oversight

Homelessness: State and Local Efforts to Integrate and Evaluate Homeless Assistance Programs

Published by the Government Accountability Office on 1999-06-29.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                  United States General Accounting Office

GAO               Report to Congressional Committees




June 1999
                  HOMELESSNESS
                  State and Local Efforts
                  to Integrate and
                  Evaluate Homeless
                  Assistance Programs




GAO/RCED-99-178
      United States
GAO   General Accounting Office
      Washington, D.C. 20548

      Resources, Community, and
      Economic Development Division

      B-281482

      June 29, 1999

      Congressional Committees

      In 1987, the Congress enacted the Stewart B. McKinney Homeless
      Assistance Act, recognizing that state, local, and private efforts alone were
      not adequate to address the growing problem of homelessness in America.
      Since the McKinney Act was passed, federal resources for alleviating
      homelessness have increased significantly, and a number of new federal
      programs have been created specifically to serve homeless people. Yet
      despite these increased federal efforts, homelessness in America has
      persisted. The most widely accepted research indicates that up to 600,000
      people may be homeless at any given time, and most experts on
      homelessness agree that programs targeted specifically to people who are
      homeless do not have sufficient resources to meet the needs of this
      population.

      To provide more assistance for homeless people and to meet their multiple
      and complex needs, states and localities are seeking to link and integrate
      homeless assistance programs with mainstream social service systems.1 In
      addition, some states and localities are beginning to use outcome
      measures to better manage their programs and to ensure that their limited
      resources are being used for those programs that achieve the best possible
      results. Using outcome measures shifts the focus from counting outputs,
      such as the types and numbers of services provided by a program, to
      measuring outcomes, such as the results achieved by the program.
      Interested in these developments, you asked us to describe some notable
      examples of efforts by states or localities to (1) link and integrate their
      homeless assistance programs with mainstream systems and (2) measure
      and evaluate outcomes for their homeless assistance programs. This is the
      second in a series of reports that you asked us to prepare on
      homelessness.2

      To identify notable examples of state or local efforts to link and integrate,
      and to measure and evaluate outcomes for, their homeless assistance

      1
       For this report, we used the term “link” for efforts that seek to improve homeless people’s access to
      mainstream resources, and we used the term “integrate” to refer to more fundamental changes in the
      ways that agencies or systems of care share or consolidate their resources, planning efforts, and
      clients to improve the services they provide to the homeless.
      2
        Homelessness: Coordination and Evaluation of Programs Are Essential (GAO/RCED-99-49, Feb. 26,
      1999) was our first report responding to your request. In addition, we recently issued a report on
      homeless assistance programs provided by the Department of Veterans Affairs, Homeless Veterans: VA
      Expands Partnerships, but Homeless Program Effectiveness is Unclear (GAO/HEHS-99-53, Apr. 1,
      1999).



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                   programs, we interviewed experts on homelessness, including government
                   officials, academics, advocates for homeless people, providers of services
                   to homeless people, and others. As a result of their recommendations, we
                   focused our review on the efforts of two counties—Franklin County, Ohio,
                   and King County, Washington—and two states—Massachusetts and
                   Minnesota. Because these efforts were identified by experts as particularly
                   effective or innovative in serving homeless people, they are not necessarily
                   representative of efforts being made throughout the country.


                   Among the sites we visited, there were several notable examples of state
Results in Brief   and local efforts to link and integrate homeless assistance programs with
                   mainstream systems. In some cases, these linkages are designed to
                   improve homeless people’s access to mainstream services. For example,
                   to increase the number of eligible homeless people enrolled in Medicaid,
                   the Massachusetts Department of Medical Assistance is conducting
                   outreach at homeless shelters and streamlining the Medicaid application
                   process for this population. In other cases, efforts are being made to
                   integrate entire systems of care. For instance, King County, Washington is
                   seeking to integrate its mental health and substance abuse treatment
                   systems. As part of this effort, King County has created the Crisis Triage
                   Unit—a single place where people, many of them homeless, undergoing
                   mental health or substance-abuse-related crises, can receive treatment and
                   referral through an integrated set of services. In addition, in some
                   communities, mainstream systems are developing policies and programs
                   designed to prevent homelessness, particularly by addressing the
                   discharge practices of institutions that may “feed” homelessness by
                   releasing people who have no place to go. For example, to reduce the
                   number of people who become homeless after leaving correctional
                   facilities, Massachusetts is making efforts to improve its discharge
                   planning for prison inmates and is allocating recovery beds for
                   soon-to-be-released inmates with substance abuse problems who are at
                   risk of becoming homeless. Despite these initiatives, many state and local
                   officials were concerned about the lack of coordination and integration of
                   homeless assistance programs at the federal level, which, they said,
                   adversely affects their efforts at the state and local levels.

                   Nationwide, communities are increasingly using outcome measures to
                   manage their homeless assistance programs, thereby focusing less on the
                   types and numbers of activities performed and more on the results
                   achieved. In Minnesota, for example, the state-funded Family Homeless
                   Prevention and Assistance Program is an outcome-based program that



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             provides agencies with flexible grants but holds them accountable for
             achieving certain measurable outcomes related to preventing
             homelessness among families. One outcome measure used by the program
             is the number of at-risk families who maintain stable housing. A growing
             number of communities across the country are also using management
             information systems to collect uniform data on the use of homeless
             assistance services as a tool for measuring outcomes and better managing
             their resources. For example, the Community Shelter Board in Franklin
             County, Ohio, has developed a comprehensive management information
             system that collects uniform data from all of the emergency shelters in the
             county. This system helps the Community Shelter Board track and
             measure the outcomes of homeless assistance programs countywide and
             hold service providers accountable for achieving the desired outcomes.
             This system also helps the community develop strategies for improving
             policies and programs to serve homeless people. In general, homeless
             assistance providers told us that they often lack the resources to conduct
             comprehensive evaluations of their homeless assistance programs, but
             they hope that their increased use of data systems and outcome measures
             will enable them to better evaluate their programs in the future.


             Homelessness in the United States is a widespread and complex problem.
Background   While the exact number of homeless people is unknown, research by the
             Urban Institute, which was conducted in 1987 but is still widely cited
             today, estimated that over a 1-week period, approximately 500,000 to
             600,000 people lived on the streets or in emergency shelters.3 About
             one-half of homeless single adults are believed to have a problem with
             alcohol abuse and about one-third with drug abuse, according to estimates
             from a series of studies funded by the National Institute of Mental Health
             in the mid-1980s. In addition, these studies estimated, about 20 to
             25 percent of homeless single adults have a lifetime history of serious
             mental illness, and about half of those with a serious mental illness also
             have an alcohol or a drug abuse problem.4 The U.S. Conference of Mayors
             estimated, in a survey of 30 major cities, that families with children made
             up about 38 percent of the homeless population in 1998, compared with


             3
              Martha R. Burt and Barbara E. Cohen, America’s Homeless: Numbers, Characteristics, and Programs
             that Serve Them (The Urban Institute Press, July 1989).
             4
              The results of these studies are described in a paper by Robert Rosenheck, Ellen Bassuk, and Amy
             Salomon entitled Special Populations of Homeless Americans. This paper was presented at the
             National Symposium on Homelessness Research: What Works, which was cosponsored by the
             Department of Housing and Urban Development and the Department of Health and Human Services in
             Oct. 1998.



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about 27 percent in 1985.5 Moreover, the needs of people who are
homeless vary greatly, as does the nature of the assistance they require.
While homelessness is an episodic event for many people who rely
temporarily on emergency shelters to help them get through a difficult
situation, it is often a chronic condition for others, particularly for those
who have a serious substance abuse disorder or a serious physical or
mental disability. Consequently, in addition to housing, these individuals
may require intensive and ongoing supportive services, such as mental
health care or substance abuse treatment, to keep them out of
homelessness.

A wide range of local, state, and federal agencies, as well as nonprofit
organizations, provide shelter and services to homeless people in America.
The Stewart B. McKinney Homeless Assistance Act (P.L. 100-77), passed
by the Congress in 1987, is the principal federal legislation designed to
assist homeless people. The McKinney Act’s programs award grants to
communities for activities that provide homeless individuals and families
with emergency food and shelter, transitional housing, and supportive
services. In fiscal year 1997, the federal government obligated over
$1.2 billion for federal programs that are specifically targeted to people
who are homeless.

Most of the federal government’s funding for programs targeted to
homeless people is administered by the U.S. Department of Housing and
Urban Development (HUD).6 HUD’s strategy for addressing the problem of
homelessness is known as the Continuum of Care. Under this strategy,
communities that apply for McKinney Act funds undertake a
community-based planning process to help identify the needs of homeless
people and develop a comprehensive system, or “continuum of care,” to
meet those needs. The Continuum of Care strategy is intended to
incorporate a wide array of resources and activities—including
homelessness prevention, outreach and assessment, emergency shelter,
transitional and permanent housing, and supportive services such as job
training, substance abuse treatment, and mental health services—into the
system that serves homeless people.




5
 A Status Report on Hunger and Homelessness in American Cities – 1998, U.S. Conference of Mayors
(Dec. 1998).
6
Other federal agencies that administer programs targeted to the homeless are the departments of
Agriculture, Education, Health and Human Services, Labor, and Veterans Affairs and the Federal
Emergency Management Agency.



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                           At the locations we visited, we found various examples of state and local
Efforts to Link and        efforts to link and integrate services for homeless people with mainstream
Integrate Homeless         systems. In some communities, these linkages seek to improve homeless
Assistance Programs        people’s access to mainstream services. In other communities, efforts are
                           under way to integrate entire systems of care so as to improve the
With Mainstream            coordination and quality of services provided to homeless people. Finally,
Systems                    in some communities mainstream systems are developing policies and
                           programs designed to prevent homelessness among people being
                           discharged from institutions such as correctional facilities and psychiatric
                           hospitals. At the same time, many state and local officials noted, a lack of
                           coordination and integration of homeless assistance programs at the
                           federal level adversely affects their efforts at the state and local levels.


Efforts to Improve         Experts on homelessness, including academics, government officials, and
Homeless People’s Access   providers of services for homeless people, differ in their opinions as to
to Mainstream Programs     whether the needs of homeless people are better served by mainstream
                           programs or by programs that are specifically targeted to homeless
                           people.7 While some experts believe that homeless people may be better
                           served by a single coordinated service system specifically targeted to
                           them, others believe that having a separate service system for homeless
                           people “institutionalizes” homelessness and diminishes the will and
                           capacity of the mainstream systems to help the homeless. However, most
                           experts take a middle position on this issue and maintain that although
                           some targeted programs are necessary to address the special needs of
                           homeless people, the major emphasis needs to be on facilitating homeless
                           people’s access to benefits and services provided through mainstream
                           programs. This approach was recognized as the preferred strategy in the
                           federal government’s long-term plan for addressing homelessness
                           published by the Interagency Council on the Homeless in 1994.8 This plan
                           states that mainstream programs must be adapted to ensure that they meet
                           the special needs of homeless people. Moreover, according to the plan,
                           creating a service system specifically for homeless people that is separate
                           from the mainstream system is both inefficient and ineffective.




                           7
                            Examples of federal programs targeted specifically to the homeless are Emergency Shelter Grants,
                           Health Care for the Homeless, and the Homeless Children Nutrition Program. Examples of federal
                           programs available to low-income people in general are Public and Indian Housing, Medicaid, and the
                           Food Stamp Program. Across the country, states and localities also offer a wide range of programs,
                           including some targeted to the homeless and others intended for low-income people generally.
                           8
                             Priority Home: The Federal Plan to Break the Cycle of Homelessness, Interagency Council on the
                           Homeless (1994).



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In the communities we reviewed, we found several examples of state and
local efforts to link homeless people with mainstream resources, thereby
improving their access to these resources. For example, in Massachusetts,
the Division of Medical Assistance has a pilot project designed to improve
homeless people’s access to Medicaid.9 The state has combined the
eligibility and enrollment process for applicants and has streamlined this
process so that it is easier for homeless people to apply for Medicaid. In
addition, the state has strengthened its outreach efforts to increase the
number of eligible homeless people who are enrolled in Medicaid and has
trained staff at emergency shelters so that they can better assist homeless
people in completing Medicaid application forms. Massachusetts is also
linking its management information system for homeless assistance
programs with an automated benefits eligibility system. This effort will
automatically link data entered into a homeless shelter’s database to a
system that will provide homeless clients with individualized information
on which federal, state, and local programs they may be eligible for.
Linking the two systems should facilitate homeless people’s access to
mainstream programs and services, according to state planning
documents. (See app. I for more detailed information on Massachusetts’
efforts in these areas.)

