Homelessness prevention

The August issue of the Journal of Primary Prevention is dedicated to articles on homelessness, addictions and mental illness. It has a US focus but many of the problems will be familiar to Canadians, too. A guest editorial (pdf) kicks off the issue by scoping out the problem, with a good summary of studies on the hidden financial costs to the public of homelessness, and then summarizes the papers in the rest of the issue:

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.

… 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).

… 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. … [T]he 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. …

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. … Backer, Howard, and Moran address the critical and difficult transition from various institutional settings into the community. … 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 …

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. … 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. … Helfrich and Fogg describe a life skills intervention that helps homeless adults with mental illness develop greater skills in everyday living. … 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. … Together these articles provide critical knowledge to inform the field and move it forward. They offer the beginning of a conceptual approach that can shape a comprehensive homelessness prevention framework and galvanize ongoing change. In sum, this issue of JPP makes it clear that the future holds tremendous hope for promising and evidence-based practices, programs and policies that can prevent homelessness. It is equally clear that we must act now before more adults, families, and children suffer needlessly. To be successful, our efforts must:

• 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.

We must address the realities of entrenched poverty, the affordable housing crisis, limited access to adequate services, stigma, an insufficient knowledge base, and lack of political will in order to prevent homelessness. We hope this special issue helps to encourage a shift away from the view that homelessness is insolvable toward a renewed energy and belief that we have the tools and the will to prevent and end it.