Homelessness and Substance Abuse: SAMHSA–CSAT Response

Homelessness and Substance Abuse: SAMHSA–CSAT Response

H. Westley Clark, MD, JD, MPH, CAS, FASAM Director

Center for Substance Abuse TreatmentSubstance Abuse and Mental Health Services Administration

U.S. Department of Health and Human Services

Oakland, CA, February 8, 2007

The Substance Abuse and Mental Health Services Administration (SAMHSA) is one of eleven grant-making agencies of the U.S. Department of Health and Human Services, with a budget of approximately 3 billion dollars.

SAMHSA

• Vision: A life in the community for everyone

• Mission: Building resiliency and facilitating recovery

SAMHSA’s Three Centers

• The Center for Mental Health Services (CMHS)

• The Center for Substance Abuse Prevention (CSAP)

• The Center for Substance Abuse Treatment (CSAT)

Substance Abuse, Co-Occurring Disorders,

and Family Homelessness

Cities Participating in the US Conference of Mayors Hunger and Homelessness Survey

• Boston• Charleston• Charlotte• Chicago• Cleveland• Denver• Des Moines• Detroit• Kansas City• Los Angeles• Louisville Metro• Miami

• Nashville• Norfolk• Philadelphia• Phoenix• Portland• Salt Lake City• San Francisco• Santa Monica• Seattle• St. Paul• Trenton

The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006

A Portrait of Homelessness

Asian2%

Hispanic13%

White39% Native-

American4%

African-American

42%



Unaccompanied Youth2%Families with

Children30%

Single Women17%

Single Men51%



26

16

0

5

10

15

20

25

30

Mentally Ill Substance Abusers


Percentage

Children & Families: Homelessness• 71% of homeless families were headed by single

parents.• Children represented 24 percent of the entire

population in emergency shelters in the cities.• 87% of the surveyed 23 cities reported that there was

an increase in homeless children in the emergency shelter system.

• The average percentage of members of homeless families who are children in the survey cities is 55%.


Main Causes of Homelessness

• Mental illness and the lack of needed services

• Lack of affordable housing

• Substance abuse and the lack of needed services

• Jobs• Domestic violence• Prisoner re-entry• Unemployment• Poverty

Factors associated with homelessness are diverse, complex and interrelated. Causes identified by the survey cities include:


18 Survey Cities Identified Mental Illness and the lack of needed services as a Major Cause of Homelessness

• Boston• Charleston• Chicago• Cleveland• Denver• Los Angeles• Louisville Metro• Miami• Nashville

• Norfolk• Phoenix• Portland• Salt Lake City• San Francisco• Santa Monica• Seattle• St. Paul• Trenton


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√ Receives a SAMHSA Grant in this area

16 Survey Cities Identified Substance Abuse and the lack of needed services as a Primary Cause of

Homelessness• Chicago• Cleveland• Los Angeles• Louisville Metro• Miami• Nashville• Norfolk• Philadelphia

• Phoenix• Portland• Salt Lake City• San Francisco• Santa Monica• Seattle• St. Paul• Trenton


√ Receives a SAMHSA Grant in this area

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17 Survey Cities Identified Lack of Affordable Housing as a Main Cause of Homelessness

• Boston• Charleston• Cleveland• Denver• Des Moines• Los Angeles• Louisville Metro• Miami

• Philadelphia• Phoenix• Portland• Salt Lake City• San Francisco• Santa Monica• Seattle• St. Paul• Trenton


13 Survey Cities Identified Low-paying Jobs as a Main Cause of Homelessness

• Boston• Chicago• Cleveland• Denver• Louisville Metro• Norfolk

• Philadelphia• Phoenix• Portland• Salt Lake City• San Francisco• St. Paul• Trenton


Seven Survey Cities Identified Domestic Violence or Prisoner Re-Entry as a Cause of homelessness

Domestic Violence• Charleston• Chicago• Kansas City• Los Angeles• Salt Lake City• San Francisco• Seattle

Prisoner Re-Entry• Boston• Cleveland• Denver• Los Angeles• Louisville Metro• Phoenix• San Francisco


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√

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√Receives a SAMHSA Grant in this area

Five Survey Cities Identified Unemployment or Poverty as a Main Cause of homelessness

Unemployment• Charleston• Chicago• Denver• Des Moines• Los Angeles

Poverty• Cleveland• Phoenix• Seattle• St. Paul• Trenton


What do we know about homelessness?

The December 2006 report from the U.S. Conference of Mayors cites trends in utilization of services (2005–2006, based on reports from 23 cities) and estimates the unmet needs of homeless persons and families. It finds:

– Overall, requests for emergency shelter beds increased in 68 percent of the cities surveyed (p. 50).

