Ending Chronic Homelessness

07/24/2015

Born and raised in Martinsburg, West Virginia, Robert M. was doing okay until he was laid off from his job at a book factory. Without income, he was soon evicted from his apartment and found himself living in a homeless shelter, a tent, and finally under a bridge. His drinking and drug use intensified, and his family stopped talking to him.

Then things got even worse. Two years ago, he was beaten and left for dead. As a result, he has a traumatic brain injury and post-traumatic stress disorder.

Then Robert M. met an outreach worker funded through SAMHSA’s Projects for Assistance in Transition from Homelessness (PATH) program. She helped him find an apartment, enroll in benefits, and get treatment for his mental health and substance use disorders. She even accompanies him to doctors’ appointments to keep him on track. For Mr. Mills, it can be hard to believe in his good luck.

“It has been a big challenge to go from being homeless to having a place to lie down and go to sleep with your eyes closed and being able to lock your door at night without fear of being beaten again,” says Robert M., who is now 37 and looking for a job. “This experience has been a dream come true.”

Robert M. is just one of the many people helped by SAMHSA’s efforts to end chronic homelessness, which the Federal government defines as more than a year of homelessness or at least four periods of homelessness over the course of three years. While the PATH program focuses on reaching out to people experiencing homelessness and engaging them in services, other SAMHSA programs ensure that those services are there whenever people need them. The Cooperative Agreements to Benefit Homeless Individuals for States (CABHI-States) program, for example, helps states coordinate their efforts and develop the infrastructure they need to develop or expand services.

Although those experiencing chronic homelessness are just a small percentage of the overall homeless population, they account for more than of half of the services consumed, according to SAMHSA’s Homelessness Resource Center. For many, behavioral health disorders contribute to their living without a home.

“Understanding the roles that mental illness and substance use disorders play in the lives of those at risk for being chronically homeless is key to addressing this public health issue,” said SAMHSA Administrator Pamela S. Hyde, J.D. “That’s why SAMHSA is helping communities connect individuals and families with the behavioral health resources they need to sustain long-term recovery in a stable housing environment.”

Overlapping Problems

There’s a big overlap between mental health and substance use disorders and chronic homelessness, said Jayme S. Marshall, M.S., Chief of the Homeless Programs Branch in SAMHSA’s Center for Mental Health Services (CMHS). According to the Office of National Drug Control Policy, about 30 percent of people experiencing chronic homelessness have a serious mental illness. Approximately two-thirds have a primary substance use disorder or some other chronic health condition. These problems can make it hard for people to get – and keep – stable housing.

“Sometimes people develop an addiction or mental illness and become homeless because of that,” said Ms. Marshall. “Other times, the homelessness really leads to the addiction or the mental illness, because living on the streets or in homeless shelters can be very traumatizing.”

In addition, she said, behavioral health disorders can keep people from forming and maintaining stable relationships with family members and others who could help shelter them. People experiencing homelessness may even push away outreach workers and others trying to help them, said Ms. Marshall. “It can be very difficult to build trust and engage individuals who have been out in the streets or living in places that aren’t meant for human habitation,” she said.

Reaching Out

Building trust and engaging people in services are the goals of SAMHSA’s PATH program. Administered by CMHS, PATH funds the 50 states, the District of Columbia, Puerto Rico, the Northern Mariana Islands, Guam, American Samoa, and the U.S. Virgin Islands, which in turn fund more than 500 providers offering services to people with serious mental illness or co-occurring substance use disorders who are experiencing homelessness or are at imminent risk of homelessness. Outreach services are a key program priority.

In rural states, that can be a real challenge. While many think of homelessness as an urban problem, it happens everywhere, but can be more hidden in rural areas, said Merritt E. Moore, M.A., L.P.C., N.C.C., C.C.A.D.C., Statewide PATH Coordinator in West Virginia’s Department of Health and Human Resources. “We have a lot of people doubled up or living in trailers without utilities,” said Mr. Moore.

Once people are identified, the next step is to find them housing. “We emphasize a ‘housing first’ approach,” said Mr. Moore. In this evidence-based practice, people don’t have to get treated for behavioral health disorders before moving into housing – a shift from how things were done in the past, when people received housing by undergoing treatment first. “Many of these folks aren’t ready for treatment at this point or aren’t amenable,” said Mr. Moore, adding that many are suspicious of offers of help. “Homelessness is a trigger for mental illness and substance use, so the mere fact that we find them housing and support is very helpful.” The state draws on funding from the U.S. Department of Housing and Urban Development to get people housed immediately.

One of West Virginia’s seven PATH providers is the West Virginia Coalition to End Homelessness. Since 2014, West Virginia has had two PATH outreach workers who fan out across the state to find people without housing and then provide intensive case management. “It can be something as simple as checking up on people to make sure that they’re washing their dishes and taking their trash out to something more complicated, such as being an ‘ambassador’ for people with the community mental health center, making sure they receive the right treatment, and get to their appointments,” said Zachary Brown, M.P.A., the coalition’s Executive Director.

Building Infrastructure

With the CABHI-States program, awardees take a much broader view. The 18 current awardees are working to enhance their states’ capacity to provide services to veterans experiencing homelessness and non-veterans who are experiencing chronic homelessness along with serious mental disorders, substance use disorders, or both. In addition to increasing the number of people placed in permanent housing, specific goals include improving planning and coordination, increasing the number of people receiving behavioral health and recovery support services, and increasing the number of people enrolled in Medicaid, Supplemental Security Income/Social Security Disability Income, and other mainstream benefits.

Massachusetts, for example, created a new interagency task force that includes representatives from interagency councils on housing and homelessness and substance abuse and prevention as well as housing and service providers and others. Together they decided to try something different: coupling a housing first approach with peer-provided case management designed to keep people housed even if they have substance use relapses. MISSION: Project Housed focuses on Boston, Cambridge, and Somerville – three communities that account for almost half the chronic homelessness in the commonwealth.

Since receiving the CABHI-States award in 2013, the program has housed almost 60 people, despite a vacancy rate of under two percent in the area. The goal is to eventually house 180 veterans and others experiencing homelessness.

“This isn’t about finding new people; it’s about all those people who haven’t been making it,” said Cheryl Kennedy-Perez, M.A., Manager of Homelessness and Housing Services in the Massachusetts Department of Public Health. “We want to focus on them and see if this constellation of services and housing will help.”

Interagency Collaboration

The United States Interagency Council on Homelessness coordinates the Federal government’s efforts to end homelessness. The council is comprised of the heads of 19 departments and agencies, including the Department of Health and Human Services.

Guiding the council’s work is Opening Doors: Federal Strategic Plan to Prevent and End Homelessness, the nation’s first comprehensive strategy for preventing and ending homelessness. The plan serves as a roadmap for the council’s members plus the public and private partners working with the council at the state and local levels.

Homelessness by the Numbers

According to the U.S. Department of Housing and Urban Development (HUD), 578,424 Americans were homeless on any given night in January 2014, with almost a third living in unsheltered locations such as streets and cars.

Since the Opening Doors Federal strategic plan was introduced in 2010, the nation has made great progress on reducing homelessness. According to data from HUD, overall homelessness has dropped 10 percent over the last four years, including a 25 percent drop in unsheltered homelessness.

Specific subpopulations are also seeing progress:

Chronic homelessness has dropped 21 percent.
Homelessness among veterans has been cut by a third, including a 43 percent decrease in the number of vets and their families living on the streets.
Families have seen a 15 percent drop in homelessness, including a 53 percent decrease in unsheltered homelessness.