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Homelessness and Substance Abuse: SAMHSA–CSAT Response H. Westley Clark, MD, JD, MPH, CAS, FASAM Director Center for Substance Abuse Treatment Substance.

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Presentation on theme: "Homelessness and Substance Abuse: SAMHSA–CSAT Response H. Westley Clark, MD, JD, MPH, CAS, FASAM Director Center for Substance Abuse Treatment Substance."— Presentation transcript:

1 Homelessness and Substance Abuse: SAMHSA–CSAT Response H. Westley Clark, MD, JD, MPH, CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration U.S. Department of Health and Human Services Oakland, CA, February 8, 2007

2 The Substance Abuse and Mental Health Services Administration (SAMHSA) is one of eleven grant-making agencies of the U.S. Department of Health and Human Services, with a budget of approximately 3 billion dollars. SAMHSA Vision: A life in the community for everyone Mission: Building resiliency and facilitating recovery

3 SAMHSA’s Three Centers The Center for Mental Health Services (CMHS) The Center for Substance Abuse Prevention (CSAP) The Center for Substance Abuse Treatment (CSAT)

4

5 Substance Abuse, Co-Occurring Disorders, and Family Homelessness

6 Cities Participating in the US Conference of Mayors Hunger and Homelessness Survey Boston Charleston Charlotte Chicago Cleveland Denver Des Moines Detroit Kansas City Los Angeles Louisville Metro Miami Nashville Norfolk Philadelphia Phoenix Portland Salt Lake City San Francisco Santa Monica Seattle St. Paul Trenton The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006

7 A Portrait of Homelessness The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006

8 A Portrait of Homelessness The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006

9 A Portrait of Homelessness The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006 Percentage

10 Children & Families: Homelessness 71% of homeless families were headed by single parents. Children represented 24 percent of the entire population in emergency shelters in the cities. 87% of the surveyed 23 cities reported that there was an increase in homeless children in the emergency shelter system. The average percentage of members of homeless families who are children in the survey cities is 55%. The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006

11 Main Causes of Homelessness Mental illness and the lack of needed services Lack of affordable housing Substance abuse and the lack of needed services Jobs Domestic violence Prisoner re-entry Unemployment Poverty Factors associated with homelessness are diverse, complex and interrelated. Causes identified by the survey cities include: The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006

12 18 Survey Cities Identified Mental Illness and the lack of needed services as a Major Cause of Homelessness Boston Charleston Chicago Cleveland Denver Los Angeles Louisville Metro Miami Nashville Norfolk Phoenix Portland Salt Lake City San Francisco Santa Monica Seattle St. Paul Trenton The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006 √ √ √ √ √ √ √ √ √ Receives a SAMHSA Grant in this area

13 16 Survey Cities Identified Substance Abuse and the lack of needed services as a Primary Cause of Homelessness Chicago Cleveland Los Angeles Louisville Metro Miami Nashville Norfolk Philadelphia Phoenix Portland Salt Lake City San Francisco Santa Monica Seattle St. Paul Trenton The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006 √ Receives a SAMHSA Grant in this area √ √ √ √ √ √ √ √

14 17 Survey Cities Identified Lack of Affordable Housing as a Main Cause of Homelessness Boston Charleston Cleveland Denver Des Moines Los Angeles Louisville Metro Miami Philadelphia Phoenix Portland Salt Lake City San Francisco Santa Monica Seattle St. Paul Trenton The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006

15 13 Survey Cities Identified Low-paying Jobs as a Main Cause of Homelessness Boston Chicago Cleveland Denver Louisville Metro Norfolk Philadelphia Phoenix Portland Salt Lake City San Francisco St. Paul Trenton The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006

16 Seven Survey Cities Identified Domestic Violence or Prisoner Re-Entry as a Cause of homelessness Domestic Violence Charleston Chicago Kansas City Los Angeles Salt Lake City San Francisco Seattle Prisoner Re-Entry Boston Cleveland Denver Los Angeles Louisville Metro Phoenix San Francisco The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006 √ √ √ √ √ √ Receives a SAMHSA Grant in this area

17 Five Survey Cities Identified Unemployment or Poverty as a Main Cause of homelessness Unemployment Charleston Chicago Denver Des Moines Los Angeles Poverty Cleveland Phoenix Seattle St. Paul Trenton The US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006

