Homelessness: State and Local Efforts to Integrate and Evaluate Homeless
Assistance Programs (Letter Report, 06/29/1999, GAO/RCED-99-178).
To provide greater assistance to homeless people and to meet their
complex needs, states and localities are trying to link and integrate
homeless assistance programs with mainstream social service systems.
Some state and localities are also beginning to use outcome measures to
better manage their programs and to help ensure that their limited
resources are being targeted to the most successful programs. This
report describes some notable examples of efforts by states and
localities to (1) link and integrate their homeless assistance programs
with mainstream systems and (2) measure and evaluate outcomes for their
homeless assistance programs. (See GAO/RCED-99-49, Feb. 1999 and
GAO/HEHS-99-53, Apr. 1999.)
--------------------------- Indexing Terms -----------------------------
REPORTNUM: RCED-99-178
TITLE: Homelessness: State and Local Efforts to Integrate and
Evaluate Homeless Assistance Programs
DATE: 06/29/1999
SUBJECT: Federal aid programs
Homelessness
State programs
Performance measures
Program evaluation
Disadvantaged persons
Housing programs
Federal/state relations
Redundancy
Management information systems
IDENTIFIER: King County (WA)
Franklin County (OH)
Minnesota Family Homeless Prevention and Assistance
Program
******************************************************************
** This file contains an ASCII representation of the text of a **
** GAO report. This text was extracted from a PDF file. **
** Delineations within the text indicating chapter titles, **
** headings, and bullets have not been preserved, and in some **
** cases heading text has been incorrectly merged into **
** body text in the adjacent column. Graphic images have **
** not been reproduced, but figure captions are included. **
** Tables are included, but column deliniations have not been **
** preserved. **
** **
** Please see the PDF (Portable Document Format) file, when **
** available, for a complete electronic file of the printed **
** document's contents. **
** **
** A printed copy of this report may be obtained from the GAO **
** Document Distribution Center. For further details, please **
** send an e-mail message to: **
** **
** **
** **
** with the message 'info' in the body. **
******************************************************************
United States General Accounting Office GAO Report
to Congressional Committees June 1999 HOMELESSNESS State
and Local Efforts to Integrate and Evaluate Homeless Assistance
Programs GAO/RCED-99-178 GAO United States General Accounting
Office Washington, D.C. 20548 Resources, Community, and Economic
Development Division B-281482 June 29, 1999 Congressional
Committees In 1987, the Congress enacted the Stewart B. McKinney
Homeless Assistance Act, recognizing that state, local, and
private efforts alone were not adequate to address the growing
problem of homelessness in America. Since the McKinney Act was
passed, federal resources for alleviating homelessness have
increased significantly, and a number of new federal programs have
been created specifically to serve homeless people. Yet despite
these increased federal efforts, homelessness in America has
persisted. The most widely accepted research indicates that up to
600,000 people may be homeless at any given time, and most experts
on homelessness agree that programs targeted specifically to
people who are homeless do not have sufficient resources to meet
the needs of this population. To provide more assistance for
homeless people and to meet their multiple and complex needs,
states and localities are seeking to link and integrate homeless
assistance programs with mainstream social service systems.1 In
addition, some states and localities are beginning to use outcome
measures to better manage their programs and to ensure that their
limited resources are being used for those programs that achieve
the best possible results. Using outcome measures shifts the focus
from counting outputs, such as the types and numbers of services
provided by a program, to measuring outcomes, such as the results
achieved by the program. Interested in these developments, you
asked us to describe some notable examples of efforts by states or
localities to (1) link and integrate their homeless assistance
programs with mainstream systems and (2) measure and evaluate
outcomes for their homeless assistance programs. This is the
second in a series of reports that you asked us to prepare on
homelessness.2 To identify notable examples of state or local
efforts to link and integrate, and to measure and evaluate
outcomes for, their homeless assistance 1For this report, we used
the term "link" for efforts that seek to improve homeless people's
access to mainstream resources, and we used the term "integrate"
to refer to more fundamental changes in the ways that agencies or
systems of care share or consolidate their resources, planning
efforts, and clients to improve the services they provide to the
homeless. 2Homelessness: Coordination and Evaluation of Programs
Are Essential (GAO/RCED-99-49, Feb. 26, 1999) was our first report
responding to your request. In addition, we recently issued a
report on homeless assistance programs provided by the Department
of Veterans Affairs, Homeless Veterans: VA Expands Partnerships,
but Homeless Program Effectiveness is Unclear (GAO/HEHS-99-53,
Apr. 1, 1999). Page 1 GAO/RCED-99-178 Integrating and
Evaluating Homeless Assistance Programs B-281482 programs, we
interviewed experts on homelessness, including government
officials, academics, advocates for homeless people, providers of
services to homeless people, and others. As a result of their
recommendations, we focused our review on the efforts of two
counties-Franklin County, Ohio, and King County, Washington-and
two states-Massachusetts and Minnesota. Because these efforts were
identified by experts as particularly effective or innovative in
serving homeless people, they are not necessarily representative
of efforts being made throughout the country. Results in Brief
Among the sites we visited, there were several notable examples of
state and local efforts to link and integrate homeless assistance
programs with mainstream systems. In some cases, these linkages
are designed to improve homeless people's access to mainstream
services. For example, to increase the number of eligible homeless
people enrolled in Medicaid, the Massachusetts Department of
Medical Assistance is conducting outreach at homeless shelters and
streamlining the Medicaid application process for this population.
In other cases, efforts are being made to integrate entire systems
of care. For instance, King County, Washington is seeking to
integrate its mental health and substance abuse treatment systems.
As part of this effort, King County has created the Crisis Triage
Unit-a single place where people, many of them homeless,
undergoing mental health or substance-abuse-related crises, can
receive treatment and referral through an integrated set of
services. In addition, in some communities, mainstream systems are
developing policies and programs designed to prevent homelessness,
particularly by addressing the discharge practices of institutions
that may "feed" homelessness by releasing people who have no place
to go. For example, to reduce the number of people who become
homeless after leaving correctional facilities, Massachusetts is
making efforts to improve its discharge planning for prison
inmates and is allocating recovery beds for soon-to-be-released
inmates with substance abuse problems who are at risk of becoming
homeless. Despite these initiatives, many state and local
officials were concerned about the lack of coordination and
integration of homeless assistance programs at the federal level,
which, they said, adversely affects their efforts at the state and
local levels. Nationwide, communities are increasingly using
outcome measures to manage their homeless assistance programs,
thereby focusing less on the types and numbers of activities
performed and more on the results achieved. In Minnesota, for
example, the state-funded Family Homeless Prevention and
Assistance Program is an outcome-based program that Page 2
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs B-281482 provides agencies with flexible grants but holds
them accountable for achieving certain measurable outcomes related
to preventing homelessness among families. One outcome measure
used by the program is the number of at-risk families who maintain
stable housing. A growing number of communities across the country
are also using management information systems to collect uniform
data on the use of homeless assistance services as a tool for
measuring outcomes and better managing their resources. For
example, the Community Shelter Board in Franklin County, Ohio, has
developed a comprehensive management information system that
collects uniform data from all of the emergency shelters in the
county. This system helps the Community Shelter Board track and
measure the outcomes of homeless assistance programs countywide
and hold service providers accountable for achieving the desired
outcomes. This system also helps the community develop strategies
for improving policies and programs to serve homeless people. In
general, homeless assistance providers told us that they often
lack the resources to conduct comprehensive evaluations of their
homeless assistance programs, but they hope that their increased
use of data systems and outcome measures will enable them to
better evaluate their programs in the future. Background
Homelessness in the United States is a widespread and complex
problem. While the exact number of homeless people is unknown,
research by the Urban Institute, which was conducted in 1987 but
is still widely cited today, estimated that over a 1-week period,
approximately 500,000 to 600,000 people lived on the streets or in
emergency shelters.3 About one-half of homeless single adults are
believed to have a problem with alcohol abuse and about one-third
with drug abuse, according to estimates from a series of studies
funded by the National Institute of Mental Health in the mid-
1980s. In addition, these studies estimated, about 20 to 25
percent of homeless single adults have a lifetime history of
serious mental illness, and about half of those with a serious
mental illness also have an alcohol or a drug abuse problem.4 The
U.S. Conference of Mayors estimated, in a survey of 30 major
cities, that families with children made up about 38 percent of
the homeless population in 1998, compared with 3Martha R. Burt and
Barbara E. Cohen, America's Homeless: Numbers, Characteristics,
and Programs that Serve Them (The Urban Institute Press, July
1989). 4The results of these studies are described in a paper by
Robert Rosenheck, Ellen Bassuk, and Amy Salomon entitled Special
Populations of Homeless Americans. This paper was presented at the
National Symposium on Homelessness Research: What Works, which was
cosponsored by the Department of Housing and Urban Development and
the Department of Health and Human Services in Oct. 1998. Page 3
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs B-281482 about 27 percent in 1985.5 Moreover, the needs
of people who are homeless vary greatly, as does the nature of the
assistance they require. While homelessness is an episodic event
for many people who rely temporarily on emergency shelters to help
them get through a difficult situation, it is often a chronic
condition for others, particularly for those who have a serious
substance abuse disorder or a serious physical or mental
disability. Consequently, in addition to housing, these
individuals may require intensive and ongoing supportive services,
such as mental health care or substance abuse treatment, to keep
them out of homelessness. A wide range of local, state, and
federal agencies, as well as nonprofit organizations, provide
shelter and services to homeless people in America. The Stewart B.
McKinney Homeless Assistance Act (P.L. 100-77), passed by the
Congress in 1987, is the principal federal legislation designed to
assist homeless people. The McKinney Act's programs award grants
to communities for activities that provide homeless individuals
and families with emergency food and shelter, transitional
housing, and supportive services. In fiscal year 1997, the federal
government obligated over $1.2 billion for federal programs that
are specifically targeted to people who are homeless. Most of the
federal government's funding for programs targeted to homeless
people is administered by the U.S. Department of Housing and Urban
Development (HUD).6 HUD's strategy for addressing the problem of
homelessness is known as the Continuum of Care. Under this
strategy, communities that apply for McKinney Act funds undertake
a community-based planning process to help identify the needs of
homeless people and develop a comprehensive system, or "continuum
of care," to meet those needs. The Continuum of Care strategy is
intended to incorporate a wide array of resources and activities-
including homelessness prevention, outreach and assessment,
emergency shelter, transitional and permanent housing, and
supportive services such as job training, substance abuse
treatment, and mental health services-into the system that serves
homeless people. 5A Status Report on Hunger and Homelessness in
American Cities 1998, U.S. Conference of Mayors (Dec. 1998).
6Other federal agencies that administer programs targeted to the
homeless are the departments of Agriculture, Education, Health and
Human Services, Labor, and Veterans Affairs and the Federal
Emergency Management Agency. Page 4 GAO/RCED-99-178
Integrating and Evaluating Homeless Assistance Programs B-281482
Efforts to Link and At the locations we visited, we found
various examples of state and local Integrate Homeless
efforts to link and integrate services for homeless people with
mainstream systems. In some communities, these linkages seek to
improve homeless Assistance Programs people's access to
mainstream services. In other communities, efforts are With
Mainstream under way to integrate entire systems of
care so as to improve the coordination and quality of services
provided to homeless people. Finally, Systems
in some communities mainstream systems are developing policies and
programs designed to prevent homelessness among people being
discharged from institutions such as correctional facilities and
psychiatric hospitals. At the same time, many state and local
officials noted, a lack of coordination and integration of
homeless assistance programs at the federal level adversely
affects their efforts at the state and local levels. Efforts to
Improve Experts on homelessness, including academics,
government officials, and Homeless People's Access providers of
services for homeless people, differ in their opinions as to to
Mainstream Programs whether the needs of homeless people are
better served by mainstream programs or by programs that are
specifically targeted to homeless people.7 While some experts
believe that homeless people may be better served by a single
coordinated service system specifically targeted to them, others
believe that having a separate service system for homeless people
"institutionalizes" homelessness and diminishes the will and
capacity of the mainstream systems to help the homeless. However,
most experts take a middle position on this issue and maintain
that although some targeted programs are necessary to address the
special needs of homeless people, the major emphasis needs to be
on facilitating homeless people's access to benefits and services
provided through mainstream programs. This approach was recognized
as the preferred strategy in the federal government's long-term
plan for addressing homelessness published by the Interagency
Council on the Homeless in 1994.8 This plan states that mainstream
programs must be adapted to ensure that they meet the special
needs of homeless people. Moreover, according to the plan,
creating a service system specifically for homeless people that is
separate from the mainstream system is both inefficient and
ineffective. 7Examples of federal programs targeted specifically
to the homeless are Emergency Shelter Grants, Health Care for the
Homeless, and the Homeless Children Nutrition Program. Examples of
federal programs available to low-income people in general are
Public and Indian Housing, Medicaid, and the Food Stamp Program.