Efforts to improve homeless people’s access to mainstream services are
also taking place through Seattle-King County’s Health Care for the
Homeless Network.10 This model for implementing the Health Care for the
Homeless program combines direct services provided by the staff of the
Seattle-King County Department of Public Health with contracted services
provided by mainstream health service providers. Dedicating public health
staff specifically to providing health care services to homeless people
helps ensure that adequate outreach is conducted to meet the special
needs of this population. At the same time, contract agreements with
hospitals and other community providers help ensure that existing
mainstream health care resources are used to serve homeless people and
that these mainstream systems are held accountable for providing care to
the homeless population. (See app. II for more detailed information on the
Seattle-King County program.)


9
 Medicaid finances health care for certain poor and disabled individuals nationwide. It is jointly funded
by the federal government and the states and is administered by the states with broad federal
guidance.
10
 Seattle-King County’s Health Care for the Homeless Network is funded, in part, by the U.S.
Department of Health and Human Services’ Health Care for the Homeless program, which provided
grants to 128 projects nationwide in fiscal year 1998, with the goal of making high-quality health care
accessible to homeless people.



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Efforts to Integrate    Experts on homelessness widely agree that integrated social service
Systems to Improve      systems are needed to meet the numerous and complex needs of homeless
Services for Homeless   people. Many of these experts believe that the social services required by
                        homeless people—such as mental health, substance abuse treatment, and
People                  job training services—already exist. However, these services tend to be
                        fragmented and uncoordinated and, as a result, are not well suited to
                        serving homeless people, who may have multiple problems and often face
                        many barriers to receiving assistance. To address this issue, many
                        communities are attempting to integrate the systems of care that are
                        provided to homeless people by different agencies. For most communities,
                        “systems integration” requires fundamental changes in the ways that
                        agencies share information, resources, and clients. Systems can be
                        integrated, for example, through the development of cross-agency
                        strategic plans and interagency management information systems, the
                        consolidation of programs or agencies, and the pooling of funds.11

                        In particular, community officials and service providers told us that people
                        who are homeless would benefit from better integration of the mental
                        health and substance abuse treatment systems. Traditionally, institutional
                        and philosophical differences have divided these two service systems,
                        creating problems in providing services to people who have co-occurring
                        mental health and substance abuse disorders—a condition common among
                        homeless people. Because people with co-occurring disorders, including
                        homeless people, frequently receive treatment from two different systems,
                        their care is often not coordinated, and neither the mental health nor the
                        substance abuse system is willing to take full responsibility for their care.
                        Furthermore, experts say, effectively treating people with co-occurring
                        disorders often requires a “holistic” approach to effectively address all of
                        their needs.

                        King County, Washington, has taken several steps to integrate its mental
                        health and substance abuse systems. The county is currently merging the
                        two divisions that provide mental health and substance abuse services and
                        has a full-time “systems integration administrator” who is responsible for
                        facilitating the integration of the two systems and creating links with other
                        county systems, such as corrections, housing, and welfare. King County’s
                        systems integration efforts operate on a “no wrong doors” philosophy,
                        under which people with mental illness or substance abuse problems are
                        offered the services they need whether they seek assistance through the
                        hospitals, detoxification centers, emergency shelters, mental health

                        11
                         The concept of systems integration is discussed more fully in a paper by Deborah L. Dennis, Joseph J.
                        Cocozza, and Harry J. Steadman entitled What Do We Know About Systems Integration and
                        Homelessness?, presented at the National Symposium on Homelessness Research (Oct. 1998).



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                            treatment facilities, or correctional facilities. As part of this effort, in
                            July 1998, the county implemented a pilot project, the Crisis Triage Unit,
                            which serves a single place where people undergoing mental health,
                            substance abuse, or other behavioral health crises can receive services
                            and referrals. About half of those brought to the unit are homeless, and
                            many more are at risk of becoming homeless. In addition, the county has
                            established the Chronic Public Inebriates Systems Solutions Workgroup to
                            help address problems related to the street homeless who are chronic
                            abusers of alcohol and often have secondary drug abuse or mental illness
                            disorders as well. The workgroup has implemented a series of measures,
                            including a sobering sleep-off center and a housing plan for this
                            population. (See app. II for more detailed information on King County’s
                            systems integration efforts.)

                            Another example of an effort to create a coordinated system for homeless
                            assistance is in Franklin County, Ohio, where the Community Shelter
                            Board, a nonprofit agency, coordinates and plans all emergency shelter
                            services for the county. According to Franklin County officials, service
                            providers, and state officials, the Community Shelter Board’s role as a
                            single coordinating body allows the emergency shelters in Franklin County
                            to work as a system rather than as a fragmented set of resources,
                            improving linkages between the emergency shelter system and
                            mainstream resources within the community. The Community Shelter
                            Board provides a single conduit for funding the shelters in the county,
                            organizes the county’s Continuum of Care plan, and serves as a bridge
                            between and among the public, private, and nonprofit sectors on issues
                            and planning efforts related to homelessness and emergency shelters. (See
                            app. III for more detailed information on Franklin County’s Community
                            Shelter Board.)


Initiatives by Mainstream   In some communities, mainstream social service systems are increasingly
Systems to Prevent          developing policies and programs designed to prevent homelessness. In
Homelessness                the past, efforts to prevent homelessness consisted mainly of activities
                            such as preventing evictions by providing short-term rental assistance to
                            families. However, there is a growing recognition that it may be possible to
                            prevent homelessness by modifying the discharge practices of institutions
                            such as correctional facilities, hospitals, and psychiatric institutions.
                            These systems may “feed” homelessness because people released from
                            these systems often have no place to go. Experts believe that collaboration
                            between these mainstream systems and the homeless assistance system
                            can facilitate the development of measures for preventing homelessness.



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                           In Massachusetts, efforts are being made to reduce the number of people
                           who become homeless after leaving correctional facilities. Both the state’s
                           Department of Correction and county correctional agencies have devoted
                           more resources to planning for the discharge of inmates who will soon be
                           released. In addition, the state’s Department of Public Health has
                           implemented a criminal justice initiative, which allocates a number of
                           recovery beds for those who are being released from the corrections
                           system, have a substance abuse problem, and are at risk of becoming
                           homeless. Moreover, the Massachusetts Department of Mental Health has
                           in place a number of policies and procedures that are designed to prevent
                           patients who are being discharged from psychiatric hospitals from
                           becoming homeless. For example, the Department’s Homeless Services
                           Unit works with formerly homeless mental health clients to help them find
                           adequate housing before they are discharged from mental health facilities.
                           Similarly, the Massachusetts Division of Medical Assistance requires the
                           private contractor that provides mental health services for many of the
                           state’s Medicaid recipients to identify strategies and resources to help
                           prevent clients who are being discharged from inpatient psychiatric
                           facilities from becoming homeless. (See app. I for detailed information on
                           Massachusetts’ homeless prevention efforts.)

                           King County, Washington, recently started the Mental Health Court, a pilot
                           effort designed, in part, to prevent individuals with mental illness from
                           cycling between homelessness and the correctional system. Under this
                           effort, mentally ill people who have been charged with misdemeanors will
                           typically have the option of receiving court-ordered treatment as an
                           alternative to prosecution or sentencing. Unlike the regular court system,
                           the Mental Health Court provides a number of individual treatment and
                           supportive services, as well as a limited amount of temporary housing.
                           County officials estimate that about one-third of those who will use the
                           Mental Health Court will be homeless and many more will be at risk of
                           becoming homeless. (See app. II for detailed information on the King
                           County Mental Health Court.)


State and Local            Several federal initiatives encourage states and localities to link and
Perceptions That Federal   integrate their homeless assistance programs with mainstream service
Efforts to Integrate       systems. For example, HUD’s Continuum of Care strategy encourages
                           communities to create linkages between services for the homeless and
Services for Homeless      mainstream services such as job training, child care, substance abuse
People Could Be Improved   treatment, and mental health services. A 1996 HUD-contracted evaluation of
                           the Continuum of Care strategy found that it had generally been successful



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in helping communities develop a more focused and structured process
for bringing together a wide range of stakeholders and encouraging
collaboration among service systems at the state and local levels.12 Efforts
by the U.S. Department of Health and Human Services (HHS) also
encourage linkages and program integration at the state and local levels.
For example, HHS’ Health Care for the Homeless program emphasizes a
multidisciplinary approach to delivering health care to the homeless,
combining outreach with integrated systems of primary care, mental
health and substance abuse services, and case management. Similarly, HHS’
Access to Community Care and Effective Services and Supports (ACCESS),
a 5-year demonstration project, has been evaluating the effectiveness of
integrated systems of care for homeless people with mental illness.

In addition, as we stated in our February 1999 report,13 efforts to assist
homeless people at the federal level are coordinated in several ways.
Coordination occurs through (1) the Interagency Council on the
Homeless,14 which brings together representatives of federal agencies that
administer programs or resources that can be used to alleviate
homelessness; (2) jointly administered programs and policies adopted by
some agencies to encourage coordination; and (3) compliance with the
requirements of the Government Performance and Results Act of 1993,
which requires federal agencies to identify crosscutting responsibilities,
specify in their strategic plans how they will work together to avoid
unnecessary duplication of effort, and develop appropriate performance
measures for evaluating their programs’ results.

However, the consensus of the state and local government officials,
advocates for homeless people, and homeless assistance providers with
whom we spoke was that the federal government has not done a good job
of coordinating its programs, and this lack of coordination adversely
affects the ability of states and localities to integrate their programs.
Although HUD and HHS have stated that they have a number of activities to
promote coordination between the two departments, state and local

12
 Ester Fuchs and William McAllister, The Continuum of Care: A Report on the New Federal Policy to
Address Homelessness (Dec. 1996).
13
 Homelessness: Coordination and Evaluation of Programs Are Essential (GAO/RCED-99-49, Feb. 26,
1999).
14
  The McKinney Act established the Interagency Council on the Homeless, an independent council
with its own funding and staff, to promote the coordination of homeless assistance programs across
federal agencies. In 1994, because of concerns that the Council was not effectively coordinating a
federal approach to homelessness, the Congress stopped appropriating funds for the Council, and it
became a voluntary working group under the President’s Domestic Policy Council. According to HUD,
the discontinuation of funding has significantly changed the role of the Council, and its activities are
now limited mostly to facilitating the exchange of information and managing limited special projects.



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officials and service providers told us that they were particularly
concerned about what they perceive as insufficient communication and
coordination between the two departments. Many were particularly
critical of what they felt was HHS’ lack of involvement in addressing
homelessness. As a result, in their opinion, HUD has funded and
administered most of the non-housing-related supportive services for the
homeless through its McKinney Act programs. Some state and local
officials also felt that HHS should do more to integrate mental health and
substance abuse programs at the federal level. Such integration, they said,
is necessary to effectively treat homeless individuals with co-occurring
disorders. These officials also said that even though various federal grants
to states and localities have similar goals, they often have differing
eligibility criteria, funding cycles, and reporting requirements, which make
it difficult to incorporate these programs into an integrated system of care
at the local level.15

In commenting on a draft of this report, while HHS agreed that more could
be done at the federal level to better serve the homeless population, it did
not agree with state and local officials’ perceptions that the department
was not adequately involved in addressing homelessness or integrating
mental health and substance abuse programs to effectively treat homeless
people with co-occurring disorders. According to HHS, it has undertaken
several initiatives in conjunction with HUD and other agencies to better
address the needs of homeless people in general, as well as serve people
with co-occurring disorders. In its comments, HHS restated its commitment
to exploring additional opportunities to improve coordination with HUD
and other federal agencies as they continue to address homelessness and
develop and implement approaches to improve services for those with
co-occurring disorders. Moreover, HHS emphasized that the coordination of
resources received from federal agencies must fundamentally occur at the
state and local levels, and that state and local entities must work together
to appropriately address and balance the needs of homeless people with
the needs of a multitude of other groups. (See app. V for the full text of
HHS’ comments on this report.)




