Bigger Facilities or Better System?

I have been thinking about a question recently posed by Deb DeSantis, who is the President & CEO of CSH (which I am paraphrasing): How do we move the collective thinking from having bigger homeless facilities to better systems of care with housing at its foundation?

Let me give a bit of context: this happened at the Michigan Conference on Ending Homelessness, an event I have attended since before I even went into consulting and have spoken at almost every year. The very first presentation I ever gave at the conference was on Housing First, before it was fashionable or the central orientation to funding and service delivery. I have given variations of that same presentation at least three times since, either as keynotes or as session presentations. Either I am a lousy communicator or there are some organizations that do not believe in Housing First at all, still get funded to the same tune (or even more) than before there was a focus on housing, and have built empires to themselves.

I want to be clear that this is not a slag against any of the State entities in Michigan that have done a terrific job in trying to move towards ending homelessness. I know, for example, that all funding decisions are inherently political. I know that they have invested heavily in training and professional development for organizations so they can actually deliver Housing First programming. I have been to many states that have a similar experience to that of Michigan.

How do we balance the inherent contradiction of states and communities declaring that they want to end homelessness while some organizations in that same state and its communities expand its homeless programs rather than focus on housing?

Case in point, as I raised a glass with some folks with a large (but not Detroit) community, a service provider was going to great lengths to tell me about all of the programming they have recently added or expanded in their shelter: housing readiness, employment readiness, substance use recovery, money management, and, life skills. I asked, "How are those activities housing first?" The reply across the board - as if I was an idiot that just fell off a turnip truck - is that these things are essential to housing first success. When I challenged them further on what Housing First is and is not it was clear they were having none of my thoughts on the issue. 

Organizations like this do not exist in isolation. I think one of the greatest frustrations that I have in this work is that for every organization that we seem to be able to transform to focus on ending homelessness, there is another one expanding their program offerings to keep people homeless longer. That is certainly the perception we often share on the OrgCode team anyway. 

So how do we get people to focus on housing-focused systems of care rather than expansion of homeless services as Deb suggested? I offer these thoughts:

1. We need to educate communities better on what it means to think and act as a system rather than a collection of projects or programs.

2. We need to educate funders, especially philanthropists, on what investments help end homelessness versus which ones prolong homelessness.

3. We need CoC in the NOFA process to grow a backbone where they have not already done so and lean into conflict to address the system needs rather than avoid them. 

4. We need communities and service providers therein to know the difference between the philosophy of housing first and the intervention of Housing First.

5. We need to soundly and publicly reject empires and approaches that have more to do with the egos of the service provider than the dignity of the households being serviced through the approach.

Better By-Name Lists

This week's blog comes from David Tweedie on the OrgCode team (David@OrgCode.com):

If you're a street outreach worker, you've likely struggled to locate people referred to you through your community's Coordinated Entry system.  You have their name, and where they were last surveyed, but knowing where someone surfaced two or twelve or twenty days ago seems a lot less helpful than where they're staying now.

If you're part of the Continuum of Care governance board or leadership, you've likely looked at your Coordinated Entry system's average length of time from identification of homelessness until housing match, or from housing match to move-in, and wondered whether that represented the best your community could achieve.

Communities where quantifying the most medically vulnerable people with longest histories of homelessness happens easily, and the length of time required to enter permanent housing happens fastest, have two key things in common: they've moved from multiple by-name lists to one, and from where someone once completed a survey to where people reside in real-time.

This requires two shifts:

When we're asked to account for people who meet the federal definition of chronic homelessness, or for veterans, or youth, or families, we may begin with a "low tech" solution outside of our seemingly impenetrable community-wide data sharing system.  When people enter our system, we enter their information manually into a spreadsheet.  When they leave, they are removed, by hand.

Maybe you're the staff responsible for that process, wondering whether manual data entry into spreadsheets represents the best that your government-funded data collection offers when it comes to by-name lists.  (Spoiler alert: IT IS NOT.)  What forces us to fix the system temporarily addressed by this patchwork solution is when we're asking to cross reference specific populations or time periods.  Of everyone who is a veteran, how many have also experienced chronic homelessness?  Of unaccompanied youth, how many have also been served as a member of a family?  When the answer looks more like a sigh of exhaustion and "those are different lists" than a quickly applied filter, "good enough" might need to approach just plain "good."  Dare we dream of even greatness?

