Is Housing First the Best Policy Approach to Homelessness?

A Policy Analysis:

Jim Wheeler

A Thesis Submitted to the Department of Public Policy and Administration School of Business and Administration California State University Bakersfield In Partial Fulfillment for the Degree of

Masters of Public Administration

Winter 2012

A Policy Analysis: Is Housing First the Best Policy Approach to Homelessness? by Jim Wheeler

This thesis or project has been accepted on behalf of the Department of Public Policy and Administration by their supervisory committee:

“Instead of serving homeless people endlessly, our mission is to end their homelessness.”

--- Philip F. Mangano, Former Executive Director, U.S Interagency Council on Homelessness.

This paper is dedicated to my friends and colleagues of the Kern County Homeless Collaborative. Your tireless effort to end homelessness in Kern County serves as a shining-light for other jurisdictions to follow. You have made many sacrifices in order to accommodate federal homeless policy and your willingness to adapt in order to bring funding to our community is inspiring. It has been an honor to work with you. I pray that you experience continued success with your mission to end homelessness in our community.

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TABLE OF CONTENTS

DEDICATION…………………………………………………………………………..………..iii

TABLE OF CONTENTS………………………………………………………………………...iv

EXECITIVE SUMMARY……………………………………………………………………...... vi

Chapter One: Introduction

Background……………………………………………………………………..…………1

Narrowing the Focus…………………………………………………………………..….2

Housing First……………………………………………………………………………...4

Statement of the Problem………………………………………………………………....6

Purpose of the Study………………………………………………………………….…..7

Importance of the Study……………………………………………………………….…8

Chapter Two: Literature Review

Housing First……………………………………………………………………………...9

HPRP and the HEARTH Act…………………………………………………….……...12

Prevention…………………………………………………………………………….….14

Summary……………………………………………………………………………....…18

Chapter Three: Policy Alternatives

Continue with Housing First………………………………………………………...…...20

Fully Implement the HEARTH Act……………………………………………………...23

Implement a Hybrid Policy……………………………………………….………...……27

Summary……………………………………………………………………………..…..30

Chapter Four: Selection of Alternative

Evaluation Criteria………………………………………………………...... 33

Proposed Alternatives…………………………………………………………………..35

Selection of the Alternative…………………………………………………………….40

Chapter Five: Summary, Recommendations and Conclusion

Summary………………………………………………………………………………..42

Recommendations………………………………………………………………………43

Conclusion…………………………………………………………………………...…44

REFERENCES………………………………………………………………………………….45

APPENDIX A: IRB APPROVAL……………………………………………………………….48

EXECUTIVE SUMMARY

Prior to 2000 most of the national conversation concerning homelessness revolved around approaches that focused on managing homelessness. Very few considered the idea that we could end homelessness. In 2000, the National Alliance to End Homelessness (NAEH) developed and distributed a 10-year plan to end homelessness altogether. This goal caught the attention of members of the Bush Administration which in turn made ending homelessness their goal. In particular, they focused on the chronic homeless population with a strategy called

“housing first.” Housing first has been the de facto homeless policy for the last decade.

While apparently successful in reducing the chronic homeless population several concerns have been raised about this policy, namely, the justification of time and resources to focus on the chronically homeless which make up only 17 percent of the homeless population.

Additional concerns have been raised about the adaptability of the policy to include families, children and youth and whether current policy and resources should be shifted toward preventing homelessness.

This paper looked at those questions and then researched possible alternatives that might be implemented to make homeless policy more comprehensive. An analysis of those alternatives was based on three criteria: the political priorities of the current Administration, fiscal constraints due to the current financial mood of the country and external factors relating to recent lessons learned and homeless services best practices. This analysis resulted in the recommendation that the best policy approach would be one that incorporates elements of housing first but also includes a greater emphasis on homelessness prevention and rapid rehousing. With this policy in place, the dream of ending homelessness could be within reach.

CHAPTER 1 – INTRODUCTION

Background

Prior to 2000 most of the national conversation concerning homelessness revolved

around approaches that focused on managing homelessness. Very few considered the idea that

we could end homelessness. Then in June of 2000, the National Alliance to End Homelessness

(NAEH) developed and distributed a 10-year plan to end homelessness altogether (National

Alliance to End Homelessness [NAEH], June 1, 2000, p. 1). The goal caught the attention of

Housing and Urban Development (HUD) Secretary Mel Martinez, who endorsed it in a keynote address at the NAEH’s 2001 conference (Jones, 2005, p. 1). Buy-in from the Secretary was

critical to promoting the concept, because HUD is one of the main federal agencies responsible

for funding and overseeing homeless assistance programs.

Additionally, two other steps were taken by the Bush administration to show their

commitment to the concept of ending homelessness. First, the president revitalized the United

States Interagency Council on Homelessness (USICH), which had been dormant for the

preceding six years. The Council was charged with coordinating 18 federal departments and

agencies in an effort to create “innovative initiatives that will bring change in the lives of those

who are homeless and at risk of homelessness and change on the streets of our country” (Jones,

2005, p. 1). Wasting little time, the USICH and HUD began promoting and implementing the

policy. Second, in 2002, President Bush put action behind his administration’s words by making

the goal of ending homelessness a “top objective” in his FY 2003 Budget (Homelessness in the

United States, n.d.).

In 2003, the U. S. Conference of Mayors adopted the goal of ending chronic

homelessness, after being challenged to do so by USICH Director, Philip Mangano (National

Alliance to End Homelessness [NAEH], n.d., p. 1). Mangano also challenged local cities and

counties to develop their own 10-year plans to end chronic homelessness and by 2004 nearly 150

had started the planning process.

In late 2005, Bakersfield Mayor Harvey Hall convened a committee of service providers

and local government agency representatives to begin work on a 10-year plan for Bakersfield and

Kern County. With assistance from United Way of Kern County (UWKC), and the Kern County

Homeless Collaborative (KCHC), the committee, made up of more than 35 partners from the

nonprofit, government, faith and business communities began its work. With funding and

technical help from HUD, and at the urging of USICH, the 10-Year Plan Committee began work on Home First! Kern County’s 10-Year Plan to End Chronic Homelessness (Kern County’s 10-

Year Plan Committee, 2008, Preface 4). Completed in June of 2008, Home First! serves as a consensus blueprint for dealing with the issues of homelessness in Kern County.

Narrowing the Focus

While the NAEHs 10-year plan was a call to end homelessness in general, most 10-year

plans quickly began to focus on a smaller segment of the homeless population known as the

chronically homeless. In recent years, the homeless have come to be divided into three

subgroups: the transitionally homeless, the episodically homeless and the chronically homeless.

These subgroups were identified largely based on research done by Kuhn and Culhane and were

based on patterns of homeless behavior (Burt & Spellman, 2007).

Transitionally homeless. The transitionally homeless make up about 80% of the homeless

population at any given time (Jones, 2005). They are those who are temporarily homeless. These

people may experience one or two short episodes of homelessness in their lifetime and most

causes are related to temporary set-backs, such as, the loss of a job or a medical emergency or an

unexpected crisis. Typically, they are able to secure permanent housing in less than a month

(Jones, 2005).

Episodically homeless. The episodically homeless tend to be younger and shuttle among

various institutions including jail, detoxification centers, residential treatment facilities and

hospitals (Kern County 10-Year Plan Committee, 2008, p. 14). Because they find themselves in a

repeating pattern of addiction, they tend to experience episodes of homelessness. This subgroup

makes up about 10% of the homeless population (Jones, 2005).

Chronically homeless. Ironically, the subgroup that the federal government and the

homeless service system chose to focus on is the most hardcore of the homeless. The chronically

homeless are the most visible segment of the homeless population and the focus of much of the

community’s frustration with homelessness due to their habitation of public places and their non-

conforming behavior (Kern County 10-Year Plan Committee, 2008, p. 15). They can be found living in the streets, under bridges, and in makeshift cardboard houses. They can be seen panhandling, collecting cans and pushing shopping carts piled high with their possessions (Jones,

2005). By definition, the chronically homeless are unaccompanied adults who have a mental

health or other disabling condition and who have had numerous and long term episodes of

homelessness.

