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Blueprint for Change: Ending Chronic
Homelessness for Persons with Serious
Mental Illnesses and Co-Occurring Substance Use Disorders
Chapter 8: Use Mainstream Resources to Serve People Who Are Homeless
Homeless assistance programs alone cannot prevent or end homelessness (NAEH,
2000). Because most people who are homeless are eligible for, and many
already are clients of, mainstream service programs, Federal agencies,
states, and communities are actively pursuing ways to make mainstream
services more accessible, relevant, and appropriate for people who are
homeless. This has taken on new urgency with the Administration’s goal to
end chronic homelessness.
As noted previously in this report, people with serious mental illnesses
and/or co-occurring substance use disorders who are homeless are eligible
for a host of mainstream health, social service, and income support programs
that are intended to meet the needs of all low-income people, though many
are not receiving them. These resources are vital to provide needed services
and supports that will prevent people from becoming homeless or help them
exit homelessness. This chapter examines (1) the type of mainstream benefits
for which homeless people with serious mental illnesses and/or co-occurring
substance use disorders are eligible and (2) strategies for making
mainstream programs available and accessible to homeless people.
A Wide Range of Available Resources
The scope of "mainstream" resources varies depending on the agency or
group examining them. In a 1999 report, the GAO identified 50 Federal
programs administered by eight Federal agencies that can provide services to
homeless people. Of these 50 programs, 16 were targeted for homeless people,
and the remaining 34 were nontargeted, or were available to low-income
people generally (GAO, 1999a). These nontargeted resources are generally
referred to as "mainstream" programs.
In its report on mainstream systems and homelessness, the Charles and Helen
Schwab Foundation (2003) defined mainstream resources as:
…publicly funded programs which provide services, housing and income
supports to poor persons whether they are homeless or not. They include
programs providing welfare, health care, mental health care, substance abuse
treatment and veterans’ assistance (p. i).
Using this definition, the Foundation report cites the following mainstream
services as being critical for people who are homeless (CHSF, 2003, p. 2):
- Income support programs such as SSI and TANF and supplements such as Food
Stamps;
- Medicaid and other health insurance programs, including Community Health
Centers and health assistance through the VA;
- Mental health and substance abuse services funded through a variety of
Federal block grant programs;
- Workforce Initiative Act (WIA) programs designed to provide training and
secure employment for low-income workers receiving benefits; and
- Housing subsidy programs, such as Federal Housing Choice and public
housing.
Additional services that affect low-income people include public schools,
jails and prisons, child protective services, and foster care.
HHS Mainstream Programs
Of the 34 mainstream programs the GAO identified in 1999, 12 programs are
administered by HHS, the parent agency of SAMHSA. The HHS Secretary’s Workgroup
on Ending Chronic Homelessness identified eight of these programs as relevant to
meet the needs of disabled adults who make up the chronically homeless
population (HHS, 2003):
- Medicaid;
- TANF;
- Social Services Block Grant;
- Community Services Block Grant;
- Community Health Centers (including Migrant Health Centers);
- Ryan White Programs;
- Substance Abuse Prevention and Treatment Block Grant; and
- Community Mental Health Services Block Grant.
Within these programs, the workgroup found considerable opportunity for the
state or grant recipient to tailor service responses to the unique needs of beneficiaries, including people who are homeless. However, the group also
noted (HHS, 2003) that:
- All programs include restrictions on offering certain services. For
example, of the eight programs, only Medicaid is authorized to pay for
inpatient services.
- The most frequently offered core services (defined as those that are needed
to move people from the streets into housing and stabilize their conditions)
include information and referral, offered by all eight programs, followed by
outreach, supportive case management, and substance abuse services, offered by
seven programs.
- Of six supportive services identified as necessary to re-integrate
individuals into the community, only one—transportation—is offered by all
eight programs. Five of the programs provide all of the supportive services.
- None of the eight programs offer the entire group of core and supportive
services the workgroup identified as necessary to prevent and end homelessness
among people with serious health and behavioral health disorders.
Making Mainstream Services Work for Homeless People
Researchers, policymakers, and advocates who have examined the issue of using
mainstream resources to prevent and end homelessness have developed a set of
strategies useful both to homeless service providers and to those who administer
and fund mainstream programs. Generally, these strategies fall into six main
areas, including:
- Preventing homelessness among clients of mainstream programs;
- Improving access to mainstream resources for people who are homeless;
- Expanding the capacity of mainstream programs to serve people who are
homeless;
- Promoting coordination and collaboration among mainstream programs;
- Building the infrastructure of housing and services that homeless people
need; and
- Creating public awareness about mental illnesses, substance use disorders,
and homelessness.
Each of these strategies is discussed in brief below.
Prevent Homelessness
Homelessness prevention activities within mainstream programs hinge on the
fact that most people who become homeless already are clients of publicly funded
programs. If these programs don’t serve them appropriately, they are at greater
risk of homelessness. This is especially true for people with serious mental
illnesses and/or co-occurring substance use disorders.
