2017 REPORT

HOMELESSNESS IN ORANGE COUNTY THE COSTS TO OUR COMMUNITY Homelessness in Orange County: The Costs to Our Community

Conducted by David A. Snow and Rachel E. Goldberg

With the assistance of Sara Villalta and Colin Bernatzky Department of Sociology University of California, Irvine

In collaboration with Orange County United Way and Jamboree

June 2017 Homelessness inOrange County: The Coststo OurCommunity 13 10 20 16 9 5

Total CostsAcross InstitutionalSectors Hospitals andEmergency Departments Non-governmental theHomeless Agencies Servicing Municipalities County Institutional Sectors Cost ComparisonsandProfiles Across Samples andCountyPopulation Sample Profile Compared withOtherOC Homeless ProceduresInterview 17 Site SamplingandMethodology Profile ofOCHomeless Comparative Demographic andBiographic Comparison withOtherCostStudyMethodologiesandDesigns Methodology andStudyDesign13 Data Sources 13 and StudyDesign Data Sources, StudyMethodology Distinctive Features Rationale Objectives Introduction List of Tables AndFigures Executive Summary CONTENTS 20 10 10 21 11 16 17 24 26

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3 | Contents Homelessness inOrange County: The Coststo OurCommunity 70 49 47 45 30 28 Chronicity, Housing andPotential CostSavings ofHomelessness Used by Category Cost ofServices ofHomelessness Utilizationby Category Service Employment of Homelessness andIncomeby Category Reasons forBecomingHomeless Rapid Re-housing and Permanent Supportive Housing Rapid Re-housingandPermanent Supportive Socio-demographic ComparisonsAcross Street, Shelter, Bridge, ofHomelessness Comparisons by Category Cost andDemographic/Biographic Law Enforcement Cluster Housing Cluster Health Cluster Major CostClusters Footnotes ScheduleandQuestionnaireAppendix 5|Homeless Interview Appendix 4|Hospital andEmergency RoomQuestionnaire Agencies QuestionnaireAppendix 3|SocialService Appendix 2|MunicipalityCostQuestionnaire Committee Appendix 1|StudyAdvisory Appendices Glossary References 28 28 29 33 49 50 42 37 51 40 30 35

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4 | Contents f irst, to estimate theeconomicexpenditures • objectives: primary conduct acountywide coststudy, withtwo The purposeofthis project hasbeento has beencompletedforOrange County. California inparticular, butnosuchcoststudy across othermajorlocalitiesintheU.S.,and There have beenanumberofcoststudies costs onthecommunitiesinwhichitexists. homelessness imposesconsiderable economic individuals andfamilieswhoexperienceit, psychological costsofhomelessnessto those devastating andtraumatizing physicaland homelessness during2015.Inadditionto the residents experiencingatleastonenightof This equatesto onein200Orange County to behomelessover thecourseofyear. given night,and15,291peoplewere expected (2,200 ofwhomwere unsheltered) onany nearly 4,500peopleexperiencedhomelessness Orange County Point in Time Countreport, been spared thiscrisis.According to the2015 County andits34municipalitieshave not homelessness continuesto persist.Orange but thecrisisofAmerican citizens experiencing number ofhomelesshave waxed andwaned, forefront intheearly1980s,estimatesof United States.Sincetheissuecameto the problem sparingfew communitiesacross the currentThe waveis apressinghomelessness of Purpose Homelessness inOrange County: The Coststo OurCommunity

to thispopulation; hospitals andnon-profits providing services governmental agencies,including service county, its34municipalities,andnon- on homelessnessthathave accruedto the F RETURN TOCONTENTS EXECUTIVE SUMMARY

assembled, this is clearly one of the most assembled, thisisclearlyone ofthemost county. Given thebreadth andvolume ofdata of 252homelessindividuals throughout the conductedwithasample survey interviews agencies aswellstructured, in-person sent to municipalities,hospitals andservice data wasgathered through questionnaires experiencing homelessnessthemselves. The addressing homelessnessandindividuals a sampleofnon-governmental agencies of SouthernCaliforniaandCalOptima), County hospitals(viathe Hospital Association the municipalitieswithincounty, Orange five mainsources: theCountyofOrange, The studyisbasedondatacollectedfrom county’s newOfficeofCare Coordination. 10 Year Planto EndHomelessness, andthe Way’s FACE 2024 strategic plan,thecounty’s conducted to leverage theworkofUnited our designandprocess. The studywasalso institutions andorganizations to served guide and practitioners fromCounty experts various representing across sectionofOrange Committee California. Inaddition,anAdvisory and theHospital Association ofSouthern County (ACC-OC), 2-1-1Orange County(211OC), of theAssociation ofCaliforniaCities–Orange withthesupport University ofCalifornia,Irvine, County UnitedWay, Jamboree, andthe This isacollaborative studyamongOrange The Study o assesstheextentto whichthe •

forms of housing. forms ofhousing. in sheltersversus thoselivinginalternative spectrum ofthoselivingonthestreets and across thehomeless vary the costs ofserving Second, t

5 | Executive Summary our sample(inorder offrequency ofmention)are: The majorfactors precipitating homelessnessin recently chosento cometo Orange County. of over 10years, rather thanindividuals who have citizens andlong-termOrange Countyresidents homeless, whethermaleorfemale, are U.S. Key Finding: f • • • lcohol and/or drugs(22%) • amily issues,whichincludedomesticviolence, • inding orretaining affordable housing, • • significantshare are middle-aged(52%are • y are predominately US-born • y are mainlylong-termOCresidents, with • following characteristics: homeless populationisdefinedlargely by the individuals indicatethatOrange County’s Results from oursampleofhomeless of the Homeless Population Demographic andBiographic Characteristics Key Findings homelessness intheUnitedStates. comprehensive studiesofthepubliccosts of Homelessness inOrange County: The Coststo OurCommunity

male (57%)andlive alone(67%) age 50orolder),non-Hispanic White(47%), A The lived inthecountyfor10years orlonger 68% ofthe252homelesssurveyed having The Release fr Physical health(13%) Mental health(17%) A death ofafamilymember(28%) family dysfunction,relationship dissolution and F including evictions andforeclosures (36%) F wages (40%) Securing orr individuals (90%) RETURN TOCONTENTS om jail/prison(7%) The vast majorityofOrange County’s etaining jobs with sustainable etaining jobswithsustainable

2014/2015. 2014/2015. entities ina12-monthperiodencompassing County by governmental andnon-governmental was spentto address homelessnessinOrange We estimatethatapproximately $299million The CostofHomelessness $1,700 to $1,800+in2015. inOCof rent forasinglebedroom apartment rental outofreach given theaverage costof categories, theseincomelevels put housing children). Nonetheless, across allhousing program dependent (whoare oftensupporting and familiesplacedinto arapid re-housing to amedianof$1,958forhomelessindividuals median of$500forthoselivingonthestreet greatly by housingstatus,ranging from a all possiblesources, is$860.Incomevaries income ofthehomelessinoursample,from the followingfinding: Themedianmonthly substantiatedby isfurther This observation homelessness insuchacontext. substance abuse,increase one’s vulnerability to Other factors, like familydysfunction,health,and with highcostsofhousingin Orange County. by lackofsufficientincomeorjoblosscombined Key Finding: associated withhomelessness inOrange County. bearthebrunt of thecosts and publicservices Key Finding: vernmental housingagencies(~$35 • • • ospitals (~$77million), • •

homeless (~$5millionwithincompletedata). Other non-go million) Non-go The County(~$62million) H Municipalities accountforthelar of thistotal (~$120million),followedby Homelessness is caused primarily Homelessness iscausedprimarily Orange County’s citygovernments vernmental agencies servicing the the vernmental agenciesservicing

gest share

6 | Executive Summary f views withthoseexperiencing • Housing—PSH) or Permanent Supportive housed inBridge, RapidRe-Housing, Emergency Sheltered Homeless versus those Costs by Housing Categories (Street and those whoare chronically street homeless. upwards by users among theheaviest service Key Finding: cost perpersondrops to approximately $10,000. dropped from theanalysis,meanannual so muchso,thatifthemostcostly10%are drive theaverageservices, costupgreatly; ofhealthandmedical consumers, particularly is approximately $45,000.Heavy service average annualcostperpersonforallservices weestimatethatthe Based onourinterviews, with othercoststudiesacross the country. health care cluster, service whichisconsistent Key Finding: contacts (police/jail/prison). $23 millionwasspentoncriminaljustice of housingforthehomeless,andanestimated spent approximately $106milliononalltypes municipalities andnon-governmental agencies period encompassing2014/2015.Counties, health care to thehomelessina12-month approximately $121millionwasspentproviding housing, andcriminaljustice),weestimatethat Across clusters(healthcare, themajorservice Homelessness inOrange County: The Coststo OurCommunity

health services and criminal justice contacts andcriminaljusticecontacts health services homelessness indicatethatuseofsocialand Our inter RETURN TOCONTENTS The costs of homelessness are driven The costsofhomelessnessare driven Costs are highestinOrange County’s

1 s aresult utilization ofdecreases inservice • the non-chronically andthechronically homeless. when thehomelessare housed. This holdsforboth category, thecostsofhomelessnessdeclines Key Finding: •

the program costsofhousing. and inemergency shelters($36,419)netof the non-chronically homelessonthestreet lower, respectively, thantheannualcost for bridge housing($22,686)is75%and38% housed inrapid re-housing ($9,175)and Similarly, theaverage annualcostforthose housing. costs ofpermanentsupportive even takinginto consideration theprogram streets andinemergency shelters($85,631), to thechronically homelesslivingonthe housing($51,587)incomparison supportive for thechronically homelessinpermanent average is40%lower annualcostofservices and criminaljusticecontacts,theestimated A the street orinemergency shelters. those whoare chronically homelesslivingon month, and100%fewer arrests, compared to 78% fewer inthelast ambulancetransports housingreported in permanentsupportive compared to thoselivingonthestreets. Those are loweramongthosewhoare housed homeless ($98,199). homeless ($98,199). housing ($43,184)andthechronically street between thoseinpermanentsupportive ($51,855), withthedisparityeven greater those onthestreet orinemergency shelters ($26,158) ishalftheannualcostincurred by among thosehomelesswhoare housed alone, theestimatedaverage annualcost When lookingathealthser Whatever the service or housing Whatever orhousing theservice vice utilization vice utilization

7 | Executive Summary f • aking into consideration theaverage cost • • Housing (PSH) Street Homeless inPermanent Supportive Cost Savings ofHousing Chronically Homelessness inOrange County: The Coststo OurCommunity

chronically street homelesswhoare the homeless are even more significantforthe The potentialcostsa housing. placed into permanentsupportive if allOrange Countychronically homelesswere savings ofapproximately $42millionperyear percapita,weestimateacost of services T street homeless($51,587versus $100,759). clients is50%lowerthanforthechronically housing per capitaforpermanentsupportive The estimateda RETURN TOCONTENTS verage annualcostofservices vings of housing the vings ofhousingthe

especially trueforthechronically homeless. among thehomelesswhoare housed,andthisis and compellingpattern:costsare markedly lower chronically street homeless,showaconsistent the the homelessingeneral, andparticularly Key Finding: costs inexcess ofonly$55,332. housingincurannual in permanentsupportive person, incur annual costs higher than $439,787 per that 10% of the chronically street homeless those intheupperdecileofcosts. for users,andinparticular heaviest service whereas themostcostly10%ofthose The cost savings data on housing The costsavings dataonhousing We find

8 | Executive Summary f 1. 0. 19. 8. 7. 6. 5. 4. 3. 12. 1. 0. Homelessness inOrange County: The Coststo OurCommunity 1 2 2 1 1 1 1 1 1 1 1. 9. 8. 7. 6. 5. 4. 3. 2.

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LIST OFTABLES ANDFIGURES

e 4:

Agencies by RespondentSex Figure 5:Abused by Member ofHousehold, Among SampleAcross HousingCategories Table 16: Among SampleAcross HousingCategories Table 15: in OC Homelessness Across Three CostClusters Figure 3:Annual CostofAddressing Table 14: Table 13: Table 12: Sectors Figure 2:CostsAcross Four Institutional Sectors Table 11: Charges Table 10: Agencies Table 9: Table 8: Table 7: Table 6: Questionnaire Table 5: Table 4: Population with OtherOCHomeless SamplesandGeneral Table 3:Profile ofProject SampleCompared Configurations Table 2: Table 1: Figure 1:CostStudyDesign Figur Status (Pg. 29) (Pg. 31) (Pg. 25) (Pg. 27) (Pg. 24) Cost Findings for Non-governmental Cost Findings forNon-governmental Survey ofNon-governmental Agency Strata andSample Cost Findings forMunicipalities Municipalities Submitting County Costs SettingsforHousing Interview Settings/Contexts Interview (Pg. 23) Socio-demographic Comparisons Socio-demographic Comparisons Length of Time inOC,by Housing (Pg. 23) Socio-demographic Comparisons Socio-demographic Comparisons Law Enforcement ClusterCosts Housing ClusterCosts Health ClusterCosts Cost Totals Across Institutional Cost Findings onOCERandInpatient (Pg. 18) (Pg. 21) (Pg. 17)

(Pg. 33) (Pg. 20) (Pg. 13) (Pg. 28) (Pg. 28)

(Pg. 22) (Pg. 16)

(Pg. 22)

(Pg. 29)

(Pg. 32) (Pg. 30)

8. 7. 5. 4. 3. 5. 4. 3. 2. 1. 9. 2. 2 2 2 2 2 3 3 3 3 3 2 2 30.

(Pg. 37) Contacts inPast Month,by Housing Category Table 19: Past Month,by HousingCategory Table 18: by Housing Status Figure 8:Sources ofIncomeinLastMonth, Category Table 17: (Current Spell),by Housing Status Figure 7:ReasonsforBecomingHomeless Table 21: by Lengthof Time ontheStreet by Street/Shelter Homeless, Conditions Reported Figure 13: Configuration UtilizationinLastYear,Services by Housing Figure 12: Clients Homeless to BridgeandRapidRe-Housing Utilization LastYear, ComparingNon-Chronically Figure 11: Homeless Housing Clientsto theChronically Supportive Utilization LastYear, ComparingPermanent Figure 10: Configuration UtilizationLastYear,Service by Housing Figure 9:MeanCostPer Person for Housing in Permanent Supportive Comparing Chronically Homelesswith Those and CriminalJusticeContactsinPast Month, Table 20: Across theDistribution by Housing Configuration Services, (Current Spell),by Respondent Sex Figure 6:ReasonsforBecomingHomeless (Pg. 40) (Pg. 36) Employment and Earnings by Housing Employment andEarningsby Housing Per Capita Annual Cost of Per CapitaAnnual Costof Average Utilization (Mean)Service Average Utilizationin (Mean)Service Mean Cost Per Person for Health MeanCostPer Person forHealth MeanCostPer Person forService (Pg. 39) Average (Mean)CriminalJustice Number of Chronic Physical Health Number ofChronic PhysicalHealth Mean CostPer Person forService (Pg. 41) (Pg. 39) (Pg. 36) (Pg. 43) (Pg. 42) (Pg. 35) (Pg. 37) (Pg. 38) (Pg. 34)

9 | List of Tables and Figuress f o assesstheextentto whichthe • irst, to estimate theeconomicexpenditures • The majorobjective ofthestudywastwofold: Objectives andpractitioners. cross-section oflocalexperts Committeecomposedof a and anAdvisory the Hospital Association ofSouthernCalifornia, County (ACC-OC), 2-1-1Orange County(211OC), the Association ofCaliforniaCities-Orange andguidanceof (UCI),withthesupport Irvine Way, Jamboree, andtheUniversity ofCalifornia, collaboratively amongOrange CountyUnited homelessness here. wasconducted The report characteristics ofthoseexperiencing and ofthedemographic andbiographic the costsofhomelessnessinOrange County, ofa year-long studyof This isthefinal report Homelessness inOrange County: The Costto OurCommunity

Second, t F and completedintheWinter of2017. and theresearch wasinitiated inSpring2016 organized inlateFall 2015andWinter2016, the county. The studywasconceived and thehomelessacross associated withserving in order to assessingreater detailthecosts biographic profile ofthe county’s homeless sought to constructademographic and forms ofhousing.Additionally, thestudy in sheltersversus thoseliving inalternative spectrum ofthoselivingonthestreets and across thehomeless vary the costs ofserving to thispopulation. hospitals andnon-profits providing services governmental agencies,including service county, its34municipalitiesandnon- on homelessnessthathave accruedto the RETURN TOCONTENTS INTRODUCTION 2

2015 on average, in foraone-bedroom apartment housing withinthecounty($1,700to $1,800, study wasconducted,betweenthecostofrental Given theextensive gap,asofthedatethis least onenightofhomelessnessduring2015. in 200Orange Countyresidents experiencing at over thecourseofyear. This equatesto one experiencing atleastonenightofhomelessness homelessness onanygiven night,with15,291 for example,nearly4,500peopleexperienced According to the2015Orange CountyPIT count, (PIT) estimatesforOrange Countybearthisout. The HUD-mandated semi-annualPoint-in-Time municipalities ofallsizes across the country. that continuesto plaguemetropolitan areas and not beenspared theproblem ofhomelessness recognition withinOrange Countythatithas First, forsometimethere hasbeengrowing based onthefollowingthree considerations. The rationale forconductingtheresearch was Rationale (24% ofOCresidents in2015 lived inpoverty for manyresidents to accessthathousing interviewed for this study living off of a monthly forthisstudyliving off ofamonthly interviewed homeless 70-year-old, African-American woman Consider, forexample,theexperienceofa or astaying inamotelfornight ortwo. doubling upforanightwithfriendsorrelatives, living inautomobiles orhiddenencampments, because itdoesnotfullycapture theunhoused or anincrease, itislikely to bealower-end count But whetherthisrecent countshowsadecline increase inthecounty’s homelesspopulation. completed 2017PIT estimatewill reveal an there isreason to believe thattherecently 4 ) andthelimitedavailability ofresources 5 3 ), ),