Across the country, states and localities also offer a wide range
of programs, including some targeted to the homeless and others
intended for low-income people generally. 8Priority Home: The
Federal Plan to Break the Cycle of Homelessness, Interagency
Council on the Homeless (1994). Page 5 GAO/RCED-99-178
Integrating and Evaluating Homeless Assistance Programs B-281482
In the communities we reviewed, we found several examples of state
and local efforts to link homeless people with mainstream
resources, thereby improving their access to these resources. For
example, in Massachusetts, the Division of Medical Assistance has
a pilot project designed to improve homeless people's access to
Medicaid.9 The state has combined the eligibility and enrollment
process for applicants and has streamlined this process so that it
is easier for homeless people to apply for Medicaid. In addition,
the state has strengthened its outreach efforts to increase the
number of eligible homeless people who are enrolled in Medicaid
and has trained staff at emergency shelters so that they can
better assist homeless people in completing Medicaid application
forms. Massachusetts is also linking its management information
system for homeless assistance programs with an automated benefits
eligibility system. This effort will automatically link data
entered into a homeless shelter's database to a system that will
provide homeless clients with individualized information on which
federal, state, and local programs they may be eligible for.
Linking the two systems should facilitate homeless people's access
to mainstream programs and services, according to state planning
documents. (See app. I for more detailed information on
Massachusetts' efforts in these areas.) Efforts to improve
homeless people's access to mainstream services are also taking
place through Seattle-King County's Health Care for the Homeless
Network.10 This model for implementing the Health Care for the
Homeless program combines direct services provided by the staff of
the Seattle-King County Department of Public Health with
contracted services provided by mainstream health service
providers. Dedicating public health staff specifically to
providing health care services to homeless people helps ensure
that adequate outreach is conducted to meet the special needs of
this population. At the same time, contract agreements with
hospitals and other community providers help ensure that existing
mainstream health care resources are used to serve homeless people
and that these mainstream systems are held accountable for
providing care to the homeless population. (See app. II for more
detailed information on the Seattle-King County program.)
9Medicaid finances health care for certain poor and disabled
individuals nationwide. It is jointly funded by the federal
government and the states and is administered by the states with
broad federal guidance. 10Seattle-King County's Health Care for
the Homeless Network is funded, in part, by the U.S. Department of
Health and Human Services' Health Care for the Homeless program,
which provided grants to 128 projects nationwide in fiscal year
1998, with the goal of making high-quality health care accessible
to homeless people. Page 6 GAO/RCED-99-178 Integrating
and Evaluating Homeless Assistance Programs B-281482 Efforts to
Integrate Experts on homelessness widely agree that integrated
social service Systems to Improve systems are needed to meet
the numerous and complex needs of homeless Services for Homeless
people. Many of these experts believe that the social services
required by People homeless people-such as
mental health, substance abuse treatment, and job training
services-already exist. However, these services tend to be
fragmented and uncoordinated and, as a result, are not well suited
to serving homeless people, who may have multiple problems and
often face many barriers to receiving assistance. To address this
issue, many communities are attempting to integrate the systems of
care that are provided to homeless people by different agencies.
For most communities, "systems integration" requires fundamental
changes in the ways that agencies share information, resources,
and clients. Systems can be integrated, for example, through the
development of cross-agency strategic plans and interagency
management information systems, the consolidation of programs or
agencies, and the pooling of funds.11 In particular, community
officials and service providers told us that people who are
homeless would benefit from better integration of the mental
health and substance abuse treatment systems. Traditionally,
institutional and philosophical differences have divided these two
service systems, creating problems in providing services to people
who have co-occurring mental health and substance abuse disorders-
a condition common among homeless people. Because people with co-
occurring disorders, including homeless people, frequently receive
treatment from two different systems, their care is often not
coordinated, and neither the mental health nor the substance abuse
system is willing to take full responsibility for their care.
Furthermore, experts say, effectively treating people with co-
occurring disorders often requires a "holistic" approach to
effectively address all of their needs. King County, Washington,
has taken several steps to integrate its mental health and
substance abuse systems. The county is currently merging the two
divisions that provide mental health and substance abuse services
and has a full-time "systems integration administrator" who is
responsible for facilitating the integration of the two systems
and creating links with other county systems, such as corrections,
housing, and welfare. King County's systems integration efforts
operate on a "no wrong doors" philosophy, under which people with
mental illness or substance abuse problems are offered the
services they need whether they seek assistance through the
hospitals, detoxification centers, emergency shelters, mental
health 11The concept of systems integration is discussed more
fully in a paper by Deborah L. Dennis, Joseph J. Cocozza, and
Harry J. Steadman entitled What Do We Know About Systems
Integration and Homelessness?, presented at the National Symposium
on Homelessness Research (Oct. 1998). Page 7 GAO/RCED-
99-178 Integrating and Evaluating Homeless Assistance Programs B-
281482 treatment facilities, or correctional facilities. As part
of this effort, in July 1998, the county implemented a pilot
project, the Crisis Triage Unit, which serves a single place where
people undergoing mental health, substance abuse, or other
behavioral health crises can receive services and referrals. About
half of those brought to the unit are homeless, and many more are
at risk of becoming homeless. In addition, the county has
established the Chronic Public Inebriates Systems Solutions
Workgroup to help address problems related to the street homeless
who are chronic abusers of alcohol and often have secondary drug
abuse or mental illness disorders as well. The workgroup has
implemented a series of measures, including a sobering sleep-off
center and a housing plan for this population. (See app. II for
more detailed information on King County's systems integration
efforts.) Another example of an effort to create a coordinated
system for homeless assistance is in Franklin County, Ohio, where
the Community Shelter Board, a nonprofit agency, coordinates and
plans all emergency shelter services for the county. According to
Franklin County officials, service providers, and state officials,
the Community Shelter Board's role as a single coordinating body
allows the emergency shelters in Franklin County to work as a
system rather than as a fragmented set of resources, improving
linkages between the emergency shelter system and mainstream
resources within the community. The Community Shelter Board
provides a single conduit for funding the shelters in the county,
organizes the county's Continuum of Care plan, and serves as a
bridge between and among the public, private, and nonprofit
sectors on issues and planning efforts related to homelessness and
emergency shelters. (See app. III for more detailed information on
Franklin County's Community Shelter Board.) Initiatives by
Mainstream In some communities, mainstream social service
systems are increasingly Systems to Prevent developing
policies and programs designed to prevent homelessness. In
Homelessness the past, efforts to prevent
homelessness consisted mainly of activities such as preventing
evictions by providing short-term rental assistance to families.
However, there is a growing recognition that it may be possible to
prevent homelessness by modifying the discharge practices of
institutions such as correctional facilities, hospitals, and
psychiatric institutions. These systems may "feed" homelessness
because people released from these systems often have no place to
go. Experts believe that collaboration between these mainstream
systems and the homeless assistance system can facilitate the
development of measures for preventing homelessness. Page 8
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs B-281482 In Massachusetts, efforts are being made to
reduce the number of people who become homeless after leaving
correctional facilities. Both the state's Department of Correction
and county correctional agencies have devoted more resources to
planning for the discharge of inmates who will soon be released.
In addition, the state's Department of Public Health has
implemented a criminal justice initiative, which allocates a
number of recovery beds for those who are being released from the
corrections system, have a substance abuse problem, and are at
risk of becoming homeless. Moreover, the Massachusetts Department
of Mental Health has in place a number of policies and procedures
that are designed to prevent patients who are being discharged
from psychiatric hospitals from becoming homeless. For example,
the Department's Homeless Services Unit works with formerly
homeless mental health clients to help them find adequate housing
before they are discharged from mental health facilities.
Similarly, the Massachusetts Division of Medical Assistance
requires the private contractor that provides mental health
services for many of the state's Medicaid recipients to identify
strategies and resources to help prevent clients who are being
discharged from inpatient psychiatric facilities from becoming
homeless. (See app. I for detailed information on Massachusetts'
homeless prevention efforts.) King County, Washington, recently
started the Mental Health Court, a pilot effort designed, in part,
to prevent individuals with mental illness from cycling between
homelessness and the correctional system. Under this effort,
mentally ill people who have been charged with misdemeanors will
typically have the option of receiving court-ordered treatment as
an alternative to prosecution or sentencing. Unlike the regular
court system, the Mental Health Court provides a number of
individual treatment and supportive services, as well as a limited
amount of temporary housing. County officials estimate that about
one-third of those who will use the Mental Health Court will be
homeless and many more will be at risk of becoming homeless. (See
app. II for detailed information on the King County Mental Health
Court.) State and Local Several federal initiatives
encourage states and localities to link and Perceptions That
Federal integrate their homeless assistance programs with
mainstream service Efforts to Integrate systems. For
example, HUD's Continuum of Care strategy encourages Services for
Homeless communities to create linkages between services for
the homeless and People Could Be Improved mainstream services
such as job training, child care, substance abuse treatment, and
mental health services. A 1996 HUD-contracted evaluation of the
Continuum of Care strategy found that it had generally been
successful Page 9 GAO/RCED-99-178 Integrating and Evaluating
Homeless Assistance Programs B-281482 in helping communities
develop a more focused and structured process for bringing
together a wide range of stakeholders and encouraging
collaboration among service systems at the state and local
levels.12 Efforts by the U.S. Department of Health and Human
Services (HHS) also encourage linkages and program integration at
the state and local levels. For example, HHS' Health Care for the
Homeless program emphasizes a multidisciplinary approach to
delivering health care to the homeless, combining outreach with
integrated systems of primary care, mental health and substance
abuse services, and case management. Similarly, HHS' Access to
Community Care and Effective Services and Supports (ACCESS), a 5-
year demonstration project, has been evaluating the effectiveness
of integrated systems of care for homeless people with mental
illness. In addition, as we stated in our February 1999 report,13
efforts to assist homeless people at the federal level are
coordinated in several ways. Coordination occurs through (1) the
Interagency Council on the Homeless,14 which brings together
representatives of federal agencies that administer programs or
resources that can be used to alleviate homelessness; (2) jointly
administered programs and policies adopted by some agencies to
encourage coordination; and (3) compliance with the requirements
of the Government Performance and Results Act of 1993, which
requires federal agencies to identify crosscutting
responsibilities, specify in their strategic plans how they will
work together to avoid unnecessary duplication of effort, and
develop appropriate performance measures for evaluating their
programs' results. However, the consensus of the state and local
government officials, advocates for homeless people, and homeless
assistance providers with whom we spoke was that the federal
government has not done a good job of coordinating its programs,
and this lack of coordination adversely affects the ability of
states and localities to integrate their programs. Although HUD
and HHS have stated that they have a number of activities to
promote coordination between the two departments, state and local
12Ester Fuchs and William McAllister, The Continuum of Care: A
Report on the New Federal Policy to Address Homelessness (Dec.
