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«DiscoVeriNg HomelessNess Volume 13, Number 1 • 2011 U.S. Department of Housing and Urban Development | Office of Policy Development and Research ...»

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I think that homeless programs should basically not push people to do things but rather try to let them know. We can see what you can do, but you need to be in charge. I can be there to help you in any way you want me to. That type of thing, and I think that’s the key to everything…. But I think too, that people need to have a say in what they want. They would say, this is what I want, and how do I go about getting there. People don’t know how to do that. Just being there, just letting people know that you are there. If you need something, I am here. Treating them like a normal person. (former street dweller) Last, the provision of sufficient financial support is critical. Many current and former high-risk individuals were benefiting from Social Security income; however, these income amounts were not

at levels sufficient to meet housing expenses. One former high-risk individual explained:

And I am moving into a new room which costs me $475 a month. And I am getting $585 in SSI. How can you live on $110 a month? I also get food stamps for $100 a month. (former street dweller) Summary and Recommendations This study about differences in perceptions of service needs between providers and consumers highlights potential areas of intervention for homeless service delivery and policies. Interview respondents shared a variety of suggestions for improving services and access to housing programs for chronically homeless street dwellers. These suggestions ranged from structural changes geared toward increasing the affordable housing stock to addressing more interpersonal issues, such as educating service staff and the larger public about homelessness. Current and former high-risk individuals focused on the need for affordable housing and more client-centered services, but providers spoke more of the need to create service programs tailored to the high-risk cohort, and many among them did not believe that street dwellers could successfully move from the streets directly into housing. These findings have several implications for homeless policies.

Policy Recommendations In 2002, the federal administration set the goal of ending chronic homelessness in 10 years by increasing access to mainstream benefits, entitlements and services, and training and employment and by planning long-term housing for individuals released from prisons, hospitals, and treatment centers (HHS, 2003). Although the provision of affordable housing was absent from this list of key strategies, local vicinities began to plan for and implement Housing First programs to address the housing needs of their chronically homeless populations with great success and reduction in public costs (Larimer et al., 2009; Meschede, 2007; MHSA, 2010). The sequential nature of the CoC model for homelessness, which promotes housing stability by requiring movement from phase to phase, has not been successful for the chronically homeless street population. HUD has also acknowledged the limitations of the CoC model for homelessness in connecting chronically homeless street dwellers to housing and has begun promoting Housing First models.

Cityscape 87Meschede

With this shift in focus to housing provision through Housing First programs, the numbers of chronically homeless individuals have begun to decline in many regions. Much work lies ahead in meeting the goal of ending chronic homelessness by 2012, however. As the findings of this research project demonstrate, access to services and benefits alone cannot solve the homelessness crisis. The long-term goal of ending chronic homelessness can be achieved only with sufficient resources to address the housing needs of this population, in addition to their service needs. As such, no services to the chronically homeless street population should be delivered without a focus on permanent housing.

Ending chronic homelessness in Boston and Massachusetts also requires a major modification in the way services are delivered to the homeless.

A serious commitment to ending chronic street homelessness necessitates a paradigm shift, part of which involves the willingness of a community and its homeless assistance providers to consider approaches that have been proven to work even though they, at least initially, represent a significant departure from traditional programs.

(Burt et al., 2004: xxii) As such, successful implementation of new housing models such as Housing First requires addressing service providers’ reluctance to support such model and the creation of different types of housing with a variety of levels of supportive services. Housing has been demonstrated to reduce hospital and detoxification admissions (Gulcur et al., 2003). Consequently, the enormous costs associated with the frequent use of medical and substance abuse services (Meschede, 2010) could be diverted into the creation of affordable and supportive housing.

Because high-risk individuals have so many different service needs, service providers need to be trained across disciplines. For example, the ability to address medical and substance abuse issues while simultaneously being knowledgeable about housing needs would enable service providers to offer a more integrated system of care to high-risk street dwellers. Alternatively, teams across professional specialties might be better able to address these issues holistically. A less fragmented system of care that supports long-term supportive relationships between providers and consumers, regardless of where consumers are in the process between the streets and housing, could be beneficial in ending homelessness for this population. It is also critical for the system to allow for client input.

It’s not easy. Programs are so strapped. What they need to do is to start looking at this homelessness, not the shelters and the programs, look at the problem. Stop putting your money into your … profits and start putting it into housing. Like the people [living in upscale inner city neighborhoods], they don’t want any of us homeless people there. But yet, they won’t fork the money to trying to help them. They rather run them out of there, and that’s not fair. There is so much you can do for a homeless person. You can teach them and point them in the right directions to their own home, own apartment, to get a job, learn skills. Give them the tools to accomplish all these things. I don’t care who you are on the streets, because when you are on the streets you know a little bit about many things. (former street dweller)

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Finally, the federal strategy of diverting entry into homelessness by referring individuals released from the criminal justice system and psychiatric hospitals to appropriate settings other than shelters can be successful only if these individuals are offered realistic housing options, rather than long-term treatment. In addition, rapid rehousing after individuals become homeless is key to preventing them from becoming accustomed to life on the streets, adopting skills that are not suitable to housing, and thus complicating the transition back into housing. Interventions at the homeless shelter system, for most the first point of entry into the homeless services system, need to address both the service needs and the housing needs of those newly entering homelessness. Shorter shelter stays and rapid rehousing are important mechanisms to ending chronic homelessness.