Prevention activities may be as simple as the use of funds to prevent
eviction or to help an individual maintain his or her housing. For example, the
Massachusetts Public Housing Authority gives preference for Housing Choice
vouchers to applicants who are subject to a court-ordered eviction when the
applicant’s rent exceeds 40 percent of his or her income (CHSF, 2003). In
Minnesota, the state pays for up to 90 days of rental housing while an
individual with a serious mental illness receives inpatient treatment.
Improving discharge planning is a system-wide effort to prevent homelessness
for individuals being released from temporary housing, such as foster care,
jails, and psychiatric hospitals. The Massachusetts Housing and Shelter Alliance
(MHSA) discovered that many of its clients had been recently released from
institutional care. To improve discharge planning, the MHSA advocated for the
use of mainstream resources with the mental health, substance abuse treatment,
corrections, and foster care systems. The group’s success rests in part with its
ability to convince the state to evaluate agencies on new performance measures
that make homelessness a bad performance outcome (CHSF, 2003). For more
information, see
http://www.nhchc.org/discharge/discharge_planning_main.htm.
Improve Access to Mainstream Programs
Homeless people face numerous barriers to the receipt of mainstream
resources, including barriers that result from the condition of homelessness
itself, such as the lack of stable housing from which to receive services (CHSF,
2003). Further, the structure and operations of Federal mainstream programs
themselves create additional barriers to serving homeless people (GAO, 2000a).
In its recent report Ending Chronic Homelessness: Strategies for Action,
HHS proposed several approaches to improve access to mainstream housing and
supports for people who are chronically homeless (HHS, 2003). They include:
- Strengthening outreach and engagement activities. Mainstream programs
that support outreach and case management should be encouraged to identify
chronically homeless people as potentially eligible for these services. This
can be accomplished by out-stationing or co-locating staff from mainstream
programs in homeless service settings. For example, staff of the SSI Outreach
Project in Baltimore provide outreach to homeless people who are eligible for
SSI and help them through the application process. This began as a
demonstration program of SSA and continues today as its own program (CHSF,
2003).
- Simplifying application procedures. Complicated, redundant applications
for mainstream services pose a significant barrier to people with serious
mental illnesses or co-occurring disorders who are homeless. An expert panel
convened to advise the GAO on barriers to mainstream resources for homeless
people suggested the use of a single application form to gather basic
information required for most Federal programs (GAO, 2000a).
- Improving the eligibility review process. Lengthy application and
appeals processes increase the risk that an individual with a serious mental
illness or co-occurring substance use disorder will become or remain homeless.
The HHS report suggests that its Operating Divisions could establish an
interagency agreement with SSA to provide cross-training for people who work
with homeless individuals on appropriate medical documentation needed to
determine disability.
- Exploring ways to maintain program eligibility. Individuals with mental
illnesses and/or co-occurring substance use disorders may lose their benefits
when institutionalized in a hospital or jail, which makes them vulnerable to
homelessness when they leave the facility. HHS encourages states to not
terminate Medicaid eligibility for individuals who are institutionalized (HHS,
2003). In Massachusetts, prisoners can be deemed eligible for Medicaid while
still in prison and be automatically enrolled on the day of their release (CHSF,
2003).
Expand the Capacity of Mainstream Programs
The homeless service system that has emerged in the 16 years since the
original McKinney Act was enacted has compiled an impressive array of
evidence-based and promising practices to serve people with serious mental
illnesses and/or co-occurring substance use disorders who are homeless. The GAO
expert panel noted that Federal agencies could do more to incorporate into
mainstream programs the various lessons learned from McKinney-Vento Act programs
and demonstration projects targeted to homeless people (GAO, 2000a).
These lessons include the need to (1) integrate services, treatment, income,
and housing; (2) link to needed supports; (3) support access to a range of
housing options; (4) make services continuously available; and (5) involve
consumers in program design and evaluation (HomeBase, 2003). One way to increase
the capacity of the mainstream system to provide these services is through the
use of training and technical assistance.
For example, HHS recommends training and technical assistance for mainstream
service providers on steps that can be taken to end chronic homelessness (HHS,
2003). The State Policy Academies sponsored by HHS and HUD are another example
of capacity building. The Policy Academies are designed to help States develop
and implement State-specific action plans to identify and address chronic
homelessness.
HHS also recommends the use of toolkits and blueprints as technical
assistance aids. To this end, HHS and HUD are developing a comprehensive tool to
educate and raise awareness among homeless service providers and homeless
individuals about various Federal mainstream benefit programs that homeless
individuals are eligible for.
Finally, the GAO expert panel called for mainstream providers at the Federal,
state, and local levels to be held accountable for serving homeless people,
including the development of a set of minimum standards for using program funds
(GAO, 2000a). The development and use of homeless-specific outcome measures by
mainstream programs will allow the agencies that fund these services to
determine how well they serve people with serious mental illnesses and/or
co-occurring substance use disorders who are homeless.
Promote Coordination and Collaboration
The need for greater collaboration among mainstream services on behalf of
people who are homeless was one of three top goals cited by HHS in its report on
ending chronic homelessness (HHS, 2003). The workgroup that prepared the report
recommended, among other strategies that HHS:
- Provide incentives for states and localities to coordinate services and
housing. One such incentive, for example, might be the ability to use
grant funds to support interagency efforts that address chronic homelessness.
