Introduction

Part 2 of this Treatment Improvement Protocol (TIP) is directed to administrators and senior staff persons and is designed to prepare you to help behavioral health staff persons in their work with clients facing homelessness and the specific challenges that homelessness presents. It can serve as a resource for you to use as you support and challenge your staff to become part of a community-wide response to the problem of homelessness. How can you support your staff members in these efforts? Do they need further training? What additional services and collaborative arrangements does your organization need? Where does funding come from? What do model programs look like?

It is important to emphasize that homelessness is a problem that deserves the attention of behavioral health organizations. Some of the clients your program is currently treating may be homeless or at high risk of becoming homeless within months of their discharge from the program. People who are homeless report more problems related to alcohol use, drug use, and mental disorders than those who are not homeless. Findings from studies of Midwest urban samples of people in shelters, food programs, or living on the street report high rates of problems related to substance use (58 percent of women; 84 percent of men [North, Eyrich, Pollio, & Spitznagel, 2004]; 55 percent of women; 77 percent of men [Forney, Lombardo, & Toro, 2007]).

A meta-analysis of studies done between 1979 and 2007 (Fazel, Khosla, Doll, & Geddes, 2008) revealed a pooled prevalence rate among homeless men for alcohol and substance dependence of 37.9 percent (10 studies) and 24.4 percent (7 studies), respectively. Providing adequate shelter for people who are homeless can be the first step toward engaging in behavioral health treatment. Transitional supportive and permanent supportive housing provided by either behavioral health programs or other programs in the community have become integral components of recovery promotion in both mental health and substance abuse treatment. (See the online literature review in Part 3 of this TIP for more details.)

Developing Services for Clients Who Are Homeless

Your behavioral health program may be interested in serving people who are homeless or at risk of becoming so for a number of reasons, many of which also apply to homelessness programs that want to develop or expand services for clients with mental illness and/or substance use diagnoses.

First, serving people with substance abuse and mental disorders who are homeless often is not a matter of choice. The clients are there! Implementing specific programmatic elements to meet their needs serves to make interventions more successful and cost-effective. It also enables staff to work more efficiently. In this sense, specialized homelessness services are an essential ingredient for quality and effective care in your organization. Many of the clients you serve are not homeless when they come into treatment but, for a variety of reasons, become homeless during treatment and have no place to live once they complete intensive treatment. Other clients receiving behavioral health services are just one paycheck or one personal or family crisis away from homelessness. Still others enter treatment because they need shelter. Having a staff with the knowledge and skills to anticipate and address these issues will help your program run more smoothly and with better outcomes.

As the behavioral health field moves toward outcome-based funding, serving clients more efficiently becomes a higher priority. When program staff members are aware of the effects of homelessness on treatment, not only does it lessen problems associated with housing instability; it also reduces the severity of social and behavioral crises that interfere with treatment. This, in turn, increases staff efficiency and client retention.

Additionally, making homelessness services apriority for your program will increase the capacity of the program and the skills of the clinical staff responding to various other social and health needs your clients may have, such as transportation services, health care, financial management, and responses to criminal justice issues. In this sense, programming for homelessness benefits all clients, not just those who are currently or potentially homeless.

Specific services for homelessness may be an opportunity for your program to find additional sources of funding to support client services. A variety of community funding resources are available to address the needs of people who are homeless, particularly those in need of behavioral health services. These additional funding streams can help stabilize your funding base and increase your program’s capacity to meet the needs of clients.

Some people in the community may question the costs for intensive and supportive care for people who are homeless and whether the benefits of such care are cost-effective. The reality is that supportive housing is cost-effective when compared with alternatives. The Corporation for Supportive Housing(CSH) report, Costs of Serving Homeless Individuals in Nine Cities (The Lewin Group, 2004), presents estimates of the costs of serving people who are homeless in various settings: supportive housing, jails, prisons, shelters, psychiatric hospitals, and acute care hospitals (Exhibit 2-1). Estimates represent the average cost of providing 1 day of service to an individual in each setting and capture the underlying costs of providing services, compared with the payments received from public payers. The CSH report defines supportive housing as a combination of program-building features and personal services to enable people to live in the community.

Exhibit 2-1

Range of Estimated Service Costs per Day by Setting.

