The Strategic Framework for Ending Chronic Homelessness in Nashville

Presented by The Mayor’s Task Force to End Chronic Homelessness

September 23, 2004

Compiled by

1 Task Force Members

Chair: Dorothy Shell Berry, Director Metro Social Services Facilitated by: Douglas Perkins, Vanderbilt University

Howard Allen, Homeless Rep, Power Project Dr. Stephanie Bailey, Director, Metro Health Department Kevin Barbieux, Homeless Rep, Power Project James Bearden, CEO, Gresham, Smith & Partners Bill Coke, Community Volunteer, Christ Church Cathedral Mark Desmond, CEO, United Way Cynthia Durant, Vice President, US Bank Howard Gentry, Vice Mayor, Metropolitan Government John Gupton, Attorney, Baker, Donelson, Caldwell & Berkowitz David Guth, CEO, Centerstone Mental Health Center Steve Halford, Director Chief, Metro Fire Department Hank Helton, Mayors Office of Affordable Housing Judge Andrei Lee, Judge, General Sessions Court Rev. Kenneth Locke, Pastor, Downtown Presbyterian Church John Lozier, Director, Nat'l Health Care for the Homeless Council Steven Meinbresse, Community Volunteer, TN Dept. of Human Services (formerly) Mike Neal, CEO, Nashville Area Chamber of Commerce Dr. David Pennington, Director, VA-TN Valley Health Care System Ed Pringle, Director, HUD-Nashville Field Office Phil Ryan, Executive Director, MDHA Father Joseph Sanches, Pastor, Holy Name Catholic Church Brenda Sanderson, Owner, Broadway Entertainment Ronal Serpas, Chief, Metro Police Department Dr. Roxane Spitzer, CEO, Nashville General Hospital Charles Strobel, Director, Campus for Human Development Rader Walker, CEO, Nashville Rescue Mission Rev. Kaki Friskics-Warren, Community Foundation of Middle TN Pam Womack, Mental Health Cooperative

2 Work Group Members Health Housing Economic Stability System Coordination Chair Chair Chair Chair John Lozier Kaki Friskics-Warren Steve Meinbresse Mark Desmond

Task Force Members Task Force Members Task Force Members Task Force Members Stephanie Bailey Howard Allen Kevin Barbieux Kevin Barbieux David Guth Kevin Barbieux James Bearden David Pennington Steve Halford Cynthia Durant John Gupton Bill Coke Roxane Spitzer Howard Gentry Mike Neal Ronal Serpas Pam Womack Kenneth Locke Joseph Sanches Andrei Lee Ed Pringle Brenda Sanderson Charles Strobel Core Team Members Core Team Members Rader Walker Kimberly Bess, Vanderbilt Theresa Armstead, Vanderbilt Core Team Members Mary Gormley, MDHA Scott Orman, Metro Health Brenda Gill, Metro Action Scott Orman, Metro Health Department Core Team Members Commission Department Pam Sylakowski, Metro Social Theresa Armstead, Vanderbilt Carrie Hanlin, Vanderbilt Doug Perkins, Vanderbilt Services Brian Christens, Vanderbilt Diana Jones, Vanderbilt Brenda Ross, Metro Social Svs. Mary Gormley, MDHA Lisa Pote, Nashville Career Suzie Tolmie, MDHA Paul Johnson, MDHA Advancement Center Community Members/Resource Phil Ryan, MDHA Persons Community Members/Resource Bart Perkey, Metro Health Community Members/Resource Community Members/Resource Persons Department Persons Persons Angela Bard, Centerstone Russanne Buchi-Fotre, Downtown Bill Barnes, Community Activist Christine Bradley, Nashville Angela Bauer, MH Court Clinic Bill Burleigh, Operation Stand Career Advancement Center Jeff Blum, Sheriff’s Office Michael Cartwright, Foundations Down Terry Horgan, Woodbine Joe Brown, Operation Stand Down Associates Penny Campbell, Park Center Community Organization Russanne Buchi-Fotre', Metro Joy Cook, TN Department of Pat Clark, MDHA Betty Johnson, Goodwill Health Department Health Bob Currie, Park Center Dani Lieberman, United Way Pat Clark, MDHA Doel Fuentes, Nashville Rescue Brian Dion, TDMHDD Darryl Murray, Welcome Home Rae Ann Coughlin, TN Dept. Mission Kathy Dodd, Woodbine Ministries Correction Estelle Garner, Samaritan Community Organization Ed Owens, Gresham Smith Linda Cross, Veterans Affairs Recovery Community Charlie Finchum, Salvation Army Partners Bob Davenport, Veterans Affairs David Grimes, Centerstone Jennifer Jones, Operation Stand Derrell Payne, Social Security Margo Fortney, MH Cooperative Jim Holzemer, Nashville Fire Down Administration Andy Garrett, Metro Police Department Ed Latimer, Affordable Housing John Poole, Campus for Human Bill Gupton, TN Dpt. of Corrections Linda Klinefelter, TN Protection & Resources Development Tony Halton, National Health Care Advocacy Rusty Lawrence, Urban Housing Shelby White, Nashville Chamber for the Homeless Council William Luttrell, Campus for Solutions of Commerce Donald Hawkins, Metro Police Human Development Jessica LeVeen, Federal Reserve Don Worrell, Nashville Rescue Mary Ann Hea, Public Defenders Sandra McMahan, Metro General Bank Mission Mike Hodge, Neighborhood Hospital Terry Livingston, HUD Resource Center James Martin, Homeless Rep Loretta Owens, Nashville Housing Doc Hooks, Metro Health Dept. Marion Mosby, HCA Healthcare Fund Harmon Hunsicker, Metro Police Sean Muldoon, Nashville CARES Ralph Perry, FannieMae Brian Huskey, Urban Housing Karl Smithson, Homeless Rep Carol Ridner, MDHA Ben Jacobs, Metro Health Linda Thomsen Don Worrell, Nashville Rescue Dani Lieberman, United Way Pam White, Nashville Prevention Mission Darlene McClung, Project Return Partnership Sandra McMahan, Metro General John York, Samaritan Recovery Hospital Community Pamela May, New Hope Fdn Lee Mitchell, MDHA Charlene Murphy, MDHA Bruce Newport, Nashville Safe Haven Family Shelter Steve Pharris, Metro Health Larry Prisco, Vanderbilt Stacey Richards, Centerstone Theresa Robinson, VA Michelle Steele, Mayor's Office of Neighborhoods Benn Stebleton, Oasis Center Marsha Travis, Sheriff's Dept. Regina Williams, Centerstone

3 Bill York, Metro Police

Introduction

A Call to Action

Homelessness – especially chronic homelessness – constitutes a multi-faceted In the 2004 count of homeless in Nashville, challenge facing communities across our volunteers and Metro officials counted 1,800 nation. The homeless are a visible homeless individuals, including 900 who reminder that some citizens do not possess met the Department of Housing and Urban one of the most basic ingredients of human Development’s definition of chronically existence – shelter from the elements. homeless. Homelessness arises from multiple causes and its complexity can easily confound the government, law enforcement, health care, and social service agencies. And homelessness affects us all – it is, by The U.S. Department of Housing and Urban Development defines a chronically homeless definition, human suffering that takes place person as an unaccompanied homeless individual in public: a daily tragedy of the few that with a disabling condition who has either been touches the many. continuously homeless for a year or more or has had at least four (4) episodes of homelessness in the past three (3) years. To be considered In a city like Nashville, recognized across chronically homeless, persons must have been the nation for its excellent quality of life, the sleeping in a place not meant for human habitation plight of our chronically homeless (e.g., living on the streets) and/or in an emergency population is especially poignant and homeless shelter during that time. problematic. It is not that our community has ignored the problem – far from it. But, The UnitedStates Interagency Council on Homelessness estimates that chronically homeless at the end of the day, research and persons make up about 10 percent of all homeless programs of the past have not marshaled persons, but consume 50 percent of available the commitment, resources, and level of resources. coordination required to solve homelessness in Nashville.