1996). 13Homelessness: Coordination and Evaluation of Programs Are
Essential (GAO/RCED-99-49, Feb. 26, 1999). 14The McKinney Act
established the Interagency Council on the Homeless, an
independent council with its own funding and staff, to promote the
coordination of homeless assistance programs across federal
agencies. In 1994, because of concerns that the Council was not
effectively coordinating a federal approach to homelessness, the
Congress stopped appropriating funds for the Council, and it
became a voluntary working group under the President's Domestic
Policy Council. According to HUD, the discontinuation of funding
has significantly changed the role of the Council, and its
activities are now limited mostly to facilitating the exchange of
information and managing limited special projects. Page 10
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs B-281482 officials and service providers told us that
they were particularly concerned about what they perceive as
insufficient communication and coordination between the two
departments. Many were particularly critical of what they felt was
HHS' lack of involvement in addressing homelessness. As a result,
in their opinion, HUD has funded and administered most of the non-
housing-related supportive services for the homeless through its
McKinney Act programs. Some state and local officials also felt
that HHS should do more to integrate mental health and substance
abuse programs at the federal level. Such integration, they said,
is necessary to effectively treat homeless individuals with co-
occurring disorders. These officials also said that even though
various federal grants to states and localities have similar
goals, they often have differing eligibility criteria, funding
cycles, and reporting requirements, which make it difficult to
incorporate these programs into an integrated system of care at
the local level.15 In commenting on a draft of this report, while
HHS agreed that more could be done at the federal level to better
serve the homeless population, it did not agree with state and
local officials' perceptions that the department was not
adequately involved in addressing homelessness or integrating
mental health and substance abuse programs to effectively treat
homeless people with co-occurring disorders. According to HHS, it
has undertaken several initiatives in conjunction with HUD and
other agencies to better address the needs of homeless people in
general, as well as serve people with co-occurring disorders. In
its comments, HHS restated its commitment to exploring additional
opportunities to improve coordination with HUD and other federal
agencies as they continue to address homelessness and develop and
implement approaches to improve services for those with co-
occurring disorders. Moreover, HHS emphasized that the
coordination of resources received from federal agencies must
fundamentally occur at the state and local levels, and that state
and local entities must work together to appropriately address and
balance the needs of homeless people with the needs of a multitude
of other groups. (See app. V for the full text of HHS' comments on
this report.) 15We will explore these issues in greater detail as
part of our planned review of the barriers faced by homeless
people in gaining access to federal programs. Page 11
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs B-281482 Use of Outcome Many communities
across the country are increasingly using outcome Measures, Data
measures to manage their homeless assistance programs, and we
found several examples of the use of the measures at the sites we
visited. Using Systems, and Program outcome measures to manage
programs is becoming increasingly popular Evaluations for
with federal, state, and local governments as they wrestle with
ways to improve the effectiveness and quality of government-
provided services Homeless Assistance while limiting the
costs to deliver these services. The use of outcome Programs
measures shifts the focus from outputs, such as the types and
numbers of activities performed, to the outcomes, or results
achieved. For homeless assistance programs, this means a shift in
focus from tracking outputs, such as the number of people
sheltered, to measuring outcomes realized, such as the number of
people who move out of homelessness and into a stable housing
situation.16 In addition to using outcome measures, more
communities are using management information systems to collect
uniform data on their homeless population and on the resources
used by them so they can improve the management and coordination
of these resources. Providers of services to the homeless and
state and local officials said that they generally lacked the
resources to conduct comprehensive evaluations of their homeless
assistance programs but hoped that the increased use of data
systems and outcome measures would improve their ability to
evaluate these programs in the future. Communities' Increasing
Communities nationwide are increasingly setting and using outcome
Use of Outcome Measures measures to evaluate their homeless
assistance programs, according to for Homeless Assistance
researchers and homeless assistance providers. Several reasons may
Programs account for this increased emphasis
by states and localities on measuring outcomes. First, there is a
growing recognition among state and local governments that they
need to spend their limited resources on programs that "work."
Consequently, agencies that provide services to the homeless are
being required to focus on achieving resultssuch as moving people
out of homelessnessrather than on just providing units of service.
Second, an increasing number of management information systems for
homeless assistance programs have been developed and implemented
in recent years. The availability of these systems makes it easier
for state and local officials to collect and use standardized
outcome data to manage their homeless assistance programs. Third,
states and localities have been 16While stable housing is
generally the ultimate outcome goal of homeless assistance
programs, many programs also have important intermediate outcome
goals for the homeless people they serve, such as involvement in
mental health or substance abuse treatment, improved level of
functioning, or improved health status. These can represent
important intermediate steps on the path to stable housing for
some homeless people, particularly those suffering from mental
illness, a substance abuse disorder, or a chronic health problem.
Page 12 GAO/RCED-99-178 Integrating and Evaluating
Homeless Assistance Programs B-281482 influenced by the federal
government's move towards the use of outcome measures under the
Government Performance and Results Act of 1993, which requires
federal agencies to set specific performance goals and to measure
outcomes for federal programs. Finally, some private foundations
are requiring greater accountability for the funds they provide to
agencies that serve the homeless. For example, in Minnesota, the
Family Housing Fund, which provides funds for two single-room-
occupancy projects that largely serve formerly homeless
individuals, requires the managers of the projects to track
several performance measures, such as tenants' stability in
housing and employment. Similarly, the United Way of King County,
Washington, outlines in its contract with the YWCA of Seattle
several specific outcome goals, such as increased housing
stability for those served by the program. At the sites we
visited, we found several examples of how states and localities
are using outcome measures to manage and improve their homeless
assistance programs, including the following: * Minnesota's state-
funded Family Homeless Prevention and Assistance Program is an
outcome-based program that focuses on three specific goals-
preventing homelessness, reducing the length of stay in emergency
shelters, and eliminating repeat episodes of homelessness. The
program provides local government and nonprofit agencies with
flexible grants that can usually be used however an agency decides
as long as the agency sets specific outcome goals, develops a
method for tracking these outcomes, and achieves and reports on
these outcomes. (See app. IV for more detailed information on
Minnesota's program.) * In Massachusetts, the state's Division of
Medical Assistance has set certain performance standards related
to homeless people in its contract with the company that provides
behavioral health services for many of the state's Medicaid
recipients. One performance standard requires the company to
implement measures that will reduce the inappropriate discharge of
people into homelessness from psychiatric facilities. The second
performance standard provides incentives to the company for
increasing the number of eligible homeless individuals enrolled in
Medicaid. The company receives financial bonuses or penalties on
the basis of its success in meeting these performance standards.
(See app. I for more detailed information on Massachusetts'
programs.) * The Ohio Department of Development has started to
implement the use of outcome measures for some of its housing
programs that serve homeless people. Agencies that receive state
funds for supportive housing programs are required to develop
outcome-based performance targets that the state Page 13
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs B-281482 will hold them accountable for achieving. For
example, a general outcome measure for a transitional housing
program might be the percentage of clients that were moved to some
kind of permanent housing. State officials told us that they hope
to improve the quality of the projects they fund by focusing on
the outcomes achieved and hope that these requirements will
encourage agencies with poorly performing programs to improve,
while highlighting the "best practices" of those agencies that
have successful programs. At the county level, the Community
Shelter Board in Franklin County, Ohio, has been working with the
state to establish outcome measures for service providers in the
county. Contracts with service providers that receive funds from
the Community Shelter Board include specific outcome measures,
such as the percentage of clients moved out of shelters into
transitional housing within a given period of time. (See app. III
for more detailed information on Ohio's efforts to use outcome
measures.) States' and Localities' A growing number of states
and localities are using various data systems Efforts to Develop
Data to manage their homeless assistance programs. Both
individual homeless Systems and Evaluate assistance
providers and entire service systems are using these Homeless
Assistance management information systems to collect,
track, and analyze Programs information on their
clients and the services they use. As many as 50 cities are using
or are in the process of implementing an estimated 15 to 18
different software applications designed to automate the
collection and management of data on the use of homeless
assistance services, according to a researcher who has worked with
several of these cities. This information can be collected at
various points in the system, such as emergency shelters,
transitional housing programs, or programs that provide supportive
services to homeless people. Communities and service providers can
use the data collected by these systems in a variety of ways, from
tracking a client's movement through the system, to assisting in a
client's case management, to gathering general demographic data on
the homeless population, to developing policies and plans.
Massachusetts, for example, is expanding its use of a computerized
record-keeping system for the homeless, called the Automated
National Client-specific Homeless services Recording (ANCHoR)
system, and is implementing the system statewide.17 This system
allows service providers to collect uniform information on their
homeless clients over time. It is designed to help service
providers assess the needs of their homeless 17The ANCHoR system
was developed with funding from HUD, HHS, and others. At present,
approximately 30 cities across the nation are either using the
system or are in the process of implementing it. Page 14
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs B-281482 population, manage their emergency shelter
resources, and provide better case management services, including
referral and follow-up. By implementing the system in emergency
shelters, transitional housing programs, and other homeless
assistance programs across the entire state, a Massachusetts
official told us, they hope to better coordinate resources for
homeless people statewide and better evaluate programs'
effectiveness. (See app. I for more detailed information about
Massachusetts' use of the ANCHoR system.) Similarly, the Community
Shelter Board in Franklin County, Ohio, has developed a
comprehensive management information system to collect uniform
data from all of the county's emergency shelters. This management
information system includes both client- and provider-specific
data and can provide information on various outcomes, such as the
average length of stay in a shelter for homeless men in the county
and the percentage of homeless people who move to permanent
housing within a given time period. A Community Shelter Board
official said that the management information system helps them
track and measure the outcomes of homeless assistance programs
countywide and hold service providers accountable for achieving
agreed-upon outcomes. In addition, the system helps the community
develop strategies for improving policies and programs for
homeless people. (See app. III for more detailed information on
Franklin County's use of management information systems.) State
and local homeless assistance providers and officials told us that
they typically have not had sufficient resources to conduct
comprehensive evaluations of their homeless assistance programs.
However, they hope that the increased use of data systems and
outcome measures will improve their ability to evaluate these
programs in the future. Experts on homelessness whom we spoke to
cited Minnesota as a state that has been unusually active in
evaluating homeless assistance programs and collecting
comprehensive data on its homeless population. Every 3 years,
Minnesota conducts a comprehensive statewide census and survey of
homeless people. According to state and local officials, these
surveys help policymakers and planners gauge trends in, and assess
the needs of, the homeless population and plan and lobby for the
resources required to address these needs. State, county, and
nonprofit agencies in Minnesota also perform a relatively large
number of evaluations to determine the effectiveness of specific
programs for homeless people. According to government officials
and service providers, these evaluations have helped them
determine which programs and activities are most effective in
aiding Page 15 GAO/RCED-99-178 Integrating and Evaluating
Homeless Assistance Programs B-281482 homeless people and in
preventing homelessness. (See app. IV for more detailed
information on Minnesota's data collection and evaluation
efforts.) Agency Comments We provided a draft of this report to
HHS and HUD for review and comment. Both departments provided us
with comments that appear in appendixes V and VI of the report,
along with our detailed responses. HHS stated that it appreciated
the timeliness of this report and our earlier February 1999 report
on homelessness because federal, state, and local agencies
continue to struggle with the persistent problem of homelessness
in the United States. However, HHS also made several points to
clarify issues raised in this report. HHS' primary concern related
to our reporting of state and local officials' perceptions that
the Department is not adequately involved in addressing
homelessness in general or in integrating federal programs to meet
the needs of people with co-occurring disorders. HHS disputed this
characterization and cited several initiatives-such as ACCESS, a
national survey of homeless assistance providers and clients, a
symposium on homelessness research, and various forms of technical
assistance that it has provided to the states-as examples of its
involvement in addressing homelessness. HHS also described several
efforts it has initiated to integrate mental health and substance
abuse programs to better serve individuals with co-occurring
disorders. While HHS agreed that more could be done to coordinate
the efforts of various federal agencies to address homelessness,
it also described several joint initiatives that it has undertaken
with HUD and other federal agencies to improve federal programs
that serve the homeless. HHS also emphasized that the coordination
of resources received from federal agencies must fundamentally
occur at the state and local levels and that state and local
entities must work together to appropriately address and balance
the needs of homeless people with those of a multitude of other
groups. In its comments, HHS also restated its continuing
commitment to developing better solutions for serving homeless
people in general, as well as those with co-occurring disorders,
and to improving coordination with other agencies. Although we
agree that HHS is engaged in several initiatives concerning
homelessness, our study raises some issues about how the
Department's efforts are perceived by states and localities. The
observations we have reported are based on interviews we conducted
with more than 50 state and local officials in four different
locations across the country and clearly suggest that many at the
state and local level believe that the Department can do more to
address Page 16 GAO/RCED-99-178 Integrating and Evaluating
Homeless Assistance Programs B-281482 the issue of homelessness.