– 23 percent of general emergency shelter requests are unmet and 29 percent of family shelter requests are unmet (p.59).

– 86 percent of the cities surveyed report that families have been turned

away from shelters due to a lack of resources (p. 59).

Hunger and Homelessness: A Status Report on Hunger and Homelessness in America’s Cities (2006). U.S. Conference of Mayors. www.usmayors.org/uscm/hungersurvey/2006/report06.pdf


Through the Continuum of Care (CoC) planning process, we know that about 744,313 persons were homeless in January 2005. These data are taken from a 2007 report by the National Alliance to End Homelessness, which compiled statistics from 463 CoC point-in-time counts.

www.naeh.org


• 41 percent, or 303,551, of the homeless population counted in January 2005 were persons in families with children.

• Nearly half (44%) of the homeless persons identified in January 2005 were unsheltered.

• 23 percent (171,192) of those in the January 2005 count were chronically homeless.

Homelessness Counts (2007). National Alliance to End Homelessness. www.naeh.org


• The statistics presented here are based on point-in-time counts.

• “The reality is that the homeless population is quite fluid—people move in and out of homelessness and most are homeless for short periods of time. [It is estimated] that between 2.3 and 3.5 million people each year experience homelessness” (p. 9).

Homelessness Counts (2007). National Alliance to End Homelessness. www.naeh.org

What do we know about substance abuse?

• In 2005, an estimated 22.2 million persons aged 12 or older were classified with substance dependence or abuse in the past year (9.1% of the population aged 12 or older).

• Of these, 3.3 million were classified as dependent on or abusing both alcohol and illicit drugs, 3.6 million were dependent on or abused illicit drugs but not alcohol, and 15.4 million were dependent on or abused alcohol, but not illicit drugs.

Results from the 2005 National Survey on Drug Use and Health: National Findings (NSDUH). SAMHSA, Office of Applied Studies (2006).

oas.samhsa.gov/NSDUH/2k5NSDUH/2k5results.htm

What do we know about co-occurring disorders?

• Co-occurring disorders are common. At least 5.2 million Americans 18 years of age and older have substance use disorders and serious psychological distress.

• Co-occurring disorders are complex. Often, people have multiple, interactive conditions that complicate their treatment and recovery.

• Co-occurring disorders are often not treated. Nearly half of people with co-occurring disorders receive no treatment for either disorder and only 6 percent receive treatment for both.

What do we know about co-occurring disorders?

• People with co-occurring disorders can and do recover.

• Prevention of co-occurring disorders is both necessary and effective. This is especially true for children with serious emotional disturbance who are at heightened risk for substance abuse.

• Evidence-based practices—including integrated treatment for the most serious disorders—improve outcomes.

• System-level changes are often needed to support innovative services.

Co-Occurrence of Serious Psychological Distress (SPD) and Substance Use Disorders

Among Adults, Aged 18 or Older: 2005

22.2 Million 24.6

Million

Co-OccurringDisorders

Substance Use

Disorder

SPD5.2

Million

* NSDUH 2005

1 Blueprint for Change, 2003. CMHS, SAMHSA.2 The DASIS Report: Characteristics of Homeless Female Admissions to Substance Abuse Treatment, 2002. Drug and Alcohol Services Information System (DASIS), SAMHSA, OAS. 3 The DASIS Report: Characteristics of Homeless Admissions to Substance Abuse Treatment, 2000. Drug and Alcohol Services Information System (DASIS), SAMHSA, OAS.

What do we know about substance abuse and homelessness?

• Half of all homeless adults have substance use disorders.1

• 13 percent of those in substance abuse treatment were homeless at the time of admission (up from 10% in 2000).2

• More than 120,000 people admitted for substance abuse treatment are homeless at the time of admission.3

What do we know about mental illness and homelessness?

• Approximately 20–25 percent of single adults who are homeless have a serious mental illness.1

• As many as two-thirds of all people with serious mental illnesses have experienced homelessness or have been at risk of homelessness at some point in their lives.2

• 20 percent of State prison inmates, 19 percent of Federal prison inmates, and 30 percent of local jail inmates with mental illnesses were homeless in the year before their arrest.2

1 National Resource Center on Homelessness and Mental Illness2 Blueprint for Change. CMHS, SAMHSA, 2003

What do we know about co-occurring disorders and homelessness?

