Collaborative Initiative to Help End Chronic Homelessness: Introduction

Lawrence D. Rickards, PhD Sarah A. McGraw, PhD Lynnette Araki, MPH Roger J. Casey, PhD, LCSW Cynthia W. High, MSW Mary Ellen Hombs, MCP Robyn S. Raysor, MSW
Abstract
The Collaborative Initiative to Help End Chronic Homelessness was a coordinated effort by the US Departments of Health and Human Services (HHS), Housing and Urban Development (HUD), and Veterans Affairs (VA), and the US Interagency Council on Homelessness to house and provide comprehensive supportive services to individuals with serious psychiatric, substance use, health, and related disabilities who were experiencing long-term chronic homelessness. Eleven communities received 3-year grants from HHS and VA (20032006) and up to 5-year grants from HUD (20032008) to implement the initiative. This article provides background on chronic
Address correspondence to Sarah A. McGraw, PhD, Center for Qualitative Research, New England Research Institutes, 9 Galen Street, Watertown, MA 02472, USA. Phone: +1-617-9237747; E-mail: smcgraw@neriscience.com. Lawrence D. Rickards, PhD, 1710 Hobart Street, NW, Washington, DC, 20009, USA. Phone: +1-202-2347818; E-mail: LDRickards@msn.com Lawrence D. Rickards, PhD, Homeless Programs Branch, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services, Rockville, MD 20420, USA. Phone: +1-202-2347818; E-mail: LDRickards@msn.com Lynnette Araki, MPH, Ofce of Planning, Evaluation, and Legislation, Health Resources and Services Administration, US Department of Health and Human Services, 5600 Fishers Lane, Room 10-49, Rockville, MD 20857, USA. Phone: +1-3014436204; Fax: +1-301-4432286; E-mail: laraki@hrsa.gov Roger J. Casey, PhD, LCSW, VA Homeless Providers, Homeless Grant/Per Diem Program, Ofce of Mental Health Services (116E), US Department of Veterans Affairs, 810 Vermont Avenue, NW, Washington, DC, 20420, USA. Phone: +1877-3320334; E-mail: Roger.Casey@va.gov Cynthia W. High, MSW, Special Needs Assistance Program, Ofce of Community Planning and Development, US Department of Housing and Urban Development, 451 Seventh Street, SW, Room 7256, Washington, DC, 20036, USA. E-mail: Cynthia.W.High@HUD.gov Mary Ellen Hombs, MCP, US Interagency Council on Homelessness, 409 Third Street, SW, Suite 310, Washington, DC, 20024, USA. Phone: +1-202-7084663; Fax: +1-202-7081216; E-mail: Maryellen.Hombs@USICH.gov Robyn S. Raysor, MSW, Special Needs Assistance Program, Ofce of Community Planning and Development, US Department of Housing and Urban Development, 451 Seventh Street, SW, Room 7262, Washington, DC, 20041, USA. Phone: +1-202-402-4891; E-mail: Robyn.S.Raysor@HUD.gov Journal of Behavioral Health Services & Research, 2009. Healthcare. c ) 2009 National Council for Community Behavioral

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homelessness, describes the federal collaboration to comprehensively address chronic homelessness, and introduces the seven articles in this special issue that describe the ndings and lessons learned from the participating communities in addressing chronic homelessness. Collectively, these articles offer insight into the challenges and benets of providing housing and services to individuals experiencing chronic homelessness.

The Collaborative Initiative to Help End Chronic Homelessness was a coordinated effort by the US Departments of Health and Human Services (HHS)*, Housing and Urban Development (HUD), and Veterans Affairs (VA) and the US Interagency Council on Homelessness (ICH). to house and provide supportive services to individuals with serious psychiatric, substance use, health, and related disabilities who were experiencing long-term chronic homelessness. Although each of the departments had supported programs that addressed homelessness, this was the rst collaborative initiative that coordinated cross-department funding, program monitoring, and technical assistance. Eleven communities received 3-year grants from HHS and VA (2003 2006). HUD funded seven 5-year Shelter Plus Care- grants (20032008) and four 3-year Supportive Housing grants (20032006), with grantees eligible to apply for renewal funding at the end of the grant period. This special issue of The Journal of Behavioral Health Services & Research includes seven articles that describe the ndings and lessons learned from the participating communities in addressing chronic homelessness. They address issues such as supportive housing approaches and stafng and managing programs, clinical and support issues and the implementation of practice models, serving individuals with co-occurring mental illnesses and substance use disorders, and client outcomes. The articles offer critical insight to providers and communities engaged in improving housing and services to persons experiencing chronic homelessness.