15
 We will explore these issues in greater detail as part of our planned review of the barriers faced by
homeless people in gaining access to federal programs.



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                          Many communities across the country are increasingly using outcome
Use of Outcome            measures to manage their homeless assistance programs, and we found
Measures, Data            several examples of the use of the measures at the sites we visited. Using
Systems, and Program      outcome measures to manage programs is becoming increasingly popular
                          with federal, state, and local governments as they wrestle with ways to
Evaluations for           improve the effectiveness and quality of government-provided services
Homeless Assistance       while limiting the costs to deliver these services. The use of outcome
                          measures shifts the focus from outputs, such as the types and numbers of
Programs                  activities performed, to the outcomes, or results achieved. For homeless
                          assistance programs, this means a shift in focus from tracking outputs,
                          such as the number of people sheltered, to measuring outcomes realized,
                          such as the number of people who move out of homelessness and into a
                          stable housing situation.16 In addition to using outcome measures, more
                          communities are using management information systems to collect
                          uniform data on their homeless population and on the resources used by
                          them so they can improve the management and coordination of these
                          resources. Providers of services to the homeless and state and local
                          officials said that they generally lacked the resources to conduct
                          comprehensive evaluations of their homeless assistance programs but
                          hoped that the increased use of data systems and outcome measures
                          would improve their ability to evaluate these programs in the future.


Communities’ Increasing   Communities nationwide are increasingly setting and using outcome
Use of Outcome Measures   measures to evaluate their homeless assistance programs, according to
for Homeless Assistance   researchers and homeless assistance providers. Several reasons may
                          account for this increased emphasis by states and localities on measuring
Programs                  outcomes. First, there is a growing recognition among state and local
                          governments that they need to spend their limited resources on programs
                          that “work.” Consequently, agencies that provide services to the
                          homeless are being required to focus on achieving results–such as moving
                          people out of homelessness–rather than on just providing units of service.
                          Second, an increasing number of management information systems for
                          homeless assistance programs have been developed and implemented in
                          recent years. The availability of these systems makes it easier for state and
                          local officials to collect and use standardized outcome data to manage
                          their homeless assistance programs. Third, states and localities have been


                          16
                            While stable housing is generally the ultimate outcome goal of homeless assistance programs, many
                          programs also have important intermediate outcome goals for the homeless people they serve, such as
                          involvement in mental health or substance abuse treatment, improved level of functioning, or
                          improved health status. These can represent important intermediate steps on the path to stable
                          housing for some homeless people, particularly those suffering from mental illness, a substance abuse
                          disorder, or a chronic health problem.



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    influenced by the federal government’s move towards the use of outcome
    measures under the Government Performance and Results Act of 1993,
    which requires federal agencies to set specific performance goals and to
    measure outcomes for federal programs. Finally, some private foundations
    are requiring greater accountability for the funds they provide to agencies
    that serve the homeless. For example, in Minnesota, the Family Housing
    Fund, which provides funds for two single-room-occupancy projects that
    largely serve formerly homeless individuals, requires the managers of the
    projects to track several performance measures, such as tenants’ stability
    in housing and employment. Similarly, the United Way of King County,
    Washington, outlines in its contract with the YWCA of Seattle several
    specific outcome goals, such as increased housing stability for those
    served by the program.

    At the sites we visited, we found several examples of how states and
    localities are using outcome measures to manage and improve their
    homeless assistance programs, including the following:

•   Minnesota’s state-funded Family Homeless Prevention and Assistance
    Program is an outcome-based program that focuses on three specific
    goals—preventing homelessness, reducing the length of stay in emergency
    shelters, and eliminating repeat episodes of homelessness. The program
    provides local government and nonprofit agencies with flexible grants that
    can usually be used however an agency decides as long as the agency sets
    specific outcome goals, develops a method for tracking these outcomes,
    and achieves and reports on these outcomes. (See app. IV for more
    detailed information on Minnesota’s program.)
•   In Massachusetts, the state’s Division of Medical Assistance has set certain
    performance standards related to homeless people in its contract with the
    company that provides behavioral health services for many of the state’s
    Medicaid recipients. One performance standard requires the company to
    implement measures that will reduce the inappropriate discharge of
    people into homelessness from psychiatric facilities. The second
    performance standard provides incentives to the company for increasing
    the number of eligible homeless individuals enrolled in Medicaid. The
    company receives financial bonuses or penalties on the basis of its success
    in meeting these performance standards. (See app. I for more detailed
    information on Massachusetts’ programs.)
•   The Ohio Department of Development has started to implement the use of
    outcome measures for some of its housing programs that serve homeless
    people. Agencies that receive state funds for supportive housing programs
    are required to develop outcome-based performance targets that the state



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                          will hold them accountable for achieving. For example, a general outcome
                          measure for a transitional housing program might be the percentage of
                          clients that were moved to some kind of permanent housing. State officials
                          told us that they hope to improve the quality of the projects they fund by
                          focusing on the outcomes achieved and hope that these requirements will
                          encourage agencies with poorly performing programs to improve, while
                          highlighting the “best practices” of those agencies that have successful
                          programs. At the county level, the Community Shelter Board in Franklin
                          County, Ohio, has been working with the state to establish outcome
                          measures for service providers in the county. Contracts with service
                          providers that receive funds from the Community Shelter Board include
                          specific outcome measures, such as the percentage of clients moved out of
                          shelters into transitional housing within a given period of time. (See app.
                          III for more detailed information on Ohio’s efforts to use outcome
                          measures.)


States’ and Localities’   A growing number of states and localities are using various data systems
Efforts to Develop Data   to manage their homeless assistance programs. Both individual homeless
Systems and Evaluate      assistance providers and entire service systems are using these
                          management information systems to collect, track, and analyze
Homeless Assistance       information on their clients and the services they use. As many as 50 cities
Programs                  are using or are in the process of implementing an estimated 15 to 18
                          different software applications designed to automate the collection and
                          management of data on the use of homeless assistance services, according
                          to a researcher who has worked with several of these cities. This
                          information can be collected at various points in the system, such as
                          emergency shelters, transitional housing programs, or programs that
                          provide supportive services to homeless people. Communities and service
                          providers can use the data collected by these systems in a variety of ways,
                          from tracking a client’s movement through the system, to assisting in a
                          client’s case management, to gathering general demographic data on the
                          homeless population, to developing policies and plans.

                          Massachusetts, for example, is expanding its use of a computerized
                          record-keeping system for the homeless, called the Automated National
                          Client-specific Homeless services Recording (ANCHoR) system, and is
                          implementing the system statewide.17 This system allows service providers
                          to collect uniform information on their homeless clients over time. It is
                          designed to help service providers assess the needs of their homeless

                          17
                           The ANCHoR system was developed with funding from HUD, HHS, and others. At present,
                          approximately 30 cities across the nation are either using the system or are in the process of
                          implementing it.



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population, manage their emergency shelter resources, and provide better
case management services, including referral and follow-up. By
implementing the system in emergency shelters, transitional housing
programs, and other homeless assistance programs across the entire state,
a Massachusetts official told us, they hope to better coordinate resources
for homeless people statewide and better evaluate programs’
effectiveness. (See app. I for more detailed information about
Massachusetts’ use of the ANCHoR system.)

Similarly, the Community Shelter Board in Franklin County, Ohio, has
developed a comprehensive management information system to collect
uniform data from all of the county’s emergency shelters. This
management information system includes both client- and
provider-specific data and can provide information on various outcomes,
such as the average length of stay in a shelter for homeless men in the
county and the percentage of homeless people who move to permanent
housing within a given time period. A Community Shelter Board official
said that the management information system helps them track and
measure the outcomes of homeless assistance programs countywide and
hold service providers accountable for achieving agreed-upon outcomes.
In addition, the system helps the community develop strategies for
improving policies and programs for homeless people. (See app. III for
more detailed information on Franklin County’s use of management
information systems.)

State and local homeless assistance providers and officials told us that
they typically have not had sufficient resources to conduct comprehensive
evaluations of their homeless assistance programs. However, they hope
that the increased use of data systems and outcome measures will improve
their ability to evaluate these programs in the future. Experts on
homelessness whom we spoke to cited Minnesota as a state that has been
unusually active in evaluating homeless assistance programs and
collecting comprehensive data on its homeless population. Every 3 years,
Minnesota conducts a comprehensive statewide census and survey of
homeless people. According to state and local officials, these surveys help
policymakers and planners gauge trends in, and assess the needs of, the
homeless population and plan and lobby for the resources required to
address these needs. State, county, and nonprofit agencies in Minnesota
also perform a relatively large number of evaluations to determine the
effectiveness of specific programs for homeless people. According to
government officials and service providers, these evaluations have helped
them determine which programs and activities are most effective in aiding



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                  homeless people and in preventing homelessness. (See app. IV for more
                  detailed information on Minnesota’s data collection and evaluation
                  efforts.)


                  We provided a draft of this report to HHS and HUD for review and comment.
Agency Comments   Both departments provided us with comments that appear in appendixes V
                  and VI of the report, along with our detailed responses.

                  HHS  stated that it appreciated the timeliness of this report and our earlier
                  February 1999 report on homelessness because federal, state, and local
                  agencies continue to struggle with the persistent problem of homelessness
                  in the United States. However, HHS also made several points to clarify
                  issues raised in this report. HHS’ primary concern related to our reporting
                  of state and local officials’ perceptions that the Department is not
                  adequately involved in addressing homelessness in general or in
                  integrating federal programs to meet the needs of people with
                  co-occurring disorders. HHS disputed this characterization and cited
                  several initiatives—such as ACCESS, a national survey of homeless
                  assistance providers and clients, a symposium on homelessness research,
                  and various forms of technical assistance that it has provided to the
                  states—as examples of its involvement in addressing homelessness. HHS
                  also described several efforts it has initiated to integrate mental health and
                  substance abuse programs to better serve individuals with co-occurring
                  disorders. While HHS agreed that more could be done to coordinate the
                  efforts of various federal agencies to address homelessness, it also
                  described several joint initiatives that it has undertaken with HUD and
                  other federal agencies to improve federal programs that serve the
                  homeless. HHS also emphasized that the coordination of resources received
                  from federal agencies must fundamentally occur at the state and local
                  levels and that state and local entities must work together to appropriately
                  address and balance the needs of homeless people with those of a
                  multitude of other groups. In its comments, HHS also restated its
                  continuing commitment to developing better solutions for serving
                  homeless people in general, as well as those with co-occurring disorders,
                  and to improving coordination with other agencies. Although we agree
                  that HHS is engaged in several initiatives concerning homelessness, our
                  study raises some issues about how the Department’s efforts are perceived
                  by states and localities. The observations we have reported are based on
                  interviews we conducted with more than 50 state and local officials in four
                  different locations across the country and clearly suggest that many at the
                  state and local level believe that the Department can do more to address



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              B-281482




              the issue of homelessness. HHS also provided us with technical comments
              that have been incorporated in the report as appropriate.

              HUD was pleased that the report highlighted the good work of several
              communities to integrate the housing and services needed by homeless
              people. However, HUD stated that the report did not fully reflect the
              significantly changed role of the Interagency Council on the Homeless. We
              have revised the report to include information that describes the current
              role of the Council.


              To identify notable examples of efforts by states and localities to (1) link
Scope and     and integrate their homeless assistance programs with mainstream
Methodology   systems and (2) measure and evaluate outcomes for their programs that
              serve homeless people, we interviewed national experts on homelessness.
              These experts included HUD and HHS officials that administer programs for
              homeless people; representatives of national advocacy groups for
              homeless people, including the National Coalition for the Homeless and
              the National Alliance to End Homelessness; and researchers and others
              with expertise in this area. Of all of the sites suggested by these experts,
              we selected four from among those most often identified as being
              particularly effective or innovative in linking or integrating homeless
              assistance programs with mainstream systems or using program
              evaluations and outcome measures to manage their homeless assistance
              programs. As a result of this process, we selected two counties—Franklin
              County, Ohio, and King County, Washington—and two
              states—Massachusetts and Minnesota. Because these counties and states
              were chosen for having programs or initiatives that experts considered
              particularly effective or innovative, they are not necessarily representative
              of all states and localities throughout the country.

