporary Assistance for Needy Families (TANF), medical assistance, and food stamps. 

The MCDHHS Crisis Center provides services for families in housing crisis after regular 

business hours. 

Eligibility Criteria for MCDHHS Emergency Services 

MCDHHS provides emergency services to any family or individual who requires financial 

assistance to remedy an eviction, foreclosure, or utility disconnection. In addition to having a 

verifiable county address, a family must appear to be in a short-term financial crisis rather than 

an ongoing condition. Prevention efforts focus on families or individuals whose inability to pay 

rent stems from a temporary illness, job loss, or other short-term problem, for which returning to 

work or a new job or income source is verified. The MCDHHS Emergency Services worker 

determines that the family will be able to maintain housing after receiving the cash payment and 

other assistance for one month. 

MCDHHS will not provide financial assistance if a client at risk of eviction or foreclosure has 

arrears in excess of several thousand dollars. Further, if the client or family is involved in a 

recidivist situation and has never followed through on a service plan to resolve the crisis, 

MCDHHS may deny assistance. 

Eligibility Determination for MCDHHS Emergency Services 

When a family presents at a MCDHHS regional office, a screener first sees them. If eligible, the 

screener sends the family to the social worker to begin the planning to resolve the emergency. 

Many problems can be solved with information and referral or helping a family to obtain 

entitlement benefits. Often, families are instructed to return with appropriate documentation, 

including writ of eviction in 30 days, utility shut-off, and documentation of income and 

expenditures. 

The social worker assesses the precipitating factors that led to the housing crisis and reviews the 

family’s income sources and budget to determine the feasibility of covering housing costs in the 

future. The family develops a service plan and agreement with the social worker to resolve the 

housing crisis. The family must complete required action steps of the service plan before 

payment is authorized to the landlord or utility company. For example, a family must attend drug 

screening or treatment, obtain credit counseling, or apply for income supports and entitlements. 

Failure to complete the application process is the main reason a family does not receive 

emergency assistance, as the service plan places the responsibility on the family to complete the 

steps to successfully resolve the housing crisis. 
Appendix B Montgomery County, Maryland 

B–5

Families with financial crises that exceed MCDHHS guidelines are referred to Emergency 

Assistance Coalition Lead Agencies. The Lead Agencies serve individuals residing within a 

particular ZIP code. These agencies may provide eviction prevention funds, utility assistance, 

food, clothing, transportation, and other goods and services. These providers collaborate to fulfill 

the particular needs of a family or individual. The goal of this approach is to gather communitywide resources in an efficient and effective manner. 

Approach with Landlords 

An essential element contributing to prevention success is the cooperative relationship that 

MCDHHS has with landlords. Over the years, landlords have depended on MCDHHS 

intervention to help them keep tenants and avoid eviction and re-rental costs. Landlords have 

been willing to negotiate payment plans for back rent and to make other accommodations to 

avoid the costs and time involved in court-ordered evictions. 

Approach with Tenants in Subsidized Housing 

The Montgomery County public housing authority, HOC, subsidizes almost 6,000 households in 

the county. Families who lose subsidized housing due to nonpayment of rent or lease violations 

present the greatest challenge to homeless service providers, as they have no viable housing 

future in the county. HOC and MCDHHS have partnered to provide emergency assistance for 

HOC residents to keep them housed. MCDHHS has posted satellite positions in three regional 

HOC offices to provide help with utilities and past due rent. In addition, HOC, primarily through 

its Division of Resident Services, intervenes and develops service agreements to keep people 

housed and to avoid their entering the homeless system. 

Staffing and Caseloads 

Staff have four-year degrees in a human services field or a B.A. in Social Work. Masters-level 

social workers provide the intensive screening, assessment, and case management for homeless 

families. Two of the MCDHHS regional offices have a shelter worker dedicated to prevention 

activities with homeless families. The regional office in Rockville has the greatest number of 

shelter assessments and caseloads and has two shelter workers. 

Funding Sources and Arrangements 

Since 1995, the county has met residents’ demand for emergency assistance, regardless of the 

budget. The services and financial assistance provided in the county are funded with Federal, 

state, and county funds to prevent family homelessness. The approach to coordinating a financial 

package for clients emphasizes referral to other mainstream sources such as TANF, food stamps, 

and Medicaid; working with the community-based Emergency Assistance Coalition to garner 
Appendix B Montgomery County, Maryland 

B–6

additional funds; and securing Federal Emergency Management Agency funds through the 

nonprofit agencies that administer the Emergency Food and Shelter Program. 

MCDHHS Emergency Services staff assess need and compile a package of resources intended to 

resolve the housing crisis. Resources are typically a combination of Emergency Assistance to 

Families with Children Grants and county Emergency Services Grants. Each funding source has 

different eligibility requirements, so that the total financial package can be flexibly applied 

depending on the circumstance. For example, some families may be eligible for a Welfare 

Avoidance Grant to receive a one-time lump sum payment of up to six months of their welfare 

grant. This payment is intended to remedy a work-related crisis so the recipient can obtain or 

maintain employment and income. However, unaccompanied adults in need of assistance to 

prevent eviction are not eligible for Emergency Assistance to Families with Children funds. 

Workers will use a combination of county grants coupled with Emergency Assistance Coalition 

funds to assist in resolving the emergency. Emergency Assistance Coalition funds can often be 

used for medications and health needs that can be particularly costly to the uninsured, elderly, or 

disabled adult not yet eligible for Supplemental Security Income, Medicaid, or Medicare. 

To avoid a recurrence of the housing emergency, workers assist families and individuals to apply 

for any or all benefits for which they might be eligible. MCDHHS oversees the county Rental 

Assistance Program and the Maryland Energy Assistance Program and can often expedite 

applications to prevent an immediate eviction, as well as to help with long-term rental and utility 

bills. 

In many cases, families and individuals first appear at MCDHHS when an eviction is imminent 

and housing cannot be preserved. In these situations, assistance with security deposit, moving 

costs, and first month’s rent is far more expedient than allowing the family to enter the shelter 

system. Unlike the state Emergency Assistance to Families with Children grants, county grants 

can be flexibly applied to preserve or re-house families, given that they have a workable plan to 

remain housed. 

MCDHHS contracts with HOC to provide the same emergency financial assistance service to 

households at risk of homelessness that reside in HOC-owned units. The Department of Housing 

and Community Affairs also allocated funds to the Office of Landlord Tenant Affairs to provide 

emergency financial assistance for at-risk households to avoid eviction. 

Approach with Transitional Housing 

For those families not helped before becoming homeless, the major challenge is in determining 

what other housing alternatives are available to them. Assessment and case management services 

that are focused on finding housing as soon as possible have led to more rapid exit from 

homelessness. Those that remain in shelter are those who have no other alternatives. The families 

in shelter with the most serious housing barriers are referred as early as possible during their 

shelter tenure to an advisory group called the Family Provider Team. This team, consisting of all 

family nonprofit provider agencies of both shelter and transitional housing, meets monthly with 

MCDHHS to review and prioritize each family in shelter for transitional housing placement. This 
Appendix B Montgomery County, Maryland 

B–7

teaming assures that the most difficult families are prioritized for the scarce transitional and 

permanent supportive housing resources. This strategy prevents families from languishing in 

shelter without a housing plan, increases provider accountability, and encourages creative use of 

collaborative case management and resources. 

Approach with the Larger Community 

To increase interagency cooperation and early intervention to prevent evictions, the Montgomery 

County Coalition for the Homeless developed an Eviction Prevention Committee as an action 

step of the county’s 10-year plan to end homelessness. The Eviction Prevention Committee 

convened in July 2003 to increase collaboration and coordination of all stakeholders and their 

resources to prevent homelessness. The Eviction Prevention Committee includes representatives 

from Montgomery County Coalition for the Homeless, HOC, MCDHHS (Special Needs Housing 

and Emergency Services), Core Services Agency (mental health), Adult Protective Services, 

Child Welfare, Housing and Community Affairs, Office of Landlord and Tenant Affairs, and the 

Sheriff. Some of the strategies planned for the next six to 12 months include: 

• Delivering information to landlords, as part of rental agency annual license renewal 

procedures, about how to provide tenants with eviction prevention resources to prevent 

court filings; 

• Pulling weekly court filings for earlier intervention with educational packages to prevent 

evictions; 

• Targeting neighborhoods with high rates of evictions to deliver educational packages to 

increase financial literacy; and 

• Including MCDHHS information and referral number on eviction notices by the Sheriff’s 

office so tenants can seek assistance to avoid evictions. 

Approach with Tenants with Special Needs 

Often mentally ill clients engage in behaviors or cause neighborhood disturbances that can 

jeopardize their housing. The MCDHHS Crisis Center serves as liaison to the Sheriff’s office 

and to landlords’ complaints about mentally ill or vulnerable tenants whose behaviors might 

otherwise lead to eviction. 

Promising New Strategies 

Montgomery County found that prevention services alone were not enough to reduce family 

homelessness. Since 2000, the county has experienced a large increase in the number of 

homeless families in need of emergency shelter. Faced with large numbers of families in motels 

awaiting shelter placement and all family shelter units at capacity, MCDHHS leadership 
Appendix B Montgomery County, Maryland 

B–8

recognized that what they were doing was not working. Due to the long waiting list for shelter 

and the difficulty of conducting assessments while families were staying in motel rooms, 

MCDHHS instituted a pilot program to focus on placing families in shelter first for a 14-day 

assessment period, rather than using motels. 

Housing Assessments 

This approach emphasizes that families must take responsibility for their housing plan from the 

moment they first approach MCDHHS. Shelter placement is a last resort, only considered after 

all other alternatives for housing have been explored or verified. 

Each homeless family is screened for shelter eligibility and housing barriers prior to assignment 

to the MCDHHS shelter worker. The shelter worker then uses a detailed interview format that 

facilitates the assessment process and formulation of a detailed action plan. The interview covers 

educational, vocational, housing, credit, criminal, mental health, chemical dependence, legal, 

physical health, family of origin, and relationship issues. Once facts have been gathered they can 

be verified with mainstream and housing databases to assess the family’s housing barriers. 

The shelter worker then begins a housing stabilization plan that involves action steps to help the 

family obtain housing as quickly as possible. The family signs and dates the plan, which includes 

action steps and a timetable. The family is then sent to a shelter placement for a 14-day 

assessment period to be conducted jointly by the shelter provider and the MCDHHS shelter case 

manager. The shelter provider receives the screening information and coordinates with the 

MCDHHS case manager to attend to the action steps and timetable of the action plan. 

Since October 2003, this housing assessment program has led to reductions in the length of time 

that families have remained in emergency shelter. MCDHHS is now expanding the pilot program 

to all three family shelter providers. The goals of this program are to: 

• Reduce the numbers of families housed in motels awaiting shelter placement; 

• Reduce the average length of stay in the family shelter; and 

• Target shelter services to only those who need them. 

DATA COLLECTION AND USE 

The major barrier to documenting prevention outcomes is the inability of a number of databases 

to “speak” to one another. Created for different purposes, each database collects different 

components of prevention—clients served, payments distributed, and shelter or other 

homelessness services. The following three databases are used to determine the effectiveness of 

prevention assistance in Montgomery County. 

• The Client Information System identifies clients who requested any type of emergency 

assistance between July 2002 and July 2003. This system was developed and is 

maintained by the Maryland State Department of Human Resources. 
Appendix B Montgomery County, Maryland 

B–9

• The Client Payment System identifies recipients by type of emergency assistance. These 

data are from two databases: SOTAS collected data between July 2002 and March 2003 

and J.D. Edwards collected data after March 2003. These two data sets were merged on 

all matching variables. 

• The Homeless Tracking System identifies those who were homeless or entered the shelter 

system at some point between July 2003 and July 2004. This system was developed and 

is maintained by Montgomery County information technology resources. 

Analysis 

The study team developed a data analysis plan for Montgomery County to determine how many 

families who received emergency services subsequently received eviction prevention payments 

and then became homeless. To determine the impact of emergency assistance, each of the three 

databases listed above was unduplicated and matched using three fields of data for each case—

first name, last name, and social security number. The selected families’ data were analyzed 

around three main outcomes: 

• Receipt of emergency assistance; 

• Receipt of homelessness prevention payment; and 

• Experience of homelessness following receipt of assistance. 

Initial Findings 

Of the more than 3,500 families for whom cases were opened for emergency assistance at 

MCDHHS, the analysis indicated that 80 percent did not receive financial assistance. 

Approximately 19 percent of the families received an eviction prevention payment and 

approximately 2 percent used emergency shelter within the following year. Of those families 

who received an eviction prevention payment, a very small number (13) became homeless during 

the following year. (See Exhibit B.1.) Because analysis of the payment data alone indicates much 

higher receipts of eviction payments, there were too many cases dropped in the initial data 

matching to validly assess outcomes. 

Exhibit B.1. Outcome Measures for Families

Families Outcome Measures Number Percent 

Recipients of emergency assistance only 2,788 80% 

Recipients of a payment only 663 19% 

Recipients of shelter only 40 2% 

Recipients of a payment followed by shelter 13 0% 

Total recipients of homelessness prevention services 3,504 100% 
Appendix B Montgomery County, Maryland 

B–10

Future Analyses 

Montgomery County has rich data on homelessness prevention and homelessness. By continuing 

to unduplicate these data, matching databases together, and developing questions to be answered, 

the county is positioned to develop robust outcomes. Recommendations for continued 

monitoring of outcomes include: 

• Merging the payment data set with the Homeless Tracking System to track outcomes for 

all emergency services clients; and 

• Developing standardized measures of housing barriers to target more intensive services to 

those clients most at risk of homelessness. 

Caveats and Limitations of Outcomes Data 

Several caveats apply to the outcomes developed for Montgomery County. There is no 

comparison or control group, so that one can argue that most families who received assistance 

would have avoided shelter regardless of receipt of county help. Those who did not receive 

assistance may indeed have lost their housing and have become homeless. The available funding 

for eviction prevention assistance is not sufficient to meet the total need, so the county prioritizes 

its resources to prevent loss of housing for those most likely to be successful in the long term. 

Because of the single point of entry and the total coverage of all family shelter providers by the 

Homeless Tracking System, the county’s documentation of prevention will measure shelter use 

by the families with the most barriers to housing. 

Documentation of Reduction in Family Homelessness 

Prevention activities, coupled with strategies to help families find housing and exit shelter as 

quickly as possible, are demonstrating promising outcomes. Continuing to measure outcomes 

related to these new strategies would demonstrate if the county can eliminate the shelter waiting 

list and if the family shelters can reduce the average length of stay for homeless families. 

Recommendations for continued monitoring of outcomes include utilizing the Homeless 

Tracking System to track all families screened for emergency shelter, the number who are placed 

and how long they stay, and their dispositions at exit and six- to 12-month followup for repeated 

shelter episodes. 

MONTGOMERY COUNTY SITE VISIT PARTICIPANTS 

Diana Bird, HOC, Supervisor 

Lillian Durham, HOC, Director of Resident Services 

Diane Horning, MCDHHS, Special Needs Housing, Administrator 

Vera Johnson, MCDHHS, Supervisor, Emergency Services, Rockville Office 

Sharan London, Montgomery County Coalition for the Homeless, Executive Director 
Appendix B Montgomery County, Maryland 

B–11

Rosetta Robinson, Community Ministry of Montgomery County, Director Congregation & 

Community Emergency Support 

Steve Stahley, MCDHHS, Crisis and Homeless Services, Senior Administrator 

Corinne Stevens, MCDHHS, Special Needs Housing, Chief 

Dudley Warner, MCDHHS, Behavioral Health and Crisis Services, Senior Administrator 

Alex Wertheim, MCDHHS, Homeless Services Coordinator 

Charles Wilkerson, Community Ministry of Montgomery County, Loan Program 

MONTGOMERY COUNTY ACRONYMS 

HOC Housing Opportunities Commission 

MCDHHS Montgomery County Department of Health and Human Services 

TANF Temporary Assistance for Needy Families 
B–12
C–1

APPENDIX C 

MID AMERICA ASSISTANCE COALITION 

The Kansas City metropolitan area comprises five counties in two states: Clay, Jackson, and 

Platte counties in Missouri, and Johnson and Wyandotte counties in Kansas. According to the 

2003 American Community Survey conducted by the Census, these counties are home to more 

than 1.8 million residents.29 The urban core of Kansas City with the highest poverty level is 

located in Jackson County, MO, and Wyandotte County, KS. Clay and Platte Counties in 

Missouri have the challenges of a suburban area and rural setting, but with less poverty. 

To address the needs of low-income and homeless families and individuals across the Kansas 

City metropolitan area, the Mid America Assistance Coalition (MAAC) developed a 

comprehensive data system that stores homelessness prevention and homeless services data. This 

data system—MAACLink—is the centerpiece of the community-wide approach to homelessness 

prevention in Kansas City. More than 175 social services agencies are connected through 

MAACLink, providing a systematic approach to coordinate community resources and to 

document client services and outcomes for funders and community stakeholders. 

During the study team’s visit to Kansas City on May 10–11, 2004, the study team interviewed 

12 staff from MAACLink and community agencies to learn about MAACLink’s communitywide approach to homelessness prevention and services. The study team also learned how 

MAACLink documents services and outcomes. A listing of all persons interviewed is included at 

the end of this appendix. The MAACLink system approach to homelessness prevention is 

described below, including the data analysis to document program impact. 

PRACTICE OF POTENTIAL INTEREST TO OTHER JURISDICTIONS 

The contact for MAAC and MAACLink is Jan Marcason (maacexec@maaclink.org). The 

MAACLink system is a model, community-wide data system that provides standardized tracking 

of homelessness prevention and homeless services data. The MAACLink data system is a 

practice of potential interest to other jurisdictions. The highlights of the system include: 

• The integration of at-risk and homeless population data; 

• The ability to share client data among all member agencies; 

 

29 Population data were obtained from the U.S. Census Bureau at: 

http://www.census.gov/acs/www/Products/Profiles/Single/2003/ACS/Narrative/380/NP38000US3760.htm (accessed 

on 10/12/2004). 
Appendix C Mid America Assistance Coalition

C–2

• Highly standardized intake and service provision processes; 

• Ongoing collaboration among social service agencies throughout the community; and 

• System development that is directly influenced by the users themselves. 

DEVELOPING THE COMMITMENT TO PREVENTION 

During 1974, the need for social services in the Kansas City metropolitan area was rising, while 

resources were shrinking—social service agencies were only able to apply “band-aids” to clients’ 

situations. The Metropolitan Inter-Church Agency reached out to five counties and found that 

clients often bounced among providers, which raised the question of how to track these clients. 

In 1975, 21 agencies in the Kansas City area established the Emergency Assistance Coalition of 

Food Pantries. During 1977, members from the Missionary Baptist Church’s Drifters 

organization and Metropolitan Lutheran Ministries founded the Warmth and Light Utility 

Assistance program. In 1984, these long-established assistance organizations merged and became 

MAAC, which incorporated as a nonprofit in 1985. 

With the shared goal of improving emergency assistance provision to low-income and homeless 

individuals, MAAC merged centralized client tracking and information and referral to provide 

better reporting on services and payments. The energy crisis in the mid-eighties further 

underscored the need for detailed reports on the use of funds and services. MAAC and 

collaborators from local social service agencies, especially funders, thought it was a good idea to 

develop a centralized database to avoid duplication of services, to track case management, and to 

determine whether funding was meeting its goals. 

MAACLink was developed as a DOS-based application in 1994. The network of participating 

providers defined requirements to track basic information about recipients, services, and case 

management outcomes. The database system design was predicated on manual record keeping on 

index cards used by all participating agencies to standardize their tracking and data collection. 

The resulting automated system was user-friendly and provided for efficient record keeping and 

reporting. 

Demand for additional agency participation prompted MAAC to upgrade the software to a 

Windows-based application, expanding its ability to share information across multiple agencies 

and communities. In 1997, the Department of Commerce provided additional funding. 

Additional matching funds from Kansas City area foundations, businesses, and individuals 

supported an upgraded and expanded system. The U.S. Department of Housing and Urban 

Development (HUD) awarded MAACLink a 1999 “Best Practice” award for its information 

tracking system that enables agencies throughout the Kansas City area to communicate about 

services and clients in real time. 

Upgrades to MAACLink have also incorporated the functionality needed to become the Kansas 

City metropolitan area Homeless Management Information System (HMIS). The Kansas City 

continuum of care adopted the MAACLink system as its HMIS in 2002. Currently, 95 percent of 

shelter beds are logged on the system. This enables tracking the prevention of homelessness as it 

is possible to determine if an individual or family who received prevention services ultimately 
Appendix C Mid America Assistance Coalition

C–3

received shelter or other homeless services. Having expanded from only six agencies on line in 

1994, MAACLink currently includes more than 175 agencies inputting information about 

emergency assistance needs and homeless services in the metropolitan area. 

COMPONENTS AND ORGANIZATION OF THE COMMUNITY STRATEGY 

The MAACLink system coordinates the provision of emergency assistance and homeless 

services throughout the Kansas City metropolitan area. MAACLink allows the Kansas City 

community to track how funds are used to deliver services or provide emergency assistance to 

prevent homelessness. MAACLink is a proven system whereby multiple agencies across state 

and county jurisdictions can share recipient and payment information confidentially. The 

elements of the approach to homeless prevention are discussed in the following sections. 