*US Department of Health and Human Services (www.HHS.gov), US Department of Housing and Urban Development (www.HUD.gov), and US Department of Veterans Affairs (www.VA.gov) are cabinet departments of the US federal government. .The Interagency Council on Homelessness (www.ICH.gov), authorized in the Stewart B. McKinney Homeless Assistance Act of 1987, is responsible for providing federal leadership for activities to assist homeless families and individuals. The major activities of the council include: (1) planning and coordinating the federal government's activities and programs to assist homeless people and making or recommending policy changes to improve such assistance; (2) monitoring and evaluating assistance to homeless persons provided by all levels of government and the private sector; (3) ensuring that technical assistance is provided to help community and other organizations effectively assist homeless persons; and (4) disseminating information on Federal resources available to assist the homeless population. -The HUD Shelter Plus Care Program provides rental assistance for hard-to-serve homeless persons with disabilities in connection with supportive services funded from sources outside the program. The program is designed to provide housing and supportive services on a long-term basis for homeless persons with disabilities (primarily those with serious mental illness, chronic problems with alcohol and/or drugs, and acquired immunodeciency syndrome (AIDS) or related diseases) and their families who are living in places not intended for human habitation or in emergency shelters. The program allows for a variety of housing choices and a range of supportive services funded by other sources, in response to the needs of the hard-to-reach homeless population with disabilities. The HUD Supportive Housing Program is authorized by the McKinney-Vento Homeless Assistance Act of 1987, as amended. It is designed to promote, as part of a local Continuum of Care strategy, the development of supportive housing and supportive services to assist homeless persons in the transition from homelessness and to enable them to live as independently as possible. Assistance in the Supportive Housing Program is provided to help homeless persons meet three overall goals: achieve residential stability, increase their skill levels and/or incomes, and obtain greater self-determination.

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Background
Denition of chronic homelessness Chronic homelessness is benign neither for individuals nor for the communities in which they live. Yet, despite this, a signicant number of Americans continue to live without housing. Kuhn and Culhane,1 in their research on shelter populations, identied clusters of individuals who remained homeless for extended periods (often for years and decades) or who frequently cycled in and out of homelessness. Kuhn and Culhane1 termed these individuals chronically and episodically homeless. HHS, HUD, and VA combined these typologies to dene chronic homelessness as the circumstance whereby an unaccompanied individual with a disabling condition who has either been continuously homeless for a year or more or has had at least four homeless episodes during the last three years. This denition of chronic homelessness was used by the Collaborative Initiative to Help End Chronic Homelessness.2 Prevalence of chronic homelessness Although few community epidemiological studies specic to chronic homelessness have been conducted, it is possible to estimate prevalence rates by extrapolating from data sources. Combining the episodic and chronic homelessness clusters referenced above1 yields 20% of shelter users who would meet the federal denition for chronically homeless. Using Continuum of Care application data, HUD estimated that 759,101 individuals were homeless in January 2006, of whom 331,000 (44%) were unsheltered and 155,623 (21%) met the federal denition of chronic homelessness. Of those experiencing chronic homelessness, 66% were unsheltered.3 These estimates are consistent with those of Burt et al.,4 who proposed a range of between 640,000 and 840,000 persons who were homeless over a 7-day period and a yearly estimate of between 2.5 and 3.5 million persons experiencing homelessness. Veterans are an at-risk population for homelessness. Estimates of the number of homeless men who are veterans vary, ranging from 18% to 49% in community samples,57 with Vietnam era veterans continuing to be at higher risk for homelessness than other veteran cohorts.6 Among those receiving homeless services, 33% of male clients were veterans, compared to 31% of men in the general population.8 Using data from the VA and the Census Bureau, the National Alliance to End Homelessness9 estimated a point prevalence of more than 195,000 veterans who are homeless on a given night in 2006, with 495,400 veterans experiencing homelessness in the course of the year. Effect of chronic homelessness on individuals Individuals living in homelessness experience an array of mental, physical, economic, and social conditions, including extreme poverty, exposure to the elements, mental and substance use disorders, malnutrition, victimization, bias, and stigma.10 These conditions have a direct bearing for the design of housing and service programs to effectively address homelessness. Behavioral Health and Substance Use Conditions Between one fourth and one third of persons experiencing homelessness have current severe psychiatric conditions, such as schizophrenia, major depression, and bipolar disorder, and 50% of these individuals have a co-occurring substance use disorder.11,12 The National Survey of Homeless Assistance Providers and Clients (NSHAPC) reported that 39% of clients had lifetime indicators of mental health problems, 38% of alcohol problems, 26% of drug problems; 30% indicated problems in all three areas; and 34% reported no mental health, alcohol, or drug problems.9 Those reporting co-occurring disorders were more likely to reside in emergency shelters (39%), to have had three or more episodes of homelessness within