              We visited each of the four sites we selected and interviewed state and
              local officials, providers of services to homeless people, advocacy groups
              for homeless people, private foundation employees, community-based
              researchers, and others to obtain information and documents on their
              efforts to integrate or evaluate their homeless assistance programs. We
              also collected information on federal initiatives to promote the
              coordination and evaluation of homeless assistance programs at the
              federal, state, and local levels from officials at HHS and HUD. We conducted
              our work between July 1998 and May 1999 in accordance with generally
              accepted government auditing standards.




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We are sending copies of this report to the appropriate congressional
committees, the Honorable Donna Shalala, the Secretary of Health and
Human Services, and the Honorable Andrew Cuomo, the Secretary of
Housing and Urban Development, and other interested parties. Copies will
be made available to others on request.

If you have any questions about this report, please call me or Anu Mittal at
(202) 512-7631. Key contributors to this assignment were Jason Bromberg
and Myrna Pérez.




Judy A. England-Joseph
Director, Housing and Community
  Development Issues




Page 18     GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
B-281482




List of Congressional Committees

The Honorable Phil Gramm
Chairman, Committee on Banking, Housing
  and Urban Affairs
U.S. Senate

The Honorable Pete V. Domenici
Chairman, Committee on Budget
U.S. Senate

The Honorable James M. Jeffords
Chairman, Committee on Health, Education,
  Labor and Pensions
U.S. Senate

The Honorable Arlen Specter
Chairman, Committee on Veterans’ Affairs
U.S. Senate

The Honorable Christopher S. Bond
Chairman, Subcommittee on VA, HUD,
  and Independent Agencies
Committee on Appropriations
U.S. Senate

The Honorable Wayne Allard
Chairman, Subcommittee on Housing
  and Transportation
Committee on Banking, Housing and
  Urban Affairs
U.S. Senate

The Honorable Bill Frist
Chairman, Subcommittee on Public Health
Committee on Health, Education,
  Labor and Pensions
U.S. Senate




Page 19    GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
Contents



Letter                                                                                                  1


Appendix I                                                                                             22
                        Background                                                                     22
Massachusetts           Improving Access to Medicaid and Setting Performance                           23
                          Standards for Managed Care Services
                        Efforts to Prevent Homelessness for Those Released From                        24
                          Correctional Facilities
                        Massachusetts’ Use of Management Information Systems                           27

Appendix II                                                                                            30
                        Background                                                                     30
King County,            Systems Integration in King County                                             30
Washington              Seattle-King County’s Health Care for the Homeless Network                     33

Appendix III                                                                                           37
                        Background                                                                     37
Franklin County, Ohio   Coordination of Emergency Shelter and Other Services Through                   38
                          the Community Shelter Board
                        Data Collection and Program Evaluation Efforts in Franklin                     40
                          County
                        State’s and County’s Use of Outcome Measures to Improve                        41
                          Programs for Homeless People

Appendix IV                                                                                            43
                        Background                                                                     43
Minnesota               Minnesota’s Family Homeless Prevention and Assistance                          44
                          Program
                        Minnesota’s Statewide Survey of Homeless People                                45
                        Minnesota’s Evaluations of Programs That Serve the Homeless                    47

Appendix V                                                                                             49
                        GAO’s Comments                                                                 53
Comments From the
Department of Health
and Human Services




                        Page 20    GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
                    Contents




Appendix VI                                                                                        54
                    GAO’s Comments                                                                 56
Comments From the
Department of
Housing and Urban
Development




                    Abbreviations

                    ACCESS     Access to Community Care and Effective Services and
                                    Supports
                    ANCHoR     Automated National Client-specific Homeless services
                                    Recording System
                    CSB        Community Shelter Board
                    DMA        Division of Medical Assistance
                    FHPAP      Family Homeless Prevention and Assistance Program
                    GAO        General Accounting Office
                    HCHN       Health Care for the Homeless Network
                    HHS        Department of Health and Human Services
                    HUD        Department of Housing and Urban Development
                    ROOF       Rebuilding Our Own Futures
                    YWCA       Young Women’s Christian Association


                    Page 21    GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
Appendix I

Massachusetts


                This appendix describes some of the initiatives taken in Massachusetts to
                improve homeless people’s access to mainstream resources, prevent
                homelessness, and use management information systems to provide better
                services for homeless people. A number of national experts on
                homelessness identified the state of Massachusetts and the city of Boston
                as particularly innovative in linking programs for homeless people with
                mainstream programs and adopting policies within their mainstream
                systems to try to prevent homelessness. The state has several efforts under
                way to improve homeless people’s access to Medicaid and ensure that the
                program’s mental health services adequately serve the needs of homeless
                people. In addition, various state agencies are implementing initiatives to
                help reduce the number of people who become homeless after being
                released from correctional or psychiatric facilities. Finally, Massachusetts
                is expanding its use of a computerized record-keeping system for
                homeless assistance services and is implementing the system statewide. It
                is also linking this system to a benefits eligibility system.


                Massachusetts had a population of about 6.1 million in 1998, according to
Background      a U.S. Census Bureau estimate. Although the state has the fourth highest
                per-capita income in the nation, its cost of living is also among the highest.
                Housing costs in Massachusetts are considerably higher than the national
                average, particularly in the Boston metropolitan area.

                About two-thirds of the state’s homeless population is located in Boston.
                In December 1998, a one-night census of the homeless conducted by the
                city counted 5,272 homeless people. Of this population, 44 percent were
                living in adult shelters, 23 percent were in family shelter programs,
                4 percent were living on the street, and the remainder were in transitional
                housing programs, hospitals, and other settings.

                The Massachusetts Department of Transitional Assistance funds the
                majority of the state’s emergency shelters. Various state agencies are
                responsible for most of the supportive services provided to homeless
                people, including mental health and substance abuse treatment. The
                state’s Interagency Task Force for Housing and Homelessness coordinates
                planning activities and services for homeless people and also develops
                programs that serve homeless people. In Boston, the city’s Emergency
                Shelter Commission coordinates policy development, advocacy, and
                public education on homelessness, while the Department of Neighborhood
                Development manages, oversees, and distributes most of the grants




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                               Appendix I
                               Massachusetts




                               received by the city for services for homeless people. The city also funds
                               two emergency shelters.


                               In Massachusetts, the Division of Medical Assistance (DMA) administers the
Improving Access to            state’s Medicaid program, known as MassHealth. DMA has initiated a pilot
Medicaid and Setting           project to increase the enrollment of homeless people in MassHealth by
Performance                    streamlining the eligibility and enrollment process for this group. DMA also
                               uses performance outcomes to manage the Medicaid contractor that
Standards for                  provides mental health and substance abuse services for most Medicaid
Managed Care                   clients in the state, and two of the performance standards that it uses are
                               related specifically to the issue of homelessness.
Services
State Initiatives to Improve   DMA has established a pilot project to increase the enrollment of homeless
Homeless People’s Access       people in MassHealth, the state’s Medicaid program. One goal of the pilot
to Medicaid                    project is to make it easier for homeless people to enroll in the program by
                               allowing the state to determine their eligibility and enroll them at the same
                               time. Normal enrollment procedures require people to go through a
                               two-step process. For the pilot project, DMA has streamlined the process to
                               suit the special circumstances faced by homeless people. For example,
                               under normal enrollment procedures, forms are sent to an applicant’s
                               permanent mailing address, but under the pilot project, these forms can be
                               sent to a staff member at an emergency shelter who serves as the
                               homeless applicant’s “contact person.”

                               In addition, DMA has increased its outreach efforts to educate community
                               organizations, advocates for homeless people, and others about
                               MassHealth, its eligibility requirements, and the enrollment process. As
                               part of these outreach efforts, DMA is providing special training to staff at
                               the four homeless shelters participating in the pilot project. Shelter staff
                               have been trained to assist homeless clients in completing the forms to
                               determine their eligibility for MassHealth and to provide information on
                               how the enrollment process works. Shelter staff have been given special
                               access to certain client-specific eligibility information that allows them to
                               call DMA to learn whether a homeless client is eligible for MassHealth.


Performance Standards for      About half of the Medicaid recipients in Massachusetts receive mental
Serving the Homeless           health and substance abuse treatment through the Massachusetts
Included in Medicaid           Behavioral Health Partnership, a private company that provides mental
                               health and substance abuse services under a contractual arrangement with
Service Provider’s Contract


                               Page 23         GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
                          Appendix I
                          Massachusetts




                          DMA. DMA  monitors the Partnership’s performance against 18 performance
                          standards that were included in its fiscal year 1999 contract. If these
                          standards are met, the Partnership receives financial bonuses and if they
                          are not met, penalties are assessed. Two of the 18 performance standards
                          specifically address issues relating to homeless people.

                          The first performance standard included in the contract expects the
                          Partnership to collaborate with advocates for homeless people to find
                          ways to ensure that patients in psychiatric facilities are not discharged
                          inappropriately to shelters. It also expects the Partnership to educate its
                          providers of inpatient mental health care and monitor their performance
                          to ensure that homeless patients are appropriately discharged from their
                          facilities. To meet this standard, officials from the Partnership told us that
                          they now require a senior manager to approve a patient’s discharge plan
                          before the patient can be discharged from a hospital to a homeless shelter.
                          They will approve a patient’s discharge to a shelter only after all other
                          alternatives and resources have been considered. The Partnership has also
                          created a Homeless Task Force that, among other things, works with
                          mental health care providers to promote appropriate psychiatric discharge
                          policies and practices. In addition, the Partnership has contributed funding
                          for the establishment of a toll-free telephone system that is being set up by
                          the Massachusetts Housing and Shelter Alliance. This system will provide
                          discharge planners and case managers with access to current information
                          on housing options and services available for homeless individuals. The
                          Partnership is giving its providers special training on how to use the
                          information that is provided by the telephone system to avoid the
                          inappropriate discharge of patients into homelessness.

                          The second performance standard included in the contract provides a
                          financial incentive through the Partnership to certain homeless shelters
                          and detoxification programs that enroll new members in MassHealth. To
                          help meet this standard, the Partnership has provided training to staff at
                          these facilities on MassHealth’s enrollment procedures and has helped DMA
                          in its efforts to streamline the eligibility and enrollment process for
                          homeless people applying for MassHealth.


                          There has long been concern about ex-offenders who become homeless
Efforts to Prevent        after they complete their sentences and are discharged from correctional
Homelessness for          facilities. In Massachusetts, the Department of Correction estimates that
Those Released From       15 percent of those released from state correctional facilities have
                          nowhere to go. Using a representative sample, the Massachusetts Housing
Correctional Facilities

                          Page 24         GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
                              Appendix I
                              Massachusetts




                              and Shelter Alliance estimated that 1,259 ex-offenders went directly from
                              state and county prisons into emergency shelters in 1998. To prevent
                              people who are leaving correctional facilities from becoming homeless,
                              Massachusetts is making efforts to improve discharge planning and is
                              targeting substance abuse recovery home beds for released inmates who
                              are at risk of becoming homeless.


Criminal Justice System’s     Over the past few years, concerns about the corrections system
Efforts to Improve            discharging people into the shelter system has led to increased
Discharge Planning for        communications between the corrections system and advocacy groups for
                              homeless people in Massachusetts. This has provided a stimulus for the
Those Leaving                 Department of Correction to seek improvements in discharge planning for
Correctional Facilities       soon-to-be-released inmates, according to a department official. One of the
                              purposes behind the move for improved discharge planning is to prevent
                              former inmates from cycling through the “revolving door” between the
                              shelter system and the corrections system.

                              In 1998, the Department of Correction revised its Release and Lower
                              Security Preparation Policy, which sought to improve discharge planning
                              and services for all soon-to-be-released inmates from the state corrections
                              system. Under this policy, when inmates in the state corrections system
                              have 1 year before their release, they attend transition workshops. A
                              personalized transition plan is developed for each inmate that addresses
                              postrelease issues such as employment and housing. The corrections
                              system has contracted with a community-based agency that makes
                              appropriate referrals for needed services and housing for each individual
                              who is to be released. The county corrections systems, which are
                              adminstered separately from the state system, have hired full-time
                              discharge planners to perform similar discharge planning functions for the
                              counties’ houses of corrections.


