A Message to Continuum of Care & Ten-Year Plan Leaders from Barbara Poppe

Not long ago, I sat in the same place that you are sitting, managing the Continuum of Care and leading our community's ten-year plan to end homelessness. You have challenging jobs to do and I know you are balancing many competing issues and priorities. I've been fortunate to visit communities that are making great progress, and to support and work with communities that still struggle. Now I would like to share some reflections on the lessons I've learned from you, my colleagues, in our mission to end homelessness. Thank you for listening and especially for acting.

Today I want to address chronic homelessness, which is the first goal in Opening Doors. We have fewer than 1,000 days to bring the number of people experiencing chronic homelessness to zero; every day and every minute counts. For people living with disabilities and disabling conditions, every day or minute spent on the streets is another day or minute spent struggling to survive.   So this message is a call to action.  I am reaching out to ask, are we doing everything we can do to end chronic homelessness by 2015?  Here are the top-ten questions you and the leaders of your ten-year plan should consider (not likely to be picked up by David Letterman but hopefully useful nonetheless): 

1) Do you rank permanent supportive housing grantees in the funding competition based on how well they serve people experiencing chronic homelessness (both in terms of targeting/prioritization and reducing barriers to admission)?

2) Have you established a centralized or coordinated entry system for permanent supportive housing with a streamlined process for application and approval, and a community-wide policy where the highest need, longest-term eligible applicants are given priority?

3) If you have established a prioritization system for permanent supportive housing, are certain programs ranked higher based on participation in this coordinated system over those that do not?

4) Do you have a plan to convert or reallocate grants from single adult transitional housing and services to expand the availability of permanent supportive housing?

5) Have you and the leaders of your ten-year plan reviewed the application and entry process for permanent support housing from the perspective of the person experiencing chronic homelessness to determine if it is client-centered, streamlined, and minimizes time spent homeless?  Are interim housing situations available while people await permanent housing placement?

6) Have you organized outreach and client-engagement services that identify people experiencing chronic homelessness? Have you included people who are vulnerable or are frequent users of high-cost public services?  Are hospitals, emergency rooms, jails, substance abuse programs, and health centers been identifying people experiencing chronic homelessness and connecting them to your system?

7) Have you identified need for permanent supportive housing based on the number of people still experiencing chronic homelessness? Have you determined how to meet this need by placing people experiencing chronic homelessness in units that become vacant from natural turnover? Are you creating more units?

8) Are you bringing all of your community's homeless providers that receive targeted homeless assistance funds to the table, such as those organizations receiving  Health Care for the Homeless grants, Projects for Assistance in Transition from Homelessness grants, Cooperative Agreements for the Benefit of Homeless Individuals, and Continuum of Care resources?

9) Have all possible mainstream resources been explored and fully leveraged for both housing and services? Has the public housing agency been engaged to provide vouchers for permanent supportive housing?

10) Have you explored how Medicaid can finance services in permanent supportive housing? Have you discussed how to better integrate health care with housing under health reform?

Proof of Concept: Communities on Track to End Chronic Homelessness 

USICH recognizes that the hard work of ending chronic homelessness ultimately happens at the state and community levels. While shrinking federal resources present challenges, communities are demonstrating that they can still make progress on ending chronic homelessness.

The 2012 Point-in-Time (PIT) count showed that the nation as a whole is currently not on track to meet the the goal of end chronic homelessness by 2015. At the same time, many communities have bucked the national trend and demonstrated that ending chronic homelessness is achievable. USICH identified seven Continuum of Care communities that represented metropolitan areas from a variety of geographic contexts that achieved notable reductions in chronic homelessness (not attributable to count methodology changes) between 2010 and 2012. These communities include Boston, MA; Minneapolis/Hennepin County, MN; New Orleans/Jefferson Parish, LA; Michigan Balance of State (BOS); Milwaukee, WI; the State of Utah; and Worcester City/County, MA:

 Exhibit 2.

