Guest Editorial: The Promise of Homelessness Prevention
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Homelessness is a tragic social problem affecting more than 2.1 million adults and 1.3 million children each year (Burt et al. 2001). Almost 10% of people living in poverty experience homelessness annually (Burt et al. 2001) and more than 25% of all people with severe mental illness will experience the devastation of losing their homes at some point in their lives (Herman et al. 1998; Susser et al. 1991).
Homelessness is far too common in our society. People who are homeless are among the most vulnerable, disenfranchised, and marginalized groups in our nation. They are disconnected from community life, reassuring routines, family and other sustaining relationships, as well as from mainstream services. Often invisible, these individuals lack a voice and are treated as inconsequential. In addition to their exclusion from community life, they are beset by the many ills associated with extreme poverty and residential instability. Life on the streets is filled with danger, extreme isolation, and deprivation – making each day a continuous struggle for survival. Many people who are homeless also have high rates of medical, mental health, and substance use conditions that are often exacerbated by their lack of a home. Homelessness itself is a traumatic event, the effects of which can last a lifetime.
The financial costs associated with homelessness are equally high. In addition to the cost of shelter, people experiencing homelessness are forced to use a variety of public systems in ways that can be inefficient and expensive. One study found that hospital stays for people experiencing homelessness were, on average, four days longer than for non-homeless people with comparable medical issues, costing approximately $2,414 more per hospitalization (Salit et al. 1998). A study of the homeless street population in Boston found that over a five year period, a cohort of 119 people had more than 18,000 emergency room visits at an average cost of $1,000 per visit (O’Connell et al. 2005). People experiencing homelessness also have significant and expensive interactions with the criminal justice system, often for minor offenses like loitering. In Asheville, North Carolina, 37 homeless men and women were arrested a total of 1,271 times over a three year period, resulting in $278,000 in jail costs alone (Asheville and Buncombe County 2005). Culhane et al. (2002) found that homeless people with severe mental illness used $40,451 per person, per year in services, which is seen by many as a conservative estimate. When researchers in San Diego followed 15 chronically homeless individuals to document their use of acute behavioral health care systems, mental health and substance use services, law enforcement interventions, and temporary periods of incarceration, they found that each of these individuals used approximately $200,000 in services over the 18 month study period (United States Interagency Council on Homelessness 2006). Citing an extreme case of a single individual, “million dollar Murray” cost the system more than an estimated $1 million in hospitalization, incarceration, detoxification, and ambulance services according to police (Gladwell 2006).
The human and financial costs of homelessness seem almost unimaginable in a society as affluent as ours. To end homelessness, we must move away from our current approach of managing and treating its consequences and begin to prevent its occurrence in the first place. This will require a paradigm shift in our thinking, planning, practice, policy, and resource allocation.
Attempts to focus on prevention are often thwarted by inadequate resources, fragmented and overly bureaucratic systems, misdirected policies, and a lack of commitment among policy makers. Policy responses are too often shaped by lawmakers’ and funders’ perceptions that constituents expect immediate solutions. This supports a short-range view of social planning in lieu of a more thoughtful approach, allowing short-term objectives to win out over those more beneficial to society. Our system of allocating resources may not be antithetical to prevention. However, our allegiance to “quick fix” remedies that alleviate symptoms may seem more compelling than addressing structural or systemic issues, which are often slow to produce results.
The National Alliance to End Homelessness has outlined a four pronged policy for ending homelessness: planning for and monitoring outcomes; closing the “front door” to homelessness by improving mainstream programs; opening the “back door” out of homelessness by facilitating quick access to housing for those who are homeless; and addressing the crisis of poverty by expanding affordable housing, increasing incomes, and improving availability of community-based services (National Alliance to End Homelessness 2000). With support from the Federal Interagency Council on Homelessness, over 200 communities have developed their own plans to end homelessness (National Alliance to End Homelessness 2006). Although these are critical first steps, it will take more than plans and task forces to prevent and end homelessness. As communities across the country grapple with how to implement their plans, they face many barriers. Their efforts require shifting priorities from treating to preventing and ending homelessness, reallocating resources, altering the operation of mainstream and targeted programs, implementing coordinated data systems, and fundamentally changing the way services, programs, and systems operate. To be successful, these efforts must include increased resources for both targeted and mainstream programs, research-based knowledge on what works for whom and in what settings, and building political will to bring about lasting, systemic change.