It is time to take up the challenge of chronic Nashville boasts a 20-year history of homelessness in Nashville. Our federal research and planning that has generated government has set the goal of ending increased services for the homeless chronic homelessness. In April of 2004, population. These achievements have been Mayor Bill Purcell appointed a task force critical yet limited in scope and often charged with making certain Nashville fragmented. This ten-year plan will give meets the federal goal within ten years. By Nashville a guide to end chronic bringing community leaders, government, homelessness, improving the lives of many and service agencies together to take on and improving our community. This is the the multiple components of chronic first time that a broad representation of the homelessness, Nashville will map a Nashville community has convened to coordinated system to address this create a vision and concrete plan to end important issue. chronic homelessness.

4 Introduction: The Planning Approach

Mayor Purcell named a task force that incomes, these systems are fraught with includes public officials; business and faith obstacles that impede access. communities; social service agency Additionally, job training, readiness and representation; homeless individuals and placement are needed for chronically committed citizens to a five-month job of homeless persons who are able to work. designing the plan. Individuals who are Systems Coordination chronically homeless do not fit one general In addition to the components already description. However, they do share discussed, the broad system of services common needs, including affordable and housing must be as seamless and housing, adequate income, and health care. coordinated as possible. Nashville must Given those common needs, the task force continue to develop a system that divided the planning into four work groups: encourages chronically homeless housing, health, economic stability, and individuals to enter permanent housing and systems coordination. access services. Service providers must coordinate and communicate to avoid Housing duplication and utilize resources effectively. A variety of housing options that ensure long-term stability must be available to and The four work groups were comprised of affordable for, chronically homeless key individuals from across the city and persons. Permanent supportive housing is were charged with creating a set of critical. But to move from chronic recommended goals. To create such a plan homelessness, there must be adequate requires commitment and ownership from emergency and transitional housing options those Task Force work group members as as well. well as from other stakeholders. The four work groups sought input from the Health homeless, business, faith community, and Individuals who experience chronic service providers. They researched other homelessness need access to a range of city’s plans and investigated best practices. comprehensive services that respond to They assessed current and past efforts in their complex and multiple health and Nashville to impact chronic homelessness. behavioral health care needs. Homeless And finally, they agreed to a finite set of individuals who meet HUD’s definition of recommended goals for the ten-year plan. chronically homeless may need services such as mental health case management or drug treatment in order to remain in stable housing and maintain employment. By focusing on the chronically homeless, population and working to end chronic Economic Stability homelessness all the homeless Most individuals who become homeless populations are better served. are eligible for assistance from public and private systems of care, including benefits that can assure steady

5 Introduction: National Perspective on Homelessness

Who Experiences Homelessness? According to the National Alliance to End Homelessness, over the course of a year, as many 3.5 million individuals or nearly 11% of the poor population become homeless. “A Status Report on Hunger and Homelessness in America’s Cities 2002”, a 25-city survey published by the U.S. Conference of Mayors documented a 19% increase in homelessness, the steepest rise Recent studies in New York and in a decade. Philadelphia

Age Studies in New York and Philadelphia The 2003 U.S. Conference of Mayors’ identified three patterns of homelessness: survey of hunger and homelessness in 25 chronic, episodic, and transitional. cities found that families with children accounted for 40% of the homeless Transitional Homelessness describes a population. It also found that single episode of homelessness that is unaccompanied minors constitute 5% of the relatively short and often occurs in times urban homeless population. of economic hardship and/or temporary housing loss. The majority of individuals who fit into this category are families and Gender and Ethnicity single adults. Most studies show that single homeless adults are more likely to be male than Episodic Homelessness refers to female. In the 2003 U.S. Conference of recurrent periods of homelessness. Mayor’s survey, single men accounted for Typically individuals who experience this 41% of the urban homeless population while are younger and use the shelter system, single women accounted for 14%. and often have substance addictions. Research indicates that 9 percent of the Like the total U.S. population, the ethnic single adult homeless population fit the makeup of homeless populations varies by pattern of episodic homelessness. geographic location. In its 2003 survey, the U.S. Conference of Mayors found that the Chronic Homelessness refers to an homeless population in the 25 cities extended episode generally lasting two or surveyed was 49% African-American, 35% more years. Homeless persons in this Caucasian, 13% Hispanic, 2% Native category are more likely to have a serious American and 1% Asian. mental illness, sometimes along with a substance addiction, unstable employment histories, and histories of hospitalization and or incarceration.

6 Introduction: Local Perspective on Homelessness

Count of Homeless On March 24, 2004, volunteers in Nashville helped to identify 447 individuals sleeping outside. On that night, shelter providers throughout the city provided a count of 1,358 individuals residing in their facilities. Together, a total of 1,805 individuals were Conditions of the Homeless counted as homeless during this point-in- When describing the conditions of chronic time survey. homelessness, it’s important to understand that some of this population will periodically, Surveying all homeless persons at a point in or even frequently, stay in shelters, while time is inherently limited by: others will often live outdoors. Of the o The transient nature of homelessness sheltered single homeless population The change in camp locations o counted on March 24, there is a o Incomplete numbers due to cheap motel prevalence of chronicity, substance abuse rental by multiple homeless persons and mental illness. In the professional o Homeless families in cars moving estimates of shelter providers responding to further out of the central service area MDHA’s point-in-time survey, 42% of the o The expansive geographic area of homeless single persons sheltered that Davidson County as a count area night met the HUD definition of “chronic”.

All of the shelter programs serving single Gender and Ethnicity individuals indicated that 55% or more of In the March 2004 count, the majority of their residents had substance abuse issues. individuals sleeping outdoors were males. Of the 13 programs, 11 estimated the Although it was not always possible for incidence to be 74% or higher and 6 out of volunteers to ascertain gender, 68% of the the 13 programs said that 100% of their unsheltered population was estimated to be residents are dealing with these issues. male. Estimates of single persons sheltered that evening who suffer from mental illness As in national data, individuals of color were averaged 37%. over-represented among the homeless in both the outdoor count and the count of The pervasiveness of addiction and mental homeless individuals residing in shelter illness was not only unique to the shelters programs. At least 38% of the individuals serving single homeless individuals, but was sleeping outdoors were confirmed to be also noted in shelters serving women and African American. 50% of the homeless children. In shelters serving single women individuals in shelters were African and families with children, estimates of American. Data from the 2000 Census persons who suffer from mental illness reports the percentage of African American averaged 27%. In these family shelter in Nashville-Davidson County to be 25.9%. programs, an average of 51% of the residents were estimated to have substance abuse problems.