Criminal Justice Initiative   Massachusetts has a criminal justice initiative whose goal is to provide
Designed to Provide           beds in recovery homes for persons with substance abuse problems who
Recovery Homes for            have been released from correctional facilities and are at risk of becoming
                              homeless. This initiative stemmed from discussions that began in 1996
Ex-Offenders With             between the Massachusetts Housing and Shelter Alliance, the Department
Substance Abuse Problems      of Correction, and the state’s Executive Office of Public Safety on ways to
                              prevent ex-offenders from becoming homeless. Because the Department
                              of Correction is not legally responsible for individuals after they have
                              completed their sentences, these groups determined that partnerships



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                              Appendix I
                              Massachusetts




                              with other agencies were required to address this issue. Since an estimated
                              80 percent of those entering the shelter system from prisons have
                              substance abuse problems, the Department of Public Health, which funds
                              the state’s substance abuse services, became involved in these
                              discussions. The criminal justice initiative began in 1996, and
                              approximately $2.1 million was allocated for this initiative in fiscal year
                              1997. These funds support about 135 recovery home beds specifically
                              targeted for persons released from correctional facilities who have
                              substance abuse problems and are at risk of becoming homeless,
                              according to a Department of Public Health official.

                              The Department of Public Health contracted with the Massachusetts
                              Housing and Shelter Alliance to coordinate the initiative. Beginning in
                              September 1997, monthly meetings were held with representatives from a
                              variety of agencies, including the state departments of Correction and
                              Public Health; the Parole Board; county corrections facilities; and
                              recovery home providers. The primary purpose of these meetings was to
                              coordinate the allocation and use of the 135 recovery home beds. For
                              example, a subcommittee was established to survey inmates and
                              determine what information the inmates needed to have about each
                              recovery home so that they could choose the facility that best met their
                              needs. Similarly, another subcommittee developed a standard application
                              form so that inmates could use one application to apply to different
                              recovery homes throughout the state. Participating agencies also
                              addressed a wide variety of other issues, including the need for
                              transitional housing for soon-to-be-released inmates for whom recovery
                              home beds are not yet available. To help gauge the impact of the program,
                              the Massachusetts Housing and Shelter Alliance will be tracking data on
                              the number of people entering shelters for the homeless after being
                              discharged from correctional facilities.


Department of Mental          The Massachusetts Department of Mental Health, which serves individuals
Health’s Efforts to Prevent   with severe and persistent mental illness, estimates that about one-third of
Discharge From State          its clients who are released from the corrections system become
                              homeless. In April 1998, the department instituted the Forensic Transition
Facilities Into               Team, whose goal is to assist mentally ill individuals who are making the
Homelessness                  transition from correctional facilities back into society. A department
                              official said that preventing homelessness is one goal of the program and
                              helping clients find housing is one task of the Forensic Transition Team.




                              Page 26         GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
                           Appendix I
                           Massachusetts




                           The initiative to prevent homelessness for mentally ill ex-inmates is part of
                           the Department of Mental Health’s general policy of preventing
                           homelessness among mentally ill clients being discharged from state
                           facilities. The department’s Homeless Services Unit is notified whenever a
                           homeless client enters an inpatient mental health facility, and the unit
                           works to secure housing and other services for the client as part of the
                           discharge planning process. Department of Mental Health staff are
                           prohibited from discharging a client into an emergency shelter unless all
                           other housing options have been considered and the client refuses the
                           housing that is offered.


                           Massachusetts is implementing a computerized management information
Massachusetts’ Use of      system statewide that will allow providers of services for homeless people
Management                 to collect and access uniform information about their homeless clients and
Information Systems        the services they use. In addition, Massachusetts is linking its management
                           information system with an automated benefits eligibility system, which
                           will allow homeless individuals to more easily identify the mainstream
                           programs and services that may be available to them.


Statewide Implementation   The Automated National Client-specific Homeless services Recording
of a Computerized          (ANCHoR) system is a computerized record-keeping system designed to
Management Information     allow service providers to collect uniform information on their homeless
                           clients. The ANCHoR system was developed with funding from the U.S.
System                     Department of Housing and Urban Development (HUD), the U.S.
                           Department of Health and Human Services (HHS), and other sources, and is
                           currently being used or is in the process of being implemented by
                           approximately 30 cities nationwide.1 The ANCHoR system is designed to
                           help service providers assess clients’ needs, manage shelter stays, and
                           provide overall case management, including referral and follow-up. When
                           a homeless individual enters an agency and requests services, the staff will
                           first conduct an intake survey and use the ANCHoR system to enter
                           information about the homeless client, such as the client’s name, age, race,
                           residential history, health status, and employment. Various steps have
                           been taken to try to ensure the client’s privacy.

                           Boston was one of 16 pilot sites that began using ANCHoR in 1996. The
                           system is currently being used by 73 programs throughout the state, of

                           1
                            In addition to the approximately 30 cities using or in the process of implementing ANCHoR, as many
                           as 20 other cities are using or are in the process of implementing an estimated 15-18 other similar
                           homeless information systems, according to data provided by a researcher who has worked with
                           several of these cities.



                           Page 27         GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
                         Appendix I
                         Massachusetts




                         which 45 are in Boston. It is also in the planning stage for an additional 15
                         programs throughout the state. In 1998, the state Executive Office of
                         Health and Human Services decided to implement ANCHoR throughout
                         Massachusetts as a coordinated statewide system. The statewide
                         expansion of ANCHoR will be supervised and coordinated by the ANCHoR
                         Steering Committee, which was created and appointed by Boston’s
                         Homeless Planning Committee in 1997. The agencies that will use ANCHoR
                         under the statewide expansion include those that provide emergency
                         shelter, transitional housing, referrals, and supportive services to
                         homeless people.

                         Implementing the ANCHoR system statewide is intended to benefit homeless
                         people, agencies that provide services to homeless people, public
                         policymakers, community planners, and researchers, according to the
                         director of the project and state planning documents. Homeless people
                         may benefit by receiving improved assessments of their needs, more
                         coordinated services, and better case management, while the agencies that
                         serve homeless people may benefit by gaining capacity to plan and manage
                         their resources, since they will have better information about patterns of
                         use and resources available to serve homeless people in other parts of the
                         state. According to state planning documents, public policymakers and
                         community planners may also benefit because the system should provide
                         them with information that will improve their ability to coordinate
                         resources communitywide, gauge programs’ effectiveness, assess the
                         overall needs of the community, and, if necessary, request more resources.
                         By implementing the system statewide, Massachusetts hopes to better
                         coordinate care for homeless people, particularly through improving
                         services and case management for individuals who may travel to providers
                         in different locations across the state. According to a state official, the
                         statewide implementation of ANCHoR could be particularly beneficial to
                         Massachusetts because, unlike most states, the state government—rather
                         than municipal or county governments—operates the majority of homeless
                         shelters and the system will give the state more comprehensive data for
                         managing all of these facilities.


Linking ANCHoR With an   Massachusetts is also the first state that is linking ANCHoR to an automated
Automated Benefits       benefits eligibility system. When a service provider enters information
Eligibility System       about a homeless client into ANCHoR, the information is automatically
                         linked to a software program called MicroMax, which has a database of
                         information and eligibility requirements for over 80 federal, state, and
                         local benefit programs, including many specific to Boston and



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Appendix I
Massachusetts




Massachusetts. Using the information about the homeless client that has
already been entered into the ANCHoR system, MicroMax can develop a
report of the public benefit programs and services for which the client
may be eligible and calculate the benefits the client would likely receive
from each program. Clients can receive individualized documents that
include a list of the programs for which they may be eligible, information
on where to apply for benefits, and applications for some of these
programs that have some of the personal information already filled out.

According to state planning documents, several benefits are anticipated
from linking the ANCHoR and MicroMax systems. First, case managers using
ANCHoR should be better able to identify homeless clients’ eligibility for a
variety of programs, including income assistance, medical services, and
job training. This information should help link homeless persons more
quickly with the mainstream public resources available to them, thereby
helping them move more quickly out of homelessness. Second, the
ANCHoR-MicroMax link should make the process of applying for
mainstream programs easier for homeless people, in part because the
system automatically prints out partially completed applications. Finally,
the aggregate data obtained from reports generated by the
ANCHoR-MicroMax link should provide useful information for planning and
policy purposes. For example, the reports will allow the state to track the
public resources used by homeless individuals, the number of homeless
clients assisted by these resources, and the types and values of the
benefits that homeless people received from various programs.




Page 29         GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
Appendix II

King County, Washington


                         This appendix describes the systems integration initiatives and the Health
                         Care for the Homeless Network of King County, Washington. The
                         communities of Seattle and King County, Washington, were identified by a
                         number of national experts on homelessness as particularly effective in
                         integrating programs that serve homeless people with mainstream
                         programs. The county’s systems integration initiative creates connections
                         between the mental health, substance abuse, and criminal justice systems
                         in an effort to address the multiple and complex needs of many of the
                         county’s homeless in a more coordinated and effective manner. The Health
                         Care for the Homeless Network, as implemented in King County,
                         illustrates how programs can be targeted specifically to the homeless
                         while tapping into existing mainstream resources.


                         About 1.7 million people lived in King County, Washington, in 1998,
Background               including about 525,000 in the city of Seattle in 1996, according to U.S.
                         Census Bureau estimates. Although personal income in King County is
                         significantly higher than the national average, about 9 percent of the
                         population lived in poverty in 1995, according to the U.S. Census Bureau.
                         King County has a tight housing market—rents are high compared with
                         income, rents have been rising, and the vacancy rate is low.

                         On any given night, about 5,500 people are homeless in King County,
                         according to the Seattle-King County Homelessness Advisory Group.
                         Roughly 54 percent of those that are homeless are single adults, and
                         46 percent are families or youth. At any given time, an estimated 1,360
                         homeless people are believed to be living on the street, while most of the
                         remainder are housed in emergency shelters or transitional housing. King
                         County’s homeless population is heavily concentrated in Seattle.

                         Seattle and King County collaborate in developing the Continuum of Care
                         plan for the community and jointly submit a single application to HUD for
                         funding through its McKinney Act programs. The King County government,
                         under contract with the state of Washington, provides most of the county’s
                         supportive services, such as mental health and substance abuse treatment.
                         Within Seattle, the city government provides funding for most of the
                         emergency shelter and transitional housing programs.


                         King County has undertaken a series of initiatives to integrate various
Systems Integration in   social service systems that serve homeless people. These include efforts to
King County              integrate the mental health and substance abuse systems, address the



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                            Appendix II
                            King County, Washington




                            problem of chronic public inebriates, and provide alternatives to county
                            jails for those with mental illness or substance abuse disorders. In
                            addition, Seattle’s participation in HHS’ Access to Community Care and
                            Effective Services and Supports (ACCESS) program has been an important
                            aid to the county’s systems integration efforts. The county defines
                            “systems integration” as the sharing of information, planning, clients, and
                            resources by different social service systems. At the operational level, this
                            means getting different systems, such as the mental health, substance
                            abuse, corrections, and housing systems, to work together in an integrated
                            fashion to provide a continuum of services to their clients.


Integration of the Mental   The primary focus of King County’s systems integration efforts has been
Health and Substance        on unifying the county’s mental health and substance abuse systems. Part
Abuse Systems               of the impetus for this integration is the recognition that many homeless
                            people in the community are dually diagnosed with both mental health and
                            substance abuse disorders. In 1998, the county created the Bureau of
                            Unified Services to stimulate the integration of systems and services for
                            individuals and families suffering from mental illness and/or substance
                            abuse. The county also proposed combining the Division of Mental Health
                            and the Division of Alcoholism and Substance Abuse Treatment Services
                            into a single Mental Health, Chemical Abuse and Dependency Services
                            Division so that the county government’s organizational structure would
                            be better aligned with the integrated systems approach. The county is
                            currently waiting for the County Council to approve this proposed
                            restructuring.