HHS also provided us with technical comments that have been
incorporated in the report as appropriate. HUD was pleased that
the report highlighted the good work of several communities to
integrate the housing and services needed by homeless people.
However, HUD stated that the report did not fully reflect the
significantly changed role of the Interagency Council on the
Homeless. We have revised the report to include information that
describes the current role of the Council. Scope and To
identify notable examples of efforts by states and localities to
(1) link Methodology and integrate their homeless assistance
programs with mainstream systems and (2) measure and evaluate
outcomes for their programs that serve homeless people, we
interviewed national experts on homelessness. These experts
included HUD and HHS officials that administer programs for
homeless people; representatives of national advocacy groups for
homeless people, including the National Coalition for the Homeless
and the National Alliance to End Homelessness; and researchers and
others with expertise in this area. Of all of the sites suggested
by these experts, we selected four from among those most often
identified as being particularly effective or innovative in
linking or integrating homeless assistance programs with
mainstream systems or using program evaluations and outcome
measures to manage their homeless assistance programs. As a result
of this process, we selected two counties-Franklin County, Ohio,
and King County, Washington-and two states-Massachusetts and
Minnesota. Because these counties and states were chosen for
having programs or initiatives that experts considered
particularly effective or innovative, they are not necessarily
representative of all states and localities throughout the
country. We visited each of the four sites we selected and
interviewed state and local officials, providers of services to
homeless people, advocacy groups for homeless people, private
foundation employees, community-based researchers, and others to
obtain information and documents on their efforts to integrate or
evaluate their homeless assistance programs. We also collected
information on federal initiatives to promote the coordination and
evaluation of homeless assistance programs at the federal, state,
and local levels from officials at HHS and HUD. We conducted our
work between July 1998 and May 1999 in accordance with generally
accepted government auditing standards. Page 17 GAO/RCED-99-
178 Integrating and Evaluating Homeless Assistance Programs B-
281482 We are sending copies of this report to the appropriate
congressional committees, the Honorable Donna Shalala, the
Secretary of Health and Human Services, and the Honorable Andrew
Cuomo, the Secretary of Housing and Urban Development, and other
interested parties. Copies will be made available to others on
request. If you have any questions about this report, please call
me or Anu Mittal at (202) 512-7631. Key contributors to this
assignment were Jason Bromberg and Myrna Prez. Judy A. England-
Joseph Director, Housing and Community Development Issues Page 18
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs B-281482 List of Congressional Committees The Honorable
Phil Gramm Chairman, Committee on Banking, Housing and Urban
Affairs U.S. Senate The Honorable Pete V. Domenici Chairman,
Committee on Budget U.S. Senate The Honorable James M. Jeffords
Chairman, Committee on Health, Education, Labor and Pensions U.S.
Senate The Honorable Arlen Specter Chairman, Committee on
Veterans' Affairs U.S. Senate The Honorable Christopher S. Bond
Chairman, Subcommittee on VA, HUD, and Independent Agencies
Committee on Appropriations U.S. Senate The Honorable Wayne Allard
Chairman, Subcommittee on Housing and Transportation Committee on
Banking, Housing and Urban Affairs U.S. Senate The Honorable Bill
Frist Chairman, Subcommittee on Public Health Committee on Health,
Education, Labor and Pensions U.S. Senate Page 19 GAO/RCED-
99-178 Integrating and Evaluating Homeless Assistance Programs
Contents Letter
1 Appendix I
22 Massachusetts Background
22 Improving Access to Medicaid and Setting Performance
23 Standards for Managed Care Services Efforts to Prevent
Homelessness for Those Released From 24
Correctional Facilities Massachusetts' Use of Management
Information Systems 27 Appendix II
30 King County, Background
30 Systems Integration in King County
30 Washington Seattle-King County's Health Care for
the Homeless Network 33 Appendix III
37 Franklin County, Ohio Background
37 Coordination of Emergency Shelter and Other Services Through
38 the Community Shelter Board Data Collection and Program
Evaluation Efforts in Franklin 40 County
State's and County's Use of Outcome Measures to Improve
41 Programs for Homeless People Appendix IV
43 Minnesota Background
43 Minnesota's Family Homeless Prevention and Assistance
44 Program Minnesota's Statewide Survey of Homeless People
45 Minnesota's Evaluations of Programs That Serve the Homeless
47 Appendix V
49 Comments From the GAO's Comments
53 Department of Health and Human Services Page 20 GAO/RCED-
99-178 Integrating and Evaluating Homeless Assistance Programs
Contents Appendix VI
54 Comments From the GAO's Comments
56 Department of Housing and Urban Development Abbreviations
ACCESS Access to Community Care and Effective Services and
Supports ANCHoR Automated National Client-specific Homeless
services Recording System CSB Community Shelter Board DMA
Division of Medical Assistance FHPAP Family Homeless
Prevention and Assistance Program GAO General Accounting
Office HCHN Health Care for the Homeless Network HHS
Department of Health and Human Services HUD Department of
Housing and Urban Development ROOF Rebuilding Our Own
Futures YWCA Young Women's Christian Association Page 21
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs Appendix I Massachusetts This appendix describes some of
the initiatives taken in Massachusetts to improve homeless
people's access to mainstream resources, prevent homelessness, and
use management information systems to provide better services for
homeless people. A number of national experts on homelessness
identified the state of Massachusetts and the city of Boston as
particularly innovative in linking programs for homeless people
with mainstream programs and adopting policies within their
mainstream systems to try to prevent homelessness. The state has
several efforts under way to improve homeless people's access to
Medicaid and ensure that the program's mental health services
adequately serve the needs of homeless people. In addition,
various state agencies are implementing initiatives to help reduce
the number of people who become homeless after being released from
correctional or psychiatric facilities. Finally, Massachusetts is
expanding its use of a computerized record-keeping system for
homeless assistance services and is implementing the system
statewide. It is also linking this system to a benefits
eligibility system. Background Massachusetts had a
population of about 6.1 million in 1998, according to a U.S.
Census Bureau estimate. Although the state has the fourth highest
per-capita income in the nation, its cost of living is also among
the highest. Housing costs in Massachusetts are considerably
higher than the national average, particularly in the Boston
metropolitan area. About two-thirds of the state's homeless
population is located in Boston. In December 1998, a one-night
census of the homeless conducted by the city counted 5,272
homeless people. Of this population, 44 percent were living in
adult shelters, 23 percent were in family shelter programs, 4
percent were living on the street, and the remainder were in
transitional housing programs, hospitals, and other settings. The
Massachusetts Department of Transitional Assistance funds the
majority of the state's emergency shelters. Various state agencies
are responsible for most of the supportive services provided to
homeless people, including mental health and substance abuse
treatment. The state's Interagency Task Force for Housing and
Homelessness coordinates planning activities and services for
homeless people and also develops programs that serve homeless
people. In Boston, the city's Emergency Shelter Commission
coordinates policy development, advocacy, and public education on
homelessness, while the Department of Neighborhood Development
manages, oversees, and distributes most of the grants Page 22
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs Appendix I Massachusetts received by the city for
services for homeless people. The city also funds two emergency
shelters. Improving Access to In Massachusetts, the
Division of Medical Assistance (DMA) administers the Medicaid and
Setting state's Medicaid program, known as MassHealth.
DMA has initiated a pilot project to increase the enrollment of
homeless people in MassHealth by Performance
streamlining the eligibility and enrollment process for this
group. DMA also Standards for uses performance
outcomes to manage the Medicaid contractor that provides mental
health and substance abuse services for most Medicaid Managed Care
clients in the state, and two of the performance standards that it
uses are Services related specifically to
the issue of homelessness. State Initiatives to Improve DMA has
established a pilot project to increase the enrollment of homeless
Homeless People's Access people in MassHealth, the state's
Medicaid program. One goal of the pilot to Medicaid
project is to make it easier for homeless people to enroll in the
program by allowing the state to determine their eligibility and
enroll them at the same time. Normal enrollment procedures require
people to go through a two-step process. For the pilot project,
DMA has streamlined the process to suit the special circumstances
faced by homeless people. For example, under normal enrollment
procedures, forms are sent to an applicant's permanent mailing
address, but under the pilot project, these forms can be sent to a
staff member at an emergency shelter who serves as the homeless
applicant's "contact person." In addition, DMA has increased its
outreach efforts to educate community organizations, advocates for
homeless people, and others about MassHealth, its eligibility
requirements, and the enrollment process. As part of these
outreach efforts, DMA is providing special training to staff at
the four homeless shelters participating in the pilot project.
Shelter staff have been trained to assist homeless clients in
completing the forms to determine their eligibility for MassHealth
and to provide information on how the enrollment process works.
Shelter staff have been given special access to certain client-
specific eligibility information that allows them to call DMA to
learn whether a homeless client is eligible for MassHealth.
Performance Standards for About half of the Medicaid
recipients in Massachusetts receive mental Serving the Homeless
health and substance abuse treatment through the Massachusetts
Included in Medicaid Behavioral Health Partnership, a
private company that provides mental Service Provider's Contract
health and substance abuse services under a contractual
arrangement with Page 23 GAO/RCED-99-178 Integrating and
Evaluating Homeless Assistance Programs Appendix I Massachusetts
DMA. DMA monitors the Partnership's performance against 18
performance standards that were included in its fiscal year 1999
contract. If these standards are met, the Partnership receives
financial bonuses and if they are not met, penalties are assessed.
Two of the 18 performance standards specifically address issues
relating to homeless people. The first performance standard
included in the contract expects the Partnership to collaborate
with advocates for homeless people to find ways to ensure that
patients in psychiatric facilities are not discharged
inappropriately to shelters. It also expects the Partnership to
educate its providers of inpatient mental health care and monitor
their performance to ensure that homeless patients are
appropriately discharged from their facilities. To meet this
standard, officials from the Partnership told us that they now
require a senior manager to approve a patient's discharge plan
before the patient can be discharged from a hospital to a homeless
shelter. They will approve a patient's discharge to a shelter only
after all other alternatives and resources have been considered.
The Partnership has also created a Homeless Task Force that, among
other things, works with mental health care providers to promote
appropriate psychiatric discharge policies and practices. In
addition, the Partnership has contributed funding for the
establishment of a toll-free telephone system that is being set up
by the Massachusetts Housing and Shelter Alliance. This system
will provide discharge planners and case managers with access to
current information on housing options and services available for
homeless individuals. The Partnership is giving its providers
special training on how to use the information that is provided by
the telephone system to avoid the inappropriate discharge of
patients into homelessness. The second performance standard
included in the contract provides a financial incentive through
the Partnership to certain homeless shelters and detoxification
programs that enroll new members in MassHealth. To help meet this
standard, the Partnership has provided training to staff at these
facilities on MassHealth's enrollment procedures and has helped
DMA in its efforts to streamline the eligibility and enrollment
process for homeless people applying for MassHealth. Efforts to
Prevent There has long been concern about ex-
offenders who become homeless Homelessness for
after they complete their sentences and are discharged from
correctional facilities. In Massachusetts, the Department of
Correction estimates that Those Released From 15
percent of those released from state correctional facilities have
Correctional Facilities nowhere to go. Using a representative
sample, the Massachusetts Housing Page 24 GAO/RCED-99-178
Integrating and Evaluating Homeless Assistance Programs Appendix I
Massachusetts and Shelter Alliance estimated that 1,259 ex-
offenders went directly from state and county prisons into
emergency shelters in 1998. To prevent people who are leaving
correctional facilities from becoming homeless, Massachusetts is
making efforts to improve discharge planning and is targeting
substance abuse recovery home beds for released inmates who are at
risk of becoming homeless. Criminal Justice System's Over the
past few years, concerns about the corrections system Efforts to
Improve discharging people into the shelter system has
led to increased Discharge Planning for communications
between the corrections system and advocacy groups for Those
Leaving homeless people in Massachusetts. This
has provided a stimulus for the Correctional Facilities
Department of Correction to seek improvements in discharge
planning for soon-to-be-released inmates, according to a
department official. One of the purposes behind the move for
improved discharge planning is to prevent former inmates from
cycling through the "revolving door" between the shelter system
and the corrections system. In 1998, the Department of Correction
revised its Release and Lower Security Preparation Policy, which
sought to improve discharge planning and services for all soon-to-
be-released inmates from the state corrections system. Under this
policy, when inmates in the state corrections system have 1 year
before their release, they attend transition workshops. A
personalized transition plan is developed for each inmate that
addresses postrelease issues such as employment and housing. The
corrections system has contracted with a community-based agency
that makes appropriate referrals for needed services and housing
for each individual who is to be released. The county corrections
systems, which are adminstered separately from the state system,
have hired full-time discharge planners to perform similar
discharge planning functions for the counties' houses of
corrections. Criminal Justice Initiative Massachusetts has a
criminal justice initiative whose goal is to provide Designed to
Provide beds in recovery homes for persons with
substance abuse problems who Recovery Homes for have
been released from correctional facilities and are at risk of
becoming Ex-Offenders With homeless. This initiative
stemmed from discussions that began in 1996 Substance Abuse
Problems between the Massachusetts Housing and Shelter
Alliance, the Department of Correction, and the state's Executive
Office of Public Safety on ways to prevent ex-offenders from
becoming homeless. Because the Department of Correction is not
legally responsible for individuals after they have completed
their sentences, these groups determined that partnerships Page 25
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs Appendix I Massachusetts with other agencies were
required to address this issue. Since an estimated 80 percent of
those entering the shelter system from prisons have substance
abuse problems, the Department of Public Health, which funds the
state's substance abuse services, became involved in these
discussions. The criminal justice initiative began in 1996, and
approximately $2.1 million was allocated for this initiative in
fiscal year 1997. These funds support about 135 recovery home beds
specifically targeted for persons released from correctional
facilities who have substance abuse problems and are at risk of
becoming homeless, according to a Department of Public Health
official. The Department of Public Health contracted with the
Massachusetts Housing and Shelter Alliance to coordinate the
initiative. Beginning in September 1997, monthly meetings were
held with representatives from a variety of agencies, including
the state departments of Correction and Public Health; the Parole
Board; county corrections facilities; and recovery home providers.