7 Of the 1,358 persons counted in "shelter" programs, 296 fell into the “family/ children” heading which is not quite 22% of the total.

Nashville’s Perspective

What’s In Place Now? and the Campus for Human Development. Over the past 20 years much has been and Area churches, Big Brothers and Ladies of continues to be done to address the Charity also contribute to this prevention housing and service needs of homeless effort. individuals. As a result of public and private Outreach Services funds and the commitment of hundreds of Outreach workers canvass areas known to generous volunteers, the spectrum of be frequented by homeless persons as well homeless programs is broader. In spite of as area shelters and feeding programs. these efforts, there are still chronically Outreach services are provided through homeless persons. local agencies including:  Metropolitan Health Department Shelter Beds and Transitional  Metropolitan Development and Housing Housing Agency Emergency shelter beds in Nashville for  Mental Health Cooperative homeless families, youth and single women  Operation Stand Down currently number 230. Current available  Oasis Center shelter beds for single adult males total  Nashville CARES approximately 912. Bed availability for all homeless individuals is reduced each spring Supportive Services due to the seasonal nature of the Room in Services available to homeless individuals the Inn program which shelters up to 200 in Nashville include emergency services, homeless individuals each night at area feeding programs, assessment and congregations and is closed mid-April to treatment for mental health issues, alcohol mid-November. Nashville’s stock of longer- and drug addictions, case management, term transitional housing is scarcer: 251 health care, employment services, units of transitional housing exist for educational services, child care, homeless individuals, and 130 units for transportation, information and referral, and homeless families. financial assistance.

Permanent Housing Peter B. is a 58-year-old who suffers from Nashville currently has an inventory of 807 severe mental illness. Peter comes to the permanent housing opportunities that are Lodge for shelter and food and is often targeted for homeless individuals. 56 units delusional and off his medicine. Because of are under development. insurance limitations, Peter is denied inpatient psychiatric treatment. Without his medicine, Prevention Services he will not seek outpatient treatment. Not a great deal is known about Peter because of Efforts to prevent homelessness focus his inability to articulate his history with any primarily on financial assistance to pay rent cohesiveness. He believes he is a country and utility arrearages. Several agencies music star. He sings and plays the guitar offer this form of assistance to individuals poorly. He says he has a house somewhere and families facing imminent threat of in a rural Tennessee town that he can’t stay in homelessness. Key players include Metro because it bothers him to be confined. He Social Services, Metro Action Commission owns an old car that he drove to Nashville. According to him, he has worked all his life

8 and now a lawyer handles his financial affairs. who appears physically as well as mentally He can’t understand this and in telling about it sicker with each visit. He has been coming to often reacts in angry outbursts. It is not the Lodge, on and off, for about a year. known if he has family or has ever been married, but it doesn’t appear he has anyone to care for him. He is a lost and lonely man Nashville’s Perspective: Past Planning Efforts This strategic framework for addressing chronic homelessness builds on a long history of planning for the homeless in Nashville. Since 1984, several plans or studies have been conducted on issues related to homelessness. o Recommended the creation of Affordable 1984 Council of Community Services Housing Inc. o Broad based effort o Recognized the need for increasing o Creation of Nashville Coalition for the housing opportunities for special needs Homeless groups o Resulted in the creation of the Downtown Clinic which was funded by Robert Wood 1998 The Metropolitan Health Johnson and Pew Memorial Trust Department’s Voice of the Homeless Survey 1986 MDHA’s Task Force on o Surveyed 630 homeless persons at 20 Homelessness sites over a two month period of time o Detailed the demographics of the o Found that 60% of those surveyed had homeless population lived in Nashville before becoming o Recommendation made resulting in homeless creation of the Guest House and the o Found that 60% reported being first time Campus for Human Development homeless o Encouraged Metro to adopt a policy o Demonstrated that only a small statement taking responsibility for the percentage of those surveyed received homeless in Nashville mainstream benefits o Recognized the need for more affordable housing and for a central database of 2001 Downtown Homeless Outreach homeless population Initiative Report to the Inter- Departmental Task Force on the 1986 and 1987 The Nashville Coalition Homeless for the Homeless and Center City o Included outreach efforts focused on Committee “Plan for Nashville” downtown Nashville o Addressed issues of housing, mental o Focused on the chronically homeless illness, substance abuse, employment population and loss of community among the o Attempted to formally liaison with the homeless population downtown business community o Defined homeless sub-populations o Recognized the need for additional 2002 The Metropolitan Health outreach and case management, for Department Needs Assessment affordable housing, for improved access o Recognized many of the same needs to mainstream services (SSI) and for identified in 1986 services for developmentally disabled homeless persons 2003 The Providers Survey o Suggested the reestablishment of the 1989 Task Force on Affordable Housing Nashville Coalition for the Homeless o Set goal to reduce Nashville’s affordable o Recommended creating 100 new housing gap by 50% by 2000 and produce permanent housing units for homeless 14,000 units of affordable housing individuals

9 o Recommended increasing the shelter beds for families with older children o Recommend simplifying the enrollment process for benefits such as SSI, food stamps, and TennCare o Recommended quantifying the extent of homelessness in Nashville Nashville’s Perspective: Past Planning Efforts

2003 Homeless Individuals in Nashville- Pinpointing Numbers and Needs in Davidson County by Vanderbilt University o Recommended a focused coordinated strategic plan to be implemented Recommended the development of a o Root Causes of Homelessness in technology based tracking system to store critical information Nashville, Tennessee o Recommended the creation of a common This extensive, but not exhaustive, list of factors must be considered when dealing with the intake form for all services to the chronically homeless. homeless Lack of Affordable Housing Nashville’s housing market does not provide enough units affordable to those on disability, Temporary Assistance for All these efforts had their merit in Needy Families or who work minimum wage jobs. informing the city, creating segments of Physical Disability Profound injuries, illness, or birth defects. Socially debilitating physical traits needed infrastructure and improving such as disfigurement, dental deficiencies, or pockets of services. In looking back at obesity. all this work, it is evident that to have a Mental Illness Schizophrenia, bipolar disorder, significant impact, a clear focus has to chronic depression and other severe and persistent be determined, the vision has to be mental illnesses. longer than 3-5 years, and the Developmental Disabilities Low IQ or head injury that hinder intellectual functioning. commitment to the plan has to be Severe Trauma A history of domestic violence, expanded to include the entire city. The abuse, combat, catastrophic loss of family, or a work done dating back to 1984 has similar traumatic event. brought Nashville to this point where a Educational Deficiencies The inability to unified coordinated 10-year plan is the read/write, the lack of basic academic skills or no logical next move. high school diploma. Learning Disabilities Dyslexia, ADD and other disorders which interfere with educational and life functioning. Addiction Drugs, alcohol, sex, gambling and other addictions. Domestic Violence partner abuse forces victims out of their homes and into shelters or on the streets. Severe Family Dysfunction Abusive parents, broken homes, multiple residences/caregivers. No Family or Significant Support System Total lack of family support due to death, alienation, or institutional childhood. Criminal History The existence of a criminal record that seriously limits opportunity. Limited Occupational Skill Set The inability to do anything beyond the most basic manual labor.

