One of the great things about working for an agency that does a lot of research into areas of interest to me; poverty, homelessness, social issues, etc., is that I find treasure in the form of great pieces of literature just about every time I wander into work. The article below by Jocelyn Apicello is one of those great pieces and I hope you'll spend the time required to read it. I suspect by the time you reach table 1 you'll be hooked; it didn't take me but a few sentences.....A Paradigm Shift in Housing and Homeless Services: Applying thePopulation and High-Risk Framework to Preventing Homelessness
Jocelyn Apicello*
Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, 722 W. 168th Street, 5th Floor, New York, NY 10032, USA
Abstract: Prevention is critical in any effort to end homelessness. Unfortunately, the practice of homelessness prevention is still in its infancy and there is little science base for its implementation. Risk factors for homelessness have been identified at multiple levels: the individual, institutional, and societal levels. Addressing all three in prevention practice is necessary. The population/high-risk framework is the most appropriate framework for conceptualizing how to design programs and policies to prevent homelessness because it draws attention to the need for direct intervention among those at most risk, and also for modifying the overall context. This review of the literature and technical reports points to a number of strategies that demonstrate preliminary effectiveness or are in need of rigorous evaluations. Reductions in homelessness as a result of targeted, high-risk approaches alone are achievable, but will be short-lived unless low-cost and affordable housing and income are addressed at the population level. Simultaneous implementation and evaluation of both population and high-risk prevention strategies will bring us closer to reaching our goal of ending homelessness.
INTRODUCTION
Prevention is critical in any effort to end homelessness. The past three decades of homeless services have focused resources primarily on managing and treating homelessness by providing crisis services to people once they become homeless. More recent policy and program development has emphasized ending chronic homelessness, focusing on the estimated 10-20 percent of people who have very long or recurrent spells of homelessness. However, homelessness is not simply a temporary emergency or a problem of those few who experience extended time without their own home; it is an entrenched phenomenon in the modern world, not only in the United States, but in other developed nations as well.
The current U.S. housing and economic crisis [1-3] brings the need for homeless prevention to the fore. This crisis could lead to thousands of households losing their homes to foreclosure and many more to face financial struggles as a result of rising unemployment. Given the increasing number of people experiencing housing loss and homelessness and the opportunity created by the $1.5 billion included in the 2008 American Recovery and Reinvestment Act for homelessness prevention, diversion and re-housing activities, we are at a critical moment for a paradigm shift in housing and homeless policies to take place.
Unfortunately, the practice of homelessness prevention isstill in its infancy and there is little science base for itsimplementation.1 There is no consensus among experts in the field on what the most appropriate approaches are for preventing homelessness. Furthermore, few methodologically rigorous evaluations of homeless prevention programs have been conducted. Most evaluations lack an adequate control group or are not randomized, have no or limited follow-up, and rely on descriptive case studies. Results from these studies can be misconstrued and misunderstood as prevention because they presume perfect success rates for anyone receiving services (i.e., that 100% of people who received the intervention would have been homeless had they not received the intervention). Additionally, well-executed cost-benefit studies that can establish marginal cost savings of prevention programs are rarely performed. With funding sources increasingly expecting the implementation of best practices and evidence-based programming, more effort must be taken to develop sound program models and execute state-of-the-art evaluations.
Current circumstances in the housing and financial markets have created a critical opportunity to bring prevention of housing loss to the foreground. In this paper I will argue for the adoption of a prevention-oriented approach to homeless services by employing the population/high-risk prevention framework. First, I will outline why preventing homelessness is important and timely. Second, I will describe the science of prevention as it applies to homelessness using the social epidemiological population/high-risk prevention framework. Third, I will review selected population and high-risk prevention interventions that have been applied to the problems of housing and homelessness. Finally, I will provide recommendations for clinical practice, program development, policy and research.
WHY PREVENT HOMELESSNESS?
The extent of the crisis of homelessness makes prevention urgently important. According to current estimates, there were approximately 672,000 sheltered and unsheltered people experiencing homelessness in the United States in January 2007 [4]. Early research has shown that approximately three to seven percent of adults have had a significant homeless experience during their lifetime [5]. More recent research estimated that the lifetime prevalence of homelessness in the U.S. is 6.2 percent [6]. The number of homeless families continues to rise since the 1980s, and families currently represent approximately 40 percent of the homeless population [4, 7, 8]. Burt and colleagues [9] estimate that 10 percent of poor families experience homelessness annually, resulting in 1.3 million children living in shelters or on the streets.