• Nearly one-quarter of homeless persons admitted for substance abuse treatment had co-occurring disorders.1

• Among homeless veterans, one-third to one-half have co-occurring mental illnesses and substance use disorders.2

• Among detainees with mental illnesses, 72 percent also have a co-occurring substance use disorder.2

1 The DASIS Report: Characteristics of Homeless Admissions to Substance Abuse Treatment, 2000. Drug and Alcohol Services Information System (DASIS), SAMHSA, OAS.2 Blueprint for Change. CMHS, SAMHSA, 2003

What do we know about family homelessness?

• 50 percent are homeless for first time• 25 percent are homeless more than a year, half in

transitional housing • 29 percent were homeless for first time before age 18• 25 percent experienced out-of-home placement before age

18• Family homelessness is expensive. The average annual cost

of shelter for a homeless family in NYC is $25,000 per year (NYC Master Panel Report, 2003, p. 51)

• 29 percent of family requests for shelter went unmet in 2006 (U.S. Conference of Mayors, 2006)

*Unless otherwise indicated, data are from Burt et al., 2001. Based on women with children.

What do we know about homeless families?

• 84 percent are single mothers

• Average age: late 20s• Average 2–3 children, most under age

6

• 66 percent are women of color (African American, 44%; Latina, 16%; Native American, 6%)

Health Care Needs* ofHomeless Families

• 27 percent have no insurance; 67 percent have Medicaid

• 27 percent needed medical treatment in the past year

• 45 percent had one or more chronic health condition

• In one study, 48 percent had at least one family member with a disability or chronic illness (Beyond Shelter, 2003)

*Burt et al., 2001, unless otherwise noted. Based on women with children.

Behavioral Health Needs* of Homeless Families

• 23 percent—Problems with alcohol

• 27 percent—Problems with drugs

• 44 percent—Mental health problems (primarily depression, anxiety, PTSD)

• 58 percent—One or more of the above

*Burt et al., 2001. Based on women with children; self-report of problems within past year.

Experience of Violence*

• 67 percent—Severe childhood physical abuse

• 43 percent—Childhood sexual abuse

• 63 percent—Severe violence by adult intimate partner(s)

*Bassuk et al., 1996. Based on women with children.

Needs of Children

• Homeless children go hungry at twice the rate of other children.

• Nearly 25 percent have witnessed acts of violence in their families, usually against their mother.

• They experience physical and sexual abuse at 2–3 times the rate of other children.

• 22 percent of homeless children spend some time apart from their family in a typical year, with 12 percent placed in foster care.

Needs of Children

Emotional and Behavioral Problems

• 12 percent of preschoolers and 47 percent of school-age children who are homeless have anxiety, depression, withdrawal, and other clinical problems.

• 16 percent of preschoolers have behavior problems, including severe aggression and hostility.

• 36 percent of school-age children exhibit aggressive or delinquent behavior.

Challenges

Homeless individuals with alcohol/substance use disorders pose substantial challenges to the substance abuse treatment community…

Especially those with co-occurring disorders.

Service System Challenges

• Inadequate screening and assessment• Fragmented services• Categorical funding• Lack of discharge planning• Poor integration of care• Other fiscal and coverage limitations

Societal Challenges

• Stigma• Oppression and racism• Discrimination • Poverty• Housing costs• Lack of employment

Treatment Challenges

• Engagement• Retention• Relapse• Interagency collaboration• Needs versus access to services• Treatment philosophies• Policy and financing

Challenges to Successful Engagement

• Social isolation• Distrust of authorities• Mobility• Multiplicity of needs

Meeting the Challenges:Engagement Challenges

• Outreach (aggressive/assertive)• Providing housing or other practical assistance• Creating a safe, nonthreatening environment• Strategies to increase motivation• Family-based treatment engagement strategy• Peer leadership

Meeting the Challenges: Retention

• The challenge of retaining clients in substance abuse and alcohol abuse treatment is intensified when the target population is homeless.

• Dropout rates of two-thirds or more are common.

Meeting the Challenges: Relapse

• Relapse must be considered to be an integral component of treatment.

• Relapses must be used in the treatment as opportunities for growth and change.

• Addiction is a chronic and relapsing condition.• Nonjudgmental intervention is critical for success.• Discharge to the street = relapse.

Successful Approaches: Interagency Collaboration

• Essential to meet multiple needs in a context of scarce community resources

• Highly complex• Necessary to reduce fragmentation of care• Linkage vs. Integrated Treatment—Which is better?