10 Life Skill Deficiency The inability to manage the Generational Poverty Two or more generations most basic life functions such as hygiene, housing, dependent on public assistance or charity for basic transportation, finances, and relationships. living needs that has fostered an attitude of Transportation Deficiencies The inability to hopelessness. purchase, maintain, insure, or legally drive a car or Nashville Coalition for the Homeless obtain transportation through public or private PO Box 280988 means. Nashville, TN 37208 Prior Long Term Institutionalization An extended 615-242-1070 ext 640 stay in juvenile institutions, mental hospitals, prison [email protected] or other institution. *Based on document from Campus for Human Development Mayor’s Task Force to End Chronic Homelessness Strategic Framework

Our vision: Within 10 years, Nashville will be a community without chronic homelessness by assuring access to safe, affordable and permanent housing with a comprehensive array of supportive services. Guiding Principles

1. Permanent Supportive Housing is a priority – individuals moving 5. Community Ownership is into housing as quickly as understanding that homelessness impacts possible the whole community – every individual, agency, and business – particularly those operating in the central city. Solutions to 2. Continuum of Supportive end homelessness can and must be found Services including health, mental health, in every public and private sector entity. substance abuse, outreach and other services are available, tailored to meet an 6. Voice and Choice of homeless individual’s need and recognize a person’s individuals is a must, both in their individual ability to change. Services are essential to circumstances and in the systems that achieving long-term housing stability. affect them.

7. Results-Driven must be imbedded 3. Systems Coordination and in all our services, programs, and collaboration between public and private endeavors. Success must be clearly defined sector service providers is critical and and measured. Only services proven necessary for long-term success. effective will be funded.

8. Prevention, funded, coordinated, 4. Self Sufficiency includes access to and well functioning systems of housing income assistance (SSI, SSDI,) and/or with social and economic supports for employment opportunities and is the best individuals at risk of homelessness is the way to assure individuals ability to maintain only lasting and cost-effective solutions to housing and live independently. chronic homelessness.

In creating a set of recommendations, work groups focused on a standardized series of tasks. These tasks included defining key terms and identifying the relevance of the work group area to the guiding principals. Additional research was conducted on the current status of the work group topic in Nashville, existing gaps and barriers, and best practices implemented in other cities. Taking all this into consideration, each work group identified a set of recommendations.

11 The findings and recommendations of the work group efforts are reflected in the following sections of this framework, Housing, Health, Economic Stability, and Systems Coordination.

“Everyone has the right to a standard of living adequate for the health and well-being of themselves and their family, including food, clothing, housing, medical care and necessary social services.” Universal Declaration of Human Rights, United Nations

Strategic Framework: Housing

Homelessness is linked to a shortage of housing for individuals and families with very low incomes. The vast majority of individuals experiencing homelessness have incomes that fall far below the typical threshold calculated for most affordable housing. Monthly rents of $0 to $160 are the maximum that can be paid by most Gaps and Barriers homeless individuals. Nashville's housing Addressing barriers to developing housing sector for homeless individuals has will be essential to the successful expansion experienced minimal development in the of affordable housing for homeless past two decades. individuals. Barriers include:  Harsh attitudes toward homeless individuals from the larger Nashville community  The "Not in my back yard" syndrome makes it difficult to locate housing for homeless and chronically homeless Key Definitions individuals  The will to create structures and systems Affordable housing is the term used to that support housing development for describe housing opportunities that are homeless individuals has been limited in available to households earning 80% or less Nashville to this point of median family income that do not cost  Land use policy and zoning restrictions more than 30% of gross monthly income. have created costly obstacles  Hopelessness (chronically homeless Permanent Supportive Housing (PSH) is individuals often are early in the "stages of the term used to describe permanent, change" process, which means that affordable housing linked to health, mental motivation for life-change can be low) health, employment and other support  Chronically homeless individuals are services. resistant to the current systems of care; at the same time, systems of care have not found successful engagement methods  Requirements of current housing and shelters do not accommodate chronically homeless individuals who are "treatment resistant" or in early stages of change (i.e., rules and regulations and program

12 expectations)  Resources needed for very low income housing development have been extremely limited

Strategic Framework: Housing 5. PSH is grounded in the principles of Best Practices integration of services, personal control, Permanent supportive housing (PSH) was accessibility, and autonomy. implemented in the early 1990's. Demonstration studies showed that PSH was very successful at stabilizing tenants in housing with retention rates at about 85% Chronic Homeless Production Chart after two or more years. The following are common tenets of PSH programs: Non-Chronic Homeless Production Chart

1. The housing is affordable for individuals with SSI income. The most comprehensive case for 2. The housing is permanent supportive housing is made by the (tenant/landlord laws apply, refusal to University of Pennsylvania's Center for participate in services is not grounds for Mental Health Policy and Services eviction). Research. Researchers tracked mentally ill 3. The housing is linked to a broad base of individuals who were homeless in New York support services. City for two years. Among their conclusions was that supportive permanent housing Housing Activity Need Estimated Cost Assumptions Development of newly constructed permanent supportive housing units 486 $19,440,000 1. Need is based on March 2004 Homeless Count Rehabilitation/Conversion activities 2. Chronic includes those found during the yielding new permanent supportive 486 $14,580,000 2004 Count to either be unsheltered or in a housing units homeless facility and identified by the provider as chronically homeless Rental assistance/subsidies 972 $5,832,000 3. New construction cost is based on $40,000 per unit 4. Rehab/Conversion cost is based on $30,000 per unit TOTAL $39,852,000 5. Rental assistance cost is based on $6000 per individual 4. The supportive services are flexible and created an average annual savings of individualized, not program driven. $16,282 per person by reducing the use of

Housing Activity Need Estimated Cost Assumptions Development of newly constructed permanent supportive housing units 397 $15,880,000 1. Need is based on March 2004 Homeless Count Rehabilitation/Conversion activities 2. Non-chronic includes those found during the yielding new permanent supportive 397 $11,910,000 2004 count who do not meet the HUD definition housing units of chronic homelessness 3. New construction cost is based on $40,000 Rental assistance/subsidies 794 $4,764,000 per unit 4. Rehab/Conversion cost is based on $30,000 per unit TOTAL $32,554,000 5. Rental assistance cost is based on $6000 per individual

13 public services, including: 72% savings resulting from a decline in the use of public health services; and 23% savings from a decline in shelter use.