Most chronically homeless individuals suffer from several overlapping conditions that

have led to their ongoing destructive behavior. These destructive behaviors result in “poor

educational achievement, an unstable work history, dependence on drugs or alcohol, criminal

activity leading to incarceration, and frequent hospitalization” (Jones, 2005).

A landmark study of homeless people with serious mental illness in New York City

found that on average, each chronically homeless person utilized over $40,000 annually in

4 publicly funded services, such as shelters, hospitals, emergency rooms, prisons, and jails. When people were placed in permanent supportive housing (PSH), the public cost to these systems declined dramatically (Kern County 10-Year Plan Committee, 2008, p. 6-7). The documented cost reductions—$16,282 per unit of permanent supportive housing—were nearly enough to pay for the permanent supportive housing. If other costs, such as the costs of police and court resources and homeless services were included, the cost savings of permanent supportive housing would likely have been higher (NAEH, April 24, 2007, p. 2).

This study served as an impetus for the development of a new model to deal with homelessness in general and chronic homelessness in particular. This new model is called a housing first approach. This approach is designed to transition the homeless away from emergency and transitional housing to permanent supportive housing as quickly as possible

(Kern County 10-Year Plan Committee, 2008, p. 5-6).

Housing First

The former system – which moved people from emergency shelters, to short term shelters, to transitional housing, to permanent housing – worked well for some in the homeless population, but for others it sent them back out to the streets and ultimately back through the same system again. This process is costly, ineffective for meeting and managing the special needs of the chronically or permanently homeless, and generally inefficient.

Much of the spending on homelessness was aimed at providing emergency services and shelter to the homeless with less emphasis on developing permanent housing solutions. The resultant cycle of shuffling people from service to service led many into chronic or permanent homelessness. The housing first approach is designed to transition the homeless away from

5 emergency and transitional housing (sometimes referred to as a housing readiness approach) to permanent supportive housing.

In the housing readiness model, people move along the Continuum of Care when they are

“ready” or “eligible” for a specific type of housing, usually by articulating a desire for change or agreeing to comply with eligibility requirements. The chronically homeless do not move along the continuum, because they are never “ready.” The housing readiness model requires compliance with service and treatment plans, and services are only available as long as a person lives at the program site. The mentally ill chronically homeless are focused on surviving from one day to the next, often not realizing the existence of their illness. They cannot move along the

Continuum, off the street, into transitional or permanent housing using the traditional components of the Continuum of Care with their high demand for cooperative, goal-oriented, and consistent behaviors. A different service delivery model has to be utilized to house the chronically homeless population.

Figure 1.1 Housing Readiness Model

Crises Event / Emergency Short-term Homelessness Shelter Shelter

Permanent Housing Transitional Housing

(Up to 2 yrs) Support Services Delivered Throughout Continuum of Care Process

However, a housing first approach seeks to assist persons to exit homelessness as quickly

as possible by placing them in permanent housing and giving them access to needed services

(service-enriched supportive housing). This approach assumes that the factors that have

contributed to a person’s homelessness (especially the chronically homeless) can best be

remedied once the individual is housed rather than in emergency shelters or transitional settings.

It also accepts that for some lifelong support may be required to prevent the reoccurrence of

homelessness. Hence it seeks to maximize utilization of mainstream resources. The model also

seeks long-term self-sufficiency, promoted through a wraparound service philosophy.

Figure 1.2 Housing First Model

Interim/Short term Housing (if Permanent Housing needed) Services Provided on Site as Needed: Crisis Event • Mental Health Services Homelessness • Substance Abuse Treatment • Case Management • Health Care Services • Training & Employment • Legal Services

The Statement of the Problem

Homeless policy over the last 10 years has almost entirely ignored the issue of prevention. In fact, by and large, HUD has not allowed any homeless dollars to be spent on the prevention or “front door” side. This becomes a real problem especially when a financial or economic crisis arises like the one we have faced over the last few years. Because of the number of foreclosures in particular, hundreds of thousands of families found themselves on the verge of

homelessness. Without the one-time infusion of short-term “stimulus” dollars given to local communities through the American Recovery and Reinvestment Act (ARRA), local communities would be helpless to prevent these at-risk individuals and families from entering homelessness.

Only after they literally became homeless would local service providers be able to spend homeless resources on them, which points to a real blind spot in the U.S. homeless policy.

Homeless policy then has essentially become one of “concentrate, don’t dissipate.” In other words, the majority of resources are being focused on the tangible and well-meaning goal of ending homelessness among the smallest, but most costly homeless population by placing them in Permanent Supportive Housing (through a Housing First strategy). This “back door” policy has consumed nearly all of the federal government’s homeless resources, as well as dominated the focus of state and local homeless service providers. In hindsight, this policy seems myopic. The current policy neglected to anticipate an economic downtown and the effect that it would have on swelling the homeless population, especially among families. This study acknowledges that while the housing first policy, adopted by HUD as a funding priority and promoted by the USICH through the creation of 10-Year Plans, has had an impact on the reduction of the number of chronic homeless individuals, it seems to have been short-sighted in failing to anticipate future economic influences on the homeless population. Thus, this study poses the question: Is Housing First the Best Policy Approach to Homelessness?

Purpose of the Study

This purpose of this study is to conduct an analysis of the housing first policy and examine whether it is the best strategy to accomplish the stated mission of ending homelessness altogether. That is:

• Does the current policy justify the focus of time and resources on the chronically

homeless?

• Is the current policy adaptable enough to be expanded to include families, children and

youth?

• Should current policy and resources be shifted toward preventing homelessness?

This analysis will be accomplished through a review of the most recent literature, through an

examination of the current best practices in providing services to the homeless and by

anticipating the latest policy priorities of the federal government.

Importance of the Study

Of those counted in the 2011 homeless census, 37% were families and another 46% were

considered non-chronic individuals (National Alliance to End Homelessness [NAEH], 2012, p.

8-9). Yet, the vast majority of homeless resources are being spent on housing chronically

homeless individuals. Additionally, three-quarters of all poor renter households are severely

housing cost-burdened. Due to the recent economic crisis these families are one or two

paychecks away from being without a place to live. This study is important because it will

examine whether homeless policy should be focused on serving the larger segment of the

homeless population as opposed to the smaller segment i.e. the chronically homeless. This study

is important because it will challenge the wisdom of spending the majority of resources on

unaccompanied homeless adults as opposed to homeless families. Finally, this study is important

because it will analyze the most cost-effective mix of programs to meet the needs of those who

are at-risk of becoming homeless as well as those who have recently slipped into homeless and those who are experiencing long-term or chronic homelessness.

CHAPTER 2 – LITERATURE REVIEW

Housing First

On any given night in the United States it is estimated that there are about 636,000 homeless persons. Of those, about 107,000 (or 17%) are designated as chronically homeless

(National Alliance to End Homelessness [NAEH], 2012, p. 3-4). As defined by the U.S.

Department of Housing and Urban Development (HUD) a chronically homeless person is an,

…unaccompanied homeless individual with a disabling condition who has either

been continuously homeless for a year, or who has had at least four episodes of

homelessness in the last three years (U.S. Department of Housing and Urban

Development [HUD], 2007, p. 3).

In the last decade, the Federal Government has focused its major homeless policies, resources and efforts on ending chronic homelessness. This goal has been adopted by not only the Federal Government, but by the homeless service provider community as well. In conjunction with this effort, the U.S. Interagency Council on Homelessness (USICH) promoted the development of 10-Year plans in every jurisdiction across the country (over 350 at last count, including Kern County) emphasizing a strategy known as Housing First.

Research on the subject generally begins with a definition of the housing first strategy.

The model for housing first was first developed in New York City by a program known as

Pathways to Housing or simply Pathways (Tsemberis, Gulcur, & Nakae, 2004, p. 651). The program was based on “the belief that housing is a basic right” and that consumers should have choice in their own treatment, or choose no treatment at all (Tsemberis et al, 2004, p. 651).

Either way, housing the individual is the priority, for housing first promotes immediate access to independent housing with no treatment requirements (Matejkowski & Drane, 2009, p. 6).