10 | Introduction provided by theincreasing recognition ofthe A second rationale for thiscoststudyis the value ofthisstudy. considerations thatprovide amajorrationale for housing. Itistheintersectionofthesevarious comparison to thoselivinginvarious typesof those livingonthestreets and in shelters homelessness varies across thespectrumof the extentto whichthecostofaddressing agencies. service This research alsoassesses agencies, includinghospitalsandnon-profit the countyandnon-governmental service county government, the34municipalitieswithin the approximate costsofhomelessnessto the The intentofthisstudyhasbeento assess costs onthecommunitiesinwhichitexists. homelessness imposesconsiderable economic those individualsandfamilieswhoexperienceit, and psychological costsofhomelessnessto to thedevastating andtraumatizing physical and municipalities.More specifically, inaddition the county’s agencies various publicservice these homelessindividualsbutalsoforboth a persistentlypressing problem notonlyfor any given night,andthisfactaloneconstitutes individuals whoare homelessinthecountyon the factremains thatthere are thousandsof for whetheritis4,000,4,500,5,000ormore, becoming fixatedontheapproximate number; to thenext,weshouldbecautiousabout But whatever thecount from onePIT estimate f than thePIT estimate. any given nightislikely to be somewhathigher of people whoare homelessinthecountyon among others,suggeststhattheactualnumber be missedinthePIT count. This example, and washherclothes.Individualslike her may Saturday, to getagoodsleep,warmshower at leastonenightaweek,usuallyFriday and/or ofthat checkto stay inamotel uses aportion six nightsaweek onabench inAnaheim, but $1,000 SocialSecuritycheck.Shesleepsfive to Homelessness inOrange County: The Costto OurCommunity

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important to note thestudy’simportant distinctive features. Before turningto ofthatresearch, summary itis having conductedthe research herein. reported that there are anumberofpressing reasons for Taken together, theforegoing rationales indicate been completedforOrange County. Silicon Valley area, butnosuchcoststudyhas Sacramento, SanDiego andtheSanJose throughout thestate,includingLosAngeles, been conductedinthemajormunicipalities and differences. To date,coststudieshave to understandthereasons forcostsimilarities areas andmunicipalitieswithinthestate, research oncostsaccruedby othermetropolitan of homelessnessinOrange Countywiththe is to provide abasisforcomparingthecosts The third rationale forconductingthe study collaborative manner. to leverage theworkoftheseinitiatives ina its fourpillars. This coststudywasconducted Strategic Plan,whichadoptedhousingasoneof Task Force andtheUnitedWay’s FACE 2024 established in2016,ACC-OC’s Homelessness new OfficeofCare Coordination, whichwas 10 Year Planto EndHomelessness, thecounty’s Included amongtheseinitiatives istheCounty’s a numberofinitiatives to dealwiththeproblem. and otherlocalorganizations, andtheoverlap of homelessness problem by theCountyofOrange individuals not only experiencing homelessness individuals notonlyexperiencing homelessness addressing homelessness, andasampleof of thefullvariety ofnon-governmental agencies Southern CaliforniaandCal Optima), asample hospitals (viatheHospitalAssociation of municipalities withinthecounty, Orange County were collected:theCountyofOrange, the 34 the variety ofsources from whichthedata comprehensiveness. This isindicatedby study. The firstdistinctive feature isthestudy’s features There are ofthis twonoteworthy Distinctive Features

11 | Introduction f unfolded andevolved asitdid.Itwasinitiated across thecounty, thestudywouldhave never institutions, organizations andindividuals the cooperation andcollaboration ofvarious but itmeritsmentionagainbecausewithout collaborative character wasmentionedabove, that itwasatrulycollaborative endeavor. Its The seconddistinctive feature ofthestudyis homelessness intheUnitedStates. studies yet conductedofthepubliccosts this isclearlyoneofthemostcomprehensive and volume ofdataassembledandanalyzed, chronic homelessness.Given thebreadth, depth the costsassociatedwithbothnon-chronic and variety ofdatasources. Additionally, wecompare if anyother, coststudiesare basedonsucha housing.Few,residing inpermanentsupportive ranging from sleepingrough onthestreets to but alsoexperiencingdifferent livingsituations, Homelessness inOrange County: The Costto OurCommunity

RETURN TOCONTENTS towards acommonobjective. within acommunitystrive to worktogether andstakeholders various interested parties what canbepursuedandaccomplishedwhen Among otherthings,thisstudynicelyillustrates itsOfficeofCare Coordination. in particular of SouthernCalifornia,211OCandthecounty, ofACC-OC, theHospitalAssociation support the studybenefittedgreatly from theongoing facilitating theresearch process. Additionally, was crucialinguidingthestudydesignand list ofcommitteemembers). This committee regarding homelessness(seeAppendix 1for andpractitionersOrange Countyexperts Committee representing across sectionof forward withtheformationofanAdvisory School ofSocialSciences,andthenmoved County UnitedWay, Jamboree, andtheUCI through thecooperative ofOrange partnership

12 | Introduction f broadened conception ofhomelessnessin In order to bothestimatethecostsofthis Data Sources violence andcan’t findhousing. a hospitalorprison,are fleeingdomestic their homes,discharged from aninstitutionlike on thestreets; orwhohave beenevicted from housingafterbeing re-housing orsupportive are staying inshelters,bridgehousing,rapid abandoned buildingsoronthestreets; orwho who sometimessleepoutdoors,incars, word “homeless”isusedto describepeople Thus, forthepurposesofthisstudy, the inclusive conceptualizationofhomelessness. objective, weoptforabroader andmore Given the study’s(see Glossary). two-fold Council’s broader andmore inclusive definition to theNationalHealthCare fortheHomeless ranging from HUD’s more limiteddefinition various conceptualizationsofhomelessness, conceptualization ofhomelessness. There are it isfirstnecessary to indicateourworking associated methodologiesandstudydesign, Before discussingourdatasources, Homelessness inOrange County: The Coststo OurCommunity

RETURN TOCONTENTS Figure 1. AND STUDYDESIGN DATA SOURCES,STUDYMETHODOLOGY Organizational Institutional- Cost Data Cost StudyDesign Hospitals withERs Non-governmental Municipalities Agencies County Costs the county, municipalities,hospitalsand institutional/organizational costdatafrom throughout thecounty. Asillustrated inFigure 1, street andinvarious housingconfigurations of 252homelessindividualslivingonthe August andDecember2016withasample conductedbetween person survey interviews questionnaires) aswellby structured in- agencies(seeAppendixforthe and service sent viaemailto municipalities,hospitals The datawere gathered through questionnaires Methodology andStudy Design themselves. individuals experiencinghomelessness thehomeless;and5) agencies servicing Optima); 4)asampleofnon-governmental Association ofSouthernCaliforniaandCal 3) Orange Countyhospitals(viatheHospital Orange; 2)themunicipalitieswithincounty; cost datafrom five sources: 1)theCountyof various housingconfigurations, wegathered homeless onthestreet andthoselivingin and to examinehowcostsdiffer betweenthe Orange Countyacross arange ofcountyactors, Rapid Re-Housing Street Homeless Bridge Housing Permanent Supportive Housing Shelters Interview Service Interview Utilization Data

13 | Data Sources, Study Methodology and Study Design f Silicon Valley methodology withinthestatewasconductedfor major completedcoststudyemploying this and localorstatehospitalizationrecords). A health, sheriffandprobation departments, ofhealth,publichealthandmental departments city, countyorstate agencies(e.g.,county identifiers from therecords service of relevant matched withcorrespondingly encrypted housing,are typically permanentsupportive adults residing inhousingforthehomeless, identifiersfrom encrypted recently homeless inwhich System (HMIS) [seeGlossary], HUD’s Homeless ManagementInformation a computertracking methodology, basedon most comprehensive studiesare thoseusing variation inscopeandmethodology. The homelessness coststudieswithconsiderable the state,there have been anumberof in comparisonto othercoststudies.Within features isitsbreadth andcomprehensiveness study design,oneofthestudy’s distinctive As notedearlierandassuggestedby the Methodologies andDesigns Comparison withOther CostStudy County. thehomeless in2015Orangeof servicing used to estimateagrand total forthecosts agenciesare aggregatedsocial service and Homelessness inOrange County: The Coststo OurCommunity limitations intheoperative statusoftheHMIS HMIS system. InOrange County, forexample, the functioningandoperative statusofthelocal one settingto thenext because ofvariation in and reliable, butitisnoteasilyreplicated from be amongthemostmethodologicallyrefined sections 4through 6below. sources willbedescribedingreater detailin The informationgathered from allofourdata andtheinstitutions/organizations. interviews integrated datafrom thein-personsurvey individuals andhousingconfigurations, we annual costsacross categoriesofhomeless

RETURN TOCONTENTS 7 To differentiate theper-personaverage 8 . This genre ofcoststudiesmay is based on comparing its public costs (e.g., is basedoncomparingitspublic costs(e.g., assessment ofthecosts homelessness variants oflongitudinal studiesinwhich and those whoare nowhousedemploys differences betweentheunhousedhomeless The otherstrategy attemptingto getatcost identification. through computerized recorddepartments study were derived from various L.A. County type HMIS studydesign,dataforpersons inthe Skid RowHousing Trust. Similarto theideal- housing)provided by permanent supportive the housing(similarto entered supportive matched witharound 1,000homelesswho and receiving General Reliefwere statistically wherein over 9,000peoplewhowere homeless strategy ofthe2009LosAngeles coststudy, designs. Oneincludesthemixed-methods Sacramento studyare twoothercoststudy study designsandthenarrow focusofthe Standing inbetweentheHMIS-based municipal questionnaire. we didfindthisstudyhelpfulinformulatingour thehomeless, costs associatedwithservicing budgets ofthecity. Whilelimitedintherange of data wassecured forthevarious operational in Sacramento. studyconducted the municipaldepartmental comprehensive coststudyofhomelessnessis At theotherend,probably theleast those whoare homeless. associated costsofothertypeshousingfor housingbypasses the permanent supportive cost data,anditstypicallyresidential focuson the spectrumofnon-governmental agency include, incomparisonto ourcoststudydesign, coverage. For example,ittypicallydoesnot it islimitedintermsofthebreadth ofitscost to note design notwithstanding,itisimportant The strengths ofthisHMIS-based coststudy methodology atthetime ourstudywasinitiated. system foreclosed thepossibilityofusingthis 10

9 For thisstudydesign,cost

14 | Data Sources, Study Methodology and Study Design placement inSanDiego year priorto placement to upto twoyears after assessing thepubliccostsforpanelone sample across thespectrumoflivingsituations, the detailed,face-to-face withour interviews is initscomprehensiveness anddepthvia Comparatively, thestrength ofourstudydesign housing. placement inpermanentsupportive comparison ofonlystreet homelessnesswith range ofnon-governmental, publiccostsandits its neglectofthecostsassociatedwith based studies,butisalsosimilarlylimitedin generally lesscomprehensive thantheHMIS- f in LosAngeles frame, ranging from afour-personpanelstudy size ofthepanelandcomparative time housing. Here intermsofthe studiesvary placement, typicallyinpermanentsupportive with thecostsoftheirsubsequenthousing and shelteruse)forapanelofindividuals ambulance andhospitaluse,arrests, jailtime, Homelessness inOrange County: The Coststo OurCommunity

RETURN TOCONTENTS 11 to a114-personpanelstudy 12 . This typeofstudyis policies inthevarious studysettings. in thedemographics andhomeless-relevant solely to studydesignbutalsoto differences Moreover, thedifferences are notattributable differences are inmagnitudeandnotofkind. this one,are notqualitative butquantitative; the the findingsofthesedifferent studies,including way ofputtingitisthatthecostdifferences in chronically homeless,are extensive. Another themost housing thehomeless,andparticularly even more significantly, thecostsavings by the costsofhomelessnessconsiderable, but, lean inthesamedirection. That is,notonlyare to emphasize thatthecostfindingsandoffsets methodologies notwithstanding,itisimportant The differences inthesestudydesignsand governmental agencies. of costdatafrom governmental andnon- housing,combinedwithcollection supportive housing, rapid re-housing, andpermanent ranging from thestreets andsheltersto bridge

15 | Data Sources, Study Methodology and Study Design or “niches” includednotonlystreet sitesthat f homeless across thecounty. geographic anddemographic variation ofthe county thatare broadly representative ofthe homelessness –anarray ofsiteswithin the of service-providers andpeopleexperiencing through which weidentified–withthehelp maximum variation samplingstrategy possible. Instead,weemployed alocational sample ofhomelessrespondents wasnot a householdsurvey, generating atrulyrandom Orange County homeless,asthere wouldbefor Because there isnosamplingframe forthe Site Sampling Methodology demographic composition. before providing adescriptionofthesample’s elaborate howthesamplewasconstituted to to answersuchquestions,itisnecessary the county’s homelesspopulation?Inorder the demographic and/orbiographic profile of to capture efforts with otherinterview-based orare thefindingsconsistent interviewed, to oursampleofthe252homelessindividuals generalizability ofourfindings: Are they peculiar questionconcernsthe An equallyimportant compare withthecounty’s general population? homeless, andhowdothesecharacteristics demographic characteristics ofthecounty’s homeless population.Whatare themajor have asenseofwhocomprisesthecounty’s the homelessacross thecounty, itishelpfulto associated withtheprovision to ofservices Before identifyingandelaborating thecosts Homelessness inOrange County: The Coststo OurCommunity

RETURN TOCONTENTS PROFILE OFOCHOMELESS COMPARATIVE DEMOGRAPHICANDBIOGRAPHIC 13 These locations locations These settings andacross thehousingconfigurations. county-wide variation bothintheinterview variation samplingstrategy, there isnotable Consistentwiththe maximum interviews. housing configurations inwhichweconducted conducted, and Table 2showsthevarious the settingsinwhichstreet were interviews housing). permanent supportive Table 1shows shelters, bridgehousing,rapid re-housing and limited, housingconfigurations (emergency lunch) butalsotherange ofavailable, albeit encampments andagenciesproviding abag were knownto befrequented (suchasparks, Table 1. TOTAL Housing Permanent Supportive Rapid Re-Housing Bridge Shelter Housing Types (SantaAna) The Courtyard Build Futures Friendship Shelter Beach TransitNewport Center Family Assistance Ministries Pioneer Park (Garden Grove) Park (Orange)Hart Lions Park (CostaMesa) Share OurSelves (S.O.S.) Santa Ana Riverbed Encampment Santa Ana CivicCenter Street Site/Location ofInterview Interview Settings/Contexts Interview 252 49 25 41 48 163 1 1 2 5 5 5 9 10 12 13 26 89 # Completed

16 | Comparative Demographic and Biographic Profile of OC Homeless f typically onlyacoupleofhomeless persons Transitat theNewport Centerthere was location,however.every interview For example, of systematicsamplingwas notpossiblein successive tentormakeshift shelter. This type withanoccupantofeach conduct interviews the encampmentandthenproceeded to spread themselves out alongthelengthof riverbed encampment,thethree researchers xth personthey encountered; andatthe pointandcountedoffevery chose astarting at theSantaAna CivicCenter, interviewers select respondents ineachlocale.For example, as possible,weattemptedto systematically a given sitewere asrepresentative ofthatsite To at ensure thattheindividualsweinterviewed ProceduresInterview Table 2. Homelessness inOrange County: The Coststo OurCommunity TOTAL Colette’s Children’s Home Mercy House Jamboree Housing Housing Permanent Supportive Family Assistance Ministries Mercy House People inNeed(SPIN) Serving Families Forward Rapid Re-housing Pathways ofHope Colette’s Children’s Home Salvation Army Families Forward Family Assistance Ministries Build Futures WISEPlace Bridge Build Futures Salvation Army (SantaAna) The Courtyard Armory Fullerton Friendship Shelter Shelter Site/Location ofInterview

RETURN TOCONTENTS Interview SettingsforHousing ConfigurationsInterview 163 3 22 24 49 2 4 5 14 25 1 5 5 6 6 8 10 41 1 4 13 15 15 48 # Completed demographic variables. elicited informationregarding somecomparable three research tools are quitedifferent, each Although the purposesandstructure ofthe the generality oftheproject samplefindings. assessing thepreviously raised questionabout findings to provide acomparative basefor the 2015Point-in-Time andthe2016VI-SPDAT the American CommunitySurvey. We include with thegeneral OCpopulationfor2015from – and system(seeGlossary) Coordinated Entry survey conductedthroughGlossary) thecounty’s Point-in-Time CountandtheVI-SPDAT (see points from twoother OCstudies–the2015 project samplealongsidecomparable data Table 3provides ademographic profile ofthe and County Population Other OCHomelessSamples Sample Profile Compared with childhood experiences. employment andother sources ofincome,and health andwellbeing,familysocialnetworks, homelessness, recent utilizationofservices, and lengthoftimehomeless,challenges living conditions,reasons forhomelessness of topics, includingbasicdemographics, current (see Appendix 5)includedquestionsonavariety the respondent’s preference. The questionnaire conducted inEnglishorSpanish,dependingon to complete onaverage. were The interviews tookThe interviews approximately 30minutes them fortheirtime. andcompensate incentivize theirparticipation Subway or Target) oftheirchoosingto offered a$10giftcard (Chevron, Starbucks, as possible,andallselectedrespondents were made to selectrespondents assystematically employed. was Whatever thesetting,aneffort forthosewhowere schedules, particularly housing siteswasoftenconstrained by their of prospective atthevarious interviewees available andtheselection forinterviews,

17 | Comparative Demographic and Biographic Profile of OC Homeless Homelessness in Orange County: The Costs to Our Community

Table 3. Profile of Sample Compared with Other Orange County Homeless Samples and General Population

Project Point-in-Time ACS Orange County Variables Sample (2015) VI-SPDAT (General Pop. 2015)

% Male 57% 61% 56% 49% % Female 43% 39% 44% 51% Median age 50 50 (unsheltered) — 38 Race/Ethnicity Hispanic 30% 39% 25% 34% Non-Hispanic White 47% 35% 53% 41% Non-Hispanic Black 15% 14% 14% 2% Asian 4% 5% 3% 19% Native American 4% 4% 2% <1% % With any schooling beyond high school 47% — — 67% % Foreign-born 10% — — 31% % Living in OC 10 years of more 68% — — — % Veteran 12% 12% 9% 5% TOTAL 252 4,452 296 3,086,331