Services 

The Kansas City community-wide approach to preventing homelessness includes 175 social 

service agencies. Each of these agencies provides a variety of services within their own funding 

limitations and conditions. The main homelessness prevention service that these agencies 

provide is assistance with utilities payments. Utility assistance is provided in one of two ways: 

• MAAC administers seven utility assistance programs and certifies eligibility for the 

Federal Emergency Management Agency (FEMA) funds. Forty agencies in the Kansas 

City metropolitan area receive utility funds to assist their clients. MAACLink is adept at 

managing these funds—the system automatically checks a client’s eligibility and reports 

real-time fund balances. 

• Some individual agencies administer their own funds. For example, the Salvation Army 

administers a utility fund and uses the MAACLink application to allocate and deliver the 

funds. The fund management application of MAACLink allows the managing agency to 

generate checks in the client’s name for immediate distribution. 

Additional services are provided through the 175 agencies that use the MAACLink system. 

Services are organized and delivered according to the particular agency. Catholic Charities 

reports that it often uses larger community funds to supplement internal agency funds. This 

practice is bolstered by the ability to determine which other agencies have community funds 

available and whether the client has already received certain funds through another agency. For 

example, a client can receive utility assistance from the Dollar Aide fund from only one agency. 

An agency intake worker can search MAACLink to determine if the client has already received 

utility assistance with Dollar Aide funding from other agencies that share the fund. If the intake 

worker fails to check the client’s service history before granting the service from Dollar Aide, 

MAACLink’s built-in safeguards inform the intake worker that the client is ineligible, prompting 

him or her to seek an alternate funding source for the service. 
Appendix C Mid America Assistance Coalition

C–4

Examples of additional services include the following: 

• Job counseling; 

• No-interest loan program for individuals with barriers to maintaining employment; 

• Food baskets and congregate meals; 

• Clothing and thrift store; and 

• Drug and alcohol counseling. 

Screening and Eligibility Issues 

In the Kansas City metropolitan area, an individual or family in need can contact either MAAC’s 

information and referral hotline or any of the service providers in the area. Most of the social 

services agencies that participate in the system provide emergency assistance with the ultimate 

goal of preventing homelessness. There is no single point of entry for clients, but there is no 

wrong door—MAACLink allows a family or individual to walk into any agency and receive 

services or a referral to another agency that can provide services. 

When a client enters any agency that is a MAACLink user, workers at that agency conduct a 

standard intake of basic client demographics. When an agency provides a service, the worker 

enters that information as well. Any agency that is part of the system can see a client’s service 

history including rental, mortgage, and utility assistance, as well as other services such as food, 

transportation, case management, and bed nights at a homeless shelter. To maintain client 

confidentiality, information regarding certain services, such as those provided through a 

domestic violence agency, cannot be accessed through MAACLink. 

Each agency and each funding mechanism has its own criteria for eligibility and its own 

restrictions as to how many times a family or individual may receive services. Typically, there 

are limits on the number of times that a family may receive services, as well as the number of 

dollars that can be spent on the person’s behalf. Although the specific requirements for each 

utility assistance fund vary, the general requirements for the utility funds administered through 

MAACLink are the following: 

• Applicant must have income at or below 150 percent of the Federal poverty level; 

• Client’s name and address on the MAACLink screen must match those on the utility bill; 

• The client and agency intake staff member must sign a confidentiality and consent 

agreement; 

• The intake date on the client’s service file in MAACLink cannot be more than 45 days 

old; 

• The date on the utility bill must be within 30 days of the client’s request for service; 
Appendix C Mid America Assistance Coalition

C–5

• The client can receive assistance twice in one year from each of seven funds from one 

agency; 

• The amount of the assistance is equal to or less than the amount of the bill; 

• The payment of the utility bill must be delinquent or the client must provide proof of a 

disconnect notice; and 

• No agency personnel may receive MAAC-managed funds from the agency that employs 

them. 

Agencies have a certain amount of discretionary flexibility depending on a client’s needs and 

available funding. In general, most providers make exceptions and provide services only for 

clients who have “hit a bump” rather than those with chronic issues or those who are at imminent 

risk of homelessness. The overall focus is on helping clients who are more likely to resolve the 

issue and have a long-term positive outcome. Not all funds managed through MAACLink are 

flexible, however. The Salvation Army is very strict in terms of eligibility—all services are needbased (client must verify income and expenses); client must have paid at least 25 percent of the 

bill during the past 90 days and must often provide a copay; client may only receive financial 

help once each year; the cap for aid is $250 for rent and $150 for utilities each year; and the 

client must make a plan toward paying the next bill.

Because the system was originally designed for use by professional case managers who employ a 

strengths-based case management method, MAACLink does not specifically identify families or 

individuals at imminent risk of homelessness.30 However, the system has the capacity to inform 

the provider about whether a client’s homelessness is acute (i.e., client receives many services 

and often) or if it is a momentary slip. This information helps workers to know the best way to 

intervene—those who “slip” may just need a quick intervention to help them avoid or quickly 

end an episode of homelessness. 

Selected System Components 

The MAACLink data system is MAAC’s most outstanding feature. Its capacity for data 

collection, as well as analysis, is broad. The unique aspects of the system are the ability to view a 

client’s service history among all participating agencies; the ability to manage funds within the 

system so that workers know where to refer clients who request financial assistance; and the 

ability to compare homelessness prevention services against homeless services to determine 

some level of prevention effectiveness within the community. 

 

30 The strengths-based case management program trains workers in the Kansas City area to serve homeless families 

using a case management module in MAACLink. This method builds on participants’ existing strengths to help 

them leave homelessness and secure permanent housing. Workers using this program have access to discretionary 

funds for program participants. The housing status and risk level for these participants is known; therefore, a 

measure of imminent risk of homelessness was not built into the MAACLink system. 
Appendix C Mid America Assistance Coalition

C–6

Another striking characteristic of MAACLink is the leverage that it has in the community. 

MAACLink has been successful in developing a large collaboration of social service agencies, 

partially due to the financial and programmatic benefits that it parlays to its members. 

Specifically, only agencies that utilize MAACLink are eligible for the energy assistance funds 

managed by MAAC. Therefore, participation in MAACLink increases agencies’ financial 

resources. 

The coordination among services and providers is the hallmark of the MAACLink system. 

Currently, the network of service providers that is coordinated through MAACLink includes 

175 agencies, most of which are nonprofits that provide emergency assistance. Even homeless 

service providers that receive no government funding report and track data using MAACLink. 

The administration of the MAACLink system is centralized at MAAC while each agency has 

remote, real time access to the system where they can enter and access data on all clients. 

Homelessness services are provided under the auspices of the providers associated with the 

Homeless Services Coalition. The Homeless Services Coalition works to move people out of 

homelessness while MAACLink providers work to prevent homelessness from occurring. 

Homeless Services Coalition statistics are tracked through MAACLink. 

Examples of collaboration and coordination within the MAACLink system include the 

following: 

• Any agency on MAACLink can look up other agencies’ shared fund balances and refer 

clients to an agency that may have aid available. This effective referral network saves the 

clients’ time and helps reduce frustration for people seeking emergency assistance. 

• City Union Mission is the largest provider of emergency shelter in the Kansas City 

metropolitan area. This agency was not required to go on-line with MAACLink, but did 

so because it recognized the value of sharing its services with the community. City Union 

Mission does not receive any Federal funding, but uses MAACLink to ensure that it 

serves clients in the best possible way. MAACLink is the connection between emergency 

assistance and homelessness services for City Union Mission.

Mainstream Agency Involvement 

Because MAAC is a private agency with a collaboration of members, it does not have access to 

mainstream funds and services. While MAAC has created a community-wide system, LowIncome Home Emergency Assistance Program (LIHEAP) and Emergency Crisis Intervention 

Program funds are distributed through another agency. LIHEAP and Emergency Crisis 

Intervention Program funds are distributed through the state of Missouri to the Community 

Action Programs (CAP) in the Kansas City metropolitan area. The CAPs use a separate data 

system and do not collaborate with MAACLink. MAACLink encourages intake workers to help 

clients apply for mainstream resources, such as LIHEAP, by prompting a pop-up referral screen 

based on the monthly household income. This screen reminds intake workers to ask the client if 

he or she has applied for or received LIHEAP or Emergency Crisis Intervention Program 
Appendix C Mid America Assistance Coalition

C–7

assistance. Intake workers may refer clients to the CAPs for Federal funds and thereby leverage 

resources in the private social services sector. Because MAACLink is not used by the CAP 

agencies, there is a significant gap in its community-wide approach to preventing homelessness. 

Funding 

MAAC and MAACLink are funded through several sources—corporate and foundation grants, 

Heart of America United Way, government grants, program income, individuals, religious 

organizations, and other sources. The utility assistance funds that MAAC administers are funded 

through Kansas City Power and Light Company, Missouri Gas Energy, Aquila (an electricity and 

natural gas company), Kansas City Star (the newspaper for the Kansas City area), and KCTV5. 

Additionally, each of the individual emergency assistance providers in the community is funded 

through several different sources, based on the particular agency. Each of these funding sources 

is tracked through MAACLink and all services are associated with a particular funding source, 

allowing MAACLink to accurately determine the costs of services provided. 

Community Relations and Advocacy 

The collaboration among service providers was established first and eventually led to the 

creation of the MAACLink data system. One of the biggest barriers to implementing a 

management information system was the collaboration among agencies and a foundation of trust 

among stakeholders. Since the Kansas City metropolitan area service providers had already 

established this; MAAC was charged with the task of creating a simple system that appealed to 

service providers. MAACLink is central to maintaining and facilitating the ongoing collaboration 

among the agencies. 

DATA COLLECTION AND USE 

MAACLink collects a vast amount of data; however, the data previously have not been used to 

measure outcomes. The study team worked with MAACLink to measure the impact of the 

provision of emergency assistance on whether a family or individual becomes homeless within 

12 months of receiving services. To assess this impact, the study team recommended that 

MAACLink examine the effect of rental and mortgage assistance to families, individuals, and 

youth on the probability that they will experience homelessness within 12 months following the 

service.

Analysis 

The study team proposed that MAACLink determine the percentage of families and individuals 

who received homelessness prevention services and then became homeless. The team defined the 

population served as families and individuals who received rental and mortgage assistance 
Appendix C Mid America Assistance Coalition

C–8

during fiscal year 2002 (October 2001–September 2002). This population was compared with 

recipients of shelter services during fiscal years 2002 and 2003 (October 2002–September 2003). 

The reason for limiting the population definition was that rental and mortgage assistance are 

generally considered to be the essential intervention used across jurisdictions to avoid shelter 

placement and to preserve housing for those most at risk of homelessness. Rental and mortgage 

assistance are also typically the highest expenditures and have stricter eligibility requirements, 

such as a plan indicating that the housing can be sustained over a period of 12 months. 

Initial Findings 

Using the data collected through the MAACLink system, staff at MAAC conducted a basic 

analysis of outcomes data. By using the analyses and variables described above, MAAC was able 

to calculate a percentage of families and individuals who received homelessness prevention 

services during 2002 and then became homeless during 2002 or 2003. The number of 

homelessness prevention services recipients is an unduplicated number based on unique heads of 

households.31 Of the 4,235 households who received homelessness prevention services during 

2002, 3.4 percent became homeless during 2002 or 2003. Of these same households, 2.7 percent 

became homeless in 2003.32 (See Exhibit C.1.) 

Exhibit C.1. Recipients of Rent and Mortgage Assistance 

Who Became Homeless the Following Year 

Recipients of homelessness prevention services 4,235 

Recipients of shelter, 2002 & 2003 145 

% Recipients who became homeless 3.4% 

Recipients of shelter, 2003 only 116 

% Recipients who became homeless 2.7% 

Future Analyses 

Two characteristics of MAACLink make future analyses and development of outcome measures 

feasible and promising: the wealth of data collected by MAACLink and the ease with which 

adjustments can be made to the system to improve data collection. Using the data that 

MAACLink currently collects, the study team recommends conducting the following analyses: 

• Determine the households that are “acute” as opposed to those that have hit a difficult 

point;33 

 

31 The MAACLink system could not identify the number of unique heads of household that requested but did not 

receive homelessness prevention services during the indicated period of time. 32 The 2003 numbers may seem disproportionately higher because that was the first full year that 95% of beds were 

being documented consistently in MAACLink (the Shelter Bed application of MAACLink was completed in 2002 

and fully implemented toward the end of that year). 

33 In this case, acute refers to those families and individuals who have experienced repeat episodes of homelessness. 
Appendix C Mid America Assistance Coalition

C–9

• Compare the characteristics of acute and nonacute households to accurately target 

prevention services; 

• Compare the characteristics of households who become homeless following rent and 

mortgage assistance with those who do not; and 

• Compare outcomes between families and individuals. 

Several simple variables could be added to the MAACLink data system to allow a more robust 

analysis of outcomes data. A variable could be added to flag individuals who requested rental or 

mortgage assistance but did not receive it, as opposed to those who requested it and then 

received it. This variable would allow analysts to select out a control group to compare whether 

receipt of rental or mortgage assistance impacted the percentage of households becoming 

homeless during the following year. 

Limitations of Data and Outcomes 

The barriers to documenting service effectiveness by MAACLink include inconsistent data entry 

among service providers and the lack of data fields that may prove vital to the development of 

outcome measures. In addition, the database has the capacity for users to track clients who 

request services but are denied, but this has not been done. With the addition of these data, robust 

outcomes could be measured for the community. 

MID AMERICA ASSISTANCE COALITION SITE VISIT PARTICIPANTS 

Estelle Banks, MAAC, Training and Community Outreach Coordinator 

Mary Lou Greim, Good Samaritan Center (Excelsior, MO) 

Bonita Harrington, Salvation Army 

Lea Jackson, MAAC, MAACLink Administrator 

David Johnson, MAAC, Chief Financial Officer and Utility Fund Manager 

Ellen Jones, Catholic Charities (Kansas City, KS) 

Kathleen Kennedy, Bishop Sullivan Center (Kansas City, MO) 

Cynthia Larcom, Homeless Services Coalition Coordinator 

Jan Marcason, MAAC, Executive Director 

Dan Pearson, Redemptorist Social Services Center (Kansas City, MO) 

Joyce Schau, The Salvation Army, Kansas City Metro Social Services (Kansas City, KS) 

Ladonna Zimmerman, MAAC, MAAC Homeless Case Manager Coordinator 

MID AMERICA ASSISTANCE COALITION ACRONYMS 

CAP Community Action Program 

FEMA Federal Emergency Management Agency 

HMIS Homeless Management Information System 
Appendix C Mid America Assistance Coalition

C–10

HUD U.S. Department of Housing and Urban Development 

LIHEAP Low-Income Home Emergency Assistance Program 

MAAC Mid America Assistance Coalition 
D–1

APPENDIX D 

MASSACHUSETTS DEPARTMENT OF MENTAL HEALTH 

Massachusetts (estimated population of 6.4 million in 2003) runs its public services through 

state agencies, with local governments playing relatively small roles. The Massachusetts 

Department of Mental Health (DMH) is responsible for all persons in the state with severe 

behavioral health problems, most of whom have extremely low incomes. The system operates 

through six regions, of which the study team visited two: Metro Boston and Western 

Massachusetts. The study team selected these two regions because Metro Boston is the state’s 

most populous region and has the highest prevalence of homelessness and the most extensive 

development of interventions for primary and secondary homelessness prevention. Western 

Massachusetts is geographically the largest region, covering the western portion of the state, 

and is home to some innovative programs to prevent homelessness. 

DMH’s Metro Boston Area covers Boston and the surrounding cities of Cambridge, 

Somerville, Brookline, Chelsea, Revere, and Winthrop. Boston is the largest city in the state 

and the 20th largest city in the nation. The 2000 population was 589,141.34 With its 

concentration of higher education, health care, financial services, professional and business 

services, and tourism and hospitality, Boston and the surrounding area transitioned from a 

manufacturing economy to a knowledge-based one. By 2000, the Boston Area was enjoying 

one of the strongest economies in the nation—employment was at an all-time high with more 

than 113,000 jobs added between 1992 and 2000, and unemployment was at a near-record low 

of 2.9 percent. The situation changed when a national recession and depressed stock market, 

coupled with the events after the September 11, 2001 terrorist attacks, led to job losses and 

reductions in state revenues and budgets (revenues declined by 26 percent during the spring 

quarter of 2002). These cuts threatened many social services and public health programs, 

especially those serving low-income and other vulnerable populations. 

Western Massachusetts, by contrast to Metro Boston, is an area of small towns with a regional 

population of approximately 626,000 adults. Springfield (2000 population of 152,000) is its 

largest city, and the location of DMH’s Western Massachusetts regional office. Also in contrast 

to Metro Boston, Western Massachusetts has suffered job and population loss for several years, 

so the recent economic downturn did not represent as drastic a change as it did for Boston. 

Preventing homelessness among people with serious mental illness has been a strong element of 

DMH’s agenda for nearly two decades. DMH efforts have been greatly strengthened since 1992, 

when the state passed its first Special Homeless Initiative legislation to provide the resources to 

 

34 Population data were obtained from the U.S. Census Bureau at: 

http://quickfacts.census.gov/qfd/states/25/2507000.html (accessed on 3/30/05). 
Appendix D Massachusetts Department of Mental Health 

D–2

reduce the incidence of homelessness among people with serious mental illness. Housing 

development, specifically for homeless people and more generally for people with serious mental 

illness, has been a strong component of the DMH effort. This effort has also included protocols 

for discharge planning, staff training to focus on housing issues, funding for outreach, 

development of transitional shelters for people with serious mental illness, and other aspects of 

prevention described in more detail below. The study team’s site visit concentrated on learning 

about the primary and secondary prevention efforts in the Metro Boston and Western 

Massachusetts regions. 

During the study team’s site visit to the state on July 13–15, 2004 and August 12, 2004, the team 

interviewed more than 70 people who represented state and local agencies devoted to behavioral 

health care and homeless services, psychiatric hospitals and inpatient units, nonprofit behavioral 

health and case management agencies, and data managers and analysts. A full listing of persons 

interviewed is presented at the end of this chapter. 

Most meetings provided information about the system and how it works; other meetings focused 

on understanding data to assess prevention and developing analytic strategies to document 

effectiveness. This report describes the services available for behavioral health (mental illness 

and substance abuse) and how they are structured; housing options developed by DMH; and 

existing and developing practices to assure that institutional release or other disruptive events, 

such as loss of a caretaker, do not render a person homeless. Information on the growth of the 

DMH housing and community services system, as it relates to homelessness, and analyses of 

data reflecting DMH’s effectiveness at preventing homelessness for people with serious mental 

illness are also described below. 

PRACTICES OF POTENTIAL INTEREST TO OTHER JURISDICTIONS 

Practices that are of potential interest to other jurisdictions are presented below. All inquiries 

about Massachusetts DMH practices should be addressed to Walter Jabzanka at 

walter.jabzanka@state.ma.us. 

1. Discharge planning policies and procedures—DMH has a highly evolved set of policies 

and procedures related to discharge planning, along with training materials and other 

means of dissemination. Assuring appropriate housing and support services is a major 

element of discharge planning, which DMH emphasizes by establishing central office and 

area housing coordinators to promote adequate supplies of appropriate housing and 

facilitate access for the people who need it. 

2. Special Homeless Initiative—DMH has substantial state resources explicitly targeted to 

prevent homelessness and assist already homeless people to regain and retain housing. 

These resources are flexible, allowing the department to “do what it takes” to reach the 

initiative’s goals within broadly defined parameters. 

3. Housing development—Housing development has been an explicit DMH focus for nearly 

two decades, during which the department has created many units and shifted the 
Appendix D Massachusetts Department of Mental Health 

D–3

emphasis from group homes to independent and semi-independent living with supportive 

services. Since the late 1980s, the Homeless Initiative and the housing development 

process have been part of DMH’s successful efforts to develop a solid community-based 

system of care while minimizing institutionalized care and homelessness among persons 

with serious mental illness. While not designed exclusively to prevent homelessness, 

growth in the community-based system has coincided with and supported the downsizing 

or closure of several state hospitals. Through well-documented plans and financing 

strategies, state administrators and the legislature reallocated resources to the community 

system. This dynamic underscored the importance of discharge planning and housing 

development, which in turn made available effective homelessness prevention. 

4. Tenancy Preservation Project (TPP)—The initial impetus for TPP came from the state’s 

housing finance agency (MassHousing), which proposed an alliance with DMH, local 

Housing Courts, and other agencies. DMH supports TPP with funding and planning 

input. TPP includes several projects across the state with specially appointed neutral 

mediators who work with people with mental health and other behavioral problems. TPP 

receives referrals of pending evictions, including many for which mental illness is a 

contributing factor, and seeks solutions with tenants and landlords to prevent eviction and 

subsequent homelessness. 

DEVELOPING THE COMMITMENT TO PREVENTION 

DMH has been evolving its current discharge planning and community-based system, including 

homelessness prevention and mitigation, since the late 1980s. Advocates from shelters and the 

Massachusetts Housing and Shelter Alliance (MHSA) provided a key stimulus for the 

department’s increased focus on homelessness in the early 1990s by documenting the significant 

number of people with serious mental illness who sought help from emergency homeless shelters 

within days or hours of being discharged from inpatient psychiatric facilities.35 The evidence, 

combined with active lobbying, stimulated the first Special Initiative to House and Serve 

Homeless Persons with Mental Illness, most often referred to as the Special Homeless Initiative 

(HI). 