The primary purpose of these meetings was to coordinate the
allocation and use of the 135 recovery home beds. For example, a
subcommittee was established to survey inmates and determine what
information the inmates needed to have about each recovery home so
that they could choose the facility that best met their needs.
Similarly, another subcommittee developed a standard application
form so that inmates could use one application to apply to
different recovery homes throughout the state. Participating
agencies also addressed a wide variety of other issues, including
the need for transitional housing for soon-to-be-released inmates
for whom recovery home beds are not yet available. To help gauge
the impact of the program, the Massachusetts Housing and Shelter
Alliance will be tracking data on the number of people entering
shelters for the homeless after being discharged from correctional
facilities. Department of Mental The Massachusetts
Department of Mental Health, which serves individuals Health's
Efforts to Prevent with severe and persistent mental illness,
estimates that about one-third of Discharge From State
its clients who are released from the corrections system become
Facilities Into homeless. In April 1998, the
department instituted the Forensic Transition Homelessness
Team, whose goal is to assist mentally ill individuals who are
making the transition from correctional facilities back into
society. A department official said that preventing homelessness
is one goal of the program and helping clients find housing is one
task of the Forensic Transition Team. Page 26 GAO/RCED-
99-178 Integrating and Evaluating Homeless Assistance Programs
Appendix I Massachusetts The initiative to prevent homelessness
for mentally ill ex-inmates is part of the Department of Mental
Health's general policy of preventing homelessness among mentally
ill clients being discharged from state facilities. The
department's Homeless Services Unit is notified whenever a
homeless client enters an inpatient mental health facility, and
the unit works to secure housing and other services for the client
as part of the discharge planning process. Department of Mental
Health staff are prohibited from discharging a client into an
emergency shelter unless all other housing options have been
considered and the client refuses the housing that is offered.
Massachusetts' Use of Massachusetts is implementing a computerized
management information Management system
statewide that will allow providers of services for homeless
people to collect and access uniform information about their
homeless clients and Information Systems the services
they use. In addition, Massachusetts is linking its management
information system with an automated benefits eligibility system,
which will allow homeless individuals to more easily identify the
mainstream programs and services that may be available to them.
Statewide Implementation The Automated National Client-
specific Homeless services Recording of a Computerized
(ANCHoR) system is a computerized record-keeping system designed
to Management Information allow service providers to
collect uniform information on their homeless System
clients. The ANCHoR system was developed with funding from the
U.S. Department of Housing and Urban Development (HUD), the U.S.
Department of Health and Human Services (HHS), and other sources,
and is currently being used or is in the process of being
implemented by approximately 30 cities nationwide.1 The ANCHoR
system is designed to help service providers assess clients'
needs, manage shelter stays, and provide overall case management,
including referral and follow-up. When a homeless individual
enters an agency and requests services, the staff will first
conduct an intake survey and use the ANCHoR system to enter
information about the homeless client, such as the client's name,
age, race, residential history, health status, and employment.
Various steps have been taken to try to ensure the client's
privacy. Boston was one of 16 pilot sites that began using ANCHoR
in 1996. The system is currently being used by 73 programs
throughout the state, of 1In addition to the approximately 30
cities using or in the process of implementing ANCHoR, as many as
20 other cities are using or are in the process of implementing an
estimated 15-18 other similar homeless information systems,
according to data provided by a researcher who has worked with
several of these cities. Page 27 GAO/RCED-99-178
Integrating and Evaluating Homeless Assistance Programs Appendix I
Massachusetts which 45 are in Boston. It is also in the planning
stage for an additional 15 programs throughout the state. In 1998,
the state Executive Office of Health and Human Services decided to
implement ANCHoR throughout Massachusetts as a coordinated
statewide system. The statewide expansion of ANCHoR will be
supervised and coordinated by the ANCHoR Steering Committee, which
was created and appointed by Boston's Homeless Planning Committee
in 1997. The agencies that will use ANCHoR under the statewide
expansion include those that provide emergency shelter,
transitional housing, referrals, and supportive services to
homeless people. Implementing the ANCHoR system statewide is
intended to benefit homeless people, agencies that provide
services to homeless people, public policymakers, community
planners, and researchers, according to the director of the
project and state planning documents. Homeless people may benefit
by receiving improved assessments of their needs, more coordinated
services, and better case management, while the agencies that
serve homeless people may benefit by gaining capacity to plan and
manage their resources, since they will have better information
about patterns of use and resources available to serve homeless
people in other parts of the state. According to state planning
documents, public policymakers and community planners may also
benefit because the system should provide them with information
that will improve their ability to coordinate resources
communitywide, gauge programs' effectiveness, assess the overall
needs of the community, and, if necessary, request more resources.
By implementing the system statewide, Massachusetts hopes to
better coordinate care for homeless people, particularly through
improving services and case management for individuals who may
travel to providers in different locations across the state.
According to a state official, the statewide implementation of
ANCHoR could be particularly beneficial to Massachusetts because,
unlike most states, the state government-rather than municipal or
county governments-operates the majority of homeless shelters and
the system will give the state more comprehensive data for
managing all of these facilities. Linking ANCHoR With an
Massachusetts is also the first state that is linking ANCHoR to an
automated Automated Benefits benefits eligibility system.
When a service provider enters information Eligibility System
about a homeless client into ANCHoR, the information is
automatically linked to a software program called MicroMax, which
has a database of information and eligibility requirements for
over 80 federal, state, and local benefit programs, including many
specific to Boston and Page 28 GAO/RCED-99-178
Integrating and Evaluating Homeless Assistance Programs Appendix I
Massachusetts Massachusetts. Using the information about the
homeless client that has already been entered into the ANCHoR
system, MicroMax can develop a report of the public benefit
programs and services for which the client may be eligible and
calculate the benefits the client would likely receive from each
program. Clients can receive individualized documents that include
a list of the programs for which they may be eligible, information
on where to apply for benefits, and applications for some of these
programs that have some of the personal information already filled
out. According to state planning documents, several benefits are
anticipated from linking the ANCHoR and MicroMax systems. First,
case managers using ANCHoR should be better able to identify
homeless clients' eligibility for a variety of programs, including
income assistance, medical services, and job training. This
information should help link homeless persons more quickly with
the mainstream public resources available to them, thereby helping
them move more quickly out of homelessness. Second, the ANCHoR-
MicroMax link should make the process of applying for mainstream
programs easier for homeless people, in part because the system
automatically prints out partially completed applications.
Finally, the aggregate data obtained from reports generated by the
ANCHoR-MicroMax link should provide useful information for
planning and policy purposes. For example, the reports will allow
the state to track the public resources used by homeless
individuals, the number of homeless clients assisted by these
resources, and the types and values of the benefits that homeless
people received from various programs. Page 29 GAO/RCED-
99-178 Integrating and Evaluating Homeless Assistance Programs
Appendix II King County, Washington This appendix describes the
systems integration initiatives and the Health Care for the
Homeless Network of King County, Washington. The communities of
Seattle and King County, Washington, were identified by a number
of national experts on homelessness as particularly effective in
integrating programs that serve homeless people with mainstream
programs. The county's systems integration initiative creates
connections between the mental health, substance abuse, and
criminal justice systems in an effort to address the multiple and
complex needs of many of the county's homeless in a more
coordinated and effective manner. The Health Care for the Homeless
Network, as implemented in King County, illustrates how programs
can be targeted specifically to the homeless while tapping into
existing mainstream resources. Background
About 1.7 million people lived in King County, Washington, in
1998, including about 525,000 in the city of Seattle in 1996,
according to U.S. Census Bureau estimates. Although personal
income in King County is significantly higher than the national
average, about 9 percent of the population lived in poverty in
1995, according to the U.S. Census Bureau. King County has a tight
housing market-rents are high compared with income, rents have
been rising, and the vacancy rate is low. On any given night,
about 5,500 people are homeless in King County, according to the
Seattle-King County Homelessness Advisory Group. Roughly 54
percent of those that are homeless are single adults, and 46
percent are families or youth. At any given time, an estimated
1,360 homeless people are believed to be living on the street,
while most of the remainder are housed in emergency shelters or
transitional housing. King County's homeless population is heavily
concentrated in Seattle. Seattle and King County collaborate in
developing the Continuum of Care plan for the community and
jointly submit a single application to HUD for funding through its
McKinney Act programs. The King County government, under contract
with the state of Washington, provides most of the county's
supportive services, such as mental health and substance abuse
treatment. Within Seattle, the city government provides funding
for most of the emergency shelter and transitional housing
programs. Systems Integration in King County has undertaken a
series of initiatives to integrate various King County
social service systems that serve homeless people. These include
efforts to integrate the mental health and substance abuse
systems, address the Page 30 GAO/RCED-99-178 Integrating and
Evaluating Homeless Assistance Programs Appendix II King County,
Washington problem of chronic public inebriates, and provide
alternatives to county jails for those with mental illness or
substance abuse disorders. In addition, Seattle's participation in
HHS' Access to Community Care and Effective Services and Supports
(ACCESS) program has been an important aid to the county's systems
integration efforts. The county defines "systems integration" as
the sharing of information, planning, clients, and resources by
different social service systems. At the operational level, this
means getting different systems, such as the mental health,
substance abuse, corrections, and housing systems, to work
together in an integrated fashion to provide a continuum of
services to their clients. Integration of the Mental The
primary focus of King County's systems integration efforts has
been Health and Substance on unifying the county's mental
health and substance abuse systems. Part Abuse Systems
of the impetus for this integration is the recognition that many
homeless people in the community are dually diagnosed with both
mental health and substance abuse disorders. In 1998, the county
created the Bureau of Unified Services to stimulate the
integration of systems and services for individuals and families
suffering from mental illness and/or substance abuse. The county
also proposed combining the Division of Mental Health and the
Division of Alcoholism and Substance Abuse Treatment Services into
a single Mental Health, Chemical Abuse and Dependency Services
Division so that the county government's organizational structure
would be better aligned with the integrated systems approach. The
county is currently waiting for the County Council to approve this
proposed restructuring. As part of its systems integration
strategy, King County developed a "no wrong doors" philosophy.