Looking at the table and beginning with the upwards.15 It is also interesting to note for

gender distribution among those interviewed Orange County residents that the only age of OC Homeless Profile and Biographic Demographic Comparative | for the project sample, we see that the majority group that is expected to grow proportionate to 18 are male, which is consistent with the other two other age groups in the next 25 years is the 65 data sources. In comparison with the proportion and older cluster.16 If this projection holds, then male for the county overall, we see that men are we might expect an upward aging trend among overrepresented among the homeless (57% to those who are homeless as well, especially 49%). This is not a surprising finding; men have since two-thirds are long-time OC residents, been overrepresented among the homeless as shown in the third row from the bottom. population throughout the country since this Considering the race and ethnic composition current wave of homelessness surfaced in of the county’s homeless population, non- the first half of the 1980s.14 It is important Hispanic Whites make up the modal category to also note that the proportion of women for the project sample. The 47% project sample has increased considerably since then, both finding falls midway between the other two nationally and in Orange County. sets of findings from the PIT and VI-SPDAT Turning to age, the median age for both the (35% and 53%, respectively), and is slightly project sample and the 2015 PIT count is 50, higher than the proportion of non-Hispanic which is considerably higher than for the county Whites for the county. Hispanics make up the overall. Whether this is indicative of an aging next-largest ethnic/racial category among trend among homeless individuals is difficult the county’s homeless population. The 30% to say at this point in time. However, it is worth finding again falls between the figures for the noting that demographic assessments of the other two samples, but is slightly lower than homeless population across the country over the proportion of Hispanics for the county. the past 30+ years does suggest a trending That Hispanics are slightly underrepresented

f RETURN TO CONTENTS Homelessness in Orange County: The Costs to Our Community

among the homeless population in comparison “transients” from elsewhere who are attracted to the county figure is not surprising given to Orange County because of its favorable similar findings in other studies.17 It would be climate, which presumably eases living on the surprising, however, if non-Hispanic Blacks streets. The contrary bottom line, however, is were underrepresented among the homeless in that the vast majority of the county’s homeless comparison to their proportion of the county’s population are long-term county residents. population. This is not the case, though, as The final noteworthy demographic characteristic non-Hispanic Blacks comprise only 2% of the shown in the second to the last row in Table 3 county’s population but 15% of its homeless shows that 12% of the homeless interviewed are population, a finding that is consistent with veterans, which is slightly more than double the virtually every other study of the racial/ethnic percentage of veterans in the county in 2015. composition of the homeless population across The overrepresentation of veterans among the country.18 the county’s homeless population is not only Another telling feature of the county’s confirmed by the parallel findings of the PIT count homeless population is its relatively low level of and VI-SPDAT survey, but it is also consistent with educational achievement: 47% of the project other studies across the country.20 sample attended some schooling beyond Earlier in this section we raised the question high school, primarily a year or two of college of the generalizability of the project sample without graduation, in contrast to 67% for the findings across the county’s homeless county as a whole. This finding, when coupled of OC Homeless Profile and Biographic Demographic Comparative

population. The observed comparability of | with the concentration of work experiences

these findings with those of the other two 19 of those who are homeless in the secondary interview-based studies, particularly the PIT labor market,19 accounts in part for the greater count, reported in Table 3, gives us confidence socioeconomic precarity and vulnerability of in the representativeness of the project sample some citizens to homelessness. findings. This confidence is also bolstered by Perhaps one of the most interesting findings the “niche” maximum variation strategy that is that only 10% of those we interviewed are guided our selection of interview sites and thus foreign-born in contrast to the county’s foreign- potential respondents. born population of 31% for 2015. This striking We will consider additional demographic and contrast is likely to be surprising to some biographic characteristics of the county’s county residents given the often-heard claim homeless population when we examine the that recent, undocumented immigrants swell extent to which these characteristics and the ranks of the homeless. associated costs vary across the spectrum of An equally compelling finding is that 68% of those living on the streets and in shelters versus the sampled individuals have lived in Orange those living in alternative forms of housing. County 10 years or longer. This is especially Next, however, we examine the institutional/ interesting because it runs counter to another organizational costs of homelessness within frequently heard stereotype regarding those the county. who are homeless: that many are migrants or

f RETURN TO CONTENTS f county costtotal are thecostsprovided by second row of Table 4. Also includedinthe sumtoservices $60,093,851, asshowninthe Aggregated, thecostsforthesevarious county funding fordedicatedemergency shelters. encampment landmanagement)andcounty resources spentby OCPublicWorks (e.g.,for Officers intheCountySheriff’s Department, and General costsforHomeless Liaison Relief), to agencies(suchasCalFresh socialservice resources forhomelessindividualsallocated Orange CountyHealth Care Agency, county providedfamilies, healthcare services by the on housingforhomelessindividualsand programs. Specifically, datawere provided across arange ofcountyagenciesand FY2015/2016 costsforhomelessservices county provided uswithalistingofactual The Director ofCare Coordination forthe County cost total. then aggregate thetotals to reach anestimated consider thecostsassociatedwitheach,and a range otherthanhousing.We of services governmental agenciesproviding socialservice the housingproviders andtheothernon- the hospitalswithemergency departments, this sector isthecounty, the34municipalities, range Includedin ofsubsistence services. to providing housingofvarious kindsanda and policingtheirmovements andactivities fashion oranother, ranging from monitoring and dealwithpeoplewhoare homelessinone durable, organizational entitiesthatintersect By institutionalsector, werefer to theclusterof Homelessness inOrange County: The Coststo OurCommunity

RETURN TOCONTENTS INSTITUTIONAL SECTORS COST COMPARISONSACROSS medical services. Care initiative targeting frequent usersof homelessness issue,suchastheWholePerson atthecountylevel to addressnewer efforts the year 2015/2016,whichdoesnotcapture several to notethatthey are important forthe fiscal when assessingtheoverall countycosts,itis major, transit centerinthecounty. Finally, monitoring andcleaningasingle,albeit is consumedby thecostsassociatedwith share ofthatcostestimate disproportionate number indicatedintheabove table,sincea homeless-related costsare higherthanthe Similarly,departments. wesuspecttheOCTA unincorporated areas withouttheirownpolice Officers assigned to 13municipalitiesand include onlythesalariesofHomelessLiaison Additionally, theSheriffDepartment’s costs jailandprobation costsare notincluded. court, sincehomeless-related estimate, particularly $62,167,417 are asomewhatconservative We suspectthatthetotal countycostsof Table 4. therefore includedintheoverall countycosts. county, itstransit are county-wideand services Although theOCTA isindependent from the the Orange County Transit Authority (OCTA). considerably higherthanfor2015/2016. the countycostsfor2016/2017 are likely to be Orange County Transit Authority Coordination andCounty) Orange County(perDirector ofCare County Department/Division TOTAL County Costs 21 The take away pointisthat $2,073,566 $60,093,851 Accumulating Costs $62,167,417

20 | Cost Comparisons Across Institutional Sectors Homelessness in Orange County: The Costs to Our Community

Municipalities applied to municipality librarians, parks and With assistance from the ACC-OC, in 2016 we recreation staff and to various administrative sent questionnaires via email to all 34 Orange personnel. Because the “opportunity cost” County municipalities soliciting information on principle was not always employed, when a FY2014/2015 expenses. The questionnaires municipality reported a percentage of their (in Appendix 2), which were based on survey Total Expenses spent on homelessness in instruments used in a cost study in Sacramento FY2014/2015 that was under 1%, we rounded (2015), asked municipalities to provide their the cost up to 1% of Total Expenses. total municipal budget for FY2014/2015, as We received completed questionnaires from well as to estimate the percent of this total 21 of the 34 municipalities in Orange County. budget spent on homelessness. In addition, A listing of these 21 municipalities is provided municipalities were asked to provide budgets in Table 5. The municipalities that did not for a variety of municipal departments, along return completed questionnaires tended to with estimates of the percentage of these be relatively small in both total and homeless departmental budgets that was spent on population. For those municipalities that did not homelessness in FY2014/2015. return questionnaires, we estimated their total Because homelessness is not a budgeted amount spent on homelessness by taking their line item in most municipalities, we asked publicly available information on FY2014/2015 municipalities to provide approximate figures Total Expenses, and estimating 1% of these based on the individual city’s estimated cost expenses. Because these municipalities Institutional Sectors Cost Comparisons Across | allocation. For example, the budget allocation tended to be relatively small in size and budget, 21 of a municipal police officer may not be based adding their imputed expenses did not greatly on how much time, if any, is consumed by increase the total cost of homelessness across dealing with local homeless individuals. We the municipalities over and above what was assume, nonetheless, that costs are incurred found for the 21 municipalities that did return by encounters with homeless people. We questionnaires. encouraged municipalities to conceptualize Table 5. Municipalities Submitting Questionnaires these types of non-budgeted costs as “opportunity costs,” which encompass costs Name of Municipality incurred by allocating resources (time, money, Aliso Viejo Newport Beach energy) to one issue or task rather than another. Anaheim Orange Even though a hypothetical police officer’s Buena Park Placentia salary may remain the same regardless of Costa Mesa San Clemente whether his/her time is allocated to stopping, Dana Point Santa Ana assisting, ticketing or arresting a homeless Fullerton Stanton Garden Grove Tustin individual, the fact that some time—say 15% Huntington Beach Villa Park of the 40-hour week—is spent attending to Irvine Westminster homeless-related issues means that 15% less Mission Viejo Yorba Linda time is allocated to other tasks. That 15% is an Laguna Beach opportunity cost that can be calculated with the officer’s line item salary and estimated as time Table 6 shows the results for the 21 consumed by dealing with issues connected municipalities that returned completed to homelessness. This same principle can be questionnaires. Indicated is the median figure

f RETURN TO CONTENTS Homelessness in Orange County: The Costs to Our Community

(one-half above and one-half below) for the the homeless, spanning a range of services municipal budgets for FY2014/2015, the including housing, food provision and health. median percent of the municipal budget spent To ensure that our sample represented the on homelessness, the median dollar amount range of services, we assigned each of the 236 spent on homelessness, and the estimated total agencies in our list to one of 12 strata based on dollar amount spent on homelessness across their services provided. These 12 strata were: the 21 cities. clinical health services, ambulance services, soup kitchens, food pantries, hygiene and/or Table 6. Cost Findings for Municipalities (FY 2014/2015) clothing, referral services, multi-purpose non- housing services, motel/housing vouchers and/ or rental assistance, emergency shelter, bridge housing, rapid re-housing, and permanent supportive housing. The number of agencies that fell into each stratum is shown in Table 7. Category Statistic # of Municipalities Reporting Statistic For strata containing more than 11 agencies, Median total municipal budget $113,645,808 21 FY 2014/2015 we randomly selected 11 agencies per stratum; Median % of municipal budget 1% 21 strata containing 11 or fewer were sampled at spent on homelessness 100%. This sampling strategy yielded a total Median municipal budget spent $1,760,510 21 on homelessness sample of 115 agencies representing the full Total amount spent on $115,158,683 21 range of services. homelessness across 22 Institutional Sectors Cost Comparisons Across | municipalities Table 7. Agency Strata and Sample 22 Note: Uses Total Expenses for FY2014/2015. Municipalities reporting a percent of the municipal budget spent on homelessness of under 1% are rounded up to 1%, as are those that did not provide a percentage.

As with the county total cost figure, we think Stratum ofPopulation Agencies # of Agencies Sampled the total cost figure of $115,158,683 for the Food Pantry 88 11 municipalities is a conservative estimate Soup Kitchen 29 11 because of the factors noted above. Hygiene and/or Clothing Services 22 10 Health Services 16 8 Non-governmental Social Service Bridge Housing 15 11 Agencies Servicing Homeless People Referral 13 11 Private Ambulance Provider 11 11 To identify non-governmental agencies that Permanent Supportive Housing 10 10 provide services to those who are homeless Rapid Re-housing 9 9 in Orange County, we first combed through Motel/Housing Vouchers and/or Rental 8 8 a list provided by 2-1-1 Orange County of Assistance approximately 600 social service agencies, and Multipurpose Non-housing Services 8 8 narrowed it down to those directly servicing the Shelter/Emergency Shelter 7 7 homeless population. We supplemented the TOTAL 236 115 211OC list with our own internet searches and We sent questionnaires via email to all knowledge of agencies in the county. In the end, 115 agencies that fell into our sample. The we compiled a list of 236 Orange County non- questionnaires (in Appendix 3) asked the governmental social service agencies servicing

f RETURN TO CONTENTS Homelessness in Orange County: The Costs to Our Community

Table 8. Survey of Non-governmental Agencies

Responding Agencies AltaMed Health Services H.O.P.E. (Helping Other People Everyday) Project HOPE Alliance Build Futures Illumination Foundation Saint Mary’s by the Sea Catholic Church CARE Ambulance Service Jamboree Housing Corporation Saint Mary’s Fullerton City Net Laurel House Salvation Army Colette’s Children’s Home Living Waters Christian Fellowship Serving People In Need, Inc. (SPIN) Costa Mesa Family Resource Center Mental Health Association of OC Share Our Selves Families Forward Mercy House Living Centers Stand Up for Kids Mission Committee of the First Presbyterian 2-1-1 Orange County Family Assistance Ministries Church of Orange Family Promise of Orange County, Inc. Off the Streets Huntington Beach South County Outreach Friendship Shelter, Inc. One Step Ministry WISE Place Grandma’s House of Hope Orange County Rescue Mission agencies to provide several pieces of cost Thirty-two agencies representing all service information, including the organization’s total areas of interest completed the agency program expenses for 2015; the percentage questionnaires. They are listed in Table 8. Their of their total budget that was spent on responses form the basis for the agency results homelessness in 2015; the percentage of their we provide below. The largest housing providers Cost Comparisons Across Institutional Sectors Cost Comparisons Across

service encounters that were with homeless all completed the questionnaire, as did the |

people in 2015; and, for each type of service largest multipurpose providers of services for 23 they provided for the homeless in 2015, the the homeless population. estimated program cost-of-service per encounter Table 9 shows the cost findings for the 32 (for example, the average cost of a clinical visit, agencies that returned the questionnaire. As we an ambulance ride or a night of housing). This did with the municipality cost figures, we report last piece of information was used, together the median figure for total program expenses with the information on actual service utilization for 2015, the number of clients per agency, the collected from our service user interviews, to percent of total service encounters with the assign a cost of services to each individual we homeless, and the percent of agency budgets sampled (these results will be provided in the spent on homelessness. The last row includes section on Cost and Demographic/Biographic the total expenditures on homelessness for the Comparisons by Category of Homelessness, reporting agencies combined. beginning on page 30).

Table 9. Cost Findings for Non-governmental Agencies

Category Statistic # of Agencies Reporting Statistic Median total program expenses in 2015 $822,126 31 Median # clients served in 2015 773 30 Median % of service encounters with homeless 72.5% 30 Median % of agency budget spent on homelessness 77.0% 31 Median amount of agency budget spent on homelessness $399,007 29 Total spent on homelessness across 29 agencies $27,170,143 29

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It is important to bear in mind that the care coverage for Orange County residents who $27,170,143 cost figure is not for all of the are eligible for Medi-Cal. It contracts with health 115 sampled non-governmental agencies, networks, physician specialists and hospitals but only for the 32 reporting agencies. It to provide health care to its members, many of is thus a conservative estimate of agency whom are indigent adults with incomes between costs, although as we noted above, the 138% and 200% of the Federal Poverty Level largest providers of services for the homeless ($11,770 for one person in 2015; $15,930 for two population are included. As will be seen in persons; and $20,090 for three persons) and who Table 11, we use the total budget information have chronic health conditions, behavioral health provided by the housing agencies that returned issues and non-health related challenges, such as questionnaires to estimate the total cost homelessness, resulting in increased ER utilization of servicing this population across all non- due to lack of primary/preventive care access. governmental housing agencies. The CalOptima ER data we assessed represented only around a third of the health network Hospitals and Emergency Departments reporting. Consequently, our cost estimate is As of 2015, there were 24 hospitals with calculated by multiplying the CalOptima ER emergency departments (ERs) within the data by a factor of 3.3. Thus, the CalOptima county. Table 10 shows the estimated costs data shows that 3,560 homeless individuals accrued to the hospitals for both ER and had 6,480 ER visits, averaging close to two per inpatient encounters with homeless individuals

client, across 20 OC hospitals, at an average cost Institutional Sectors Cost Comparisons Across | for 2015. The estimated total for emergency of approximately $900 per person, which we department encounters is $19,245,600; for multiplied times 3.3, yielding the estimated cost 24 inpatient encounters it is $57,319,434. The total for ER encounters of $19,245,600. for the two estimates combined is $76,565,034.

The data on which these estimates are based OSHPD Inpatient Data come from two major sources: CalOptima, The hospitalization data, lagging a year (2014), through the Hospital Association of Southern reveal that 1,609 homeless individuals were California, for the ER data; and OSHPD (Office of hospitalized for an average of 10.4 days at an Statewide Health Planning and Development), average charge of $35,624.28. Multiplying the via the Orange County Health Care Agency, for number of hospitalizations times the average the inpatient data. charge yields the estimated hospitalization cost of $57,319,434. CalOptima ER Data In addition to the total hospitalization charge, the CalOptima is a public agency that provides health demographic characteristics of the homeless

Table 10. Cost Findings on Orange County Hospital ER and Inpatient Charges

Agency/Hospital Emergency Department Inpatient Subtotal Cal Optima via Hospital Association 6,480 x $900 x 3.3 = $19,245,600 — $19,245,600 of Southern California OSPHD files via OC Health Care Agency — 1,609 x $35,624.28 = $57,319,434 $57,319,434 TOTAL $76,565,034 Note: Only one major OC hospital provided detailed cost data. The above are aggregated figures across all OC hospitals and emergency rooms.