- Reward coordination across HHS assistance programs to address chronic
homelessness. The HHS workgroup proposed, as an example, an incentive
program in which States submitting block grant applications that demonstrate a
coordinated set of activities across mainstream programs to address chronic
homelessness would be eligible for a partial bonus payment up front, with the
balance of the bonus based on the achievement of selected performance goals.
- Permit flexibility in paying for services to individuals experiencing
chronic homelessness. This might be accomplished by allowing states to
blend a portion of funds from multiple, relevant HHS assistance programs to
target homelessness.
Public systems currently are overburdened and underfunded, making it
difficult for them to serve current clients, much less meet increased demands (CHSF,
2003). In the absence of incentives such as those recommended by the HHS
workgroup, they rely on the homeless service system to meet the needs of those
individuals who have complex problems (NAEH, 2000).
In addition, restrictive eligibility criteria and separate funding streams
make it difficult for mainstream programs to cooperate with one another on
behalf of people with multiple conditions. However, numerous reports cite
examples of innovative financing and program models that serve individuals whose
problems cross service system boundaries (e.g., SAMHSA, 2002b; NASMHPD and
NASADAD, 2002).
As an outgrowth of its report to Congress on the prevention and treatment of
co-occurring mental illnesses and substance use disorders, SAMHSA will
disseminate strategies that States and communities have used to address this
growing problem. These include strategies to build consensus around the need for
an integrated response to the prevention and treatment of co-occurring
disorders; to develop aggregated funding mechanisms; to cross-train staff; and
to measure success by improvements in client functioning and quality of life.
Build the Infrastructure of Housing and Services
Improving access and coordinating services will be of little use unless there
is a full range of housing and services available to which homeless people can
be referred. The National Alliance to End Homelessness makes this clear in its
report A Plan: Not a Dream. How to End Homelessness in Ten Years (NAEH,
2000). "Attempts to change the homeless assistance system must take place within
the context of larger efforts to help very poor people," the report notes (p.
2).
In particular, the National Alliance calls for an increase in affordable
housing units, an increase in wages that will allow workers to afford housing
and needed services, and increases in the availability of such services as
mental health and substance abuse treatment and child care. Some additional
suggestion follow.
- Increased entitlements and health insurance benefits. Many people with
serious mental illnesses and/or co-occurring substance use disorders depend on
SSI and/or SSDI, and the corresponding health insurance programs, Medicaid and
Medicare, respectively. Any increases in these vital benefit programs will
help lift these individuals out of poverty and improve their chances of
maintaining residential and psychiatric stability.
- Improved work incentives. People with serious mental illnesses or
co-occurring disorders who are homeless often are afraid to work for fear of
losing public benefits, especially health insurance. Though the Ticket to Work
and Work Incentives Improvement Act of 1999 addressed some of these issues,
questions remain about the usefulness of these incentives for people who are
homeless (HRSA BPHC, 2000). Advocates can monitor implementation of this
legislation to be certain that people who are homeless are able to take full
advantage of its provisions.
- Increased housing subsidies. Housing subsidies alone won’t solve the
problem of homelessness among people with serious mental illnesses and/or
co-occurring substance use disorders, especially where affordable housing is
in short supply. Yet research reveals that housing subsidies can help people
with serious mental illnesses and/or co-occurring substance use disorders who
are homeless find independent living arrangements (CMHS, 1994).
Create Public Awareness
Individuals who understand that, with appropriate treatment and support, most
people with serious mental illnesses or co-occurring disorders can and do
recover may be less likely to discriminate against individuals who have these
diseases. Some effective strategies include:
- Education about the nature of serious mental illnesses and substance use
disorders. Be certain to include the perspective of consumers and
recovering persons in all written materials and public forums. Their stories
provide powerful testimonies about the strength and resiliency of the human
spirit.
- Education about the causes of homelessness and ways to prevent and end
homelessness. Get the word out to the public and your legislators that
we know what works. This can be as simple, yet powerful, as inviting a
lawmaker to spend a few hours in a shelter or drop-in center. Invite the media
to record the event.
- Community integration of all people with disabilities. This Nation is
poised to improve the lives of all people with disabilities by redoubling its
efforts to seek full community integration in housing, employment, and social
activities. Take advantage of this momentum to be certain that people with
serious mental illnesses and substance use disorders who are homeless benefit
fully from these efforts.
Moving Forward
Throughout this Blueprint, the message is clear: We know what works
to end homelessness among people with serious mental illnesses and/or
co-occurring substance use disorders. The time has come to put what we know
to work.
This Nation has learned much and accomplished much since publication in 1992
of Outcasts on Main Street. However, the work is not done. There
is an urgent need, through research and services, to continue to discover the
most effective combination of treatment, housing, and supports that will end the
cycle of homelessness for people who have serious mental illnesses and/or
co-occurring substance use disorders.
The guidance and action steps highlighted in this report are an important
first step.
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