The Housing First Approach

One of the first decisions you will make in developing services for people who are homeless is whether a Housing First approach is suitable for the clients you expect to serve and for your community. Housing First approaches are used to engage people into services who are homeless and have behavioral health conditions. They are low demand, offer permanent housing for people who are homeless, and do not require the client to enter treatment or document abstinence. Many, though not all, Housing First participants receive Federal disability benefits, and many programs encourage clients to participate in money management programs that ensure payment for housing. Housing First programs provide substance abuse, mental health, and medical services through community case management or multidisciplinary teams. Clients choose which services to receive. More information about these programs is available on the Corporation for Supportive Housing Web site (http://www.csh.org).

Housing First programs demonstrate substantial enrollment into services and housing stability for individuals who are chronically homeless and have long-standing mental illness and, in most cases, substance use disorders (Pearson, Locke, Montgomery, Buron, & McDonald, 2007). Enrollment status is determined more by continued contact with case managers and other service providers and less by whether the client is continuously residing in program housing. Temporary departures from housing are not uncommon; program staff continue to follow up with clients even when they are away from their housing. Many programs hold units for up to 90 days and encourage clients to return.

Housing First programs range from scattered-site independent housing leased from private landlords (thus increasing individual choice in both housing and neighborhoods) to congregate living programs in which the program owns or controls the housing (allowing staff to provide a high level of onsite supervision and response to client crises). Staff members are available around the clock to help clients maintain their housing and meet their other needs.

Implementing Housing First models in suburban or rural areas can present challenges that require modifications to the model. Staffing may need to be composed of smaller teams resembling assertive community treatment(ACT) teams, which maintain low caseload ratios and broker some services from community providers. Teams can feature interdisciplinary staff from different organizations. Resources may be needed to purchase or use extra vehicles. Housing choices may be restricted to renting a room in someone’s home, sharing a house, or waiting until a single unit is found. (For descriptions of Housing First programs, see U.S. Department of Housing and Urban Development [HUD], 2007b.)

Communication among staff members is often accomplished through daily team meetings so that they can respond immediately to client needs. Many programs also have automated documentation services for collecting information on client status and outcomes.

Funding for Housing First programs comes from diverse sources. The programs seek Medicaid reimbursement for mental health case management services and State or county funding for clinical services. Additional sources of funding might include foundations and other private sources. HUD assistance programs provide rental assistance. State or local funds may cover short-term stays in a hotel while a client seeks housing, or rental assistance may be provided to clients who are ineligible for HUD assistance programs.

These programs often use a representative payee system to handle clients’ income. This is a money-management system that assigns a third party to handle disbursement of funds for individuals receiving Supplemental Security Income or Social Security Disability Insurance (American Association of Community Psychiatrists, 2002). It is often a practical need and helps people develop independent living and money management skills.

Many Housing First programs strongly encourage representative payee arrangements for certain clients. People with representative payees at baseline are more likely to stay housed(HUD, 2007b). Although representative payee arrangements can be a valuable intervention for individuals who are severely disabled, you and your staff should carefully consider potential consequences of removing client responsibility for deciding how and when to spend money. Power struggles can result when a client’s request for money is denied to cover higher priority needs (e.g., when the request conflicts with paying rent). One way to reduce power struggles is to have personnel other than the counselor act as the “banker,” permitting the counselor to work more effectively with the client on money management skills. For more on representative payee arrangements, see the Social Security Administration’s Web site (http://www.socialsecurity.gov/payee/).

Unless you do adequate groundwork, the process of establishing a Housing First program may run into unexpected obstacles. First, it is important to separate a client’s clinical issues from his or her responsibilities as a housing tenant (Stefancic & Tsemberis, 2007). This may represent a significant change for staff.

One challenge in implementing Housing First programs is the presence of preexisting agency policies that couple housing with requirements that the client maintain abstinence. Rigid, rigorous housing eligibility requirements that often discriminate against clients with psychiatric symptoms or substance abuse can also be challenging. Housing First programs usually accept clients on a first-come, first-served basis.

Another challenge is ensuring collaborative agreements with the immediate neighborhood where any congregate facility is to be located. Steps toward collaboration include:

• Involvement of neighborhood associations or boards on the board of advisors for the program.
• Development of a good neighbor code of conduct.
• Development of shared responsibility in use and maintenance of public resources (such as parks or gardens).
• Rapid response to security or sanitary issues, including police attention.

Challenges in Adapting Programs To Address the Needs of People Who Are Homeless

You may decide to add homelessness rehabilitation services to your existing programming rather than choosing a Housing First approach. When you decide to implement specialized homelessness programming in your behavioral health organization, you will find some special challenges, the solutions to which can be ultimately productive for your program. Still, to institute new services, you must overcome several hurdles.