The HI received funding in state fiscal year (SFY) 1992 with state resources of $1 million and in 

SFY 1993 with $2 million. Ongoing advocacy from MHSA, in collaboration with DMH and the 

governor’s office, increased that amount to funding levels of approximately $22 million each 

year in SFY 2001. HI is supplemented with an additional $1 million each year in DMH services 

funding explicitly devoted to this population. DMH HI and supplemental homeless funding 

levels have remained constant during the last few years despite severe state budget shortfalls, 

testifying to the state’s commitment to support approaches to prevent or end homelessness for 

people with serious mental illness. 

 

35 MHSA is a statewide coalition of housing and shelter providers that organizes, lobbies, advocates, and otherwise 

works to promote solutions to homelessness in Massachusetts. 
Appendix D Massachusetts Department of Mental Health 

D–4

DMH has used these and other department funds to purchase services, leverage additional funds 

for housing development with supportive services supplied by DMH, and focus increasing 

attention and resources on preventing and ending homelessness for the target population. In 

addition to funding, DMH commissioners have understood the need for housing and the 

difficulties of homelessness for people with serious mental illness. These commissioners have 

been proactive in leading the department to develop housing and systems aimed at preventing 

and ending homelessness for persons with serious mental illness. 

DMH, which serves the most disabled and the poorest, estimates that approximately 48,000 

adults in the state have serious mental illness. Its clients’ incomes hover around 15 percent of the 

area median income and most clients are not employed. These circumstances leave them very 

vulnerable to homelessness should hospitalization or loss of a caretaker disrupt their housing 

arrangements. Targeting is a matter of clinical assessment to determine whether a person’s 

mental illness meets state and Federal criteria for becoming a DMH client. DMH outreach teams 

actively look for clients and potential clients among homeless people on the streets and in 

shelters. Identification of potential clients triggers further assessment, formal enrollment as a 

DMH client, and efforts to help the person move to safe and stable housing. The characteristics 

that make a person DMH-eligible signify a level of disability that indicates a high risk of 

homelessness if the person has no family or obvious means of support. 

COMPONENTS AND ORGANIZATION OF THE COMMUNITY STRATEGY 

DMH has invested heavily, both directly and indirectly, in addressing homelessness among 

persons with serious mental illness.36 Elements of homelessness prevention are present 

throughout the department’s multifaceted system of inpatient and outpatient continuing care. 

Most of DMH’s core services are relevant to homelessness associated with serious mental 

illness. The department also sponsors initiatives aimed at preventing first-time homelessness and 

assuring that people with serious mental illness who do become homeless can obtain stable 

housing before their homelessness can become chronic. The department’s homelessness 

prevention efforts are supported primarily with state-appropriated funds, and implemented in 

conjunction with Federal resources. Much of DMH’s efforts to prevent homelessness are 

conducted through contractual arrangements with nonprofit and for-profit providers. 

Some of DMH’s activities and programs address primary prevention of homelessness; they try to 

avert a first episode and keep people with serious mental illness stably housed. Housing 

development, coupled with attending to housing at discharge, is important because many people 

stay in DMH continuing care units for many months. They may have been housed upon 

admission but lose that housing while they are in the hospital. Primary prevention involves 

assuring that housing is available for them once they are ready to leave. 

Other DMH activities and programs address secondary prevention; quickly identifying people 

with serious mental illness who become homeless and supplying housing and services to assure 

 

36 Much of this description is taken verbatim or with minor modification or reordering from documents provided by 

DMH. 
Appendix D Massachusetts Department of Mental Health 

D–5

that their period of homelessness is short and does not happen again. The study team examined 

both primary and secondary prevention components. These include discharge planning, housing 

development and the various forms of permanent supportive housing that have been created, 

transitional residential services (transitional shelters in Boston), outreach, and referral to housing 

and supportive services for people with serious mental illness found on the streets or in shelters. 

The study team has ordered the presentation of these service components from the most to the 

least pertinent to homelessness prevention. The focus is on the Metro Boston Area because it has 

a more complex service structure and serves the most people. DMH also asked that we visit 

Western Massachusetts to learn about some particularly innovative programs such as the 

Tenancy Preservation Project and the housing options that have been accomplished there, both of 

which are described below. Each of the service components developed together and work 

simultaneously to prevent initial homelessness and to end homelessness quickly for those who do 

become homeless. 

Mental Health Services 

Publicly funded mental health services are managed in tandem by DMH and the Behavioral 

Health Program of MassHealth, the state’s Medicaid managed care program. Individuals who 

qualify for services through MassHealth, due to serious mental illness or serious emotional 

disturbance, are served by one of two means. Some individuals enroll in a health maintenance 

organization that becomes responsible for all of their care, including mental health services. 

Others choose a primary clinician option; in this case, services related to their behavioral health 

needs and the funds needed to meet those needs are separated out from Medicaid’s normal 

reimbursement structure and managed for DMH by the Massachusetts Behavioral Health 

Partnership (MBHP). 

MBHP is a private for-profit managed care organization that is a division of Value Options, one 

of the nation’s largest managed behavioral health organizations. MBHP provides a 

comprehensive continuum of mental health and substance abuse treatment, including outpatient 

therapy and medication, acute inpatient and day treatment services, partial hospitalization 

programs, family stabilization teams, and a range of substance abuse services. Nearly all DMH 

clients receive MassHealth benefits as described above. The MBHP director reports directly to 

the commissioner of DMH. 

DMH is a provider and purchaser of “continuing care mental health” services, which begin after 

a course of acute treatment does not achieve adequate improvement in an individual’s status. 

DMH community services are provided, contingent upon an individual’s eligibility for DMH 

services. Eligibility for adults, adolescents, and children is based on one or more qualifying 

mental health conditions (e.g., major affective, psychotic, severe personality, and eating 

disorders), the duration of the condition (one year or longer, observed or predicted), significant 

functional impairment due to mental illness, and a need for at least one service that is only 

available from DMH. DMH services include program- and home-based residential, wraparound 

services, case management, Programs of Assertive Community Treatment (PACT), homeless 

outreach services, supported employment, and other day and vocational services. 
Appendix D Massachusetts Department of Mental Health 

D–6

Discharge Planning 

Discharge planning assures that people leaving inpatient psychiatric facilities operated or paid 

for by DMH exit to stable housing and not to homelessness. The department has an explicit 

written discharge planning policy that includes a housing search component and the willingness 

to extend someone’s hospital stay (i.e., to justify paying for more days than may be medically 

necessary) until appropriate housing is found. The policy prohibits DMH state hospitals and 

community mental health centers from discharging clients from inpatient wards with directions 

to seek housing or refuge in an emergency shelter. It directs staff to make every effort to place 

clients in suitable, affordable housing coupled with clinically appropriate services. 

Many DMH clients with an inpatient episode, particularly those with longer stays, are at risk of 

homelessness because they lose their housing while receiving care due to eviction; family, 

partner, or sibling abandonment; and other situations. Such housing loss makes discharge 

planning (and developing appropriate housing resources) particularly important and a form of 

primary prevention. DMH has made great efforts to train staff to think that housing is one-half 

the job and is a critical component of mental health or clinical care. That is, people cannot 

respond well clinically unless their housing is secure. 

DMH discharge policy has received extensive publicity as a practice model. It is formally 

promulgated and referenced in regulations; regular trainings and refresher courses are offered 

statewide; and Metro Boston has its own procedures on implementing the policy due to the high 

volume of clients. However, key people whom the study team interviewed in the state, 

particularly at DMH, noted that a do-not-discharge-to-homelessness policy is only as good as the 

housing options for people leaving psychiatric facilities. Therefore, DMH has been committed to 

creating housing options for clients with serious mental illness who would otherwise face 

homelessness. 

Housing Supply and Development 

As of August 2004, DMH maintains more than 3,000 self-contained housing units of DMHaffiliated housing for people with serious mental illness and can house 5,869 people (some units 

have more than one person). Some of this housing is specifically targeted toward formerly 

homeless people. DMH-affiliated housing is any housing for which DMH or its agents have been 

successful in providing or otherwise proactively securing for its clients by helping to build it, 

providing match money for grants and other financing, or by other mechanisms. DMH-affiliated 

housing also includes clients living independently under their own leases. 

An additional 1,792 DMH clients receive varied continuing residential community support 

services while living in housing that DMH did not secure. Of the total number of DMHaffiliated, self-contained housing units, approximately 1,400 are HI units. The Boston Metro 

Area has 2,278 DMH-affiliated housing units. 

DMH has increased its housing inventory primarily since the early 1990s, and continues to add 

to it at every opportunity. The department’s access to substantial resources through the HI and 
Appendix D Massachusetts Department of Mental Health 

D–7

other community services initiatives has allowed it to provide services funding for many housing 

units to match the housing component most commonly supplied by Federal resources (primarily 

the U.S. Department of Housing and Urban Development’s (HUD) McKinney-Vento Homeless 

and Section 811 programs). DMH’s statewide community residential capacity increased from 

2,746 during 1991 to 7,651 in 2004. DMH-affiliated housing increased its ability to 

accommodate people from 1,969 to 5,869 people during the same period. (See Exhibit D.1)37 

Exhibit D.1. Growth in DMH Residential Housing Capacity, Affiliated Housing Statewide, 

and Metro Boston Capacity, 1991–2004 

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

Units

Capacity 2746 3386 3649 4291 4885 5180 5449 5629 5769 6108 6390 6822 7092 7651

Affiliated Housing 1969 2342 2603 3119 3569 3815 3980 4112 4229 4558 4783 5105 5345 5869

Metro Boston 470 1389 1881 2278

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

 

Exhibit D.2. DMH Funding for Community-Based Housing and Services, 1999–2004 

0

50

100

150

200

250

300

Dollars (in millions)

Total 203.8 215.1 226.5 231.6 238.1 244.7

Residential 141.7 148.1 155.7 159.2 164.5 168.7

Support Services 62.1 67.0 70.7 72.4 73.6 76.0

1999 2000 2001 2002 2003 2004

 

37 DMH-affiliated housing is housing for which DMH has generated capital dollars, such as permanent supportive 

housing. DMH “capacity” includes DMH-affiliated housing and clients living on their own in the community (e.g., 

with family, or in their own apartments) for whom DMH supplies supportive services to help keep them from having 

an exacerbation of their mental illness and from losing housing. Metro Boston could only supply data for 1991, 

1995, 2000, and 2004, hence the blank cells and absence of a connecting line in Exhibit D.1. 
Appendix D Massachusetts Department of Mental Health 

D–8

In Metro Boston, capacity increased from being able to house 470 people to the present capacity 

for 2,278 people (shown as separate triangles because not all data points are present). Exhibit D.2 

shows DMH funding increases, in millions, from 1999 through 2004, total and separately for 

community-based residential and related rehabilitative supportive services. With increases 

running at slightly more than 5 percent each year, these funds have done better than inflation 

during this period, enabling DMH to sustain its community-based supports despite overall 

budget cuts and layoffs since SFY 2002. 

Residential Services Other than Permanent Housing 

The HI has allowed DMH to serve and house an average of 2,400 homeless persons each year in 

approximately 1,400 units. In addition to extensive development of permanent supportive 

housing, HI has allowed DMH to enter into contracts with traditional shelters to provide 

supportive mental health services, to create five transitional shelters in the Boston Area, and to 

develop several Safe Haven projects across the state, including two in Boston. All of these 

programs are intended to help people with serious mental illness who have become homeless to 

leave that condition as quickly as possible and avoid a worsening of their mental illness. With 

many newly homeless people, these activities constitute secondary prevention efforts. DMH 

funds mental health services in the four largest traditional shelters in the state. All are in Boston 

and are operated by private nonprofit agencies. These services help shelter guests directly, but 

also make referrals to other services to help guests determine whether they are eligible for DMH 

continuing care services. If eligible, their prospects for ultimately becoming housed and 

receiving ongoing community supports through DMH increase substantially. 

Metro Boston’s Department of Mental Health Transitional Shelter (DMH/TS) programs, with a 

collective capacity of 165 beds, are affiliated with the area’s mental health centers. Every effort 

is made to move homeless people with serious mental illness from traditional emergency shelters 

and the streets to more appropriate settings, such as DMH/TS facilities. DMH/TS are better 

prepared than generic shelters to keep people with serious mental illness safe and help them 

handle their mental health and other issues. Some people also come to DMH/TS from inpatient 

psychiatric units when a more permanent placement in the short term is not possible. DMH/TS 

facilities serve homeless people with serious mental illness who are waiting for permanent 

housing or not yet ready and willing to participate in the department’s residential services 

programs. The goal in DMH/TS is for people to leave within 90 days, although average lengths 

of stay are approximately twice that goal, due in part to long stays of people who are difficult to 

place and the unavailability of suitable housing. 

Safe Haven programs, another link in DMH’s array of services, are aimed at reducing 

homelessness among people with serious mental illness. These programs are mostly targeted 

toward chronically homeless people with serious mental illness, typically with co-occurring 

substance abuse or other issues, and are not directly relevant to the present project’s focus on 

primary or secondary prevention. Several Safe Havens operate around the state. Metro Boston 

has recently opened its second Safe Haven as an enhanced facility offering services and housing 

referrals typically not found in traditional Safe Havens projects. After only a few months, three 
Appendix D Massachusetts Department of Mental Health 

D–9

of its first eight residents are already moving into permanent housing. Another Safe Haven is 

under development in Metro Boston. 

Services in Support of Stable Housing 

DMH has devoted substantial resources to sustaining people with serious mental illness in 

community-based living. These resources may offer primary or secondary homelessness 

prevention as part of treating people’s serious mental illness and helping to avert housing crises. 

These include PACT teams, a contract with MBHP that provides behavioral health services to 

MassHealth clients through a behavioral health carveout arrangement, and other specialized 

services. 

Programs of Assertive Community Treatment 

A collaboration between DMH and MBHP has been developing PACT teams across the state. 

Currently, 13 PACT teams serve approximately 750 people each year. These teams are funded 

with approximately $10.4 million in state resources each year. PACT teams proactively offer 

outreach and highly individualized, flexible, community supports to meet each client’s needs. 

PACT does not focus exclusively on homelessness and homelessness prevention, but it addresses 

and prevents first-time or extended homelessness through supporting people to stay housed. Each 

PACT team sponsored by DMH and MBHP has a significant number of homeless or at-risk 

people in its caseload. PACT teams also work to prevent people with no homeless history from 

becoming homeless or at risk through their comprehensive services approach. Staffing standards 

for PACT teams require that the teams include employment and housing specialists. 

MBHP’s Behavioral Health Care Services 

MBHP manages mental health and addiction services for all people with MassHealth coverage 

who choose to participate in the Primary Care Clinician Plan for their medical care. Members go 

to their own doctor for physical health care, and to services paid for through MBHP for their 

behavioral health care. MassHealth covers approximately 320,000 people, of whom 

approximately 120,000, mostly adults, receive behavioral health services through MBHP. These 

people have the most complex needs, including homeless individuals and those with both mental 

illness and addictions problems. 

MBHP pays for services but does not deliver them. Service delivery occurs through a network of 

more than 1,200 credentialed inpatient, outpatient, and single-practice behavioral health 

providers, and is coordinated with more than 1,200 primary care clinicians. Services covered 

include inpatient and outpatient treatment, detoxification, medication management, and 

community support services. 
Appendix D Massachusetts Department of Mental Health 

D–10

Employment Services 

As the majority of DMH clients are under-employed or not working, DMH sponsors several 

community-based employment programs to further employment or educational objectives for all 

clients. DMH contracts with private vendors to supply these services, which occur across the 

state but concentrate in Metro Boston, where most of the state’s homeless people live. The main 

types of services are Services for Education and Employment (SEE) and Community Support 

Clubhouses.38 Specialized services for homeless and formerly homeless clients include Metro 

Boston’s Employment Connections and the new Boston project, the HomeWorks Demonstration, 

that DMH and several partners recently won under the 2004 HUD-Department of Labor (DOL)-

U.S. Department of Veterans Affairs (VA) competition to supply housing and employment 

services. 

SEE consists of 25 projects across the state with an annual budget of more than $6 million. This 

program served 2,423 clients in SFY 2003 and found 2,334 jobs for 1,064 clients. SEE helps 

participants secure employment in competitive settings, provides training, and addresses 

remedial, basic, or post-secondary education needs through flexible, individualized supports. 

Clubhouses offer similar types of employment-related services, as well as a “work-ordered day” 

in settings that include services and supports that extend well beyond employment-related 

activities. DMH allocates approximately $15.6 million each year to Clubhouses, which found 

2,201 job placements for 1,780 members among 880 employers. DMH clients may also receive 

employment supports through PACT with other types of community support. 

Among DMH’s homeless-specific employment initiatives, Employment Connections (EC) 

operates through JOB-NET, a DOL-funded one-stop Career Center. This program provides 

DMH clients employment-related assistance integrated with other people seeking employment 

help. EC is a collaboration between DMH Metro-Boston and the state Department of 

Employment and Training; in SFY 2003 it served 73 DMH clients and helped secure 67 jobs. 

DMH partnered with JOB-NET, the Boston Private Industry Council, the Boston Office of 

Neighborhood Development, the Metro Boston Housing Partnership, and the Boston Emergency 

Shelter Commission to win support for HomeWorks in the 2004 HUD-VA-DOL national 

competition. The project houses chronically homeless individuals and uses the EC model to help 

them find and keep employment; 20 of the participants are DMH clients. 

Specialized Services 

DMH supports other specialized services through contracts, including education services and an 

Aggressive Treatment and Relapse Prevention (ATARP) program to keep homeless clients with 

co-occurring mental illness and substance abuse disorders in housing. Most of these programs 

are small, each serving fewer than 100 people each year, and most would not be considered 

either primary or secondary prevention. 

 

38 Clubhouses are nonresidential community programs for people with serious mental illness. They offer a major 

emphasis on work both in and for the clubhouse and through transitional and supported employment in regular jobs. 
Appendix D Massachusetts Department of Mental Health 

D–11

Outreach and Referral 

DMH sponsors outreach programs to streets, shelters, and other places where homeless persons 

may be found. These programs identify and engage individuals with mental illness and connect 

them to services and, ultimately, to residential programs and housing. 

DMH uses Federal Projects for Assistance in Transition from Homelessness (PATH) funding 

(approximately $1.3 million each year from the U.S. Department of Health and Human Services, 

Center for Mental Health Services, matched by $600,000 in state funds) for its statewide 

outreach, engagement, and referral activities, which mostly involve visiting adult homeless 

shelters across the state. Clinical social workers offer eligible people on-site direct care, housing 

search and advocacy, and referrals to services such as housing, job training, literacy education, 

mental health and substance abuse services, and benefits and entitlements. Anyone with serious 

mental illness and a need for ongoing mental health services is referred to DMH to determine if 

they are eligible to enroll as a DMH client for continuing care services. During Federal fiscal 

year 2003, PATH clinicians screened 5,259 individuals and enrolled 3,701 as PATH clients. 

DMH has also funded a Homeless Outreach Team (HOT), partially supported by PATH funding, 

in the Boston Area for more than 15 years. Clinicians and homeless specialists search out 

homeless people with mental illness who are or could become eligible for DMH services, and 

encourage them to accept assistance from DMH or other sources. Team members visit each 

shelter and known street homeless populations in Metro Boston at least once a week. They 

connect eligible homeless people to DMH housing and residential services opportunities, as well 

as medical, psychiatric, and substance abuse treatment. HOT moves appropriate people from the 

generic shelter environment to DMH transitional shelters, where they have more privacy and can 

receive more intensive services to access permanent housing and address their behavioral health 

needs. One HOT member is also assigned to work with MBHP to assist discharge planners to 

high-volume acute care facilities. 

The department’s Aggressive Street Outreach program supplements PATH and HOT by 

proactively focusing on streets, parks, and similar places. It is funded by HUD McKinney funds 

through the Statewide Continuum of Care, in which DMH is an active participant. 

Department-Wide Emphasis on the Importance of Housing 

Each year, DMH serves 20,290 adult men and women over age 18 years with serious mental 

illness. Of this number, 2,552 are served in DMH continuing care inpatient facilities, which have 

a capacity of approximately 930 clients. Criteria for acceptance as a DMH continuing care client 

were described earlier. To be accepted for continued DMH inpatient care, clients must meet 

those and certain additional criteria. 

DMH maintains a housing staff of three at its central office and one in each of the state’s six 

regions, with Metro Boston being the most creative, proactive, and productive. These staff 

members work with DMH providers and state and local housing agencies to promote housing 

supply efforts; increase housing subsidies to DMH clients; and assist case managers, discharge 
Appendix D Massachusetts Department of Mental Health 

D–12

planners, and other DMH and provider staff to help DMH clients obtain housing or housing 

subsidies. The department identifies available housing resources and assists relevant agencies 

and providers to apply for all Federal and state homeless and non-homeless housing 

opportunities. 

Policies and protocols emphasize the importance of housing for people with serious mental 

illness, adding assistance to find and keep housing as part of the services considered essential. 

Training for department and contract staff stresses the importance of housing, and that treatment 

cannot work if people do not have stable housing. The HI has been focused on establishing a 

comprehensive DMH service capacity dedicated to this population, and using the service funds 

to leverage and access transitional and affordable, permanent housing with services. DMH’s 

$22.2 million of HI funds are used to leverage more than $85 million in Federal and other 

housing resources to develop and provide client access to housing units, mostly through HUD’s 

McKinney Homeless Programs. 