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hospitalized warrant mention: 72% were male, There is also another factor that suggests that 28% female; 67% Non-Hispanic White, 19% the estimated total cost figure is conservative. Hispanic and 8% Non-Hispanic Black; 51% were We refer to the aforementioned finding that 45-64 years old and 5% were 65+. Notably, these the average length of hospitalization for the demographic characteristics of the hospitalized homeless is 10.4 days, which is at least triple homeless are skewed in the same direction that for inpatients with housing. The cost as our project sample demographic profile implication of this finding is that other inpatient portrayed in Table 3. referrals are diverted to other hospitals because of the absence of available beds, thereby Additional Corroborating Data leading to an escalation of costs across the Initially we attempted to collect cost data from board. Were there sufficient housing to which the 24 hospitals with ERs by sending brief the homeless clients could be released, their questionnaires to them via email. Because of average length of stay would be reduced HIPPA regulations regarding the confidentiality considerably, as would the associated spiraling, of health care data, coupled with the absence downstream costs. of a government-defined screening process for the determination of homeless clients, this Total Costs Across Institutional Sectors outreach effort proved not to be very effective. The accumulating and aggregated cost figures However, one of the major hospitals, located for the institutional sectors intersecting with in the county’s central corridor where many homelessness are shown in Table 11. The Cost Comparisons Across Institutional Sectors Cost Comparisons Across | of the homeless are located, did complete the sectors are listed vertically in the first column questionnaire in considerable detail. Counting from the highest to the lowest total costs 25 as homeless only those individuals who gave accrued. The second column includes the no residential address upon admission, this costs based on the previously discussed data central hospital reported 1,283 encounters in collected for each sector, but note that we 2015. These encounters included ER visits, have divided the non-governmental sector inpatient admissions, clinic visits, and rehab and into housing agencies and other agencies psychiatric admissions. Multiplying the average for reasons we will explain. The third column cost for each of these types of encounters includes the total cost for each sector plus an by the number of encounters per type yielded imputation if warranted. an annual cost of medical services for the An imputation is an analytic technique homeless of $17,295,564. This annual cost used to determine and assign replacement figure is for only one of the county’s 24 hospitals values for missing data. As noted earlier, with ERs, albeit one of the larger hospitals. If we not all municipalities and sampled agencies assume this cost approximates the average for submitted their cost information to us via the medical encounters with homeless individuals questionnaires we sent them. Thus, in order to in the five largest hospitals in the central account for the non-respondents in our totals, we corridor of the county, then the total of the five needed to find a way to impute cost information, combined is more than the estimated total in or assign some cost value to them. In the case Table 10. This suggests that the estimated total of the municipalities, 13 of the 34 did not return cost of $76,565,034 for homeless ER visits and completed questionnaires, so we looked up their hospitalizations across the county is likely a FY2014/2015 budgets and took 1% of the total quite conservative estimate. expenses for the municipality for that year.

f RETURN TO CONTENTS Homelessness in Orange County: The Costs to Our Community

Table 11. Cost Totals Across Institutional Sectors

Accumulating Costs Accumulating Costs Based on Data Collected Cost Categories Based on Data Collected Plus Imputations

$120,338,343 (imputation: 1% of Municipalities $115,158,683 (21 reporting) FY2014/2015 Total Expenses) Hospitals and Emergency Depts. $76,565,034 $76,565,034 (no imputation) County $62,167,417 $62,167,417 (no imputation) Non-governmental $34,563,038 (imputation: median budget $21,531,320 (20 reporting) Housing Agencies spent on homeless by 20 reporting) Other Non-governmental Agencies $5,638,823 (9 reporting) $5,638,823 (no imputation) Serving the Homeless TOTAL $281,061,277 $299,272,655

Notes: Housing agencies are agencies providing overnight shelter, bridge housing, rapid re-housing, or permanent supportive housing services, and the figure provided totals the program budget spent on homelessness across these agencies.

The $120,338,343 figure in the far right of services across non-housing social service column reflects what was reported by providers is a major underestimate, based only the 21 municipalities that submitted on cost data from nine agencies. questionnaires, plus what we estimated for the Overall, the imputations for the municipalities 13 municipalities that did not. Note that this and housing agencies increased the total costs imputation increased the municipality totals Institutional Sectors Cost Comparisons Across |

across the institutional sectors, but only by costs by only slightly more than $5 million, a slightly less than 10 percent, from $281,951,277 26 relatively insignificant increase due largely to to close to $300,000,000. Figure 2 displays the fact that the 13 municipalities for which the graphically the distribution of these adjusted imputation was done are among the smaller costs across the four major institutional sectors municipalities in the county. per the above analyses. Figure 2 indicates We also did imputations for the non- that the estimated $120 million borne by the governmental housing agencies from which municipalities accounts for the largest share we did not receive information, basing our of the $299 million total, followed by hospitals, estimates on the median cost of services the county and then the non-governmental provided by the 20 housing agencies that housing agencies. While aggregating the costs did provide us with budget information. This at the institutional level, we have yet to consider imputation did increase the estimated cost for separately a number of expenditures associated all housing providers quite significantly, from with addressing homelessness, including the $21,531,320 to $34,563,038. provision of housing and social and health services, policing as well as mitigating the However, we did not estimate costs for other, consequences of street homelessness, all of non-housing social service providers that did which we examine in the next section as we drill not provide us with data; therefore, the cost into and unpack this aggregated figure.

f RETURN TO CONTENTS Homelessness in Orange County: The Costs to Our Community

Figure 2. Annual Cost of Addressing Homelessness Across Four Institutional Sectors in OC

$140,000,000 $120,338,343 $120,000,000

$100,000,000

$80,000,000 $76,565,034 $62,167,417 $60,000,000 DOLLARS $40,000,000 $34,563,038

$20,000,000

$0 Municipalities Hospitals County Housing agencies (21 reporting plus (20 reporting plus 13 imputed) 21 imputed)

Notes: Housing agencies are agencies providing overnight shelter, bridge housing, rapid re-housing, or permanent supportive housing services, and the figure provided totals the program budget spent on homelessness across these agencies. Cost Comparisons Across Institutional Sectors Cost Comparisons Across |

27

f RETURN TO CONTENTS f Table 13. Table 12. data forthecounty. Inaddition,weestimated previously discussedCalOptimaandOSPHD the Orange CountyHealth Care Agency andthe medical system.Includedare thecostsfrom costsacross service multiplelevels of the Table 12provides estimatesofhealthcare Health Care Cluster specialized housing. in theevent oftheprovision ofadditional, attention to potentialareas ofcostsavings utilizationandneed,directsareas ofservice on thearray ofcostsassociatedwiththemajor becauseit sheds light assessment isimportant of health,housingandlawenforcement. This an assessmentofcostclustersintheareas homelessness inthecounty, wenowturnto institutional sectors intersectingwith Having assessedthecostsacross the Homelessness inOrange County: The Coststo OurCommunity TOTAL housing,housingchoicevouchers) supportive County (fundingforContinuumofCare, dedicated shelters,veterans affairs, Non-Governmental Housing Agencies housinginitiatives) Municipalities (eightreporting Cost Categories Cost Categories Hospital Inpatient Orange CountyHealthCare Agency Emergency Departments Mental Health Services Other Physicaland Ambulance Services TOTAL

RETURN TOCONTENTS MAJOR COSTCLUSTERS Housing ClusterCosts Health Care ClusterCosts

Data Source OSPHD data County data Cal Optimadata program cost-per-visitdatafrom ouragencyquestionnaire utilizationdatafrom and Service ourhomeless interviews possessed by OCambulancecompaniesin2015 CARE Ambulance dataandOCHCA dataon#ofvehicles $105,932,061. (e.g.,vouchers)or housing-related is services they returned. The combinedcostforhousing housing initiatives inthecostquestionnaires agencies andeightmunicipalitiesreporting from thecounty, non-governmental housing for peoplewhowere formerlyhomeless Table 13estimatesexpenditures forhousing Housing Cluster of $120,582,177. of $120,582,177. of theseentitiesyieldsatotal healthcare cost Aggregating interviews). thecostsfrom each datafromagencies andtheservice-use our on datacollectedfrom non-governmental (based physical andmentalhealthservices companies inthecountyandto outpatient costs accruedto bothindependentambulance

$105,932,061 $32,530,693 $34,563,038 $58,841,342 Estimated Cost Estimated Cost $57,319,434 $25,474,611 $19,245,600 $16,055,550 $2,486,982 $120,582,177

28 | Major Cost Clusters Homelessness in Orange County: The Costs to Our Community

Table 14. Law Enforcement Cluster Costs

Cost Categories Data Source Estimated Cost Police Departments (Reports by 17 Municipalities, and Municipality questionnaires $17,468,183 Imputation to 1% of Dept. Budget for Other 17 Municipalities) and online budget data Homeless interview data Jail/Prison and jail bed cost provided by $5,523,109 Sheriff’s Department Sheriff’s Department (Homeless Liaison Officers) County data $780,000 TOTAL $23,771,292

Notes: Municipalities reporting a percentage of the police department budget spent on homelessness of under 1% are rounded up to 1%, as are those that did not provide a percentage. These figures do not provide estimates for probation.

Law Enforcement Cluster It is also interesting to note that the aggregated Table 14 provides estimates from aggregating cluster costs of $250,285,530 account for 84% the homelessness-related expenditures from the of the institutional sector total of $299,272,655. sheriff’s department and the municipal police This is an important finding as well, as it departments, and from our interviews, asking, underscores our previous observation that the among other things, whether they had been sector total likely represents a conservative jailed or imprisoned in the past month. The total estimate of the costs of homelessness across for these three items sum to $23,771,292, which the county. strikes us as quite conservative given the items Major Cost Clusters |

not included, such as court costs and probation Figure 3. Annual Cost of Addressing Homelessness 29 costs, whether from the county or state. Across Three Cost Clusters in OC

Figure 3 indicates that the three sets of cluster $140,000,000 costs add to $250,285,530, with the health $120,582,177 $120,000,000 care cluster at $120,582,177 accounting for $105,932,061 $100,000,000 48% of the total, followed by the housing $80,000,000 cluster and then law enforcement. This is a $60,000,000 significant finding in that it indicates that the DOLLARS $40,000,000 homelessness problem will not be solved by $23,771,292 the provision of housing alone, but with housing $20,000,000 associated with the provision of sufficient $0 Health Housing Law health care and supportive services. This is the Care Cluster Enforcement promise of permanent supportive housing, of Cluster Cluster course, but to date Orange County has a serious shortfall in such housing.

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COST AND DEMOGRAPHIC/BIOGRAPHIC COMPARISONS BY CATEGORY OF HOMELESSNESS

In addition to estimating the economic Socio-demographic Comparisons expenditures on homelessness that have Across Street, Emergency Shelter, accrued to the county, its municipalities and Bridge Housing, Rapid Re-Housing non-governmental service providers, we have and Permanent Supportive Housing also sought to assess the extent to which the Tables 15 and 16 show how the homeless costs of serving homeless people vary across individuals in our sample are distributed the spectrum of those living on the streets and demographically and biographically by in shelters versus those living in alternative residential situation at the time of the interview, forms of housing. We now turn to this second ranging from living on the street to residing in objective by drawing on the previously discussed permanent supportive housing. Here we note 252 in-person surveys in order to assess the only a few key findings. Considering gender demographic distribution of our sampled first, we find that males are overrepresented respondents across the various residential among those living on the streets and in possibilities and to differentiate the per-person shelters in comparison to the total proportion Comparisons By Category of Homelessness Cost and Demographic/Biographic | average annual costs across categories of of males in the sample, and underrepresented 30 chronicity and housing configuration. We begin among those in bridge housing and rapid re- by considering the socio-demographic and housing. The residential situation of women is biographic characteristics of our sample by the reverse; they are underrepresented on the housing category. streets and in shelters, but overrepresented in

Table 15. Socio-Demographic Comparisons Among Sample Across Housing Categories

Rapid Permanent Variables Street Shelter Bridge Re-Housing Supportive TOTAL

% Male* 73% 65% 37% 28% 53% 57% % Female* 27% 35% 63% 72% 47% 43% Median age* 48 52 43 42 53 50 Race/Ethnicity* % Hispanic 28% 23% 46% 36% 22% 30% % Non-Hispanic White 52% 40% 34% 28% 65% 47% % Non-Hispanic Black 10% 25% 12% 28% 8% 15% % Asian 3% 9% 0% 4% 2% 4% % Native American 7% 2% 2% 4% 2% 4% % Foreign-born 10% 8% 17% 16% 4% 10% % Veteran 16% 13% 5% 8% 10% 12% % With any schooling 42% 52% 51% 40% 45% 46% beyond high school Number Interviewed 89 48 41 25 49 252

* Differences between housing categories are statistically significant at p<0.05 level.

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bridge and rapid re-housing, largely because to 47% for the overall sample), with all of the there are more housing facilities in the county to other groups underrepresented in permanent accommodate single women and women with supportive housing. children than for single men. However, men and Figure 4 shows the length of time living in women are almost proportionately represented Orange County by residential status. Here we in permanent supportive housing. see the previously mentioned finding that 68% Turning to age, the youngest residential of the current or previously homeless persons inhabitants, in comparison to the median age of we interviewed have lived in the county for 10 50, are in bridge and rapid re-housing, with the years or more. When we add those who have oldest in permanent supportive housing, which resided here six years or longer, the percent of makes sense given that chronicity is defined by long-time current or recent homeless residents both length of time homeless and presence of jumps to 75 percent. Two other observations poor health, and chronicity is a pre-requisite for also stand out. candidacy for permanent supportive housing. The first is that whatever the residential Looking at the distribution across the configuration, 50% or more of the homeless residential possibilities by race and ethnicity, sample are long-time county residents, living the most striking findings are that non-Hispanic here 10 years or longer. The second observation Whites are the only group overrepresented is that the data highlights that the homeless among the homeless living on the street, other categories with the highest proportion of long- Cost and Demographic/Biographic Comparisons By Category of Homelessness Cost and Demographic/Biographic

than Native Americans, in comparison to time county residents are also those with the |

their proportion of the total homeless sample, highest proportion of chronic homelessness 31 and that they are highly overrepresented in (which we elaborate in the next section) – permanent supportive housing (65% compared those living on the streets, in shelters and,

Figure 4. Length of Time in Orange County, by Housing Status

100%

90%

80% 52% 70% 65% 56% 73% 68% 60% 80% 50%

PERCENT 40% 5% 12%

30% 6% 15% 7% 24% 6% 5% 20% 15% 13% 9% 10% 10% 9%4% 158% % 20% 5% 12% 8% 10% 0% 6 % 7% Street Shelter Bridge Rapid Permanent Total Re-Housing Supportive

0-6 months 7-12 months 1-5 years 6-10 years >10 years

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most notably, permanent supportive housing. Illustrative of chronic homelessness so defined This suggests that some of the county’s most is the case of a multi-racial man in his 40s, vulnerable residents who are most in need of who we interviewed outside of his makeshift housing and health assistance have been left housing arrangement (consisting of discarded, to survive on the streets through their own blue construction plastic, 2 X 4s, cement subsistence devices, becoming even more blocks, and scrap, corrugated aluminum) at the compromised over time. Santa Ana riverbed encampment. He had been homeless for six consecutive years and was Turning to Table 16, which includes mainly suffering from asthma, arthritis, anxiety/panic biographic characteristics, we see that around a disorder, episodic depression and cancer, for third of those living on the streets in our sample, which, he said, he had been hospitalized three and just over 40% in emergency shelters, are times in the past six months for up to three classified as chronically homeless. Trying to weeks. Clearly there is a spectrum of chronicity, approximate HUD’s operationalization of chronic with this encampment resident at the most homelessness (see Glossary), we classified compromised (and costly) end of the spectrum. individuals in our sample as chronically homeless if the following conditions obtained: An even more telling characteristic of the they resided on the street or in an emergency homeless population is their limited social shelter, reported being homeless for 12 or more capital, as conventionally indicated by various months in the current spell, and reported one or markers of social connection.22 Here we have

more disabilities, such as having trouble getting three such markers: whether they are married, Comparisons By Category of Homelessness Cost and Demographic/Biographic | things done over the last 30 days because of live alone, and/or live with children. Only 6% of alcohol or drugs, and/or difficulty getting from all respondents indicated they were married 32 one place to another, working or just getting and 67% said they lived alone; 17% lived with through the day because of a serious mental children, most of whom were living in rapid illness, PTSD, brain injury or developmental re-housing or bridge housing. Although all of disability, or chronic physical illness. these indicators of connection or social capital

Table 16. Socio-demographic Comparisons Among Sample Across Housing Categories

Rapid Permanent Variables Street Shelter Bridge Re-Housing Supportive TOTAL

% Chronically homeless* 34% 42% ------

% Homeless ≥3 years in most recent spell* 37% 46% 18% 11% 88% 42%

% Married 2% 2% 12% 12% 10% 6%

% Live alone* 71% 85% 60% 8% 80% 67%

% Live with children under 18* 1% 0% 34% 84% 12% 17%

Average # children under 18* 0 0 0.7 1.8 0.2 0.3

% Reporting fair/poor health 53% 40% 37% 28% 55% 45% % Reporting feeling depressed most or all 22% 19% 5% 8% 27% 18% of the time in the last 30 days* % Experienced sexual and/or physical 27% 35% 39% 36% 29% 32% abuse as a child Number Interviewed 89 48 41 25 49 252

* Differences between housing categories are statistically significant at p<0.05 level.