– Research on this question is mostly descriptive – Controlled comparisons are prohibitive

Challenges to Integrating Services

• Well-established programs and a specialized work force

• Interagency turf battles • Funding limitations • Lack of technology and resources to support

information needs • Lack of available services • Size and complexity of the service system • Lack of political will and mechanisms to channel

public support• Legislative and political opposition

“No Wrong Door” Policy

• Each provider should be aware that he/she has the responsibility to address the range of client needs whenever a client presents for care.– Properly refer clients for appropriate care as needed– Follow up on referrals to ensure clients received proper

care

Federal Response to Homelessness

Federal Response to Homelessness

• Targeted Homeless Assistance Programs • Resources• Coordination/Linkages

– Treatment for Homeless Program– Homeless Family Program– Collaborative Initiative to Help End Chronic

Homelessness• Policy Academies• Federal Leadership

Creating a Comprehensive Service System for Homelessness

• Support concept of “No Wrong Door” to services

• Provide services determined by evidence to be effective

• Change ineffective policies or regulations

• Leverage existing resources

• Use mainstream resources

• Pursue new resources

Steps to Achieving a Comprehensive Service System

• Involve key stakeholders

• Establish a formal plan

• Build linkages and partnerships from top-down and bottom-up

• Enhance funding and other resources

• Streamline the administration of funding

• Perform ongoing monitoring and quality assurance

Federal SpendingTargeted Homeless Assistance Programs (Budget Authority in Millions of Dollars)

FY 2005 FY 2006Agency Totals Enacted Enacted

HUD 1,241.0 1,327.0VA 1,642.9 214.6HHS 379.6 380.9USDA 189.6 189.5FEMA 151.8 151.3EDUCATION 62.5 61.9DOL 23.3 24.3ICH 1.4 1.8SSA 8.0 0.0TOTAL 3,700.1 2,593.9

HHS Mainstream Programs (listed alphabetically) FY06 AppropriationAccess to RecoveryCommunity Mental Health Services Block GrantCommunity Services Block GrantConsolidated Health Centers (CHC) Head Start Maternal & Child Health Services Block GrantMedicaid Ryan White CARE Act Social Services Block Grant State Children’s Health Insurance Program Substance Abuse Prevention & Treatment Block Grant Temporary Assistance for Needy Families Total $ for HHS Mainstream Programs

HHS Homeless Specific Service Programs (listed alphabetically)Treatment for Homeless GrantsHealth Care for the Homeless Programs for Runaway & Homeless Youth Projects for Assistance in Transition from HomelessnessSurplus Property/ Title VOther Targeted Homeless ActivitiesTotal $ for HHS Homeless Specific Service Programs

$98$429$630

$1,782$6,786

$693$192,334

$2,063$1,700$5,775$1,759

$17,058$231,107

$34.4$150.0$102.9$54.3

$0$36.1

$377.6

FY ‘06 HHS Funding for Mainstream and Homeless Specific Service Programs Relevant to Homelessness ((dollars in millions)dollars in millions)

* Mainstream programs are designed to serve low-income populations or to address specific health care needs; HHS Homelessness Specific (or targeted programs) are programs designed specifically to serve persons experiencing homelessness

SAMHSA Resources to Address Homelessness (Dollars in Millions)

CMHS 2004 2005 2006PATH $49.8 $54.8 $ 54.2

Treatment for Homeless $ 3.3 $ 6.1 $ 5.8CHI $ 3.6 $ 3.4 $ 3.7Best Practices $ 4.9 $ 2.5 $ 2.6Subtotal $ 61.6 $ 66.8 $ 66.3

CSATTreatment for Homeless $ 29.9 $ 29.7 $ 30.4CHI $ 4.3 $ 4.2 $ 3.6Other $ 0.2 --- $ 0.5Subtotal $34.4 $33.9 $ 34.5TOTAL $96.0 $100.8 $100.8

SAMHSA Resources to Address Homelessness (Dollars in Millions)

CMHS 2006 2007(CR) 2008(Pres)PATH $54.22 54.26 $ 54.26

Homelessness PRNS $ 9.49 $ 8.49 $ 4.42Best Practices $ 2.61 $ 2.61 ---------- Subtotal $ 66.32 $ 65.36 $ 58.68

CSATGrants to Benefit Homeless Individuals

$ 34.52 $ 34.52 $ 32.59

Subtotal $34.52 $34.52 $ 32.59TOTAL $100.84 $99.88 $91.27

Treatment for Homeless Program (CSAT/CMHS)

• Provides services linkages among SA/MH services with housing programs/other services for homeless persons

• Grantees are embedded within an integrated, comprehensive, community-based system

• Grantees conduct followup outcome evaluations

• 137 grants awarded since 2001

• 87 active grantees (23 new grantees were awarded in September 2006)