One by-name list that accounts for people in real-time -- as they change providers, demographics and engagement -- remains the best practice for data driven decision-making.  If nothing else, by 2017 we should be able to easily know the names and locations of the people we have the privilege to engage and permanently house.  One poor staff, diligently updating this information into an Excel spreadsheet, is not that.  Neither is waiting days (or weeks!) to obtain this information.  Difficult to obtain reports are a megaphone telling you the community data system is failing.

But we need not just someone's name but also where they're currently staying.  It's not particularly helpful to direct street outreach to locate someone based on where they were surveyed six days, weeks or months ago.  How many times have we heard someone's years long struggle through homelessness, only to see that they hadn't yet been surveyed?  For the purpose of our by-name list, they remained invisible, because our by-name list only contained people with VI-SPDATs.

When our by-name lists have completed surveys as a common denominator rather than everyone currently experiencing homelessness, regardless of survey status, we're left to comb cold, tired lists of long passed locations rather than where they reside right now.

And the by-name list is just the first step!  With one-by name list of people experiencing homelessness in real-time, we can then define our community's priorities to build a priority list of those we're actively working to house.  Our by-name list represents the biggest possible universe: everyone experiencing homelessness.  A subset of that list -- our priority list -- represents a significantly smaller universe of people who have consented to our assistance, completed required surveys, collected essential documentation for housing, and now engage staff to locate units and enter permanent housing with supports.

By definition, everyone (and everything) can't be a priority.  Of the dozens, hundreds or thousands of people on our by-name list, who represents our community's first priority to house -- people with the longest histories of homelessness?  The medically frail?  Those living and sleeping outdoors?  Veterans?  Youth?  Of two equally vulnerable people both experiencing chronic homelessness, who gets access to a resource if only enough exists to serve one person?  As we drill down on our by-name list to identify, and then progressively engage, people who represent our community's priority populations, we secure the documentation required for housing, at which point they represent our smaller priority list of people we're actively working to house.

This community measure of our progress -- to what extent are we ending homelessness? -- should be accessible, and not just to the HMIS or HIFIS Lead Agency!  For those who've consented to the data sharing process, everyone from the case manager who sees the new keys enter the lock of the first home secured in years, to the Executive Director of that agency and the funders of that process can see where our Coordinated Entry system succeeds and where we have obstacles to overcome together.  They can run this report themselves -- or even have it waiting in their HMIS inbox as they begin each morning.  Who has been housed, how long that took, and who is returning should be easily accessible from the very by-name list that drives that process.

Ending Youth Homelessness

Erin Wixsten is the youth lead with OrgCode and provides this week's blog. You can reach her at ewixsten@OrgCode.com

Can we get a collective ‘Huzzah!’ (sorry, it’s Renaissance Festival season here in Minnesota) for youth homelessness finally getting some attention -- and by attention, I mean new resources -- thirty three million dollars to be exact.  I know I’m not alone in my eagerness to see how the 10 communities who were recipients of the Youth Homelessness Demonstration Project (YHDP) funds are going to allocate their awards, and while likely not enough to end homelessness for all young people experiencing it in those communities, it represents a significant gain in what is needed to support systems planning, innovative solutions, and an increase in supportive services and programs that work to end youth homelessness.

What it takes to end homelessness for youth who are experiencing it isn’t radically different than what works for singles and families, however I’ve seen ‘adult’ service providers tremble when talking about serving youth.  They aren’t aliens, they are just young.  Services need to be developmentally appropriate, and in addition to being Housing First and Trauma-Informed, programming needs to be grounded in Positive Youth Development.  They need to be collaborative rather than punitive.  Overall, they need to be a safe space from which youth can begin their journey out of homelessness.