It is imperative to conceptualize, develop, and implement services for homelessness in the context of your current programming. In effect, the new services need to be natural additions that complement existing programs. Not to do this would mean having a unique homelessness program that is not integrated but rather a separate, isolated entity. In this context, the new service elements have to be conceptualized in response to the question “How can this new service integrate with and complement the services we already offer?”

Second, instituting a new service component for homelessness in your behavioral health program means staff development to confront the myths about people who are homeless, the services they need, and how the services can and should be provided. Staff development may mean additional skills development or enhancing and specializing skills that already exist among staff members, who will need to learn about additional resources in the community and how to collaborate with the organizations and people that provide them. They might need cross-training to work with the specific needs of people who are homeless while maintaining their skills in behavioral health services. Working with homelessness may require case management and outreach skills unfamiliar to most of the staff. For instance, behavioral health counselors working with clients who have substance use disorders may end up doing outreach with clients who show no interest in changing substance use patterns; mental health workers may feel uneasy at first seeing clients in settings other than their office.

You and your staff will need to interact with a different network of community services. Programs primarily addressing homelessness in the community may have a different orientation to services. For instance, programs for homelessness may have a social service orientation; behavioral health programs, a healthcare-focused perspective. Rehabilitation in homelessness programs may be more oriented to life skills development, whereas behavioral health programs focus on treatment and specific psychological strengths. Thus, community programs created for homeless populations may have different goals, staffing patterns, funding streams, or client goals. Behavioral health program administrators, who often are more experienced in working in the health, substance abuse, and mental health fields, should recognize these different perspectives and view them as strengths, not impediments.

In addition to formal relationships among organizations, an informal system of community involvement, interorganizational relationships, and services planning is required to bridge gaps between traditional behavioral health and homelessness services. Later in this chapter, the discussion of collaborative partnerships and service modification highlights this issue.

Modifying Behavioral Health Services To Meet the Needs of Clients Who Are Homeless

To serve people who are homeless, your organization can adapt its programs to provide services that were not previously available. These service modifications to meet the needs of people who are homeless take different routes based on knowledge about the target population. A bottom-up approach to service modification (described below) begins by evaluating the needs of the people who will receive the services. In a top-down approach, the impetus for change comes from administrators, boards of directors, funding resources, and the like. If you are unfamiliar with your community’s homeless population, a bottom-up approach is best; top-down integration works best when you know the population well and can assess in advance the major barriers to care and the broad initiatives needed to overcome them. Top-down modifications often require some bottom-up information to make the right choices. You can tentatively commit to a plan but then engage in community discussion before acting, making modifications as necessary.

Bottom-Up Service Planning

Bottom-up service planning is a process of using peer workers, case managers, clinicians, supervisors, and administrators to develop a program that meets identified needs of a special client population. It often starts with a few unique, complex cases—for example, developing services for people who often use emergency shelters, emergency rooms (ERs), or detoxification centers. The project scale increases incrementally as effective practices are established and resources become available. The first stage of bottom-up service integration is to identify the target population and engage people in services and then develop feedback mechanisms to identify what works and how to improve program efficiency. Ask people from the target population about their priorities informally or via surveys or focus groups. The National Health Care for the Homeless Council Web site (http://www.nhchc.org/advisory.html) offers a manual for involving a formal consumer advisory board.

Collaborating with partners to identify and engage the target population

Bottom-up service modification can be a collaboration between nongovernmental organizations (NGOs) or between programs within an NGO. The first step is small but dynamic: collaborating with other service providers who can help identify your target population and introduce you to new clients. These collaborations can be informal or formal. Documentation at this stage is simple: tracking where people are identified and their progress through the system. Exhibit 2-2 lists some helpful elements in bottom-up modification.

Exhibit 2-2

Key Components for Bottom-Up Modification. Sense of urgency. Frontline staff may fear that failing to engage people in services will lead to victimization on the streets, untreated physical illness, or deteriorating life situations. This fear propels (more...)

How do you perform bottom-up services modification?

Step 1: Perform a needs assessment. The needs assessment includes gathering data not only on the demographics and expressed needs of the homeless population to be served, but also on how those services can be most effectively delivered, which services seem to result in client change, and which services can be offered over time (see needs assessment steps listed on p. 164).