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the past year (39%), and to have episodes of homelessness of more than 24-month duration (35%) than homeless clients without such disorders.9 Poor Health Extended homelessness threatens the health and welfare of those who endure its deprivations.13 Individuals experiencing homelessness suffer from chronic and acute health conditions that may be caused or exacerbated by homelessness, including respiratory disorders (such as tuberculosis and chronic lung disease), cardiovascular diseases (such as hypertension, peripheral vascular disease, and cardiac arrhythmias), ulcers, frostbite and hypothermia, skin diseases, diabetes, liver disease, dental and periodontal disease, genitourinary tract infections, seizures, cancer, human immunodeciency virus/AIDS, cognitive impairments, and traumatic injuries due to assaults, falls, and accidents.14,15 In addition, they are subject to common colds, inuenza, and muscle aches and pains, as are the general population, but these conditions are magnied by poor health care, exposure, and the crowded and unsanitary conditions of shelters and encampments.16 Those with serious mental illnesses may be at particular health risk. In a study of community-based case management, Desai and Rosenheck17 found that 43.6% of persons who are homeless and have serious mental illnesses had unmet needs for medical care at the time of program entry. Individual and systemic barriers to adequate health care for persons experiencing chronic homelessness contribute to signicant disparities in health outcomes and mortality rates. OConnell18 noted that, on the individual level, the immediacy of the daily struggle for shelter, food, and other necessities relegates health needs to a distant priority, and mental illnesses, social isolation, and mistrust of authority and institutions make requesting service difcult. Thus, common illnesses and injuries are left untreated, leading to increased emergency hospital visits and acute care admissions. Treatment plans appropriate for those with homes are often unworkable for persons experiencing homelessness, with bed rest often impossible, sanitary dressing changes difcult, medications hard to obtain and appropriately store, and diet control and adherence to regimens requiring multiple daily dosing unlikely.19 At the systemic level, access to health care and aftercare is extremely limited, hampered by a lack of health insurance, difculty in accessing Medicaid, and a shortage of community health clinics. These barriers to health care translate to high health care costs for providers and funders of services. Encounters with the Legal System Individuals experiencing chronic homelessness are at risk for arrest and incarceration. The NSHAPC reported that 54% of homeless clients had been incarcerated, as communities may have panhandling restrictions, laws that regulate public sleeping and camping,9 and anti-loitering ordinances.19 Homeless individuals may also be subject to arrest for such disorderly conduct offenses as public drinking or urination, as well as for other more serious misdemeanors and felonies. Persons who are homeless and have mental illnesses or co-occurring disorders are more likely to be arrested and to be held in jail for longer duration than non-homeless inmates.20,21 Those who are homeless also have contact with the legal system due to their high rates of victimization.21 The NSHAPC9 reported that the majority of clients had been criminally victimized while homeless, including robberies, physical assaults, and sexual assaults. Effect of chronic homelessness on communities States and cities that do not address chronic homelessness may face substantial nancial implications for their jurisdictions. These costs are primarily in the health care and legal systems. Health Care Costs Studies conducted on emergency department use and hospital admissions in metropolitan areas across the nation have reported high utilization by chronically homeless persons. In a study of hospital costs associated with homelessness, Salit et al.22 reported that 52%

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of individuals who are homeless were admitted for mental or substance abuse treatment, compared to 23% of non-homeless low-income patients, and the length of hospital stay for homeless patients was 36% longer per admission than for non-homeless patients. OConnell,23 in a work with the Boston Health Care for the Homeless Program, reported that 119 street folks had an aggregate of 18,348 emergency department visits over a 5-year period and that 44 of the cohort (37%) died over a 7-year period. Rosenheck and Seibyl24 reported that health care costs for homeless veterans were more than 13% higher than the cost of care for non-homeless veterans. Cumulatively, the reliance on the use of emergency departments as the safety net for medical care, the excess of acute and chronic conditions that result from delayed or inadequate care, and the longer stays per hospital admission result in disproportionately high medical service costs for facilities providing care to individuals experiencing chronic homelessness and for payers at all levels.25,26 Legal System Costs A second concentration of high community cost related to chronic homelessness is within the legal system. Persons who are homeless and have mental illnesses or co-occurring disorders are at greater risk for legal system involvement, both as offenders and as victims.21,27 Such involvement may be with police and sheriff personnel, public defenders, ofcers of the court, jails, prisons, and legal guardians.21 Kushel et al.,28 found that 23% of homeless emergency department users had lifetime histories of incarceration; 29% had been arrested in the previous year, and 57% had been a victim of crime during the prior year. In their review of administrative data on service utilization, Culhane et al.25 documented that, among a population of individuals experiencing homelessness and severe mental illness disabilities, 12% had spent time in jail, averaging 82.7 days in jail per person. The types of offenses that lead to arrest often relate to the individuals homelessness, poverty, and co-occurring disorders and include shoplifting, theft, or robbery; substance-use-related violations; disorderly conduct/criminal mischief; assault or threatening behavior; and criminal trespass. Some statutes, such as obstruction of sidewalks and sitting or lying in public spaces, are more likely to be enforced against people experiencing homelessness and result in increased legal system costs.29 Because individuals who are chronically homeless live much of their lives in public spaces, there are also frequent informal encounters with police that do not lead to arrests.21 Cumulatively, considerable legal system attention and resources are directed towards persons experiencing homelessness.