This means that persons with mental or addictive illness are
offered the services they need whether they seek assistance
through a local hospital, detoxification center, emergency
shelter, mental health treatment program, or correctional
facility. In July 1998, as a pilot project, the county opened the
Crisis Triage Unit at Seattle's Harborview Medical Center. The
triage unit is designed to serve as a single place where someone
experiencing a behavioral health crisis, particularly related to
mental health and/or substance abuse issues, can receive immediate
care and referral to other longer-term services. According to
county officials, about half of the people who are brought to the
triage unit are homeless and more are at risk of becoming
homeless. The triage unit is staffed with personnel qualified to
assess medical, mental health, and substance abuse conditions, as
well as with a housing coordinator, who assists clients in gaining
access to short-term housing or Page 31 GAO/RCED-99-178
Integrating and Evaluating Homeless Assistance Programs Appendix
II King County, Washington in maintaining existing housing. The
triage unit is designed, in part, to divert people from local
jails or hospitals, where they might otherwise be taken, to more
appropriate housing and treatment situations. Efforts to Address
the In September 1997, King County began searching for
solutions to the issue Problem of Homeless of chronic
public inebriates. These individuals are usually homeless Public
Inebriates chronic abusers of alcohol who often have
secondary problems with drug abuse or mental illness. The county
convened a Chronic Public Inebriates Systems Solutions Workgroup,
which included representatives from the city and county
governments, the business community, homeless assistance service
agencies, and other affected parties. This effort stemmed, in
part, from a recognition in the community that many of the
severely distressed individuals in this population were repeatedly
entering certain parts of the county's systems, such as hospital
emergency rooms and the courts, where their conditions could not
be appropriately addressed. In December 1997, the workgroup
developed a housing plan that recommended a series of policy
changes and housing actions to help address the needs of chronic
public inebriates living on the streets, as well as reduce the
negative effects of this population on the community. The actions
taken thus far have included opening a sobering sleep-off center,
reaching agreement with downtown merchants not to sell certain
alcoholic products favored by street inebriates, improving
outreach services, and taking steps to develop more supportive
housing units for this population. Alternatives to Jail for
Beginning in 1985, in response to concerns that the county's jails
Offenders With Mental contained large numbers of mentally
ill inmates whose needs would be Illness and Substance
better addressed through treatment, King County developed several
jail Abuse Disorders diversion projects. These
projects sought to prevent recidivism among mentally ill
offendersa large percentage of whom were homelessby providing them
with increased services and intensive case management as an
alternative to incarceration. In 1997, these projects were
redesigned, resources for treatment were increased, a housing
component was added, and for the first time, persons whose primary
disorder was substance abuse were included in the project. These
projects were jointly funded by the county agencies overseeing
criminal justice, detention, mental health, and substance abuse
services, as well as by the city of Seattle. Page 32
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs Appendix II King County, Washington In December 1998, the
county replaced these jail diversion projects with the Mental
Health Court, a pilot project that incorporates many of the
elements of the prior projects. Defendants with mental illness who
have been charged with misdemeanors can now choose to have their
cases heard in a special court, where they typically receive
court-ordered treatment as an alternative to prosecution or
sentencing. On the basis of past experience, King County officials
expect that about one-third of those using the Mental Health Court
will be homeless and many more will be at risk of becoming
homeless. Integration Efforts According to King County
officials, an important aid to their systems Stimulated by
Participation integration efforts has been Seattle's
participation in the HHS' ACCESS in ACCESS Program
program. ACCESS is a 5-year demonstration program that began in
1994 and will end in 1999. The goal of ACCESS is to evaluate the
impact of systems integration on the provision of services for
homeless people who are severely mentally ill. Eighteen sites-nine
control sites and nine experimental sites-in nine states across
the country were selected to participate in the ACCESS program.
Seattle is home to both a control site and an experimental site,
located in different parts of the city. Both Seattle sites
received resources to fund services for homeless people who are
mentally ill, and the experimental site received additional
resources to fund activities designed to enhance systems
integration. This included the hiring of a full-time systems
integration administrator within the King County Department of
Community and Human Services and the creation of working groups
designed to improve collaboration and communication between
provider agencies and the community. Although the ACCESS program
will end this year, a county official told us that the county is
"institutionalizing" the lessons learned from the program through
the creation of a new Homeless Outreach, Stabilization and
Transition Program, which will incorporate many of the systems
integration activities that were provided under ACCESS. Seattle-
King County's The goal of HHS' Health Care for the
Homeless program is to make Health Care for the high-
quality health care accessible to homeless people nationwide. The
program awards grants to local public or private nonprofit
organizations Homeless Network to provide health
care services to the homeless. In fiscal year 1998, the Health
Care for the Homeless program funded 128 projects nationwide that
were administered by local public health departments, community
Page 33 GAO/RCED-99-178 Integrating and Evaluating
Homeless Assistance Programs Appendix II King County, Washington
and migrant health centers, hospitals, and local community
coalitions. According to HHS, the program encourages an
interdisciplinary approach that incorporates health, mental
health, substance abuse, and social services to build a
coordinated network of services for homeless people within a
community. Health Care for the Homeless projects throughout the
country are implemented through a variety of different
organizational models. About half of the projects are housed in
community health centers, about 25 percent in public health
departments, and the remainder in other organizations, such as
nonprofit agencies, hospitals, and shelter coalitions. The Health
Care for the Homeless Network (HCHN) model in Seattle-King County
combines services provided directly by the county's public health
staff with contracted services provided by mainstream health care
providers. Several national experts on homelessness told us that
Seattle-King County's HCHN was particularly effective. However,
Seattle-King County's model is one of many that have been
successful and experts say that the most appropriate model for
implementing Health Care for the Homeless in any given location
will depend on the specific needs and characteristics of the
particular community. County and Mainstream Seattle-King
County's HCHN is administered by the Seattle-King County Services
Linked Through Department of Public Health, which provides
certain services directly to HCHN homeless
people and contracts with mainstream health care providers for
other services. Services provided directly by Department of Public
Health staff include immunizations, family planning, dental
screening, tuberculosis outreach, communicable disease control,
and health education. Most of these services are provided at sites
operated by the department. The Department of Public Health also
has a full-time public health nurse available to provide technical
assistance on health and safety issues to agencies that serve
homeless people. For example, the public health nurse provides
training to staff in emergency shelters on first aid and disease
prevention. The Department of Public Health also provides
emergency shelters with certain supplies, like soap and liquid
soap dispensers, to help improve the general hygiene of their
homeless clients. The Department of Public Health contracts with
10 community-based health care providers, including hospitals,
community health centers, and social service agencies, to provide
most of the network's services. These services include street
outreach, primary care, substance abuse and mental health
services, medical respite, and assistance with enrollment Page 34
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs Appendix II King County, Washington and the use of
Medicaid managed care. To be more accessible to the homeless
population they serve, most of the health care professionals
working for the community-based health care providers are located
at emergency shelters. Benefits of County's HCHN The Health
Care for the Homeless model implemented in Seattle-King Model
County has a number of benefits, according to local officials.
These include better access to city-, county-, and community-based
resources; more continuity in the provision of services to
homeless people; and improved data collection capabilities that
can help city and county governments better plan services for
homeless people. According to a Seattle official, placing the
Seattle-King County HCHN within a major government agency like the
Department of Public Health, rather than in a community-based
nonprofit service agency, improves its access to the community's
major health care resources. At the same time, by contracting with
community providers for health care services, HCHN is able to tap
into existing mainstream resources, such as hospitals and
community health centers, without having to create a separate
system of care for homeless people. The requirements in HCHN's
contracts with providers in mainstream systems also allow HCHN to
hold these systems more accountable for serving homeless people,
who are traditionally a more difficult and expensive population to
serve. These requirements also ensure that mainstream systems
provide the special outreach and support that the homeless
population requires. Moreover, components of Seattle-King County's
HCHN help to ensure continuity of care for homeless people as they
move from location to location, and even after they move out of
homelessness. Under the Pathways Home program, a team of health
care professionals track and monitor homeless familieswhether they
are living on the street, in an emergency shelter, or in temporary
housingand continue to provide them with the range of health care
services that they need, from screening and case management to
comprehensive mental health treatment. The team provides health
care to these clients for up to a year after they have been placed
in permanent housing. Finally, the Seattle-King County HCHN has in
place a data system that provides important information on
homeless people and the services they are receiving. Each provider
that contracts with HCHN records every encounter with a homeless
client on a standardized intake form. All of the Page 35
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs Appendix II King County, Washington data are maintained
on a central database, and each homeless client is given a unique
identification number that allows HCHN to track the client
throughout the system. According to a program official, the
Seattle-King County HCHN database has recorded about 60,000
encounters with about 20,000 individuals in the past year. This
information aids city and county governments in identifying the
major health problems affecting homeless people, as well as in
monitoring general health and demographic trends among this
population. Page 36 GAO/RCED-99-178 Integrating and
Evaluating Homeless Assistance Programs Appendix III Franklin
County, Ohio This appendix describes the efforts of Franklin
County, Ohio, to integrate its emergency shelter programs and
related homeless assistance services into a coordinated and
unified system, primarily through its Community Shelter Board.
Franklin County, which includes the city of Columbus, was
identified by a number of national experts on homelessness as
particularly successful in getting communitywide support for its
homeless assistance programs, coordinating its emergency shelter
resources, and reducing the administrative burden on providers.
The county also has a management information system that allows it
to collect client-specific data in a uniform fashion across the
entire emergency shelter system. The Community Shelter Board, with
guidance from the state, is using these data to develop and
measure programs' outcomes so that it can better manage homeless
assistance programs and services. Background The population
of Franklin County, in central Ohio, was just over 1 million in
1998, according to a U.S. Census Bureau estimate. The majority of
the county's population resides in Columbus, which in 1996 had a
population of about 660,000. Franklin County has a fairly strong
economy and relatively low unemployment. While housing costs are
lower than those of many other metropolitan areas nationwide, the
county has a shortage of affordable housing for low-income
residents and a substantial waiting list for subsidized housing.
During 1998, 840 shelter beds served 8,911 homeless individuals in
Franklin County. In addition, there were 1,042 transitional
housing beds in the county. The number of families needing
emergency shelter has risen significantly in the past several
years. Currently, about half of the people that use the county's
emergency shelters are families with children and half are single
adults, whereas in the past most of the homeless were single adult
men. The county's homeless population is heavily concentrated in
Columbus. The Community Shelter Board (CSB) is a nonprofit
organization that coordinates and administers most of the
government and private funding for Franklin County's emergency
shelters and certain related services for homeless people. In its
fiscal year ending March 1999, CSB budgeted about $4.8 million to
help fund 11 agencies. About two-thirds of this funding was used
to support adult and family shelter programs, and most of the
remaining funds were used for homeless prevention programs,
housing resource programs, technical assistance, research, and
special services. CSB receives funds from both government and
private sources, including Page 37 GAO/RCED-99-178
Integrating and Evaluating Homeless Assistance Programs Appendix
III Franklin County, Ohio the city of Columbus, Franklin County,
the state of Ohio, HUD, the United Way, and private donations. CSB
also coordinates the Continuum of Care planning process for
Franklin County. The Franklin County Department of Human Services,
which is supervised by the Ohio Department of Human Services,
provides certain supportive services that benefit low-income
people in the county, such as income support programs and
Medicaid. The Alcohol, Drug and Mental Health Board of Franklin
County, which is funded and overseen by the Ohio Department of
Mental Health and the Ohio Department of Alcohol and Drug
Addiction Services, contracts with 52 agencies to provide the
county's mental health and substance abuse services. In addition,
the Ohio Department of Development administers a variety of state-
and federally-funded programs that benefit homeless people
statewide, including the Emergency Shelter Grants and Supportive
Housing for the Homeless programs. The Coalition on Homelessness
and Housing in Ohio, a nonprofit agency, coordinates the statewide
Continuum of Care planning process and provides advocacy,
technical assistance, training, and some direct assistance to
state agencies and homeless service providers. Coordination of
The Community Shelter Board serves as an intermediary between
funding Emergency Shelter sources and the nonprofit
agencies that provide emergency shelter and related services to
homeless people in Franklin County. Many of the and Other Services
government officials, advocates, and providers of services for
homeless Through the people that we spoke withat
the county, state, and national levelsdescribed CSB as a highly
effective organization. They noted that its Community Shelter
distinctive role allows it to plan countywide shelter services and
foster Board successful collaborations
between the various players and systems that serve the homeless in
Franklin County. Benefits of Intermediary CSB is neither a
government agency nor a direct provider of services to Role
homeless people; instead, it functions as an intermediary between
the sources that fund shelter services and the agencies that
provide these services. As a result, CSB benefits from the
community's perception that it is a neutral body that is not
unduly influenced by either local government politics or service
providers' agendas. For example, CSB receives most of its funding
from government sources; however, because it is a private
nonprofit agency, it is perceived as somewhat immune to local
politics when making funding and planning decisions. Moreover,
because CSB itself Page 38 GAO/RCED-99-178 Integrating
and Evaluating Homeless Assistance Programs Appendix III Franklin
County, Ohio does not provide direct services to homeless people
and because the agencies that it funds do not have positions on
its board of trustees, it is able to represent the interests of
homeless people and yet avoid the conflicts that might occur if
funding and planning decisions were seen as based solely on the
interests of the agencies it funds. In addition, because CSB was
founded by a group of local businesspeople and has a number of
business and civic leaders on its board of trustees, it has been
able to attract a high level of support and participation from the
local business community. Benefits of Centralized CSB serves as
the single organization that coordinates and plans all shelter
Structure services in Franklin County and
coordinates the county's Continuum of Care planning process. In
this role, CSB can ensure that all of these services and programs
are considered as part of a whole "system" that works together
rather than as a fragmented set of independent resources.