18 What do we know about homelessness? The December 2006 report from the U.S. Conference of Mayors cites trends in utilization of services (2005–2006, based on reports from 23 cities) and estimates the unmet needs of homeless persons and families. It finds: –Overall, requests for emergency shelter beds increased in 68 percent of the cities surveyed (p. 50). –23 percent of general emergency shelter requests are unmet and 29 percent of family shelter requests are unmet (p.59). –86 percent of the cities surveyed report that families have been turned away from shelters due to a lack of resources (p. 59). Hunger and Homelessness: A Status Report on Hunger and Homelessness in America’s Cities (2006). U.S. Conference of Mayors. www.usmayors.org/uscm/hungersurvey/2006/report06.pdf

19 What do we know about homelessness? Through the Continuum of Care (CoC) planning process, we know that about 744,313 persons were homeless in January 2005. These data are taken from a 2007 report by the National Alliance to End Homelessness, which compiled statistics from 463 CoC point-in-time counts. www.naeh.org

20 What do we know about homelessness? 41 percent, or 303,551, of the homeless population counted in January 2005 were persons in families with children. Nearly half (44%) of the homeless persons identified in January 2005 were unsheltered. 23 percent (171,192) of those in the January 2005 count were chronically homeless. Homelessness Counts (2007). National Alliance to End Homelessness. www.naeh.org

21 What do we know about homelessness? The statistics presented here are based on point-in- time counts. “The reality is that the homeless population is quite fluid—people move in and out of homelessness and most are homeless for short periods of time. [It is estimated] that between 2.3 and 3.5 million people each year experience homelessness” (p. 9). Homelessness Counts (2007). National Alliance to End Homelessness. www.naeh.org

22 What do we know about substance abuse? In 2005, an estimated 22.2 million persons aged 12 or older were classified with substance dependence or abuse in the past year (9.1% of the population aged 12 or older). Of these, 3.3 million were classified as dependent on or abusing both alcohol and illicit drugs, 3.6 million were dependent on or abused illicit drugs but not alcohol, and 15.4 million were dependent on or abused alcohol, but not illicit drugs. Results from the 2005 National Survey on Drug Use and Health: National Findings (NSDUH). SAMHSA, Office of Applied Studies (2006). oas.samhsa.gov/NSDUH/2k5NSDUH/2k5results.htm

23 What do we know about co-occurring disorders? Co-occurring disorders are common. At least 5.2 million Americans 18 years of age and older have substance use disorders and serious psychological distress. Co-occurring disorders are complex. Often, people have multiple, interactive conditions that complicate their treatment and recovery. Co-occurring disorders are often not treated. Nearly half of people with co-occurring disorders receive no treatment for either disorder and only 6 percent receive treatment for both.

24 What do we know about co-occurring disorders? People with co-occurring disorders can and do recover. Prevention of co-occurring disorders is both necessary and effective. This is especially true for children with serious emotional disturbance who are at heightened risk for substance abuse. Evidence-based practices—including integrated treatment for the most serious disorders—improve outcomes. System-level changes are often needed to support innovative services.

25 Co-Occurrence of Serious Psychological Distress (SPD) and Substance Use Disorders Among Adults, Aged 18 or Older: 2005 22.2 Million 24.6 Million Co-Occurring Disorders Substance Use Disorder SPD 5.2 Million * NSDUH 2005

26 1 Blueprint for Change, 2003. CMHS, SAMHSA. 2 The DASIS Report: Characteristics of Homeless Female Admissions to Substance Abuse Treatment, 2002. Drug and Alcohol Services Information System (DASIS), SAMHSA, OAS. 3 The DASIS Report: Characteristics of Homeless Admissions to Substance Abuse Treatment, 2000. Drug and Alcohol Services Information System (DASIS), SAMHSA, OAS. What do we know about substance abuse and homelessness? Half of all homeless adults have substance use disorders. 1 13 percent of those in substance abuse treatment were homeless at the time of admission (up from 10% in 2000). 2 More than 120,000 people admitted for substance abuse treatment are homeless at the time of admission. 3

27 What do we know about mental illness and homelessness? Approximately 20–25 percent of single adults who are homeless have a serious mental illness. 1 As many as two-thirds of all people with serious mental illnesses have experienced homelessness or have been at risk of homelessness at some point in their lives. 2 20 percent of State prison inmates, 19 percent of Federal prison inmates, and 30 percent of local jail inmates with mental illnesses were homeless in the year before their arrest. 2 1 National Resource Center on Homelessness and Mental Illness 2 Blueprint for Change. CMHS, SAMHSA, 2003