Housing first then refers to the “rapid and direct placement of homeless individuals into

permanent housing with supportive services available, but without service utilization or

treatment required as a condition of receiving housing” (Kertesz, Crouch, Milby, Cusimano, &

Schumacher, 2009, p. 498). Because, the chronically homeless, by definition suffer from one or

more disabling conditions, including mental illness and substance abuse disorders housing first

remains popular because it focuses on the homeless population that “often elude existing

program efforts” (Tsemberis, Gulcur, & Nakae, 2004, p. 651).

Housing first does however have its detractors as it departs from the predominant service

delivery model of the previous decade, referred to as the Continuum of Care (CoC). The CoC

model is a linear approach that is as it sounds, designed to move the homeless individual along a

continuum of care, or several program components such as outreach, treatment, case

management, transitional housing, and if the all program demands are met, permanent supportive

housing (Tsemberis et al, 2009, p. 651). The purpose of this model is to “enhance clients housing

readiness” by encouraging “sobriety and compliance” (Tsemberis et al, 2009, p.651).

Here we see the main difference between the two approaches. Housing first is a low- demand strategy that follows a “harm reduction approach” (Tsemberis et al, 2009, p. 652). Harm reduction is a pragmatic approach that seeks to minimize the adverse effects of drug abuse and mental illness. It acknowledges that consumers are at various and differing stages of recovery and interventions, and therefore should be treated as such, without having to submit to a one- size-fits-all treatment program. Regardless of their treatment choices, their housing status will not be threatened (Tsemberis et al, 2009, p. 652). A CoC approach, on the other hand, requires strict adherence to “treatment and sobriety” without which housing stability is not possible.

Three questions arise out of this comparison between the two approaches. The first

question has to do with determining how the housing first approach affects already accepted and

proven treatment models, such as assertive community treatment (ACT). ACT is one of the most

“well-defined” and “researched” treatment models for indigent people with mental illness

(Matejkowski & Drane, 2009, p. 6). In order for ACT to be integrated into a housing first model,

it will need to be modified. How will these modifications affect success rates in housing first

consumers? Research done in this area is promising, but according to Matejkowski & Drane

(2009), the ability to “fully implement ACT components appeared limited by clients choosing

not to access services” (p. 10), which is the consumer’s prerogative in low-demand housing.

A corollary to the first question has to do with, the various types of disabilities that the chronically homeless face. Does housing first work equally well for those suffering from substance addictions as it seems to for those with mental illness disorders? There is conflicting research in this area. An housing first program in Seattle that targets adults with severe alcohol problems called 1811 Eastlake, has shown promising results (Larimer et al, 2009, p. 1350).

However, studies done on similar programs in Germany and Philadelphia have shown that consumers that suffer from primarily substance abuse issues do not fare as well in housing first settings (Kertesz et al, 2009, p. 505).

The second question is a natural one. Will the housing first model work for non-chronic homeless populations such as the transitionally homeless, which are primarily homeless families and transitional age youth? Homeless families are the fastest growing segment of the homeless population. Little research is currently available, although Kertesz & Weiner (2009) address the question and press for more research on the subject (p. 1823). Cunningham indicates that emerging research does show that the best way to respond to family homelessness is different

than that of chronic homelessness. This is the case since homeless families generally have lower

rates of substance abuse and mental health challenges. Homeless families exhibit characteristics

that more closely match “other low-income,” but not homeless families (Cunningham, 2009, p.

5).

The final question is in relation to the cost effectiveness of the program. Cost

effectiveness is a big selling point with housing first. Based on the Pathway program in New

York City and the 1811 Eastlake program in Seattle, it seems as though housing first is indeed a

cost effective means of dealing with the chronic homeless population. A study of mentally ill

homeless persons in New York indicted a cost of nearly $41,000 per person to the system each

year. By housing these individuals immediately service costs declined markedly (Kertesz &

Weiner, 2009, p. 1822). The authors of the Seattle study also reported a substantial net savings to

the system by employing a housing first approach (Larimer et al, 2009, p. 1349). Whether the

policy is truly cost effective remains to be seen, however the most recent results of the HUD

Point-in-Time (PIT) homeless census indicates that chronic homelessness is decreasing. In 2011, the chronic homeless population decreased by 3 percent from 110,911 in 2009 to 107,148, and has decreased by 13 percent since 2007 (National Alliance to End Homelessness [NAEH], 2012, p. 5).

HPRP and the HEARTH Act

In 2009-2010 two significant events occurred that could change the face and focus of homelessness policy. First, a unique opportunity came along due to the economic crisis. On

February 17, 2009, President Obama signed the American Recovery and Reinvestment Act of

2009 (ARRA), which included $1.5 billion for a Homelessness Prevention Fund. Funding for the program, called the Homelessness Prevention and Rapid Re-Housing Program (HPRP), was

distributed based on the formula used for the Emergency Shelter Grants (ESG) program. What

was unique about this one-time “stimulus” funding was that it allowed for the first time

(temporarily), federal monies to be spent on preventing homelessness. This opportunity gave

service providers and policy makers the chance to see if ending homelessness might be best

approached at the front door i.e. preventing homelessness before it happens. According to The

State of Homelessness in America 2012 report, HPRP was successful in its goal of preventing a

significant increase in homelessness. “In 2010, its first year of operation, it assisted nearly

700,000 at-risk and homeless people” (National Alliance to End Homelessness [NAEH], 2012, p.

2).

The second event involved the passage of the Homeless Emergency Assistance and Rapid

Transition to Housing (HEARTH) Act. The HEARTH Act amended and reauthorized the

McKinney-Vento Homeless Assistance Act with substantial changes, including

•A consolidation of HUD's competitive grant programs;

•The creation of a Rural Housing Stability Assistance Program;

•A change in HUD's definition of homelessness and chronic homelessness;

•A simplified match requirement;

•An increase in prevention resources; and,

•An increase in the emphasis on performance.

(U.S. Department of Housing and Urban Development [HUD], n.d.)

Unfortunately, as of this date major portions of HEARTH cannot be implemented due to the federal budget crisis. However, it does indicate that the federal government is open to a homeless policy that includes a prevention element.

Prevention

What this prevention element might look like is still not clear and according to Culhane

et al, implementing a prevention centered approach is fraught with difficulties (Culhane,

Metraux, & Byrne, 2010, p. 3). Some of these difficulties include determining an effective means

of identifying those individuals and families that are at-risk of homelessness, a lack of affordable

housing resources, and a lack of accountability with regard to mainstream system discharge

planning policies.

First, effectively identifying those who are at-risk of homelessness is not an easy task. In

2010 there were 6.8 million people “doubled up” or “couch-serving” (people who live with friends, family or other nonrelatives for economic reasons). From 2005 to 2010 there was a 50 percent increase in this population (National Alliance to End Homelessness [NAEH], 2012, p. 5).

While these people are not technically homeless (they do not fit the HUD definition of homelessness), they are certainly precariously housed and at-risk. There are another 6 million households who have what Culhane calls “worst case housing needs.” He identifies them as having “less than 50% of their areas’ median income” and either paying “over half of that income for housing or live in severely substandard housing” (Culhane, Metraux, & Byrne, 2010, p. 5). While members of this population are precariously close to becoming homeless, most will not become so.

The key question then becomes, how does a program identify those households who would become homeless without the issuance of prevention resources while at the same time minimizing the issuance of those resources to those households with similar circumstances but who would not ultimately need the assistance? As Culhane points out, any “savings realized through averting a case of homelessness could become washed out by the cost of assisting many

‘false positive’ cases” (Culhane, Metraux, & Byrne, 2010, p. 5). Unfortunately, as of yet, there

are no easy solutions to this problem. Any strategy that does not attempt to reach the household

with assistance before they are at the shelter door is not truly a primary prevention program. If

the family arrives at the shelter door a secondary prevention program might be practical, rapid

rehousing for example (the R in HPRP). But rapid rehousing is considered to be more of a shelter

diversion program involving short term housing subsidies (Cunningham, 2009, p. 2).

Rapid rehousing is a fairly new concept that has been used successfully to reduce lengths

of homeless episodes. It typically involves short-term housing assistance (including up to 18 months of rental assistance), housing placement services, and an array of appropriate services for families including, housing search and landlord mediation assistance, short-term or flexible rental assistance and transitional case management services. According to Mary Cunningham of the Urban Institute “Once families are living in stable, safe, affordable housing, providers should connect them to community-based supports to help them maintain housing stability and improve their economic well-being” (Cunningham, 2009, p. 8) and ideally, to prevent any more reoccurrences of homelessness. Any homeless policy change then, would likely (and should) include an emphasis on both primary prevention and secondary preventions strategies i.e. rapid rehousing.