The ultimate goal is housing and recently we got a grant to work with Mass Mental [Health Center] and that is one of the overall goals, why we are partnering with them. Hopefully we can get them in the DMH system to eventually get them housing and it has happened for some people. DMH has housing available and the same case with DMR and you can get other services along with that. It’s easier to get housing this way than through Section 8. (service provider) Significance of Study

Assessing outcomes of the homeless services delivery system has moved to the forefront at the federal level and in the state of Massachusetts. In 2001, the 107th Congress stated the following goals:

The conferees reiterate and endorse language included in the Senate report regarding the need for data and analyses on … the effectiveness of McKinney Act [the major source of federal funding for homeless programs] programs …” and “… analyze their [homeless people’s] patterns of use of assistance, and document the effectiveness of the systems. (U.S House of Representatives, 2001: 110) Outcomes associated with current policies regarding homelessness and programs derived from these policies are of utmost interest to many program administrators and public officials at the local, state, and national levels. In addition, several Massachusetts departments, by uniting their efforts to address homeless services in the state, have voiced the need for evaluations of homeless services. Because this study evaluated the effectiveness of the first step in the homeless CoC— homeless outreach—it added to a body of knowledge informing federal and local policymakers on current homeless policies, especially for the chronically homeless.

Many jurisdictions at the city, county, and state levels have been creating new plans to end homelessness in 10 years, focusing in particular on the chronically homeless. To qualify for federal funding under the McKinney Act, the main source of financial support for most homeless programs, every local CoC program for the homeless has to specify plans to address chronic homelessness in their jurisdictions. Many, if not all, of the individuals identified at high risk of dying—the target group of this study—have been homeless for many years and most of them have multiple barriers to successful transition to more permanent living situations. Learning more about their service-use patterns and assessing the service delivery system will add to the understanding of what it might take to end chronic homelessness. In that, the findings from this study will contribute to a better understanding of how homeless people decide to use services offered to them, which services they use, and what outcomes are associated with service use.

Cityscape 89Meschede

Study Limitations This study focused on a defined group of chronically homeless street dwellers in Boston, which may differ from chronically homeless street dwellers in other communities where service provision and delivery may also differ. As such, the generalizability of this study’s findings may be compromised.

In addition, only a small group of individuals was selected for qualitative interviews. Qualitative research focuses on understanding the essentials of the experience of the phenomena, emphasizing depth, rather than breadth, in the information gathering process. The issues of service delivery, service needs, and service outcomes are relevant, however, for other municipalities that are struggling with reducing the number of chronically homeless street dwellers and improving service delivery to this group. Lessons learned from this Boston-based study can inform the homeless services delivery systems in cities across the country.

Acknowledgments The author thanks Carole Upshur, Donna Haig Friedman, and Alan Clayton-Mathews for valuable feedback on this research, and the Boston Health Care for the Homeless Program, specifically Jim O’Connell and his street outreach team for sharing a great deal of information about homeless individuals living on the streets. The author also thanks current and former homeless street dwellers who shared their stories and those providing services to them. The author hopes that this work will help create better services and, most importantly, housing opportunities for those still on the streets. The author received funding for this research from the Massachusetts Department of Public Health, a Department of Housing and Urban Development Doctoral Dissertation Grant, and two University of Massachusetts Boston doctoral dissertation grants.

Author Tatjana Meschede is the research director for the Institute on Assets and Social Policy at the Heller School for Social Policy and Management at Brandeis University.


Boston Health Care for the Homeless Program (BHCHP). 2001. Respite Care for Homeless Persons:

A Description of Programs in the United States and Canada. Boston: Boston Health Care for the Homeless Program.

Burt, Martha R., John Hedderson, Janine Zweig, Mary Jo Ortiz, Laudan Aron-Turnham, and Sabrina M. Johnson. 2004. Strategies for Reducing Chronic Street Homelessness. Report prepared for the U.S.

Department of Housing and Urban Development, Office of Policy Development and Research.

Available at http://www.huduser.org/portal/publications/homeless/chronic_homeless.html.

Clark, Colleen, and Alexander R. Rich. 2003. “Outcomes of Homeless Adults With Mental Illness in a Housing Program and in Case Management Only,” Psychiatric Services 54: 78–83.

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Culhane, Dennis P., Stephen Metreaux, and Trevor Hadley. 2002. “Public Service Reductions Associated With Placement of Homeless Persons With Severe Mental Illness in Supportive Housing,” Housing Policy Debate 13 (1): 107–163.

DiNitto, Diana M. 2000. Social Welfare: Politics and Public Policy (5th edition). Boston: Allyn and Bacon.

Erickson, Sally, and Jaimie Page. 1999. To Dance With Grace: Outreach and Engagement to Persons on the Street. 1998 National Symposium on Homeless Research. Washington, DC: U.S. Department of Housing and Urban Development and the U.S. Department of Health and Human Services.

Goldman, Howard H., Joseph P. Morrissey, Robert A. Rosenheck, Joseph Cocozza, Margaret Blasinsky, and Frances Randolph. 2002. “Lessons From the Evaluation of the ACCESS Program,” Psychiatric Services 53: 967–969.

Gulcur, Leyla, Ana Stefancic, Marybeth Shinn, Sam Tsemberis, and Sean N. Fischer. 2003. “Housing, Hospitalization, and Cost Outcomes for Homeless Individuals With Psychiatric Disabilities Participating in Continuum of Care and Housing First Programs,” Journal of Community and Applied Social Psychology 13 (2): 171–186.

Hwang, Stephen W. 2000. “Mortality Among Men Using Homeless Shelters in Toronto, Ontario,” Journal of the American Medical Association 283 (16): 2152–2157.

Hwang, Stephen W., Joan M. Lebow, Michael F. Bierer, James J. O’Connell, E. John Orav, and Troyen A. Brennan. 1998. “Risk Factors for Death in Homeless Adults in Boston,” Archives of Internal Medicine 158 (13): 1454–1460.

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