What accounted for the reductions in chronic homelessness in these communities? To answer this question, the U.S. Interagency Council on Homelessness (USICH) conducted a telephone survey of these seven communities asking them to identify the factors and practices key to their successes. These surveys confirmed that the key ingredients for success in ending chronic homelessness at the local level are:

Collaborative goal setting and collective action

Communities attributed their success to the setting and adoption of a shared goal among key stakeholders to end chronic homelessness, including specific numeric "take-down" targets for achieving this goal. This shared goal was often codified in a plan to end homelessness, and efforts towards this shared goal were typically led and coordinated by a local or state interagency council on homelessness who also served as, or coordinated closely with, the local Continuum of Care (CoC) lead agency.  Five communities had annual goals for ending chronic homelessness either expressed in terms of reducing the number of people experiencing chronic homelessness each year or increasing the number of permanent supportive housing units created each year. For example, Utah's statewide ten-year plan, developed in partnership with twelve Local Homeless Coordinating Committees across the state, included a goal of ending chronic homelessness, and included a specific commitment from the Lieutenant Governor to create several hundred permanent supportive housing units.

Increasing permanent supportive housing (PSH) using all available resources

Critical to communities' success was the focus on increasing permanent supportive housing availability through the leveraging of targeted homelessness grants (e.g. CoC funding and HUD-VASH) as well as mainstream housing resources including local and state funds, tax credits, HOME, Community Development Block Grants (CDBG), and Neighborhood Stabilization Program funds.  Public housing authorities (PHAs), mental health service organizations, other homeless service providers, and private developers played an important role in increasing PSH in these communities. In four of the seven communities, PHAs had either adopted a homeless preference and/or instituted policies to reduce barriers (e.g., criminal history, prior evictions) for people experiencing chronic homelessness. PHAs in these communities created homelessness preferences to increase the availability of Housing Choice Vouchers and/or public housing units for people experiencing chronic homelessness. Where the PHAs were involved they took the primary lead in developing chronic homeless housing units and for the other locations the housing development was accomplished by other homeless service providers and/or private developers. Boston noted that "at the center is the Boston Housing Authority which has been willing to innovate and has used existing housing stock for a homeless preference."  (Click here for new HUD Notice on how PHAs can help end homelessness)

Data-driven performance measurement and improvements

All seven communities emphasized the importance of data as a tool for ending chronic homelessness, specifically where Homeless Management Information Systems (HMIS) and the PIT count data are used to evaluate and improve the performance of their homeless programs and service delivery systems, as well as to inform funding and resource allocation decisions. In addition, communities used PIT count data to track their progress, determine if corrections were needed, and to improve the identification and rapid connection to housing of people experiencing chronic homelessness. The State of Utah uses PIT count data, and increasingly HMIS data, in order to set annual goals for PSH creation, measure system performance, and make decisions regarding funding. As of the 2012 PIT, Utah experienced a 72 percent reduction compared with the 2005 PIT for chronic homelessness.

Targeting and prioritizing individuals experiencing chronic homelessness

Nearly all of the communities intentionally used HMIS or other data to identify and prioritize individuals experiencing chronic homelessness for permanent supportive housing. This prioritization was made on the basis of individuals' length of homelessness or shelter use (as verified in HMIS), vulnerability (as measured by a vulnerability index or assessment tool), or the utilization of public services such as hospital emergency departments. Communities like New Orleans and Boston prioritized individuals for PSH access using a combination of these characteristics. In addition, some of the communities incorporated this prioritization policy as part of a centralized application and intake process for permanent supportive housing. As the contact for the New Orleans/Jefferson Parish CoC noted, "You will never end homelessness without sorting out who is the most vulnerable and getting them into housing." (See below for more information on how communities are prioritizing supportive housing)

Local government commitment and support

All of the communities cited the importance of local political support for the goal of ending chronic homelessness, and for reinforcing the importance of collective action and alignment of resources. Communities spoke about the role of the commitment of local elected officials, as well as the importance of intergovernmental cooperation, such as between city and county agencies and departments. Several communities indicated the instrumental role that mayors and municipal/county chief executives have and continue to play in ending chronic homelessness. Milwaukee cited one of the reasons for a reduction was "there is a good collaboration between city and county... both Mayor and County Executive are engaged."  In Boston, the city leadership council on homelessness is appointed by Mayor Thomas Menino and progress is reviewed with the mayor and the committee on a quarterly basis.