Before I came to be part of the OrgCode team, I was the Director of Housing and Homeless Services at an incredible Minneapolis non-profit called The Link.  In nearly 12 years in that role, I helped to develop, open, and supervise a variety of supportive housing programs for young people who were exiting homelessness -- key word is exiting, and my team used that language intentionally to reiterate that the crisis of homelessness was over and our role was to support them in such a place.  This did not mean that there weren’t many other challenges and opportunities to come, but we wanted to ground our work in being housing and stability focused.  When I started in that role at The Link over 12 years ago now, my first task was to create a program model for their first ever housing program: hire and train staff, develop programming, oversee case management, etc.  For years I had worked with youth at risk of, or experiencing homelessness through programs such as drop-in centers, outreach, emergency shelter, and transitional living programs.  However there were almost no supportive housing programs for young people in my community at that time.  As a housing provider, I would attend funder and community meetings and trainings, policy sessions, etc. and while technically the youth in our programs were adults (18-24 years old) I immediately realized I needed to look at the information, funding, program development, staffing structure, etc. through a youth-friendly lens and translate it into a developmentally appropriate model for youth.  I was in a unique position to be straddling both the adult and youth sectors, and while challenging, at first feeling like I was at the wrong table on both sides, empowering youth voice in decision making made it much easier.  Young people helped to develop programs that they themselves either would, or had been served by.  Essentially, applying what is working for singles and families in a way that works for young people.

The most significant observation that I had from my perspective as a youth housing provider at the time was how differently youth services and interventions were applied than with singles and families.  In most ways, youth were given incredible support for extended periods of time to stabilize and were connected with intensive supportive services, programming, advocacy and case management.  Young people were nurtured within those programs and were supported in setting and achieving incredible goals around education, employment, and other personal objectives.  They had passionate advocates to help them succeed.  Unfortunately, this was most often happening in a shelter or drop-in setting.  This was over a decade ago but I recognized our role at the time was to create and implement programs that would provide that same intensity of services within a housing context with the one goal in mind:  end youth homelessness.

• Youth in a youth shelter are still homeless and while the shelter setting and services may be incredibly high quality, youth-centered, and full of highly trained and professional staff, we want young people out of the crisis of homelessness, and stably housed, as soon as possible. Housing is the solution to homelessness.

• For every bed occupied tonight by a youth in a youth shelter, there are three, six, ten sleeping outside or in a place that is unsafe for them. By quickly moving young into housing -- with the necessary supports -- more youth could be sheltered who otherwise would not be.

• Evaluating data over time, it became clear that if we were operating from a Housing First framework -- supporting youth to transition out of homelessness, and applying protective factors around areas that put them most at risk of losing their housing and becoming homeless again -- we saw that young people stabilized much quicker -- and transitioned in place, or into another housing option, much more quickly -- which allowed us to serve more youth.

• Housing First for youth is trauma informed and asset based. It directly applies the belief that young people can, and should, be housed. That they are ‘ready’ and while they may need a different length or intensity of services once housed, it’s absolutely something they can do and deserve. Housing is not a reward for good behavior or program participation. While we want to employ the principles of Youth Engagement in our programs, housing and/or services are not a result of how engaging or engaged a young person is.

• As a community or even at an agency level, we need to be creative in how we solve the challenge of the lack of affordable housing. This pairs nicely however, with what we know about young people needing a variety of options from which to choose and potentially move around in as they seek to find what works best for them. We must be solution-focused when faced with this challenge and move away from talking about what we don’t have in our community to creating what we need.

Housing First is not housing only but rather a service orientation from which all services and supports for young people experiencing homelessness should center.  Housing stability supports and housing focused, client-centered service planning are critical for housing success.  It’s invigorating and encouraging to see communities embrace this orientation for how we support young people who are experiencing homelessness, and see systems reorganize and collaborate on effective interventions that end homelessness for youth and young adults.

Stay tuned for a brief webinar coming out in the next couple of weeks that can give you some ideas (and lessons learned) on what Housing Stabilization looks like for young people.