Snapshot of chronic homelessness What emerges from a review of the literature on chronic homelessness are individuals who have been in and out of emergency shelters, psychiatric facilities, jails, and prisons. These are people who have constant or relapsing conditions, such as mental and substance use disorders, trauma, and chronic and acute physical conditions, who are unlikely to receive consistently appropriate treatment and who, if they should receive such treatment, are challenged with participating in aftercare plans that may require bed rest, clinic appointments, and complex medication regimens. The daily struggle and vigilance needed for survival makes it unlikely that they will be able to participate fully in addressing chronic and relapsing psychiatric and substance use conditions or to engage in other recovery-oriented activities, such as job training, supported employment, psychoeducation programs, or other community engagement activities. Fragmented systems of care virtually guarantee that the multiple needs of individuals who are chronically homeless will not be comprehensively addressed. Persons who are chronically homeless experience extreme poverty and are unlikely to have medical insurance; they do not have the resources to cushion crises. Because they are homeless and may look odd or smell different, they must also contend with societal disapproval, stigma, and bias, factors which may lead to ostracism, more frequent contact with law enforcement, and profound social alienation and isolation. Individuals experiencing chronic

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homelessness have learned to mistrust those in authority, be they police, outreach workers, or shelter providers. Progress in addressing chronic homelessness Although this snapshot presents a bleak picture of chronic homelessness, strides have been made that provide hope that ending chronic homelessness can become a reality. These advances include more intensive outreach and engagement in services, efforts to provide longer-term or permanent housing, better coordinated health care, assistance with obtaining nancial and health care benets, and more systematic application of practices to support individuals in their housing (including intensive case management), as well as mental health, substance abuse, and medical treatment. Outreach and Engagement As it pertains to homelessness, outreach and engagement involves locating people on the streets, in transit terminals, under bridges, in encampments, or in emergency shelters and responding to their immediate needs for food, clothing, and shelter.28 Effective outreach is exible in the type and number of services provided and may require extended contact with the client before trust and rapport can be established.28,30 When provided within a context of client-determined need and choice, low demand, and cultural competency, even individuals with severe disabilities can be engaged in services and housing.28,31,32 Closely linked to outreach and engagement, Assertive Community Treatment (ACT) is a case management model with documented effectiveness for use with persons experiencing chronic homelessness.33,34 When implemented with delity, including multidisciplinary teams, active outreach and engagement of clients, shared caseloads among the team, a low 10:1 client to staff ratio, 24-h/day client accessibility to staff, treatment plans tailored to individual client needs, regular home visits and client contact,35 clients who are homeless demonstrate improvement in such domains as housing stability,36 participation in mental health and substance abuse treatment,33 and primary health care utilization and treatment.37 Co-Occurring Mental Health and Substance Abuse Treatment Advances have also been made in the treatment of co-occurring mental and substance use disorders. It is increasingly recognized, though not yet routinely implemented, that integrated treatment (the coordinated treatment of both co-occurring conditions) is the most effective approach in addressing co-occurring disorders for individuals with both serious mental illness and substance use disorders.12,38,39 The critical components of integrated treatment include staged interventions, assertive outreach, motivational interventions, counseling, group interventions, pharmacological interventions, social support interventions, contingency management, a long-term recovery perspective, comprehensiveness in addressing multiple client needs, cultural sensitivity and competence, and both consumer and family strategies.39,40 From their research on 10-year outcomes for clients with co-occurring schizophrenia and substance use disorders, Drake et al.41 reported that participants demonstrated steady improvement in the domains of symptoms, substance use, institutionalization, functional status, and quality of life. Integrated treatment has been successfully provided to a range of client populations in a variety of settings.42 Supportive Housing Advances have been made in housing for individuals experiencing homelessness. Over the past two decades, HUD has funded housing and services to address homelessness through McKinney-Vento Act homeless assistance discretionary grant programs. HUD currently provides approximately a billion dollars annually to 6,000 housing and service projects through its Continuum of Care competition. Supportive housing has become a program model for homeless assistance and mental health systems.43 Although embracing both transitional and permanent housing, single-site and scattered-site models, and an array of stafng and program