Linkages and alliances with other departments and providers, statewide and regionally, have 

been important to develop the current level of housing. Statewide examples include the 

following. 

• An agreement with MassHousing ensures that 3 percent of all units developed with 

MassHousing financing are directed to DMH and the Department of Mental Retardation 

(DMR) to house people with serious mental illness or mental retardation. DMH clients 

now lease more than 400 such self-contained, scattered-site units. MassHousing and 

some local housing authorities contribute to TPP to keep their tenants stabilized and 

housed. 

• An agreement with Massachusetts Department of Housing and Community Development 

(DHCD) to operate several state-funded programs includes a rental assistance program 

exclusively serving more than 600 DMH clients, a bricks and mortar housing 

development program through statewide DHCD grants to local housing authorities for 

DMH and Massachusetts’ DMR clients (with a DMH capacity of more than 600 clients), 

and special project-based voucher allocations to DMH housing development projects. 

• DHCD operates the Facilities Consolidation Fund (FCF) bond program, providing grants 

and loans to nonprofit developers for DMH and DMR housing development and housing 

homeless persons with serious mental illness. The FCF is an important source of capital 

resources for community-based housing. It originated in 1992 with bonding authority to 

invest capital into community-based housing instead of state hospital campuses. DMH 

has used it to help develop 83 housing projects for 658 of its clients. FCF was recently 

renewed for $101 million over the next 10 years, with $50 million earmarked for DMH. 

• Agreements with the state’s Department of Capital Asset Management ensure housing for 

DMH clients as a part of rental housing projects being developed on five former DMH 

state hospital campuses. 
Appendix D Massachusetts Department of Mental Health 

D–13

• Linkages with the Department of Public Health (DPH) in the ATARP efforts include a 

housing component. 

• Area Housing Coordinators for local Continuums and DMH central office staff 

participate in the Continuum of Care application process through DMH. 

Outreach to Inpatient Psychiatric Units 

The study team learned about two different activities in three sites related to identifying people 

just after entry into inpatient psychiatric units and subsequent interventions to prevent 

homelessness. One is in Metro Boston, one in Western Massachusetts, and one in Central 

Massachusetts. 

Metro Boston 

Each private inpatient unit screens incoming patients and, for everyone identified as homeless at 

intake, contacts DMH’s HOT to work with the unit’s discharge planners to make a discharge 

arrangement other than homelessness. HOT members are DMH staff with extensive training and 

experience working with homeless people with serious mental illness. Connections made either 

by HOT, the unit’s discharge planner, or other DMH staff usually succeed in linking the patient 

to housing options in the community. Occasionally, a patient in Metro Boston will have to be 

released to DMH/TS until more permanent housing can be arranged. People served are those 

with serious mental illness who experience an acute episode requiring emergency hospitalization 

who present at any of Metro Boston’s private psychiatric facilities or private facilities elsewhere 

in the state that refer to DMH in Boston.39

Although most DMH and private inpatient units refer relevant patients to HOT, length of stay in 

these units is often short (averaging seven days) and HOT often does not get the referral until a 

day or two before expected discharge. The short notice makes it difficult to arrange housing by 

the time of discharge. To increase the speed with which referrals are made to HOT, one HOT 

member has been assigned to work closely with one of the major private psychiatric inpatient 

hospitals in greater Boston. Preliminary impressions are that this alliance has significantly 

improved the speed with which HOT receives referrals, and thus increased the time that the team 

has to make appropriate discharge arrangements for that hospital. 

Western and Central Massachusetts 

A special activity of MBHP in Western and Central Massachusetts is Peer Support in Aftercare 

(PSIC). This project has trained consumers (individuals with mental health or substance abuse 

disorders) to offer support to individuals who have been hospitalized. After being notified that a 

patient at one of the two regional acute inpatient psychiatric units is a member of MBHP, PSIC 

 

39 DMH contracts for acute emergency psychiatric inpatient units throughout Massachusetts. 
Appendix D Massachusetts Department of Mental Health 

D–14

staff interview people about discharge, offering them aftercare for 90 days to help them stabilize 

in housing and remain stable. Thirty to 40 percent of these patients enter the hospital homeless, 

and many of the remainder are at risk of homelessness upon discharge because they do not have 

a home to return to. Between 60 and 70 percent of those approached agree to participate. PSIC 

staff meet discharged patients twice a week while they stabilize, and do whatever is necessary to 

connect them to additional services and benefits. Data collected and analyzed by MBHP indicate 

that PSIC increases the number of days that DMH clients are able to remain in the community 

without becoming hospitalized. 

Springfield/Hamden County Tenancy Preservation Project 

The Springfield TPP was established to help tenants threatened with eviction because their 

mental illness, substance abuse, or cognitive disability led to lease violations and the exhaustion 

of landlord ability to handle the situation. Its goals are to preserve existing tenancies or to 

connect households to alternate and possibly more appropriate housing. If eviction or relocation 

cannot be achieved, TPP refers to the local homeless outreach team for further work with the 

household. 

TPP is an alliance among local Housing Courts, MassHousing, DMH, DMR, DPH, several local 

housing authorities, and the Mental Health Association, Inc. (MHA), of Springfield, 

Massachusetts. MHA is a major DMH provider in Western Massachusetts, offering residential, 

housing, and homeless services among other things. 

Cases likely to be referred to TPP come into Housing Court when a landlord (either private or a 

housing authority) is planning to file eviction papers on a tenant after other efforts to resolve the 

issues have failed. The Housing Court judge, landlord, legal services staff, or other referring 

agency usually know or suspect that the tenant has a mental disability or other problems. They 

refer the person to TPP, where workers assess the situation, screen for eligibility, make referrals 

and establish linkages, and strive to stabilize the household through discussions and negotiations 

with housing managers, Housing Court mediators, relevant agencies, and the threatened tenants. 

The goal is to overcome problems that might otherwise result in loss of housing and potential 

homelessness through eviction or hospitalization. 

The Springfield TPP is a pilot project of MassHousing, DMH, and their partner agencies. Similar 

projects now operate in three other Massachusetts communities—Northampton, Brockton, and 

Boston. Projects are also in various stages of development in Worcester, New Bedford/Plymouth 

County, Essex County, and Franklin County. 

DATA COLLECTION AND USE 

The Massachusetts DMH prevention strategy is not as simple to describe as this study’s other 

sites because it is an entire state rather than a city, county, or small group of counties. Its strategy 

has many components, and the picture is further complicated by the fact that different regions of 

the state customize the operation of many components to fit their own circumstances. Further, 
Appendix D Massachusetts Department of Mental Health 

D–15

the state has been evolving its approach for more than a decade, so some components are well 

established statewide, others are emerging from “pilot” or “demonstration” status to broader 

application, and some are just beginning the pilot stage in a few communities. The consequence 

of this complexity is that data on the success of homelessness prevention efforts are componentspecific, and sometimes also location-specific. 

Statewide Changes, 1992–2003, Excluding Metro Boston 

Many things happened between 1992 and 2003 that might have affected the likelihood that 

people with serious mental illness would become homeless in the state. Factors likely to reduce 

the odds of becoming homeless were significant investments in housing, supportive services, and 

planning to prevent homelessness by DMH and others, as well as DMH policies designed to 

house its clients and keep them housed. Factors likely to increase the odds included the closure 

of several state mental hospitals, shifts in inpatient services for others, and drastic reductions in 

affordable housing, especially in the Metro Boston Area. 

DMH has data on admissions and discharges to its own continuing care facilities throughout the 

state, excluding Metro Boston, that provide a broad look at how its policies and practices might 

have served as primary or secondary prevention strategies. Since 1993, hospitals have recorded if 

someone is homeless at admission, and if people are homeless at discharge. Some people also 

lose their housing during a hospital stay, especially if it lasts a long time, and join the numbers 

who entered homeless in being at risk of homelessness at exit. Data are available for 13–15 

facilities for the earlier years and six to seven facilities for the later years of the period (the 

difference stems from hospital closures, not from failure to report in later years). 

Exhibit D.3 shows the pattern of all hospital admissions and admissions as homeless between 

1993 and 2003. All admissions fell substantially during this period—later years have seen only 

approximately 35 percent of the admissions recorded during the early years. One would expect, 

therefore, that homeless admissions would have decreased proportionally. In fact, however, 

admissions as homeless have decreased to only 15 percent during 2002–2004 of what they were 

during 1993–1995 (averaging over the first and last three years). There is some question about 

how “homeless at admission” has been recorded in recent years; however, the data indicate that 

through its many activities in support of people with serious mental illness, a substantial 

reduction in homelessness at admission has been achieved. 
Appendix D Massachusetts Department of Mental Health 

D–16

Exhibit D.3. Changes in Homeless and Total Admissions to DMH Continuing Care Units, 

Excluding Metro Boston, 1993–2003 

0

1000

2000

3000

4000

5000

Admissions

All admissions 3980 4204 4274 3116 1891 1720 1607 1563 1576 1397 1415

Homeless admissions 356 418 418 247 142 132 114 133 95 52 27

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

 

Exhibit D.4, compares admissions as homeless to discharges as homeless and illustrates that far 

fewer people are homeless when they exit DMH continuing care facilities than those who entered 

homeless. This indicates an accomplishment of secondary prevention. This figure also shows that 

discharges as homeless have followed the same pattern as admissions as homeless; they dropped 

to a level during 2002–2004 of approximately 15 percent of their level during 1993–1995. A 

combination of housing and community services to stabilize persons with serious mental illness 

at risk of homelessness may account for much of this impact, as well as an increased amount of 

DMH-affiliated housing to accommodate those who became homeless while hospitalized. 

Exhibit D.4. Changes in Homeless Admissions and Discharges in DMH Continuing Care 

Units, Excluding Metro Boston, 1993–2003 

0

100

200

300

400

500

Discharges/Admissions

Homeless discharges 69 103 56 67 8 11 5 22 15 9 10

Homeless admissions 356 418 418 247 142 132 114 133 95 52 27

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Appendix D Massachusetts Department of Mental Health 

D–17

Exhibit D.5. Changes in Proportions of Homeless Admissions and Discharges to All 

Admissions in DMH Continuing Care Units, Excluding Metro Boston, 1993–2003 

0

2

4

6

8

10

12

Proportion

Proportion of homeless admissions 8.9 9.9 9.8 7.9 7.5 7.7 7.1 8.5 6.0 3.7 1.9

Proportion of homeless discharges 1.7 2.5 1.3 2.2 0.4 0.6 0.3 1.4 1.0 0.6 0.7

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

 

Exhibit D.5 shows ratios of homeless admissions and discharges to all admissions. The line 

showing the ratio of homeless admissions to all admissions indicates the same relationship as in 

Exhibit D.3, but presented as a proportion—homeless admissions declined over the years as a 

proportion of all admissions. The ratio of homeless discharges to all admissions follows the same 

pattern. 

Metro Boston 

The study team received data from three types of facilities—DMH transitional shelters, one 

DMH extended care inpatient unit, and almost all major private hospitals with acute psychiatric 

inpatient units. The timeframes covered for each type of facility differ, but the data show patterns 

of entering homeless but exiting housed, as well as how DMH-eligible clients fare compared to 

those who are not DMH-eligible. 

DMH Transitional Shelters 

SFY 2004 data for the 165 DMH/TS beds (in six facilities) show that of 225 admissions during 

the year, the average length of stay was 150 days. At entry, all were homeless—45 percent were 

from the streets and shelters and 47 percent were from either DMH or private hospitals and had 

nowhere to go at discharge. At discharge, 73 percent were not homeless (58 percent moved to 

DMH housing or their own housing, 15 percent moved in with family or friends, 12 percent 

entered other institutions, and 15 percent exited to the streets or shelters, after being offered 

housing alternatives). 

DMH Extended Care Hospitalization 

One DMH extended care facility in Metro Boston provided reliable data on annual admissions 

and discharges as homeless from 1992 through 2001. 
Appendix D Massachusetts Department of Mental Health 

D–18

• Approximately 30–32 percent of all admissions from 1992 through 1996 were homeless. 

• Homeless admissions increased to 35–37 percent of all admissions from 1997 through 

2001, with a peak of 42.5 percent during 1998. 

• In the balance of the state, the proportion of homeless to all admissions stayed between 

7 percent and 10 percent for the same period. 

• Homeless discharges during the same period were less than 10 percent of admissions, 

with two years (1993 and 1999) dipping to 1.7–2.0 percent. 

• Outside Metro Boston, discharges to homelessness from DMH extended care facilities 

were 0.3–2.2 percent of admissions. 

The data for Metro Boston present a more challenging picture of a patient moving from 

homelessness to DMH extended care inpatient facilities. However, regardless of location, these 

facilities succeed in reducing homelessness at discharge to 20–30 percent of the number who 

came in homeless, acknowledging that some who entered from housing may have lost it while 

hospitalized. During years when much new housing was coming on line throughout the state, the 

ratio of homeless at discharge to homeless at admission fell below 10 percent. Beginning in 

2000, it began to climb again, testifying to the need for continued system development and the 

inability of any state agency and its partners to overcome the housing cost and unemployment 

increases of the early 2000s. 

Discharges from Private Acute Psychiatric Units 

The Metro Boston Area supplied three years of data on the housing status of people discharged 

from acute psychiatric units in private hospitals, where the average length of stay is seven days. 

As described earlier, these hospitals are all supposed to notify the HOT of people who are 

homeless at admission. HOT members, together with hospital social workers, then determine 

DMH eligibility and a collaborative effort results in comprehensive treatment planning to 

address the continuum of treatments and housing needs. Exhibit D.6 shows the discharge 

dispositions for DMH-eligible and non-DMH-eligible patients in acute psychiatric care facilities 

for SFY 2002–2004. 
Appendix D Massachusetts Department of Mental Health 

D–19

Exhibit D.6. Discharge Destinations of People Leaving Private Acute Psychiatric Care, 

Metro Boston, SFY 2002–2004

 DMH-Eligible Not DMH-Eligible 

State Fiscal Year 2001–2002 2002–2003 2003–2004 2001–2002 2002–2003 2003–2004 

All admissions for which 

HOT notified 820 813 513 476 276 251 

Discharge Destination 

 Streets or generic shelter 

 DMH transitional shelter 

 DMH community housing 

 Family or friends 

 Treatment/institution 

 Non-Metro Boston clients 

 0% 

27% 

43% 

 0% 

30% 

 0% 

13% 

36% 

 7% 

 0% 

28% 

12% 

34% 

20% 

14% 

12% 

21% 

 0% 

23% 

 0% 

 0% 

53% 

23% 

 0% 

 6% 

 0% 

 0% 

55% 

39% 

 0% 

80% 

 0% 

 0% 

10% 

10% 

 0% 

As Exhibit D.6 shows, DMH eligibility makes a substantial difference in the discharge 

destination of people who are homeless and who enter private acute care psychiatric facilities. In 

three of the three years, the proportion released to the streets or to generic shelters is 

substantially lower for DMH-eligible patients. Many DMH-eligible people go to DMH/TS, so 

they would still be counted as literally homeless but very few leave DMH/TS and return to 

streets and shelters. DMH-eligible people are also moving into DMH community housing, 

whereas the most common destination at discharge for non-eligible people is family and friends. 

People not eligible for DMH continuing care tend not to be as sick as those determined to be 

eligible, and family and friends may be more able and willing to give them a home. 

It is also clear from Exhibit D.6 that many people leaving acute psychiatric facilities need 

additional care, as movement to treatment or institutional settings (including DMH or other 

extended inpatient care, substance abuse treatment, or correctional settings) suggests. 

Effectiveness of Western Massachusetts’ TPP 

As noted above, TPP began in 1998, and since that time has opened 441 cases and closed 366 of 

them, with 23 households refusing TPP services. Of these cases, only 19 percent had ever been 

homeless, while 81 percent were potentially facing homelessness for the first time. Outcome data 

are from TPP case records for cases accepted and closed, and from Housing Court records for 

cases waitlisted but never served (our comparison group). Outcomes of cases closed between 

July 1, 1998 and June 30, 2004 (six years of operations) are displayed in Exhibit D.7. 

Three-quarters of the people served by TPP had a non-age-related mental illness, either by itself 

(55 percent) or together with substance abuse (23 percent). Most of the households served by 

TPP did not become homeless, with approximately one-half staying in their original housing and 

approximately one-third moving to alternative housing. The biggest problems for homelessness 

prevention are with people who have both mental illness and a complicating addictions problem. 

More than twice as many of this group became homeless than those with only one of these 

problems. 
Appendix D Massachusetts Department of Mental Health 

D–20

Exhibit D.7. TPP Case Status, Total Closed, by Diagnosis, and Comparison Cases 

Tenancy 

Preserved 

Moved to Alternative 

Housing 

Became 

Homeless 

All cases served and closed by TPP 

(n=366) 

51% 34% 15% 

By Diagnosis 

 Mental health (n=202) 

 Substance abuse (n=43) 

 Dual Diagnosis (n=83) 

 Elder or Cognitive (n=24) 

 Other (n=13) 

55% 

51% 

37% 

71% 

38% 

32% 

37% 

35% 

21% 

62% 

13% 

12% 

28% 

8% 

0% 

Note: Percentages run across each row; each row totals 100%. 

These outcomes can be compared to cases that the Housing Court sent to TPP, but because of 

TPP workload the cases were waitlisted and never served. These cases had similar issues and 

difficulties, at the same level of seriousness or threat of eviction, and thus make a reasonable 

comparison group to determine what would have happened without TPP. There are 21 such cases 

for which outcomes were retrieved from court records. They are as follows: 

• 24 percent were resolved favorably for the tenant, who retained tenancy in the 

original unit; 

• 48 percent resulted in eviction; 

• 29 percent left their original residence and subsequent location is unknown; and 

• For the 76 percent that did not stay in their original housing, subsequent location is 

not known. 

Ideally, the study team would like to assess two outcomes by comparing TPP clients served to 

people referred but waitlisted—retention of original housing and becoming homeless. The study 

team can certainly assess TPP’s effect on the first of these—TPP appears to have preserved 

original housing for twice as many people as would have retained it without TPP services. 

Determining the proportion of people referred to TPP from Housing Court who would have 

become literally homeless without TPP is not as easy, however, because the court records do not 

contain information about ultimate homeless status. Making the most conservative assumption—

of those who left their original housing, the same proportion of TPP clients and waitlist people 

became homeless—the study team can calculate that 23 percent of all waitlist people became 

homeless, compared to 15 percent of those who received TPP services. By this calculation, TPP 

reduced homelessness by 35 percent—at least one out of three people who would have become 

homeless without the assistance of TPP. TPP effects are probably even stronger than those just 

calculated, since the odds of becoming homeless for the waitlist people who left their original 

housing is higher than for TPP clients in the same situation. 