Most local communities support discrete homelessness prevention efforts such as housing counseling and advocacy, short-term grants/loans to people facing eviction for non-payment of rent or utility bills, and in-kind emergency assistance. An array of housing and service models such as Housing First and permanent supportive housing is also demonstrating success in housing homeless people with disabilities for extended periods. Unfortunately, most of these efforts are modest in scope, not connected to larger, coordinated community-wide homelessness prevention efforts, and have not been fully evaluated to determine their impact.
Research is also needed. To date, most studies of homelessness prevention have focused on determining the combination of risk and protective factors that increase the likelihood that someone will become homeless (Caton et al. 2005; Shinn et al. 1998). Although many factors have been identified, this knowledge has resulted in only a limited ability to predict homelessness. As some have argued, homelessness prevention efforts must be both effective and efficient to be successful–effective in preventing homelessness and efficient in targeting those most likely to become homeless unless they receive assistance (Burt et al. 2005; Burt et al. this issue). Analyses that document the costs associated with homelessness also (Culhane et al. 2002; Martinez and Burt 2000) are being conducted and used to advocate for a variety of housing-based homelessness prevention strategies.
With homelessness prevention in its infancy, many challenges lie ahead. A broadly based, commonly accepted prevention framework has not yet been developed. Although people who are homeless experience a variety of illnesses and disabilities, homelessness is a social condition, not an illness. The conceptualization of homelessness prevention does not easily fit into the traditional public health prevention paradigms (Gordon 1983; Mrazek and Haggerty 1994). The causes of homelessness are multi-faceted and interconnected. Structural and economic factors play a significant role: the growing gap between rich and poor; the lack of decent affordable housing; and the growth in service industry jobs that do not pay livable wages. Individual problems, such as mental illness and chronic health conditions, make some more vulnerable to these larger social forces. Like homelessness itself, homelessness prevention is complicated.
This special issue of The Journal of Primary Prevention gathers some of the best thinking about preventing homelessness. The articles describe the most promising and innovative prevention strategies being used to reduce the risk of homelessness, facilitate transition into the community, and stabilize formerly homeless people in permanent housing. To develop this special issue, we broadly disseminated an open call for papers and received an overwhelming response. We included articles representing a range of strategies at the systems, services, and individual levels, targeted across the life span.
To provide an additional dimension, we asked for commentaries from a physician who provides medical care to individuals living on the streets, and an individual who operates a consumer-run housing development corporation who has direct experience with the mental health system. These two commentaries offer real-life perspectives on the immediate need for homelessness prevention. O’Connell describes the deadly reality of homelessness: people living on the streets experience a mortality rate four times higher than housed people. His “call-to-action” cautions us that our efforts to improve the care and treatment of people who are homeless are not sufficient and must be coupled with broader systems change to improve access to housing and community-based services and supports. Wireman outlines some of the key consumer-oriented principles that must be considered as we shift our focus toward prevention. He reminds us that the goal of homelessness prevention must be housing and high quality services in mainstream community settings. Prevention efforts must account for the unique needs of each individual and facilitate individual growth and recovery. Most importantly, Wireman underscores how involving consumers in the planning and implementation of all prevention activities helps to ensure relevance.
The first set of articles focuses on broad, systems-level strategies. Burt, Pearson, and Montgomery review community-wide prevention by summarizing findings from a U.S. Department of Housing and Urban Development funded study. The article provides a useful road map for communities by highlighting elements of successful community efforts, including accurate targeting, jurisdictional commitment, mainstream agency involvement, and continuous system improvement. Backer, Howard, and Moran address the critical and difficult transition from various institutional settings into the community. The authors present a three-component model connecting discharge planning to assessment and treatment, and community-based services, illustrating their discussion with descriptions of innovative programs. The article asserts that effective discharge planning should promote “spanning the boundary” between institutions and the community, playing a major role in preventing homelessness. Doherty and Stuttaford take a broader, international perspective examining the European Union’s efforts to prevent and address homelessness among people with substance use disorders and provides an informative case study of a significant community-wide effort underway in Fife, Scotland. This paper illuminates the problem of homelessness in Europe and the shift toward prevention that is occurring there.
