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

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    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
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