MASSACHUSETTS SITE VISIT PARTICIPANTS

Susan Abbott, Vinfen-Supported Housing, Behavioral Health Rehabilitation Services, Senior 

Vice President 

Eric Adelman, MBHP, Medical Care Management, Essential Care, Clinical Director 
Appendix D Massachusetts Department of Mental Health 

D–21

Michele Anzaldi, DMH/Solomon Carter Fuller MHC, Director of Community Programs 

Beth Avery, YWCA, Berkeley Residence, Manager 

Elizabeth Babcock, CEEH, President and CEO 

Rand Bailey, Pine Street Inn, Psychiatric Nurse 

Kathleen Beretto, Pine Street Inn/Anchor Inn, Psychiatric Clinician 

Lori Button-Szczygiel, MBHP, AVP, Regional Operations 

Chuck Carter, MBHP, Metro Boston Region, Director 

Lynne Chapman, Pine Street Inn, Vice President for Programs 

Ed Chase, MassHousing, Community Services Officer 

Elizabeth Childs, DMH, Commissioner 

Daniel Clague, Pine Street Inn, Psychiatric Division 

Anne Clement, Providence Behavioral Health Hospital, Adult Psychiatric Inpatient Services, 

Senior Clinician 

Linda Contorelli, Pine Street Inn, Men's Transitional Housing Program, Clinical Case Manager 

Jim Cooney, Solomon Carter Fuller MHC, DMH, Director of Social Work 

Ann Detricks, DMH, Assistant Commissioner 

Susan Douglass, Vinfen-Supported Housing, Program Director 

Lyndia Downie, Pine Street Inn, Executive Director 

Brooke Doyle, DMH, Massachusetts MHC 

Janet Erickson, Committee to End Elder Homelessness, Assistant Director of Outreach 

Suzanne Estes-Shaw, DMH-HOT, Director 

Peter Evers, B.E.S.T./BMC, Division of Psychiatry, Clinical Director 

Doreen Fadus, Mercy Medical Center, Community Health, Executive Director 

MaryAnn Ferguson, Pine Street Inn, Psychiatric Services, Director 

Joe Finn, MHSA, Executive Director 

Donna Haig, Friedman, Center for Social Policy, University of Massachusetts, Boston, Director 

Kjim Greene, Emergency Shelter Commission, Acting Director 

Barbara Hand, Women's Inn, Psychiatric Clinician 

Ruth Harel, BayCove/TPP, Residential Services, Senior Program Director 

David Hoffman, DMH, Medical Director 

Peggy Ireland, Paul Sullivan, Housing Administrator 

Walter Jabzanka, DMH 

Bonnie Johnson, MBHP, Emergency Services Program, Statewide Director 

Peggy Johnson, Boston Medical Center, Clinical Psychiatry, Vice Chair 

Margaret Jordan, Human Resources Unlimited, Mental Health Services, Director 

Patricia Kenny, DMH, Director of Community Services 

Carol Kress, MBHP, Clinical Affairs, Vice President 

Heidi Krueger, Lemuel Shattuck Hospital, Admissions and Discharge Coordinator 

Nancy Lane, MBHP, CEO 

Jim Laprade, MBHP, Substance Abuse Services, Director 

Peggy Lester, DMH, Director of Program Management 

Jay Levy, Transitional Living Program at Stony Hill, Assistant Program Director 

Alisa Lincoln, Boston University, School of Public Health, Substance Abuse and Mental Health 

Services Administration Safe Haven Project, Evaluator 

Judy Lipton, Pine Street Inn, Engage Program, Clinical Administrator 

Monique Loizzo, DMH, Eligibility Coordinator 
Appendix D Massachusetts Department of Mental Health 

D–22

Janet MacDonald, DMH, Metro Region HOT, Assistant Director 

Nancy Mahan, BayCove, Director of Residential Services 

Meg Mastriana, Psychiatric Crisis Services/Behavioral Health Network, Inc., Crisis Program 

Director 

Roseanna Means, MBHP, Primary Care Clinician Plan, Associate Medical Director 

Ronnie Michaels, DMH, Metro Boston, Acting Area Forensic Director 

David Modzelewski, DMH Western Massachusetts, Housing Coordinator 

Jon Murphy, Vinfen-Supported Housing, Director of Services 

Sandy Nowoslawski, DMH, Central Office, Program Operations 

John O'Brien, Interagency Council on Homelessness, National Coordinator 

Jerry Ray, MHA, Director of Homeless Services 

Anthony Raynes, Arbour Health System, Psychiatrist-in-Chief 

Eileen Reilly, Boston HCH Program, Street Team 

Clifford Robinson, DMH, Metro Boston Area Director 

Jessica Ruchbruck, DMH/Metro Boston, Subsidy Coordinator 

Richard Sheola, MBHP, Value Options, President 

Brian Simpson, DMH, Metro Area HOT and MBHP liaison to Arbour 

Elizabeth Sullivan, DMH Western Massachusetts, Area Director 

Bobbie Smith, DMH/TS at Lindemann, Manager 

Elizabeth Souffront, St. Francis House, Counseling and Clinical Services, Day Shelter and Rehab 

Programs, Director 

Susan Sprung, DMH Western Massachusetts, Director of Community Services 

Michael Stepansky, Tri-City MH/R Center, Housing Advocate 

Peggy Stevens, MBHP, VP, Administrative Ops 

Steven Switzer, North Suffolk MHA 

Jennifer Tripp, MBHP, Senior Research Associate 

Wendy Webber, BayCove PACT Team, Team Leader 

Kevin Weir, MBHP, Regional Network Manager 

Linda Williams, MHA, Executive Director 

MASSACHUSETTS ACRONYMS 

ATARP Aggressive Treatment and Relapse Prevention Programs 

DHCD Massachusetts Department of Housing and Community Development 

DOL U.S. Department of Labor 

DMH Massachusetts Department of Mental Health 

DMH/TS Department of Mental Health Transitional Shelter 

DMR Massachusetts Department of Mental Retardation 

DPH Massachusetts Department of Public Health 

EC Employment Connections 

FCF Facilities Consolidation Fund 

HI Homeless Initiative 

HOT Homeless Outreach Team 

HUD U.S. Department of Housing and Urban Development 

MBHP Massachusetts Behavioral Health Partnership 
Appendix D Massachusetts Department of Mental Health 

D–23

MHA Mental Health Association, Inc. 

MHSA Massachusetts Housing and Shelter Alliance 

PACT Programs for Assertive Community Treatment 

PATH Projects for Assistance in Transition from Homelessness 

PSIC Peer Support in Aftercare 

SEE Services for Education and Employment 

SFY State Fiscal Year 

TPP Tenancy Preservation Project 

VA U.S. Department of Veterans Affairs 
D–24
E–1

APPENDIX E 

PHILADELPHIA, PENNSYLVANIA 

With population of 1.5 million (in 2000), Philadelphia is the nation’s fifth largest city. The city 

has been losing population and experiencing economic disinvestment for several decades.40

Between 1973 and 1993, the city lost 200,000 jobs and housing vacancies soared. Although a 

major reinvestment effort during the 1990s slowed that decline and revitalized the downtown and 

many residential neighborhoods, the city still faces circumstances that generate homelessness 

(Kromer, 2001). Its 1999 poverty rate was twice that of the nation as a whole (22.9 percent 

versus 11.3 percent) and its average 2003 unemployment rate was also higher (7.6 percent versus 

6.0 percent).41

Similar to four other large cities (e.g., Baltimore, New York City, St. Louis, and San Francisco), 

Philadelphia is its own county, with city agencies serving both city and county functions. 

Preventing homelessness among people with serious mental illness has been on the agenda in 

Philadelphia for many decades. Outreach efforts began during the early 1980s and expanded 

significantly during the late 1990s. These efforts have been combined with Safe Havens, 

permanent supportive housing, and other supports. Recent efforts have focused on preparing for 

an individual’s release from an institution, such as jail or psychiatric inpatient setting. Such 

efforts build supports that will prevent homelessness, including housing. The study team’s site 

visit concentrated on learning about these efforts as primary and secondary prevention. (An 

earlier study focused on the work in Philadelphia to reduce chronic street homelessness among 

people with serious mental illness and others, Burt et al., 2004.)

 

40 1970–2000, -22.2 percent; 1990–2000, -4.3 percent; 1980–1990, -6.0 percent; 1970–1980, -13.4 percent. 

Calculated from data that were obtained from the U.S. Census Bureau at: 

www.census.gov/population/cencounts/pa190090.txt (accessed 3/23/03). 41 1999 poverty statistics for Philadelphia obtained from the U.S. Census Bureau at: 

quickfacts.census.gov/qfd/states/42/42101/html; 1999 poverty statistics for the U.S. obtained from the U.S. Census 

Bureau at: quickfacts.census.gov/states/00000.html; 2003 unemployment statistics for Philadelphia obtained from 

the Bureau of Labor Statistics at: ftp://ftp.bls.gov/pub/special.requests/philadelphia/fax_9527.txt; and 2003 

unemployment statistics obtained for the U.S. obtained from the Bureau of Labor Statistics at: 

http://www.bls.gov/cps/overview (accessed 6/25/04). 
Appendix E Philadelphia, Pennsylvania 

E–2

During the study team’s visit to Philadelphia on June 9–11, 2004, the team interviewed more 

than 30 people who represented city agencies providing behavioral health care and homeless 

services; psychiatric hospitals and inpatient units; nonprofit behavioral health and case 

management agencies; jails and prisons; and data managers and analysts. A full listing of persons 

interviewed is located at the end of this appendix. 

Several meetings provided information about the system and how it works; other meetings 

focused on understanding the data available to assess prevention and develop strategies to 

document effectiveness. The service structure for behavioral health in Philadelphia (mental 

illness, substance abuse care, and case management); housing options for people with serious 

mental illness who are at high risk for homelessness upon release from inpatient care; and the 

structures in place or in development for assuring that institutional release does not leave a 

person homeless are described below. Also described are the databases available for assessing 

the impact of efforts to prevent homelessness. 

PRACTICES OF POTENTIAL INTEREST TO OTHER JURISDICTIONS 

The contacts for discharge planning practices in Philadelphia are Marcella Maguire 

(Marcella.Maguire@phila.gov) and Rob Hess (Robert.Hess@phila.gov). Practices that are of 

potential interest to other jurisdictions are presented below. 

1. Collaboration between the behavioral health and corrections systems. The Office of 

Behavioral Health (OBH) has developed arrangements with both the state prison system 

and the Philadelphia jail system to receive notification of people leaving these corrections 

systems. Checks to identify OBH clients who will be released allow interventions to try 

to prevent homelessness. 

2. Supplying case managers to OBH clients when they enter jail. Data sharing also occurs at 

intake in jail, allowing OBH to re-link inmates who have been clients to their case 

managers, who may have lost contact with them. Mental health case managers and jail 

social workers try to develop an appropriate discharge plan together. 

3. Access to data across systems. Authorized people at OBH can check child welfare and 

public assistance case records, as well as case records under its own aegis for mental 

health and substance abuse treatment and services. The access is reciprocal, so child 

welfare and Temporary Assistance for Needy Families (TANF) workers can check if a 

client is also an OBH client. Case plans can be designed with an eye to avoiding 

conflicting demands on clients and providers and maximizing use of appropriate 

resources. OBH is also able to check the management information system maintained for 

homeless services, and thus can determine if a client is or has been homeless. 
Appendix E Philadelphia, Pennsylvania 

E–3

DEVELOPING THE COMMITMENT TO PREVENTION 

Philadelphia has a strong public organizational structure for both behavioral health and homeless 

services. Creative bureaucratic negotiations during the mid-1990s established the city’s 

Behavioral Health System, which is now formalized as OBH. The Behavioral Health System 

integrates agencies that offer prevention, outreach, and services for people with mental illness or 

substance abuse problems, primarily by contracting with nonprofit agencies. 

To serve the homeless, in 1988 Mayor Wilson Goode exercised political will—supported by 

advocacy and coupled with control of city and county public resources—created the Office of 

Services for the Homeless and Adults. The office director became the “homeless czar,” a 

position the next two mayors maintained and expanded, and whose official designation is the 

Deputy Managing Director for Special Needs Housing. Through this office, and in partnership 

with a strong array of providers, advocates, and businesses, the city has planned for and 

subsequently undertaken extensive investment in programs and services to end homelessness. 

At the time of the study team’s visit, Community Behavioral Health (CBH), the city’s Medicaid 

Managed Care agency, was in the final stages of developing discharge planning standards that 

would span several agencies. These included Behavioral Health System agencies, homeless 

services, child welfare, and the county jail. The process began two years ago, following 

recognition that many clients of city agencies have serious mental illnesses in addition to the 

specific problems that brought them to the attention of the various agencies. Originally, the 

process focused on clients involved with the Behavioral Health System, as well as child welfare 

and juvenile justice. Under the guidance of Estelle Richman, who orchestrated the creation of the 

Behavioral Health System, CBH and other city practices designed to improve service delivery, 

representatives of these three agencies became acquainted. 

Approximately 25 people regularly attended the planning and implementation meetings to 

develop an understanding of each other’s systems and the ways in which clients were served. 

Department heads still attend these meetings. It became clear that these systems were not 

communicating well with each other. For instance, it was not uncommon for CBH to have a 

parent and child in its system, in separate cases, and unknown to each person’s care manager, 

and for child welfare and juvenile justice to be unaware that a member of the family was a CBH 

client. 

Most agencies were not doing an adequate job of ensuring that people with serious mental illness 

who were released from their care had a reasonable plan in place to meet their ongoing needs. 

The lack of communication and cooperative working relationships apparent between CBH and 

the child welfare system was also true for CBH clients and others with serious mental illness in 

several other systems—homeless assistance, juvenile justice, and the city and state correctional 

systems. In addition, communication difficulties plagued whole systems and how providers in 

each system dealt with clients. Providers tended to see an episode of care, not a whole client. If a 

provider served a person in an outpatient or emergency room setting, the provider frequently did 

not know or find out that the client had an inpatient history, the services or medications the client 

was using, or the options within the system for dealing with the client. 
Appendix E Philadelphia, Pennsylvania 

E–4

After a considerable amount of work, Philadelphia was poised to assure better communication 

and services to people with serious mental illness who were clients of its various agencies. This 

resulted from changes in the ways that staff worked with each other and in staff access to client 

information across several agencies’ data systems. A discharge planning guide was written to 

prompt information exchange and collaborative case planning. It outlined the information that 

each system could share with each other and with other care providers, and described the 

procedures for getting information from each agency’s data system. 

COMPONENTS AND ORGANIZATION OF THE COMMUNITY STRATEGY 

While in Philadelphia the study team discussed how the system is set up to prevent homelessness 

and provide appropriate mental health care for people with serious mental illness who leave two 

different institutional settings: inpatient psychiatric facilities and adult corrections. 

Philadelphia’s Behavioral Health Care System 

Within OBH, the Office of Mental Health (OMH) and the Coordinating Office of Drug, Alcohol, 

and Addictions Programs (CODAAP) are city offices whose staff monitor and clinically manage 

services, shelter, and housing through contracts. CBH authorizes mental health and substance 

abuse treatment of many varieties for its clients. Independent of the homeless services system, 

OMH and CODAAP maintain an extensive network of residential settings, ranging from highlysupervised units to board and care homes and very low-demand housing that resembles Safe 

Havens. More than 1,900 units in these residential settings are earmarked for people with serious 

mental illness. These two offices also contribute to supportive housing options within the 

homeless continuum of care. OBH contracts with homeless shelter intake and the outreach teams 

under the Outreach Coordination Center run by Project H.O.M.E., as well as supporting outreach 

teams of their own. 

System Components 

CBH is the system’s insurer, and hence the entity that authorizes and pays for the care its clients 

receive. It is funded through a Medicaid behavioral health carveout, as well as city funds for 

clients who are not covered by Medicaid.42 CBH care managers must approve inpatient episodes 

and other types of care if providers are going to get paid when they treat CBH clients. 

 

42 A carveout is one way to compensate for the fact that regular HMOs do not usually provide appropriate care for 

people with chronic mental illnesses and/or addictions. It takes the resources that Medicaid historically spent on a 

fee-for-service basis for mental health and substance abuse services and gives it to a specialized HMO that provides 

Managed Behavioral Health care (MBHOs). Most MBHOs are for-profit entities, unlike CBH, which is city-owned 

and reinvests its “profits” to provide additional services, including those related to homeless and formerly homeless 

people with serious mental illness. 
Appendix E Philadelphia, Pennsylvania 

E–5

Most components of the mental health system in Philadelphia are actually delivered by nonprofit 

and for-profit entities, either under contract to OMH or CODAAP or on a fee-for-service basis 

paid by CBH. These include: 

• Five Crisis Response Centers that are similar to psychiatric emergency rooms, but 

reconfigured eight years ago to handle people with co-occurring disorders and conditions; 

• Approximately 20 inpatient psychiatric units in various hospitals; 

• Two extended acute units with 62 beds for people who may stabilize with 

hospitalizations that are longer than the average length of stay; 

• More than 12 acute partial hospitalization programs; 

• Three crisis residences for people awaiting housing placement; 

• Fourteen agencies of three different types that offer case management for people with 

serious mental illness and co-occurring substance use disorders: coordinated community 

treatment, intensive case management, and resource coordination; 

• At least six detoxification programs; 

• Three hospital-based drug rehabilitation programs for people with co-occurring serious 

mental illness; 

• More than 15 non-hospital residential substance abuse treatment programs that specialize 

in treating pregnant and parenting women; 

• More than 300 progressive demand residence beds, for which an Axis I diagnosis and 

sufficiently high Global Assessment of Functioning (GAF) score are criteria for entry, are 

available under contract from private providers through OMH’s Access to Alternative 

Services (AAS), which is the gatekeeper for residential services in the mental health 

system;43 and 

• 2,600 residential beds in programs ranging from group homes to locked facilities, 

available through AAS contracts. 

Planning and Organizing for Discharges that Prevent Homelessness 

The various agencies and systems that previously were unable to determine if their clients were 

involved in other systems have convened to share information and work together. The first 

 

43 An Axis I diagnosis indicates that a person has a clinical mental disorder including psychotic, mood, anxiety, and 

cognitive disorders. The GAF score measures a person’s psychological, social, and occupational functioning along a 

100-point scale. 
Appendix E Philadelphia, Pennsylvania 

E–6

activities were meetings to get to know each other and identify barriers that made it difficult for 

clients of more than one agency to receive appropriate assistance. Each agency brought its rules, 

regulations, and governing legislation to document the legal framework and obligations under 

which they worked. The group analyzed compatibilities and incompatibilities across systems, 

looked for places where change could happen, and began to develop mechanisms to assure that 

the person or family was the focus of treatment and assistance. Mechanisms include systematic 

CBH assessment of its clients entering an acute care psychiatric unit, shared client lists, shared 

databases, co-located care managers, notification that a person has a CBH multiagency team, and 

regular case conferencing. Other mechanisms include the following. 

• Emergency shelter intake. CBH staff have begun to co-staff shelter intake one day each 

week to screen for mental illness and divert eligible people to more appropriate care. If 

they are not already CBH clients, staff will enroll them and provide AAS shelter or 

housing options with supportive services. 

• Child welfare. CBH staff are now co-located at the Department of Human Services to 

check on the CBH client status of adults and children in families involved with child 

welfare procedures (abuse and neglect investigations, child protective services, and foster 

care). At the Department of Human Services, CBH staff make assessments, conduct 

screenings and intake procedures, and authorize immediate care for those in need, all 

with access to CBH databases. A computer accessing Department of Human Services 

case records is now installed at CBH to cross-reference households being served in both 

systems. 

• Corrections. Behavioral Health System linkages with correctional institutions for the 

appropriate treatment of inmates with serious mental illness are described in more detail 

below. 

The System for Adults in Adult Inpatient Care 

With respect to adults in inpatient psychiatric care, OBH has established the Admissions, 

Discharges, and Planning Team (ADAPT) to assure appropriate care for individuals experiencing 

extended psychiatric hospital stays. ADAPT provides a clinical assessment specialist who 

determines if a client will likely stabilize in one week or two, which is the usual limit of acute 

inpatient care. If ADAPT judges that the client will need longer acute inpatient care, but will 

eventually stabilize, it recommends “extended acute” care, while still retaining the possibility 

that the client will do well enough in acute care not to need the extended service. 

If the client requires extended acute care, the ADAPT specialist monitors progress at least once 

each month in case conferences, during which time treatment and discharge planning are 

discussed with the aim of reducing recidivism into acute care. The goal is to reach agreement on 

the most appropriate place for care, and for that care to be available. ADAPT and others work 

with clients and inpatient providers, using information from the client’s past history to assure 

that unsuccessful past discharge plans are not repeated (i.e., if someone has been discharged four 
Appendix E Philadelphia, Pennsylvania 

E–7

times to the same board and care facility that is not able to keep the person stable, a new plan is 

needed). 

At present, providers are not held accountable for repeating discharge plans that previously have 

failed or for failing to assess important aspects of a discharge situation. New provider contracts 

with CBH will include outcome measures related to discharge planning as part of their 

performance requirements. Coupled with training in discharge planning, expanded knowledge of 

care options, and CBH’s willingness to pay for providers’ additional work to fulfill these 

requirements, CBH expects these contract changes to stimulate improvements in discharge 

planning. 

Relationships Among Crisis Response Centers, Hospital Social Workers, CBH Case 

Managers, and CBH Care Managers 

When a CBH client enters a Crisis Response Center, the center contacts CBH to learn the 

person’s situation, history of care, and support system. This contact allows the Crisis Response 

Centers to know if the client has a crisis plan on file. Targeted case managers develop this crisis 

plan for each client and enter it into the CBH data system. If inpatient care is needed 

(approximately 60 percent of people coming to the Crisis Response Centers are hospitalized), the 

Crisis Response Center can send the person to an inpatient ward that has worked with him or her 

in the past. The Crisis Response Center also contacts the CBH case manager and follows any 

other recommendations for handling the client in a crisis situation, including backup plans if the 

primary plan cannot be followed. 

When a CBH client enters an inpatient psychiatric unit, three people have responsibilities related 

to discharge. The first two are the hospital social worker and the person’s CBH-contracted case 

manager. The third person is the CBH care manager, who, as the insurance representative, must 

approve payment for the inpatient treatment and parts of the aftercare plan. The CBH care 

managers are in the best position to understand the whole picture of a person’s involvement with 

CBH, and to make judgments about what has and has not worked in the past, at least as far back 

as 1997. They can share this information with the hospital social worker and targeted case 

manager and develop a discharge plan (primary and backup) with the greatest chance for 

success. Because there are never enough available placements to take everyone who needs one, 

some people leaving inpatient care may stay in an interim placement, including extended acute 

care, in one of the city’s crisis residences, in an OBH-supported shelter bed, or in a substance 

abuse treatment facility if substance abuse is an issue. 

At a meeting involving social workers from three of the city’s 20 inpatient units, targeted case 

managers from three of its 14 case management agencies, and CBH care managers, discussion 

focused on how placement decisions are made. The answers to a series of questions guide the 

decisions. The primary question is: Where was the person living immediately prior to entering 

inpatient care? If possible, this location is the first choice for post-release placement. The social 

worker and case manager explore barriers to return and offer resources to remove those barriers. 

If the person owes back rent or utility bills, negotiations are undertaken to resolve these bills. If 

personal conflicts and dissatisfactions exist, negotiations will again try to address these barriers. 
Appendix E Philadelphia, Pennsylvania 

E–8

If additional outside supports are needed for a family to be willing to take someone back, 

anything from periodic case manager visits to full-scale Assertive Community Treatment team 

supports may be offered. 

If returning to one’s earlier residence is not an option, other questions explore the range of 

alternatives. These questions include whether the person has income or other outside supports; 

what brought the person into treatment (diagnosis, medications, co-occurring substance abuse or 

other conditions); how often the person has been hospitalized; what the person is willing to do; 

and where the person is willing to go. Because a hospital stay is usually not long enough to 

arrange for the best housing placement (average length of stay on most psychiatric units is five to 

10 days), social workers and case managers try to find appropriate interim placements, from 

which it is more likely that an optimal placement can follow. For instance, the presence of a 

substance abuse aids discharge planning because the person can enter a residential rehabilitation 

program while housing options are being explored. 

