Street to Home: Re-Defining the Role of Homeless Outreach in the Housing First Era

I sit on the City of Atlanta’s homeless outreach committee, surrounded by fellow social service providers and agencies dedicated to homeless outreach efforts within the metropolitan area. We have been summoned to address our efforts and collaborate to find solutions for a specific neighborhood with a persistently high number of chronically homeless individuals, all of whom live with either mental health issues, substance abuse and/or physical disabilities that perpetuate their homelessness. Yet, despite that fact that the neighborhood sits on the path of over 15 outreach teams in city, and even though the city has recently started implementing a series of policies known as “Housing First” designed to make it easier than ever before for challenging homeless individuals to access housing, the neighborhood’s actual homeless remains largely unserved. This bears the question — Why is the outreach not working despite Housing First?

The Housing-First Era
 Housing First is not a new subject. With its conceptions in 1988 in Los Angeles, it is an “approach of tackling homelessness that centers on providing homeless people with housing quickly and then providing services as needed — rather than delivering services to people who are living on the streets.”[1] Before Housing First, traditionally, if a homeless individual was referred to Permanent Supportive Housing (PSH) they would’ve had to meet certain requirement to make sure they were “ready” for housing, such as compliance with mental health medication, treatment and/or sobriety. These requirements have historically created barriers to housing against those who don’t have the ability to deal with the complexities of treatment while in the streets, labeling them “difficult”, and in the process perpetuating their homelessness. Instead, Housing First advocates treating the issues while and/or after housing at the client’s own pace.

The implementation of Housing First became prominent nationwide when in 2004 the Department of Housing and Urban Development (HUD) started using its formidable administrative and regulatory power to mandate cities to maximize services to the chronically homeless, shifting focus to this exact difficult population.[2] Since then, this initiative has been spreading around cities re-shaping social services, specifically mandating PSH’s to adapt to Housing First by changing admission requirements that might discriminate based on a disability. If PSH’s don’t comply, they jeopardize losing their HUD funding.

The model is substantially back up by research as “consumers in a Housing First model access housing faster and are more likely to remain stably housed. [Additionally] PSH’s under Housing First have a long-term housing retention rate of up to 98 percent.”[3] From a macro perspective, cities that implement Housing First policies also show fewer emergency visits, fewer crimes committed, increased employment; less homelessness; reduced mortality; fewer incarcerations; reduced use of homeless shelters; and even increased income and sale tax.[3] While Housing First requires allocating higher monetary aid to homeless services, it saves money in the long run by creating a more functional urban ecosystem.

Coordinated Entry
To help implement Housing First policies as well as the prioritization of challenging chronic individuals, in 2017 HUD mandated cities to establish their own coordinated entry systems which grant city governments oversight of all referrals to PSH.[4] Before coordinated entry, every PSH would get referrals directly from homeless shelters, hospitals, jails, community clinics and even take walk-in applications. This made the path to housing a rather chaotic system without a central body to keep PSH’s accountable as to who they actually house, and who they turn away.

This changed with coordinated entry. Today, under the current scheme, in order to get into PSH, individual cases must go through city departments specifically in charge of handling the task. These government entities are known as Continuum of Care’s (CoC).[4] First, the social service agency must score their client using a vulnerability assessment and submit the case to their city CoC. The CoC then prioritizes the highest scoring client (the most vulnerable), matches them to the best PSH and gives an appropriate referral. This system ensures that all players involved comply with HUD’s initiative of servicing the chronically homeless, ensures that the most vulnerable get prioritized, it makes the pathway to housing equal and accessible and allows cities to monitor PSH’s compliance with Housing First. This centralization of housing power actually creates a streamlined model (see image 1) that has proven itself very effective as explained by an anonymous homeless outreach worker in Atlanta:

“Before coordinated entry, no one would take my referrals. I would work with extremely difficult chronic clients in the streets, submit their applications and I would never hear back from PSH. After coordinated entry started, they are now obligated to take them, because the city is watching. There was this PSH, in particular, that was notoriously difficult to get into. For years the case managers only accepted people that they knew — a friend’s uncle, a friend’s brother, or old ladies that had manageable problems like chronic depression. Naturally, this made their caseloads super easy to work with. But now they can no longer just pick and choose who they want. If they don’t have a score high enough to get in, they simply won’t get the referral”.
(Image 1) coordinated entry

Problems with Traditional Outreach
Issues, however, don’t just lie with housing providers, as Housing First is forcing everyone in the homeless field to adapt, and outreach teams are particularly in trouble. Under coordinated entry and HUD’s initiative, homeless individuals who score the highest in the vulnerability assessment are the most likely to get prioritized for housing. Explicitly, the assessment prioritizes those who currently sleep on the streets, have untreated mental health or substance abuse issues, those that are not taking medication, who are service-resistant, and those who have cognitive/mental impairments and who are physically disabled. This means that, even though coordinated entry is accessible from multiple entities like shelters, hospitals, churches and community clinics, homeless outreach teams are the most likely to encounter the highest scoring individuals and therefore are at the forefront of this housing movement. This is where things get complicated.

