Strategies for Improving Access to Mainstream Services: A Study from the Urban Institute

1. Strategies for Improving Access to Mainstream Services: A Study from the Urban Institute MHSA Promising Practices TA Call May 11, 2011

2. Overview • This study examines how seven communities sought to improve homeless people’s access to mainstream services following funding shifts at HUD. • By examining the different organizations used and activities undertaken by communities to maximize homeless people’s access to mainstream benefits and services, this study provides communities with models and strategies that they can use. • It also highlights the limits of what even the most resourceful of communities can do to enhance service and benefit access by homeless families and individuals.

3. Description of Study • Study conducted by The Urban Institute pub. December, 2010 • Prompted by policy shift at HUD in 2000: more HUD funding for housing, less HUD funding for supportive services; • Shift requires that communities find other sources for services for homeless persons (mainstream resources); • Identifies three groups of barriers to access; • Identifies three categories of mechanisms communities could use to reduce these barriers.

4. Description of Study • Cities Selected for Study • Large Cities: • Denver, Colorado • Miami-Dade County, Florida • Medium-sized Cities: • Pittsburgh/Allegheny County, Pennsylvania • Albuquerque, New Mexico • Small Cities: • Portland, Maine • Norfolk, Virginia • Albany and Albany County, New York

5. Description of Study • Approach: Qualitative Inquiry • Site visits • Interviews with multiple key informants • Supplemented with analysis of existing quantitative data

6. Barriers to Access • Three Categories of Barriers to Access: • Structural Barriers • Benefits are available, person is eligible, but implementation and structure issues create barrier.

7. Barriers to Access • Three Categories of Barriers to Access: • Capacity Barriers • Inadequate resources to meet the need of all people who are eligible for a benefit or service.

8. Barriers to Access • Three Categories of Barriers to Access: • Eligibility Barriers • Set by program rules that establish criteria for who can receive the benefit and who may not.

9. Mechanisms to Overcome Barriers • Three Categories of Mechanisms: • Smoothing Mechanisms • Reduce the structural barriers, do not involve changes in eligibility or capacity.

10. Smoothing Mechanisms • Smoothing Mechanisms developed by study communities: • providing transportation; • doing outreach; • Co-location of mainstream eligibility workers; • creating “one-stop” intake centers; • situating mainstream offices conveniently; • providing “quick question” lines at benefit offices; • providing access to computers that let applicants fill in their own data;

11. Smoothing Mechanisms (continued) • training homeless assistance caseworkers in mainstream application procedures; • establishing good communications among homeless assistance workers and mainstream agency eligibility workers; and • developing strategies for “pending” applications and “suspending” benefit receipt for people in institutions so their benefits will be available to them immediately upon discharge.

12. Mechanisms to Overcome Barriers • Three Categories of Mechanisms: • Changing Mechanisms • Alter eligibility criteria without changing overall capacity.

13. Changing Mechanisms • Changing mechanisms include modifications of restrictions on eligibility for housing subsidies for ex-offenders, and establishing “homeless priorities” for health care, mental health care, and housing subsidies. • Other examples would be a health clinic that set aside particular days or hours to serve homeless people, or a rent subsidy program that established a priority for homeless households.

14. Mechanisms to Overcome Barriers • Three Categories of Mechanisms: • Expanding Mechanisms • Add resources to serve more people

15. Specific Benefits and ServicesFood Stamps • SMOOTHING: • Simplified applications, • Waiver of face-to-face interview requirements, • Expedited access, • Outreach, • Outstationing, • “Pending” applications, and • Suspending rather than terminating benefits during institutional stays

16. Specific Benefits and ServicesFood Stamps • Issues: • Cannot change eligibility; set at federal level. Can smooth application procedures and facilitate acquisition of needed documentation. Recent federal policy is pushing streamlined procedures that increase access

17. Specific Benefits and ServicesMedicaid • SMOOTHING: • Enroll children, through TANF office, • Enroll mentally ill offenders through SOAR Project • Use specialized SSI staff, • Use consolidated application • Homeless Action Response Team • Outreach at hospitals • Ensure rapid enrollment in medical assistance managed care program

18. Specific Benefits and ServicesMedicaid • EXPANDING • MaineCare noncategorical eligibility • Albany NY -all General Assistance [GA] recipients eligible for state-funded Medicaid)

19. Specific Benefits and ServicesMedicaid • Issues: • Cannot change eligibility for basic program; set at federal level. • Can smooth application procedures and acquisition of needed documentation. • Some states set up additional eligibility categories and pay for coverage entirely with state dollars. Among study communities, Maine and New York do this.