Money is always a limiting condition. If the person has no income, every effort is made to help 

the person qualify for Supplemental Security Income or any other cash assistance for which she 

or he might be eligible. Clients do not have to pay for housing managed by AAS, but more 

independent living arrangements require the client to pay a portion or all of the rent. 

Caseworkers take advantage of all available subsidies, including project-based Section 8 and 

Shelter+Care vouchers. 

If a CBH client entering a psychiatric ward does not already have a targeted case manager, the 

client applies for one, thus ensuring some continuity of support during moves from hospital and 

treatment settings into more stable housing situations. If the client has a targeted case manager, 

the case manager is often of most help to the hospital social worker due to knowledge of the 

client’s history and housing options. CBH care managers have become a vital link among the 

workers assigned to work with a client’s situation at and after discharge. The CBH care manager 

can put the hospital social worker in touch with a person’s case manager, tell both people about 

the client’s presenting situation at the Crisis Response Center, authorize care, and provide history 

and context. 

What Prevention Services Do People Get? 

A primary goal of case management is to help clients access benefits for which they may be 

eligible. Likewise, it is important to enroll everyone possible into Medicaid to save scarce city 

dollars for those without insurance. However, if the client is not eligible for Medicaid, the city 

will cover medical costs for enrolled clients. Case managers will also facilitate negotiations with 

landlords and families; food and transportation assistance; screening and referral for health, 

mental health, and substance abuse services; crisis care; housing location; and supportive 

services. 
Appendix E Philadelphia, Pennsylvania 

E–9

Staffing and Caseloads 

The social workers, case managers, and care managers involved in the efforts to prevent 

homelessness in Philadelphia among CBH clients with serious mental illness minimally have 

four-year degrees in a human services field. Social workers frequently have more education, 

including some clinical training. CBH requires that each person working as a case manager 

receive 10 weeks of directly relevant training before pursuing casework duties. The city offers 

this training three times each year and will not allow case management agencies to bill for work 

performed by people who have not completed the training. Training covers everything a case 

manager needs to know: housing issues, benefits and applications, involuntary commitment 

rules, crisis management, understanding the resources available in the community, learning how 

to negotiate with landlords, and how to work with families. 

Shelter Diversion 

Many people approaching shelter intake are seriously mentally ill. Shelter intake staff have the 

ability to divert these individuals into behavioral health-supported shelter beds at one of three 

facilities, two of which are co-located with the central intake site for families and the one for 

singles. Services include staff trained in working with persons with serious mental illness, 

psychiatric care, and emergency medicine if consumers’ Medicaid benefits are not active at the 

moment of prescription by the program psychiatrist. If this happens, the person does not appear 

as a homeless shelter intake in the Office of Adult Services data system, but does enter the 

Chronic Homeless Initiatives database and begins receiving care. 

Recently, CBH staff realized that there was a need for a psychiatric triage service to co-exist 

with shelter intake. CBH is now stationing a person to conduct psychiatric assessments at shelter 

intake one day each week and to determine if there is a need for an even greater presence at 

shelter intake. CBH hopes that screening will identify people who have recently become 

homeless and who may have no idea of where to go for help. Intervention at this early stage of 

homelessness may help avert long-term homelessness among people with serious mental illness. 

Special Projects for Corrections Discharges of Inmates with Serious Mental Illness 

Behavioral Health System is involved in several efforts to ease the transition of jail and prison 

inmates whose serious mental illness puts them at considerable risk of homelessness. Two efforts 

focus on inmates of the city jail (one of which also tries to assure appropriate care while in jail 

by working with jail social workers), while the third focuses on inmates returning to Philadelphia 

from the state prison system. 

Projects with the City’s Jail System 

The first project with the Philadelphia jail system was to increase communications and links to 

case managers. Although it was well known that many jail inmates have serious mental illness, 
Appendix E Philadelphia, Pennsylvania 

E–10

poor communications among jail social workers, mental health case managers, and OBH often 

led to inmates not receiving mental health services in jail or appropriate discharge planning to 

prevent their becoming homeless. This situation changed during February 2003 when jail 

personnel began sending daily lists of intakes and releases to OBH. OBH checks the lists against 

its client database to determine which new inmates are its clients (with serious mental illness or 

with serious mental illness and co-occurring substance use disorders) and which have assigned 

case managers. OBH then notifies the case managers of their clients’ whereabouts and instructs 

them to contact the client in jail. The jail social workers determine appropriate treatment while 

the person is in jail and appropriate placement once the person is released. 

Stakeholders felt that this increase in communication significantly increased in-jail contacts of 

case managers and clients, improved working relationships with jail social workers, and 

improved housing circumstances upon release. Workers believed that these factors have led to a 

reduced likelihood that the inmate will be “released to shelter” or end up homeless. 

The second project was supplied with a case manager for the most severely mentally ill jail 

inmates with co-occurring substance abuse, but without a case manager. OMH recognized that 

release from jail often puts seriously mentally ill people at risk for homelessness, that cooccurring substance abuse further complicates the situation, that many such jail inmates do not 

get appropriate treatment while in jail, and that many do not already have a Behavioral Health 

System case manager or may not even be CBH clients. These circumstances prompted OMH to 

apply for a pilot demonstration grant to see how much difference a case manager could provide. 

Two years ago, AAS applied for and received a grant from the Pennsylvania Council on Crime 

and Delinquency (PCCD) to test the efficacy of supplying a case manager to about-to-bereleased jail inmates at the highest risk due to mental illness and lack of viable connections to 

housing. The grant went to the Philadelphia Mental Health Care Corporation Council (PMHCC), 

a nonprofit umbrella organization serving as a major human services systems management 

company for special programs and initiatives.44 PMHCC provides critical administrative services 

to mental health, substance abuse, mental retardation, human services, and special health and 

related city offices and programs. 

This PCCD Project, as it is called, includes a clinical specialist and assessor, and a behavioral 

health case manager. Jail personnel refer inmates to the PCCD Project for evaluation and 

eligibility determination. Project staff screen, conduct chart reviews and clinical interviews, 

determine present care needs, and make appropriate discharge arrangements. Many of the 

inmates who fit the project criteria have never been homeless; some have been homeless but are 

not chronically homeless people; and some have been homeless for years. Project staff track 

inmates through OMH/CODAAP data systems to learn the services they have received and learn 

about their treatment and family history, as well as if they received services as children. This 

information can be compared to what the inmate says about his or her own situation to allow the 

staff to assess needs. Project staff can authorize neurological, psychiatric, and substance abuse 

 

44 PMHCC originated when Philadelphia participated in the Robert Wood Johnson integrated services grant in the 

late 1980s. 
Appendix E Philadelphia, Pennsylvania 

E–11

workups to determine if underlying neurological conditions are creating or exacerbating 

symptoms of mental illness.45

During its first two years, the PCCD Project has evaluated 115 people, 58 of whom have been 

released from jail. Inmates with serious mental illness tend to have very long jail terms—average 

length of stay in the Philadelphia jail is approximately 76 days, but for the 58 clients of the 

PCCD Project, it was approximately 300 days. Their behavior stemming from unrecognized and 

untreated illness usually means no “time off for good behavior,” and they tend to serve out their 

full sentences. Some may never even get sentenced, as they go back and forth from jail to mental 

hospitalization to the courts. 

Getting post-release placements for people whose only problem is substance abuse is not 

difficult. The city supports approximately 360 recovery beds, but these facilities do not accept 

people who also have a mental illness, which is the case for PCCD Project clients. Nor are most 

of the people seen by the PCCD Project appropriate for board and care, as they do not have 

enough self-control to function well in a low-service environment. Project staff work with 

providers to adapt the rules for their clients. A new housing project, New Keys, began during 

March 2003 for people with co-occurring disorders, and has been an important resource for the 

project. Project staff believe that if enough appropriate housing were available, they could get 

their clients released regardless of the sentence, as jail is usually inappropriate. 

Of the 58 people in the PCCD Project released so far, seven went to other institutional settings 

(six to state prison, one to the hospital). Forty-one (71 percent) went to known residential 

settings (10 to family or own residence, eight to boarding home, and 23 to AAS- or CODAAPstructured housing). Residence upon release was unknown for only 11 people (19 percent). A 

check of these 11 against the city’s shelter database indicated that, so far at least, only one had 

used the shelter system post-release. 

The ability of PCCD Project staff to make a difference for imprisoned people with co-occurring 

disorders has stimulated the city to undertake two new projects. The Consortium Forensic Case 

Management Project began in April 2004 and the Mental Health Association Prison to 

Community Project began in July 2004. Both projects will supply case management services to 

jail inmates who are CBH clients but who do not have a case manager. Data documenting the 

progress and effectiveness of both projects should be more comprehensive than for the PCCD 

Project because the clients will have data in the CBH information system. 

Liaison with the State Department of Corrections 

OBH funds the position of forensic liaison within PMHCC. The forensic liaison helps the state 

Department of Corrections place state prison inmates who reach their maximum sentence and 

will be returning to Philadelphia. The Department of Corrections tracks all inmates taking 

 

45 For instance, temporal lobe seizures produce symptoms very similar to some mental illnesses. Such seizures are 

very amenable to treatment, after which the person’s “mental illness” may be cured. Serious childhood head injuries 

may also produce “mental illness-like” symptoms. Some neurological conditions make violent behavior more likely; 

they also may make it easier to qualify for SSI than would be true for mental conditions. 
Appendix E Philadelphia, Pennsylvania 

E–12

psychotropic medications and offers care through its Mental Health Roster (for the less severely 

impaired) and Psychiatric Review Team (for people receiving therapy as well). The Department 

of Corrections houses approximately 40,000 prisoners at any given time, of whom approximately 

7,000 are on the Mental Health Roster and approximately 1,500 receive services from the 

Psychiatric Review Team. 

Each year, approximately 120 state prisoners being released to Philadelphia are referred to 

PMHCC’s forensic liaison to determine eligibility for housing placement services. Of these, 

approximately one-half have a place to live and are stable with respect to their mental illness. 

The remaining half, approximately five each month, do not have viable housing options other 

than what the city can offer. The liaison works to obtain placements for these 60 people each 

year. Placement will be in the most appropriate mental health residential setting available 

through AAS. People may not be able to enter the most appropriate residential setting 

immediately, either because no bed is available or the person must first establish eligibility for 

benefits and services. The liaison works to develop a primary and a backup plan, as well as to 

begin the process of establishing eligibility for medical assistance and cash benefits. 

Participation is voluntary on the part of the soon-to-be-released inmate because after serving a 

full sentence, the Department of Corrections has no oversight of the person (that is, there is no 

parole period). 

Funding for Casework and Prevention Services 

CBH has a yearly budget of $400 million and handles 70,000 of Medicaid’s 395,000 

beneficiaries in Philadelphia. CBH uses Medicaid to cover in-plan services (80 percent) and the 

remaining 10–20 percent are paid for with other funds. OMH and CODAAP provide the nonMedicaid dollars, using Federal block grants, state welfare and health department funding, and 

city dollars. OMH and CODAAP funding sources allow them the flexibility to serve clients 

whether or not they are on Medicaid, and to provide services with one funding source that 

another will not cover. Even so, CBH also has an interest in qualifying every client for Medicaid 

or other medical assistance so that city dollars can be reserved for those without other funding 

sources. 

Who is Served? 

The prevention focus of this project involves people with serious mental illness leaving 

institutional settings. The primary population consists of people who are already CBH clients, 

which means that they already “qualify” for Medicaid based on a diagnosis of mental illness, 

substance abuse, or both conditions. Eligibility for Medicaid is determined by a standard 

eligibility and employability assessment. People in corrections institutions or homeless shelters 

with serious mental illness, with or without a co-occurring substance abuse problem, who are not 

yet CBH clients are a secondary population for which homelessness prevention efforts have 

recently focused. Enrolling them in medical assistance and getting them on the CBH rolls is a 

first step. 
Appendix E Philadelphia, Pennsylvania 

E–13

DATA COLLECTION AND USE 

1. Philadelphia has several administrative databases that, in combination, could afford an 

excellent opportunity to assess the impact of interventions to prevent homelessness 

among people with serious mental illness leaving institutional settings. The Office of 

Adult Services shelter database tracks all emergency shelter episodes dating back to 1989 

and contains fields for name, age, race, gender, social security number, and other 

identifying information. It also records each night that each person has spent in 

emergency shelter and nights that people spend in some transitional housing programs 

funded by the city. 

2. The OBH/CBH/OMH database. The OBH data system maintains records of care received 

and payments made for every client. Within OBH, the Research and Information 

Management Division manages much of the OBH data. This includes all of the 

information pertaining to CBH payments, residency in the AAS network of mental health 

housing, Chronic Homeless Initiatives Services including street outreach and Safe Haven 

residency information, case management, and emergency behavioral health services 

including psychiatric commitment and use of mobile emergency services. 

3. The CBH database. CBH maintains Medicaid administrative records of all of the 

information pertaining to CBH payments (and therefore client services). Services include 

inpatient psychiatric and substance abuse treatment, detoxification services, outpatient 

mental health and substance abuse treatment, and case management services. 

4. The Philadelphia jail database. The Philadelphia jail maintains its own records and 

recently has been informing OBH daily of the people who have entered and who have 

exited the jail within the previous 24 hours. The Research and Information Management 

Division would not be able to search this database directly, but communications between 

the jail and OBH are such that this division will be able to learn about jail inmates whose 

mental illness would qualify them for OBH services. 

Philadelphia had several opportunities for creating comparison groups that were roughly 

equivalent to the groups experiencing some of its interventions. These opportunities placed it in a 

strong position to show the effects of prevention interventions, if the relevant agencies were 

cooperative and the databases could be brought together. Possibilities for documenting the 

effectiveness of efforts to prevent homelessness among people with serious mental illness 

discussed during the site visit included: 

1. Using three of the databases listed above (Office of Adult Services shelter database, 

OBH/CBH/OMH database, and the jail database) to examine the effect of increased 

communication among jail, OBH, and case managers on the probability that seriously 

mentally ill jail inmates will experience homelessness within six months after release. 

This could be done using a sample of people released from jail in 2002, before the 

communication began, and 2004, when it was in place. 
Appendix E Philadelphia, Pennsylvania 

E–14

2. With jail inmates, compare the PCCD sample (inmates with serious mental illness who 

are given a case manager) to similar inmates who do not receive a case manager. Assess 

homelessness within one year of release using the Office of Adult Services shelter 

database and the Outreach Coordination Center database. This would test the effect of 

supplying case management to seriously mentally ill jail inmates on the probability of 

homelessness after release. 

3. Using OMH information on its clients released from psychiatric units in private hospitals, 

compare the likelihood of homelessness within one year after discharge (from the Office 

of Adult Services and Outreach Coordination Center databases) depending on the 

services they received—specifically, the hospital they were in, the organization supplying 

each person’s case manager, what type of care they received, and their housing 

arrangement at discharge. 

Unfortunately, merging databases from different institutional sources is a time-consuming 

activity, and such analyses do not take priority over routine system demands on data analysts. 

The OBH data managers were not able to complete any of these analyses for the present study. 

PHILADELPHIA SITE VISIT PARTICIPANTS 

Patricia Alexander, Philadelphia Jail Worker 

Mary Baker, Temple University Hospital, Episcopal Campus, BHCM Social Worker 

Eve Barnett, Belmont Center for Comprehensive Treatment, Clinical Social Worker/Supervisor 

Joseph Carter, Mental Health Association—Access West Philadelphia, Intensive Case Manager 

Laura DeRiggi, CBH, Director of Clinical Development 

David Dorschu, Kirk Bright Center 

Joseph Dweh, Horizon House, Intensive Case Manager 

Charles J. Fix, Philadelphia Department of Corrections, Bureau of Health Care Services, 

Assistant Chief of Psychological Services 

Nancy Guarino, Office of Emergency and Shelter Services 

Rob Hess, Office of Adult Services, Deputy Managing Director 

Staci Horwitz, CBH, Clinical Care Manager 

Jamie Hulsman, CBH, Clinical Care Manager 

Leon Jablaki, CBH, Clinical Care Manager 

Movita Johnson, Office of Adult Services, Managing Director's Office, Coordinator, Chronic 

Homeless Initiatives 

Frank Jost, Behavioral Health System/AAS, Program Manager 

Carolyn Kennedy, CBH, Clinical Care Manager 

Leon Korein, Project H.O.M.E., Outreach Coordination Center Coordinator 

Renate Kuder, Pennsylvania Hospital, Hall-Mercer Mental Health/Mental Retardation Center, 

Access Program Intensive Case Manager 

Amanda Latshaw, CBH, Clinical Care Manager 

Kevin Lenny, CBH Admissions, Discharges, and Planning Team (ADAPT), Clinical Assessment 

Specialist 
Appendix E Philadelphia, Pennsylvania 

E–15

Marcella Maguire, Office of Adult Services, Managing Director's Office, Director of Chronic 

Homeless Initiatives 

Dawn McCade, PMHCC, Coordinated consumer services, Specialized Operations, Behavioral 

Health Case manager (PCCD Project) 

Dana McClary, CBH, Clinical Care Manager 

Jacqueline Miles, Philadelphia Jail, MIS 

Cheryl Morrison, Philadelphia Jail, MIS 

Coleman Poses, OBH/OMH, Mental Health Research Supervisor 

L. J. Rasi, Temple University Hospital, Episcopal Campus, BHCM Social Worker 

Luanne Russell, Pennsylvania Hospital, Hall-Mercer Mental Health/Mental Retardation Center, 

Access Program Intensive Case Manager 

Sandy Short, Mental Health Association—Access West Philly, Resource Coordinator 

Monica Thompson, PMHCC, Coordinated consumer services, Specialized Operations, Forensic 

Liaison (state prison releases) 

Elizabeth Welch, CBH, Clinical Care Manager 

Toni Welch, PMHCC, Coordinated Consumer Services, Specialized Operations, Clinical 

Specialist and Assessor (PCCD Project) 

Novenia Woodard, CBH 

PHILADELPHIA ACRONYMS 

AAS Access to Alternative Services (part of OMH within OBH) 

ADAPT Admissions, Discharges, and Planning Team (part of OBH) 

CBH Community Behavioral Health 

CODAAP Coordinating Office of Drug, Alcohol, and Addiction Programs 

MBHO Managed Behavioral Health Care 

OCC Outreach Coordinating Center 

OBH Office of Behavioral Health 

OMH Office of Mental Health 

PCCD Pennsylvania Council on Crime and Delinquency 

PMHCC Pennsylvania Mental Health Care Coordinating Council 

TANF Temporary Assistance for Needy Families 
E–16
F–1

APPENDIX F 

URBAN PEAK 

The population of Denver is approximately 545,000. More than 57,000 of those individuals are 

between the ages of 15 and 24 years. Urban Peak estimates that there are approximately 1,500 

homeless youth in the state, of whom more than one-half are in the Denver area (Office of 

Homeless Youth Services, (2003). Most of the homeless youth seeking services at Urban Peak 

have a history of substance abuse and mental health issues. Further, many of the youth lack a 

high school diploma or a General Educational Development (GED) degree. These facts make it 

difficult for the youth to obtain housing in Denver even though the rental vacancy rate for 2003 

was approximately 13 percent and the median rent was $394.46 

Urban Peak, which began as a storefront offering meals and counseling services, is now an 

umbrella organization that oversees four affiliate agencies serving high-risk youth in Denver and 

Colorado Springs. The agencies and their functions include: 

• Urban Peak Denver provides outreach, shelter, and support services; 

• The Spot provides drop-in services; 

• Urban Peak Housing Corporation owns and manages permanent supportive housing for 

youth; and 

• Urban Peak Colorado Springs provides outreach, drop-in services, medical care, 

education, and case management services to youth in Colorado Springs. 

Through collaboration and strategic partnerships, Urban Peak offers a systematic approach of 

both primary and secondary prevention services to high-risk homeless and runaway youth. 

Services are mostly secondary and tertiary prevention services and are offered through outreach, 

a drop-in center, shelter, employment and education services, and housing. During 2003, 

65 percent of the 762 youth who accessed case management services through Urban Peak 

Denver experienced a successful housing outcome (e.g., moved into own apartment, obtained 

permanent supportive housing, returned to family of origin). On an average night, approximately 

34 youth slept in the shelter. 

 

46 Housing information obtained from the U.S. Census Bureau at: 

http://www.census.gov/acs/www/Products/Profiles/Single/2003/ACS/CO.htm (accessed on 11/9/04). 
Appendix F Urban Peak 

F–2

During the study team’s visit to Urban Peak on June 17–18, 2004, the team interviewed nine 

Urban Peak staff responsible for the management, outreach, employment, housing, and shelter 

aspects of Urban Peak. The study team visited an evening session at The Spot and visited the 

PS-1 Charter School, the outreach and educational services center located across the street. The 

study team also met with several youth at a monthly community breakfast where Urban Peak 

Denver staff and youth share a meal and experiences. 

Data collection is a high priority at Urban Peak. For the past five years, the Urban Peak Client 

Database has stored vital information on the youth, services, and payments that are currently 

used to document program outcomes. The study team spoke with Urban Peak staff and outside 

researchers who are collecting and analyzing data to document the characteristics and outcomes 

of youth served. Results are available, and the data analysis addressed documenting additional 

prevention outcomes. A list of persons interviewed is located at the end of this appendix. 