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are markedly low, it is interesting to note that abuse among homeless individuals, and those respondents living in bridge and rapid particularly among current or former homeless re-housing, with the strongest indication of women, is markedly high, but also because connection, are least likely to report fair to poor it suggests that the lifelong trauma of such health or feelings of depression most or all of abuse may negatively impact the capacity to the time in the last 30 days.23 form and sustain viable connections. In turn, this experience may increase one’s vulnerability A final biographic characteristic warrants to such conditions as homelessness given attention: nearly one-third of the 252 individuals the absence of affordable housing and/or interviewed experienced sexual and/or resources to access that housing. This takes us physical abuse as a child, and it occurred to consideration of the reasons for or “causes” almost proportionately across all residential of homelessness. categories. Furthermore, as shown in Figure 5, it is clear that childhood abuse is experienced Reasons for Becoming Homeless much more heavily among females who are or were homeless than among males; One of the questions the 252 respondents were indeed, almost one in five female respondents asked concerned the reasons contributing to experienced both physical and sexual abuse their becoming homeless in the most recent as a child. These are remarkable findings, spell. They were given a list of multiple factors not only because the incidence of childhood and asked to check or indicate all that applied Cost and Demographic/Biographic Comparisons By Category of Homelessness Cost and Demographic/Biographic |

33

Figure 5. Abused by Member of Household During Childhood, by Respondent Sex

25 19.63

19.44 20 17.93 15.89 15 11.55

10

5.56 4.67 5 2.39 0.69 0 Physical and Sexual Abuse Physical Abuse Only Sexual Abuse Only

Male Female Total

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Figure 6. Reasons for Becoming Homeless (Current Spell), by Respondent Sex

50%

45% 43%

40% 40% 36% 36% 36% 36%

35% 34%

30% 28% 26% 25% 23% 22% PERCENT 20% 19% 17% 16% 15%

15% 14% 13% 13%

10% 9% 7%

5% 5%

0% Lost Job/ Prison/Jail Foreclosed Family Issues Family Mental Health Drugs/Alcohol Released From Released Physical Health Physical Insufficient Wages Insufficient High Rent/Evicted/

Male Female Total Comparisons By Category of Homelessness Cost and Demographic/Biographic |

34 Note: Family issues include domestic violence, indicated by 11% of the sample but 24% of the women, other family relationship issues, which was indicated by 12% of the sample, and family death, indicated by 7%. to their situation. Figure 6 presents the findings. housing and work that pays a wage sufficient It shows that the two major sets of factors to enable the economically marginal to access accounting for homelessness in the experience that housing. This gap, as is well known, is of our respondents were securing or retaining much larger in Orange County than in most jobs that paid a living wage (40%) and finding other metropolitan areas of the country. or retaining affordable housing encumbered by Thus, the findings in Figure 6 suggest that the experience of evictions and foreclosures homelessness in the county is caused primarily (36%).24 Other factors in descending order by the intersection of insufficient income, due of influence were a cluster of family issues, to job loss, unemployability or work in the low- including domestic violence, family dysfunction, wage, secondary labor market, and the county’s relationship dissolution and death of a family high-cost housing market, particularly its rental member (28%), substance abuse (22%), mental market in relation to homelessness.25 The other, health (17%), physical health (12%), and release more individualistic mentioned factors—family from jail or prison (7%). dysfunction and abuse, substance abuse and mental and physical health problems—are These findings are revelatory in the sense that facilitative rather than determinative in that they they shift the focus of attention from the often- increase one’s vulnerability to homelessness repeated stereotypical causes of homelessness, in such contexts – that is, in the residential namely mental illness and substance abuse, to contexts in which there is a wide, and often the gap between the availability of affordable

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Figure 7. Reasons for Becoming Homeless (Current Spell), by Housing Status

50%

45%

40%

35%

30%

25%

PERCENT 20%

15%

10%

5%

0% Lost Job/ Prison/Jail Foreclosed Family Issues Family Mental Health Drugs/Alcohol Released From Released Physical Health Physical Insufficient Wages Insufficient High Rent/Evicted/ Cost and Demographic/Biographic Comparisons By Category of Homelessness Cost and Demographic/Biographic |

Street Shelter Bridge Rapid Re-Housing Permanent Supportive 35

widening, gap between the availability of low- Employment and Income by Category cost housing and the financial resources to of Homelessness access that housing. The dilemma confronted by those who are Figure 7 shows the distribution of experienced homeless in accessing the low-rent housing causes of homelessness by residential status. market, such as it is, in Orange County, is Consistent with the causal attributions for accented when we consider the median both men and women in the previous table, monthly income in our sample. As indicated we see that income insufficiency and housing in the second to last row in the last column of affordability are the most often-cited causes Table 17, the median monthly income from across all of the residential configurations. Other all possible sources is $860, which is clearly than this consistent finding, also interesting insufficient for accessing the lowest reaches is the finding that health-related issues (both of the rental market in the county. There is mental and physical) are most salient for those noteworthy variation in monthly income by in permanent supportive housing, and family housing status, ranging from a median of $500 issues, especially domestic violence, for those for those living on the streets to a median of in shelters, bridge housing and rapid-rehousing. $1,958 for homeless individuals and families

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Table 17. Employment and Earnings by Housing Category

Rapid Permanent Variables Street Shelter Bridge Re-Housing Supportive TOTAL

% Worked in last 30 days* 15% 17% 49% 76% 16% 27% Median job earnings in last 30 days $0 $0 $420 $1,114 $0 $0 (includes not employed)* Median earnings from other sources $410 $304 $800 $490 $892 $544 in last 30 days Median total earnings from job and $500 $520 $1,500 $1,958 $898 $860 other sources in last 30 days* Number Interviewed 89 48 41 25 49 252 * Differences between housing categories are statistically significant at p<0.05 level.

(typically with children) residing in rapid re- especially for those sleeping on the streets or housing. Nevertheless, these income levels, encampments and in shelters, it is reasonable across all of the residential situations, still put to wonder how they subsist. What is the source housing rental out of reach given the previously of their incomes, however little or much they noted average cost of rent for a single bedroom make per month? How do they stay afloat, apartment in the county of $1,700 to $1,800 literally? Figure 8 provides some answers. plus in 2015. Scanning Figure 8 clearly indicates that there Given the low median monthly incomes is no single means or pathway to material and Comparisons By Category of Homelessness Cost and Demographic/Biographic |

across the range of residential situations, and physical subsistence among the homeless 36

Figure 8. Sources of Income in Last Month, by Housing Status

100%

90%

80%

70%

60%

50%

40%

30%

20% PERCENT REPORTING SOURCE REPORTING PERCENT 10%

0% General Alimony SSI/SSDI Assistance Employment Food Stamps Food Shadow Work Social Security Family/Friends/

Street Shelter Bridge Rapid Re-housing Permanent Supportive Total

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Table 18. Average (Mean) Service Utilization in Past Month, by Housing Category

Rapid Permanent Variables Street Shelter Bridge Re-Housing Supportive TOTAL

# times accessed soup kitchen or food pantry* 16.96 22.90 2.12 2.88 2.22 11.45

# times accessed substance abuse services* 1.14 0.79 3.46 1.25 0.67 1.37

# times in ER 0.37 0.42 0.20 0.29 0.33 0.33

# times in ambulance 0.20 0.15 0.02 0 0.06 0.11

# times inpatient in hospital 0.13 0.06 0.02 0 0.08 0.08

# times accessed mental health services 1.18 0.54 1.61 0.83 1.31 1.12

# times accessed other health services* 0.63 0.52 0.85 0.71 1.78 0.88

# nights in shelter or emergency shelter* 0.24 18.48 2.15 0 0 3.97

Number Interviewed 89 48 41 24 49 251

* Differences between housing categories are statistically significant at p<0.05 level. Note: “Other health services” encompass any physical health services not detailed above, e.g., annual physicals, physician office visits, etc. population across their varying residential of the street homeless, food stamps most situations. Rather, whatever the housing status, importantly for those in bridge housing, it appears that subsistence is contingent on and employment engaged in most often Cost and Demographic/Biographic Comparisons By Category of Homelessness Cost and Demographic/Biographic

cobbling together a mix of resources drawn by residents of rapid re-housing. |

from various sources and limited possibilities. 37 The spectrum of possibilities includes food Service Utilization by Category stamps, “shadow work” such as canning, flying of Homelessness 26 signs and panhandling, employment via As a first step in assessing the cost savings of regular work and/or day labor, SSI and SSDI, housing the homeless, we examine differences securing support from family or friends, general by housing configuration in the utilization of 27 assistance, and Social Security. social and health services as well as contacts In addition to showing that most people with the criminal justice system. In the Cost of experiencing homelessness pursue a mixture Services Used by Category of Homelessness of subsistence strategies or possibilities, section (pages 40-42), we will assign costs the strategies vary considerably across the to these encounters based on information different housing situations, with shadow work provided through our other data sources. figuring most prominently in the subsistence

Table 19. Average (Mean) Criminal Justice Contacts in Past Month, by Housing Category

Rapid Permanent Variables Street Shelter Bridge Re-Housing Supportive TOTAL

# times ticketed* 0.68 0.10 0.11 0.05 0.08 0.30 # times appeared in court 0.20 0.08 0.22 0.29 0.02 0.15 # times arrested* 0.15 0.02 0.02 0 0 0.06 # nights in holding cell, jail or prison 0.34 0.17 0.37 0 0 0.21 Number Interviewed 89 48 41 24 49 251

* Differences between housing categories are statistically significant at p<0.05 level.

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Table 20. Average (Mean) Service Utilization and Criminal Justice Contacts in Past Month, Comparing Chronically Homeless with Those in Permanent Supportive Housing

Variables Chronically Homeless in Street or Shelter Permanent Supportive

# times accessed soup kitchen or food pantry* 19.13 2.22

# times in ER 0.58 0.33

# times in ambulance* 0.27 0.06

# times inpatient in hospital 0.17 0.08

# times accessed other health services* 0.62 1.78

# times ticketed* 0.46 0.08

# times arrested* 0.15 0

# times appeared in court* 0.20 0.02

# nights in holding cell, jail or prison 0.13 0

# nights in shelter or emergency shelter* 6.9 0

Number Interviewed 53 49

* Differences between housing categories are statistically significant at p<0.05 level.

As can be observed in Table 18 (page 37), observed for virtually all categories of service. social and health service utilization in the last For example, permanent supportive housing Cost and Demographic/Biographic Comparisons By Category of Homelessness Cost and Demographic/Biographic

month is lower among the housed than the clients reported 88% fewer soup kitchen or food |

unhoused across the majority of service types. pantry visits, 78% fewer ambulance transports, 38 For example, respondents in rapid re-housing 100% fewer arrests, and 90% fewer court reported 100% fewer ambulance transports appearances in the last month than those who and inpatient stays than respondents living on were chronically homeless. the street, and 83% fewer soup kitchen or food In both Tables 18 and 20, other (non-hospital) pantry visits. Table 19 (page 37) also shows large health services are the main exception to the differences between the housed and unhoused in trends toward lower service utilization among the number of reported criminal justice contacts those who are housed. The housed use these in the past month, with far fewer contacts of all types of health services more frequently than types among those housed, particularly those in the unhoused, perhaps because once housed permanent supportive housing. they are better able to access needed routine Because permanent supportive housing and preventive services. This may also reflect is targeted to the chronically homeless in a shift toward outpatient rather than hospital particular, in Table 20 we compare permanent visits. Either way, accessing these types of supportive housing clients to the group that health services can be expected to decrease provides a more direct comparison: the overall health service costs. Use of substance chronically homeless that are currently on the abuse services is also greater among those in street or in emergency shelters. As in Tables 18 bridge and rapid re-housing (Table 18), which and 19, trends toward lower service utilization may reflect utilization of services required by and fewer criminal justice contacts can be the particular housing providers.

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Figure 9. Mean Cost Per Person for Service Utilization in Last Year, by Housing Configuration

$120,000 $100,759 $100,000

$80,000

$58,560 $60,000 $51,587

DOLLARS $42,010 $44,923 $40,000 $25,816 $22,686 $20,000 $9,175

$0 Total Bridge Street (Chronic) Street Shelter (Chronic) Rapid Re-Housing Street (Non-chronic) Street Shelter (Non-chronic) Permanent SupportivePermanent

Notes: Cost estimates consider utilization of soup kitchens, food pantries, substance abuse services, ambulance services, ER services, inpatient hospital stays, mental health services, other health services, motel/voucher/rental assistance services, shelter nights, bridge housing nights, rapid re-housing nights, permanent supportive housing nights, policing, nights in jail/prison. These estimates do not Cost and Demographic/Biographic Comparisons By Category of Homelessness Cost and Demographic/Biographic capture other potential costs, including probation, changes in property values, park maintenance costs, etc. Reports from the last | month are annualized. 39

Figure 10. Mean Cost Per Person for Service Utilization in Last Year, Comparing Peramanent Supportive Housing Clients to the Chronically Homeless

$120,000 $100,759 $100,000 $85,631 $80,000

$58,560 $60,000 $51,587 DOLLARS $40,000

$20,000

$0 Total Chronic Total Chronic Street Chronic Chronic Shelter Chronic (Street and Shelter) (Street Permanent SupportivePermanent

Note: See notes in Figure 9.

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Figure 11. Mean Cost Per Person for Service Utilization in Last Year, Comparing the Non-chronically Homeless to Bridge and Rapid Re-Housing Clients

$45,000 $42,010 $40,000 $36,419 $35,000 $30,000 $25,816 $25,000 $22,686

DOLLARS $20,000 $15,000 $9,175 $10,000 $5,000 $0 Bridge Total Non-chronic Total Rapid Re-Housing Non-chronic Street Non-chronic (Street and Shelter) (Street Non-chronic Shelter Non-chronic

Note: See notes in Figure 9. Cost and Demographic/Biographic Comparisons By Category of Homelessness Cost and Demographic/Biographic |

Cost of Services Used by Category month, the monthly cost for this service would 40 of Homelessness be estimated as $900 per visit x two visits = To differentiate the per-person average annual $1,800. Monthly service costs were annualized costs across categories of chronicity and assuming equal service utilization across all housing configuration, we triangulate data months of the year. from the in-person survey interviews and the Based on this methodology, we estimate from institutions/organizations. Specifically, the our interviews that the mean annual cost per interviews were used to identify frequency person for all services, across all categories of service utilization in the last month for of housing configuration and chronicity, is individuals who fall into the various categories approximately $45,000 (Figure 9, page 39). of homelessness; these results were provided Heavy service consumers, particularly of health above in the Service Utilization by Category and medical services, drive the average cost of Homelessness section (pages 37-38). We up greatly; so much so that if the most-costly then use data on average cost per encounter 10% are dropped from the analysis, the mean provided by the institutions/organizations (for annual cost per person drops from $45,000 to example, the average cost of an emergency approximately $10,000. room visit, average cost of an ambulance ride or average program cost of a night of permanent Figure 9 shows differences in the mean annual supportive housing), to assign cost estimates per capita cost of services across all of the to the service information provided by our housing configurations. Figures 10 and 11 respondents. For example, if an individual (pages 39-40) provide comparisons more reported two emergency room visits in the last focused on the target populations for each

f RETURN TO CONTENTS Homelessness in Orange County: The Costs to Our Community

Figure 12. Mean Cost Per Person for Health Service Utilization in Last Year, by Housing Configuration

$98,199 $100,000 $90,000 $80,000 $70,000 $60,000 $53,604 $50,000 $43,184 $39,020 $40,184 DOLLARS $40,000

$30,000 $20,716 $20,000 $17,624 $10,000 $5,975 $0 Total Bridge Street (Chronic) Street Shelter (Chronic) Rapid Re-Housing Street (Non-chronic) Street Shelter (Non-chronic) Permanent SupportivePermanent

Note: Cost estimate considers utilization of substance abuse services, ambulance services, ER services, inpatient hospital stays, mental health services, and other health services. Reports from the last month are annualized. Cost and Demographic/Biographic Comparisons By Category of Homelessness Cost and Demographic/Biographic | of the housing types. In particular, Figure 10 by the housed is lower than the cost of services 41 (page 39) compares chronically homeless for unhoused, even net of the program costs of respondents on the street and in emergency housing. Specifically, the average annual cost shelters to respondents in permanent for those housed in rapid re-housing ($9,175) supportive housing. It indicates that as a and bridge housing ($22,686) is 75% and 38% result of the decreases in service utilization lower, respectively, than the annual cost for the and criminal justice contacts documented non-chronically homeless on the street and in in Table 20, the estimated average annual emergency shelters ($36,419). cost of services is approximately 50% lower Figure 12 shows differences by housing for the homeless in permanent supportive configuration in the mean annual cost per housing ($51,587) compared to the chronically person for health services only. Because health homeless living on the streets ($100,759), even service costs (particularly ER and inpatient after taking into consideration the program hospital visits) are among the most expensive, costs of permanent supportive housing. When the dollar amounts given in Figure 12 are not the chronically homeless on the streets and in much lower than the costs for all services emergency shelters are considered together, shown in Figures 9 through 11 (pages 39-40). the mean annual cost for permanent supportive The mean annual cost per person for health housing clients is 40% lower than that of the services is just over $40,000 when aggregated combined group ($51,587 versus $85,631). over all categories of housing configuration and Figure 11 (page 40) shows that for the non- chronicity. The estimated average annual cost chronically homeless, also, the annual cost of of health services incurred by the chronically services and criminal justice contacts incurred homeless on the street ($98,199) is more than

f RETURN TO CONTENTS Homelessness in Orange County: The Costs to Our Community

Figure 13. Number of Chronic Physical Health Conditions Reported by Street/Shelter Homeless, by Length of Time on the Street

100% 90% 15% 23% 33% 80% 35% 70% 44% 60% 38% 50% 40% 50% 30% 33% PERCENT 20% 29% 10% 0% 0-12 Months 1-2 Years 3+ Years

0- Conditions 1-2 Conditions 3 or More Conditions

Note: Chronic physical health conditions include arthritis, asthma, cancer, cardiovascular disease, chronic bronchitis, chronic obstructive lung disease, cirrhosis or severe liver damage, diabetes, emphysema, epilepsy or other seizure disorder, HIV/AIDS, hypertension, leukemia and lymphoma. double that of those in permanent supportive Overall, then, the findings presented in this housing ($43,184). The health costs estimated section provide a consistent and compelling Comparisons By Category of Homelessness Cost and Demographic/Biographic | for those in rapid re-housing and bridge housing pattern: costs are markedly lower among 42 are also lower than those estimated for both the the formerly homeless who are now housed. non-chronically and chronically homeless on the Potential cost savings from providing housing streets and in emergency shelters. are suggested for both the chronically and non- chronically homeless. Figure 13 provides some context for these findings by showing the concentration of poor Chronicity, Housing and Potential health among the chronically homeless. While Cost Savings 50% of individuals on the street for under a year report no chronic physical health conditions, In the Cost of Services Used by Category this drops to 29% among individuals on the of Homelessness section (pages 40-42), street for three or more years. Similarly, the based on findings presented in Figure 10, we proportion of individuals with three or more noted that the estimated mean annual cost of health conditions is 15% for those on the services and criminal justice contacts is 40% street for under a year, jumping to 33% for lower for permanent supportive housing clients those on the street for more than three years. relative to the chronically homeless living on These patterns make unequivocally clear the the streets and in emergency shelters ($51,587 temporal relationship between homelessness versus $85,631). From this difference in costs, and health: whatever health conditions one we can derive an estimate of the potential cost brings with them when they become homeless savings from placing all of the Orange County will be exacerbated the longer they are living chronically homeless into permanent supportive on the streets or in shelters, and the longer housing. The 2015 Point-in-Time (PIT) survey one is homeless, the greater the odds of being indicated that there were 3,126 homeless encumbered with new health conditions. on the streets or in emergency shelters in

