Meeting the Service Needs of Homeless People and Communities

Introduction

Researchers and homeless assistance providers have long recognized that serving homeless people requires more than simply providing a daily shelter. Rather, it requires additional services that address both immediate needs, such as emergency housing and food provision, as well as those more pervasive issues that can lead individuals into unstable living situations, including mental illness and domestic abuse. The services that communities provide to their homeless citizens, however, can be inadequate due to limited resources or minimal coordination among service providers. These limitations are particularly apparent in rural areas where service providers are responsible for large geographic areas and have few resources at their disposal. In an effort to help communities overcome the challenges of serving the homeless, HUD's Continuum of Care approach recognizes the benefits of - and provides incentives for - greater coordination among housing and homeless service providers.

This issue of URM looks at recent research on how communities are providing services to their homeless citizens and the positive fiscal impacts that can result from greater coordination among providers within a locality. The first study, "Evaluation of Continuums of Care for Homeless People," assesses the Continuum of Care approach, wherein communities plan and develop integrated service systems to meet a variety of homeless needs. The second study, "Public Service Reductions Associated with Placement of Homeless Persons with Severe Mental Illness in Supportive Housing," presents research demonstrating the cost savings associated with supportive housing and its effectiveness in increasing housing stability for homeless people with severe mental illness. The final report, "Hard to Reach: Rural Homelessness and Health Care," describes the causes of rural homelessness and how the health care issues of the rural homeless differ from those in urban areas.

Continuum of Care Increases Service Coordination

In an effort to encourage communities to take a more holistic approach to the provision of homeless services and to streamline existing competitive funding and grant-making under the McKinney-Vento Homeless Assistance Act, HUD introduced the Continuum of Care (CoC) approach in 1995. As essentially local systems, CoCs provide housing and services appropriate to the whole range of homeless needs in the community. No two CoCs are identical; each is developed to meet the unique needs of their local community. A recently completed HUD-sponsored study, "Evaluation of Continuums of Care for Homeless People," presents an evaluation of this approach - particularly the processes that localities have established for the planning, developing, implementing, and monitoring of CoCs - and the impact of these integrated systems on the provision of homeless services.

The study analyzed 25 of the more than 300 applicants for HUD CoC funding with the sample deliberately skewed toward high-performing communities and those with unique components that could provide lessons for other CoCs. The final report, published in May 2002, focused on the impact of HUD's funding requirements on the planning and coordination of services, the configuration of service structures, access to services, involvement of mainstream agencies, and progress toward establishing a viable Homeless Management Information System (HMIS).

The study reveals several interesting results. First, there is some consistency across CoC structures with most of the 25 communities in the study adopting a single system covering a locally defined area and including a variety of service components. Second, each community took a slightly different approach to the intake of homeless individuals with some allowing access to the system through any service provider, while others establish a more centralized system by allowing access to the network through only one or a few providers. Similarly, the CoCs presented a range of involvement with mainstream services - such as mental health providers, substance abuse programs, Temporary Assistance to Needy Families (TANF), or veterans programs - with minimal coordination being the norm. Finally, the study identified a range in planning that communities conducted in response to HUD's CoC approach. The analysis suggests that appropriate planning is a key determinant in a community's capacity to meet the constantly changing needs of its homeless population and to increase its ability to be more flexible in the years to come.

Cost Savings through Supportive Housing

While the CoC study presents an analysis of how communities are planning to more effectively integrate homeless services, recent research by Culhane, Metraux, and Hadley provides new information on the cost savings associated with increased service utilization. This report, entitled "Public Service Reductions Associated with Placement of Homeless Persons with Severe Mental Illness in Supportive Housing," examines a supportive housing program provided through an initiative funded by the City of New York and New York State (NY/NY) targeted to homeless people with severe mental illness (SMI). The program provides either scattered-site or single-room occupancy (SRO) housing combined with support from community-based services or community residence facilities that deliver services on site.

This study utilized administrative data from public health, psychiatric, criminal justice, and shelter service providers to assess the aggregate level of service demand before and after the individuals were placed into the supportive housing program and for a matched set of controls. The study tracked the service use of each individual for a two-year period before program placement and for two years thereafter.

The study showed that the placement of homeless individuals with SMI in supportive housing is associated with a substantial reduction in homelessness. These homeless individuals experienced both a decreased need for shelters as well as a significant reduction in hospitalizations, length of stay per hospitalization, and time incarcerated. Cost savings based on their decreased use of these services were also apparent. Before placement, homeless people with SMI used about $40,451 per person per year in services (1999 dollars). Placement was associated with a reduction in service use of $16,281 per housing unit per year. Annual unit costs for placement are estimated at $17,277 for a net cost of $995 per unit per year over the first two years.

It is important to note that this study was able to quantify for the first time the extent of service use by homeless people with severe mental illness before a housing placement. Moreover, this study provides a foundation from which future research can be conducted to look more closely at the effects of various housing types on patterns of service use.

Barriers to Health Services in Rural Communities

The array of public services used by homeless people in New York stands in stark contrast to the limited homeless services available in rural areas that are discussed in the National Health Care for the Homeless report entitled "Hard to Reach: Rural Homelessness and Health Care." Data from a variety of sources are used to provide background information about the causes of rural homelessness and the different healthcare services that the rural homeless require. This paper is focused on insights gleaned from interviews with rural service providers in 17 states.

Homeless people in rural areas face a limited availability of types and levels of healthcare services. The interviews reveal that although similar chronic health conditions are observed in both urban and rural homeless patients, the rural homeless are more likely to delay medical attention, with their illnesses becoming more advanced as a result. The study finds that rural homeless people face three major barriers to receiving adequate healthcare:

• A lack of transportation, which prevents many people from reaching services, especially for illnesses that require regular treatment.
  
• A lack of medical insurance, especially for those without Medicaid assistance.
  
• A lack of services, particularly in small communities where they already face a shortage of healthcare providers.

The report notes that many communities simply are not large enough to warrant services targeted specifically to the homeless and recommends that localities develop strategies to ensure that service needs are adequately addressed.

In summation, the new research on homeless issues discussed in this issue of URM lends encouragement to the current trend in many communities to integrate service provision and create systems that more effectively and efficiently meet the needs of the homeless. Moreover, this work provides a basis from which additional research can be conducted that looks more closely at the impact that different types of organizational structures created to streamline service provision have had on reducing the incidence of homelessness in our communities.