Background
A cornerstone effort of the increased focus on chronic homelessness was the development of the Collaborative Initiative to Help End Chronic Homelessness (CICH), an innovative demonstration project coordinated by the U.S. Interagency Council on Homelessness (USICH), jointly funded by the Departments of Housing and Urban Development (HUD), Health and Human Services (HHS [SAMHSA and HRSA]), and Veterans Affairs (VA). Recognizing that homelessness is an issue that cuts across various agencies in the federal government, this unique effort across Departments offered permanent housing and supportive service funding through a consolidated application process. The evaluation of the CICH is supported by HHS (Office of the Assistant Secretary for Planning and Evaluation), VA, and HUD, and is being conducted by the VA's Northeast Program Evaluation Center.
This jointly funded $55 million demonstration ($35 million funding in 2003, with $20 million added in subsequent years) initiated in 2003 focuses on improving outcomes for chronically homeless individuals by making funding available to support 11 communities working to integrate housing and treatment services for disabled individuals who have experienced long-term and/or repeated homelessness. The following six core services are provided for 3-5 years: permanent supportive housing, case management, mental health treatment, substance abuse treatment, primary health care, and veteran's health services. The sites include: Chattanooga TN; Chicago, IL; Columbus, OH; Denver CO; Ft. Lauderdale, FL; Los Angeles, CA; Martinez, CA; New York NY; Philadelphia PA; Portland, OR; and San Francisco, CA.
Methods
The evaluation includes both client and system components. For the client component, 1,242 individuals were enrolled into the program, and of those persons, 734 (59 percent) participated in the evaluation and gave their written informed consent to be part of the research sample. Local VA research staff administered quarterly follow-up assessments during the first years of the evaluation. For the system component, a network participation survey gathering information about characteristics of the lead and partner agencies at each site such as system integration was administered at baseline and each year thereafter for two additional years.
Client Outcomes
Interim data on client service use and outcomes at baseline and after the first 12 months of program participation indicate the following:
- At the time of program entry, CICH clients had been homeless an average of 8 years in their lifetimes, 72 percent had substance abuse problems, 76 percent had mental health problems, and 66 percent reported medical problems. Thirty percent (220) of the sample of 734 evaluation participants were veterans.
- A summary measure of service use (any amount of use of each of the six core services was counted as "yes" versus "no" for nonuse) indicated that the proportion of the six services received by each client rose from 64 percent at baseline to 78-81 percent during the following 12 months suggesting that clients remained engaged in most aspects of the CICH intervention during their first year in the program.
- The average number of days that CICH clients were housed in the previous 90 days increased over time. At baseline, the average was 18 days of the previous 90 days; at the 3 month follow-up, the average was 68 days of the previous 90 days; and at the 12 month follow-up, the average was 83 days of the previous 90 days. Although the CICH clients did not stay the full 90 days (of the previous 90 days) at any of these measurement intervals, this data suggests increasing stability over time.
- The mean monthly public assistance income of the CICH clients increased steadily from $316 at baseline to $478 at 1 year, a 50% increase.
- Although statistically significant, improvements of a modest magnitude of the CICH clients were observed in overall quality of life, mental health functioning, and reduced psychological stress.
- Total quarterly health costs per CICH client declined by 50%, from $6,832 at baseline to $3,376 at 12 months.
- The alcohol and drug problems of CICH clients remained largely unchanged over time.
- Improved coordination of services and positive relationships between CICH clients and their primary mental health/substance abuse practitioners were the strongest predictors of positive client outcomes.
- Comparisons of overall group differences and rates of change between CICH clients and a similar comparison group of homeless clients (N=118) who received some lesser combination of housing and services (i.e., usually available) than the CICH clients provided evidence that the CICH increased access to housing, physical health and mental health care, and community-based case management resulting in a more integrated package of services.
System Outcomes
Interim system-level findings after the initial two years of the CICH included:
- There was a significant increase in the implementation of practices that encourage system integration, as well as in actual levels of system integration themselves, particularly on the measure of joint service planning and coordination.
- There was a significant increase in the availability of information on client and service delivery, in the implementation of homeless management information systems, and in the use of evidence-based mental health practices.
- There was no significant association between client outcomes and the use of evidence-based practices or measures of collaboration and trust among CICH network agencies during CICH clients' first year of participation in the program.
The preliminary client outcome 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 physical health services, mental health services, and substance abuse treatment. The interim network findings highlight several positive trends in the characteristics and activities of CICH networks over the first two years of the study.
Additional reports on clients and agencies involved in the CICH for 3 years will be available in the future.
Acknowledgements
Peggy Halpern, Paul Dornan, Pete Dougherty, Anne Fletcher, Cynthia High, Mark Johnston, Robyn Raysor, and Gay Koerber participated in the Federal Funders CICH Evaluation Group representing HUD, DHHS, and VA provided essential oversight and review on earlier drafts of this paper.
We wish to acknowledge specifically the CICH evaluation site coordinators who coordinated data collection at their sites: Joyce Jones and Daniel White (Chattanooga), Eugene Herskovic (Chicago), JuanitaWilson (Columbus), Richard DiBlasio (Denver), Daniel Robbin and Elaine Stein (Ft. Lauderdale), John Nakashima (Los Angeles), Phyllis Larimore (Martinez), Julie Irwin (New York), Vincent Kane and Kimberly Lewis (Philadelphia), Lawrence Brennan (Portland), and Charlene Nason (San Francisco).
Brandi Williams coordinated data management at the VA Northeast Program
Evaluation Center (NEPEC) and Dennis Thompson provided computer programming support.