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Orange County. If 39% of these individuals are the homeless are greatest for the chronically chronically homeless (based on the percentage homeless who are the most heavy service users, in our sample), this suggests a total of 1,219 particularly those in the upper decile of costs. chronically homeless individuals in the county. Ten percent of the chronically street homeless incur annual costs higher than $439,787, and The total annual cost of services for the 10% of the chronically homeless in emergency chronically homeless can be estimated as 1,219 shelters incur costs in excess of $433,845 per individuals multiplied by $85,631 per person, person. By contrast, the comparable figure for which equals $104,384,189. The annual cost the most costly 10% of those in permanent if these individuals were instead in permanent supportive housing is only $55,332. These supportive housing can be estimated as 1,219 differences amount to a $384,455 annual multiplied by $51,587, or $62,884,553.28 From savings per the most-chronically homeless living these two figures, we estimate a cost savings on the streets, and a $338,513 annual savings of approximately $41.5 million per year per the high-end chronically homeless residing ($104,384,189 minus $62,884,553) if all Orange in emergency shelters. County chronically homeless on the streets and in emergency shelters were placed into Given these striking cost discrepancies and permanent supportive housing.29 savings, it would appear fiscally irresponsible, as well as inhumane, not to provide permanent Finally, to provide a sense of the extent to supportive housing for these individuals. But which the heaviest service users drive the cost

two obstacles stand in the way of doing Comparisons By Category of Homelessness Cost and Demographic/Biographic

differences observed in Figures 9 through 12, | so: the most obvious one is the shortfall in

Table 21 presents the 25th, 50th, 75th and 43 permanent supportive housing units across 90th percentiles for the annual per capita cost the county and its municipalities; the second of services, by housing configuration. The and less obvious obstacle is the protracted 50th percentile figures represent the median process through which the severely chronically costs—50% of the homeless in each category homeless are identified, slotted for, and moved have costs below the figure provided, and 50% into permanent supportive housing. above. The 90th percentile figures represent upper decile costs—90% of the homeless To illustrate and put some flesh on these figures incurred costs lower than the given amount, and and challenges, let us consider one of Orange 10% incurred costs above. Table 21 indicates County’s “million-dollar Murrays.” Murray is/was that the potential cost savings of housing a chronically homeless, alcoholic man living

Table 21. Per Capita Annual Cost of Services, by Housing Configuration Across the Distribution

Housing Configuration 25% 50% 75% 90%

Street (Chronic) $3,010 $11,372 $21,720 $439,787

Shelter (Chronic) $1,695 $8,081 $33,740 $433,845

Permanent Supportive Housing $9,914 $11,094 $16,844 $55,334

Shelter (Non-chronic) $3,897 $7,880 $14,459 $28,384

Street (Non-chronic) $1,180 $4,870 $14,640 $27,680

Bridge $6,158 $10,166 $16,768 $24,827

Rapid Re-Housing $3,394 $5,161 $12,477 $18,233

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for years on the streets of Reno, Nevada, who of these encounters by the average cost per was immortalized by Malcolm Gladwell’s New encounter, the total cost was over $300,000, but Yorker essay titled “Million Dollar Murray.”30 It we suspect the actual cost of these encounters was so titled because of the expenses Murray was much more because of the severity of reportedly accumulated, estimated to be a Charlie’s health problems. And this was for only million dollars or more over the course of medical emergencies for one year. Charlie also his 10 years on the streets. Using Gladwell’s frequented soup kitchens regularly and would appellation as an umbrella-like metaphor, we go to an emergency shelter when he could interviewed a good number of people living on when the weather turned bad, always getting the street whose experiences cluster under about by public transit. that umbrella because of the cost of severe Returning to “Million Dollar Murray,” recall that chronic homelessness. One such person the estimated million was for a 10-year period. we interviewed, who we’ll call Charlie, was Charlie, in contrast, has been homeless for 17 a heavy-set, 65-year-old, wheelchair-bound years and is equally, if not more compromised, White male who had been homeless and living health-wise, than Murray. Moreover, we know on the streets for the past 17 years. Charlie that for at least one of those 17 years Charlie says he initially became homeless after his accumulated emergency and hospitalization biological mother passed away and his step- costs of over $300,000, and we have good father threw him out of the house to make room reason to suspect that he accumulated similar for a new woman-friend. At the time, Charlie

annual costs over the 17 years given his many Comparisons By Category of Homelessness Cost and Demographic/Biographic was financially-strapped, severely overweight, | health problems. Thus, we have good reason to

and already compromised physically. At the 44 assume that Charlie has been a “Million Dollar time we interviewed him 17 years later, the Murray” times a factor of three or four. years of being homeless, usually “sleeping rough” in parks, hidden alcoves and at bus The bicycle police officer in Reno, who came stations, had clearly taken its toll. When asked to know Murray well, concluded, “It cost us about the health conditions he currently had, one million dollars not to do something about Charlie checked off diabetes, asthma, chronic Murray.” We in Orange County might turn that obstructive lung disease, high blood pressure, into a question regarding Charlie, and ask: heart disease, and physical disability due to his What does it cost us—that is, the county, its inability to walk, as evidenced by the wheelchair municipalities, hospitals and agencies—to in which he was sitting. We also asked Charlie, keep Charlie and others like him on the streets, as we did all of the persons we interviewed, as well as those who are not currently as whether he had been to an emergency room, encumbered physically and mentally but may hospitalized and transported by an ambulance become so the longer they are homeless? during the past month or six months. Charlie couldn’t pin down the exact times, but did say, It has been the aim of this study to answer and repeated again, that during the past year that question, and we now know that the he had gone to an emergency room 12 times, answer is “plenty,” and a “whole, whole lot was transported by ambulance each time, more” than if Charlie and other chronically and and was hospitalized eight times, twice due non-chronically homeless were housed in the to heart problems. When we multiplied each appropriate configuration of housing.

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REFERENCES

American Civil Liberties Union of Southern California. 2016. Flaming, Daniel, Patrick Burns, and Michael Matsunaga. Nowhere To Live: The Homeless Crisis in Orange County & 2009. Where We Sleep: Costs When Homeless and Housed in How to End It. Orange County, CA: ACLU. Los Angeles. Los Angeles: Economic Roundtable.

Baker, Susan Gonzalez. 1994. “Gender, Ethnicity, and Flaming, Daniel, Halil Toros, and Patrick Burns. 2015. Home Homelessness: Accounting for Demographic Diversity on Not Found: The Cost of Homelessness in Silicon Valley. Los the Streets.” American Behavioral Scientist 37: 476-504. Angeles: Economic Roundtable.

Bartley, Tim and Wade T. Roberts. 2006. “Relational Gladwell, Malcolm. 2006. “Million Dollar Murray.” The New Exploitation: The Informal Organization of Day Labor Yorker, February 13: 96. Agencies.” Working USA: The Journal of Labor and Society 9: 1089-7011. Kim, John and Aiko Tan. 2016. “Chronic Care Plus ER Diversion for High Utilizer Chronically Homeless.” Irvine, CA: Burns, Donald W. and David L. DiLeo (Eds.) 2016. Ending Illumination Foundation (4 page report). Homelessness: Why We Haven’t, How We Can. Boulder, CO: Lynne Rienner Publishers. Lee, Barrett A., Kimberly A. Tyler, and James D. Wright. 2010. “The New Homeless Revisited.” Annual Review of Sociology Burt, Martha, Laudan Y. Aron, and Edgar Lee with Jesse 36: 501-521. Valentine. 2001. Helping America’s Homeless: Emergency Shelter or Affordable Housing? Washington, D.C. The Urban Lin, Nan, Karen Cook, and Ronald S. Burt (Eds.). 2001. Social Institute Press. Capital: Theory and Research. New York: Aldine De Gruyter. References | Burt, Martha. 2016. “Three Decades of Homelessness.” Pp. Lofland, John, David A. Snow, Leon Anderson, and Lyn 47-66 in Burns, Donald W. and David L. DiLeo (Eds.), Ending G. Lofland. 2006. Analyzing Social Settings: A Guide to 45 Homelessness: Why We Haven’t, How We Can. Boulder, CO: Qualitative Observation and Analysis. 4th Edition. Belmont, Lynne Rienner Publishers. CA: Thomson/Wadsworth.

City of Sacramento 2015 (October). “Cost of Homelessness National Health Care for the Homeless Council. 2016. “What to the City of Sacramento” (6 page report). is the official definition of homelessness?” Nashville, TN: National Health Care for the Homeless Council, Inc. Cohen, Sheldon. 2004. “Social Relationships and Health.” American Psychologist, 676-684. Orange County Community Indicators Project. 2015. OC Community Indicators 2015. Santa Ana: OC Community Collins, Jeff. 2015. “Want to live in Orange County? It’ll cost Indicators Project. you $1,848 a month for an apartment – an all-time average high.” Orange County Register, July 15. Price, Susan. 2016. An Assessment of Homeless Services in Orange County. Santa Ana, CA: Office of Care Coordination, Desmond, Matthew. 2016. Evicted: Poverty and Profit in The The County of Orange. American City. New York: Crown Publishers. Roberts, Wade T., and T. Bartley. 2004. “The wages of day Erlandson, David, Edward L. Harris, Barbara L. Skipper, and labor: Homeless workers in the temporary help industry.” Steven D. Allen. 1993. Doing Naturalistic Inquiry: A Guide to Journal of Poverty 8:65–89. Methods. Newbury Park, CA: Sage. Snow, David A. and Leon Anderson. 1993. Down on Their Fermanian Business & Economic Institute at PLNU. 2016. Luck: A Study of Homeless Street People. Berkeley, CA: Housing San Diego’s Homeless at Greatest Risk: A Cost University of California Press. Benefit Analysis. San Diego: Point Loma Nazarene University.

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Tobin, Kerri and Joseph Murphy. 2016. “The New U.S. Department of Housing and Urban Development 2015. Demographics of Homelessness”. Pp. 29-45 in Burns, Donald The 2015 Annual Homeless Assessment Report (AHAR) to W. and David L. DiLeo (Eds.), Ending Homelessness: Why We Congress. Washington, D.C.: US Department of Housing Haven’t, How We Can. Boulder, CO: Lynne Rienner Publishers. and Urban Development, Office of Community Planning and Development. Umberson, Debra and Jennifer Karas Montez. 2010. “Social Relationships and Health: A Flashpoint for Health Policy.” U.S. Department of Housing and Urban Development 2016. Journal of Health and Social Behavior 51: S54-S66. The 2016 Annual Homeless Assessment Report (AHAR) to Congress. Washington, D.C.: US Department of Housing United Way of Greater Los Angeles. 2009 (October). and Urban Development, Office of Community Planning and “Homeless Cost Study” (4 page report). Development. U.S. Department of Housing and Urban Development 2014. The 2014 Annual Homeless Assessment Report (AHAR) to Congress. Washington, D.C.: US Department of Housing and Urban Development, Office of Community Planning and Development. References |

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GLOSSARY

Chronically Homeless Individuals refers to Coordinated Entry System (CES) encompasses those homeless who have been continuously a process developed to ensure that all people homeless for one year or more, or who experiencing a housing crisis have fair and have experienced at least four episodes of equal access and are quickly identified, homelessness in the last three years where the assessed, referred and connected to housing combined length of time homeless in those and assistance based on their needs. The occasions is at least 12 months, and who have Coordinated Entry System allows resources to a diagnosable disability (e.g., serious mental be better matched with individuals’ needs. A key illness, developmental disability, post-traumatic component of this system is the Vulnerability stress disorder, substance use disorder, Index – Service Prioritization Assistance Tool cognitive impairments resulting from a brain (VI-SPDAT) [see below]. injury or chronic physical illness or disability). Homelessness is variously defined depending Continuums of Care (CoC) are local planning on the governmental entity. The most bodies ideally responsible for coordinating commonly referenced and restrictive is HUD’s, the full range of homeless services in a which includes four clusters of individuals: (1) Glossary

geographic area, which may cover a city, individuals and families who lack a fixed, regular, |

county, metropolitan area or an entire state. and adequate nighttime residence, as defined; 47 According to HUD, it is “a community plan to (2) individuals and families who will imminently organize and deliver housing and services to lose their primary nighttime residence; (3) meet the specific needs of people who are unaccompanied youth and families with children homeless as they move to stable housing and and youth who are defined as homeless under maximize self-sufficiency. It includes action other federal statutes who do not otherwise steps to end homelessness and prevent a qualify as homeless under this definition; and return to homelessness.” Components include (4) individuals and families who are fleeing, prevention, street outreach, a Coordinated Entry or are attempting to flee, domestic violence, System (see below), emergency shelter, bridge dating violence, sexual assault, stalking or housing and permanent housing placement other dangerous or life-threatening conditions through rapid re-housing and permanent that relate to violence against the individual or supportive housing. To receive federal financial a family member. Somewhat more expansive support for homeless services, HUD requires is the definition from the McKinney-Vento each community to work collaboratively to Homeless Assistance Act which is used by submit a single CoC application rather than many federal programs: A homeless person is allowing applications from individual providers an individual without permanent housing who in a community. HUD’s intent underlying this may live on the streets; stay in a shelter, mission, application process is to stimulate community- single room occupancy facilities, abandoned wide planning and coordination of programs for building or vehicle; or in any other stable or non- homeless individuals and families. permanent situation. This also includes persons who are “doubling up” and previously homeless individuals who are to be released from prison or a hospital without a stable residence to f RETURN TO CONTENTS Homelessness in Orange County: The Costs to Our Community

which they can return (National Health for the in motels /hotels or “couch surfing,” are not Homeless Council, 2016). included. The one-night counts are conducted by Continuums of Care nationwide and occur Homeless Management Information System during the last week in January of each year. (HMIS) is a HUD-based local information technology system used to collect homeless, Rapid Re-Housing (RRH) is a housing client-level data and data on the provision model designed to provide temporary of housing and services to homeless housing assistance to people experiencing individuals and families and persons at risk homelessness, moving them quickly out of of homelessness. Each Continuum of Care is homelessness and into housing, typically for responsible for selecting an HMIS software six months or less. It provides time-limited solution that complies with HUD’s data collection, assistance for market-rate rental units that management, and reporting standards. When covers move-in costs, deposits and rental and/ the system is fully and reliably functional at the or utility assistance. community level, the data has been used as Bridge Housing is a housing program that the basis for conducting cost studies wherein provides temporary residence, ranging from encrypted identifiers from recently homeless six to 24 months, for people experiencing adults residing in housing for the homeless, homelessness. It typically includes supportive typically permanent supportive housing, are services to help residents secure some stability matched with correspondingly encrypted and enhance their employability, with many identifiers from the service records of relevant Glossary

residents being employed. In addition to being | city, county or state agencies (e.g., county

referred to as “bridge” and “interim” housing, 48 departments of health, public health and mental it is sometimes called “transitional” housing. health, sheriff and probation departments, and Whatever the preferred term, its application is local or state hospitalization records). much the same: relatively short-term housing Permanent Supportive Housing (PSH) is a that ideally is to function as a conduit to a more program designed to provide housing (project- permanent housing situation. and tenant-based) and supportive services on Vulnerability Index – Service Prioritization a long-term basis to formerly chronic homeless Decision Assistance Tool (VI-SPDAT) is an people. In addition to being homeless, clients assessment tool used within the Coordinated are required to have a disability. As such, Entry System to prioritize which homeless clients are typically categorized as chronically should receive housing assistance first. It is homeless. The program is based on a “housing designed to assist case management and first” approach to homelessness. to improve housing stability outcomes via Point-in-Time Counts are one-night, homeless clients’ responses to a short set of unduplicated counts of the literally homeless questions regarding their history of housing within communities as defined by HUD. and homelessness, risk, daily functioning, and The literally homeless include those living wellness. With each question, the respondent unsheltered on the streets, in a vehicle or is given a point for answering “Yes,” thus other places not fit for human habitation or exhibiting increased vulnerability and a higher in emergency shelters. These counts provide score for service priority. By using the SPDAT, snapshot estimates of the incidence of social services can target vulnerable homeless homelessness, since many people considered populations that are most service-dependent homeless, such as those in prison or jail, living and in need of assistance.

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APPENDICES

APPENDIX 1 | STUDY ADVISORY COMMITTEE

Whitney Ayers George Searcy Regional Vice President, Orange County, Vice President, Jamboree Hospital Association of Southern California Heather Stratman Julia Bidwell Chief Executive Officer, Association of California Deputy Director for Housing and Community Cities-OC Development, Orange County Community Brenyale Toomer-Byas Resources, County of Orange Director of Housing and Income, Orange County Helen Cameron United Way Director of Supportive Housing, Jamboree Carla Vargas Max Gardner Chief Operating Officer, Orange County President and Chief Executive Officer, United Way Appendices

Orange County United Way | Margie Wakeham 49 Kimberly Goll Executive Director, Families Forward Executive Director, Children & Families Karen Williams Commission of Orange County President & Chief Executive Officer, 2-1-1 Orange Larry Haynes County and Co-Chair of Data Workgroup of Executive Director, Mercy House and Chair Commission to End Homelessness of Prevention and Outreach Workgroups UNIVERSITY OF CALIFORNIA, IRVINE (UCI) of Commission to End Homelessness RESEARCH TEAM: Becks Heyhoe Colin Bernatzky Housing and Income Program Manager, Graduate Research Assistant, UCI Orange County United Way Rachel Goldberg Scott Larson Assistant Professor, Department of Sociology, UCI Executive Director, HomeAid and Chair of Commission to End Homelessness David Snow Distinguished Professor of Sociology, UCI Karen McGlinn Chief Executive Officer, Share Our Selves Sara Villalta Graduate Research Assistant, UCI Carolyn McInerney Manager of Special Projects, CEO Office, County of Orange

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APPENDIX 2 | MUNICIPALITY COST QUESTIONNAIRE

Orange County United Way, Jamboree & UCI Study of the Costs of Homelessness We are soliciting your cooperation in our efforts to conduct a cost study of homelessness in Orange County. By homelessness, we refer, in accordance with HUD, to individuals or families who reside in places not meant for human habitation, or in emergency, transitional or supportive housing when they came from the streets, or who have been evicted from private dwellings, discharged from an institution, or are fleeing domestic violence without the resources or networks needed to obtain housing. Please contact Dr. David A. Snow with any questions or concerns ([email protected]). Thank you for your cooperation and support.