There is evidence that primary prevention policies have been successful in Europe because they have been able to effectively identify and target those at-risk of homelessness before-hand. “The most serious and long term commitment is evident in Germany, where concerted efforts to drive down rent arrears related evictions (the predominant cause of homelessness in Germany) have clearly paid dividends, particularly with respect to family homelessness. In Finland, too, ‘primary’ prevention via expanded access to housing, as well as a

16 very rigorous response to family homelessness whenever it threatens, has virtually eliminated it as a phenomenon” (Fitzpatrick, Johnsen, & Watts, 2012, p. 6).

Like the programs in Germany and Finland, the few prevention programs that have been successful in the U.S. have focused on identifying key “triggers” for homelessness including a breakdown in domestic relationships (for example between spouses and/or domestic partners and parent-child relationships) and evictions (Culhane, Metraux, & Byrne, 2010, p. 11).

The second difficulty a prevention centered approach will face is a lack of affordable housing resources. According to Cunningham, “Researchers have spent the past two decades uncovering what causes homelessness, and while the evidence shows that poverty and personal difficulties such as mental illness, substance use, and health problems leave people vulnerable to homelessness, the primary driver of homelessness is the availability of affordable housing”

(Cunningham, 2009, p. 2). Culhane concurs. “Instituting a nationwide housing policy that includes an entitlement to decent, affordable housing, for example, would eliminate the need to provide homeless services. Even a substantial investment in subsidies could significantly reduce shelter demand…” (Culhane, Metraux, & Byrne, 2010, p. 4).

To meet the stated goal of ending homelessness U.S. housing policy will have to be adjusted and affordable housing will have to be made a priority. Particularly, housing policy will need to move away from an emphasis on ownership for all, to one that encourages investment in rental housing. This could be done by greatly increasing the federal government’s funding of housing vouchers and giving financial incentives for state and local governments to produce affordable housing (Cunningham, 2009, p. 9).

It has been suggested that Congress should fund an “additional 200,000 vouchers a year” and increase investment in “affordable housing programs—such as 202 and 811—for the elderly

and people with disabilities” (Cunningham, 2009, p. 9) including a fully funded the National

Housing Trust Fund. While HUD’s efforts to increase the number of Permanent Support Housing

(PSH) beds through the chronic homeless initiative seems to have paid off (an increase from

188,636 in 2007 to 266,968 in 2011), these beds are for individuals and not families. In fact, the

number of affordable housing units available to extremely low-income and very low-income families has decreased by about 400,000 between 2009 and 2010 (Bolton, 2012, p. 1-2). This is not a problem that will be going away anytime soon.

The third difficulty a prevention centered approach will face is a lack of accountability with regard to mainstream system discharge planning policies. The term “discharge planning” has evolved over the years to refer to the planning for a person’s exit or discharge from a

“treatment, correctional, or other custodial setting into the community and into a residential setting” (Backer, Howard, & Moran, 2007, p. 230). When it comes to homelessness HUD generally focuses on four areas of mainstream system discharges, hospitals, jails & prisons, foster care and mental health facilities. According to the State of Homelessness Report 2012, the odds for a person in the general U.S. population of experiencing homelessness in the course of a year are 1 in 194. For an individual living doubled up the odds are 1 in 12. For a released prisoner they are 1 in 13. For a young adult who has aged out of foster care they are 1 in 11

(National Alliance to End Homelessness [NAEH], 2012, p. 5). In fact the foster care system is one of the leading entry points into homelessness for unaccompanied youth, sometimes referred to as transitional age youth or TAY. One national study reported that more than one in five youth who arrived at shelters came directly from foster care, and that more than one in four had been in foster care in the previous year (National Coalition for the Homeless [NCH], 2007, p. 1). “As many as 5 percent of individual adult shelter entrants spent the previous night in a jail, prison, or

18 juvenile detention facility, while converging data suggests that “20 to 25 percent of released prisoners will be homeless within a year following their release” (Cunningham, 2009, p. 6).

These mainstream systems of care can all do a better job of working with the local homeless service providers to prevent these discharged individuals from entering the homeless shelters. In fact, HUD requires that the local community CoC’s work with the mainstream systems that receive HUD funding to prevent discharging individuals into homelessness but they generally lack any enforcement mechanisms. Policymakers should insist on a “zero tolerance” policy for discharging into homelessness and incentivize through funding the prevention of discharging into shelters or the streets (Cunningham, 2009, p. 8).

HomeBase, a well-respected homelessness advocacy group produced a short paper with several policy recommendations relating to discharge planning. They include: 1) the prohibition of discharges into homelessness from all publicly funded institutions such as hospitals, treatment facilities, prisons and jails, and the foster care system. 2) The Investment in recuperative care facilities for patients without homes who require supervised medical care but are not ill enough to remain hospitalized. 3) The requirement that all publicly funded institutions providing residential care, treatment or custody to secure all available entitlements for residents prior to discharge and to provide staff persons trained in housing placement assessment and assistance. 4)

The enactment of legislation that encourages better planning and services for individuals being discharged from correctional institutions into the community (HomeBase, p. 5).

Summary

The review of the literature points to the potential effectiveness of a housing first approach and the wisdom of focusing HUD resources on housing the chronically homeless.

There are still questions however, about how housing first, with its low-demand philosophy, will

ultimately help the chronically homeless with their issues that have kept them from remaining

permanently housed. Additionally, with its focus on unaccompanied adults with various

disabilities, there are question about whether the housing first model will work for non-chronic homeless populations primarily homeless families. Evidence seems to indicate that most families who experience homelessness have different needs than chronically homeless adults. The other issue with housing first has to do with whether it is truly cost effective. Recent data seems to indicate that it is so, but further research will be necessary to determine its true cost effectiveness. One thing seems to be indisputably clear this approach is effective in reducing the

actual number of the chronic homeless population.

The review of literature indicates that there is a willingness on the part of the homeless

establishment to focus on preventing homelessness in the first place. There is also an actual need

to do so. Through the passage and implementation of HPRP we are learning that a primary

prevention strategy can be effective. Accompanied with a secondary prevention strategy like

rapid rehousing, homeless families can be identified and prevented from showing up at the local

shelter or at the very least diverted from front door entry into the shelter system.

Difficulties do remain with the implementation of an efficient and effective prevention

policy including identifying those that will need preventions services and finding adequate and

affordable housing for them. An additional difficulty has to do with a lack of coordination among

mainstream service providers and discharge planning protocols.

CHAPTER 3 – POLICY ALTERNATIVES

Homeless assistance has come a long way from the days of “three hots and a cot!” 30 years ago the issue of homelessness was barely on the nation’s radar. Most people when asked about the homeless would think in terms of hobos or bums or derelicts. Fast-forward to the present and the federal government is spending nearly three billion dollars a year on more than

20 homeless programs. (McKelway, 2011). With the addition of another 1.5 billion in federal stimulus dollars for the Homelessness Prevention and Rapid Rehousing Program (HPRP) it is obvious that homelessness is an issue that has our national attention. But where do we go from here? What policy best fits the current literature and understanding of the needs of the homeless?

What strategy will best help the federal government reach its stated goal of ending homelessness? In this chapter we will attempt to examine three alternatives that could give further direction to U.S. homeless policy.

Continue with Housing First

Housing first is built on the concept of “concentrate, don’t dissipate.” In other words, it is the strategy of focusing the majority of homeless resources on a specific target population with the expectation that it will reap results that can then be used to garner additional resources for the cause of ending homelessness. The main advantage to this approach is cost-effectiveness. Over the last several years more than 65 studies from various communities have been undertaken to try to determine exactly how much of a burden the homeless population, and the chronically homeless in particular, was placing on each community’s resources. Specifically, mental health services, ambulance services, emergency room and healthcare services, law-enforcement and substance abuse treatments. The chart below (Figure 3.1) illustrates some of the costs accrued by the chronically homeless populations in four different jurisdictions.