Step 2: Get internal buy-in. Take your needs assessment to the CEO, chief clinical officer, and/or board members and develop a plan for how to proceed that includes identifying potential funding sources, stakeholders, staff members, and services that can reasonably be added to drive the initiative.

Step 3: Make contact with funding sources. Organization administrators seek funding to meet the needs of the population. Once the possibility of funding exists, go to Step 4.

Step 4: Identify stakeholders. Identify other participants in your effort, begining with your clinical staff and fellow administrators. Other potential stakeholders include:

• Your board of directors.
• The local continuum of care (housing providers; mental health, substance abuse, and medical treatment providers; hospital emergency departments; and staff members of criminal justice programs).
• Local business owners and legislators with whom your organization has strong relationships.
• Program alumni and other community supports (e.g., faith-based institutions).
• Community boards.
• Private foundations for matching funds.

Step 5: Create and formally present a concept paper. A strong grant-writing team or consultant creates the concept paper. Critical issues to address include:

• A clearly articulated problem statement, proposed plan, implementation process, timeline, and evaluation process. Describe the problem using a combination of statistics and short personal stories.
• How the resources you are seeking fit your organization’s mission/strategic plan.
• The roles to be played by your partners.
• If you are seeking private funding, a plan for transitioning to public funding.

Step 6: Conduct postpresentation activities. Homelessness is a politically charged issue; handle contacts with funders with tact.

Step 7: Receive funding. Designing and funding your initiative ends; implementation begins.

Adapting clinical services to meet the needs of the target population

At this stage, you and the clinical staff learn to adapt clinical practices to meet the needs of clients and influence institutional policy. Focusing on individual cases of homelessness makes it easier to understand the context of counselor–client work and the barriers to doing the work. For example, counselors in a detoxification program (in the same organization as an intensive substance abuse treatment program) request case-by-case exceptions for people who are homeless to a policy barring readmission of clients within 30 days of discharge. In each case, the counselors argue that the policy is a barrier to rapid readmission to substance abuse treatment, which would reduce the relapse severity and the length of treatment needed by the client. As the cases brought to the administrator accumulate, he or she eventually changes the policy.

As project scale increases and clients engage, you will identify other components of care:

• Frontline staff note good collaborative experiences with some NGOs, whereas others do not meet the expected clinical standards when working with people in intensive substance abuse treatment who are homeless. Referrals are withheld from the latter, which may stimulate development of more flexible services in the community and a corresponding increase in referrals. Counselors, case managers, and supervisors realize the need for service and policy modifications to better meet the population’s needs. For example, after observing that some people feel isolated when placed in their own apartments, create an alumni program to facilitate connection to community recovery supports and help people successfully transition to permanent housing.
• Documentation and use of surveys and feedback loops become more sophisticated and formalized to enable sharing of information with funding sources and State authorities.
• As clinical and administrative leaders formalize the integration of people who are homeless into the organization and the treatment system, their bottom-up efforts lead, directly or indirectly, to top-down integration opportunities.

Interacting With Community Resources To Build a Continuum of Care

HUD defines a continuum of care as a local planning process involving the range and diversity of stakeholders in a community in assessing and planning for the needs of people who are homeless. Normally, one superagency is designated as the coordinator of the continuum of care planning process, and one application is made on behalf of the community for HUD funding. “Community” is defined by the continuum of care planning process as the geographic area included in the application. The application is based on assessed needs for three types of housing in the community: emergency shelter, transitional housing, and permanent housing, along with the supportive services needed to address each of these housing needs. One of the features that makes the continuum of care process unique is that it may include nonprofit agencies, governmental agencies, community-based organizations, agencies in the community that provide supportive services (such as mental health and substance abuse treatment programs), local businesses, law enforcement, and consumers who are homeless or were formerly homeless.

Rarely is one program able to meet all of the client’s needs, as the continuum of care implies. As a result, collaboration among programs is essential. Although your program’s counselors may interact with other agencies at the level of the individual client through outreach, treatment planning, case management, treatment, and follow-up, administrators must work to develop collaborative continua of care, overcome interagency barriers, and ensure that there is “no wrong door” through which to enter services. This is particularly true when addressing the needs of clients who have two or more urgent, severe problems—homelessness and substance abuse or mental illness. Likewise, although a homelessness program may employ behavioral health counselors, they are seldom equipped or funded to provide the full complement of services necessary for comprehensive substance abuse and mental health treatment.