Many of the articles in this special issue consider innovative service-level prevention efforts and provide valuable information on implementation. Two of these focus on the central role of housing and supports. Stefancic and Tsemberis report on the effectiveness of Housing First with a group of chronic shelter users, the majority of whom were able to maintain permanent, independent housing over a four year period. The article describes how this practice was replicated in a suburban community. Since Housing First is a major component of initiatives to end homelessness and is undergoing replication in communities across the country, its demonstrated success outside of urban areas offers great promise to the field. Fisk and Rowe describe a program targeted toward homeless people with substance use problems. The program provides rental subsidies for sober housing that were found to enhance recovery and facilitate transition from treatment to community-based living. This paper calls our attention to the dire need for assertive outreach and innovative housing strategies for this major subgroup of people experiencing homelessness.
Several articles focus on facilitating the transition from shelter to housing and enhancing residential stability over the long term. Herman, Conover, Felix, Nakagawa, and Mills explain how Critical Time Intervention (CTI) is being used successfully to prevent the recurrence of homelessness among individuals with mental illness by ensuring continuity of care during the transition from shelter to housing. The authors describe the CTI model, document what is known about its effectiveness, and describe an adaptation of the model to assist homeless women transitioning from shelter to housing. Helfrich and Fogg describe a life skills intervention that helps homeless adults with mental illness develop greater skills in everyday living. Based on theories of empowerment and situated learning, the intervention was found to significantly improve skills in self care management and safe community participation among a group of homeless adults with mental illness living in emergency or single room occupancy housing. Pickett-Schenk, Cook, Grey, and Butler report that greater contact with close relatives, more frequent telephone contact, and greater satisfaction with family relationships were associated with greater housing stability. Policy and program strategies for strengthening family ties to prevent future homelessness are explored. Finally, Shaheen and Rio articulate the importance of employment in the lives of people experiencing homelessness and mental illness. The authors argue that employment must be seen as an early, critical component of preventing and ending homelessness, and outline strategies to facilitate employment opportunities. As a group, these articles emphasize the vital role strategic, time-sensitive, and targeted interventions can play in breaking the cycle of recurrent homelessness.
The last set of papers examines the prevention of homelessness among various important subgroups. Gewirtz examines the needs of formerly homeless children living with their families in permanent supportive housing. This paper describes an innovative alliance working to advance practice and research in mental health prevention and early intervention for formerly homeless children and their families. Backer and Howard look at the unique needs of people with cognitive impairments, describing the scope and nature of the problem, its impact on service access and utilization, and strategies providers can use to better serve individuals with such disabilities. Finally, McGuire highlights the unique needs of incarcerated veterans transitioning into the community and describes efforts being taken by the U.S. Department of Veterans Affairs to provide targeted outreach and transition services to these individuals. These articles remind us that to be effective, prevention efforts must be targeted to meet the unique needs of various groups at both the clinical and systems levels.
Involve consumers in designing, implementing, and evaluating all homelessness prevention efforts.
Identify and target subgroups of people at greatest risk of homelessness.
Adequately fund mainstream programs and make them more responsive to the needs of people at-risk of homelessness.
Coordinate and integrate targeted and mainstream resources into community-based approaches that are comprehensive, responsive to individual needs, and user-friendly.
Facilitate the systematic use of promising and evidence-based practices while encouraging on-going program innovation.
Support program and systems level research that determines the effectiveness of various homelessness prevention interventions and improves communities’ efforts to target these efforts to those at greatest risk.
Galvanize public and political will to end homelessness and support the development of adequate safe, affordable housing; comprehensive community-based services and supports; and increased incomes for vulnerable populations.
The development of this special issue was done through the Center for Mental Health Services (CMHS)-funded National Resource and Training Center on Homelessness and Mental Illness (contract # 270-03-4005) which is operated by The CDM Group, Inc. in partnership with the National Center on Family Homelessness and the CMHS-funded Homelessness Resource Center (contract # HHSS280200600029C) which is operated by The Institute on Homelessness and Trauma. We are grateful to CMHS and The Journal of Primary Prevention for supporting this important effort. We would like to thank Deborah Stone, Ph.D. of the CMHS Homeless Programs Branch for her enthusiasm and unwavering support. Preston Britner, Ph.D., editor of The Journal of Primary Prevention, welcomed this project from the beginning and was very helpful in facilitating its completion. We offer special thanks to Michael Keane, Dr.P.H. of the CDM Group, Inc. for providing on-going support and guidance and Megan Grandin of the National Center on Family Homelessness for managing the logistics around the special issue with tremendous grace and competence. Finally, we thank all the authors who submitted papers for the special issue. We appreciate their hard work and commitment to addressing the tragedy of homelessness.