Municipality:

Address:

Name of Municipal Respondent: Respondent Phone #:

Respondent Email: Date:

1. What is the population of the municipality?

2. What was the total budget of the municipality for FY2014/15?

3. Approximately what percent of the total budget was spent on homelessness? Appendices

4. Please complete the following table to the best of your ability. Some of the department designations may |

not apply in your case, so please ignore or modify as appropriate: 50

Approximate % of Department City Department: FY2014/2015 Budget Budget Spent on Homelessness

Mayor/Council City Attorney City Manager Community Development Economic Development Fire Department Emergency Medical Services (EMS) Parks and Recreation Police Department Other: (specify) Other: (specify) Other: (specify)

5. List 3 to 4 non-government agencies that are key service providers for the homeless in your municipality:

6. List key health service providers in your municipality:

7. List major locations in your municipality where the street homeless congregate:

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APPENDIX 3 | SOCIAL SERVICE AGENCIES QUESTIONNAIRE

Orange County United Way, Jamboree & UCI Study of the Costs of Homelessness We are soliciting your cooperation in our efforts to conduct a cost study of homelessness in Orange County. By homelessness, we refer, in accordance with HUD, to individuals or families who reside in places not meant for human habitation, or in emergency, transitional or supportive housing when they came from the streets, or who have been evicted from private dwellings, discharged from an institution, or are fleeing domestic violence without the resources or networks needed to obtain housing. Please contact Dr. David A. Snow with any questions or concerns ([email protected]). Thank you for your cooperation and support.

Organization Name:

Address:

Name of Organizational Respondent: Respondent Phone #:

Respondent Email: Date:

1. How many clients did your organization serve in 2015? 2. What were your organization’s total program expenses for 2015? (By program costs, we mean expenses reported in IRS Form 990 minus administrative and fundraising costs.) 3. What percent of the total budget was spent on homelessness in 2015? (Provide your best guess if this percentage is not known.) 4. What percentage of your service encounters were with the homeless in 2015? (Provide your best guess if this percentage is not known.) Appendices |

5. Which of the following services does your organization offer? 51

Service If Yes, Estimated If Yes, Estimated # of Offered? Program Cost of Service Homeless Served (2015) Yes No Per Encounter (2015)* Substance Abuse Services   Mental Health Services   Health: Ambulance Services   Other Health Services   Soup Kitchen Food &   Hygiene Food Pantry   Services: Hygiene and/or Clothing   Shelter/Emergency Shelter   Transitional Housing   Housing**: Rapid Re-Housing   Permanent Supportive Housing   Referral Service   Other: Crisis Service  

* Our definition of encounter”“ is flexible depending on the type of service (for example, it can be a meal, a clinical visit, a counseling session, a night in an emergency shelter, the cost per year for a housing unit, etc.). We do ask that you please specify what definition you are using (e.g., cost per housing unit per year) in each cell you fill in. ** Per year

6. If your organization provides housing, how many beds does it have for single adults or youth? 7. If your organization provides housing, how many units for families does it have? 8. Is your organization 501(c)(3) tax-exempt?  501(c)(3)  Other ______9. Does your organization receive funding from HUD?  Yes  No

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APPENDIX 4 | HOSPITAL AND EMERGENCY ROOM QUESTIONNAIRE

Orange County United Way, Jamboree & UCI Study of the Costs of Homelessness We are soliciting your cooperation in our efforts to conduct a cost study of homelessness in Orange County. By homelessness, we refer, in accordance with HUD, to individuals or families who reside in places not meant for human habitation, or in emergency, transitional or supportive housing when they came from the streets, or who have been evicted from private dwellings, discharged from an institution, or are fleeing domestic violence without the resources or networks needed to obtain housing. Please contact Dr. David A. Snow with any questions or concerns ([email protected]). Thank you for your cooperation and support.

Hospital Name:

Address:

Name of Hospital Respondent: Respondent Phone #:

Respondent Email: Date:

Please fill out the table below to the best of your ability. Approximations are acceptable if exact amounts are not known.

Estimated # of Service Offered? Total # of Patients Average Cost Per Homeless Patients Served in 2015 Encounter in 2015* Yes No in 2015 Appendices | Emergency Room   52 Inpatient Services  

Ambulance Services**  

Other: (optional)  

Other: (optional)  

Other: (optional)  

* Our definition of encounter”“ is flexible depending on the type of service (for example, it can be an EMS dispatch, emergency room visit, cost per bed for inpatient services, etc.). We do ask that you please specify what definition you are using (e.g., cost per bed per night) in each cell you fill in. ** If ambulance services are contracted out, list name of private agency here:

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APPENDIX 5 | HOMELESS INTERVIEW SCHEDULE AND QUESTIONNAIRE

Orange County United Way, Jamboree & UCI Study of the Costs of Homelessness

Interview #: Start of Interview:

Location:

Field Interviewer:

End of Interview:

Introduction Hello, my name is ______. I’m helping to conduct a survey of Orange County’s homeless population for United Way and the University of California, Irvine. The survey is intended to provide local service agencies with a better understanding of the causes, needs and costs of Orange County’s homeless population. Your participation is very important. The interview will take approximately 20 minutes. In order to compensate you for your time, I will give you a $10.00 gift card that you can use at a local business upon completion of the interview. Your participation is voluntary, of course, and your responses will be kept completely confidential.

Demographics Appendices | We’re going to start off with a few basic questions about yourself. 53 1. When were you born? Month ______Day ______Year ______

Don’t know ...... -1 Refuse ...... -2

2. What is the highest level of schooling you have completed? (Interviewer: show respondent list of categories.)

No formal education ...... 1 Grade 1-8 ...... 2 Grade 9 ...... 3 Grade 10 ...... 4 Grade 11 ...... 5 High school graduate with diploma ...... 6 GED or high school equivalent ...... 7 Attended technical school, but did not graduate ...... 8 Technical school graduate ...... 9 Attended college, but did not graduate ...... 10 College graduate or higher ...... 11 Other (specify) ______...... 12 Don’t know ...... -1 Refuse ...... -2

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3. Are you currently enrolled in school?

Yes ...... 1 No ...... 2 Don’t know ...... -1 Refuse ...... -2

4. Are you Hispanic or Latino?

Yes ...... 1 No (Skip to question 6) ...... 2 Don’t know (Skip to question 6) ...... -1 Refuse (Skip to question 6) ...... -2

5. What is your Hispanic or Latino background? (Interviewer: circle all that apply.)

Mexican ...... 1 Cuban ...... 2 Puerto Rican ...... 3 Central American ...... 4 South American ...... 5 Other (specify) ______...... 6 Don’t know ...... -1 Appendices |

Refuse ...... -2 54 6. Which of the following best describes your race—White, Black or African American, Asian or Pacific Islander, or Native American or Alaskan Native?

White (Skip to question 8) ...... 1 Black or African American (Skip to question 8) ...... 2 Asian or Pacific Islander ...... 3 Native American or Alaskan Native (Skip to question 8) ...... 4 Other (specify) ______(Skip to question 8) ...... 5 Don’t know (Skip to question 8) ...... -1 Refuse (Skip to question 8) ...... -2

7. What is your Asian or Pacific Islander background? (Interviewer: circle all that apply.)

Chinese ...... 1 Filipino ...... 2 Vietnamese ...... 3 Japanese ...... 4 Korean ...... 5 Indian ...... 6 Other (specify) ______...... 7 Don’t know ...... -1 Refuse ...... -2

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8. Considering gender, how do you describe yourself?

Male ...... 1 Female ...... 2 Transgender ...... 3 Do not identify as male, female or transgender ...... 4 Don’t know ...... -1 Refuse ...... -2

9. What is your current marital status—married, separated, divorced, widowed or never married?

Married ...... 1 Separated ...... 2 Divorced ...... 3 Widowed ...... 4 Never married ...... 5 Don’t know ...... -1 Refuse ...... -2

10. Considering sexuality, do you consider yourself to be heterosexual or straight, gay or lesbian, or bisexual?

Heterosexual or straight ...... 1 Gay or lesbian ...... 2 Appendices |

Bisexual ...... 3 Don’t know ...... -1 55 Refuse ...... -2

11. Have you ever served in the armed forces of the United States?

Yes ...... 1 No (Skip to question 14) ...... 2 Don’t know (Skip to question 14) ...... -1 Refuse (Skip to question 14) ...... -2

12. In what year were you discharged? Year ______

Don’t know ...... -1 Refuse ...... -2

13. Where did you serve? (Interviewer: select all that apply)

Vietnam ...... 1 Iraq ...... 2 Afghanistan ...... 3 Stateside ...... 4 Other (specify: ______) ...... 5 Don’t know ...... -1 Refuse ...... -2

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Living Conditions Now we’re going to move onto some questions about your living situation.

14. Where did you spend the night…...... last night? ▼

15. Where do you plan to spend the night…...... tonight? ▼

16. During the last 30 days, where did you spend…...... most nights? ▼

Transitional/interim housing...... 1. . . . . 1. . . . . 1 A rapid re-housing unit ...... 2. . . . . 2. . . . . 2 Permanent supportive housing...... 3. . . . . 3. . . . . 3 Your own home or apartment...... 4. . . . . 4. . . . . 4 Home of a relative...... 5. . . . . 5. . . . . 5 Home of a friend...... 6. . . . . 6. . . . . 6 Church ...... 7. . . . . 7. . . . . 7 Abandoned building...... 8. . . . . 8. . . . . 8 Homeless shelter...... 9. . . . . 9. . . . . 9 Domestic violence shelter ...... 10. . . . .10. . . . .10 On the streets...... 11. . . . .11. . . . .11 In a camp...... 12. . . . .12. . . . .12 Park...... 13. . . . .13. . . . .13

Substance abuse treatment facility or detox center...... 14. . . . .14. . . . .14 Appendices |

Hospital ...... 15. . . . .15. . . . .15 56 Psychiatric hospital or other psychiatric facility...... 16. . . . .16. . . . .16 Hotel or motel...... 17. . . . .17. . . . .17 Car or vehicle...... 18. . . . .18. . . . .18 Jail, prison or juvenile detention facility...... 19. . . . .19. . . . .19 Bus or train station...... 20. . . . .20. . . . .20 Other (Specify ______)...... 21. . . . .21. . . . .21 Don’t know...... -1. . . . .-1. . . . .-1 Refuse ...... -2. . . . .-2. . . . .-2

For the purpose of this study we’re using the word “homeless” to describe people who sometimes have to sleep outdoors, in cars, in abandoned buildings or on the streets; or who are staying in shelters, transitional housing or supportive housing after being on the streets; or who have been evicted from their homes, discharged from an institution like a hospital or a prison, or are fleeing domestic violence and can’t find housing.

17. Using this definition, are you currently homeless?

Yes ...... 1 No (Skip to question 19 if evidence of homelessness, if no evidence terminate) ...... 2 Don’t know ...... -1 Refuse ...... -2

f RETURN TO CONTENTS Homelessness in Orange County: The Costs to Our Community

18. How long have you been homeless currently?

Less than 7 days ...... 1 7-30 days ...... 2 1-6 months ...... 3 7-12 months ...... 4 1-2 years ...... 5 3 or more years ...... 6 Don’t know ...... -1 Refuse ...... -2

19. Over your lifetime, how many different times have you been homeless?

0 (Skip to question 21 if evidence of homelessness, if no evidence terminate) ...... 0 1 ...... 1 2 ...... 2 3 ...... 3 4 ...... 4 5 ...... 5 More than 5 ...... 6 Don’t know ...... -1

Refuse ...... -2 Appendices |

20. How old were you when you first became homeless? | ____ | ____ | 57

Don’t know ...... -1 Refuse ...... -2

21. How long have you been in Orange County?

Less than 7 days ...... 1 7-30 days ...... 2 1-6 months ...... 3 7-12 months ...... 4 1-5 years ...... 5 6-10 years ...... 6 More than 10 years ...... 7 Don’t know ...... -1 Refuse ...... -2

22. Over the past 30 days, which city has been your primary home base?

Specify city: (______) ...... 1 Don’t know ...... -1 Refuse ...... -2

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23. Of the various problems or activities you have to deal with, can you tell me how difficult you find the following activities? Do you find them not difficult at all, somewhat difficult, difficult, or very difficult? (Interviewer: show respondent list of categories. If respondent housed, ask before housed and after housed. Note response with check marks.) AH AH AH AH AH AH BH ■ BH ■ BH ■ BH ■ BH ■ BH ■ Not Difficult At All At Difficult Not ■ Difficult Somewhat ■ Difficult ■ Difficult Very ■ Know Don't ■ Refuse ■

A Finding food 1 2 3 4 -1 -2

B Finding a safe space to sleep 1 2 3 4 -1 -2

C Finding a place to wash and shower 1 2 3 4 -1 -2

D Getting clean clothes 1 2 3 4 -1 -2

E Finding a toilet 1 2 3 4 -1 -2 Finding a place to “hang out” – F 1 2 3 4 -1 -2 a place free from being hassled Finding a reliable friend or G acquaintance – someone you 1 2 3 4 -1 -2 can count on Getting from one place to another H 1 2 3 4 -1 -2 in the county Appendices |

I Feeling good about yourself 1 2 3 4 -1 -2 58

24. While homeless, how often have you been (or were you) verbally harassed, like being called a bum or lazy? (Interviewer: show respondent list of categories.)

Often ...... 1 Sometimes ...... 2 Rarely ...... 3 Never ...... 4 Don’t know ...... -1 Refuse ...... -2

25. While homeless, how often have you been (or were you) hit, slapped, punched or kicked? (Interviewer: show respondent list of categories.)

Often ...... 1 Sometimes ...... 2 Rarely ...... 3 Never ...... 4 Don’t know ...... -1 Refuse ...... -2

f RETURN TO CONTENTS Homelessness in Orange County: The Costs to Our Community

26. While homeless, how often have you had (or did you have) something stolen from where you were staying, or where you were stowing your belongings? (Interviewer: show respondent list of categories.)

Often ...... 1 Sometimes ...... 2 Rarely ...... 3 Never ...... 4 Don’t know ...... -1 Refuse ...... -2

27. While homeless, how often have you had (or did you have) something taken from you by someone who threatened you with violence if you didn’t give it to them? (Interviewer: show respondent list of categories.)

Often ...... 1 Sometimes ...... 2 Rarely ...... 3 Never ...... 4 Don’t know ...... -1 Refuse ...... -2

28. If the challenges of making it while homeless are divided into physical and psychological, which do you find most difficult to deal with—physical challenges, psychological challenges or both equally?

Physical challenges ...... 1 Appendices | Psychological challenges ...... 2 59 Both equally ...... 3 Don’t know ...... -1 Refuse ...... -2

f RETURN TO CONTENTS Homelessness in Orange County: The Costs to Our Community

Services One of the things we’re interested in is the kinds of services you use. We’re going to ask you a few questions about that now.

29. How many times in the last month, if at all, have you used or had an encounter with the following kinds of services, agencies or facilities? If you can’t remember the exact number of times, just give us your best guess. (Interviewer: If easier for respondent to provide average number of times/week, multiply estimate by 4. If respondent says “don’t know” or “refuse,” write “DK” or “R” in corresponding cell. In rows H-K, refer to “number of nights in last month” rather than “times.”)

Number of Times Number of Times Number of Times in Last Month in the Last 6 Over Whole Time (“Nights” For H-K) Months Homeless

A Soup kitchens

B Food pantries

Hygiene or clothing services (for example, getting C donated soap or razors, or donated clothing)

D Mental health services

E Substance abuse services (alcohol or drugs)

Other type of health service (for example, visiting F a community health clinic)

G Motel/housing vouchers and/or rental assistance Appendices H Shelters or emergency shelters |

I Transitional (bridge or interim) housing 60

J Rapid re-housing

K Permanent supportive housing

Crisis services, including sexual assault crisis, L mental health crisis, family/intimate violence, distress centers or suicide prevention hotlines

M Emergency room

N Ambulance

O Hospitalization as an inpatient

P Been ticketed

Q Appeared in court

R Been arrested

30. A. In the last month, how many nights did you stay in a holding cell, jail or prison, whether that was a short- term stay like drunk tank, a longer stay for a more serious offence, or anything in between? | ____ | ____ |

Don’t know ...... -1 Refuse ...... -2

30. B. How about the last 6 months? | ____ | ____ |

Don’t know ...... -1 Refuse ...... -2

f RETURN TO CONTENTS Homelessness in Orange County: The Costs to Our Community

30. C. How about throughout the entire time you have been homeless? | ____ | ____ |

Don’t know ...... -1 Refuse ...... -2

31. Have you ever been convicted of a felony?

Yes ...... 1 No ...... 2 Don’t know ...... -1 Refuse ...... -2

Reasons for Homelessness Let’s switch to a question on why you became homeless. 32. What would you say were the main reasons you became homeless most recently (for example, losing a job, drugs or alcohol, abuse or violence)? (Interviewer: select all that apply)

A. Lost or quit job ...... 1 B. Insufficient pay/wages ...... 2 C. Loss or decrease in government benefits ...... 3 D. Couldn’t afford rent/evicted from housing/foreclosure ...... 4 E. Drugs ...... 5

F. Alcohol ...... 6 Appendices | G. Physical health problems ...... 7 61 H. Mental health problems ...... 8 I. Release from prison/jail ...... 9 J. Immigration ...... 10 K. Abuse or violence at home ...... 11 L. Divorce or separation ...... 12 M. Other (Specify ______) ...... 13 N. Don’t know ...... -1 O. Refuse ...... -2

Health Now we’ll ask a few questions about your health. 33. In general, would you say your health is excellent, very good, good, fair or poor? (Interviewer: show respondent list of categories.)