When cities train agencies to submit homeless clients to coordinated entry, they do so under the assumptions that the same agencies will help navigate the clients into housing once they receive a referral. “This would be an easy task if the clients getting referrals were independent and high-functioning,” says another anonymous outreach social worker in Atlanta. In reality, because only high-scoring low-functioning clients get the referrals, the process between referral and moving-in is an incredibly tedious and complex one that is often beyond many agencies’ capacities. The same social worker narrates his barriers to housing the chronically homeless:

“I work for an outreach team that is linked to a community clinic. I go out 4 times a week and our job is really to refer folks back to our site. Because we encounter a lot of chronic folks we decided to partake in coordinated entry. I assess clients in the streets and place their information in the Atlanta CoC. Once their names come up for housing I usually only have 2 days to accept it. So in those two days, I have to try to get in touch with my client. Most chronically homeless don’t have cell phones so I call everyone I know and search for them in the streets. Mind you this could take hours so I have to ask my team for permission.
 
 So let’s say I find him and he wants to move in. I file the paperwork and he has an appointment, but guess what? They need ID, social security card, birth certificate, income verification, a tuberculosis test, a mental health diagnosis on paper and a background check. I might have some of those things. Some. If I’m missing the ID, I can’t just tell my client to go to Driving Services. This person is severely schizophrenic, elderly, has no income and could never maneuver public transportation alone. There’s another issue — who pays for it? Our outreach team doesn’t really have funds for documents. Sure, there are agencies that help with that, but again, my client is severely incapable of going there by himself.
My agency doesn’t have a car I can use. So now I have to transport my client in own my car, under my own insurance and liability. And then I must spend a whole day at Driving Services and pay for the ID with my own money. I might get it reimbursed by my agency. I say might because, again, paying for documents is not a service we provide. So then I have to take my client to get a tuberculosis test at a clinic, and that’s another three hours with traffic. Not even knowing if I will get reimbursed for mileage. And then I have to pick him up again in three days and take him back to get the test read.
I literally spend 2 whole working days with my client alone, but the thing is this isn’t my job. My job was not created to work directly with coordinated entry, and neither are more most people’s who are assessing the homeless. I just so happen to work with the homeless and that’s why the city recruits me to “collaborate”. I’m an outreach worker. I only work 4 days a week and most of that time has to be spent engaging with people in the streets. Whenever I have a housing referral, I literally have to ask higher-ups for permission and drop everything I do. And I think that’s what the city doesn’t get. We are not equipped to do that, not financially, not structurally, not even in terms of manpower, yet we are pressured to partake in the coordinated entry system. Everyone is. The city is training all these assessors everywhere and they are compiling this list of people waiting for housing, but these assessors don’t have the time to navigate them into housing. They have existing jobs”.

Cities nationwide call upon outreach teams to collaborate, pressuring them to partake in coordinated entry to get an even coverage across their streets and make sure every homeless person that needs housing gets assessed. But these gaps to service occur when outreach teams that predate coordinated entry are pressured to aid in this housing movement while having their own pre-existing goals in place. An outreach team might be number driven, having to engage with as many individuals weekly as possible. They might have the goal to refer to their own agencies if they are part of a bigger organization like a hospital or clinic. Or they might have the goal of feeding crowds, going out every day with meals and water and as a result, many outreach teams are structurally unprepared for the monumental task of helping the acutely mentally ill navigate housing once they get the referral. It’s a harsh reality that in many cities, social service providers are unprepared and unequipped to work with the type of client cities want to prioritize into housing — that’s the conundrum.

The Street-to-Home Model
 To adapt to the demands of HUD’s initiative, Housing First and coordinated entry, outreach teams wanting to partake in the housing of their homeless clients must first adapt by restructuring their goals and funding to match the needs of the population. This is the case with the Street-to-Home model pioneered by the country’s most successful outreach agency in terms of housing — Breaking Ground. Founded in 1990 and based in New York City, its “Street to Home program, begun in 2004, reduced homelessness by 87% in the 20-block area around Times Square and by 43% in the 230 blocks of nearby West Midtown Manhattan. […] The model was so successful, it was adopted by the New York State Department of Homeless Services in 2007.”[5]

The Street-to-Home model operates essentially as an outreach team, engaging and interacting with clients on the streets in many ways, such as giving referrals or feeding. Once a chronically homeless person in need of housing is identified, the team continues to engage them time after time building a trusting relationship, diverging outreach efforts to specifically engage with them. This is important as many chronically homeless will refuse services due to their mental illness or having been repeatedly dropped by social services. This process of relationship building oftentimes takes weeks, months, and sometimes even years. This model is also different from most outreach teams who might engage an individual once and never follow up.

