Approaches to Primary and Secondary Prevention of Homelessness

Martha R. Burt, Urban InstituteCarol Pearson, Walter R. McDonald &

Assoc.COHHIO Annual Conference, April 15,

2008

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Strategies for Preventing Homelessness

• Looking first at people with SPMI, second at families

• Based on “Strategies for Preventing Homelessness,” Burt, M.R., Pearson, C., and Montgomery, A.E. (see www.urban.org or www.huduser.org).

• Conducted by Walter R. McDonald & Associates, Inc. and the Urban Institute

• Conducted from October 2003 through April 2005

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What are primary and secondary homeless prevention strategies?

• Primary prevention strategies:– Prevent new cases of homelessness and stop people

from ever becoming homeless

• Secondary prevention strategies:– Focus on intervening early during a first spell of

homelessness to help the person leave homelessness and not return

• Tertiary prevention strategies:– Seek to end long-term homelessness, thus preventing

continued homelessness

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What makes a good prevention strategy?

• Identify risk factors for homelessness– Improves odds of designing effective

interventions– Research identifies antecedents, but hard for

communities to eliminate risk factors– Communities can use knowledge of risk factors

to screen individuals or families for high homelessness risk to target resources toward those at highest risk

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Creating effective prevention strategies

– Offer effective prevention activities efficiently

– Effective activities stop homelessness (primary prevention) or end it quickly (secondary prevention)

– Efficient systems target well, delivering effective activities to people most likely to become homeless without help

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Approach: Field Research

• Identify communities with:– Conscious, organized, community-wide prevention

approach AND – Data to document the effects of prevention efforts in

reduced or avoided homelessness • Describe these strategies and component activities• Review community data that:

– Measure achievements in preventing homelessness– Provide evidence that prevention activities were

effective

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Approach: Field Research

• Conducted canvass to identify six communities that met the study criteria reasonably well, but

• We found very few such communities, despite considerable effort– The “have data” criterion was the real killer– But it was not that easy to identify communities that

had thought through and were executing a systematic community-wide effort, either

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Communities Highlighted For This Talk

• Massachusetts, and DMH in particular, to examine efforts to prevent homelessness for people with severe and persistent mental illness (SPMI)

• Hennepin County, Minnesota, to examine family homelessness prevention efforts

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Limitations of the Data Available from Study Sites

• None of the communities in our study had a control or even a comparison group, with one small exception (Mass. DMH - Tenancy Preservation Project)

• One had time series data (Mass. DMH)• All the family sites and one of the SPMI sites had

the ability to see whether the people who received prevention assistance showed up later in their homeless programs—but only one routinely did so (Hennepin County, MN)

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Massachusetts DMH Prevention Efforts for Its SPMI Clients

• ~48,000 people with SPMI in Massachusetts

• DMH serves the poorest and neediest—average income around 15% of poverty level

• 2 decades of focus on preventing homelessness among DMH clients and people who are DMH eligible, even if not already clients

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Massachusetts DMH Prevention Efforts for Its SPMI Clients

• State funding specifically for purpose—Special Homelessness Initiative (HI)—– Began in SFY 1992 at $1 million– Has been about $22-24 million a year for the past 5 or 6

years. “Do what it takes” flexible funds– Urban Institute recently completed a 3-stage larger-scale

evaluation of HI’s impact, so information for this talk comes from both studies

• This is on top of basic departmental budget that had begun to shift toward community-based residential and support options several years before HI

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Massachusetts DMH Prevention Efforts for Its SPMI Clients

• Key element—Housing development– From about 2,700 units of community housing in 1991

to over 7,600 in 2005, and increasing– From mostly group homes to mostly independent and

semi-independent living– New Safe Havens and beginning direct access to

housing

• Key element—community supports– Strong ACT, Clubhouse, employment, peer-to-peer,

and other supports for maintaining housing

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Massachusetts DMH Prevention Efforts for Its SPMI Clients

• Key element—recognition that “housing is a clinical issue;”

• Doing the ongoing staff training that is needed to shift a largely clinical endeavor to including housing status as a matter of their concern

• Developing thorough discharge planning protocols and assuring that the housing would exist to make them likely to succeed

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Figure 1: Growth in DMH Residential Housing Capacity and Affiliated Housing Statewide, and Metro Boston Capacity

SFY 1991-2004

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1000

2000

3000

4000

5000

6000

7000

8000

9000

19911992199319941995199619971998199920002001200220032004

Capacity, in Beds (People)

Growth in DMH Community Housing Capacity

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Reduced Proportion Homeless at Admission and Discharge

• Due in part to deliberate and sustained efforts to increase housing capacity and supportive services, – Reduced the proportion of people being admitted to

state continuing care facilities who were homeless

– Reduced the proportion of people being discharged to homelessness from state continuing care facilities

– True over and above drastic drop in overall admission levels due to hospital closures

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Figure 2: Changes in proportions of homeless admissions and discharges to all admissions, statewide in DMH

continuing care units excluding Metro Boston, 1993-2003

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2

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10

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Percentages

HL admits/all admits 8.9 9.9 9.8 7.9 7.5 7.7 7.1 8.5 6 3.7 1.9

HL discharges/all admits 1.7 2.5 1.3 2.2 0.4 0.6 0.3 1.4 1 0.6 0.7

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Reduced Proportion Homeless at Admission and Discharge