Figure 3.1 Chronic Homeless Costs

City Study Facts Cost Facts Other Avg. Costs Factors per Person* San Diego Costs/Services Subjects 1745 trips by $26,431 (health tracked for 227 accrued $6 ambulance care costs only) Source: Serial individuals over million in Inebriate Program 18 months health care 2358 hospital costs visits

Costs/Services Subjects $133,333 tracked for a accrued $3 (health care subset of 15 million in costs only) highest utilizers health care over 18 months costs

Boston Utilization of Total Medicaid 18,384 ER visits $25,000 (does Medical Services costs $13 not include Source: by 119 homeless million 871 Medical detox, Massachusetts individuals 1999 hospitalizations ambulance, Housing & Shelter – 2003 other health Alliance Study by 831 Respite care costs) Dr. David Foster admissions

King Tracked In year 2000 (Includes jail $54,542 County, homeless 20 individuals days, ER, WA. individuals with accrued costs Inpatient stays, SAMH to $1,090,842 detox & SA determine treatment) Source: 2003 High Utilizer Study, service King County utilization & In year 2003 Highest utilizers $49,489 Mental Health, costs in 2000 & Chemical Abuse 24 individuals cost $100K/yr pp and Dependency 2003 accrued costs in ER/hospital Division $1,187,746 services alone

Asheville Tracked costs in Total accrued *Jail/Court – $39,444 (legal, N.C. three areas (Jail, cost $1.45 $17,514 medical, Hospital/EMS, million per shelter) Emergency year *Medical – Source: Asheville’s 10-Year Plan Shelter) of 37 $14,730 chronic homeless people over a *Shelter – three year period $7,200

*Costs are reflected as an average per person, per year.

National research indicates that on average, the total yearly cost for a community to care for one chronically homeless individual is between $40,000 and $60,000. Some are much higher.

On the other hand, some studies have indicated that to place an individual in permanent

supportive housing can save the system as much as $18,000 per person per year (Source:

Accountability, Cost Effectiveness and Program Performance: Since 1998; 2007 National

Symposium on Homelessness Research; Culhane, Parker, Poppe, Gross and Sykes). If there are

372 chronically homeless persons in Kern County (according to the 2011 Homeless Census), providing permanent supportive housing to them could save the County as much as $6.7 million.

That savings alone could pay for a large percent of the service enriched housing costs including operations and services. Even if a small portion of those back-end expenditures could be redirected toward homeless prevention, the community could see a large benefit. Imagine those kinds of costs savings on the larger national scale.

There are of course certain disadvantages to continuing with housing first as the priority policy for homelessness. The first disadvantage includes the complexity that is involved in transferring this strategy over to other homeless population groups. Take for example, homeless families. There are very few chronically homeless families, and their needs differ significantly from those of “unaccompanied adults” or chronically homeless individuals. Additionally, as indicated in the literature review many homeless families are only homeless for a short-time.

They can be helped best with a housing voucher or rental assistance and a security deposit. In this case, the need is not permanent supportive housing like that emphasized in housing first, but rather a rapid rehousing through a shallow housing subsidy.

Another disadvantage to a housing first approach is that it tends to be reactive instead of proactive. Housing first is by its nature is a post-crisis policy. It deals with the individuals after the homeless crisis has occurred, so the housing first model is really a back door approach, since its focus is on those who are already homeless. Essentially then, the goal in housing first is to help people exit homelessness through the back door into permanent supportive housing. There

is no attempt to prevent homelessness at the front door. Most resources in the housing first model

are spent on supportive housing. What many at-risk or newly homeless families need is affordable housing. They need shelter-diversion and a way to stay housed.

A final disadvantage to the housing first policy is that it de-emphasizes services. HUD’s spending priority for the last decade has been on creating more permanent supportive housing. In

Kern County alone 13 homeless supportive service only (SSO) programs have lost HUD funding. The Kern County Homeless Collaborative (KCHC) had to make serious and painful decisions about cutting its share of supportive service dollars in order to be awarded housing funding from HUD. This scenario has occurred all across the country. So while the KCHC has been able to create hundreds of new supportive housing beds for the chronically homeless, they have also lost an equal amount of homeless service programs that provided mobile health services, medical and dental shelter services, services and training for homeless individuals with mental and physical disabilities, funding for domestic violence victims (who are by nature homeless when they leave their abusive situation) and other shelter programs. Because these programs had to be given up first, and because of the time-lag between dropping programs and creating housing, the cost-savings associated with the housing first model have yet to be realized.

Fully Implement the HEARTH Act

The McKinney-Vento Homeless Assistance Act has been around since its passage in

1987 and has been amended 5 times (1988, 1990, 1992, 1994 and 2009). Its stated purpose was

threefold. To establish an Interagency Council on the Homeless, to use public; resources and

programs in a more coordinated manner to meet the critically urgent needs of the homeless of the

Nation; and to provide funds for programs to assist the homeless, with special emphasis on

elderly persons, handicapped persons, families with children, Native Americans, and veterans.

McKinney-Vento was the first significant federal legislative response to homelessness.

The Act originally had fifteen programs providing a spectrum of services to homeless people and

many of the current programs and strategies developed in those early years are still inexistence

and being used today in the Continuum of Care process, including: the Supportive Housing

Program, the Shelter Plus Care Program, and the Single Room Occupancy Program, as well as

the Emergency Shelter Grant Program (McKinney-Vento Act, n.d.).

Since its enactment, numerous proposals have been debated, but controversies prevented

Congress from passing any significant reauthorizations. However, a number of changes were

made to the McKinney-Vento programs by HUD and by Congress through the annual

appropriations process. The most significant change by HUD was the creation of the Continuum of Care system, which was first implemented in 1995. That is until 2009. Note: Continuum of

Care refers to both a method of helping the homeless (see figure 1.1) and the system established

by HUD to apply for and administer HUD funding in each local community.

On May 20, 2009, President Obama signed the most significant and substantial

amendment to the McKinney-Vento Act since it passage. The Homeless and Emergency

Assistance and Rapid Transition to Housing (HEARTH) Act of 2009 reauthorized McKinney-

Vento with several major changes, including:

•A consolidation of HUD's competitive grant programs;

•The creation of a Rural Housing Stability Assistance Program;

•A change in HUD's definition of homelessness and chronic homelessness;

•A simplified match requirement;

•An increase in prevention resources; and,

•An increase in the emphasis on performance

(U.S. Department of Housing and Urban Development [HUD], n.d.)

One advantage to HEARTH is that it greatly expands the focus on Homelessness

prevention. Previously, a portion of McKinney-Vento funding was designated for Emergency

Shelter Grants (ESG). These funds were to be used entirely for providing emergency shelter and

outreach services. However, while these funds will continue to be distributed by the same formula to the same jurisdictions as before, HEARTH now changes the title to the Emergency

Solutions Grant (ESG) signifying a shift to funding homelessness prevention and re-housing, as well as outreach and emergency shelter. Some of the new activities allowed in the new ESG

program are short-term and medium-term rental assistance, housing relocation or stabilization

services such as housing search, mediation, or outreach to property owners, legal services, credit

repair, security or utility deposits, utility payments, final month’s rental assistance, and moving costs or other relocation or stabilization activities.

Another advantage to the HEARTH is that it changes the overall scope of homeless policy. It is very performance driven and seeks to reward high achieving CoCs who develop proven strategies to reduce homelessness. For example, a community that has fully implemented

a proven strategy can apply for the incentive and use it for any other eligible activity, including

“the prevention and re-housing activities allowed under the new ESG program” (National

Alliance to End Homelessness [NAEH], 2009, p. 5).

A third advantage is that it continues the existing emphasis on creating permanent supportive housing for people experiencing chronic homelessness and adds an emphasis on chronically homeless families. It also beefs up the need in rural communities by giving them the option of applying under a different set of guidelines that offer more flexibility and more assistance with capacity building.