An integrated system of care that provides a continuum of housing services increases communication among the organizations involved, improves coordination among providers, and serves more people who are homeless. Examples of the interrelationship of a continuum of care, organizational strategies for supporting program development and service modification, and strategies for effective service delivery appear later in this chapter. Exhibit 2-3 highlights the benefits of an integrated system of services for people who are homeless.

Exhibit 2-3

Integrated System of Homelessness Services.

Collaborative Partnerships

In interacting with other community resources and becoming part of your community’s continuum of care, you can establish collaborative partnerships with other agencies that serve substance abuse and mental health clients who are homeless. These partnerships can help your organization expand its range of services, link up with other systems, and foster innovative programming, funding, and community acceptance (Substance Abuse and Mental Health Services Administration [SAMHSA], 2006).

Successful collaboration requires negotiation, compromise, and commitment to address a problem about which all stakeholders experience a sense of urgency and responsibility. An early step in forming partnerships is sharing different perspectives on the problem (e.g., lack of treatment resources versus lack of appropriate housing stock) and establishing guiding principles or assumptions for the collaboration. Failure to resolve different perspectives can cause covert power struggles. Other barriers to overcome when pursuing partnerships include:

• Competition for scarce resources among community organizations.
• Unwritten policies of daily service delivery.
• Service organizations that resist change.

Creating Interorganizational Partnerships

To address system and service delivery problems with people who are homeless, assess the problem and gather information about the target population and the strategies needed to resolve the problem.

Interorganizational needs assessment

To assess the needs of an interorganizational continuum of care, determine the size and characteristics of the population that is homeless and assess issues raised by community members, governmental agencies, and service providers. One way to start is by talking with other service providers who work with people who are homeless and working with the organization that will apply or has applied for HUD funds. In some localities, a single organization or agency represents the community’s needs. The information contained in the “Continuum of Care” application often provides a thorough review of strengths and gaps in the community’s services.

Intraorganization assessment

To assess your organization’s ability to assist people who are homeless, analyze the number and characteristics of people seeking services who are homeless or at risk of homelessness. Start by counting the number of people who are homeless or at risk of homelessness who are admitted to substance abuse or mental health treatment during a 2- to 4-week period. Other measures include the number of people admitted with criminal justice involvement and the number discharged without employment, job training, or stable housing. This type of assessment includes staff discussion of findings at team meetings to better understand how organizational factors influence findings.

Steps in the assessment process

• Determine the population’s gender, ethnic, and racial makeup; criminal justice experience; family status; language; and nature of homelessness (i.e., situational, episodic, chronic).
• Determine whether these characteristics are reflected in the staff providing services.
• Identify gaps in the continuum:

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  Are people not staying in treatment?

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  Are some counselors seeing 1 client who is homeless per month while others see 10?

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  Are clients referred from other services in a coordinated fashion, or are they walking in without referrals?

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  Are clients transitioning out of substance abuse or mental health treatment without employment and housing?

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  Do clients have a primary care provider and affordable access to needed medication?

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  Are some programs in the organization declining referrals because the clients are homeless?

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  Do some programs in the organization have particular difficulty working with clients who have either substance use disorders or mental illnesses?

• Identify policies and procedures contributing to service gaps and consider how to change them; use a formal continuous quality improvement methodology. See the Network for the Improvement of Addiction Treatment’s Primer on Process Improvement (2008). The Addiction Technology Transfer Center Network (2004a,b) also offers useful publications on the topic.
• Identify issues in the community, such as:

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  More people living on the streets.

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  Legislation that handles homelessness through arrest rather than social services.

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  Insufficient affordable housing stock.

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  Insufficient mental health, substance abuse, and medical treatment services.

• Determine whether this is an opportunity to partner with other providers to improve access to services, create resources to meet the needs of people who are homeless, and reduce costs to the community:

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  If services to address these issues are compatible with your organizational mission and strategic plan, then develop programming.

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  If these services aren’t part of your strategic plan or mission, look for community partners.

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  If other providers can’t offer needed services, consider developing them in your agency.

Exhibits 2-4 and 2-5 provide information on forming and documenting partnerships.

Exhibit 2-4

How To Develop Partnerships. Identify organizations in your community affected by homelessness and NGOs and government entities that already provide services or interact in the community with people who are homeless. Reach out to and become familiar with (more...)