Car Dealerships & Homeless Facilities

Car dealerships try to get you to do three things:

1. Buy/lease from them

2. Finance through them

3. Service your vehicle with them

The entire experience of the dealership keeps reinforcing these three things, implicitly and explicitly. In the process of buying/leasing the car they talk with you about finance options and how great the service team is. When engaging with the finance people, they reinforce your purchase/lease and talk about how great the service team is. Go to get your oil change, and they have stimulation that reinforces your purchase/lease and may even get you thinking about the next vehicle with them because of the sales team or the amazing financing opportunities. 

Visually, the car dealership knows their business and reinforces it unrelentingly. The psychology of reinforcing decisions through advertising is rather amazing. What you won't see in a car dealership, for example, is messaging about the importance of taking public transit or why biking to work is good for you and the environment. 

Maybe it is time homeless service facilities like shelters and drop-ins starting functioning more like car dealerships.

Let us assume that we all agree that we are in the business of ending homelessness. (As an aside, I know that sentiment is not universal.) Our business model - and advertising - needs to support our objective. If we are not doing that, with fierce singularity of purpose, we may be inadvertently be making our work that much harder. 

When I tour through homeless shelters, what do I see on the walls and bulletins boards and such? In a nutshell, confusion. I see advertisements for spaghetti dinner at the local church and when the podiatrist is coming to visit and day labor services and what the VA can do and where to worship and where to get clean underwear. I see advertisements for AA meetings and when the career fair is and how to use the telephone and when to do laundry and who to meet with to get a bus pass. I see rules posted and changes to operating hours of another organization and places to worship and when the barber is coming and a reminder not to loiter outside the front doors on the sidewalk. Some of these are on colored paper. Some of these have long-since expired. Some lack sufficient detail for me to know exactly what to do. Some are so seemingly intrusive I wonder who got access to the facility to post it and why they were granted permission to do so.

What I don't see in most shelters and drop-ins? Clear advertising and messaging - implicitly and explicitly - about the core business, which is getting people out of homelessness. We bombard people with noise and confusion. Generally we are well-intentioned but misguided. We overwhelm service users with stuff that does NOT help them get out of homelessness, but rather help them manage their experience of their homelessness.

When we work on homeless service facility improvement, one of the first things we do is try to harness the message so that the business intention is clear. All of those things (podiatrists to AA to spaghetti dinners - and everything in between) may be well-intentioned. Heck, for some they may even be helpful (though maybe more helpful after moving into housing). But they are the WRONG things to be supporting, messaging and focusing on in homeless shelters and drop-ins. 

My request of you this week is to take a look around - literally - and remove anything that is not absolutely focused on the core business of ending homelessness. If that seems to extreme, then consider housing messaging to be the dominant focus with all else relegated to its own area. 

What should that housing messaging be? Think back to the car dealership. How do people get housing (the ability to figure it out on their own or through a program like Rapid ReHousing or Permanent Supportive Housing)? How do people maintain their housing (what supports and community resources will help people when they are in housing)? And, how do we make sure that people do not return to homelessness? You can enhance the message by infusing data like the number of people that moved into housing, how long it took, and how many returned. 

Our ability to focus on housing should be unapologetic and blatant. For some, this will be a focus on how people can figure it out on their own. For others, it will be how coordinated entry works, the assessment process and such. Confusing the message only confuses the process and strays us away from the core business of what we are trying to achieve. 

Be more like the car dealership. Even if you loathe car salespeople (especially of the used variety). You may not like them, but they are really effective. People that you serve don't necessarily need to like you, but you too need to be effective.

Hurricanes Do Not Discriminate, but Others Do

The full extent of Irma's devastation at the time of writing is not known. I hope there are few if any fatalities. I want to focus on a couple of aspects of the hurricane as it relates to homelessness.

The first is that there were definitely two groups of people served in advance of the hurricane when it came to sheltering. Take a look at this story from Volusia County (Daytona) here. 

In a nutshell, those that were seeking shelter but had a permanent residence were offered one type of shelter. Those that were homeless were told that they needed to go to a homeless shelter.