An extensive list of negative health and socialconsequences are associated with homelessness [10-13],making preventing its onset and duration a critical goal for the health and well-being of individuals and communities. Research suggests that homeless experiences can exacerbate existing illnesses, impede recovery, and provoke newillnesses [10, 12, 14-16]. Mortality among clients served by Health Care for the Homeless projects in 19 cities was estimated as 3.1 times that of the general U.S. population [16], and in New York City age-adjusted mortality rates of homeless individuals were four times those of the general U.S. population and two to three times those of the general population in New York City [10]. Compared to poor, housed children, homeless children have worse health, more developmental delays, more anxiety, depression andbehavior problems, poorer school attendance andperformance, and other negative conditions [17, 18].O’Flaherty [19] infers that “a community with a history of more homelessness in the past is likely to be a community with more disabilities in the present, and so is likely to experience more homelessness in the future.” Breaking the cycle of homelessness can help foster healthy individuals and communities.
The financial costs of homelessness are also sobering. The U.S. federal government spends $1.9 billion every year on dedicated homeless services, and that is not counting the funding that assists homeless families and individuals from mainstream programs, such as Medicaid, TANF, ormainstream housing programs [20] or resources provided by private, non-profit and faith-based organizations. Thus, the burden of managing homelessness is not only borne byhomeless service providers, but also other mainstream and social service providers. People who are homeless are more likely to access costly health care services [21, 22] and spend more time in jail or prisons [11, 23]. Furthermore,emergency shelters too often serve as long-term housing, which costs HUD’s Emergency Shelter Grants program over $8,000 more than the average annual cost of a federalSection 8 housing subsidy [24].
WHY SHIFT TO A PREVENTION FOCUS NOW?
With decades of research on the individual, social and economic costs associated with homelessness, there have been several recent initiatives that focus on ending it. For example, between 2001 and 2007, the U.S. Department of Health and Human Services (DHHS) convened a Homeless Policy Academy Initiative, in partnership with the U.S. Departments of Housing and Urban Development (HUD), Veterans Affairs, Labor, and Education. The Initiative was designed to help state and local policymakers improve access to mainstream services for people experiencinghomelessness. In 2000, the National Alliance to End Homelessness (NAEH), a nonpartisan organizationcommitted to preventing and ending homeless in the U.S., released a comprehensive Ten-Year Plan to EndHomelessness to address the challenges that localjurisdictions face. In just a few years, over 300 localities have drafted plans to end homelessness [25]. Although the large majority of 10-year plans focus on ending chronic homelessness, their initial success at putting homelessness back on the agenda of local policymakers has created a unique opportunity to draw attention to prevention.
Preventing homelessness is also timely with respect to federal, state, and local emergency response procedures to both natural and unnatural disasters. For example, in 2005, Hurricane Katrina displaced over 600,000 individuals across the Gulf Coast in the month following the storm and destroyed nearly 228,000 homes in New Orleans, Louisiana [26]. The slow-to-develop plans to rebuild affordable housing units and provide people with housing subsidies have been grossly inadequate. One of the consequences of this event has been the refocusing of national attention on the affordable housing crisis, the burden of which is disproportionately borne by low-income and minority communities, and its role in creating homelessness.
Moreover, the recent housing crisis is wreaking havoc on more then just the stock market, the housing market, and our economy: thousands of individuals and families face foreclosure and increasing material hardship. A recent U.S. Conference of Mayors report indicated that U.S. cities are reporting significant increases in homelessness as a result of the foreclosure crisis, and that many of them are homeless for the first time after losing their home [27]. CNN reports that authorities in Santa Barbara, California, have made 12 gated parking lots available to families living in their cars – the first such program in the U.S. [28].
As foreclosures and general housing instability are expected to rise, programs that help prevent individuals and families from losing their homes and facing homelessness are imperative. In February 2009, Congress passed the nearly $800 billion American Recovery and Reinvestment Act, which includes $1.5 billion for homelessness prevention and re-housing for households who are homeless or at risk of homelessness. This critical funding could provide theopportunity to transform housing and homeless assistance from a treatment-focused agenda to a prevention-focused one.