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strategies, common characteristics of supportive housing include targeting to persons with disabilities, subsidies limiting rent to 3050% of tenant income, and a range of services and programs to meet a diversity of tenant needs.44 For persons experiencing homelessness to engage fully in mental health and substance abuse treatment and recovery services, it is increasingly recognized that the stability and safety provided by housing are a necessary precondition.44,45 Improved housing stability and willingness to engage in treatment are obtained when persons experiencing homelessness are provided immediate access to housing, choice and control of living arrangements, support through intensive case management, and linkage to psychiatric and substance abuse treatment and other services.36 Despite these promising ndings, concerns remain about high departure rates from permanent housing, that tenants may not voluntarily engage in needed supportive, employment, and treatment services and the potential policy ramications of illicit drug use in publicly funded housing.46,47 Goldnger et al.45 noted that stability is aided when providers are attuned to tenants at particular risk for housing loss and those experiencing high levels of distress and crises. Mojtabai48 reported that housed formerly homeless individuals with mental illness who participate in treatment are at no greater risk for housing loss or eviction than are tenants without mental illness. In their study on the use of acute care services by formerly homeless tenants living in permanent supportive housing, Martinez and Burt49 reported that in addition to attaining residential stability, tenants also reduced emergency department visits and inpatient hospital use. Permanent supportive housing has also resulted in reductions in shelter use, state hospital admissions, VA medical center inpatient days, and in arrests and incarceration, resulting in substantial cost reductions in these sectors.26,50 Systems Collaboration An advance in the provision of services to persons experiencing chronic homelessness is the conceptual shift to a systems collaboration approach to service delivery. This approach recognizes the multiple needs of those experiencing chronic homelessness and combines individual services into a network of interconnected providers to take a comprehensive approach to service delivery. Mental health agencies that work with homeless populations provide mental health services and, increasingly, are also providing substance abuse treatment, housing services, benets and income support application assistance, formal linkage to programs that provide primary and dental care, educational and vocational services, legal consultation, and other services and supports.28,51

Federal Response: the Collaborative Initiative to Help End Chronic Homelessness

In response to the human and community needs related to chronic homelessness, the ICH coordinated the planning of four federal departments to develop the comprehensive programmatic response that became the Collaborative Initiative to Help End Chronic Homelessness (CICH). The primary goals of the initiative were to: address the complex needs of individuals experiencing chronic homelessness by improving access to support, mental health, substance abuse, and other health and recovery services, create additional permanent supported housing for individuals experiencing chronic homelessness, help those living on streets and in shelters to move into permanent housing, and provide assistance to help them achieve residential stability. Particular attention was given to linking veterans who are chronically homeless with VA and appropriate community services and to increasing the use of mainstream resources to support treatment and services in grantee communities. With the documented advances made in efforts to engage and support individuals experiencing chronic homelessness (as described in the preceding section), positive client outcomes could be predicted. The four core elements of the CICH initiative are described below.

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Policy Group The ICH formed a working policy group of decision makers from the HHS, HUD, and VA. HHS representatives included the Ofce of the Assistant Secretary for Planning and Evaluation and two operating divisionsHealth Resources and Services Administration (HRSA) and the Substance Abuse and Mental Health Services Administration (SAMHSA).* The policy group negotiated the structure and processes for CICH, forming a $55 million initiative that provided 3 years of funding from HHS and VA (20032006) and either 3-year Supportive Housing (2003 2006) or 5-year Shelter Plus Care (20032008) funding from HUD. Although HUD denes supportive housing to include transitional, congregate, and permanent housing (which may be linked to required services), under CICH, a more narrow denition was used that focused on permanent housing with services available and encouraged, but not mandatory, as a condition of tenancy. Because of statutory and regulatory requirements, the departments were not able to issue a single unied funding announcement. Rather, community agencies or partnerships were required to submit three applications/proposals for: (1) HUD Supportive Housing or Shelter Plus Care grants; (2) SAMHSA mental health, substance abuse, and homeless services grants; and (3) a comprehensive plan that described the target population, plan for leveraging resources, structure of the proposed collaboration and plan to monitor and measure progress, and the coordinated approach that would be utilized to integrate the grants, services, and resources at the community level. Applicants could submit two optional proposals for VA support for veterans and HRSA support for primary health care. Applicants who did not submit applications for VA and/or HRSA support were required to describe how services to veterans and primary care were to be provided through other resources. In most instances, local organizations collaboratively applied for support from the four federal funding agencies, with one local partner taking the role of lead organization for the purposes of coordinating the comprehensive plan. Each federal department reviewed the applications for its funding. Review scores were collated for each applicant across departments, with an interagency federal team review of the comprehensive plan applications. Grantees were selected on the basis of highest overall review score. Eleven sites/communities were awarded CICH grants. Implementation Teams To monitor the CICH grants, the policy committee created implementation teams for each grantee community comprised of government project ofcers (GPO) from each of the federal funding agencies. The teams were to maintain programmatic collaboration between the federal departments, provide a consistent voice in monitoring grantees, and arrange for consultation and technical assistance to sites on an as-needed basis. The departments differed in their internal organization; HHS uses centralized GPOs based in the Washington, DC area, whereas HUD staffs regional and eld ofces, and VA provides support through its medical centers. Thus, the composition of each implementation team was unique, resulting in more than 40 implementation team representatives involved in CICH. Department interactions with grantees also differed. For example, HUD regional and eld representatives and HRSA GPOs did not conduct site visits, while VA local medical center staff were able to participate with the grantees on a regular and ongoing basis, and SAMHSA GPOs were limited to yearly site visits. Thus, communications, coordination, and consistency were challenges from the very beginning. Despite these challenges, the project ofcers established positive working relationships with the grantees that focused on helping them meet the goals of their project and often provided invaluable telephone consultation to address problem issues.
*The HRSA, an agency of the US Department of Health and Human Services, is the primary federal agency for improving access to health care services for people who are uninsured, isolated, or medically vulnerable. The SAMHSA, an agency of the US Department of Health and Human Services, was established by an act of Congress in 1992 under Public Law 102-321. SAMHSA was created as a services agency to focus attention, programs, and funding on improving the lives of people with or at risk for mental and substance abuse disorders.