Strategic Framework: Housing

Recommendations 1. Develop Permanent Supportive  Ongoing assessment and evaluation of Housing (PSH) Opportunities for adequate housing development for Homeless Individuals and Families. PSH homeless persons will be conducted utilizing is housing made affordable to homeless annual counts and other monitoring efforts individuals that has links to health, mental health, employment and other social services. By providing homeless individuals with a way out of expensive emergency 2. Identify All Existing Funding Sources public services and back into their own while developing new funding initiatives to homes, PSH not only improves the lives of finance the permanent supportive housing. its residents but also generates significant When considering financing for permanent public savings. Currently Nashville has an supportive housing, three distinct costs must affordable housing inventory of 807 housing be kept in mind: funds for housing opportunities targeted to homeless development (rehab and new construction), individuals. funds for rental subsidies (ongoing), and funds for support services (ongoing). PSH development includes the following features: Funding Opportunities to explore:  Successful housing options for the homeless  Property transfer tax for housing population must include a variety of options development (THDA -HOUSE Program) to promote choice and "goodness of fit"  Support from THDA to develop an  Adequate development along the housing innovative pilot housing project that could be continuum includes a combination of used as a state model or "best practice" of scattered-site (single units, duplexes, etc.), homeless housing modular, congregate living and single room  Local housing trust fund with a recurring, occupancy units dedicated funding source  Development can be accomplished through  Tennessee's federal HOME dollars for construction, renovation, or master leasing Community Housing Development of existing housing stock Organizations specifically developing  Low-density, de-concentrated sites are housing for homeless population preferred. The Housing Work Group defines  HUD 811, 202, 221 (d) and 236 housing low density as fewer than 20 units per development programs development. As the density of housing  Community Development Block Grant increases (up to 20 units), supportive (CDBG) and HOME allocations to the services will need to increase in proportion. Nashville area  PSH must have access to public  HOPWA, Ryan White, and SAMHSA federal transportation, and be located within walking funding distance of essential services and amenities  THDA low income housing tax credits (food, laundry facilities, bus routes, etc.) (LIHTC) and bond financing programs  Establishment of community as peer support  Federal Home Loan Bank of Cincinnati and is linked to long-term housing stability Atlanta under the Affordable Housing

14 Program Nashville Housing Fund as well as local and  Local allocation for low-income housing regional banks development  Faith-based community initiatives and  HUD Continuum funding investments  Instate local development fee for housing development  Development financing through the Strategic Framework: Housing

3) Establish leadership committee to 6) Apply to the Nashville Civic Design secure lead private gifts for housing Center for consultation on housing development. This initiative will be design that can meet homeless resident directed by leaders in the public and private and neighborhood needs. sectors. This fund could be administered within an existing nonprofit (i.e., The United 7) Establish an emergency fund for the Way or The Community Foundation of purpose of preventing chronic homeless Middle Tennessee). The faith community, individuals and families from relapsing business community, foundations, into homelessness after they move into corporations and individuals will be permanent housing. educated on this philanthropic opportunity. These interventions would be limited to Philanthropic gifts would be focused on the chronically homeless individuals who are one-time expense of housing development. already in the coordinated system of care developed for support services. 4) Develop a community education Interventions could include supportive initiative regarding homelessness in services, rental assistance, homemaker Nashville. The Housing Committee services, addiction and mental health identified public attitude as a primary barrier treatment. Keeping people in housing is to housing development. Community easer and less costly than reestablishing education on the permanent supportive them in housing. housing model will be essential to successful implementation. A broad 8) Train service providers on the community education campaign should be permanent supportive housing model. initiated early in the housing development Permanent Supportive Housing is a new phase. To effectively penetrate concept for many Nashville service discrimination, this education campaign will providers. Training will be needed at the include; the root causes of homelessness, local level to assist providers with extent of homelessness, human and public implementation and management skills cost of homelessness and cost necessary to develop this new service effectiveness of best practice interventions. approach. The training needs to include: stages of change, motivational interviewing, 5) Address discrimination against harm reduction intervention models, low homeless individuals, which violates demand housing operations and human rights and dignity. If Nashville is management. to be “One City All People” and housing opportunities are to be developed, discrimination issues must be addressed. We recommend that the Metro Human Relations Commission address homeless discrimination issues including the criminalization of homelessness.

15 Strategic Framework: Health and Behavioral Health Care

Homeless persons have all the same Profile of Health Care Needs of physical and behavioral health problems as Homeless Persons in Nashville individuals with homes, but at greatly Metro Public Health Department analyzed elevated rates, with multiple diagnoses and calendar year 2003 encounter data from its disabling conditions being common. By Downtown Clinic for the Homeless and “health” this report refers to the full complex encounter data for homeless persons of physical health, mental health and served by Bridges to Care, a program that substance abuse problems. Homelessness links uninsured persons in Nashville to inevitably causes or worsens serious health safety net providers and hospitals. While problems. not representative of all, these data provide  Undetected and untreated information about the health care needs of a communicable diseases including substantial portion of the homeless. As the HIV/AIDS and tuberculosis threaten the table below shows, these homeless persons health of other homeless individuals in averaged 4 health care encounters per year particular and of the public in general. and behavioral health problems (substance  Trauma resulting from violence and abuse and mental health) were among the conditions caused by exposure to the top diagnostic groups. Dental problems elements are also common among were also prevalent. homeless individuals.  Twenty-five percent (25%) of homeless persons have some form of physical disability or disabling health condition.  Approximately 20% of homeless persons have a serious mental illness.  At least 40% have substance use disorders (Blueprint for Change, DHHS Pub. No. SMA-04-3870 2003).

Homeless Patients -- Calendar Year 2003 Downtown Clinic Bridges to Care Av. # Visits/Person 4.1 3.9 Gender Males = 83% Males = 66% Females = 17% Females = 33% Race Black = 54% Black = 45% White = 41% White = 54% Other = 5% Other = 1% Age 18 – 34 (24%) 45 – 54 (31%) 65 and > (2%) 18 – 34 (26%) 45 – 54 (30%) 65 and > (0%) 35 – 44 (36%) 55 – 64 (7%) 35 – 44 (36%) 55 – 64 (7%) Top Ten Diagnostic Substance abuse = 23% Substance abuse = 12% Groups (ICD- 9 Mental illness & mental health screening = 16% Mental illness & mental health screening = 10% Codes) based on Physical Health Conditions = 34.5% Physical Health Conditions = 27.5% primary diagnosis (1) Dental = 15% Dental = 7.5% Hypertension = 8% Hypertension = 5% Respiratory infection = 4% Respiratory infection = 3% Diabetes = 3% Diabetes = 4% COPD = 2.5% COPD = 2% Injury = 2% Injury = 6% (1) This is the primary problem for which the patient was treated during the visit and therefore does not represent all possible health and behavioral health conditions a person may have at the time.