One of the problems that many homeless service providers have had with the current

homeless policy is with HUD’s definition of both chronic homelessness and homelessness in

general. HEARTH adds families to the definition of chronic homelessness and it modifies the

definition of homelessness in positive ways. Particularly, it allows grantees to use some CoC

funding for people who have not been technically homeless under HUD's definition in the past,

but are homeless under other federal agencies’ definitions of homelessness. Ironically, not all federal agencies define homelessness in the same way. HUD's existing definition of homelessness includes people living in places not meant for human habitation (i.e. the streets,

abandoned buildings, parks and vehicles), and who are living in an emergency shelter or

transitional housing facility. New language in the HEARTH Act adds those “facing the loss of

housing within the next seven days with no other place to go and no resources or support

networks to obtain housing” (National Alliance to End Homelessness [NAEH], 2009, p. 3). This

definition then speaks to situations where a person is at imminent risk of homelessness or where

a family or unaccompanied youth is not stably housed. Imminent risk includes situations where a

person must leave his or her current housing within the next 14 days with no other place to go

and no resources or support networks to obtain housing.

There are at least two disadvantages to this policy alternative, one minor and one major.

The minor disadvantage relates to the timing of both HEARTH and the American Recovery and

Reinvestment Act (ARRA) of 2009. ARRA was passed in February of 2009 and HEARTH was

passed a few months after in May of 2009. This led to an interesting scenario where HUD staff

was trying to design a program to expend its ARRA allocation (through what would become

HPRP) and also at the same time begin the implementation of HEARTH. Unfortunately, law-

makers were not able to utilize the many lessons that would be learned through HPRPs

enactment. While much of HPRP is based on HEARTH and they have many similar elements,

both were designed for implementation on very different scales. HPRP is temporary stimulus

designed to time out, while HEARTH is meant to be permanent ongoing policy. If HEARTH had

been passed in 2011 as opposed to 2009, it might look completely different with a much greater

emphasis on prevention and housing stabilization.

The major disadvantage to HEARTH is the cost for full implementation. It has been

estimated that it would take a budget authorization of at least $2.2 billion to fully implement

HEARTH. As you can see from Figure 3.2 no HUD homeless appropriations have reached that level before or since HEARTH was enacted.

Figure 3.2 HUD Homeless Allocations

FY CoC ESG Total HUD Homeless Shortfall Needed to Implement Allocations HEARTH 2008 1.326 billion 160 million 1.486 billion N/A 2009 1.558 billion 160 million 1.718 billion N/A 2010 1.411 billion 160 million 1.571 billion 629 million 2011 1.473 billion 225 million 1.698 billion 502 million Source: HUD Homeless Assistance Allocations (U.S. Department of Housing and Urban Development [HUD], n.d.)

With a $502 million shortfall in needed funding, it may be awhile before HEARTH can be fully

implemented. Certainly, the funding issue will be a major factor in recommending this policy

alternative.

Implement a Hybrid Policy

This third policy alternative is considered a hybrid policy because it encompasses the

basic philosophy behind the housing first model (which is to get the homeless into stable housing

as quickly as possible) with the lessons that have been learned from the implementation of

HPRP. The basic idea of this model revolves around the concept of “housing stabilization.” This

approach has been referred to as “stair-casing” (Fitzpatrick, Johnsen, & Watts, 2012, p. 5) or

“progressive engagement” (Culhane, Metraux, & Byrne, 2010, p. 29). In this approach those

who are at-risk or who are already homeless go directly to the appropriate level of intervention,

depending on the depth of their need and on the basis of a crisis assessment. While this may

sound similar to a continuum of care or housing readiness model (see figure 1.1) it has major differences. The continuum of care emphasized shelter, then transitional housing and then permanent supportive housing, this approach focuses on early intervention and direct assistance with resolving the housing crisis, so that the goal of housing stabilization is achieved.

Figure 3.3 Staircase Model

Level Purpose Target Program System Provider of Activities Service

One Prevention & At-risk or Eviction Housing Shelter Imminently Avoidance & Counseling Diversion Homeless Housing Groups; Stabilization Community Orgs; Emergency Shelters

Two Rapid Re- Recently Crisis Homeless Service Housing & Homeless Intervention; Providers Housing Short and Relocation Medium-Term Subsidies

Three Long-term Long-term & Permanent Mainstream Subsidy & Chronically Supportive Systems Service Homeless Housing Engagement

In figure 3.3 the various levels of intervention are illustrated. Level one is about

prevention and keeping the household out of the shelter system. The focus of this level is on

29 those who are at-risk of, or on an imminent path to homelessness without some kind of assistance. The services needed for this group are directly related to keeping them housed.

Intervention services at this level should seek to resolve the ongoing conflict between the soon to be displaced household and the current housing arrangements. Culhane et al suggest that this intervention could include family/friend mediation (for those doubled-up or couch surfing) to landlord-tenant mediation (for those who are living in a dwelling as a primary tenant) to “less than formal” mediation such as housing counseling and discussions of non-shelter alternatives

(Culhane, Metraux, & Byrne, 2010, p. 31). The goal as stated above is to avert the potential eviction and stabilize the housing need. These prevention activities may be best suited to housing counseling groups and other community organizations that can also provide training on money management and other household skills to prevent future crisis. With HEARTH the responsibilities for these prevention activities fall on the emergency shelters. However, with the stair-case model emergency shelters are a provider of last resort for prevention services.

Emergency shelters should be free to focus on those who are newly or already homeless.

One other element can be addressed at this level and that is people being discharged from public institutions such as prisons and substance abuse facilities. According to Culhane et al

“…nearly one-third of adults entering shelter were recently discharged from a treatment or penal institution” (Culhane, Metraux, & Byrne, 2010, p. 31). It should always be the responsibility of the discharging agency to provide both a housing plan and housing-placement services. One disadvantage to this approach is that without some type of federal leadership and strict regulatory guidance, there is no incentive for discharging agencies to comply.

Level two is there for those times when shelter diversion has been unsuccessful. When households find themselves literally homeless they will need to use the shelter system. It is at

30 this level that trained homeless service providers can best be utilized. The goal here is to focus on rapid-rehousing and housing relocation. Through crisis intervention and assessment a relocation plan can be developed that involves either short-term or medium-term rental assistance. Studies have shown that helping homeless families get back into housing largely depends on their ability to pay rent and their capacity to navigate the rental market, as well as the availability of affordable housing in the community. Many times, housing vouchers alone can help families exit homelessness (Cunningham, 2009, p. 5). Often, what a recently homeless family needs is nothing more than an affordable place to stay and help with the first month’s rent and a security deposit. The disadvantage to this model again is the availability of vouchers or rental assistance dollars and the lack of affordable housing. The waiting list for subsidized housing with the Housing Authority of the County of Kern (HACK) is five years. And recently the waiting list has been closed to new additions.

Level three is very basic as it involves a housing first approach. The focus here is on the long-term, chronically homeless households that need deeper subsidies and significant wraparound services. Permanent supportive housing is the best way to address this population as has been discussed earlier. The one major change that would occur with the stair-case model is that providing housing and services to this population would be handed off to the mainstream service providers and no-longer remains under the responsibility of the homeless service system as is the case now. This seems sensible because clients that are residing in permanent support housing should no longer be considered homeless.

Summary of Alternatives:

When considering future homeless policy direction, there are several options available.

This analysis focuses on the three most likely to be implemented. The first policy option is to

continue with the housing first model. This is in essence the status quo alternative. The principle

advantage to this option is its cost-effectiveness. Disadvantages include the unlikelihood that this

model can be successful in addressing the needs of all homeless populations, that it tends to be

reactive instead of proactive and it de-emphasizes services.

The second alternative is to focus on fully implementing the HEARTH Act. Advantages

to this alternative include a new emphasis on prevention, an expanded focus on performance and

best practices and a broadening of both the homeless and chronic homeless definitions. There are

two disadvantages to this alternative. The first is that HEARTH was passed before the lessons of

HPRP be could be learned, thus it misses out on some very critical new data about prevention

and rapid re-housing. The second disadvantage relates to the cost of implementation. Congress has yet to fund homeless programs and HEARTH in particular at the necessary levels in order to implement all of its programs pieces.

The third alternative is to develop a hybrid model. The advantage to this alternative is that it builds on the lessons learned from both housing first and HPRP. In this staircase model housing stability is the goal across homeless populations. Each population is treated at the point of their need. This treatment involves assessment and case-management as early in the household’s crisis as possible. Level one is directed at those who are at-risk or imminently

homeless. The purpose of this level is prevention and shelter diversion. The program activity

involves eviction avoidance and immediate housing stabilization. Level two is directed at those who are recently homeless. The purpose of this level is rapid re-housing and housing relocation.