PRACTICES OF POTENTIAL INTEREST TO OTHER JURISDICTIONS 

The contact for all Urban Peak practices is Jerene Petersen (Jerene.Petersen@urbanpeak.org). 

Because Urban Peak serves homeless youth, several practices are of potential use to other 

jurisdictions. These practices include the following: 

• Continuum of prevention and homelessness services. To ensure that the needs of a diverse 

population are met, Urban Peak Denver provides outreach and shelter services to 

homeless youth, drop-in services to homeless and at-risk youth, and permanent 

supportive housing to youth transitioning from the streets or other unstable living 

environments. 

• Community relations and advocacy. To provide innovative services for a unique 

population, Urban Peak advocates with the local government and other funders. 

• Innovative data collection methods. Due to the unique characteristics of the population 

served by Urban Peak, the agency has been creative in the methods it uses to collect data 

and in developing followup data collection instruments and methods. Urban Peak has 

participated in several point-in-time surveys to gather information about drop-in clients’ 

experiences, as well as to measure the prevalence of sexually transmitted infections 

within this population. Further, Urban Peak is considering utilizing Web-based 

technology to gather important followup data from the youth who have exited services. 

DEVELOPING THE COMMITMENT TO PREVENTION 

Urban Peak opened during 1988 as a storefront office with a small annual budget, provided by 

the Capital Hill United Neighborhood Association, in response to the increasing number of 

runaway and homeless youth who gathered in the community. At that time, the agency provided 

food and basic counseling services. During 1992, the agency incorporated and expanded services 
Appendix F Urban Peak 

F–3

to include a 20-bed youth shelter—Safe at St. Paul’s—which the United Methodist Church had 

opened to serve youth living on the streets. 

In response to a budget crisis during 1995, Urban Peak initiated a strategic planning process that 

incorporated consistent planning into the agency culture. Leadership and a commitment to 

intensive planning has provided a blueprint for the agency to respond flexibly to new 

opportunities, the changing needs of youth, budget realities, and necessary changes in 

organizational structure. Key planning goals included the construction of a new shelter facility in 

Denver, the development of housing for homeless and runaway youth, the expansion of 

programming, including education, and the development of an Urban Peak facility in Colorado 

Springs. 

Urban Peak developed housing for substance-abusing homeless young adults in December 1997 

by using a 10-year Shelter+Care grant received from the U.S. Department of Housing and Urban 

Development (HUD). Urban Peak developed and incorporated Urban Peak Housing 

Corporation—which soon opened Rowan Gardens, the first apartment facility designed to serve 

the unique needs of the young adults served by Urban Peak and other agencies. Urban Peak 

Denver partnered with the Urban Peak Housing Corporation, the State of Colorado, the Denver 

Department of Human Services, and HUD to provide 12 units for young adults who were 

addicted to drugs or alcohol, 16 units for young adults with disabilities, and 35 units for youth 

who were aging out of foster care. The units for youth aging out of foster care were not funded 

by HUD. The Urban Peak Housing Corporation also provided access to Section 8 vouchers for 

youth living independently in foster care at the age of 16 or older. The Urban Peak Housing 

Corporation currently owns and operates two apartment buildings and operates a third. 

During June 1998, Urban Peak Denver designed and moved to a new shelter in South Denver. 

Designed for serving the needs of homeless and runaway youth, the facility included space for 

expanded programs—such as a room for an on-site school and increased shelter capacity from 20 

to 40 beds—by replacing mats on a church floor with bunk beds. Urban Peak Denver partnered 

with the Denver Public Schools to open an on-site school program and computer labs. 

During 1999, a group of service providers in Colorado Springs reported that youth homelessness 

was getting out of control. Staff from Urban Peak conducted a one-day outreach effort and 

identified 85 youth living on the streets during a two-hour period. Colorado Springs, raised the 

necessary funds and, with the help of Urban Peak Denver, established Urban Peak Colorado 

Springs to conduct outreach and drop-in services. 

During 2002, the General Assembly of the State of Colorado established an Office of Homeless 

Youth Services. One of the architects of Urban Peak’s community collaboration moved into city 

government as the manager of the Denver Department of Human Services, reporting to the 

Mayor of Denver. This department has established the Mayor’s Commission to End 

Homelessness and is working diligently to this objective. Urban Peak serves on this commission 

and has been a leader in assembling Denver-area nonprofit agencies serving youth into a 

supportive collaboration. 
Appendix F Urban Peak 

F–4

During 2003, the state experienced a significant economic downturn that resulted in state and 

county budget reductions in youth programs. Employment opportunities for youth decreased 

while housing prices continued to increase. Denver also experienced an increase in gang activity. 

When state-funded youth services declined, there was an increase in the development of faithbased drop-in centers for street youth, offering youth survival essentials without services. It was 

recognized that when youth can obtain food and showers even without other services, they are 

able to survive on the streets. However, without these services they are less likely to achieve 

successful housing outcomes. Therefore, it became even more important for Urban Peak Denver 

to collaborate extensively with the other agencies providing services to homeless and runaway 

youth. Through this collaboration, youth could receive short-term services from several 

providers while still having contact with Urban Peak Denver, which offers a continuum of 

services to help youth exit the streets. 

Due to the challenges of the economic downturn and the growing competition for youth services, 

Urban Peak partnered with a longstanding drop-in center in downtown Denver to expand 

services and begin to reach out to a more diverse street culture. In 2003, Urban Peak merged 

with The Spot, an evening drop-in center founded in 1994 by gang members, homeless youth, 

and graffiti artists. Accessible by public transportation, The Spot is located downtown in a gangneutral environment. Offering a balance of positive social interaction, adult guidance and 

referrals, and fun- and skills-building activities, this merger created a more wide-ranging 

organization in terms of geography and services. Around this time, Urban Peak Denver also 

developed an alliance with the PS-1 Charter School through The Spot, increasing the 

opportunities for youth to receive their high school diplomas and GEDs. 

COMPONENTS AND ORGANIZATION OF THE COMMUNITY STRATEGY

Homeless and runaway youth require a continuum of support with employment, education, 

health care, drug and alcohol treatment, and housing issues. The continuum of services provided 

through Urban Peak ranges from outreach as the point of initial contact for many homeless youth 

to resources that provide previously homeless youth with permanent supportive housing. This 

continuum of services comprises the community-wide approach to address youth homelessness 

in the Denver metropolitan area. Urban Peak is recognized as the core service provider for the 

high-risk youth population. Each of these services is described in greater detail below. 

 

Outreach 

Consistent with the objectives of Urban Peak Denver, the Urban Peak Outreach Team works 

throughout metropolitan Denver to build relationships with youth who are living on the street. 

The primary focus of outreach services is to build relationships with street youth as a means to 

remove barriers that inhibit them from accessing services through Urban Peak Denver and other 

agencies. The Urban Peak Outreach Team provides education about risk reduction, while 

distributing condoms, dental dams, hygiene products, bleach kits, food, and clothing. If 

appropriate, the Urban Peak Outreach Team will provide youth with information and referral to 

needed services. 
Appendix F Urban Peak 

F–5

The Urban Peak Outreach Team provides services targeted to needs of homeless and runaway 

youth in the locations where they gather. These locations are constantly adjusted with seasonal 

variations and input from collaborating partners, such as the police and the Downtown Denver 

Partnership, the business owners of downtown Denver. For example, the Urban Peak Outreach 

Team visits The Spot twice each week to offer alternative hangouts in the evening. To better 

understand where youth are sleeping at night, the Urban Peak Outreach Team conducts several 

late-night outreaches each month, mostly in one of the downtown mall areas. 

Collaboration with police, downtown businesses, and other providers of services to youth is an 

important strategy to facilitate referrals to Urban Peak Denver and to target resources. The Urban 

Peak Outreach Team participates in multiple speaking engagements at junior high and high 

schools, as well as area businesses and agencies. The purpose of these outreach efforts is to begin 

the engagement process to help youth permanently exit the street. 

Who is Served? 

Since 1999, the Urban Peak Outreach Team has tracked contact information in the Urban Peak 

Denver database. These data have provided useful demographic information regarding outreach 

clients, as well as the types of services they most frequently access. Due to the anonymity of the 

contacts, it is difficult to unduplicate counts and determine when the youth had initial contact 

with the agency. The data reveal that the characteristics of those contacted through outreach are 

similar to the characteristics of others served at Urban Peak Denver. 

The Urban Peak Outreach Team conducted a point-in-time survey of 215 youth on September 4, 

2002. The results of this survey verified the demographic composition of the population, ranging 

in age from 14 to 21 years. Sixty-two percent of youth surveyed were male, 37 percent female, 

and the remaining 1 percent transgendered. The majority (67 percent) of those surveyed were 

Non-white, while the remaining youth were Latino (8 percent), African-American (7 percent), 

and Native American (7 percent). Most of these youth were living on the streets (32 percent) or 

with friends (11 percent). Some youth also reported living in motels or “couch surfing” (i.e., 

moving from one location to another). Survey data also indicated that the majority of the youth 

(greater than 70 percent) used alcohol, marijuana, and cigarettes during the past 30 days. A 

sizeable percentage of these youth also reported using harder drugs and some reported injecting 

drugs. The study also found that 11 percent of the youth admitted to participating in survival sex, 

defined as sex in exchange for money, food, shelter, or drugs (Van Leeuwen, 2002; Van 

Leeuwen et al., manuscript submitted for publication). 

The expertise of the Urban Peak Outreach Team was also tapped to study an innovative way to 

test for and treat chlamydia and gonorrhea. Through a collaboration between the Denver 

Department of Public Health and Urban Peak, 414 chlamydia and 302 gonorrhea tests were 

conducted. The Department of Public Health and the Urban Peak Outreach Team workers met 

with the youth in a popular public park and arranged for the collection of urine samples, tested 

the samples, and provided subsequent treatment for youth with positive results. A total of 49 

infections were diagnosed and 61 percent of these individuals received treatment. This activity 
Appendix F Urban Peak 

F–6

was not only important from a larger public health perspective, but also for increasing the 

documentation of the youth’s needs and characteristics (Van Leeuwen, Rietmeijer, LeRoux, 

White, and Petersen, 2002). 

Drop-In Services 

The Spot is an evening drop-in center for youth between the ages of 14 and 24. The Spot is 

influenced by the hip-hop culture and provides a place where youth may socialize, dance, and 

record music. The Spot provides several activities that are aimed at building youth’s skills and 

providing positive social interactions. These activities include music recording in professional 

recording studios, break dancing in facilities intended for that use, Internet access, and 

recreation. Additional services include HIV testing, health clinic services, GED preparation at 

the PS-1 Charter School, and college entry assistance. The Spot has several case managers who 

work informally with the clients. Since merging with Urban Peak Denver, the Urban Peak 

Outreach Team makes contact with high-risk youth at the Resource Center located at The Spot. 

Who is Served? 

Any interested youth may visit or access services at The Spot, which serves from 90–100 youth 

each night. Point-in-time survey data indicate that The Spot serves a more diverse population in 

this downtown setting. The majority of youth who frequent The Spot on a regular basis are older, 

aged 18–24 years, and non-white, mostly African-American. Almost 17 percent of the youth 

identify as gay, lesbian, bisexual, or transgendered. Many of the youth (36 percent) currently live 

with their parents, followed by their own housing (25 percent), or with friends (18 percent). 

However, almost one-half (46 percent) of the youth are living in temporary living situations 

(Scandlyn and Grove, 2004). 

Emergency Shelter and Support Services 

Urban Peak Denver serves youth between the ages of 15–21 years. Services include overnight 

shelter, case management, education and employment resources, medical services, and general 

drop-in services. Drop-in services consist of three meals each day, a computer lab, drug and 

alcohol groups, and information and referral services directing the youth to resources outside of 

Urban Peak. 

When a youth accesses any of the services provided by Urban Peak Denver, he or she is assigned 

a case manager. The case manager conducts an assessment with the youth, addressing areas such 

as mental health, legal issues, substance use, HIV status, and education. The case manager works 

with the youth to determine their needs and goals and to develop a case plan. Youth may access 

shelter at Urban Peak Denver as long as they continue to move forward on their case plans. To 

facilitate that forward movement, Urban Peak Denver offers employment services including 

counseling and job coaching, assistance with resumes, and connections with potential employers. 

Urban Peak Denver’s education services provide GED classes and computer training. 
Appendix F Urban Peak 

F–7

The typical approach to serving homeless and at-risk youth at Urban Peak Denver begins with a 

30-day orientation period, during which time staff conduct an assessment of the youth, establish 

treatment needs, and obtain identification and other documents from the youth. Critical to this 

assessment is contact with the family of origin if the youth is under the age of 18—staff must 

obtain permission form the youth’s parent or guardian for the youth to receive services. If this 

permission is not obtained, staff are obliged to contact the Department of Human Services. For 

youth younger than 15 years who are involved with Social Services and for whom living 

independently is not an option, Urban Peak Denver collaborates with several agencies to either 

reunite the families or identify additional beds available to homeless youth. 

During this period of time, staff expect the youth to stay in the shelter every night. Staff believe 

that this stability will help the youth to exit the streets more quickly. After the youth have been 

involved with Urban Peak Denver and have completed the initial steps in the process, staff meet 

to review the client’s service plan, including obtaining employment and completing education, 

and to determine the next steps for the youth’s progress. After this team meeting, the youth will 

be responsible for adhering to the case plan, including employment and education, case 

management, and housing. Following four months of service at Urban Peak Denver, the case 

manager may provide some aftercare services, and upon discharge from the program, the youth 

and case manager will determine the services for which the youth is eligible and interested. 

Education services provided at Urban Peak Denver are designed to meet the specific needs of 

youth. GED courses are offered through a number of vehicles—Denver Public Schools, a 

collaboration with The Spot and the PS-1 Charter School, and a second collaboration between 

The Spot and the Community College of Denver. Other educational services include financial 

assistance for higher education at the Community College of Denver and the Metropolitan State 

College of Denver. The employment program through Urban Peak Denver is funded through the 

Workforce Investment Act, which stems from the Mayor’s Office of Workforce Development. 

Services provided to youth through this program include resume writing, job coaching, and 

employer connections. 

Youth who receive services through Urban Peak Denver typically have immediate mental and 

physical health needs—60 percent require mental health services and 40 percent require dental 

health care. Due to recent cutbacks in state and Federal funding, the provision of these services 

was significantly reduced. Presently, Urban Peak Denver provides four hours of medical clinic 

staffing each week and hires a half-time clinician to work with the youth. To cover necessary 

services that are no longer easily funded, Urban Peak Denver identified new sources of funds and 

was awarded a grant through the Substance Abuse and Mental Health Services Administration to 

fund drug and alcohol treatment for 25 youth each year. These treatment services are provided 

through the Starting Treatment and Recovery (STAR) program of the University of Colorado 

Health Sciences Center, Addiction Research Treatment Services. Urban Peak Denver has applied 

for several additional grants and other funding in order to increase the level of health and mental 

health services provision. 
Appendix F Urban Peak 

F–8

Permanent Supportive Housing 

The Urban Peak Housing Corporation owns two multiunit buildings and manages another for the 

City of Denver. It performs property management for the buildings while Urban Peak Denver 

provides the supportive services. Rowan Gardens and STAR are located in multiunit buildings 

owned by Urban Peak Housing Corporation and are funded through HUD Shelter+Care grants. 

Each housing program serves youth with disabilities. STAR is a contingency-based housing 

program for substance-addicted youth enrolled in drug or alcohol treatment. Rowan Gardens is a 

16-unit building that houses youth with disabilities. 

The Rocky Mountain Youth Housing Program—a collaboration between Urban Peak and the 

Denver Department of Human Services—is a 35-unit apartment complex that houses homeless 

youth involved with child welfare. Two-thirds of this project is subsidized by Volunteers of 

America through a U.S. Department of Health and Human Services (HHS) Transitional Living 

Program (TLP). The state provides additional funding for this project through the HUD-funded 

Family Unification Program, which provides Section 8 vouchers for young people aging out of 

foster care. Urban Peak Denver also has a TLP grant through HHS that provides rent subsidies 

for youth. 

Youth typically move from the Urban Peak Denver shelter to permanent supportive housing 

through Urban Peak Housing Corporation. Each building where permanent housing is offered 

has an on-site resident manager who is available to assist the resident, as well as to oversee the 

property. Youth receive supportive services through Urban Peak Denver and work with a case 

manager on their case plans. 

Community Advocacy and Collaboration 

Collaboration with other agencies and institutions is critical to the success of a community-wide 

approach to serving homeless and runaway youth. The City Council, Mayor’s Office, and 

Downtown Denver Partnership are key players in the development of the community-wide 

approach. Urban Peak serves on local networks and conducts a great deal of local collaboration. 

Urban Peak also works with a lobbyist to monitor bills in the state legislature and advocates 

against those that would have a negative impact for youth. 

Urban Peak could not deliver wraparound services to youth without partnerships with other 

agencies and institutions. These partnerships help reduce the costs associated with serving youth 

and increase the collaboration and coordination essential to success. Key agency partners and 

collaborations include the following: 

• The Children’s Hospital provides staff for the medical clinic, HIV testing, and the on-site 

pharmacy; 

• Denver Health and Hospitals provides street outreach and testing for sexually transmitted 

infections; 

• Denver Public Schools provides on-site GED and title one educational services; 

• Educo provides recreational outings for the youth; 
Appendix F Urban Peak 

F–9

• Family Tree provides transitional housing for homeless youth and families; 

• Health One provides staff for the medical clinic; 

• Human Services, Inc., provides transitional housing; 

• Mental Health Association of Colorado provides funding for treatment services; 

• Mental Health Corporation of Denver provides on-site mental health services; 

• Planned Parenthood provides pregnancy prevention services; 

• Rocky Mountain Youth provides staff for the medical clinic; 

• State of Colorado, Department of Human Services provides assistance for youth aging 

out of child welfare services; 

• Stout Street Clinic provides psychological evaluations; and 

• Volunteers of America provides transitional housing. 

A good example of Urban Peak’s community-wide advocacy, planning, and collaboration is the 

steps that it took to write standards to create the shelter for homeless youth. In 1997, Urban Peak 

advocated for the passage of the Homeless Youth Act that led to regulations that made it easier 

to serve this population. Urban Peak was instrumental in drafting the new state standards for 

youth shelter, eventually leading to Urban Peak operating the first and only youth shelter in the 

state. The Homeless Youth Act includes provisions for family intervention reconciliation 

services, as well as crisis intervention and alternative residential services. Most importantly, this 

Act required that the Colorado Department of Human Services license homeless youth shelters.47

DATA COLLECTION AND USE 

Urban Peak is dedicated to collecting data and has a Research Committee comprised of members 

from local universities who meet on a bi-monthly basis. Urban Peak Denver has an ACCESS 

database, which staff use to record data on every client served from outreach through permanent 

housing, with the exception of drop-in services at The Spot. Created in 1999, the Urban Peak 

Denver database now has more than five years of data ensuring an accurate, unduplicated count 

of youth served. The database includes a variety of information, including tracking services for 

each day that a youth presents at Urban Peak Denver (either in a drop-in or shelter capacity). 

This system provides tracking information needed by HHS for the Runaway and Homeless 

Youth Management Information System, HUD, the Workforce Investment Act, and state and 

city stakeholders. Street outreach youth are also entered in the database. Youth who have been 

discharged from Urban Peak are followed up at six months by their case manager.

Urban Peak Denver collects an important, fundamental outcome measure—the annual 

percentages of youth who receive services through Urban Peak Denver and then experience a 

successful housing outcome. For fiscal year 2004, 63 percent of the youth served at Urban Peak 

Denver experienced a successful housing outcome. The successful outcome dispositions were: 

 

47 House Bill 97–1079. (1997). 
Appendix F Urban Peak 

F–10

• Youth moved into own apartment; 

• Youth moved into other independent living (e.g., Job Corps, Youth Transitional Housing, 

or supportive housing with another agency); 

• Youth entered an approved placement (e.g., foster care); 

• Youth returned home; 

• Youth moved into an Urban Peak Housing Corporation property; or 

• Youth moved into Volunteers of America housing. 

Dispositions that were not successful include the following: 

• Youth terminated services; 

• Youth went to jail; and 

• Urban Peak Denver terminated services with the youth (due to age, violence, or lack of 

parental consent). 

Exhibit F.1 lists outcomes for youth who received services at Urban Peak Denver between 2000 

and 2004. With the data it collects, Urban Peak Denver has the potential to analyze other 

outcome measures to determine the long-term success of its clients. These potential analyses are 

discussed in the following section. 

Exhibit F.1. Outcome Measures for Urban Peak Denver, 2000–2004 

Measure 2000 2001 2002 2003 2004 

Number of youth with successful housing outcomes 308 343 368 426 435

Percentage of youth with successful housing outcomes 48% 52% 53% 65% 63%

Innovative Data Collection Methods 

To collect followup data from youth discharged from Urban Peak programs, the staff have 

considered innovative data collection methods. These methods include using Web-based 

applications, including list serves and followup data collection forms posted to the Urban Peak 

Web site. Urban Peak staff also discussed ways to make this type of data collection more 

palatable to the youth, including incentivizing data collection and involving the youth in 

developing this new system of Web page outreach, followup, and data collection. Staff at Urban 

Peak also believe that following up with clients will not only provide useful data but also an 

additional intervention point for the youth and will help them to maintain their stability. 