16 Strategic Framework: Health and Behavioral Health Care

The harsh reality is that homeless persons Gaps in the Service System and are often faced with co-occurring or multiple Barriers to Care health and behavioral health problems that Although there are multiple providers of increase the difficulty of overcoming their health and behavioral health care in the homelessness. Homelessness is prolonged community who have served the homeless for persons who cannot stabilize and population for many years, there continue to manage their health conditions and who are be barriers to care and significant gaps in consequently less likely to maintain their the existing health care delivery systems in housing or job. Moreover, health care Davidson County. There are several key services are markedly less effective when factors that prohibit or limit homeless delivered to persons without the basic persons from receiving proper health care. protections afforded by a home (protection from the elements, sanitary conditions, 1. Housing shortage. Housing is health opportunity to rest, refrigeration for food and care. Many of the health problems of medicines): housing is health care. homeless individuals relate directly to their lack of housing. Current Service System 2. Lack of access to health insurance The current homeless service system in and health and behavioral health care. Davidson County is comprised of a variety Homeless individuals often are uninsured of organizations that provide some type of and therefore lack access to comprehensive health or behavioral health care or service health care. Often they go without care until to homeless persons. The types of entities relatively minor problems become include: expensive medical emergencies.  Entities whose sole purpose is to serve 3. Lengthy disability determination the homeless population (e.g., homeless process. The length of time for a person to shelters and the Downtown Clinic) complete the eligibility process for  Entities that offer a range of services but Supplemental Security Income (SSI) or have a component of their service that is Social Security Disability Insurance (SSDI) targeted to the homeless population (e.g., is a major barrier to the receipt of benefits, a homeless outreach service of a which include health insurance and monthly community mental health provider) income. Regrettably, persons with  Entities that do not target the homeless substance abuse disorders are often not population but due to the nature of their eligible under current federal law. However, service provide care to homeless persons many homeless persons appear to be (e.g., hospitals, emergency rooms, safety eligible but are not receiving disability net medical clinics, community mental health centers, substance abuse benefits which could help resolve their providers, community social service homelessness. agencies). Emergency rooms in particular 4. Fragmented, uncoordinated and are the most expensive level of care but unorganized system of care. Persons are frequently utilized inappropriately by trying to access needed services often face homeless and other uninsured persons. a service system that is not organized  Entities that provide a public service and effectively or efficiently. They consequently in the course of their work must respond have difficulty knowing what “mainstream” to the needs of the homeless population or “homeless-specific” services and benefits (e.g. EMTs-Fire Department). are available, or how to navigate the system in order to access services.

17 5. Lack of single point of accountability 11. Lack of knowledge regarding needs for homeless persons with mental of homeless persons suffering from illnesses. Fragmentation and lack of clear mental retardation or other responsibility within the service delivery developmental disabilities. There is little system inhibits service providers from available data on the incidence rate of providing optimal care. homeless persons suffering mental 6. Lack of Needed Services. Certain retardation or other developmental services are not available to meet the disabilities, though service providers current needs of homeless and other poor frequently observe these conditions. persons (e.g., detoxification, dental care, Therefore little is known about this respite care after discharge from a hospital, population and their service needs. specialty health care, substance abuse 12. Criminalization of behavior related to treatment). a mental health or substance abuse 7. Lack of services that allow for disorder. Criminal sanctions including relapse. The nature of mental illness and incarceration are ineffective responses that substance abuse disorders is that do not comprehend or help to resolve the individuals will relapse. Zero tolerance underlying health problems. policies in some current treatment and 13. Stigma. Homeless persons, persons housing programs reflect the lack of with a mental illness and persons with a understanding of these disorders. substance abuse disorder are often 8. Lack of access to services that stereotyped, viewed inaccurately by the incorporate an understanding of dual public, in print or other media. Stigma often diagnosis and co-occurring conditions. leads to barriers in assuring the availability The multiple diagnoses of many homeless of and access to services, or unfair persons (involving physical, mental and discrimination or practices. addiction disorders) require sophisticated 14. Funding, funding, and funding. care that does not focus on one condition of There is a need for additional funding to an individual separately from other support the development or enhancement of conditions. needed services. 9. Limited outreach and engagement between the service system and homeless persons. The service system is not always responsive to the needs of the homeless persons and the homeless persons are not always ready to receive services. Additionally, outreach efforts of the system are poorly coordinated. 10. The nature of certain illnesses keeps some persons from accessing or maintaining contact with services. So- called “treatment avoidance” is often symptomatic of addictions and mental illnesses, and is aggravated for many homeless persons by prior bad experiences within the treatment system.

Strategic Framework: Health and Behavioral Health Care

18 Elements of an Effective and 10. Expedited assessment and eligibility Responsive System determinations for mainstream benefits, Key elements of an effective and responsive especially disability and health insurance health and behavioral health care system benefits. Benefits assistance services that will help homeless persons get well and include education, assessment, application move out of homelessness include: assistance, documentation/records procurement, and advocacy. 1. Mechanisms that facilitate a coordinated and integrated service Key Definitions delivery system. Persons who are Outreach Services – An array of therapeutic homeless have complex problems that services delivered directly to the individual require comprehensive services that are outside of traditional service delivery locations, well coordinated. as well as connecting individuals to existing 2. Aggressive outreach. Outreach is now service providers. It typically focuses on those considered the first and most important step persons who are not aware of vital services or who are prevented by a variety of factors from in providing access for homeless individuals accessing services. to needed mental health, substance abuse Assertive Community Treatment – A service and social services, and to housing delivery model that provides comprehensive, (Blueprint for Change, DHHS Pub. No. community based treatment to individuals with SMA-04-3870 2003). serious and persistent mental illness. It is a 3. Engagement is essential to develop the multidisciplinary team of staff that provides trust, the rapport and the relationship crisis intervention, medication monitoring, needed to help individuals accept more case management, rehabilitation, substance long-term services, the ultimate goal of abuse treatment and support to those who outreach efforts. (Interagency Council on are the most seriously ill who require this the Homeless, 1991; McMurray-Avila, intensive level of care. The team is accessible 1997). 24 hours a day, 7 days a week and delivers services in the community and not in the 4. Assertive Community Treatment. ACT office. Case loads are small and usually do provides a full range of community- based not exceed more than a ratio of 1:10. The integrated services to persons 24 hours per ACT model has proven effective for certain day, 7 days a week. populations including those individuals who 5. Treatment services for persons with co- are homeless and who have a serious mental occurring disorders and multiple health illness. conditions. Primary Health Care – The "medical home" 6. Prevention strategies. Health services for a patient, ideally providing continuity and that address the known risk factors for integration of health care. All family physicians homelessness. and most pediatricians and internists are in 7. Easy and quick access to primary care. The aim of primary care is to provide the patient with a broad spectrum of detoxification services care, both preventive and curative, over a 8. Service principles and values that period of time and to coordinate all of the care respect consumer’s voice and right to the patient receives. self-determination and actively involve Specialty Health Care – Refers to medical consumers in service planning and services provided by physicians upon referral provision of service. by a primary care physician. Examples would 9. Low-demand approach. The include orthopedics, dermatology, cardiology, recognition that participation in treatment neurology, gastroenterology, gynecology, etc and receipt of services should not be required in order to gain access to housing.