28 What do we know about co-occurring disorders and homelessness? Nearly one-quarter of homeless persons admitted for substance abuse treatment had co-occurring disorders. 1 Among homeless veterans, one-third to one-half have co-occurring mental illnesses and substance use disorders. 2 Among detainees with mental illnesses, 72 percent also have a co-occurring substance use disorder. 2 1 The DASIS Report: Characteristics of Homeless Admissions to Substance Abuse Treatment, 2000. Drug and Alcohol Services Information System (DASIS), SAMHSA, OAS. 2 Blueprint for Change. CMHS, SAMHSA, 2003

29 What do we know about family homelessness? 50 percent are homeless for first time 25 percent are homeless more than a year, half in transitional housing 29 percent were homeless for first time before age 18 25 percent experienced out-of-home placement before age 18 Family homelessness is expensive. The average annual cost of shelter for a homeless family in NYC is $25,000 per year (NYC Master Panel Report, 2003, p. 51) 29 percent of family requests for shelter went unmet in 2006 (U.S. Conference of Mayors, 2006) *Unless otherwise indicated, data are from Burt et al., 2001. Based on women with children.

30 What do we know about homeless families? 84 percent are single mothers Average age: late 20s Average 2–3 children, most under age 6 66 percent are women of color (African American, 44%; Latina, 16%; Native American, 6%)

31 Health Care Needs * of Homeless Families 27 percent have no insurance; 67 percent have Medicaid 27 percent needed medical treatment in the past year 45 percent had one or more chronic health condition In one study, 48 percent had at least one family member with a disability or chronic illness (Beyond Shelter, 2003) *Burt et al., 2001, unless otherwise noted. Based on women with children.

32 Behavioral Health Needs * of Homeless Families 23 percent—Problems with alcohol 27 percent—Problems with drugs 44 percent—Mental health problems (primarily depression, anxiety, PTSD) 58 percent—One or more of the above *Burt et al., 2001. Based on women with children; self-report of problems within past year.

33 Experience of Violence * 67 percent—Severe childhood physical abuse 43 percent—Childhood sexual abuse 63 percent—Severe violence by adult intimate partner(s) *Bassuk et al., 1996. Based on women with children.

34 Needs of Children Homeless children go hungry at twice the rate of other children. Nearly 25 percent have witnessed acts of violence in their families, usually against their mother. They experience physical and sexual abuse at 2–3 times the rate of other children. 22 percent of homeless children spend some time apart from their family in a typical year, with 12 percent placed in foster care.

35 Needs of Children Emotional and Behavioral Problems 12 percent of preschoolers and 47 percent of school- age children who are homeless have anxiety, depression, withdrawal, and other clinical problems. 16 percent of preschoolers have behavior problems, including severe aggression and hostility. 36 percent of school-age children exhibit aggressive or delinquent behavior.

36 Challenges Homeless individuals with alcohol/substance use disorders pose substantial challenges to the substance abuse treatment community…

37 Especially those with co-occurring disorders.

38 Service System Challenges Inadequate screening and assessment Fragmented services Categorical funding Lack of discharge planning Poor integration of care Other fiscal and coverage limitations

39 Societal Challenges Stigma Oppression and racism Discrimination Poverty Housing costs Lack of employment

40 Treatment Challenges Engagement Retention Relapse Interagency collaboration Needs versus access to services Treatment philosophies Policy and financing

41 Challenges to Successful Engagement Social isolation Distrust of authorities Mobility Multiplicity of needs

42 Meeting the Challenges: Engagement Challenges Outreach (aggressive/assertive) Providing housing or other practical assistance Creating a safe, nonthreatening environment Strategies to increase motivation Family-based treatment engagement strategy Peer leadership

43 Meeting the Challenges: Retention The challenge of retaining clients in substance abuse and alcohol abuse treatment is intensified when the target population is homeless. Dropout rates of two-thirds or more are common.

44 Meeting the Challenges: Relapse Relapse must be considered to be an integral component of treatment. Relapses must be used in the treatment as opportunities for growth and change. Addiction is a chronic and relapsing condition. Nonjudgmental intervention is critical for success. Discharge to the street = relapse.