Excellent ...... 1 Very good ...... 2 Good ...... 3 Fair ...... 4 Poor ...... 5 Don’t know ...... -1 Refuse ...... -2

f RETURN TO CONTENTS Homelessness in Orange County: The Costs to Our Community

34. What health problems, if any, do you have? These may be physical or mental health problems, including a physical disability. (Interviewer: show respondent list of categories. Select all that apply. Probe: anything else?)

Diabetes ...... 1 Asthma ...... 2 Emphysema, chronic bronchitis or chronic obstructive lung disease ...... 3 High blood pressure ...... 4 Epilepsy or another seizure disorder ...... 5 Arthritis ...... 6 Heart disease ...... 7 Back problems ...... 8 Other physical disability (specify:______) ...... 9 Cirrhosis or serious liver damage ...... 10 Cancer, lymphoma or leukemia ...... 11 HIV/AIDS ...... 12 Anxiety or panic disorder ...... 13 Depression ...... 14 Post-traumatic stress disorder (PTSD) ...... 15 Other condition (specify: ______) ...... 16 None (SKIP TO Q36) ...... 17 Appendices

Don’t know (SKIP TO Q36) ...... -1 |

Refuse (SKIP TO Q36) ...... -2 62

35. How difficult have these problems, or any other condition, made it for you to get from one place to another, to work or to just get through the day on your own—not difficult at all, somewhat difficult, difficult or very difficult?

Not difficult at all ...... 1 Somewhat difficult ...... 2 Difficult ...... 3 Very difficult ...... 4 Don’t know ...... -1 Refuse ...... -2

36. Over the past 30 days, how often did you feel depressed—most or all of the time, a lot of the time, sometimes, or never or rarely?

Most or all of the time ...... 1 A lot of the time ...... 2 Sometimes ...... 3 Never or rarely ...... 4 Don’t know ...... -1 Refuse ...... -2

f RETURN TO CONTENTS Homelessness in Orange County: The Costs to Our Community

37. In the past 30 days, how often have you gotten drunk on alcohol? (Interviewer: read and show respondent list of categories.)

Never ...... 1 Less than once a week ...... 2 1 or 2 days a week ...... 3 3 or 4 days a week ...... 4 Every day or almost every day ...... 4 Don’t know ...... -1 Refuse ...... -2

38. In the past 30 days, how often did you use drugs to get high? (By drugs, we mean anything other than alcohol that can get you high.) (Interviewer: read and show respondent list of categories.)

Never ...... 1 Less than once a week ...... 2 1 or 2 days a week ...... 3 3 or 4 days a week ...... 4 Every day or almost every day ...... 4 Don’t know ...... -1 Refuse ...... -2

(If question 37=1 and question 38=1, skip to question 41) Appendices | 39. Over the last 30 days, have you had trouble getting things done that you wanted to do because 63 of alcohol or drugs?

Yes ...... 1 No ...... 2 Don’t know ...... -1 Refuse ...... -2

40. Over the last 30 days, have you been in a hospital or an overnight treatment program for alcohol or drug use?

Yes ...... 1 No ...... 2 Don’t know ...... -1 Refuse ...... -2

Family and Social Networks Now we’re going to ask a few questions about your family and friends. 41. Are you currently living alone or with someone else?

Alone (Skip to question 44) ...... 1 With someone else ...... 2 Don’t know (Skip to question 44) ...... -1 Refuse (Skip to question 44) ...... -2

f RETURN TO CONTENTS Homelessness in Orange County: The Costs to Our Community

42. Who do you live with? (Interviewer: select all that apply, probe as needed to ascertain relation)

A spouse or romantic partner ...... 1 Friend(s) ...... 2 Mother ...... 3 Father ...... 4 Sibling(s) ...... 5 Child(ren) ...... 6 Other family members ...... 7 Refuse ...... -2

(If selected children in question 42, ask question 43) 43. For each of the children who live with you, could you tell me their age and sex? Age Sex ______

______Appendices |

44. Do you currently have a pet living with you? 64

Yes ...... 1 No ...... 2 Don’t know ...... -1 Refuse ...... -2

45. If you think about friends as someone you talk to about important things, or can turn to for support and can count on for assistance, how many friends would you say you have today—none, 1 or 2, 3-5, or more than 5?

None (Skip to question 47) ...... 1 1 or 2 ...... 2 3-5 ...... 3 More than 5 ...... 4 Don’t know (Skip to question 47) ...... -1 Refuse (Skip to question 47) ...... -2

46. How many of these friends are currently homeless—none, some, most or all?

None ...... 1 Some ...... 2 Most ...... 3 All ...... 4 Don’t know ...... -1 Refuse ...... -2

f RETURN TO CONTENTS Homelessness in Orange County: The Costs to Our Community

47. How often are your relatives or friends available to do the following with you? Are they available often, sometimes, rarely or never? (Interviewer: show response categories on card.) Often Sometimes Rarely Never Know Don’t Refuse A. To have a good time with? 1 2 3 4 -1 -2 B. To provide you with food? 1 2 3 4 -1 -2 C. To provide you with a place to stay? 1 2 3 4 -1 -2 D. To listen to you talk about yourself or your problems? 1 2 3 4 -1 -2

Childhood The next questions are about your experiences growing up. 48. When you were growing up, did you spend any time in the following living situations? (Interviewer: show respondent categories on card. Circle all categories that respondent says apply.)

Both biological parents ...... 1 One biological parent only ...... 2 Adoptive parents ...... 3 Other relatives responsible for your care ...... 4 Foster parents ...... 5 Appendices 6 In a juvenile correctional facility ...... |

In an orphanage ...... 7 65 Don’t know ...... -1 Refuse ...... -2

49. On a scale of 1 to 5, how well-off economically would you say your family was, with 1 being the least well-off and 5 being the most well-off? | ____ |

Don’t know ...... -1 Refuse ...... -2

50. When you were growing up, did your parents or other adult members of your household have a problem with alcohol or drug use?

Yes ...... 1 No ...... 2 Don’t know ...... -1 Refuse ...... -2

51. When you were growing up, were you ever physically abused or sexually abused by your parents or other members of your household? (Interviewer: if yes, probe for physical or sexual abuse.)

Yes, physically abused ...... 1 Yes, sexually abused or assaulted ...... 2 Yes, both physically abused and sexually abused ...... 3 No ...... 4 Don’t know ...... -1 Refuse ...... -2

f RETURN TO CONTENTS Homelessness in Orange County: The Costs to Our Community

52. At any time while you were growing up, did your parents or immediate family ever have to spend at least one night in a shelter, outdoors, in a car, in an abandoned building or on the streets?

Yes ...... 1 No ...... 2 Don’t know ...... -1 Refuse ...... -2

Employment Turning to your work experience… 53. During the past 30 days, did you work at a job for which you were paid, and if so, how many jobs did you work?

Yes, one job ...... 1 Yes, two or more jobs ...... 2 No (Skip to question 56) ...... 3 Don’t know (Skip to question 56) ...... -1 Refuse (Skip to question 56) ...... -2

54. Was this work full-time, part time, day labor or some combination? How long have you worked this job/ these jobs and how many hours on average per week do you work? (Interviewer: circle all categories that respondent says apply.)

Full-time (length of employment: ______hours per week: ______) ...... 1 Appendices

Part-time (length of employment: ______hours per week: ______) ...... 2 |

Day labor (length of employment: ______hours per week: ______) ...... 3 66 Other (specify: ______/ length of employment: ______hours/week: ______) ...... 4 Don’t know ...... -1 Refuse ...... -2

55. About how much did you earn from this job/these jobs over the last 30 days? | ____ | ____ | ____ | ____ | Don’t know ...... -1 Refuse ...... -2 (If working a full-time or part-time job, skip to question 59)

56. When did you last work at a job for which you received a regular paycheck?

Within the past 12 months (Specify the month ______) ...... 1 One to five years ago ...... 2 More than five years ago ...... 3 Never held a regular job ...... 4 Don’t know ...... -1 Refuse ...... -2

57. Are you currently looking for a regular job?

Yes, looking (Skip to question 59) ...... 1 No, not looking ...... 2 Don’t know (Skip to question 59) ...... -1 Refuse (Skip to question 59) ...... -2

f RETURN TO CONTENTS f 60. 59. Now, letmeaskyou aboutthevarious ways you’ve gottenmoney orthingsyou neededinthepastmonth, 58. Homelessness inOrange County: The Coststo OurCommunity

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In schoolortraining program Refuse Which ofthesehasbeeny Refuse Don’t know None ofthe above (Skip to question62) Other (specify:______) Worker’s comp Veteran’s benefits Unemployment insurance Pension Social Security SSI/SSDI Food stamps General assistance Sex formoney Selling ordelivering drugs Alimony and/orchildsupport Money from familymembersand/orfriends Panhandling Signing orflyingsigns–e.g.“Will Work For Food” Selling personalbelongings/junk Selling cans/recycling Selling newspapers Selling blood/plasma from anyofthefollowingsources? from regular payingapart jobsand/orday labor. Inthelast30days, have you received incomeorsupport Refuse Don’t know Other (specify______) Stay athomeparent Believe noworkavailable Personal/family reasons Don’t want/need to work Disabled/health problem What isthemainr Don’t know writeinthenumberofrespondent’s(Interviewer: selection.) ...... eason you are notlookingforaregular job? ...... our most important source of income or support in the last 30 days? | ____ | ____ | inthe last30days? |____ source ofincomeorsupport our mostimportant . . . (Interviewer: showrespondent (Interviewer: list.Circle allthatapply.) ...... (Interviewer: circle(Interviewer: one) 18 17 16 15 14 13 12 11 10 20 19 -2 -2 -2 -1 -1 -1 2 1 7 6 5 4 3 2 1 9 8 7 6 5 4 3

67 | Appendices f did you firstmoveyear 66. Inwhat to theUnitedStates?|____ were you65. Inwhatcountry born? ere you borninthe UnitedStates? 64. very important, somewhat important, ifatall,isyournot religious faithtoit ow important, you? Is 63. 62. Before wefinish,want to ask you a few finalquestionsabout yourself. Demographics Continued 61. About howmuchdidyou earnfrom these othersources ofincome over thelast30days? Homelessness inOrange County: The Coststo OurCommunity

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Refuse Don’t know (______) Specify country: Refuse Don’t know No Yes W Refuse Don’t know thananythingelse More important Very important Somewhat important Not important thananything else? ormore important important H Refuse Don’t know Other (______) Muslim Hindu Buddhist Jewish Other Christian(______) Catholic Protestant (suchasAssembly ofGod,Baptist,Lutheran, Methodist,Presbyterian, etc.) None/atheist/agnostic What isy Refuse Don’t know | ____ . .

(End ofinterview) ...... (End ofinterview) . . our present religion? . . . . . (End ofinterview) . . . . . (Skip to question 64) ...... -2 -2 -2 -2 -2 -1 -1 -1 -1 -1 6 5 4 3 2 1 1 2 1 4 3 2 1 9 8 7

68 | Appendices f R-1 Comments: Observations: Interviewer 67. Are you aU.S.citizen, alegalpermanentresident, arefugee, beengranted asylum,onavisa Homelessness inOrange County: The Coststo OurCommunity

RETURN TOCONTENTS Refuse Don’t know Neither On avisa Granted asylum Refugee resident withagreen cardpermanent Legal U.S. citizen or noneofthese? ......

-2 -1 6 5 4 3 2 1

69 | Appendices f er 1994,pp.,478-480; Tobin andMurphy2016, or discussionofthemaximumvariation sampling ermanian BusinessandEconomic Instituteat laming, Burns,andMatsunaga 2009. laming, Toros, andBurns2015. o notethisisnotto disparage thePIT countsor figure fromoverty Orange CommunityIndicators (2016,p.18)and ange basedonPricereport or anoverview ofthehomelessnessproblem across esearch wasconductedwiththeapproval ofUCI’s Homelessness inOrange County: The Coststo OurCommunity 14 13 12 11 10 9 8 7 6 5 4 3 2 1

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PLNU 2016. See Bak homelessness, seeSnowandAnderson 1993,p.22. For anearlierapplicationofthestrategy to studying strategy, seeErlandsonetal.1993;Lofland2006. F F United W F City ofSacr F cover a12-month period. analysis, theanchoryear was2015,andallbudgets it is2015/2016.However, throughout theresearch and data covers the2014/2015fiscal year, andforthecounty availability ofthebudgetdata. Thus, themunicipality is thefiscal year. There isalsosome variability inthe cycle; forsomeitisthecalendaryear, andforothersit institutions/organizations are onthe samebudget It isimpor forthehomeless. of services for various policyconsiderations regarding theprovision investigating trends over time,andtherefore are useful for assessingthescopeofhomelessnesslocallyand estimates, forthey provide auseful,bi-annualbaseline T adjusted forthehighcostofhousingincounty. estimatesforOrangepoverty Countybecauseitis Project (2015,p.3). This rate ishigherthanthefederal P (2015). Collins article Rental r Wright 2010. ofsocialscienceresearch,summary seeLee, Tyler, and 2016.For over a the country thepast30+years, seeBurt F Institutional Review Board (IRBHS# 2016-2994). The r physical illnessordisability. or developmental disability, alcoholordrugs,chronic because ofaseriousmentalillness,PTSD, brain injury to another, workingorjustgettingthrough theday longer andwhohave difficultiesgettingfrom oneplace Individuals whoha FOOTNOTES p. 33;andLee, Tyler, andWright 2010,p.505. ay ofGreater LosAngeles2009. tant to notehere thatnotallsurveyed amento 2015. ve beenhomelessforayear or

ange CountyCommunityIndicators Project. 2015,p.2. , thisishardly asurprising finding,asonestudy lthough there are various conceptualizations ofsocial Tobin of andMurphy2016,p35;U.S.Department etal. 2001; Tobiner 1994;Burt andMurphy2016, 19 16 15 23 22 21 20 18 17

turnover rate. foradvancement andhave ahigh limited opportunity are generally lowinpay, prestige andsecurity, offer Or (See Table 1.1,pp.32-33). averagedcountry betweenalowof33andhigh40. the average ageofhomeless in eightcitiesacross the that For example,SnowandAnderson (1993)report older thanthehomelessofmid1980sand1990s. it appears thatthehomelessoftoday are somewhat when thehomelessofpast35years are compared, that thecurrent wave issomewhatyounger. However, with thoseofthe1950sandearlier, there isnoquestion When thecurrent wave ofhomelessare compared of the1950sascomparative point ofreference. beginning inthemid-1980suseSkidRowresidents Most discussionsoftheagestructur Montez 2010. See, forexample,Cohen2004,andUmberson social connectionsonbothmentalandphysicalhealth. and publichealth)underscores thesalubriouseffects of after anotheracross fields(e.g.,sociology, psychology Clearly concept andrelated research. (2001)foranexpandeddiscussionofthe and Burt networks thathave productive benefits.SeeLin,Cook, capital, mostdefinitionsfocusonsocial relations and A but wassubmittedforatotal of$9.6 million. through December2020.Phase2hasyet to beawarded for $23.5millionaperiodbeginningNovember 2017 more efficientandeffective useof resources. Phase1is of improved healthandwell-beingthrough beneficiary applicable, inapatient-centered mannerwiththegoals of health,behavioral as healthandsocialservices, Whole Person Care focusesonthecoordination mentally illwhomay alsobeexperiencinghomelessness. that are experiencinghomelessness andtheseriously State ofCaliforniato provide targeted to services those The WholeP Housing andUrbanDevelopment 2014. See The secondar pp 33-34. See Bak See, forexample,Bak erson Care Initiative isfundedthrough the y labormarket encompassesjobsthat er 1994, Table 2,pp484-485. e of the homeless e ofthehomeless

70 | Footnotes f or discussionandanalysisoftheday laborandtheday 26 s ofmid-2015,Orange to have Countywasreported “the 25 or anup-closediscussionoftheexperienceandeffects 24 Homelessness inOrange County: The Coststo OurCommunity 27

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Shadowworkisaconceptcoinedb A F

and Bartley 2004. and Bartley 2006;Roberts labor industry, andRoberts seeBartley F Anderson 1993,p146). andinnovative nature”its highlyopportunistic (Snowand wage laboreconomy, shadowworkischaracterized by unofficial, unenumerated workexistingoutsideofthe provide amore reliable being meansofsurvival….Besides assistance isinsufficient,orbecausesuchstrategies markets failsto provide alivingwage,becausepublic inthose existing labormarkets, becauseparticipation more conventional workbecauseofexclusion from that are fashionedandpursuedintheshadowsof In theirusage,itencompasses“subsistence strategies situation ofhomelessby SnowandAnderson (1993). (1981), butthetermwasadaptedandappliedto the social criticIvan Illichinhisbookbearingthattitle areas” (Collins2015). seventh-highest askingrent among82large U.S.metro of housingeviction, seeDesmond’s Evicted (2016). y philosopher and y philosopherand ection ofthesefindingsisconsistentwith 30 29 28

Gladwell (Kimand inpatient services Tan 2016). had beenheavy usersofthehospital’s emergency and Care housing)who (similarto permanentsupportive chronically homelessintheFoundation’s Recuperative a tremendous costsavings wasrealized by housing38 Illumination Foundation andSt.JosephHospital, wherein also consistentwithapilotstudyconductedby the magnitude. Locally, theestimatedcostsavings is Institute atPLNU2016),althoughwithvariation in 2015) andSanDiego(Fermanian Business&Economic (Flaming etal.2009),theSiliconValley (Flaming etal. previously mentionedcoststudiesinLosAngeles other coststudiesthroughout thestate,suchas The dir it assumesthatthehousingstock already exists. costs ofbuildingnewhousingfacilities.Inotherwords, housing,andnottheone-time permanent supportive This estimateincludesonlythepr 2006. ogram costsof

71 | Footnotes