Contents
Introduction
After two decades of federal and statewide planning, and numerous local initiatives, homelessness remains a problem for America. While most persons experience homelessness for only a brief period of time, an estimated one-in-ten experience chronic homelessness (Kuhn & Culhane, 1998). In partial response to the goal of eliminating chronic homelessness and to further the goal that federal agencies increase their level of collaboration, a new federal initiative, the Collaborative Initiative to Help End Chronic Homelessness (CICH) was initiated in 2004. Through this program persons experiencing chronic homelessness receive permanent supported housing and related primary healthcare, mental health services and social services (NOFA, 2003). A chronically homeless person is defined in this initiative as an unaccompanied homeless individual with a disabling condition who has either been continuously homeless for 1 year or more or has had at least four episodes of homelessness in the past 3 years,
The objective of the CICH National Performance Client Outcomes Assessment is to monitor both the use of services and client outcomes systematically and uniformly at each of the 11 participating sites to answer 4 questions: First, who was seen in the CICH initiative? Second, what changes were observed in both use of services and outcomes over the course of the initiative? Third, to what extent did service use patterns and client outcomes vary across sites and did observed variation in patterns of service use explain differences in outcomes? Fourth, did outcomes for CICH clients differ from those of a comparison sample of chronically homeless clients from the same communities who did not have access to CICH services?
Methods
Basic screening data were obtained on 1,430 potential clients, 1,242 of whom were enrolled into the program, and 734 (59%) of whom gave written informed consent to participate in the national evaluation (i.e., referred to as CICH clients hereafter). Local VA research staff administered nearly 2,400 quarterly follow-up assessments during the first years of the client evaluation (taking place between March 2004 and May 2006). This report, presents data on screening, enrollment, and both CICH client service use and outcomes during the first 12 months of program participation. Data are also presented on a comparison group, recruited for this evaluation, who did not receive CICH services. Twelve months was chosen as a cut-off point for inclusion in this report because most (80%) of the 12-month data on CICH clients has been collected enough to provide a stable estimates of both service use patterns and client outcomes in the program. A further report will be prepared after all data is collected for both CICH client and comparison group subjects.
Results
At the time of program entry, CICH clients had been homeless an average of 8 years in their lifetimes; 72% had substance abuse problems; 76% had mental health problems, and 66% reported medical problems (Table 4).
Of the six core services targeted for CICH clients, the proportion of these services received by individual clients, including both housing and healthcare services, increased from an average of 64% at baseline to 78-81% during the following 12 months (Table 7).
The average number of days housed in the previous 90 days increased dramatically from 18 at baseline, to 68 at the 3-month follow-up, and rose steadily thereafter to 83 at the 12 month follow-up (Table 7). Mean monthly public assistance income increased steadily from $316 at baseline to $478 one year later, a 50% increase. Significant improvements of modest magnitude were also observed in overall quality of life, mental health functioning, and reduced psychological distress. Alcohol and drug problems remained largely unchanged over time. Total quarterly health costs declined by 50%, from $6,832 at baseline to $3,376 at 12 months.
Measures of service use that were most strongly associated with client outcomes, among 19 measures examined, showed that improved coordination of services and positive relationships between clients and their primary mental health/substance abuse treater (the therapeutic alliance) were the strongest predictors of positive outcomes (Table 16, columns 10 and 18).
Comparisons of overall group differences and of rates of change between CICH clients and a similar comparison group of homeless clients who did not receive CICH services, at five of the sites, provide evidence that CICH increased access to housing, to primary providers of both physical health and mental health care, to community-based case management, and to a more integrated "package" of housing and supported services (Table 18).
Perhaps because they were provided with a fuller array of services, CICH clients showed substantially greater improvement in the mean number of days housed (14 days at baseline to 81 days at 12-months for CICH clients vs. 17 to 50 days among comparison group subjects). Similar differences are observed in mean monthly public support income ($317 at baseline to $484 at 12-months for CICH [a 53% increase] vs. $327 to $408 [a 25% increase] for comparison group subjects) (Table 18).
Conclusion
These preliminary findings suggest that a diverse population of chronically homeless adults with disabling conditions can successfully be housed and can maintain their housing when provided with a mix of permanent housing, intensive case management, and access to primary physical health services, mental health services, and substance abuse treatment. The CICH initiative has thus largely met its objectives for service delivery and outcomes in reaching out to a highly vulnerable population.