According to community officials, CSB has provided a centralized
structure for what was previously a decentralized set of
community-based services and programs. An example of the benefit
of this centralized structure is CSB's work on a plan to address
the needs of homeless men who live in an area of Columbus called
the Scioto Peninsula. Half of the city's single men's shelter beds
are located in this area, and many of the city's street homeless
people reside there. In 1997, the city asked CSB to develop a plan
to address the needs of the large number of homeless men who would
be affected by development planned for the area. CSB coordinated
the Scioto Peninsula Relocation Task Force, which used the Scioto
Peninsula issue as an opportunity to conduct a more comprehensive
review of the needs of all single adult homeless men in Columbus
and Franklin County. The task force's resulting report serves as a
strategic plan that incorporates all of the various systems and
resources required to address the needs of this population,
including emergency shelters, permanent housing, and supportive
services. Benefits of a Single CSB serves as a single
conduit for funding from a variety of different Conduit for
Funding sources, thus reducing the administrative burden
for the community-based service providers who receive these funds.
CSB receives funds from a number of sources, including city and
county general tax funds, the federal Emergency Shelter Grants and
Community Development Block Grant programs, the Ohio Housing Trust
Fund, the United Way and other public Page 39 GAO/RCED-
99-178 Integrating and Evaluating Homeless Assistance Programs
Appendix III Franklin County, Ohio and private sources. Service
providers apply directly to CSB for these funds rather than to the
funding sources. CSB determines, on the basis of program
evaluations, eligibility requirements, and other considerations,
how much and which funds each provider will receive from each
source. Each provider signs a contract with CSB ensuring that it
will comply with any program requirements associated with the
funds it receives. This "one stop" blended funding process lessens
the administrative burden placed on service providers in several
ways. First, it reduces the number of funding applications they
have to complete. Second, it reduces the need for them to keep
track of the differing reporting and fiscal year requirements used
by different funding sources. Finally, it can help ease cash flow
problems that service providers may face. For example, as a
financial intermediary, CSB is in a position to advance money to
providers who have been awarded grants but have not yet received
the money. Data Collection and CSB collects both client-
specific and systemwide data from Franklin Program Evaluation
County's emergency shelter system. These data are used in a
variety of ways for planning, policy analysis, evaluation, and
needs assessment for Efforts in Franklin homeless
assistance programs. County Uniform, Systemwide Data CSB has
implemented a management information system to collect Collected
comprehensive, uniform data from the entire emergency shelter
system in Franklin County. CSB stipulates in its contract with
each of the county's emergency shelters what types of data must be
collected on homeless clients. A standardized intake form is used
by each shelter and includes questions about basic client
demographics, as well as income and benefits and the reasons for
homelessness. The information is collected and entered into CSB's
centrally located management information system. CSB officials
said that although the computer system and software itself are
somewhat dated (there are plans to move to a more modern Windows-
based system in the near future), the information management
system has allowed them to develop a uniform historical database
that includes information from all of the county's shelters on the
clients they have served since 1991. Data Used for Managing,
The data collected by CSB from emergency shelters in Franklin
County are Planning, and Evaluating used in a variety of ways
to better manage the resources available in the Services
community to serve homeless people. For example, CSB's management
Page 40 GAO/RCED-99-178 Integrating and Evaluating
Homeless Assistance Programs Appendix III Franklin County, Ohio
information system can provide information on the use of shelter
beds over time, both at individual shelters and systemwide,
allowing CSB to track the use of these scarce resources. The
system can also provide information on the demographics of shelter
clients and the patterns of shelter use over time. This
information has been used by the community for policy development,
needs assessment, and planning. In addition, because each shelter
client is given a unique identifying number, individual clients
can be tracked across time as they move through the system and are
referred to different service agencies. CSB can thus develop an
unduplicated count of how many people are using shelters and
analyze the movement of clients from program to program. The
Scioto Peninsula Task Force used CSB's historical database to
analyze patterns of use of the men's shelter system. They found
that 15 percent of the city's homeless men used 56 percent of the
shelter system's resources, while the remaining 85 percent of the
men entered the system transitionally for relatively short stays.
In addition, CSB found that the long-term users of the shelter
system often needed other services, such as mental and physical
health services or substance abuse treatment. To meet these needs,
the task force's final plan recommended that the city and county
develop service-enriched supportive housing for long-term users of
the system, thereby freeing shelter resources for those requiring
shelter for only a short period of time. State's and County's
The state of Ohio has started to develop performance standards
that are Use of Outcome intended to measure programs'
outcomes and improve the provision of services to homeless people.
In Franklin County, CSB has been working Measures to Improve
with the state to establish outcome measures for the service
providers it Programs for funds. Homeless People
Like some other state housing agencies nationwide, the Ohio
Department of Development has recently started to use outcome
measures for its housing programs that serve homeless people.
State officials told us that their intent is to improve the
quality of the programs they fund by focusing more on results-such
as moving people out of homelessnessrather than on outputssuch as
the number of units of service delivered. Like many other private
and government organizations that provide funding for homeless
programs, the state wants to ensure that it is getting the best
results for its dollars. State officials believe that the use of
outcome measures will encourage poorly performing agencies to
improve their programs, as well as identify the "best practices"
of providers who are Page 41 GAO/RCED-99-178 Integrating
and Evaluating Homeless Assistance Programs Appendix III Franklin
County, Ohio meeting their outcome goals and can provide
replicable models for other agencies to use. In 1998, the Ohio
Department of Development began a pilot project under which
agencies that receive state supportive housing grants were
required to develop outcome-based performance targets and were to
be held accountable for meeting their outcomes. All 53 of the
department's supportive housing grantees have attended special
training seminars that were intended to clarify and provide
guidance on how outcome measures and goals should be developed.1
As their efforts progress, state officials told us, they hope to
refine their benchmarks and set individualized outcome measures
that better reflect the nature of each grantee's work and the
population the grantee serves. For example, the general outcome
measure for a transitional housing program might be the percentage
of clients who move into some kind of permanent housing after a
certain period of time. However, an agency that serves a more
difficult population, such as the mentally ill, would not be
expected to have the same success rate as an agency that serves a
population with fewer barriers to becoming self-sufficient. In
Franklin County, CSB has been working with the Ohio Department of
Development to establish outcome measures for the service
providers it funds. For emergency shelters, these outcomes include
success in moving clients out of shelters and into more
appropriate housing, such as transitional housing. For a
transitional housing program, the outcomes measured include
occupancy rates (to ensure that resources are being fully used),
length of stay (to ensure that clients are not staying too long
without moving forward), and the percentage of clients that move
to permanent housing. CSB's management information system is able
to provide the data needed to measure many of these outcomes. It
does not, however, follow up on clients after they leave the
homeless service system altogether. 1The training session was
provided by the Rensselaerville Institute, a not-for-profit
institute that provides consultation services to government and
nonprofit organizations on performance and outcome management.
Page 42 GAO/RCED-99-178 Integrating and Evaluating
Homeless Assistance Programs Appendix IV Minnesota This appendix
describes Minnesota's use of outcome measures, data collection,
and program evaluation to address the problem of homelessness in
the state. National experts on homelessness with whom we spoke
consistently identified Minnesota as especially active and
innovative in evaluating its programs for homeless people and
using outcome measures to manage these programs. In particular,
Minnesota's Family Homeless Prevention and Assistance Program
provides communities with flexible grants but uses outcome
measures to hold providers accountable for achieving results.
Minnesota also conducts a comprehensive statewide survey of its
homeless population, which is used to assess the needs of, and
plan programs for, homeless people. In addition, Minnesota
conducts a relatively large number of evaluations to measure the
effectiveness of specific homeless assistance programs. Background
Minnesota had a population of about 4.7 million in 1998, of whom
about 2.8 million lived in the Minneapolis-St. Paul metropolitan
area in 1996, according to U.S. Census Bureau estimates. The state
has expressed concerns about a shortage of affordable housing,
particularly in the metropolitan area, where the economy is
relatively strong but the housing market is tight, with a rental
vacancy rate of about 2 percent. There are also concerns about a
lack of affordable housing in smaller communities outside the
metropolitan areas where employment is growing. A statewide survey
in October 1997 found that about 5,590 persons were homeless in
Minnesota on a given night. More than three-quarters of the
homeless individuals in temporary housing were women and children.
The number of homeless families in Minnesota has increased
significantly since 1991. About 82 percent of the homeless
individuals live in the Minneapolis-St. Paul metropolitan area,
while the remaining individuals live in other parts of the state,
known as Greater Minnesota. The Minnesota Housing Finance Agency
funds and administers several state homeless service and
prevention programs, coordinates the Continuum of Care plan for
Greater Minnesota, and convenes the state's Interagency Task Force
on Homelessness. The task force is composed of representatives
from a variety of state agencies and helps coordinate and
administer state programs specifically targeted for homeless
people. The state's Department of Children, Families, and Learning
administers the state's federally funded Emergency Shelter Grant
program, as well as other programs that serve homeless people.
Individual county governments-especially Hennepin County, which
includes Minneapolis, Page 43 GAO/RCED-99-178 Integrating and
Evaluating Homeless Assistance Programs Appendix IV Minnesota and
Ramsey County, which includes St. Paul-also provide housing and
services to homeless people. Municipal governments in Minnesota
play a limited role in providing or funding services for homeless
people. Minnesota's Family Minnesota uses outcome measures to
manage its Family Homeless Homeless Prevention Prevention and
Assistance Program (FHPAP). The state expects agencies to meet the
outcomes set for their programs and, in return, gives the agencies
and Assistance considerable flexibility in using program
funds. Program FHPAP is a state-funded program
whose goals are to (1) prevent homelessness, (2) reduce the length
of time people stay in emergency shelters, and (3) eliminate
repeat episodes of homelessness. The program is targeted primarily
to homeless families and provides funding for such things as
short-term rental assistance, security deposits needed to secure
housing, and housing search services. FHPAP is administered by the
Minnesota Housing Finance Agency in conjunction with the state's
Interagency Task Force on Homelessness. The state legislature
provided $6.05 million for the program for the 1997-99 biennium,
according to a state official, during which time it awarded 16
grants. In the Minneapolis-St. Paul metropolitan area, FHPAP made
grants to county agencies, which generally distributed the money
to the community-based nonprofit service providers that were the
subgrantees. In Greater Minnesota, FHPAP has usually provided
grants directly to nonprofit organizations. FHPAP grants are very
flexible, and grantees have considerable leeway in spending the
funds. However, grantees are required to (1) set specific
performance goals and outcome measures that are consistent with
each program's objectives, (2) develop a method for tracking these
outcomes, and (3) achieve and report on the outcomes they have
set. Each of these requirements is described below. Setting Goals
and Measures. When applying for program funds, grantees must state
specific, measurable outcome goals for their projects that relate
to FHPAP's three overall goals. The agencies must include the time
frames within which these goals will be achieved. For example, a
program for preventing homelessness might state that 90 percent of
the families and youth that participate in the program will be in
stable housing 6 months after they leave the program. According to
a program official, the program allows outcome goals to be set by
grantees rather than by the state, partly because conditions vary
so greatly in different parts of the state. Page 44
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs Appendix IV Minnesota Tracking Outcomes. FHPAP grantees
are required to develop methods of tracking and measuring their
programs' outcomes. For example, a grantee may choose to conduct
follow-up phone surveys with families that have received
assistance through a program or review clients' records at an
emergency shelter to measure how long the clients stay in the
shelter. Hennepin County, which had 28 FHPAP subgrantees in fiscal
year 1998, has developed its own data system for tracking
purposes. This system provides all of the subgrantees with
software that allows them to collect basic demographic and outcome
information on clients. These data are later entered into a
centralized data management system administered by the county. The
system assigns each client a unique identifier, which allows the
county to evaluate programs' outcomes by determining, for example,
how many of the clients who are enrolled in a homeless prevention
program are staying at an emergency shelter. Achieving and
Reporting Outcomes. Each FHPAP grantee is required to submit a
quarterly and an annual report to the state that provides
programs' overall results and outcome data for individual clients.