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Technical Assistance Three federal departments supported contracts that provided technical assistance, training, and consultation to CICH grantees. The National Technical Assistance Center on Chronic Homelessness (NTACH), supported by SAMHSA, provided program support, logistical and meeting planning, national process evaluation and dissemination activities, and technical assistance to grantees. HUD supported Permanent Housing and Special Efforts for Subpopulations Technical Assistance Program, a technical assistance center, focused primarily on housing and support services and increased access to mainstream social services, especially Social Security disability benets. The US Department of Labor funded the Chronic Homelessness Employment Technical Assistance Center to support grantees under the Ending Chronic Homelessness through Employment and Housing Initiative. The federal partners coordinated the technical assistance resources to avoid duplication and overlap. Through NTACH, grantees were able to participate in needs assessment; regular technical assistance conference calls were targeted to on-site-selected issues and in yearly grantee meetings. NTACH conducted information-gathering site visits, analyzed grantee annual reports, conducted two seminars for grantees on Cost Analysis and Project Sustainability, and developed a range of products to describe CICH activities. Evaluation Three types of evaluations were conducted during the 3-year project period: (1) local program evaluations conducted by the grantees, (2) a process/lessons learned assessment conducted by NTACH, and (3) a cross-site national outcome performance evaluation conducted by the VA Northeast Program Evaluation Center (NEPEC) in collaboration with the grantee sites. Grantees and Service Approaches Table 1 provides a description of each of the 11 CICH grant sites that received funding from the four federal partners, including project name, the lead agency for community collaboration, setting and geographic area served, target population, and housing approaches. SAMHSA grantees served as the lead agency for the community collaboration in seven sites; HUD grantees in three sites; and an HRSA grantee in one site. In all 11 projects, the settings were primarily urban or suburban, with three projects also serving some rural areas. Although all projects focused on a chronically homeless population, four sites targeted those with signicant or multiple disabilities; and four sites targeted those with co-occurring mental and substance use disorders. The remaining three sites dened a more focused target population: one site targeted those with substance use disorders; one site targeted those with serious and persistent mental illnesses; and one site focused on those with high shelter use. Service approaches were complex, multifaceted, and included a range of conceptual underpinnings. Practice models that were used by projects included ACT in six sites, motivational interviewing (MI) in six sites, and integrated dual disorder treatment in one site.

Introduction to the Special Issue

Evaluation Methodology Because it was a service initiative and not a formal study, the CICH included program evaluation and the collection of some data elements from all participating communities but did not include the use of comparison groups. The papers presented in this special issue are based on both qualitative and quantitative analyses of data drawn from CICH. Three qualitative papers draw on archival documents and site visitor notes and reports. Three papers describe the ndings based on quantitative analyses of the outcomes data gathered by NEPEC.