These communities and many others are demonstrating that ending chronic homelessness is within reach.  Moreover, while this survey was neither large in sample nor rigorously designed, it nonetheless points to some of the most important ingredients that can lead to success in ending chronic homelessness. USICH looks forward to hearing about more communities who are "driving towards zero" and ensuring that homelessness is ended for the most vulnerable and longest-term people experiencing homelessness.

For more resources on meeting the goal of ending chronic homelessness, please visit the USICH Solutions Database and Tools for Local Action.

Chattanooga, New Orleans, and Columbus are examples of communities that target housing to people experiencing chronic homelessness.

Several years ago, the national effort to end homelessness experienced a significant paradigm shift with the recognition that ending homelessness meant finding ways to identify and prioritize the subset of people experiencing homelessness that have the highest needs and who have been homeless most persistently. (Read the blog from USICH Policy Director Richard Cho for more about this shift.) Since that realization, communities across the country have been developing innovative tools and approaches to prioritizing individuals experiencing chronic homelessness with the highest level of need for permanent supportive housing. These tools and approaches vary, but all share in common the goal of identifying people who are most persistently homeless, most vulnerable, and/or highest cost and placing them at the front of the line to receive housing. Among the innovative tools and approaches include:

HMIS analysis to identify long-term homeless - Homeless Management Information Systems (HMIS) contain data that can be used for targeting, including information on health challenges, disabilities, length of time in shelter, and number of times in shelter. Communities can use this data to sort and prioritize individuals for permanent supportive housing (PSH). For example, a community may select all the records on individuals reporting disabilities in their HMIS and sort them based on their lengths of stay or number of episodes. They can then work with housing providers to ensure that available PSH is offered to individuals in the top 10 percent or quarter, or equal to the number of unit about to become available in a new project.

Innovator: Chattanooga, Tennessee

Chattanooga has used HMIS analyses to identify and prioritize people experiencing chronic homelessness and provide them with permanent supportive housing. Through this approach, Chattanooga experienced an 89 percent decrease in chronic homelessness from 2007 to 2011. 

Vulnerability indices and assessment tools - These clinically-oriented questionnaires seek to identify the subset of people experiencing homelessness, who are most vulnerable, measured in terms of a set of social, clinical, and health challenges. Some tools focus on health conditions that increase the risk of mortality for people experiencing homelessness while others focus on both health and functional challenges. The best known examples of these are Community Solutions' Vulnerability Index and Downtown Emergency Service Center's Vulnerability Assessment Tool.

Innovator: New Orleans, Louisiana

In the City of New Orleans, UNITY, the Continuum of Care lead agency, and their partners have been working with the community to use Community Solutions' Vulnerability Index to prioritize people for access to permanent supportive housing. The Vulnerability Index was paired with the recent Point in Time Count. As interviewers met people experiencing chronic homelessness, they sat with them for 20 minutes to learn about their needs. A team of agencies then use the working list to enable people most in need to access housing as it becomes available, thus causing a meaningful trajectory towards the goal of ending chronic homelessness.

Targeting on high service utilization and costs - Many communities use data from public service systems like jails, homeless services, hospitals, and Medicaid to identify the subset of people experiencing homelessness who are high utilizers of emergency public services. The premise behind these approaches is that priority for housing should be given to individuals who are caught in a revolving door of crisis and who also drive up public costs as a result. While some communities use a simple cross-match of data between HMIS and health care or corrections data, other communities use more sophisticated predictive algorithms that help to select individuals who are expected to continue their pattern of high utilization. Examples of these approaches include: King County (WA)'s Client Care Coordination High Utilizer Database Project, the Economic Roundtable's 10th Decile Triage Tool, and the Corporation for Supportive Housing's Frequent User Systems Engagement project.