20. Specific Benefits and ServicesMental Health Services • SMOOTHING: • Miami (purchase of services); • Norfolk (Projects for Assistance in Transition from Homelessness [PATH] and Assertive Community Treatment [ACT] teams); • Albany (single point of access, co-location); • Pittsburgh (case management, provider coordination, co-location); • Albuquerque (co-location)

21. Specific Benefits and ServicesMental Health Services • EXPANDING: • Miami(Homeless Trust purchase of services, state and federal grants, county funds); • Denver (new ACT team); • Pittsburgh (new funds for behavioral health managed care entity)

22. Specific Benefits and ServicesMental Health Services • Issues • Funding falls extremely short of need in all study communities.

23. Specific Benefits and ServicesUse of CDBG and HOME • CHANGING/EXPANDING: • Using similar resources from state housing authority and/or housing finance agency

24. Specific Benefits and ServicesUse of CDBG and HOME • Issues: • Rare nationally, so having four out of seven study communities allocating Housing and Urban Development block grants to homeless-related residential programs reflects the consequences of high-level executive leadership on ending homelessness.

25. Understanding the Role of Central Organizing Structures • Each study community has a 10 Year Plan to end homelessness and has a communitywide organizing structure with the responsibility to carry it out. • Increasing access to mainstream benefits is part of all these plans. • Studies have shown that a strong central organizing structure focused on a particular goal is key to achieving communitywide, systemwide effects. • These structures have the capacity to identify barriers to access and to generate ways to reduce these barriers.

26. Understanding the Role of Central Organizing Structures • Five study communities have strong central organizing structures that identify gaps and take steps to fill them, including gaps in homeless people’s access to mainstream benefits and services. • Two have strong mayoral support • Three benefit from major involvement of the public agency that controls core public benefits

27. Understanding the Role of Central Organizing Structures • Albany has a working alliance among its homeless coalition and two county government agencies that has generated significantly more access mechanisms than neighboring counties, despite the absence of the types of political support found in Denver and Norfolk. • Albuquerque does not have the benefit of a strong central structure, but provider efforts over the years have gone some way toward improving access to mainstream services for their own clients through various arrangements with public agencies.

28. Understanding the Role of Central Organizing Structures • Effective community organizing structures in study communities take the multi-year view of improving mainstream access. • They set goals, identify gaps in existing service offerings or approaches that would get in the way of meeting goals, develop strategies to fill gaps and meet goals, assess their progress, and alter course if needed.

29. Understanding the Role of Central Organizing Structures • The more strongly organized communities are the ones that have: • Thought through and put in place a range of mechanisms to improve access; • Made sure those mechanisms covered the whole community; • Made more of an impact on how mainstream agencies do business; and • Significantly increased the degree of coordination and collaboration among homeless assistance providers, among mainstream agencies, and between the two groups.

30. Understanding the Role of Central Organizing Structures • Albany has a working alliance among its homeless coalition and two county government agencies that has generated significantly more access mechanisms than neighboring counties, despite the absence of the types of political support found in Denver and Norfolk. • Albuquerque does not have the benefit of a strong central structure, but provider efforts over the years have gone some way toward improving access to mainstream services for their own clients through various arrangements with public agencies.

31. Understanding the Role of Central Organizing Structures • Ending homelessness will not occur without housing opportunities for individuals and families who are now homeless. • However, often housing alone is not sufficient. There must also be supports, particularly mainstream benefits and services. • Those supports are more likely to be available under certain conditions:

32. Understanding the Role of Central Organizing Structures • First, a community will need an organizational structure for addressing changes in the policies and practices of homeless assistance programs and public agencies so that access to benefits continues and improves. • Characteristics of effective structures can be defined.

33. Understanding the Role of Central Organizing Structures • They take a perspective covering many years; • They set goals that are broadly accepted by the larger community, but work to bring the larger community along toward the goals that will end homelessness; • They identify unmet needs; • They tend to have strong political support; • They assemble information about what works and apply that knowledge to improve things; and • They pay serious attention to building, maintaining, and expanding community support for their efforts.

34. Understanding the Role of Central Organizing Structures • Second, communities should look for mechanisms to improve access that show some evidence of effectiveness in other communities.

35. Understanding the Role of Central Organizing Structures • First, a community will need an organizational structure for addressing changes in the policies and practices of homeless assistance programs and public agencies so that access to benefits continues and improves. • Characteristics of effective structures:

36. Understanding the Role of Central Organizing Structures • Third, communities should make greater efforts to use their Homeless Management Information System (HMIS) assertively. In the seven study communities, HMIS do not appear to be structured in ways that give coordinators and program managers essential information in a timely manner. • As a result, communities have no way to systematically determine how well they are doing with respect to assuring access to mainstream benefits and services and where there are gaps that need to be addressed.

37. Why is this Information Important for Us? • MHSA Housing Program is an important piece of the puzzle in your community. • Working across silos with other community agencies and organizations will allow you to be more effective – and will help all programs make a greater impact. • Adopting some practices cited in this study will strengthen your community. • Collaboration is key.