Exhibit 2-5

How To Document Partnerships. A memorandum of agreement is a written agreement between parties (e.g., NGOs, Federal or State governments, communities, and/or individuals) to work together on a project or meet an objective. An MOA outlines the responsibilities (more...)

Internet Resources

Becoming informed about housing programs is one way you can help your program create relationships with other community agencies serving people who are homeless. A great deal of information is available on the Internet from the following Web sites:

• U.S. Department of Housing and Urban Development: http://www.hud.gov
• National Alliance to End Homelessness: http://www.naeh.org
• Corporation for Supportive Housing: http://www.csh.org
• SAMHSA’s National Registry of Evidence-Based Programs and Practices: http://nrepp.samhsa.gov
• National Health Care for the Homeless Council: http://www.nhchc.org
• U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration Information Center: http://www.hrsa.gov
• U.S. Department of Veterans Affairs (VA) Web site on reaching out to veterans who are homeless: http://www1.va.gov/homeless
• VA Web site on health benefits eligibility for veterans: http://www.va.gov/healtheligibility
• National Resource Center on Homelessness and Mental Illness: http://www.nrchmi.samhsa.gov

Integrating Behavioral Health Services With a Community System of Homelessness Services

Across the continuum of rehabilitation services for people who are homeless, a variety of community care providers may be engaged with the client. Some of these services include mental health and substance abuse treatment, housing and rehabilitation services specifically for people who are homeless, general healthcare programs, and other community social and rehabilitation services. Your program may be a small part of the larger services continuum, or may be a major provider of care that spans several of these domains. In either case, it is important that programs have a common goal of quality care for people experiencing homelessness, a recognition that homelessness in the community cannot be addressed by simply providing shelter, and a commitment to and a strategic plan for the coordination and nonduplication of services.

Additionally, there are distinct phases of care for persons who are homeless and are affected by substance abuse or mental illness. These are described in Part 1, Chapter 1, and include engagement, intensive care, and ongoing rehabilitation (McQuistion, Felix, & Samuels, 2008). Two additional transition phases (from engagement to intensive care and intensive care to ongoing rehabilitation) are critical times during which clients may regress from their homelessness rehabilitation, experience a relapse to their substance use or psychiatric symptoms, or drop out of treatment; these phases are therefore important to consider in your community programming.

In a few communities, the entire continuum of care might be offered by one comprehensive program, but it is more likely that different organizations work at different points on the continuum. Be aware of services provided in your community, the scope of the services in an individual agency, and the extent to which outreach and treatment services for behavioral health are provided. This will allow you to identify gaps in services and develop programs to address them.

The phases of rehabilitation form a framework that can guide your decisionmaking about program development, implementation, management, and evaluation. The outline below lists the ways your agency can prepare for and participate in providing services to clients who are in each phase of rehabilitation from homelessness.

Building Linkages Among Services

Individuals facing homelessness deal with multiple stressors in their lives. In many communities, services to address these stressors have historically been segregated, making it difficult for the client to access and use them. The lack of access to primary healthcare services can be a major difficulty. In recent years, however, community health centers have become an integral component of healthcare delivery for individuals and families affected by homelessness. Some community health programs provide only primary healthcare services, but others have expanded to outreach, behavioral health, health promotion, and other activities.

Funding Community Homelessness Services

Various community, State, and national resources provide funding for homelessness services. These funding sources may be private foundations, government entities, or community groups. Only rarely can health insurance be a reliable funding source for homelessness services. Funding may be for “bricks and mortar,” for provisions such as food or clothing, or for the targeting of specific needs, such as substance abuse treatment, mental health services, primary health care, or case management. One place to start with program development is to survey what resources for homelessness exist in your community, what services those resources provide, and who offers the funding for available services. Ideally, services should arise from identified community needs (bottom-up planning); however, it is not uncommon that services arise from available funding (top-down planning) or a combination of both.

Federal funding for homelessness services can be divided into two major categories: direct funding for housing and funding for services that support individuals who are homeless. The primary source of direct funding for housing is HUD. In fiscal year 2011, $1.63 billion was available for Continuum of Care (CoC) grants. CoC programs are based on community needs assessment and have a goal of helping individuals and families who are homeless quickly transition to self-sufficiency and permanent housing. In a CoC community, a local or regional planning board coordinates funding for housing and homelessness services for the geographic area. Local programs seeking funding apply jointly with other community programs in a single application to HUD. The four primary components of CoC are:

• Outreach, intake, and assessment.
• Emergency shelter to provide immediate and safe alternatives for people who are homeless.
• Transitional housing with supportive services.
• Permanent supportive housing.