Recommended Data Analyses 

The study team recommended several data analyses to strengthen the power of Urban Peak 

Denver’s outcome measures. Because Urban Peak Denver currently determines the percentage of 

youth with successful housing outcomes following service provision, the recommended data 

analyses focus on gathering additional follow back and followup data. These data would help 

staff to know where the youth were prior to entering Urban Peak Denver (follow back) and how 

they fare after leaving (followup). Descriptions of these analyses follow. 
Appendix F Urban Peak 

F–11

To determine the predictive factors of youth who become homeless and receive services 

through Urban Peak Denver. 

By adding a 30-day followback calendar to standard intake and assessment protocols, the agency 

would be able to collect data to quantitatively demonstrate the path that many youth follow from 

homelessness to shelter at Urban Peak Denver. These data would help staff to refine the 

progression of service provision for youth based on their experiences prior to entering shelter. 

The worker conducting a client intake at Urban Peak Denver would administer a 30-day 

followback calendar to determine the client’s housing stability for the 30 days prior to reporting 

homelessness. This calendar will provide variables including number of changes in living 

situation and types of living situations in which the client lived during the 30-day period. 

To assess the six-month and 12-month outcomes of youth who received services through 

Urban Peak Denver and then exited the program. 

These analyses would demonstrate the long-term effectiveness of services provided at Urban 

Peak Denver with the mission of preventing repeated episodes of homelessness among youth. 

Further, these analyses would allow Urban Peak Denver staff to more effectively target services 

to youth that would increase the likelihood of their having positive outcomes following exit from 

shelter. Urban Peak Denver would collect six- and 12-month followup data on youth who 

experienced successful housing outcomes after receiving services from Urban Peak Denver. 

Followup data would include current living situation, employment status, recidivism, and receipt 

of services from Urban Peak Denver following exit from shelter. 

Next Steps 

To utilize the rich data that it collects, Urban Peak Denver has developed a request for quotations 

to secure a contractor to help them meet three data-related goals: 

• Develop an on-line followup instrument; 

• Transfer the data from the agency database to a statistical package and develop a working 

relationship to determine the appropriate uses and analyses of the data; and 

• Post previously conducted research on-line to allow public access. 

Continuing its tradition of collecting timely and important data on homeless youth, Urban Peak 

is participating in a point-in-time survey taking place in November in seven cities across the 

country. This study, funded in part through a national network dedicated to the issues of 

homeless and runaway youth, will collect health-related data on this population and provide 

aggregate data as well as comparisons across sites. 
Appendix F Urban Peak 

F–12

URBAN PEAK SITE VISIT PARTICIPANTS 

John Ammerman, Urban Peak Housing Corporation, Director 

Juston “MA” AT Cooper, The Spot, Education Coordinator 

Steven Dobo, Urban Peak Denver, Employment and Education Manager 

Heidi Grove, The Spot, Youth Development Specialist 

Jerene Petersen, Urban Peak Denver, Executive Director 

Jean N. Scandlyn, University of Colorado at Denver, Adjunct Assistant Professor 

Bill Smyth, Urban Peak, IT/Office Manager 

Wendy Talley, The Spot, Executive Director 

James Van Leeuwen, Urban Peak Denver, Associate Executive Director 

URBAN PEAK ACRONYMS 

GED General Educational Development 

HHS U.S. Department of Health and Human Services 

HUD U.S. Department of Housing and Urban Development 

STAR Starting Treatment and Recovery 

TLP Transitional Living Program 
G–1

APPENDIX G 

METHODS 

The methods involved in this study consisted of site selection, site visits, and development of 

data analysis plans with the selected sites. 

SITE SELECTION 

The study team conducted a two-stage canvass to identify potential homelessness prevention 

programs. The first stage focused on identifying reputable, community-wide homelessness 

prevention programs, and the second stage consisted of in-depth screening calls with these sites. 

The first stage of the process began by contacting sources identified in previous studies of 

homelessness by Walter R. McDonald & Associates, Inc. (WRMA), and Urban Institute (UI). In 

addition, the study team consulted national experts in homelessness, including national 

associations, state and local agencies, and mental health and homelessness consortia. These 

contacts included: 

• Community Shelter Board (Columbus, OH); 

• Corporation for Supportive Housing; 

• Department of Human Services (St. Louis County, MO, and Spokane, WA); 

• Housing Information Office (St. Paul/Ramsey County); 

• National Alliance for the Mentally Ill; 

• National Alliance to End Homelessness; 

• National Association of State Alcohol, Drug, and Alcohol Abuse Departments; 

• National Association of State Mental Health Program Directors, Research Institute; 

• National Coalition on the Homeless; 

• New York City Department of Homeless Services; 

• Office of Emergency Shelter and Services (Philadelphia); and 

• The Community Partnership (Washington, DC). 

This first stage of the site selection process identified 28 communities for the second stage of 

screening to determine whether they met the study criteria. For some communities, the study 

team identified multiple agencies, although it was not necessary to speak with each of them to 

learn about the prevention efforts within that community. The team used two factors to 

determine the appropriateness of a site for potential study: 

• Presence of a community-wide approach to primary prevention services for those at 

imminent risk of homelessness; and 

• Adequate data to document the prevention of homelessness.
Appendix G Methods 

G–2

The study team’s initial discussions with each of the 28 potential sites provided a brief 

description of homelessness prevention efforts within a particular program as well as in the 

larger community. The discussions were loosely organized by a canvass discussion guide. (See 

Exhibit G.1). 

Exhibit G.1. Canvass Discussion Guide 

The discussions with the 28 homelessness prevention programs identified 19 communities that 

met the basic study criteria—a community-wide approach to homelessness prevention and at 

least some data potentially available for analysis. This canvassing process found that the 

28 communities with which the study team had discussions were of three types: 

Community (State): 

Name of Agency: 

Name/Title/Contact Information of Person: 

Role of Person: 

Date: 

Discussion Person: 

My name is________________________ and I work for ______________, a research company based in 

________________. We have contacted you as part of a project funded by the U.S. Department of Housing and Urban 

Development to describe communities that have been successful in preventing homelessness. Our focus is on programs and

services that help people at imminent risk of homelessness to avoid becoming literally homeless. We are using the HUD 

definition of “imminent risk” for our target population referring to those for whom homelessness is likely to occur in one or two

days. We are speaking with representatives of different communities who are knowledgeable about their community’s 

homeless assistance network and its prevention efforts. We hope to identify a small number of communities with successful 

prevention activities that we can study further in this project. I’d like to talk to you about your community today. The 

discussion may take up to 30 minutes, if your community is doing something substantial to prevent homelessness, or it could

be quite short. Would now be a good time to start the discussion or is there a more convenient time we could schedule? 

1. How does your program serve those at imminent risk of homelessness? (By imminent risk we mean those for whom 

homelessness is likely to occur in one or two days. How imminent and how certain is the risk of homelessness?) 

2. Whom do you serve? (Probes: families, individuals, special populations.) 

3. Describe the locations or settings in which you provide the services. 

4. Do you think that there is a community wide approach to providing services to those at imminent risk of 

homelessness? If so, describe the other programs or partners participating in the provision of services to those at risk 

of homelessness? (e.g., nonprofit emergency assistance providers, discharge planning from psychiatric hospitals or 

prisons, other entry points to homeless assistance services.) 

5. How does your program or community document the success of these services (i.e., can you show that you have 

actually prevented homelessness)? 

 a. Even if you haven’t actually analyzed any data to show prevention, do you HAVE any data that COULD be 

analyzed to show prevention? (Suggest possibilities, e.g., Does a Homeless Management Information System 

exist capable of providing data over several years? If yes, could it be used to track whether a household helped by 

your agency subsequently became homeless?) 

 b. If data exist, would you be willing, potentially, to analyze it for a HUD study? 
Appendix G Methods 

G–3

• Ten communities served households at risk of homelessness; 

• Nine communities served specialized populations, such as people with serious mental 

illness, ex-offenders, and youth; and 

• The remaining nine communities did not offer a community-wide approach to 

homelessness prevention or did not offer prevention services, and did not direct the study 

team to another agency in the community. 

The study team recommended six sites for further study. These sites were in two categories: 

• Community-wide strategies with families and individuals; and 

• Community-wide strategies with specialized populations, including persons with serious 

mental illness and homeless and runaway youth. 

Exhibit G.2 lists the sites selected for this study and indicates the type of population that their 

strategies target. 

Exhibit G.2. Study Sites 

Community-Wide Strategies with 

Specialized Populations 

Site 

CommunityWide 

Strategies with 

Families and 

Individuals 

People with 

Serious Mental 

Illness 

Homeless and 

Runaway 

Youth 

Hennepin County X 

Montgomery County X 

Mid America Assistance Coalition, Kansas City X 

Massachusetts Department of Mental Health X 

Philadelphia X 

Urban Peak, Denver X 

SITE VISITS 

The study team visited six sites. A two-person team visited Montgomery County over the course 

of three days; the Kansas City metropolitan area in two days; and Denver in two days. A team 

member visited Hennepin County for two days; Philadelphia for two days; and two separate trips 

to Massachusetts for a total of three days. The site visits had the following primary objectives: 

• To collect more detailed information on program design to expand upon the information 

collected during the canvass; 

• To observe the data systems in action and speak to their users at every level; 

• To begin developing the data analysis plans for the communities; and 

• To tour agencies and programs providing primary homelessness prevention services. 
Appendix G Methods 

G–4

Prior to the site visits, the study team collected preliminary information from each of the six 

sites, including available annual and statistical reports. During site visits, the study team 

collected qualitative information about each effort, including the meaning of community-wide as 

it applies to that community, the target population, the history of the approach, current operating 

procedures, multiagency involvement and coordination, funding sources, data systems and 

documentation, and outcome measures. The study team spoke with staff knowledgeable about 

the approach to learn the scope of what it entails. The study team also spoke with information 

technology staff to learn the specific characteristics of the data systems they used, the data they 

collected, and how they might analyze these data to assess the effectiveness of their 

homelessness prevention programs. 

The study team developed a site visit protocol to guide discussions with community members 

and program staff. (See Exhibit G.3. at the end of this appendix.) The study team adapted the 

discussion guide before visiting each site, confirmed the information already collected about that 

site, and asked additional questions. The study team wrote site summaries expanding upon 

information collected during the canvass calls and the site visits, including relevant contextual 

information. A general outline of the factors the study team examined during the site visits 

follows. 

• Community-Wide Approach 

- Definition of “community-wide;” 

- Goals; 

- Key players; 

- Multiagency coordination; and 

- How and why the approach developed. 

• Target Population 

- How sites determine “imminent risk of homelessness;” 

- Population focus; 

- Client identification, pathways to service, and screening; and 

- Eligibility criteria. 

• Operations 

- Services; 

- Staff; 

- Settings and locations; and 

- Length of services (average and range). 

• Program Funding and History of Sources 
Appendix G Methods 

G–5

• Data Systems and Documentation 

- Data collection; 

- Homeless Management Information System (HMIS); 

- Typical analyses sites perform and report; 

- Degree to which sites prevent homelessness; and 

• Outcomes Expected and Evidence That They Have Been Achieved 

DATA ANALYSIS PLANS 

The study team worked with five sites (not including Hennepin County, which already 

documented the outcomes of its homelessness prevention activities) to develop data analysis 

plans. The study team also proposed methods to measure the effectiveness of each site’s 

approach to homelessness prevention. The main focus of these plans was to help communities 

identify data elements and data sources that they could use to document their own prevention 

outcomes. Through this process, the study team hoped to identify a small set of measures of 

prevention success that could be promulgated as data standards for prevention for HMISs 

throughout the country. 

To clearly delineate the specific types of data and analyses needed for this study, the study team 

collected specifications based on each site’s data to develop plans with the sites to guide 

appropriate data analyses. Using these plans, all but one of the study communities (Philadelphia) 

conducted their own data analyses. The study team collected the following information about 

each relevant data set: 

• Community; 

• Name of data system; 

• Agency that maintains the system; 

• Purpose of system; 

• Date of implementation; 

• Software platform; 

• Analytical software available; 

• Analytical staff available; 

• Key staff contact information; and 

• Inclusion of fields that 

- Identify recipients of primary (or any other) prevention services; 

- Identify eligibility criteria used to determine each recipient’s homelessness risk; 

- Determine start and end of primary prevention services; 

- Determine reason for ending primary prevention services; 

- Determine number of families served with primary prevention services; 

- Determine number of individual adults (including independent youth) served with 

primary prevention services; and 

- Match individuals and families in the service database to the recipients of shelter 

services in the community during the six or 12 months following receipt of 
Appendix G Methods 

G–6

primary prevention services, or otherwise identify homelessness within a period 

following receipt of prevention services. 

The study team worked with the agencies responsible for the community approach to define 

common units of measure and to develop a plan to analyze program effectiveness. 

Exhibit G.3. Site Visit Protocol

CHECKLIST FOR INITIAL SITE VISITS 

□ Complete Site Visit Discussion Guide (attached) 

□ Begin developing technical assistance plan 

□ Tour prevention program facilities (if feasible) 

SITE VISIT DISCUSSION GUIDE 

Thank you for meeting with us. As you may recall, we are from WRMA/Urban Institute and are here visiting [name of this 

community] as part of a project funded by the U.S. Department of Housing and Urban Development (HUD). The goal of this 

study is to describe agencies or communities that have been successful in preventing homelessness. Our focus is on 

programs and communities that provide services to people who are at imminent risk of homelessness, i.e., about to 

become homeless if services are not provided. We are also interested in the way that your agency and community collect 

data and how these data may be analyzed to determine the success of your efforts at homelessness prevention. 

We are visiting six communities as part of this study and our report will identify each of these by name. We will not identify 

you individually without first giving you a chance to review materials and obtaining your consent. We appreciate your 

candor as you share your experiences and perspectives. 

Community-wide Approach 

1. What is your definition of “community-wide?” 

2. What is this community’s approach for preventing homelessness? 

• What is the goal of the approach? 

3. Who are the key players in the community’s approach to preventing homelessness? 

• What agencies or programs are involved and how? 

• What is the role of each? 

• What is your agency’s relationship with the continuum of care? 

4. Who coordinates and administers the community’s approach to preventing homelessness? 

5. How did the approach develop? 

• What were the issues or tensions, and what pushed things forward? 

• What were its steps toward getting to be the system it is today? 

• What are the perceived barriers to program effectiveness? 

• What are the controversial aspects of the approach and was there any opposition to it? 

Target Population 

6. How do your agency and your community define “imminent risk of homelessness?” 

• Do you serve only those at imminent risk of homelessness? 

• If no, who else do you serve? 

• How do your (primary) prevention activities relate to your other activities? 

7. Who do you serve? Do you have any special population focus? (If this agency or approach does not serve 

“everyone at risk,” ask question 9.) 
Appendix G Methods 

G–7

 

8. How are people identified or referred to your program? 

• Where do the people you serve for homelessness prevention come from? 

Self-referrals—How do they learn about the prevention services you offer? 

Referrals from other agencies—How do the agencies know about your services? 

Outreach you conduct yourselves—Where, when, to whom, please describe? 

• How do you identify persons who are at imminent risk of homelessness? 

What screeners do you use? What criteria? (get copy of screener) 

Who would you not serve? 

Do people have to meet every screening criterion? Are some more important than others? 

Do you have limits on the number of times a person can get prevention help? Other limits? 

Are the criteria the same for everyone, or are there some special criteria for different 

 subgroups? If different, for whom, and in what ways? 

9. How did you develop your criteria? Have they changed over the years? If yes, why? 

• Did you establish any of your current criteria because you had a sense that people who meet that 

criteria “do better” (are more likely to avoid homelessness) than those who don’t meet the criteria? If 

yes, which ones? 

10. If your agency only serves a particular population (e.g., families, singles, people with mental illness, youth), are 

there other systems in this community that have a focus on preventing homelessness among any of the types of 

people that you do not serve? 

• What are they and who do they serve? 

• How does your own system relate to those other systems? (e.g., cross-referrals, shared planning, 

shared resources, other) 

Operations 

11. What specific services do you provide to prevent homelessness? To what services do you refer clients? 

• Cash benefits 

□ Emergency assistance 

□ Rental assistance 

□ Security deposits/first month rent 

□ Moving assistance 

□ Preventing utility shut-off 

□ Public assistance 

□ Food 

□ Transportation 

• Services 

□ Crisis intervention 

□ Case management 

□ Negotiating with landlords 

□ Screening and referral for alcohol or drug treatment 

□ Mental health services 

□ Health services 

□ Employment services 

□ Domestic violence 

• Housing 

□ Emergency shelter 

□ Hotel/motel vouchers 

□ Transitional 

□ Permanent supportive 

□ Affordable housing 

• Other (specify) 
Appendix G Methods 

G–8

12. What type of staff provides these services? 

• Who are your staff? Background, training? 

• What is their caseload? 

• In what setting do you provide the services? (e.g., an entry point to homeless assistance services such 

as a family resource center, psychiatric institution, hospital, prison, a specialized court program, other) 

13. For approximately what length of time does a person receive services from your organization to prevent 

homelessness? 

14. How long has your organization been providing homelessness prevention services? 

• When you started, did you have what you have today? 

• If not, what has changed, approximately when, and why? 

Program Funding and History of Sources 

15. How is your organization’s approach currently funded? 

16. What is the funding history for the community’s approach to preventing homelessness? 

17. How many other agencies are involved in terms of providing staffing or funding? 

Data Systems and Documentation 

18. How does your organization document your services to prevent homelessness? 

19. In addition to basic information on clients and services, have you ever checked whether the people you help with 

prevention services actually manage to avoid homelessness? 

• If yes, how do you do this? 

• How are data collected and analyzed? What datasets do you use? 

• Do you follow up with clients who have received prevention services? If so, how and for what length of 

time? 

• Have any state or local evaluations been conducted? If so, what are the findings of those studies? 

20. Does a Homeless Management Information System exist capable of providing data over several years? 

• Could it be used to track whether a household helped by your agency subsequently became 

homeless? 

• Have you done this type of analysis? 

• What would be needed for you to do it? 

21. What are barriers to data collection and analysis regarding program effectiveness? 

Outcomes 

22. How does the agency know if homelessness has been prevented? 

• What outcome measures are used to determine prevention? 

• How are data analyzed to determine prevention? 

• What measure of prevention does the agency use? 

23. Is the success rate the same for the different types of persons who are identified? For example, does the 

program have the same success rate for individuals as well as families? 

24. Does the range of services or the service mix potentially influence the success rate? 

25. What other outcomes are measured? 
H–1

APPENDIX H 

GLOSSARY 

AAS Access to Alternative Services (Philadelphia) 

ADAPT Admissions, Discharges, and Planning Team (Philadelphia) 

ATARP Aggressive Treatment and Relapse Prevention Programs (Massachusetts) 

CAP Community Action Program 

CBH Community Behavioral Health (Philadelphia) 

CoC Continuum of Care 

CODAAP Coordinating Office of Drug, Alcohol, and Addiction Programs 

DHCD Massachusetts Department of Housing and Community Development 

DMH Massachusetts Department of Mental Health 

DMH/TS Department of Mental Health Transitional Shelter (Massachusetts) 

DMR Massachusetts Department of Mental Retardation 

DOL U.S. Department of Labor 

DPH Massachusetts Department of Public Health 

EC Employment Connections (Massachusetts) 

ESG Emergency Shelter Grant 

FCF Facilities Consolidation Fund (Massachusetts) 

FEMA Federal Emergency Management Agency 

FHPAP Family Homeless Prevention and Assistance Program (Hennepin County) 

GAF Global Assessment of Functioning 

GED General Educational Development 

HHS U.S. Department of Health and Human Services 

HI Special Initiative to House and Serve Homeless Persons with Mental Illness 

Homeless Initiative (Massachusetts) 

HMIS Homeless Management Information System 

HOC Housing Opportunities Commission 

HOT Homeless Outreach Team (Massachusetts) 

HSD Human Services Department (Hennepin County) 

HUD U.S. Department of Housing and Urban Development 

LIHEAP Low-Income Home Emergency Assistance Program 

MAAC Mid America Assistance Coalition 

MBHO Managed Behavioral Health Care (Philadelphia) 

MBHP Massachusetts Behavioral Health Partnership 

MCDHHS Montgomery County Department of Health and Human Services 

MHA Mental Health Association, Inc. (Massachusetts) 

MHFA Minnesota Housing Finance Agency 

MHSA Massachusetts Housing and Shelter Alliance 

OBH Office of Behavioral Health (Philadelphia) 

OCC Outreach Coordinating Center (Philadelphia) 

OMH Office of Mental Health (Philadelphia) 

PACT Programs for Assertive Community Treatment 

PATH Projects for Assistance in Transition from Homelessness 

PCCD Pennsylvania Council on Crime and Delinquency
Appendix H Glossary 

H–2

PMHCC Pennsylvania Mental Health Care Coordinating Council 

PSIC Peer Support in Aftercare (Massachusetts) 

RFP Request for Proposal 

SEE Services for Education and Employment (Massachusetts) 

SFY State Fiscal Year 

SHP HUD’s Supported Housing Program 

SSI Supplemental Security Income 

SSO Supported Housing Program, Services Only grant 

STAR Starting Treatment and Recovery (Urban Peak) 

TANF Temporary Assistance for Needy Families 

TLP Transitional Living Program 

TPP Tenancy Preservation Project (Massachusetts) 

UI Urban Institute 

VA U.S. Department of Veterans Affairs 

WRMA Walter R. McDonald & Associates, Inc. 
November 2005

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