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Table 1
Description of chronic homeless initiative sites Setting Urban/ suburban/ rural Broward County SMI Scattered site Geographic area served Housing model Primary target populationa Collaboration

Site; name of Initiative

Lead agency

Broward County, FL; Housing and Health Options Provide Empowerment (HHOPE)

Homeless Initiative Partnership (HIP) Administration

Chattanooga, TN; Chattanooga Collaborative Initiative Urban/ suburban City of Chattanooga Co-occurring

Fortwood Center

Scattered site

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Chicago, IL; ARCH (ACT Resources for the Chronically Homeless) Urban

Chicago Dept. of Human Services

South Side of Chicago (22 neighborhoods)

SUD and co-occurring

Mixed

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Homeless Initiative Partnership Administration (lead) with HSD, HUD, HRSA, local VA hospital, MH, SA, local University Fortwood Center (SAMHSA, lead) with local Housing Authority, HUD, HRSA, VA, local rehab and detox centers Chicago DHS (HUD and VA, lead) with local ofce of MH, SAMHSA, HRSA, local psychiatric rehab center

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Columbus, OH; Rebuilding Lives PACT Team Initiative (RLPTI)

Southeast/ Community Shelter Board

Urban/ suburban/ rural

Franklin County

SMI or co-occurring

Clustered

Chronic Homelessness Initiative

Contra Costa, CA; Project Coming Home (PCH)

Contra Costa Ofce of Homeless Programs

Urban/ suburban/ rural

Contra Costa County

Signicant disability

Scattered site

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Denver, CO; Denver Housing First Collaborative Urban Six County Metropolitan Denver Area

Colorado Coalition for the Homeless

Multiple disabilities

Mixed

Southeast (SAMHSA, lead) with Community Shelter Board, HUD (2), HRSA, VA, Ofce of Homeless Programs (Public Health, lead) with HUD, SAMHSA (6), HRSA (4), VA, consumers (2), legislative and executive branch members (7) Colorado Coalition for the Homeless (SAMHSA and HRSA, lead) with DHS (HUD), Denver Health Medical, MH, SA, VA.

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Table 1
(continued)

Site; name of Initiative Setting Urban Skid Row (Central City East) SMI and co-occurring Mixed Housing model

Lead agency

Geographic area served

Primary target populationa

Collaboration

Los Angeles, CA; Skid Row Collaborative

Skid Row Housing Trust

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New York, NY; In Homes Now (IN)

Project Renewal

Urban

Manhattan

SUD

Scattered site

Skid Row Housing Trust (HUD, lead) with HUD, SAMHSA, MH, Homeless Healthcare Los Angeles, HRSA (2), VA (2), LA Homeless Services Authority, Corp. for Supportive Housing Project Renewal (lead) with HUD, SAMHSA, HRSA, VA, VA healthcare

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Chronic Homelessness Initiative

Philadelphia, PA; Home First

City of Philadelphia and Horizon

Urban

Specic census tracts in Center City

Highest shelter users with history of behavioral health service utilization

Mixed

Portland, OR; Community Engagement Program (CEP)

Central City Concern (CCC)

Urban

Multnomah County

Signicant disability

Mixed

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San Francisco, CA; Direct Access To Housing (DAH)

S.F. Dept. of Public Health Housing and Urban Health

Urban

Civic Center, Tenderloin, South of Market Street

Multiple disabilities

Clustered

City of Philadelphia (lead) with Horizon House (HUD and SAMHSA), Phil. Health Management (HRSA), Phil. VA Medical Center Central City Concerns (lead) with SAMHSA, HUD, VA, County Aging and Disability Services, Vocational Rehab, HRSA San Francisco Dept. of Public Health (lead) with Housing and Urban Health (SAMHSA), 2 non-prots (HUD), SAMHSA, HRSA, VA

SMI serious mental illnesses, SUD substance use disorders, Co-occurring SMI and SUD a Taken from SAMHSA applications and rst site visit reports