                            As part of its systems integration strategy, King County developed a “no
                            wrong doors” philosophy. This means that persons with mental or
                            addictive illness are offered the services they need whether they seek
                            assistance through a local hospital, detoxification center, emergency
                            shelter, mental health treatment program, or correctional facility. In
                            July 1998, as a pilot project, the county opened the Crisis Triage Unit at
                            Seattle’s Harborview Medical Center. The triage unit is designed to serve
                            as a single place where someone experiencing a behavioral health crisis,
                            particularly related to mental health and/or substance abuse issues, can
                            receive immediate care and referral to other longer-term services.
                            According to county officials, about half of the people who are brought to
                            the triage unit are homeless and more are at risk of becoming homeless.
                            The triage unit is staffed with personnel qualified to assess medical,
                            mental health, and substance abuse conditions, as well as with a housing
                            coordinator, who assists clients in gaining access to short-term housing or



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                           Appendix II
                           King County, Washington




                           in maintaining existing housing. The triage unit is designed, in part, to
                           divert people from local jails or hospitals, where they might otherwise be
                           taken, to more appropriate housing and treatment situations.


Efforts to Address the     In September 1997, King County began searching for solutions to the issue
Problem of Homeless        of chronic public inebriates. These individuals are usually homeless
Public Inebriates          chronic abusers of alcohol who often have secondary problems with drug
                           abuse or mental illness. The county convened a Chronic Public Inebriates
                           Systems Solutions Workgroup, which included representatives from the
                           city and county governments, the business community, homeless
                           assistance service agencies, and other affected parties. This effort
                           stemmed, in part, from a recognition in the community that many of the
                           severely distressed individuals in this population were repeatedly entering
                           certain parts of the county’s systems, such as hospital emergency rooms
                           and the courts, where their conditions could not be appropriately
                           addressed.

                           In December 1997, the workgroup developed a housing plan that
                           recommended a series of policy changes and housing actions to help
                           address the needs of chronic public inebriates living on the streets, as well
                           as reduce the negative effects of this population on the community. The
                           actions taken thus far have included opening a sobering sleep-off center,
                           reaching agreement with downtown merchants not to sell certain
                           alcoholic products favored by street inebriates, improving outreach
                           services, and taking steps to develop more supportive housing units for
                           this population.


Alternatives to Jail for   Beginning in 1985, in response to concerns that the county’s jails
Offenders With Mental      contained large numbers of mentally ill inmates whose needs would be
Illness and Substance      better addressed through treatment, King County developed several jail
                           diversion projects. These projects sought to prevent recidivism among
Abuse Disorders            mentally ill offenders–a large percentage of whom were homeless–by
                           providing them with increased services and intensive case management as
                           an alternative to incarceration. In 1997, these projects were redesigned,
                           resources for treatment were increased, a housing component was added,
                           and for the first time, persons whose primary disorder was substance
                           abuse were included in the project. These projects were jointly funded by
                           the county agencies overseeing criminal justice, detention, mental health,
                           and substance abuse services, as well as by the city of Seattle.




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                              Appendix II
                              King County, Washington




                              In December 1998, the county replaced these jail diversion projects with
                              the Mental Health Court, a pilot project that incorporates many of the
                              elements of the prior projects. Defendants with mental illness who have
                              been charged with misdemeanors can now choose to have their cases
                              heard in a special court, where they typically receive court-ordered
                              treatment as an alternative to prosecution or sentencing. On the basis of
                              past experience, King County officials expect that about one-third of those
                              using the Mental Health Court will be homeless and many more will be at
                              risk of becoming homeless.


Integration Efforts           According to King County officials, an important aid to their systems
Stimulated by Participation   integration efforts has been Seattle’s participation in the HHS’ ACCESS
in ACCESS Program             program. ACCESS is a 5-year demonstration program that began in 1994 and
                              will end in 1999. The goal of ACCESS is to evaluate the impact of systems
                              integration on the provision of services for homeless people who are
                              severely mentally ill. Eighteen sites—nine control sites and nine
                              experimental sites—in nine states across the country were selected to
                              participate in the ACCESS program.

                              Seattle is home to both a control site and an experimental site, located in
                              different parts of the city. Both Seattle sites received resources to fund
                              services for homeless people who are mentally ill, and the experimental
                              site received additional resources to fund activities designed to enhance
                              systems integration. This included the hiring of a full-time systems
                              integration administrator within the King County Department of
                              Community and Human Services and the creation of working groups
                              designed to improve collaboration and communication between provider
                              agencies and the community. Although the ACCESS program will end this
                              year, a county official told us that the county is “institutionalizing” the
                              lessons learned from the program through the creation of a new Homeless
                              Outreach, Stabilization and Transition Program, which will incorporate
                              many of the systems integration activities that were provided under
                              ACCESS.



                              The goal of HHS’ Health Care for the Homeless program is to make
Seattle-King County’s         high-quality health care accessible to homeless people nationwide. The
Health Care for the           program awards grants to local public or private nonprofit organizations
Homeless Network              to provide health care services to the homeless. In fiscal year 1998, the
                              Health Care for the Homeless program funded 128 projects nationwide
                              that were administered by local public health departments, community



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                          Appendix II
                          King County, Washington




                          and migrant health centers, hospitals, and local community coalitions.
                          According to HHS, the program encourages an interdisciplinary approach
                          that incorporates health, mental health, substance abuse, and social
                          services to build a coordinated network of services for homeless people
                          within a community. Health Care for the Homeless projects throughout the
                          country are implemented through a variety of different organizational
                          models. About half of the projects are housed in community health
                          centers, about 25 percent in public health departments, and the remainder
                          in other organizations, such as nonprofit agencies, hospitals, and shelter
                          coalitions.

                          The Health Care for the Homeless Network (HCHN) model in Seattle-King
                          County combines services provided directly by the county’s public health
                          staff with contracted services provided by mainstream health care
                          providers. Several national experts on homelessness told us that
                          Seattle-King County’s HCHN was particularly effective. However,
                          Seattle-King County’s model is one of many that have been successful and
                          experts say that the most appropriate model for implementing Health Care
                          for the Homeless in any given location will depend on the specific needs
                          and characteristics of the particular community.


County and Mainstream     Seattle-King County’s HCHN is administered by the Seattle-King County
Services Linked Through   Department of Public Health, which provides certain services directly to
HCHN                      homeless people and contracts with mainstream health care providers for
                          other services. Services provided directly by Department of Public Health
                          staff include immunizations, family planning, dental screening,
                          tuberculosis outreach, communicable disease control, and health
                          education. Most of these services are provided at sites operated by the
                          department. The Department of Public Health also has a full-time public
                          health nurse available to provide technical assistance on health and safety
                          issues to agencies that serve homeless people. For example, the public
                          health nurse provides training to staff in emergency shelters on first aid
                          and disease prevention. The Department of Public Health also provides
                          emergency shelters with certain supplies, like soap and liquid soap
                          dispensers, to help improve the general hygiene of their homeless clients.

                          The Department of Public Health contracts with 10 community-based
                          health care providers, including hospitals, community health centers, and
                          social service agencies, to provide most of the network’s services. These
                          services include street outreach, primary care, substance abuse and
                          mental health services, medical respite, and assistance with enrollment



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                            Appendix II
                            King County, Washington




                            and the use of Medicaid managed care. To be more accessible to the
                            homeless population they serve, most of the health care professionals
                            working for the community-based health care providers are located at
                            emergency shelters.


Benefits of County’s HCHN   The Health Care for the Homeless model implemented in Seattle-King
Model                       County has a number of benefits, according to local officials. These
                            include better access to city-, county-, and community-based resources;
                            more continuity in the provision of services to homeless people; and
                            improved data collection capabilities that can help city and county
                            governments better plan services for homeless people.

                            According to a Seattle official, placing the Seattle-King County HCHN within
                            a major government agency like the Department of Public Health, rather
                            than in a community-based nonprofit service agency, improves its access
                            to the community’s major health care resources. At the same time, by
                            contracting with community providers for health care services, HCHN is
                            able to tap into existing mainstream resources, such as hospitals and
                            community health centers, without having to create a separate system of
                            care for homeless people. The requirements in HCHN’s contracts with
                            providers in mainstream systems also allow HCHN to hold these systems
                            more accountable for serving homeless people, who are traditionally a
                            more difficult and expensive population to serve. These requirements also
                            ensure that mainstream systems provide the special outreach and support
                            that the homeless population requires.

                            Moreover, components of Seattle-King County’s HCHN help to ensure
                            continuity of care for homeless people as they move from location to
                            location, and even after they move out of homelessness. Under the
                            Pathways Home program, a team of health care professionals track and
                            monitor homeless families–whether they are living on the street, in an
                            emergency shelter, or in temporary housing–and continue to provide them
                            with the range of health care services that they need, from screening and
                            case management to comprehensive mental health treatment. The team
                            provides health care to these clients for up to a year after they have been
                            placed in permanent housing.

                            Finally, the Seattle-King County HCHN has in place a data system that
                            provides important information on homeless people and the services they
                            are receiving. Each provider that contracts with HCHN records every
                            encounter with a homeless client on a standardized intake form. All of the



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Appendix II
King County, Washington




data are maintained on a central database, and each homeless client is
given a unique identification number that allows HCHN to track the client
throughout the system. According to a program official, the Seattle-King
County HCHN database has recorded about 60,000 encounters with about
20,000 individuals in the past year. This information aids city and county
governments in identifying the major health problems affecting homeless
people, as well as in monitoring general health and demographic trends
among this population.




Page 36       GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
Appendix III

Franklin County, Ohio


               This appendix describes the efforts of Franklin County, Ohio, to integrate
               its emergency shelter programs and related homeless assistance services
               into a coordinated and unified system, primarily through its Community
               Shelter Board. Franklin County, which includes the city of Columbus, was
               identified by a number of national experts on homelessness as particularly
               successful in getting communitywide support for its homeless assistance
               programs, coordinating its emergency shelter resources, and reducing the
               administrative burden on providers. The county also has a management
               information system that allows it to collect client-specific data in a
               uniform fashion across the entire emergency shelter system. The
               Community Shelter Board, with guidance from the state, is using these
               data to develop and measure programs’ outcomes so that it can better
               manage homeless assistance programs and services.


               The population of Franklin County, in central Ohio, was just over 1 million
Background     in 1998, according to a U.S. Census Bureau estimate. The majority of the
               county’s population resides in Columbus, which in 1996 had a population
               of about 660,000. Franklin County has a fairly strong economy and
               relatively low unemployment. While housing costs are lower than those of
               many other metropolitan areas nationwide, the county has a shortage of
               affordable housing for low-income residents and a substantial waiting list
               for subsidized housing.

               During 1998, 840 shelter beds served 8,911 homeless individuals in
               Franklin County. In addition, there were 1,042 transitional housing beds in
               the county. The number of families needing emergency shelter has risen
               significantly in the past several years. Currently, about half of the people
               that use the county’s emergency shelters are families with children and
               half are single adults, whereas in the past most of the homeless were
               single adult men. The county’s homeless population is heavily
               concentrated in Columbus.

               The Community Shelter Board (CSB) is a nonprofit organization that
               coordinates and administers most of the government and private funding
               for Franklin County’s emergency shelters and certain related services for
               homeless people. In its fiscal year ending March 1999, CSB budgeted about
               $4.8 million to help fund 11 agencies. About two-thirds of this funding was
               used to support adult and family shelter programs, and most of the
               remaining funds were used for homeless prevention programs, housing
               resource programs, technical assistance, research, and special services.
               CSB receives funds from both government and private sources, including




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                           Appendix III
                           Franklin County, Ohio




                           the city of Columbus, Franklin County, the state of Ohio, HUD, the United
                           Way, and private donations. CSB also coordinates the Continuum of Care
                           planning process for Franklin County. The Franklin County Department of
                           Human Services, which is supervised by the Ohio Department of Human
                           Services, provides certain supportive services that benefit low-income
                           people in the county, such as income support programs and Medicaid. The
                           Alcohol, Drug and Mental Health Board of Franklin County, which is
                           funded and overseen by the Ohio Department of Mental Health and the
                           Ohio Department of Alcohol and Drug Addiction Services, contracts with
                           52 agencies to provide the county’s mental health and substance abuse
                           services.