Innovator: Columbus, Ohio

One example of a community that has combined these approaches and adopted them as a system-wide approach is Columbus/Franklin County, Ohio.  As part of a larger effort to make the permanent supportive housing entry process more efficient, streamlined, and client-centered for the most vulnerable and high-need people experiencing homelessness, the Alcohol, Drug, and Mental Health Board of Franklin County (ADAMH), the Columbus Metropolitan Housing Authority (CMHA) and the Community Shelter Board (CSB) developed and implemented the Unified Supportive Housing System (USHS). USHS is a streamlined and centralized system for supportive housing entry and vacancy management that includes a unified application, a streamlined application and approval process, and a system for prioritizing highest-need individuals. Through data matching by the ADAMH Board, USHS prioritizes eligible applicants on the basis of their behavioral health services utilization and length of homelessness. In addition, USHS also prioritizes individuals who may not be known to the behavioral health system but who nonetheless have high needs, as assessed using a vulnerability assessment tool.  At full implementation the USHS could include over 1600 units of supportive housing currently in Franklin County.

USICH applauds the efforts by communities to develop and use innovative tools and approaches to ensure that the highest need, most vulnerable, and most costly individuals experiencing chronic homelessness obtain the permanent housing and services they need.

Find more community innovations by exploring the Solutions Database 

New research and tools are now available to help your community implement the proven solution of Housing First.

An essential component in the effort to end chronic homelessness is the Housing First approach, in which individuals and families experiencing homelessness are given immediate access to permanent affordable or supportive housing with minimal barriers and clinical prerequisites like completion of a course of treatment or evidence of sobriety. The evidence on Housing First is clear: people stay housed longer, do not return to homelessness, and decrease their use of crisis services and institutions.

More and more, communities today are adopting the Housing First approach in their efforts to end all types of homelessness, including chronic homelessness.  Meanwhile, the body of evidence and knowledge around Housing First available to help communities adopt this approach continues to grow. Some of the latest additions to this body are research and tools that begin to define the critical components of Housing First and provide lessons for how to implement the model. Taken together, these resources contribute to a better understanding of what Housing First really means in practice and how communities and providers can implement it:

USICH's Housing First Checklist: USICH has created an easy-to-use tool for policymakers and practitioners to identify and assess whether a program or community is using a Housing First approach. This three-page tool breaks down the Housing First approach into distinguishing components at both the program and community levels.

Unlocking the Door: An Implementation Evaluation of Supportive Housing for Active Substance Users in New York City- The National Center on Addiction and Substance Abuse at Columbia University and the Corporation for Supportive Housing evaluated the implementation of nine scattered-site Housing First permanent supportive housing programs serving approximately 500 people experiencing chronic homelessness with active substance abuse disorders in New York City. The report concludes with useful lessons for what is critical to implementing a Housing First permanent supportive housing model. A full impact evaluation of these programs will be completed later in 2013. Preliminary findings indicate that the programs were successful in helping people exit homelessness, remain stably housed, and reduce their use of emergency services.

The Housing First Fidelity model index- In the April 2013 edition of Substance Abuse Treatment, Prevention, and Policy, Watson and colleagues (2013) discuss the development and testing of their Housing First Fidelity instrument. The study finds that the instrument is effective in assessing the quality of Housing First programs and for making implementation decisions.

Pathways to Housing - Housing First Model - Pathways to Housing produced a step-by-step manual presents a comprehensive guide to Pathways to Housing's Housing First approach.

Did you miss our webinar on Housing First?  Check it out here.

Reliable Financing for Reliable Supports: Medicaid's Role in Ending Chronic Homelessness

At the center of efforts to end chronic homelessness is permanent supportive housing (PSH), a proven, cost-effective housing model designed to help people with the most severe challenges attain housing stability and exit homelessness. What makes PSH so successful is that it enhances affordable housing with assertive and individualized case management services that promote housing stability and link tenants to needed clinical services, health care, and other social services. Ironically, however, communities have never had a simple and straightforward way to finance the "support" in supportive housing. PSH providers have had to patch together funding a variety of public and private sources to create these services (many funding streams for services are limited to people with only certain health conditions), and as a result, the approach to financing PSH services and the quality and consistency of services may vary greatly from one community to another. 