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The analyses completed for the four qualitative papers are based on data drawn from 150 CICH documents. These documents, produced between 2003 and 2007, came from two primary sources. First, each of the 11 CICH projects generated proposals as part of the original application process as well as annual reports to the federal sponsors for monitoring and oversight. In addition, continuation applications were submitted to SAMHSA at the end of the rst and second funding years to continue the support service teams. Second, documents were produced by NTACH as part of the site visit and technical assistance monitoring functions, including: (1) notes on staff interviews and group discussions with clients completed during the site visits, (2) site visit reports, (3) notes on conference calls conducted to provide program-wide technical assistance, (4) reports written by consultants following technical assistance provided to individual project sites, and (5) project notes and summary reports of annual grantee meetings. NTACH staff conducted qualitative analysis to identify domains and themes to describe and explain core concepts within the CICH program and across each of the 11 CICH projects. Separate analyses were carried out for each of the six manuscripts under the direction of a qualitative researcher and a senior member of the NTACH team. Two research assistants assembled all project documents. Documents were in electronic format, with the exception of the initial and continuation funding applications, which were available only in hard copy. Atlas.ti software52 facilitated the text search and coding procedures. For each of the four papers based on qualitative data, the coding and analysis followed an iterative process, integrating both deductive processes53 and inductive processes following grounded theory.54,55 In the rst step, co-authors (members of the NTACH team familiar with the CICH program) listed and dened a series of relevant coding terms for the general domains to be covered in the paper (e.g., practice model, housing, low demand, co-occurring, etc.). Using the initial coding list, the research assistants coded all documents and selected text matching the denitions for the domain of interest. In a second step, the authors read the selected text and listed themes or core ideas within each domain. These themes were compared across coder/co-author. In the nal step, themes emerging from this level of analysis were clustered into higher-order themes to reect explanatory concepts and relationships among the codes. The analysis presented in each paper incorporates all higher-order themes identied, not just those that were most common. Results are presented conceptually rather than organized by frequency. Limitations There are limitations to the qualitative assessments conducted on program sites: (1) the study design is primarily descriptive, (2) a systematic survey of sites was not conducted, and (3) the data analysis consisted of existing documents. Thus, client and program activities can be described, but there are limits to the attribution of causation to changes observed. Introduction to the Articles The articles in this special issue address topics relevant to providing housing and services at the community level to those experiencing chronic homelessness. Three papers report on interim results of the NEPEC outcome evaluation: 1. 12-Month Client Outcomes and Service Use in a Multi-Site Project to End Chronic Homelessness56 describes the systematic and uniform monitoring of both service use and client outcomes at the grant sites to answer four primary questions: a) Who were the clients served during the initiative? b) Were there observed changes in service use and outcomes resulting from the initiative? c) Did service use patterns and client outcomes vary across grantees and did variations in pattern explain differences in outcomes?

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d) Did outcomes for CICH clients differ from those of a comparison sample of like clients? 2. An Evaluation of an Initiative to Improve Coordination and Service Delivery of Homeless Services Networks57 reports on the development of interorganizational relationships within the collaborative networks that implemented the CICH at each of the grant sites and their association to service system integration. 3. Inter-Agency Collaboration and 12-Month Treatment Outcomes Among Adults Experiencing Chronic Homelessness58 reports on the association of system-level measures of interorganizational cooperation and trust within the collaborative networks with measures of client service use and outcomes during the rst year of CICH. The remaining four papers present the lessons learned through the experiences of CICH grantees over the course of the 3-year grants: 4. Adopting Best Practices: Lessons Learned in the Collaborative Initiative to Help End Chronic Homelessness59 describes the experience of CICH sites in implementing ACT and MI, factors that inuence the implementation of these best practices, variations in the application of these practices across sites and over time, and lessons learned about adopting new practices for agencies and staff. 5. Stafng Challenges and Strategies for Organizations Serving Individuals Who Have Experienced Chronic Homelessness60 reports on the qualitative study that examined stafng challenges at CICH sites, including strategies that employed multidisciplinary teams and peer providers; approaches for supervision, training, and staff support; and issues of staff burnout, recruitment, and staff retention. 6. Supportive Housing Approaches in the Collaborative Initiative to Help End Chronic Homelessness61 describes the variation of supportive housing approaches employed by CICH grantees, the perceived advantages and disadvantages of housing approaches, and the challenges of working with landlords and resident managers to integrate the services and management functions of supportive housing. 7. Co-Occurring Disorders Among Individuals Experiencing Long-Term Homelessness: Lessons Learned from Collaborative Initiative to Help End Chronic Homelessness62 describes the epidemiology of co-occurring mental health and substance use disorders in chronically homeless populations, the strategies of CICH projects to provide recovery-oriented services to individuals transitioning to permanent housing, and lessons learned in advancing treatment and services to the target population.

Implications for Behavioral Health

The goal of this special issue is to present lessons learned in the organization and delivery of comprehensive services to individuals experiencing chronic homelessness. Collectively, these papers offer insight into the challenges of providing housing and services to individuals with an array of complex needs, operating in settings diverse in their service constellations and strategies, and of the unwarranted expectation that short-term programs can adequately stem conditions, both individual and societal, that have been decades in the making. These papers also describe critical lessons for local providers as they engage in the difcult and complex endeavor of service improvement and systems change that can help bring an end to chronic homelessness.

Acknowledgments
Recognition and appreciation to the members of the Policy Group that developed the Collaborative Initiative to Help End Chronic Homelessness: ICH: Philip F. Mangano and Mary

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Silveira; HHS: Walter Leginski, Jane Taylor, Michael J. English, Frances L. Randolph, Jean Hochron, and Lyman Van Nostrand; HUD: John Garrity, Mark Johnston, and Laura Hogshead; and VA: Pete Dougherty, Robert Rosenheck, and Al Taylor. Appreciation to Dr. James Herrell, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, for his contribution as editor for this special issue.

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