                           In addition, the Ohio Department of Development administers a variety of
                           state- and federally-funded programs that benefit homeless people
                           statewide, including the Emergency Shelter Grants and Supportive
                           Housing for the Homeless programs. The Coalition on Homelessness and
                           Housing in Ohio, a nonprofit agency, coordinates the statewide Continuum
                           of Care planning process and provides advocacy, technical assistance,
                           training, and some direct assistance to state agencies and homeless
                           service providers.


                           The Community Shelter Board serves as an intermediary between funding
Coordination of            sources and the nonprofit agencies that provide emergency shelter and
Emergency Shelter          related services to homeless people in Franklin County. Many of the
and Other Services         government officials, advocates, and providers of services for homeless
                           people that we spoke with–at the county, state, and national
Through the                levels–described CSB as a highly effective organization. They noted that its
Community Shelter          distinctive role allows it to plan countywide shelter services and foster
                           successful collaborations between the various players and systems that
Board                      serve the homeless in Franklin County.


Benefits of Intermediary   CSB is neither a government agency nor a direct provider of services to
Role                       homeless people; instead, it functions as an intermediary between the
                           sources that fund shelter services and the agencies that provide these
                           services. As a result, CSB benefits from the community’s perception that it
                           is a neutral body that is not unduly influenced by either local government
                           politics or service providers’ agendas. For example, CSB receives most of
                           its funding from government sources; however, because it is a private
                           nonprofit agency, it is perceived as somewhat immune to local politics
                           when making funding and planning decisions. Moreover, because CSB itself



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                          Appendix III
                          Franklin County, Ohio




                          does not provide direct services to homeless people and because the
                          agencies that it funds do not have positions on its board of trustees, it is
                          able to represent the interests of homeless people and yet avoid the
                          conflicts that might occur if funding and planning decisions were seen as
                          based solely on the interests of the agencies it funds. In addition, because
                          CSB was founded by a group of local businesspeople and has a number of
                          business and civic leaders on its board of trustees, it has been able to
                          attract a high level of support and participation from the local business
                          community.


Benefits of Centralized   CSB serves as the single organization that coordinates and plans all shelter
Structure                 services in Franklin County and coordinates the county’s Continuum of
                          Care planning process. In this role, CSB can ensure that all of these services
                          and programs are considered as part of a whole “system” that works
                          together rather than as a fragmented set of independent resources.
                          According to community officials, CSB has provided a centralized structure
                          for what was previously a decentralized set of community-based services
                          and programs.

                          An example of the benefit of this centralized structure is CSB’s work on a
                          plan to address the needs of homeless men who live in an area of
                          Columbus called the Scioto Peninsula. Half of the city’s single men’s
                          shelter beds are located in this area, and many of the city’s street homeless
                          people reside there. In 1997, the city asked CSB to develop a plan to
                          address the needs of the large number of homeless men who would be
                          affected by development planned for the area. CSB coordinated the Scioto
                          Peninsula Relocation Task Force, which used the Scioto Peninsula issue
                          as an opportunity to conduct a more comprehensive review of the needs
                          of all single adult homeless men in Columbus and Franklin County. The
                          task force’s resulting report serves as a strategic plan that incorporates all
                          of the various systems and resources required to address the needs of this
                          population, including emergency shelters, permanent housing, and
                          supportive services.


Benefits of a Single      CSB serves as a single conduit for funding from a variety of different
Conduit for Funding       sources, thus reducing the administrative burden for the community-based
                          service providers who receive these funds. CSB receives funds from a
                          number of sources, including city and county general tax funds, the federal
                          Emergency Shelter Grants and Community Development Block Grant
                          programs, the Ohio Housing Trust Fund, the United Way and other public



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                           Appendix III
                           Franklin County, Ohio




                           and private sources. Service providers apply directly to CSB for these funds
                           rather than to the funding sources. CSB determines, on the basis of
                           program evaluations, eligibility requirements, and other considerations,
                           how much and which funds each provider will receive from each source.
                           Each provider signs a contract with CSB ensuring that it will comply with
                           any program requirements associated with the funds it receives.

                           This “one stop” blended funding process lessens the administrative
                           burden placed on service providers in several ways. First, it reduces the
                           number of funding applications they have to complete. Second, it reduces
                           the need for them to keep track of the differing reporting and fiscal year
                           requirements used by different funding sources. Finally, it can help ease
                           cash flow problems that service providers may face. For example, as a
                           financial intermediary, CSB is in a position to advance money to providers
                           who have been awarded grants but have not yet received the money.


                           CSB collects both client-specific and systemwide data from Franklin
Data Collection and        County’s emergency shelter system. These data are used in a variety of
Program Evaluation         ways for planning, policy analysis, evaluation, and needs assessment for
Efforts in Franklin        homeless assistance programs.

County
Uniform, Systemwide Data   CSB has implemented a management information system to collect
Collected                  comprehensive, uniform data from the entire emergency shelter system in
                           Franklin County. CSB stipulates in its contract with each of the county’s
                           emergency shelters what types of data must be collected on homeless
                           clients. A standardized intake form is used by each shelter and includes
                           questions about basic client demographics, as well as income and benefits
                           and the reasons for homelessness. The information is collected and
                           entered into CSB’s centrally located management information system. CSB
                           officials said that although the computer system and software itself are
                           somewhat dated (there are plans to move to a more modern
                           Windows-based system in the near future), the information management
                           system has allowed them to develop a uniform historical database that
                           includes information from all of the county’s shelters on the clients they
                           have served since 1991.


Data Used for Managing,    The data collected by CSB from emergency shelters in Franklin County are
Planning, and Evaluating   used in a variety of ways to better manage the resources available in the
Services                   community to serve homeless people. For example, CSB’s management



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                       Appendix III
                       Franklin County, Ohio




                       information system can provide information on the use of shelter beds
                       over time, both at individual shelters and systemwide, allowing CSB to
                       track the use of these scarce resources. The system can also provide
                       information on the demographics of shelter clients and the patterns of
                       shelter use over time. This information has been used by the community
                       for policy development, needs assessment, and planning. In addition,
                       because each shelter client is given a unique identifying number, individual
                       clients can be tracked across time as they move through the system and
                       are referred to different service agencies. CSB can thus develop an
                       unduplicated count of how many people are using shelters and analyze the
                       movement of clients from program to program.

                       The Scioto Peninsula Task Force used CSB’s historical database to analyze
                       patterns of use of the men’s shelter system. They found that 15 percent of
                       the city’s homeless men used 56 percent of the shelter system’s resources,
                       while the remaining 85 percent of the men entered the system
                       transitionally for relatively short stays. In addition, CSB found that the
                       long-term users of the shelter system often needed other services, such as
                       mental and physical health services or substance abuse treatment. To
                       meet these needs, the task force’s final plan recommended that the city
                       and county develop service-enriched supportive housing for long-term
                       users of the system, thereby freeing shelter resources for those requiring
                       shelter for only a short period of time.


                       The state of Ohio has started to develop performance standards that are
State’s and County’s   intended to measure programs’ outcomes and improve the provision of
Use of Outcome         services to homeless people. In Franklin County, CSB has been working
Measures to Improve    with the state to establish outcome measures for the service providers it
                       funds.
Programs for
Homeless People        Like some other state housing agencies nationwide, the Ohio Department
                       of Development has recently started to use outcome measures for its
                       housing programs that serve homeless people. State officials told us that
                       their intent is to improve the quality of the programs they fund by focusing
                       more on results—such as moving people out of homelessness–rather than
                       on outputs–such as the number of units of service delivered. Like many
                       other private and government organizations that provide funding for
                       homeless programs, the state wants to ensure that it is getting the best
                       results for its dollars. State officials believe that the use of outcome
                       measures will encourage poorly performing agencies to improve their
                       programs, as well as identify the “best practices” of providers who are



                       Page 41       GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
Appendix III
Franklin County, Ohio




meeting their outcome goals and can provide replicable models for other
agencies to use.

In 1998, the Ohio Department of Development began a pilot project under
which agencies that receive state supportive housing grants were required
to develop outcome-based performance targets and were to be held
accountable for meeting their outcomes. All 53 of the department’s
supportive housing grantees have attended special training seminars that
were intended to clarify and provide guidance on how outcome measures
and goals should be developed.1 As their efforts progress, state officials
told us, they hope to refine their benchmarks and set individualized
outcome measures that better reflect the nature of each grantee’s work
and the population the grantee serves. For example, the general outcome
measure for a transitional housing program might be the percentage of
clients who move into some kind of permanent housing after a certain
period of time. However, an agency that serves a more difficult population,
such as the mentally ill, would not be expected to have the same success
rate as an agency that serves a population with fewer barriers to becoming
self-sufficient.

In Franklin County, CSB has been working with the Ohio Department of
Development to establish outcome measures for the service providers it
funds. For emergency shelters, these outcomes include success in moving
clients out of shelters and into more appropriate housing, such as
transitional housing. For a transitional housing program, the outcomes
measured include occupancy rates (to ensure that resources are being
fully used), length of stay (to ensure that clients are not staying too long
without moving forward), and the percentage of clients that move to
permanent housing. CSB’s management information system is able to
provide the data needed to measure many of these outcomes. It does not,
however, follow up on clients after they leave the homeless service system
altogether.




1
 The training session was provided by the Rensselaerville Institute, a not-for-profit institute that
provides consultation services to government and nonprofit organizations on performance and
outcome management.



Page 42           GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
Appendix IV

Minnesota


              This appendix describes Minnesota’s use of outcome measures, data
              collection, and program evaluation to address the problem of
              homelessness in the state. National experts on homelessness with whom
              we spoke consistently identified Minnesota as especially active and
              innovative in evaluating its programs for homeless people and using
              outcome measures to manage these programs. In particular, Minnesota’s
              Family Homeless Prevention and Assistance Program provides
              communities with flexible grants but uses outcome measures to hold
              providers accountable for achieving results. Minnesota also conducts a
              comprehensive statewide survey of its homeless population, which is used
              to assess the needs of, and plan programs for, homeless people. In
              addition, Minnesota conducts a relatively large number of evaluations to
              measure the effectiveness of specific homeless assistance programs.


              Minnesota had a population of about 4.7 million in 1998, of whom about
Background    2.8 million lived in the Minneapolis-St. Paul metropolitan area in 1996,
              according to U.S. Census Bureau estimates. The state has expressed
              concerns about a shortage of affordable housing, particularly in the
              metropolitan area, where the economy is relatively strong but the housing
              market is tight, with a rental vacancy rate of about 2 percent. There are
              also concerns about a lack of affordable housing in smaller communities
              outside the metropolitan areas where employment is growing.

              A statewide survey in October 1997 found that about 5,590 persons were
              homeless in Minnesota on a given night. More than three-quarters of the
              homeless individuals in temporary housing were women and children. The
              number of homeless families in Minnesota has increased significantly
              since 1991. About 82 percent of the homeless individuals live in the
              Minneapolis-St. Paul metropolitan area, while the remaining individuals
              live in other parts of the state, known as Greater Minnesota.

              The Minnesota Housing Finance Agency funds and administers several
              state homeless service and prevention programs, coordinates the
              Continuum of Care plan for Greater Minnesota, and convenes the state’s
              Interagency Task Force on Homelessness. The task force is composed of
              representatives from a variety of state agencies and helps coordinate and
              administer state programs specifically targeted for homeless people. The
              state’s Department of Children, Families, and Learning administers the
              state’s federally funded Emergency Shelter Grant program, as well as
              other programs that serve homeless people. Individual county
              governments—especially Hennepin County, which includes Minneapolis,



              Page 43     GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
                      Appendix IV
                      Minnesota




                      and Ramsey County, which includes St. Paul—also provide housing and
                      services to homeless people. Municipal governments in Minnesota play a
                      limited role in providing or funding services for homeless people.


                      Minnesota uses outcome measures to manage its Family Homeless
Minnesota’s Family    Prevention and Assistance Program (FHPAP). The state expects agencies to
Homeless Prevention   meet the outcomes set for their programs and, in return, gives the agencies
and Assistance        considerable flexibility in using program funds.