EMPIRICAL STUDIES IDENTIFYING RISKFACTORS FOR HOMELESSNESS
Prevention science is based on the notion that risk and protective factors that are empirically derived can predict the likelihood of outcomes. Over two decades of research on the risk factors associated with homelessness has uncovered a range of points to intervene—precursors to the development of prevention programs. Common to all studies is the fact that people experiencing homelessness live in extreme poverty.
Numerous forces that contribute to increases in poverty play a role in the existence of and increase in homelessness. People who are on the losing end of these fundamental forces—for example, unemployed people, people with no assets, or people with physical, mental or developmental disabilities—are then vulnerable toexperiencing homelessness. However, as not all persons living in poverty experience homelessness [9, 29, 30], many studies have attempted to understand the factors that increase the risk of homelessness among poor persons.
These empirical studies largely focused on identifying characteristics at three different levels: (1) the individual level: single individuals or families who are currently homeless, formerly homeless or at-risk of homelessness; (2) the institutional level: community institutions or facilities that can be public or private and that provide either formal or informal services to people who are homeless or at-risk of homelessness; and (3) the social level: the characteristics of larger social systems, which include social, economic, political and cultural forces.
Table 1 contains a summary of risk factors forhomelessness in the U.S. at the individual, institutional and social levels. Importantly, homeless episodes result from a combination of factors that accumulate over the lifecourse: Individual vulnerabilities, taken within the context of institutional experiences and the social environment,contribute greatly to the complexity of the problem of homelessness, particularly when it comes to predicting who is most likely to become homeless in the first place [31]. In fact, it may be the conjunction that counts; in other words, being the wrong person in the wrong place at the wrong time [32]. A concerted effort is needed to prevent homelessness before it occurs by addressing root causes in the general social environment. Additionally, preventing homelessness among identified high-risk groups, such as persons with mental health, substance abuse or trauma histories, require targeted interventions that go beyond what is done to improve the social environment for the general population. Addressing these multiple levels from a prevention-oriented approach, rather than a crisis management and rehabilitative treatment approach, requires a comprehensive conceptuali-zation of prevention that addresses the fundamentalcontextual and individual causes of homelessness.
OVERVIEW OF CONCEPTUAL PREVENTION FRAMEWORKS
Preventing homelessness requires an appropriate framework to guide the development of prevention
Table 1. Summary of Empirically Identified Risk Factors for Homelessness. People who are on the losing end of these fundamental forces—for example, unemployed people, people with no assets, or people with physical, mental or developmental disabilities—are then vulnerable toexperiencing homelessness. However, as not all persons living in poverty experience homelessness [9, 29, 30], many studies have attempted to understand the factors that increase the risk of homelessness among poor persons.
These empirical studies largely focused on identifying characteristics at three different levels: (1) the individual level: single individuals or families who are currently homeless, formerly homeless or at-risk of homelessness; (2) the institutional level: community institutions or facilities that can be public or private and that provide either formal or informal services to people who are homeless or at-risk of homelessness; and (3) the social level: the characteristics of larger social systems, which include social, economic, political and cultural forces.
Table 1 contains a summary of risk factors forhomelessness in the U.S. at the individual, institutional and social levels. Importantly, homeless episodes result from a combination of factors that accumulate over the lifecourse: Individual vulnerabilities, taken within the context of institutional experiences and the social environment,contribute greatly to the complexity of the problem of homelessness, particularly when it comes to predicting who is most likely to become homeless in the first place [31]. In fact, it may be the conjunction that counts; in other words, being the wrong person in the wrong place at the wrong time [32]. A concerted effort is needed to prevent homelessness before it occurs by addressing root causes in the general social environment. Additionally, preventing homelessness among identified high-risk groups, such as persons with mental health, substance abuse or trauma histories, require targeted interventions that go beyond what is done to improve the social environment for the general population. Addressing these multiple levels from a prevention-oriented approach, rather than a crisis management and rehabilitative treatment approach, requires a comprehensive conceptualization of prevention that addresses the fundamental contextual and individual causes of homelessness.
OVERVIEW OF CONCEPTUAL PREVENTION FRAMEWORKS
Preventing homelessness requires an appropriate framework to guide the development of prevention
Table 1. Summary of Empirically Identified Risk Factors for Homelessness
(See? I told you you'd be hooked!)