Treatment for Homeless Awards

Three-Year Grant Period• 17 grants funded for $9.8M in 2001• 19 grants funded for $10.9M in 2002• 14 grants funded for $7.8M in 2003Five-Year Grant Period• 34 grants funded for $13.5M in 2004• 30 grants funded for $11.9M in 2005• 23 grants funded for $9.0M in 2006

TOTAL = 137 $62.9M (first-year awards only)

Number of Treatment for Homeless Grants Funded 2001 to 2006

22CO

10

NM

TX 10

GA

MO

WI

IL IN 1

OHPA 1

NY16

TN 5 5

3

4

6

OR 2

4

3

MI 3

MA 8CT 2

MD 3

DE 1DC 2

3

OK 2

AK 1

AZ 2

FL

WV 1CA

AL 2

NJ 2

WA 1

KY 1

NV 1

SC 1 AR 1

U.S.V.I. 1

Results: GPRA Intake to 6-month Follow-up: All Active Grants N=87

GPRA Measures% at Intake

% at 6-Mth Follow-up

% Change

Increase % of adults receiving services who:Did not use alcohol or illegal drugs 49.6% 71.5% 44.0%

Had no/reduced involvement with CJS 92.1% 96.3% 4.6%

Were currently employed or attending school

14.4% 33.8% 133.9%

Had no alcohol or illegal drug related health consequences

45.7% 57.5% 25.9%

Were socially connected 80.5% 84.5% 5.0%Had a permanent place to live in the community

8.8% 24.2% 173.9%

Results: GPRA Intake to 6-Month Followup: All Active California Grants N=18

GPRA Measures % at Intake

% at 6-Mth Follow-up

% Change

Increase % of adults receiving services who:Did not use alcohol or illegal drugs 44.8% 79.8% 78.0%

Had no/reduced involvement with CJS 90.7% 97.2% 7.2%

Were currently employed or attending school

8.0% 31.4% 292.3%

Had no alcohol or illegal drug-related health consequences

49.4% 71.7% 45.0%

Were socially connected 90.5% 93.4% 3.2%Had a permanent place to live in the community

9.3% 14.3% 54.8%

Homeless Families Program

CSAT/CMHS collaboration• A 5-year knowledge development initiative that

documented and evaluated intervention models targeted to homeless mothers who have psychiatric, substance use, or co-occurring disorders

• This is the first multi-site study to focus on interventions for homeless families in which the mothers have psychiatric and/or substance abuse disorders.

• Conducted in two phases– Phase I began FY 1999; consisted of 14 sites– Phase II began in FY 2001; consisted of 8 sites

Homeless Families Program

• Phase I consisted of cross-site outcome study to explore and describe effective program interventions that: – Reduce homelessness– Increase housing stability– Promote family preservation/reunification – Decrease substance use– Improve mental health– Improve social functioning

• Phase II consisted of site-specific evaluation and cross-site outcome evaluations that provide new knowledge about serving homeless mothers with dependent children.

Homeless Families Program—Preliminary Findings

• Approximately 1,600 women and their families received services

• Psychiatric symptoms among the women declined significantly at 9 and 15 months after entry

• Illegal drug use declined from 25 to 14 percent from baseline to 15 months

Homeless Policy Academies• Purpose: To enhance State capacity to develop

Homelessness Action Plans• Conducted in collaboration with HUD and Departments of

Labor, Education, Justice, Agriculture, Veterans Affairs, and Interagency Council on Homelessness

• High-level stakeholder attendance: State Medicaid directors, substance abuse agencies, providers, community representatives, etc.

• All States have attended as well as D.C., Puerto Rico, U.S. Virgin Islands, Pacific Territories

Homeless Policy Academies

• 9 Academies conducted: 5 focused on chronic homelessness, 4 on families and children

• Two mini-Policy Academies for the Pacific Basin focusing on individuals and families with children who are homeless were convened in Pago Pago, American Samoa, and in Tumon, Guam (with a team from the Commonwealth of the Northern Mariana Islands participating)

• An In-State Policy Academy focusing on chronic homelessness was convened in Olympia, Washington

• State and Territory Action Plans can be viewed at http://www.hrsa.gov/homeless

SAMHSA/CSAT Information

• www.samhsa.gov• SHIN 1-800-729-6686 for publication ordering

or information on funding opportunities– 800-487-4889 – TDD line

• 1-800-662-HELP – SAMHSA’s National Helpline (average # of tx calls per mo.- 24,000)

Questions & Answers

Documents

Homelessness and Substance Abuse: SAMHSA–CSAT Response