The program activity involves crisis intervention, relocation services and the provision of short and medium-term rental subsidies and vouchers. The third level is directed at the hardcore and chronically homeless. The purpose of this level is to provide long-term subsidies and increased

32 service engagement. Program activities mainly focus on providing permanent supportive housing. Additional advantages to this alternative include its emphasis on prevention and discharge planning. It also broadens the number of systems that are involved in the process relieving the burden that has generally to this point been placed entirely on the homeless service provider system. The most apparent disadvantage to this alternative is the lack of affordable housing units and subsidies.

CHAPTER 4 – SELECTION OF ALTERNATIVE

U.S. Homeless policy stands at a crossroads with several policy alternatives to choose

from. In the first alternative it can choose to continue on with the status quo, utilizing a housing

first policy, while seeking to expand its tenets to incorporate more homeless populations. In the

second alternative, policy-makers can fully fund and implement the HEARTH Act, passed in

2009, which incorporates many of the concepts and strategies found to be effective in HPRP. In

the third alternative policy-makers can create a hybrid policy that incorporates the best of both

housing first and HPRP, often referred to as a stair-casing approach. In this chapter we will examine these three policy alternatives and make a recommendation based on specific evaluation criteria.

Evaluation Criteria

Since homeless policy solutions require consideration of several constantly changing factors, it is not always easy to know which criteria to use when making policy choices. This is largely due to the political, fiscal and external realities of federal policy-making. The political realities involve such things as elections. Each time a new President is elected it serves as an opportunity for his administration to place his imprint on the federal bureaucracy. Additionally, it often takes time for that bureaucracy to reflect the administration’s policy priorities. There is usually a lag between the election of a new administration and the implementation of a new policy. Fortunately, on the issue of homelessness policy-makers frequently rely on the input of advocacy groups like the National Alliance to End Homelessness (NAEH). This allows for some continuity between homeless policy and the changing of administrations, although, each new administration will want to sponsor their own “policy initiatives.” Recently, for example the

United States Interagency Council on Homelessness (USICH) released the Federal Strategic Plan

to Prevent and End Homelessness. In it four goals were established.

• Finish the job of ending chronic homelessness

• Prevent and end homelessness among veterans

• Prevent and end homelessness for families, youth and children

• Set a path to end all types of homelessness

These goals carry with them the full weight of the federal government as it is reflected in the

policy of the Obama Administration (United States Interagency Council on Homelessness

[USICH], 2010, p. 4).

Another reality that homeless policy-makers have to consider is a financial one. This is

particularly true since homeless program costs by their nature are significant. At the present time,

the fiscal mood of the country is one of constraint. This hampers the ability of policy-makers to be creative and dynamic in their approaches to the issue of homelessness. It also, means that policy-makers must be willing to be more strategic in their approaches due to limited resources.

Thirdly there are external realities that must be considered when creating or evaluating policies. These factors include the presence of advocacy groups, media memes and best practices from other jurisdictions and organizations. Again, this is significantly true with the issue of homelessness. Homelessness is a reality everywhere around the world. Additionally, the federal government is not the only source of funding and services to help the homeless. Many great policy ideas for addressing homelessness have come from outside the federal government.

Therefore, federal policy-makers must be aware of what is and isn’t working outside of the efforts of the U.S. Government. This means that any good policy evaluation criteria will need to be aware of these three realities and use them accordingly. Therefore, the criteria for evaluating

the three policy alternatives presented will be based on political priorities, fiscal constraints and

external factors.

Proposed Alternatives

Alternative#1 – Continue with Housing First

This is the status quo alternative since housing first has been the priority for the last

decade and has been generally accepted as an effective approach to the problem of ending

chronic homelessness. However, it has not been as well accepted as a strategy when it comes to

dealing with families and other homeless populations.

Political Priorities:

When compared to the four priority goals established by the Obama Administration in the

federal strategic plan it obviously matches well with the first goal of finishing the job of ending

chronic homelessness. It also can be partially adapted to the second goal of preventing and

ending homelessness among veterans since the chronic homeless population tends to have a high

concentration of veterans. However, its limitations become apparent when comparing to the third

goal of preventing and ending homelessness for families, youth and children. Additionally

housing first is a back door approach to homelessness and does not truly focus on prevention. It

also comes up lacking on the fourth goal of setting a path to end all types of homelessness

because it is not a flexible approach. Based on these four priorities, the decision to continue with

a housing first approach alone would be short-sighted and questionable.

Fiscal Constraints:

The main advantage to a housing first approach over all others has been the promise of

cost-effectiveness. This is a positive given the current demand for greater fiscal accountability in governmental programs. By continuing with housing first as a priority approach HUD’s

homeless allocation levels would not need to change and if there were significant cuts to HUDs funding which is a real possibility most programs would be able to withstand the hit. However, it is important to remember that with the need to fund permanent supportive housing beds to meet the demand of a housing first approach many other supportive services have been cut. Overall, the issue of fiscal constraints is a positive for this alternative.

External Factors:

Housing first has been accepted as a best practice by the homeless service community

across the spectrum from local, state and federal government agencies to non-governmental and

faith based providers to the international homeless community. It is an integral part of every

effective homeless strategy being utilized. However, housing first is generally seen as only a part

of an ongoing series of strategies to deal with homelessness. It is currently held that a

comprehensive strategy to deal with homelessness must include a prevention element.

Therefore, while this alternative fits well with current external realities of homeless services it

cannot be seen as a net positive because it neglects prevention.

Alternative #2 – Fully Implement the HEARTH Act

The Homeless and Emergency Assistance and Rapid Transition to Housing (HEARTH)

Act of 2009 reauthorized McKinney-Vento. It was the first major legislative change to homeless policy in several years. It included a consolidation of HUD's competitive grant programs; the creation of a Rural Housing Stability Assistance Program; a change in HUD's definition of homelessness and chronic homelessness; an increase in prevention resources; and, an increase in the emphasis on performance.

Political Priorities:

When compared to the four priority goals established by the Obama Administration in the federal strategic plan this alternative holds up well. It aligns with the goal of ending chronic homelessness at it continues to make permanent supportive housing a major focus of its funding.

It also smartly expands the definition of chronic homelessness to include families. It also adds an element of prevention that has been missing to date. This is important because goals two and three of the strategic plan focus on prevention. On the other hand, it does not specifically address homeless veterans. Additionally, HEARTH is missing a few key elements that could help it accomplish goal four of the strategic plan i.e. setting a path to end all types of homelessness. As a whole this criteria is a slight positive for this alternative.

Fiscal Constraints:

It was originally determined that in order to fully implement all facets of HEARTH

Congress would need to authorize not less than $2.2 billion. In none of the last four fiscal years has Congress appropriated that much to HUD for homeless services. It is estimated that in order to meet the $2.2 billion figure an additional $500-600 million would need to be approved. In light of the current fiscal crisis it is unlikely that full-funding will occur. Some of HEARTH will be implemented as it is now, but to meet its policy purpose new funding is needed. Fiscal constraints then are a negative for this alternative.

External Factors:

Since HEARTH’s passage in 2009, several best practices have been adopted directly as a result of the lessons learned from HPRP. While elements of HPRP are in HEARTH there are also several differences. The main difference is related to the scope of the focus on prevention.

While HEARTH moves in a prevention direction, it is not a priority direction. Most of its focus

is still on housing first. HEARTH also continues to view prevention in the narrow prism of the

homeless service system, whereas many international and non-governmental homeless service

providers are turning to mainstream systems to take the lead in the area of prevention. Viewed

comprehensively, this criterion is slightly negative for this alternative.

Alternative #3 – Implement a Hybrid Policy

This third policy alternative is a hybrid policy encompassing the basic philosophy behind

the housing first model with the lessons that have been learned from the implementation of

HPRP. The key objective of this model is “housing stabilization.” This approach has been

referred to as “stair-casing” where those who are at-risk or already homeless go directly to the appropriate level of intervention, depending on the depth of their need and on the basis of a crisis assessment.