Then there is what happened in Miami. As this story from the Toronto Star demonstrates, people that were homeless were assessed for the Baker Act to forcibly remove them from the street. 

I get that people who are poor, including those that are homeless, struggle to have transportation options to vacate a location where a hurricane is projected to hit. And, I would argue that there may be instances where it is justified to use an instrument like the Baker Act to take people out of harm's way if they are not making good decisions for their own safety.

But I struggle in the selective application of an instrument like this. Maybe I am naive. I watched CNN. I heard telephone interviews with people in the Keys who were not in great structures planning on getting drunk and riding out the storm. I saw people going out for a jog in the rain in the background of a segment on CNN, even with a curfew, and even with debris falling all around. I saw interviews with people planning on riding out the storm on their boat, and post-hurricane interviews with people from mobile home parks. Maybe as a person that lives with a mental illness I find it stigmatizing that we think of just those who are homeless as unwell and in need of assessment prior to a hurricane, rather than looking also at those that are making poor decisions about where they will be during a hurricane. 

Finally, there will be billions spent in disaster relief, including some forms of assistance for that that did not have any or the right type of insurance. Now I will be naive and suggest this - imagine if we saw homelessness as the disaster that it is, and invested in the same way with the same urgency.

We Need to Tackle Grant Per Diem Funded Programs – NOW

If there is one pressing issue to be tackled from a policy and funding perspective in the pursuit of ending homelessness, it is grant per diem funding in any homeless services. While much of the spotlight has been on Veterans Affairs and its massive inventory of GPD funded beds, they are not alone. Other jurisdictions have wrestled with the concept of GPD funding in shelters for quite some time – and with little success. I say now is the time for tough change to get GPD aligned to the pursuit of ending homelessness.

If you don’t know what a GPD program is, in a nutshell it goes like this: as a service operator, you get a set fee for a head on a bed each night. Used in a sheltering context (which varies by jurisdiction, but can include things like transitional shelter, something resembling transitional housing, or emergency shelter…or in some antiquated models in the northeast something resembling a nursing home), the service provider most often provides some support services to the participants in this program.

In my experience and travels, these services are all over the map in terms of intensity, professionalism of delivery, and purpose. For example, in some instances I have seen highly qualified addiction counsellors provide a form of residential support and counselling to those striving for sobriety. But I have also seen too many poorly constructed life skills and budgeting classes, as well as terrible employment readiness programs. Some GPD programs offer around the clock access and supports. Others have periods of time where residents are expected to be out during the day. Some GPD programs require sobriety or meeting with a case manager within a certain number of days of entry or an employment plan. Others are much more low barrier. I guess my point is, people say “GPD” and make assumptions that they are all the same thing, when there is overwhelming diversity and a lack of quality assurance from city to city (or even within the same city). Country to country it is even more diverse.

What should bother us more than the diversity of programming though – and what I don’t get – is how any community or leader on the one hand can say they are all for housing first and then in the next breath support a GPD program. GPD, as it is most often delivered, is the epitome of housing readiness, which is the antithesis of housing first. The programs do not facilitate rapid access to permanent housing with supports wrapped around in the community.

GPD incentivizes homelessness. No service operator, from a financial perspective, wants to have people vacate their program until whatever imposed stay limit is exhausted. Why? They would have to find another head for the bed to ensure financial sustainability. Maybe this is not a concern in communities where there is considerable demand that outstrips supply, but the demand should not be what drives the program or its funding model in this instance. Should people stay homeless longer because it is in the financial best interest of the operator?

Those in the know will say GPD programs cannot and will not change until there is a legislative change, which steers the ship for providers. So what are we waiting for? If we know the answer, why is there little movement in most jurisdictions to rectify the matter? Is there a GPD lobby group so strong that it should overwhelm evidence and dare I say common sense? This is a classic example of a leadership void for a solution waiting to happen; an instance where popularity of a program and the fear of backlash trumps what is necessary.

Let me layout a funding transition plan that would get the ball rolling.

Offer each GPD provider guaranteed income of $25 per bed in their facility. Multiple that by 365 days. That should be enough to keep the place with a bare-bone staff and pay essential operating bills. In a 25 bed facility, that would equal $228,125.