To overcome these challenges, communities are increasingly looking to Medicaid as a way to finance services in PSH. A health insurance program for people in poverty, Medicaid is able to cover certain case management and care coordination services, such as those provided in permanent supportive housing. As a Federal entitlement, Medicaid has the potential for being a more reliable and stable source of financing of PSH services. Many states and communities have already been able to cover PSH services under Medicaid, typically through Assertive Community Treatment teams or through options or waivers such as the Home and Community Based Services waivers. 

The Affordable Care Act (ACA) only further increases the opportunities to finance services in PSH through Medicaid. The expansion of Medicaid eligibility means that more people experiencing homelessness can be covered under Medicaid; in states that choose to expand Medicaid, virtually 100 percent of people experiencing homelessness will become Medicaid eligible simply by virtue of their extremely low-incomes. Moreover, the ACA includes provisions that look to improve the quality and approach to care delivery place greater emphasis on addressing social determinants of health (including housing instability) and on the role of care coordination and "high touch" case management services in improving health. New Medicaid state plan options like Health Homes encourage the creation of collaborations between health care providers and social services providers, including PSH providers. 

In short, while Medicaid has been available as a way to finance services in PSH prior to the ACA, Medicaid may have covered only certain services, provided by certain providers, and for only subsets of people experiencing chronic homelessness. The ACA now opens the door for Medicaid to cover a greater range of PSH services, provided by Medicaid-eligible provider networks, and for nearly all people experiencing chronic homelessness set of PSH services.

The ACA opens the door; it is left to states, communities, and providers to decide to walk through it.  The following resources may be useful to states, communities, and providers exploring how Medicaid can help finance services that support housing stability in PSH:

• The U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation published Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Literature Synthesis and Environmental Scan, a comprehensive overview of ways that Medicaid can finance services in permanent supportive housing. 

• Leveraging Medicaid, a joint publication of the Technical Assistance Collaborative and the Corporation for Supportive Housing, provides an in-depth overview of Medicaid authorities that can cover services in PSH, including a crosswalk of the set of services provided in PSH and those coverable under various Medicaid authorities.  Developed prior to the Affordable Care Act, this document does not contain some of the more recent advancements such as the Health Homes state plan option.

• The Center for Health Care Strategies and the Corporation for Supportive Housing developed a policy brief that lays out a "business case" for why states should finance PSH services through Medicaid to end homelessness, improve health outcomes, and lower costs among high-need Medicaid beneficiaries experiencing homelessness.  The brief also contains a summary of some of the evidence on PSH's potential to improve health and achieve cost offsets.

• This issue brief from the Technical Assistance Collaborative describes how various Medicaid authorities were adopted by the State of Louisiana to cover services in 3,000 PSH units.

Stay tuned to www.usich.gov for updates and forthcoming information on how Medicaid can help finance PSH services.

Department of Housing and 

  

Read the full press release from HUD and access the guidance

HUD Releases Notice on Public Housing Authorities' Strategies in Expanding Housing Options to Individuals and Families Experiencing Homelessness

  

On Monday, June 10, 2013, the HUD's Office of Public and Indian Housing (PIH) released a new Notice outlining strategies that Public Housing Authorities (PHAs) can pursue to expand housing options for individuals and families experiencing homelessness. This Notice clarifies the definition of homelessness for the purpose of IMS/PIC reporting, and provides guidance on HUD policies and program regulations related to the following topics: waiting list management and preferences; admissions policies regarding criminal activity, substance use/abuse, and rental history; program termination and eviction policies; and project-basing vouchers for Permanent Supportive Housing (PSH). 

   

Access the Notice

 

  

 

Department of Health and Human Services