Strategic Framework: Health and Behavioral Health Care Each year, many individuals in Nashville are Recommendations homeless and are in desperate need of

19 health care, behavioral health care and social services. In order to achieve the 2. Conduct a comprehensive assessment overarching goal that untreated health of health care system capacity and need, conditions, illnesses and injuries will no to indicate additional areas for expansion or longer cause or prolong homelessness in rescission. Assessment should include Nashville, the Health Work Group provides careful review of programs and service the following recommendations. designs developed in other cities. The requirements of such a study exceeded the 1. Establish new/expanded services. resources available to the Work Group. Complement existing health care services by adding the following capabilities: 3. Service system characteristics. Assure that existing health and behavioral  Permanent supportive housing, with health services for homeless persons primary care, behavioral health care and incorporate the following characteristics: case management services available on site.  Involvement of consumers in service  Aggressive outreach to assess need, planning and delivery of services. engage and re-engage homeless  Protection of confidential information persons into systems of care; includes about homeless consumers and respect service-oriented outreach teams to of their right of self-determination. intervene in cases of disruptive behavior  Integration of treatment for co-occurring  Expedited enrollment procedures for mental health and substance abuse SSI, SSDI, TennCare and other public disorders. benefits  Incorporation of relapse tolerance into  Single-agency responsibility for housing and service programs. homeless persons with mental illnesses  Provision of transportation to assure  Assertive Community Treatment teams effective access to health and that provide on-going treatment and behavioral health services not available case management without time on site. limitations  Evaluation of programs according to  24/7 alcohol and drug detoxification, outcomes. screening and assessment  On-going community education  Increased residential substance abuse regarding the needs of homeless treatment for indigent and uninsured persons and available resources. persons  Improved community partnerships to  Respite Care setting(s) for recuperation promote an effective service delivery of persons without homes after hospital system. discharge

Strategic Framework: Economic Stability Culhane’s University of Pennsylvania- It is well documented that the chronically supported 2001 landmark study is often homeless, many of whom are mentally ill, cited as the benchmark on the effects of often with co-occurring diseases, consume homelessness and service-enriched inordinate levels of resources. Dennis housing on mentally ill individual’s use of

20 publicly funded services. While focusing on Stigma, discrimination, and misperceptions New York City data, it is representative of by the larger community about the the impact of offering supported housing chronically homeless will impact options to a chronically homeless implementation strategies without a strong population. top-down, long-term commitment by local government, the private sector and faith- In general, once placed in supportive based community leadership. housing, a homeless mentally ill person reduced his or her use of publicly funded Local homeless and specialized job training services by 30%. This reduction in and employment-related activities are often utilization paid for 95% of the costs of population-specific and may include specific building, operating and providing services in funder requirements or dis-incentives to supportive housing. The service reduction working with a chronically homeless resulted in fewer and shorter population. hospitalizations, reduced shelter use, and reduced use of medical and mental health Sample Initiative services. Chrysalis was founded in 1984 to create and locate employment opportunities to help Current Status homeless and other disadvantaged individuals Nashville currently offers a variety of low- become self-supporting. The program has income job training and employment received numerous awards and recognition for successfully bringing private sector business activities for which homeless individuals are models to a difficult social service issue. eligible. However, specific and effective Initially a homeless employment day center, outcome-based assessment, training, and Chrysalis went on to develop and operate a employment services for the chronically temporary employment agency and multiple homeless are basically non-existent. businesses that serve as training and market wage employment for homeless individuals. Identified Gaps and Barriers Their approach is to create and offer Low income service providers offering job employment programs that foster individual training and employability programs have initiative and independence within an environment that is very similar to private not sufficiently engaged the business sector work. The intent is to instill a positive community in effectively developing work ethic and good work habits applicable to outcome-based activities for difficult to any employment setting. Chrysalis promotes serve populations, especially the chronically itself as preparing a motivated low-income homeless willing and able to work. workforce, with strong supervisory oversight and post placement oversight. Chrysalis utilizes a “work first” philosophy that helps individuals maintain and upgrade employment after finding a job. Chrysalis acknowledges job retention as a primary problem and has instituted an enhanced case management Local employers lack uniform and system to improve retention. comprehensive information about available 516 South Main Street, Los Angeles, CA tax credit and incentive programs for 90013 training and hiring marginalized populations. (310) 392-4117, Lesley Goldberg, VP of Development Strategic Framework: Economic Stability homeless funding generated through Recommendations Metro government. Calls for proposals will 1. Nashville will utilize an outcome follow agreed upon criteria established by based funding approach to be monitored open committees comprised of both service at least annually for any continued providers and other interested parties such as the Chamber of Commerce and the

21 Downtown Partnership. An inability to meet homeless individuals through the federal performance targets could lead to de- Department of Labor (Office of Disability funding. All programs working with the Employment Policy, Employment and Training chronically homeless would be encouraged to Administration), as well as state administered develop milestones and performance target programs from the Department of measurement structures regardless of the Labor/Workforce Development, the funding source. Department of Human Services, and the 2. Nashville will develop a formal Department of Mental Health. “Income Maintenance – Training – 6. Nashville should obtain the services of Employment Continuum.” The focus will a full time homeless programs be to meet the needs of the homeless development director to maximize resource individual with accountability, as they are development for the chronically homeless. (A ready and able to participate. Development Director could also explore new 3. Nashville will develop formal or underutilized program options such as Memorandums of Understanding with Americorp or partnering with Metro Action key public service providers. Key Commission to apply for discretionary CSBG providers will include the local Social Security funds.) Office, the State Office of Disability 7. Nashville should establish a pilot Determination Services, the Department of project to facilitate access to basic local Human Services, the TennCare Bureau, banking services for homeless Tennessee Department of Labor and others to individuals such as free basic checking ensure full early access by homeless accounts and debit cards as are provided to individuals to all publicly funded benefit and high school students. service programs. 8. Nashville will conduct an analysis of 4. Nashville will develop at least one the public transportation barriers that results-based chronically homeless job prevent homeless individuals from readiness/ training/ employment pilot participating in job training programs or project. This project will involve the maintaining employment. The analysis Chamber of Commerce, Metropolitan done by Metropolitan Transit Authority will Development and Housing Agency, the include the participation of service providers, Downtown Partnership, the Convention and homeless individuals, low-income employment Visitors Bureau, Metropolitan Transit and training agencies, major employers of Authority, Metro Action Commission, the low-income individuals and other interested Nashville Career Advancement Center, Metro parties. Social Services, Park Center, Matthew 25, Nashville does not have sufficient detailed Goodwill Industries, and others. demographics on the make-up of its chronically homeless population. While we know it is primarily adult men, we do not know much about the existence of families, the elderly, or the specific nature and frequency of disabilities. As such, this limits the community’s ability to effectively prioritize new or targeted job training 5. Nashville will aggressively seek new and employment services for this population. It funding for job training and employment is critical to understand where Nashville’s chronic programs. This could include discretionary homeless population is along the “income Workforce Development grants that target maintenance – employability continuum” before new services are developed. Strategic Framework: Systems Coordination coordinated as possible. Among the many An array of distinct components is and often complex issues under the necessary to construct an effective systems coordination umbrella, the Work response to chronically homeless Group divided into subcommittees to focus individuals. We must assure that the broad on three main topics: system of services and housing available to homeless individuals is as seamless and