As long as providers successfully achieve the outcome goals they
have set for their programs, the state does not specify how they
must spend their FHPAP funds. A state official told us that this
flexibility benefits service providers because it reduces their
administrative burden, allows them to tailor their programs to
local needs and situations, and gives providers the freedom to try
new ways of preventing homelessness. In addition, the results
reported by the service providers have helped the state revise the
program on the basis of what has proved to be effective or
ineffective in addressing homelessness. For example, a state
official told us that service providers no longer use FHPAP funds
for long-term rental assistance because outcome information from
past programs showed that this was not a cost-effective way of
serving a large number of people. Minnesota's Statewide Minnesota
has been conducting a statewide survey of its homeless Survey of
Homeless population since 1991. Although other states
count and survey their homeless populations, Minnesota's survey is
notable because it is People comprehensive
and has been conducted every 3 years. Minnesota conducted
comprehensive surveys of the state's homeless population in 1991,
1994, and 1997, and plans another survey in 2000. These surveys
were commissioned by Minnesota's Interagency Task Force on
Homelessness and were conducted, under contract, by the Wilder
Page 45 GAO/RCED-99-178 Integrating and Evaluating
Homeless Assistance Programs Appendix IV Minnesota Research
Center.1 The surveys were funded jointly by state agencies,
including the Minnesota Housing Finance Agency and the Minnesota
Department of Human Services, as well as by nonprofit service
providers and private foundations. The cost of the most recent
survey was about $100,000. For the 1997 survey, more than 440
trained volunteers surveyed homeless individuals at 150 different
agencies that serve homeless people in 48 cities, as well as 18
street locations in 8 cities. The survey identified 5,590 people
as homeless on one particular night, including people in emergency
shelters, transitional housing, and battered women's shelters, as
well as living on the street and in other nonshelter locations.
Separate surveys were conducted for adults (including families)
and for unaccompanied youth. The surveys not only produced a
statewide count of the homeless but also provided comprehensive
data on the characteristics of the homeless population. Adults and
youth in shelters and transitional housing, as well as those
living on the street, were asked a detailed set of questions
covering demographics, income, shelter use, housing, employment,
substance abuse, and mental and physical health. State and local
officials have used the results of these surveys for a variety of
purposes in planning their programs for homeless people. For
example, because the surveys have been conducted at regular
intervals, state policymakers and others have been able to use the
results to gauge trends in the homeless population over time. One
trend that the surveys have shown is a significant and steady
increase in the number of homeless families and in the proportion
of the overall homeless population that families represent. The
surveys have also documented a rise in the percentage of homeless
people who are employed. According to an official at Wilder
Research Center, this suggests that homelessness in Minnesota may
be increasing more because of a shortage of affordable housing
than because of a lack of income sources. Officials from the
Wilder Research Center and two of the organizations that funded
the survey told us that two of the primary uses of the survey
results are to help persuade lawmakers and others of the need for
more resources and to help prepare grant applications. For
example, city planners often use the data from the survey when
they write grant proposals, and state agencies and providers use
the information to support their requests for more resources. One
official stated that the results of the 1The Wilder Research
Center is the research arm of the Wilder Foundation, a private
nonprofit foundation that focuses on social welfare issues in the
St. Paul metropolitan area. Page 46 GAO/RCED-99-178
Integrating and Evaluating Homeless Assistance Programs Appendix
IV Minnesota surveys were a factor in convincing the state
legislature of the need to create the Family Homeless Prevention
and Assistance Program. The information collected through the
surveys is also useful in assessing the needs of and in planning
programs for homeless people, according to a state official. For
example, when survey data indicated an increase in the number of
unaccompanied homeless youth (i.e., children who are not with
their parents), communities increased their efforts to address the
needs of this population in their Continuum of Care plans.
Minnesota's Minnesota has also conducted a number of
evaluations to determine the Evaluations of effectiveness
of some of its programs for homeless people. Some of these are
described below. Programs That Serve the Homeless
Evaluation of the Supportive Housing Demonstration Program. The
Minnesota Supportive Housing Demonstration Program provided $2.2
million in state funding for 180 supportive housing units for
people with mental illness, substance abuse disorders, or HIV/AIDS
who were either homeless or at risk of becoming homeless. The
project used a portion of the funds that would normally have been
used to provide institutional care (such as in group homes) for
these people and allowed the money to be used more flexibly to
provide them with supportive housing (independent housing with
supportive services). In June 1998, the Wilder Research Center
published a 1-year evaluation report on the demonstration project.
The report evaluated (1) the effectiveness and quality of the
supportive housing and services provided and (2) the cost-
effectiveness of this supportive housing compared with that of the
housing and services provided in other institutional settings.
Officials at the Corporation for Supportive Housing, which
coordinates the demonstration project, said that the Wilder
evaluation was the first study that ever quantified and compared
the cost of supportive housing with the costs of alternative
public-sector service systems. The cost of the housing and
services provided by the demonstration's supportive housing were
compared with the costs that the public sector would have incurred
to provide these residents with shelter and services. Public-
sector costs were estimated from data provided by systems such as
the state criminal justice system (for costs associated with
correctional facilities), county detoxification centers (for costs
associated with providing detoxification services), and the state
Department of Human Services (for costs associated with prior
residential care, hospital stays, General Assistance Page 47
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs Appendix IV Minnesota grants, and other social service
grants). The evaluation reported that, compared with the other
systems, the demonstration project improved the quality of life
for participants and reduced the costs of caring for them.
Anishinabe Wakiagun. Anishinabe Wakiagun is a permanent supportive
housing program for Native American men and women who are chronic
inebriates. The goal of the project is to provide a safe and
stable alternative to the street for this population, while
improving the civic atmosphere and reducing the amounts of money
spent on detoxification units, emergency rooms, and jails. The
project opened in September 1996 and is located in Minneapolis.
The Hennepin County Office of Planning and Development evaluated
the Anishinabe Wakiagun program for the period from September 1996
through March 1998. As part of this evaluation, the following two
outcome goals were analyzed: (1) reducing the population's use of
detoxification and emergency rooms and (2) stabilizing the
population's housing status. For each of the residents, the
evaluation compared their history 1 year before they were admitted
into the program with their status while they were in the program.
It evaluated data on their use of detoxification units, use of
hospital emergency room facilities, and booking in the adult
detention center. Other Evaluations. The Wilder Research Center
has also conducted or is conducting the following evaluations of
other homeless assistance programs in Minnesota: * A 6- and 12-
month follow-up evaluation of homeless people who are currently
living in transitional housing. The objective of the evaluation is
to gauge the effectiveness of transitional housing in moving
homeless people into permanent housing. * An evaluation of what
happens to youth once they have left Project Foundation, an
emergency shelter for homeless youth in Minneapolis. * An
evaluation of Rebuilding Our Own Futures (ROOF), a transitional
housing program for families. The study evaluated outcome measures
such as participants' success in obtaining permanent housing,
increasing income, and maintaining children's school attendance.
Page 48 GAO/RCED-99-178 Integrating and Evaluating
Homeless Assistance Programs Appendix V Comments From the
Department of Health and Human Services Note: GAO comments
supplementing those in the report text appear at the end of this
appendix. Page 49 GAO/RCED-99-178 Integrating and Evaluating
Homeless Assistance Programs Appendix V Comments From the
Department of Health and Human Services See comment 1. Page 50
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs Appendix V Comments From the Department of Health and
Human Services See comment 2. See comment 3. Page 51
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs Appendix V Comments From the Department of Health and
Human Services Page 52 GAO/RCED-99-178 Integrating and
Evaluating Homeless Assistance Programs Appendix V Comments From
the Department of Health and Human Services The following are
GAO's comments on the Department of Health and Human Services'
(HHS) letter dated June 9, 1999. GAO's Comments 1. We agree
that HHS has undertaken several initiatives to address
homelessness; however, we disagree with the Department that our
reporting of state and local officials' perceptions about its lack
of involvement in addressing homelessness is not adequately
substantiated or lacks specificity and documentation. The
observations we have reported are based on interviews we conducted
with more than 50 state and local officials in four different
locations across the country. The consistent nature of their
comments clearly suggests that many at the state and local level
believe that HHS needs to do more to address the needs of homeless
people. 2. We agree that there is a need to obtain more
information on the barriers created by federal, state, and local
policies. This information can be used by federal agencies to
better coordinate their efforts and help them implement changes
that can eliminate some of these barriers. However, this issue was
not within the scope of this assignment. We plan to address this
issue in a future review. 3. As we stated in comment 1, HHS has
made some efforts in this area, but, according to our review, they
are not perceived as adequate by some state and local officials.
Page 53 GAO/RCED-99-178 Integrating and Evaluating Homeless
Assistance Programs Appendix VI Comments From the Department of
Housing and Urban Development Note: GAO comments supplementing
those in the report text appear at the end of this appendix. See
comment 1. See comment 2. Page 54 GAO/RCED-99-178 Integrating
and Evaluating Homeless Assistance Programs Appendix VI Comments
From the Department of Housing and Urban Development Page 55
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs Appendix VI Comments From the Department of Housing and
Urban Development The following are GAO's comments on the
Department of Housing and Urban Development's (HUD) letter dated
June 2, 1999. GAO's Comments 1. We revised the report to
clarify the role of the Interagency Council on the Homeless. 2.
After reviewing HUD's comments, we deleted the sentence cited
because it was not the primary concern of the state and local
officials with whom we spoke. (385760) Page 56
GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance
Programs Ordering Information The first copy of each GAO report
and testimony is free. Additional copies are $2 each. Orders
should be sent to the following address, accompanied by a check or
money order made out to the Superintendent of Documents, when
necessary. VISA and MasterCard credit cards are accepted, also.
Orders for 100 or more copies to be mailed to a single address are
discounted 25 percent. Orders by mail: U.S. General Accounting
Office P.O. Box 37050 Washington, DC 20013 or visit: Room 1100
700 4th St. NW (corner of 4th and G Sts. NW) U.S. General
Accounting Office Washington, DC Orders may also be placed by
calling (202) 512-6000 or by using fax number (202) 512-6061, or
TDD (202) 512-2537. Each day, GAO issues a list of newly available
reports and testimony. To receive facsimile copies of the daily
list or any list from the past 30 days, please call (202) 512-6000
using a touchtone phone. A recorded menu will provide information
on how to obtain these lists. For information on how to access GAO
reports on the INTERNET, send an e-mail message with "info" in the
body to: [email protected] or visit GAO's World Wide Web Home Page
at: http://www.gao.gov PRINTED ON RECYCLED PAPER United States
General Accounting Office Bulk Rate Washington, D.C.
20548-0001 Postage & Fees Paid GAO Permit No. G100 Official
Business Penalty for Private Use $300 Address Correction Requested
*** End of document. ***