The four primary programs available to provide these services are:

• Supportive Housing Program, now part of the Continuum of Care program.
• Shelter Plus Care Program, now part of the Continuum of Care program.
• Section 8 Moderate Rehabilitation Single Room Occupancy Program.
• Dwellings for Homeless Individuals (Section 8/SRO) Program.

Other HUD-sponsored housing programs include:

• Base Realignment and Closure.
• Housing Opportunities for Persons With AIDS Program.
• Veterans Affairs Supportive Housing Program.
• Disaster Housing Assistance Program.
• Housing Choice Voucher Program (Section 8).
• Public Housing Program.
• Section 202 Supportive Housing for the Elderly Program.
• Section 811 Supportive Housing for Persons With Disabilities.

Additionally, a variety of funding is available for supportive services for individuals and families who are homeless or at risk of homelessness. Some of these programs can also fund housing services, but often only on a temporary or transitional basis. In addition to HUD funding for services, programs from HHS, VA, the U.S. Department of Justice, and the U.S. Department of Labor contribute substantial funding to address homelessness.

Projects for Assistance in Transition from Homelessness (PATH) is a SAMHSA-supported formula grant program to provide homelessness services for people with serious mental illness, including those with co-occurring substance use disorders. The program provides funding to all 50 States and the U.S. Territories and possessions through almost 600 local agencies. Services include community-based outreach, mental health and substance abuse treatment, case management and other support services, and limited housing options. Application for funding is made through each State’s Single State Agency designated to manage PATH funding. The services provided in a particular State depend on that State’s needs. For instance, in rural areas, funding may be available for outreach in areas where homelessness services have not traditionally been available. Some States have support programs for special populations with SMI. Other States coordinate services with local community mental health centers to ensure that individuals who are homeless or at risk of homelessness receive comprehensive care for mental illness or CODs. PATH monies are also available for training local providers on effective strategies to assist people with SMI who are homeless.

Other programs available through HHS for persons and families who are homeless include:

• Health Care for the Homeless. This multidisciplinary, comprehensive program provides primary health care, substance abuse treatment, emergency care with referrals to hospitals for inpatient care services, and outreach services to help difficult-to-reach people who are homeless establish eligibility for entitlement programs and housing.
• Services in Supportive Housing (SSH) (SAMHSA). The SSH program helps prevent and reduce chronic homelessness by funding services for individuals and families experiencing chronic homelessness and living with a severe mental and/or substance use disorder. Grants are awarded competitively for up to 5 years to community-based public or nonprofit entities. Services supported include, but are not limited to, outreach and engagement, intensive case management, mental health and substance abuse treatment, and assistance with obtaining benefits.
• Grants for the Benefit of Homeless Individuals (GBHI) (SAMHSA). GBHI is a competitively awarded grant program that helps communities expand and strengthen their treatment services for people experiencing homelessness. Grants are awarded for up to 5 years to community-based public or nonprofit entities. Funds may be used for substance abuse treatment, mental health services, wrap-around services, immediate entry into treatment, outreach services, screening and diagnostic services, staff training, case management, primary health services, job training, educational services, and relevant housing services.

VA provides a variety of programs to assist veterans who are homeless. In cooperation with HUD, VA provides permanent supportive housing and ongoing case management services for veterans who require those supports to live independently. HUD has also allocated more than 20,000 Housing Choice Section 8 vouchers to Public Housing Authorities throughout the country for eligible veterans who are homeless. The Housing Choice Section 8 vouchers program is particularly beneficial to female veterans, veterans recently returned from overseas, and veterans with disabilities. Housing is permanent and accompanied by supportive services; the voucher is portable, allowing users to move to different locations or get better housing solutions as they become available.

VA also funds community-based agencies to provide transitional housing and supportive services for veterans who are homeless through the Capital Grant Component program. For more information on this program and the Homeless Providers Grant and Per Diem Programs, contact Jeff Quarles toll-free at 1-877-332-0334.

Stand Down programs, located throughout the United States, are developed and operated by veterans service organizations, local CoC programs, community groups, military personnel, and other interested citizens to provide shelter, meals, clothing, employment services, and medical care for veterans who are homeless. Normally, Stand Down programs are time limited (1–3 days). VA funding is available for up to $10,000 to conduct events each year.