Once the person expresses willingness to work toward housing, the same outreach worker will place them into coordinated entry or help them apply to other housing options. The same outreach worker then becomes a case manager who, through funds specifically allocated for documentation, and through transportation specifically allocated to the task, single-handedly helps the clients obtain the documents required. This a process that might involve sitting in a social security office for a few hours, taking them the Driving Services for an ID, ordering a birth certificate themselves, or picking them up from the street to take them to their mental health appointments. This is radically different from most outreach teams who often refer out for these extra services, losing many clients in the process. A key part the Street-to-Home model is that the helping professional becomes a one-stop-shop for everything the clients need, overseeing the whole process from the first point of contact to move in, advocating for them in the process and helping them navigate the plethora of agencies involved.

Three key factors play a major role in how this model differs from other outreach teams. Firstly, the goals of a Street-Home program are not measured by how many people they encounter or outreach. Success is measured by how many people they house. Secondly, the flexibility of roles is crucial. While outreach workers in this model do perform outreach it is not the bulk of their work. Outreach is a way to obtain clients. Once clients have been identified the worker can switch modes to individual case management. They are not tied to daily outreach duties or tasks irrelevant in getting clients housed. Thirdly, the agency allocates funding and resources in place to avoid referring clients out. This means having transportation in place; bus passes; liability insurance; funding to pay for documents and background checks; and having established community partnerships like community clinics that can provide mental health.

In 2008, the Street to Home model was replicated in five cities, Atlanta, Boston, Chicago, Denver, Washington DC, all with positive results. Today it is an internationally used model to treat Chronic Homelessness. In 2017, Breaking Ground engaged with 3,400 chronically homeless individuals, had 941 on caseload and housed 382.[6] That’s only a mere 11.23% who funneled down into housing. And while that percentage, combined with the amount of money it takes to run a comprehensive Street-to-Home program, might be discouraging to many number-driven grants or institutions looking to operate a similar model, they should be observed as a reflection of the amount of intensive work that it takes to house the population.

Conclusion
When speaking of Housing First one intrinsically thinks of housing. Many of the conversations gravitate around removing barriers to entry within PSH’s, but there seems to be a lack conversations as to what it actually takes to get a client housed — what happens before housing. PSH’s operating under Housing First might be accessible to people with mental and physical disabilities, and they might have inclusive policies of admission, it is not however barrier-free. There seems to be a lack of understanding as to how much work it actually takes the disabled the do the things most people take for granted. Something as simple as getting an ID when you have nothing to prove your identity, getting to an appointment in time, taking the bus, or even having the courage to believe that someone promising housing will actually deliver their promise after being rejected for years by social services are often monumental actions to those living with mental illness, and sadly often unachievable when you have no one guiding you through it. This is where outreach teams can step in. With Housing First and HUD’s initiative to house the chronically homeless not going anywhere soon, outreach teams can find themselves in productive positions to aid in this housing movement by adapting to the needs of the population in a way that is radically client-centered and inclusive to mental and physical disabilities.

References

“Housing First.” Win-Win Project. Accessed November 09, 2018. https://insight.livestories.com/s/v2/housing-first/8cf26349-1afe-4652-8b65-3ff760266ba9/.

Duffield, Barbara. “Are We Creating Chronic Homelessness?” ICPH. October 2016. Accessed November 9, 2018. icphusa.org.

“Housing First.” National Alliance to End Homelessness. April 20, 2016. Accessed November 09, 2018. https://endhomelessness.org/resource/housing-first/.

“Coordinated Entry Brief.” Hud Exchange. https://www.hudexchange.info/resources/documents/Coordinated-Entry-Policy-Brief.pdf.

Ducker, Garrett. “Breaking Ground.” SAMHSA. February 18, 2016. Accessed November 09, 2018. https://www.samhsa.gov/homelessness-programs-resources/hpr-resources/breaking-ground.

“2017 Annual Report.” Breaking Ground. 2017. Accessed November 9, 2018. https://d2cbcykciwaak1.cloudfront.net/documents/Breaking_Ground_Annual_Report_2017_FINAL.pdf?mtime=20181025172202.