Political Priorities:

Because stair-casing has a specific purpose, target, program activity and system provider

for each level of homelessness or potential homelessness it is more comprehensive in nature.

Because it takes a comprehensive approach it fits well with the four priority goals established by

the Obama Administration in the federal strategic plan. This alternative addresses chronic

homelessness in level three and aligns with priority goal one. This alternative addresses

prevention in level one and therefore aligns with priority goals two and three. This alternative

targets the all types of homelessness including those at-risk, those who are recently homeless or

those in long-term (chronic) homelessness, whether they are unaccompanied adults, children,

families, youth or even veterans. This criterion is a positive for this alternative.

Fiscal Constraints:

Since this alternative moves many services to the mainstream systems it can potentially

reduce the fiscal constraints brought to bear on the homeless services system. For example if

prevention services were transferred from shelters to community and housing placement groups

this would free up time and resources for the shelters to focus only on those who are already

homeless. Likewise, if the chronically homeless residing in permanent supportive housing were

moved from the responsibility of the homeless service systems to mainstream providers the results would be additional homeless resources in order to rehouse the homeless as quickly as possible. For this alternative to be effective, however, new housing subsidies would be required

and the federal government would need to find a way to fund these subsidies. This is not likely

given the current realities with federal spending. On the whole, this criterion is neutral for this

alternative because with acceptable funding levels in other areas major savings in homeless

services could be realized.

External Factors:

While the policy concept of homelessness prevention is recent, it is rapidly becoming the

hot topic in the homeless service community. Since the development and implementation of

HPRP homeless policy experts have been looking over the results and developing best practices

from what has been learned. While there is not a great deal of research available, there are

enough apparent successes to give direction to future homeless policy. Some of these lessons

learned include the importance of stabilization and rapid-rehousing, the necessary use of housing

subsidies, and security deposits, the need to focus on shelter diversion, the need to create an

organized and functional federal discharge planning policy and the need to utilize a multi-system approach. This alternative incorporates nearly all of those practices. It addresses the needs of

40 those who would become homeless, those who slip into homelessness and those who are in long term homelessness. It is the most comprehensive policy approach. Therefore, this criterion is a positive for this alternative.

Selection of the Alternative

The purpose of this project was to answer the question: Is housing first the best policy approach to homelessness? In attempting to answer that question through the analysis of housing first and two other policy alternatives several conclusions can be drawn.

1. No single current policy can address all of the evolving issues related to homelessness

in America. While housing first meets the policy priority of reducing the chronic

homeless population, it is also clear that additional strategies will have to be developed

to meet all of the goals found in the federal strategic plan. This is particularly true

because housing first in its technical sense does not lend itself to the needs of homeless

families, children and youth.

2. The current fiscal environment will hamper any truly comprehensive efforts to end

homelessness. In this regard, housing first has a distinct advantage in that it is proven

to be cost-effective. Conversely, the whole point behind the Chronic Homeless

Initiative (and its housing first strategy) was to concentrate the majority of funding on

one specific population in order to reduce costs and garner additional resources (i.e.

concentrate don’t dissipate). These additional resources could then be used to reduce

homelessness in other populations. Those fiscal benefits have not yet been realized.

3. There is a growing consensus that if we truly want to end homelessness then

prevention will need to be an important element to homeless policy. Both of the other

policy alternatives have prevention elements. Housing first does not.

Given these conclusions then, housing first cannot be considered the best policy. It can and should however, be a prominent part of any alternative policy selected.

Figure 4.1 – Policy Alternative Matrix

Criteria #1 Criteria #2 Criteria #3 Political Priorities Fiscal Constraints External Factors Alternative #1 Positive Positive Negative Housing First Alternative #2 Positive Negative Negative HEARTH ACT Alternative #3 Positive Neutral Positive Hybrid

While alternative two, the HEARTH Act, better aligns with the priority goals of the federal strategic plan, it has two negative aspects. First, the cost for implementation is prohibitive and unrealistic and second, it fails to fully reflect the importance of prevention and housing stability in accomplishing an end to homelessness.

This leaves alternative three. By implementing a hybrid approach, policy-makers can best accomplish the policy priorities of the federal strategic plan. This alternative is also the most comprehensive in its approach to ending homelessness because it incorporates not only a prevention element, but also rapid rehousing and housing first. Thus it best reflects the most recent lessons learned from HPRP and other best practices. This alternative will be costly due to the need for increased housing subsidies, but because it moves many of those costs to other mainstream service providers, it should have a neutral effect on HUD’s homeless allocations. In the next chapter, we will make several recommendations related to implementation and monitoring of this alternative.

CHAPTER 5 – SUMMARY, RECOMMENDATIONS AND CONCLUSION

Summary

Since 2008, the federal government has spent well over $7 billion to address the issue of

homelessness ($5.5 billion in regular HUD allocations and $1.5 billion for HPRP). Clearly, there

is a will on the part of the American people and policy-makers to deal with homelessness. But what is the best way to deal with this policy issue? For most of the last decade the focus has been on ending chronic homelessness through a housing first strategy. This was largely the focus of the Bush administration’s Chronic Homeless Initiative. However, with the financial crisis came an opportunity to change the focus of homeless policy. Through the passage of the HEARTH

Act, Congress indicated its desire to see homeless policy go beyond the chronically homeless population and its back door approach. The HEARTH Act expanded the focus to emphasize families, children and youth. It also included for the first time prevention elements. Through the passage and implementation of HPRP we learned that a primary prevention strategy can be effective. Accompanied with a secondary prevention strategy like rapid rehousing, homeless families can be identified and prevented from showing up at the local shelter or at the very least diverted from front door entry into the shelter system. Additionally, with the advent of a new administration federal policy priorities changed as well. The U.S. Interagency Council on

Homelessness released the federal strategic plan which included four specific goals relating to homelessness.

When taking all of these factors into account, it became clear that while housing first is a good homeless policy it is an incomplete homeless policy. It fails to truly address the needs of all of the various homeless populations. It also completely ignores the newest best practices relating to prevention. For these reasons, it could not be recommended as the best policy choice for

43 ending homelessness in America. The HEARTH Act also falls short because it is not fiscally feasible. While elements of HEARTH can be implemented, major portions cannot because of their costs.

That leaves the third alternative. This alternative is a hybrid approach in that it includes the best practices and most current strategies involving homelessness; specifically, prevention, rapid-rehousing and housing first. This approach is the best option because it fits with the priority goals of the federal strategic plan. Although, it will cost more to implement than what is currently being allocated, these costs can be spread out over more agencies and departments so that the entire financial burden is not born solely by the homeless service provider system. This alternative is comprehensive in its approach. It has a strategy for those who are at-risk of homelessness, those who are recently homeless and those who are experiencing long-term homelessness.

Recommendations

The following recommendations will be critical if this policy choice is to be successful in the long run.

Implementation Strategy

There is currently no framework in place to implement this alternative and one will need to be developed. This task should not be too difficult because all of the elements are already functioning and could be quickly brought together with federal direction. Housing counseling groups are already in place and have been vetted by HUD. They could be easily transitioned from their current focus on mortgage modifications to one of “housing stabilization.”

Additionally, because of HPRP, most communities have an infrastructure in place to deal with landlord issues and housing crisis mediation on the prevention side. The shelter system is already

experienced at rapid re-housing and administrating housing subsidies. The mainstream services

systems will need to take over the administration of those chronically homeless individuals in

permanent supportive housing. Success will require a multi-system commitment, but it can be done.

Monitoring and Evaluation

One of the most important lessons learned from both housing first and HPRP is that accurate data collection can be an integral part of program evaluation. To that end, the current system known as Homeless Management Information Systems (HMIS) can easily be adapted and vital data can be made available to each community regarding those that are receiving assistance, their level of need, their service and benefit history and their eligibility for deeper assistance if needed. Information gleaned from these reports could be used for reports to the community on progress, program monitoring and evaluation and cost-effectiveness research.

Conclusion

However implemented and monitored, the goal of homeless policy should be to provide assistance to those who would be homeless without it, to offer a pathway out of homelessness for those who find themselves in the shelter system, and a bridge to long-term supportive housing for those who might otherwise end up on the streets experiencing chronic homelessness.

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APPENDIX A: IRB APPROVAL LETTER