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Figure 3: Changes in statewide DMH community residential capacity,

in 1,000s of people, compared to changes in homeless admissions and discharges as a percentage of all admissions to DMH continuing care

units excluding Metro Boston, 1991-2003

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2

4

6

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"Capacity" in 1,000s of people;

others in percentages

% Homeless at Admission and Discharge in Relation to Housing Capacity Growth

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Special Case: Tenancy Preservation Project

• DMH contracts with CBO to work with local housing courts, to prevent evictions of people with behavioral health problems

• 51% tenancy preserved, compared with 24% for people waitlisted and never served—and probably none of the latter moved to alternative housing.

Tenancy Preserved Moved to Alternative Housing Became Homeless All cases served and closed by TPP (n=366) 51 34 15 By Diagnosis Mental health (n=202) Substance abuse (n=43) Dual Diagnosis (n=83) Elder or Cognitive (n=24) Other (n=13)

55 51 37 71 38

32 37 35 21 62

13 12 28 8 0

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Massachusetts DMH Prevention Efforts for Its SPMI Clients

• So, against ideal prevention research design, Massachusetts– Doesn’t have a true control group; only TPP could

generate a comparison group– But does have change over time in homelessness tracked

against changes in housing capacity—not perfect, but suggestive

– Targeting is probably pretty good, as housing basically goes to people who have no other viable housing alternatives—and DMH does search for those alternatives

– TPP targeting is to people with a filed eviction action

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Hennepin County’s Rapid Exit (RE) Strategy for Families

• Background : – 1993, HSD/MHFA created Family Homeless

Prevention and Assistance Program (FHPAP) legislation

– FHPAP provides flexible outcome-based funding – 2001 crisis level increase in homeless families

led to creation of screening, admission, and rapid exit system

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Homelessness Prevention for Families

• Operates through 17 nonprofit agencies

• Offers emergency assistance and other services

• Criteria for receiving help funded by FHPAP are uniform

• Organized by geographical catchment area

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Key Elements of Rapid Exit (RE) Strategy

• Screening and Diversion– Established priorities for families to be placed in

shelter– Screened families to be placed in shelter to

determine on greatest need, literal homelessness– Increased number of families able to secure

alternative housing

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Key Elements of Rapid Exit (RE) Strategy

• Rapid Exit Coordinator/Screener assesses housing barrier levels (4):

• Level 1: No Barriers except economic ones

• Level 2a: Has some of the following barriers:– No rental history – No HS/GED – Physical Dis – HH < 18

– No more than one eviction –– No criminal – No drug/alch

• Level 2b: Has some of the following barriers:– Up to 3 evictions – DV – recent minor drug, crim, jail hist

– Mild beh probs – No current CD – Male teen – Open CPS

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Key Elements of Rapid Exit (RE) Strategy

• Housing barrier levels assessment (cont.):– Level 3: Has some of the following barriers:

• Actively using drugs

• Recent serious criminal history

• Adult with severe behavior problems

• Current sexual abuse in the family unit

• 4 or more evictions

• Current battering with the abuser in the family unit

• Children with severe behavior problems

• Has recent record of property damage to rental housing

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Key Elements of Rapid Exit (RE) Strategy

– Separating sheltering and “move ‘em out” casework/supportive services

– Conditioning continued shelter stay on progress toward exit (vouchered three days at a time)

– Casework agency performance is monitored contract renewal depends on performance

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Changes in Hennepin County Family ES Outcomes

• Cut average shelter LOS by one-half (from almost 60 days to approximately 30 days)

• Eliminated use of motels• Reduced the number of families in shelter

from 317 to fewer than 116 at any given time• Reserves shelter resources for families with

the most serious housing barriers (Level 2b and lower Level 3).

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Client Difficulty of Families Admitted to Shelter

• Has changed drastically from 1995, when concerted efforts began, to 2003

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Change in Housing Barriers of Sheltered Families Barrier Level 1995 1998 2003

Level 1—No/few barriers 15% 0% 0% Level 2a—A few barriers 40% 43% 2% Level 2b—Many barriers 40% 44% 70% Level 3—Most serious barriers 5% 13% 28% Source: Hennepin County, MN, FHPAP Annual Report for SFY 2003, page 14

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Outcome—Return to Shelter

• Family prevention—95 percent of families did not use shelter within 12 months; 5 percent did (based on 1,170 families receiving assistance)

• Family rapid exit from shelter—88 percent did not return to shelter within 12 months; 12 percent did (based on 1,024 families using shelter)– That’s WITHOUT a subsidy

• Family transitional housing—96 percent did not return to shelter within 12 months after their case was closed; 4 percent did (based on 47 families).

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Documenting Prevention Effectiveness

• Matching against shelter records

• Changes over time documented within a single database

• Special data collection/longitudinal follow-up

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Discussion: Implications for Policy and Practice

• Offer only prevention activities that research documents as effective

• Services should be targeted• Organize the community• Develop data systems that reflect and

improve system performance