Ensure GPD providers take people with the highest acuity first. So, the deeper the need on the part of the person that is homeless, the more likely they are to get access to the bed.

Then, offer an incentive of $500 for each person housed out of the GPD funded program. If the person does not return to homeless for three months, provide an additional $100. Do the same at 6 and 9 months. At the 12 months mark, if the person has not returned to homelessness, $1,500 bonus. If 100 people were housed through the program each year, this would actually result in the GPD funded program operator having a slightly greater annual budget (from GPD resources) than operating in the traditional manner – and it would move us all closer to ending homelessness. That would more than take care of all other staffing and building costs.

At the same time, ensure there is a financial disincentive for anyone that has a prolonged stay in a GPD program (perhaps with some exceptions for people that are palliative). So, for example, if someone has not had a positive housing destination within 6 months, the GPD provider only gets $15 for that person each night. If that reaches a year it is $10 for that person. If the person is still in GPD at 18 months, the provider only gets $5 in funding for that person.

That would work for the “traditional” GPD programs.

Then, if there is an appetite for service enriched programs like the professionally staffed addiction counselling and substance use recovery programming that I referenced earlier, call it something other than a GPD program. Give it block funding. Because really, a substance use recovery program is great (and needed for many people) but do NOT confuse a substance use recovery program with a homeless program. Homeless programs end homelessness through housing. Substance use recovery programs end the use of substances. They are NOT the same thing.

At the same time we need analysis on what the right size of GPD needs to be in each community. Some of this work has started, I know. If there has been such a HUGE investment in things like SSVF programs for veterans, and rapid rehousing in other jurisdictions where GPD is not limited to veterans, we should be seeing a reduction in GPD demand. As such, we should start decreasing the overall volume of GPD beds. With proper (and simple) analysis, this should be something that could be implemented over the next 12-18 months.

Now onto something I am going to say that will certainly be unpopular in some circles: until you have wrestled your GPD programs to the ground, do not make a claim that you have ended homelessness for veterans or any other population group for that matter. When, for example, any group doesn’t want to include GPD beds as people being homeless it is a misrepresentation of the true state of homelessness. When, for example, a community gets “cute” with how they name or classify their GPD beds in order to claim some sort of victory in getting an entire population housed, they are kidding no one and creating an overwhelmingly dangerous interpretation of what is actually happening on the ground. Out of sight does not mean out of mind. In fact, I will go so far as to say take any claim of ending homelessness with a grain of salt until there is a transparent answer on what is happening with its GPD beds. New Orleans did a good job of being transparent in this manner; but even then I would argue they should be called something other than a GPD bed.

As more and more communities start claiming “functional zero” in ending homelessness for veterans across the United States while having full GPD programs, it is a powder keg waiting to explode in the media and a public relations disaster waiting to happen. It doesn’t matter what any “takedown list” was, so long as people that are homeless continue to be served by GPD programs that are actually any variation of a shelter or transitional housing program, then let us have the courage to say: “They are still homeless and we are not done ending homelessness yet.”

Let me tackle the other argument that I hear a lot regarding any sheltering program that is funded through GPD. It goes something like this: “But, (insert name of population group like veterans, survivors of domestic or intimate partner violence, youth, people in recovery, people with concurrent disorders, recently hospitalized, etc.) NEED this GPD program in order to be successful in permanent housing.” What I think people are confusing is a mechanism for funding from a specific type of program. There are loads of great programs for different population groups. We know some work. We are still learning more about others. We know that other types of programs quite plainly fail. It is an injustice to suggest that a program that incentivizes a longer length of stay because of its funding source is a BETTER program.  I can think of no population group that has a better housed experience through a prolonged homeless experience.

So now is the time to take action. Now is the time to challenge what is occurring and demand that we do better. If we are serious about ending homelessness in any community (and I really hope we are), we have to get serious about changing the nature of GPD programs to get more people housed. In the meantime, we need to be counting people in GPD funded programs as homeless. Calling it anything else is not an honest representation of what is really happening.