Program               FHPAP  is a state-funded program whose goals are to (1) prevent
                      homelessness, (2) reduce the length of time people stay in emergency
                      shelters, and (3) eliminate repeat episodes of homelessness. The program
                      is targeted primarily to homeless families and provides funding for such
                      things as short-term rental assistance, security deposits needed to secure
                      housing, and housing search services. FHPAP is administered by the
                      Minnesota Housing Finance Agency in conjunction with the state’s
                      Interagency Task Force on Homelessness. The state legislature provided
                      $6.05 million for the program for the 1997-99 biennium, according to a
                      state official, during which time it awarded 16 grants. In the
                      Minneapolis-St. Paul metropolitan area, FHPAP made grants to county
                      agencies, which generally distributed the money to the community-based
                      nonprofit service providers that were the subgrantees. In Greater
                      Minnesota, FHPAP has usually provided grants directly to nonprofit
                      organizations.

                      FHPAP grants are very flexible, and grantees have considerable leeway in
                      spending the funds. However, grantees are required to (1) set specific
                      performance goals and outcome measures that are consistent with each
                      program’s objectives, (2) develop a method for tracking these outcomes,
                      and (3) achieve and report on the outcomes they have set. Each of these
                      requirements is described below.

                      Setting Goals and Measures. When applying for program funds, grantees
                      must state specific, measurable outcome goals for their projects that relate
                      to FHPAP’s three overall goals. The agencies must include the time frames
                      within which these goals will be achieved. For example, a program for
                      preventing homelessness might state that 90 percent of the families and
                      youth that participate in the program will be in stable housing 6 months
                      after they leave the program. According to a program official, the program
                      allows outcome goals to be set by grantees rather than by the state, partly
                      because conditions vary so greatly in different parts of the state.



                      Page 44       GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
                        Appendix IV
                        Minnesota




                        Tracking Outcomes. FHPAP grantees are required to develop methods of
                        tracking and measuring their programs’ outcomes. For example, a grantee
                        may choose to conduct follow-up phone surveys with families that have
                        received assistance through a program or review clients’ records at an
                        emergency shelter to measure how long the clients stay in the shelter.
                        Hennepin County, which had 28 FHPAP subgrantees in fiscal year 1998, has
                        developed its own data system for tracking purposes. This system
                        provides all of the subgrantees with software that allows them to collect
                        basic demographic and outcome information on clients. These data are
                        later entered into a centralized data management system administered by
                        the county. The system assigns each client a unique identifier, which
                        allows the county to evaluate programs’ outcomes by determining, for
                        example, how many of the clients who are enrolled in a homeless
                        prevention program are staying at an emergency shelter.

                        Achieving and Reporting Outcomes. Each FHPAP grantee is required to
                        submit a quarterly and an annual report to the state that provides
                        programs’ overall results and outcome data for individual clients. As long
                        as providers successfully achieve the outcome goals they have set for their
                        programs, the state does not specify how they must spend their FHPAP
                        funds. A state official told us that this flexibility benefits service providers
                        because it reduces their administrative burden, allows them to tailor their
                        programs to local needs and situations, and gives providers the freedom to
                        try new ways of preventing homelessness. In addition, the results reported
                        by the service providers have helped the state revise the program on the
                        basis of what has proved to be effective or ineffective in addressing
                        homelessness. For example, a state official told us that service providers
                        no longer use FHPAP funds for long-term rental assistance because outcome
                        information from past programs showed that this was not a cost-effective
                        way of serving a large number of people.


                        Minnesota has been conducting a statewide survey of its homeless
Minnesota’s Statewide   population since 1991. Although other states count and survey their
Survey of Homeless      homeless populations, Minnesota’s survey is notable because it is
People                  comprehensive and has been conducted every 3 years.

                        Minnesota conducted comprehensive surveys of the state’s homeless
                        population in 1991, 1994, and 1997, and plans another survey in 2000.
                        These surveys were commissioned by Minnesota’s Interagency Task Force
                        on Homelessness and were conducted, under contract, by the Wilder




                        Page 45       GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
Appendix IV
Minnesota




Research Center.1 The surveys were funded jointly by state agencies,
including the Minnesota Housing Finance Agency and the Minnesota
Department of Human Services, as well as by nonprofit service providers
and private foundations. The cost of the most recent survey was about
$100,000.

For the 1997 survey, more than 440 trained volunteers surveyed homeless
individuals at 150 different agencies that serve homeless people in 48
cities, as well as 18 street locations in 8 cities. The survey identified 5,590
people as homeless on one particular night, including people in emergency
shelters, transitional housing, and battered women’s shelters, as well as
living on the street and in other nonshelter locations. Separate surveys
were conducted for adults (including families) and for unaccompanied
youth. The surveys not only produced a statewide count of the homeless
but also provided comprehensive data on the characteristics of the
homeless population. Adults and youth in shelters and transitional
housing, as well as those living on the street, were asked a detailed set of
questions covering demographics, income, shelter use, housing,
employment, substance abuse, and mental and physical health.

State and local officials have used the results of these surveys for a variety
of purposes in planning their programs for homeless people. For example,
because the surveys have been conducted at regular intervals, state
policymakers and others have been able to use the results to gauge trends
in the homeless population over time. One trend that the surveys have
shown is a significant and steady increase in the number of homeless
families and in the proportion of the overall homeless population that
families represent. The surveys have also documented a rise in the
percentage of homeless people who are employed. According to an official
at Wilder Research Center, this suggests that homelessness in Minnesota
may be increasing more because of a shortage of affordable housing than
because of a lack of income sources.

Officials from the Wilder Research Center and two of the organizations
that funded the survey told us that two of the primary uses of the survey
results are to help persuade lawmakers and others of the need for more
resources and to help prepare grant applications. For example, city
planners often use the data from the survey when they write grant
proposals, and state agencies and providers use the information to support
their requests for more resources. One official stated that the results of the


1
 The Wilder Research Center is the research arm of the Wilder Foundation, a private nonprofit
foundation that focuses on social welfare issues in the St. Paul metropolitan area.



Page 46          GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
                      Appendix IV
                      Minnesota




                      surveys were a factor in convincing the state legislature of the need to
                      create the Family Homeless Prevention and Assistance Program.

                      The information collected through the surveys is also useful in assessing
                      the needs of and in planning programs for homeless people, according to a
                      state official. For example, when survey data indicated an increase in the
                      number of unaccompanied homeless youth (i.e., children who are not with
                      their parents), communities increased their efforts to address the needs of
                      this population in their Continuum of Care plans.


                      Minnesota has also conducted a number of evaluations to determine the
Minnesota’s           effectiveness of some of its programs for homeless people. Some of these
Evaluations of        are described below.
Programs That Serve
                      Evaluation of the Supportive Housing Demonstration Program. The
the Homeless          Minnesota Supportive Housing Demonstration Program provided
                      $2.2 million in state funding for 180 supportive housing units for people
                      with mental illness, substance abuse disorders, or HIV/AIDS who were
                      either homeless or at risk of becoming homeless. The project used a
                      portion of the funds that would normally have been used to provide
                      institutional care (such as in group homes) for these people and allowed
                      the money to be used more flexibly to provide them with supportive
                      housing (independent housing with supportive services). In June 1998, the
                      Wilder Research Center published a 1-year evaluation report on the
                      demonstration project. The report evaluated (1) the effectiveness and
                      quality of the supportive housing and services provided and (2) the cost-
                      effectiveness of this supportive housing compared with that of the housing
                      and services provided in other institutional settings.

                      Officials at the Corporation for Supportive Housing, which coordinates the
                      demonstration project, said that the Wilder evaluation was the first study
                      that ever quantified and compared the cost of supportive housing with the
                      costs of alternative public-sector service systems. The cost of the housing
                      and services provided by the demonstration’s supportive housing were
                      compared with the costs that the public sector would have incurred to
                      provide these residents with shelter and services. Public-sector costs were
                      estimated from data provided by systems such as the state criminal justice
                      system (for costs associated with correctional facilities), county
                      detoxification centers (for costs associated with providing detoxification
                      services), and the state Department of Human Services (for costs
                      associated with prior residential care, hospital stays, General Assistance



                      Page 47       GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
    Appendix IV
    Minnesota




    grants, and other social service grants). The evaluation reported that,
    compared with the other systems, the demonstration project improved the
    quality of life for participants and reduced the costs of caring for them.

    Anishinabe Wakiagun. Anishinabe Wakiagun is a permanent supportive
    housing program for Native American men and women who are chronic
    inebriates. The goal of the project is to provide a safe and stable
    alternative to the street for this population, while improving the civic
    atmosphere and reducing the amounts of money spent on detoxification
    units, emergency rooms, and jails. The project opened in September 1996
    and is located in Minneapolis.

    The Hennepin County Office of Planning and Development evaluated the
    Anishinabe Wakiagun program for the period from September 1996
    through March 1998. As part of this evaluation, the following two outcome
    goals were analyzed: (1) reducing the population’s use of detoxification
    and emergency rooms and (2) stabilizing the population’s housing status.
    For each of the residents, the evaluation compared their history 1 year
    before they were admitted into the program with their status while they
    were in the program. It evaluated data on their use of detoxification units,
    use of hospital emergency room facilities, and booking in the adult
    detention center.

    Other Evaluations. The Wilder Research Center has also conducted or is
    conducting the following evaluations of other homeless assistance
    programs in Minnesota:

•   A 6- and 12-month follow-up evaluation of homeless people who are
    currently living in transitional housing. The objective of the evaluation is
    to gauge the effectiveness of transitional housing in moving homeless
    people into permanent housing.
•   An evaluation of what happens to youth once they have left Project
    Foundation, an emergency shelter for homeless youth in Minneapolis.
•   An evaluation of Rebuilding Our Own Futures (ROOF), a transitional
    housing program for families. The study evaluated outcome measures such
    as participants’ success in obtaining permanent housing, increasing
    income, and maintaining children’s school attendance.




    Page 48       GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
Appendix V

Comments From the Department of Health
and Human Services

Note: GAO comments
supplementing those in the
report text appear at the
end of this appendix.




                             Page 49   GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
                 Appendix V
                 Comments From the Department of Health
                 and Human Services




See comment 1.




                 Page 50      GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
                 Appendix V
                 Comments From the Department of Health
                 and Human Services




See comment 2.




See comment 3.




                 Page 51      GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
Appendix V
Comments From the Department of Health
and Human Services




Page 52      GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
                 Appendix V
                 Comments From the Department of Health
                 and Human Services




                 The following are GAO’s comments on the Department of Health and
                 Human Services’ (HHS) letter dated June 9, 1999.


                 1. We agree that HHS has undertaken several initiatives to address
GAO’s Comments   homelessness; however, we disagree with the Department that our
                 reporting of state and local officials’ perceptions about its lack of
                 involvement in addressing homelessness is not adequately substantiated or
                 lacks specificity and documentation. The observations we have reported
                 are based on interviews we conducted with more than 50 state and local
                 officials in four different locations across the country. The consistent
                 nature of their comments clearly suggests that many at the state and local
                 level believe that HHS needs to do more to address the needs of homeless
                 people.

                 2. We agree that there is a need to obtain more information on the barriers
                 created by federal, state, and local policies. This information can be used
                 by federal agencies to better coordinate their efforts and help them
                 implement changes that can eliminate some of these barriers. However,
                 this issue was not within the scope of this assignment. We plan to address
                 this issue in a future review.

                 3. As we stated in comment 1, HHS has made some efforts in this area, but,
                 according to our review, they are not perceived as adequate by some state
                 and local officials.




                 Page 53      GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
Appendix VI

Comments From the Department of Housing
and Urban Development

Note: GAO comments
supplementing those in the
report text appear at the
end of this appendix.




See comment 1.




See comment 2.




                             Page 54   GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
Appendix VI
Comments From the Department of Housing
and Urban Development




Page 55      GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
                 Appendix VI
                 Comments From the Department of Housing
                 and Urban Development




                 The following are GAO’s comments on the Department of Housing and
                 Urban Development’s (HUD) letter dated June 2, 1999.


                 1. We revised the report to clarify the role of the Interagency Council on
GAO’s Comments   the Homeless.

                 2. After reviewing HUD’s comments, we deleted the sentence cited because
                 it was not the primary concern of the state and local officials with whom
                 we spoke.




(385760)         Page 56      GAO/RCED-99-178 Integrating and Evaluating Homeless Assistance Programs
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