22 Outreach individual to needed community services Nashville must have an engagement system and supports.” that effectively encourages chronically homeless individuals to enter permanent housing and access appropriate services. Sample Initiative Webster Dictionary defines outreach “as an Via State General Funds, California effort to build connections from one person operates programs in 24 counties and two or group to another”. It is these connections cities that provide integrated services to that offer street homeless individuals the persons who are mentally ill and opportunity to be linked with other segments homeless, at risk of homelessness, and or of the social service system, and ultimately, at imminent risk of being incarcerated. an end to their homelessness. Known as the “AB 2034” programs (2034 is the number of the Assembly Bill Collect Accurate Data that authorized the funding), they have Service providers must coordinate and demonstrated success in breaking the communicate to assure no duplication and cycle of chronic homelessness for utilize limited resources effectively. A individuals with serious mental illnesses. comprehensive homeless management The State gives broad discretion to the information system (“HMIS”) will be a key county contractors that administer the component of this systems framework. programs, but makes performance the basis for payment -- not services provided. Higher payments are given to counties that show the greatest reduction Coordinate Discharge Planning in homelessness, incarceration, etc. We must work to prevent the discharge of (National Alliance to End Homelessness) persons exiting publicly funded institutions from immediately resulting in http://www.dmh.cahwnet.gov/PGRE/Integr homelessness. ated_Services.asp

The definition of discharge planning taken from the Massachusetts Housing and Shelter Alliance is “the process to prepare a person in an institution for return or re-entry into the community and linkage of the

Strategic Framework: Systems Coordination- Outreach o Not enough street outreach Problems/Issues/Gaps o Too much ineffective floating  Lack of geographical coordination and outreach information sharing between outreach  Lack of formal training provided to providers outreach workers  Current outreach system is ineffective at reducing street homeless

23  Constant cycling of chronically homeless in and out of criminal justice 4. Develop a Community Court, where system alternative sentencing is used to prevent the creation of a criminal Recommendations record for many homeless 1. Create a Centralized Outreach individuals in Nashville, and to Coordination Center (OCC) belonging to a address the underlying causes that single entity, (possibly Metro government) led them to homelessness. should be designated, and charged to Community courts utilize a non- coordinate outreach efforts across various traditional approach to working with agencies in Nashville. With the full backing offenders, using sentencing of the city, housing providers, mental health alternatives and legal sanctions to agencies, substance abuse agencies and promote rehabilitation and address the Metropolitan Police Department the the deeper issues of criminality. OCC would be responsible for providing strategic direction of outreach efforts as well Sample Initiative as defining objectives and goals for At the community court in Austin, TX, reducing street homeless on an annual when a defendant presents at the initial basis. court hearing, it is first determined if they are a candidate for treatment. When 2. Create an Interdisciplinary Street treatment is deemed necessary, a referral Outreach Team by re-configuring/ is made to the court’s clinical evaluator for expanding existing outreach services into a assessment and recommendations. “dream team” including a city-wide When mental illness and/or substance coordinator, social workers, a Nurse abuse are identified as contributing factors Practitioner, a Licensed Alcohol and Drug to the defendant’s criminal behavior, the counselor, a mental health professional and court then makes a referral to the a dedicated Metro Nashville police officer. resources that will best serve the The team would be housed at one location, defendant. The defendant’s participation preferably the OCC and be directly in treatment then becomes part of their accountable to its hiring agency. The team sentencing. For those not needing formal would be flexible in terms of days/times out treatment, the judge can craft on the street. rehabilitative sentencing to include a range of social services such as counseling, work training, outpatient day treatment, etc. The referral to these social services is coordinated and followed-up by court-based social workers. http://www.ci.austin.tx.us/comcourt/overvi 3. Provide Formal Training for Outreach ew.htm Workers that should be required of all outreach workers including specifics on local resources, building trust, how to engage clients, understanding community resources, and worker safety. Strategic Framework: Systems Coordination - Data Collection challenges faced by the city is how to Nashville has a broad network of homeless collect comprehensive data on individuals service providers that offer homeless who are homeless and served at many services ranging from outreach to points in the system. To paint an accurate permanent supportive housing. Among the picture of the problem and evaluate efforts to address it, we must coordinate all of

24 these services in a way that promotes and Recommendations rewards data collection and information 1. Implement the Homeless Management sharing within and between service Information System (HMIS) currently providers. under development by the Metropolitan Health Department. Nashville needs a centralized system to gather information on A Homeless Management Information homeless services. System (HMIS) provides a means of generating an unduplicated count of 2. Mandate that All City-Funded homeless individuals, as well as analyzing Homeless Programs Participate in HMIS. service use and the effectiveness of local Currently, only those agencies assisted by systems at reducing homelessness. HUD HUD’s Continuum of Care homeless has been directed by Congress to work funding are required to participate in HMIS. with jurisdictions to gather homeless data The Systems Coordination Work Group across the country. The standard recommends that Nashville-Davidson features: County broaden this mandate to include all city-funded programs that serve homeless individuals. Agencies that are privately • Provide an unduplicated count of funded and those that receive no persons served government funding must also be urged to • Track data on individuals who enter participate in HMIS, in order to glean the homeless system, including optimal benefits. demographics, where they were prior to entry, what services they access while in the system and how they exit the system 3. Conduct Point-In-Time Count of • Track bed registry, incident Homeless Individuals No Less than management Every 2 Years. This will help the community • Facilitate case management across monitor progress on outcomes related to agencies in a centralized manner through reducing homelessness. the use of case management notes • Provide reports and data on homelessness in Nashville, including the number of chronically homeless •Require one entry of initial data into the system so that both service providers and homeless individuals save time that is now wasted in intake processes at multiple agencies

Strategic Framework: Systems Coordination - Coordinated Discharge Planning  Institutions may deny or delay treatment Gaps and Barriers to chronically homeless No Institutional  Internal Policies or Practices of Follow-Up of Implementation of Institutions Discharging Homeless Discharge Plan

25  Lack of Services for Homeless Without Diagnosed Disability  No Services Available during the Weekend  Lack of Available Housing

Recommendations 1. Identify a comprehensive list of Sample Initiative discharge related staff at institutions and The Massachusetts Housing and Shelter facilities state-wide that serve a high Alliance (MHSA) developed Discharge number of individuals who are homeless Planning Protocols in Massachusetts, a and at risk of being homeless. Begin set of strategies that centers on the involving them in a planning process by prevention of homelessness, especially for having them complete the discharge those at risk of chronic homelessness. planning survey, and use the results to MHSA documents the connection between assess and analyze the extent of the growing homelessness and discharge from problem. public systems of care, to create resources, and to develop a comprehensive strategy 2. Educate and coordinate with key of homeless prevention that assures administrators and discharge personnel successful discharge to the community. from hospitals, mental health, (Interagency Council on Homelessness) correctional, and residential treatment http://www.ich.gov/innovations/1/index.html facilities in order to reduce rates of recidivism among the homeless population. Develop training curricula and implement an on-going series of regional training workshops and technical assistance to institutions and facilities. Specific educational topics should include: a) homeless discharge planning protocols; b) benefits facilitation and acquisition; c) data collection and discharge review tools; d) community resources and referral process; e) cross-training and communication; f) service planning and linkage; and g) client advocacy.

3. Establish criteria for exemplary discharge planning practices for individuals who are homeless and those who are at risk of being homeless

4. Assure pre-release assistance with enrollment and public assistance programs