45 Successful Approaches: Interagency Collaboration Essential to meet multiple needs in a context of scarce community resources Highly complex Necessary to reduce fragmentation of care Linkage vs. Integrated Treatment—Which is better? –Research on this question is mostly descriptive –Controlled comparisons are prohibitive

46 Challenges to Integrating Services Well-established programs and a specialized work force Interagency turf battles Funding limitations Lack of technology and resources to support information needs Lack of available services Size and complexity of the service system Lack of political will and mechanisms to channel public support Legislative and political opposition

47 “No Wrong Door” Policy Each provider should be aware that he/she has the responsibility to address the range of client needs whenever a client presents for care. –Properly refer clients for appropriate care as needed –Follow up on referrals to ensure clients received proper care

48 Federal Response to Homelessness

49 Targeted Homeless Assistance Programs Resources Coordination/Linkages –Treatment for Homeless Program –Homeless Family Program –Collaborative Initiative to Help End Chronic Homelessness Policy Academies Federal Leadership

50 Creating a Comprehensive Service System for Homelessness Support concept of “No Wrong Door” to services Provide services determined by evidence to be effective Change ineffective policies or regulations Leverage existing resources Use mainstream resources Pursue new resources

51 Steps to Achieving a Comprehensive Service System Involve key stakeholders Establish a formal plan Build linkages and partnerships from top-down and bottom-up Enhance funding and other resources Streamline the administration of funding Perform ongoing monitoring and quality assurance

52 Federal Spending Targeted Homeless Assistance Programs (Budget Authority in Millions of Dollars) FY 2005FY 2006 Agency TotalsEnactedEnacted HUD1,241.01,327.0 VA1,642.9214.6 HHS 379.6 380.9 USDA 189.6 189.5 FEMA 151.8 151.3 EDUCATION 62.5 61.9 DOL 23.3 24.3 ICH 1.4 1.8 SSA 8.0 0.0 TOTAL 3,700.12,593.9

53 HHS Mainstream Programs (listed alphabetically) FY06 Appropriation Access to Recovery Community Mental Health Services Block Grant Community Services Block Grant Consolidated Health Centers (CHC) Head Start Maternal & Child Health Services Block Grant Medicaid Ryan White CARE Act Social Services Block Grant State Children’s Health Insurance Program Substance Abuse Prevention & Treatment Block Grant Temporary Assistance for Needy Families Total $ for HHS Mainstream Programs HHS Homeless Specific Service Programs (listed alphabetically) Treatment for Homeless Grants Health Care for the Homeless Programs for Runaway & Homeless Youth Projects for Assistance in Transition from Homelessness Surplus Property/ Title V Other Targeted Homeless Activities Total $ for HHS Homeless Specific Service Programs $98 $429 $630 $1,782 $6,786 $693 $192,334 $2,063 $1,700 $5,775 $1,759 $17,058 $231,107 $34.4 $150.0 $102.9 $54.3 $0 $36.1 $377.6 ( dollars in millions) FY ‘06 HHS Funding for Mainstream and Homeless Specific Service Programs Relevant to Homelessness ( dollars in millions) * Mainstream programs are designed to serve low-income populations or to address specific health care needs; HHS Homelessness Specific (or targeted programs) are programs designed specifically to serve persons experiencing homelessness

54 SAMHSA Resources to Address Homelessness (Dollars in Millions) CMHS200420052006 PATH$49.8$54.8$ 54.2 Treatment for Homeless$ 3.3$ 6.1$ 5.8 CHI$ 3.6$ 3.4$ 3.7 Best Practices$ 4.9$ 2.5$ 2.6 Subtotal$ 61.6$ 66.8$ 66.3 CSAT Treatment for Homeless$ 29.9$ 29.7$ 30.4 CHI$ 4.3$ 4.2 $ 3.6 Other$ 0.2 ---$ 0.5 Subtotal$34.4$33.9$ 34.5 TOTAL$96.0$100.8

55 SAMHSA Resources to Address Homelessness (Dollars in Millions) CMHS20062007(CR)2008(Pres) PATH$54.2254.26$ 54.26 Homelessness PRNS$ 9.49$ 8.49$ 4.42 Best Practices$ 2.61 ---------- Subtotal$ 66.32$ 65.36$ 58.68 CSAT Grants to Benefit Homeless Individuals $ 34.52 $ 32.59 Subtotal$34.52 $ 32.59 TOTAL$100.84$99.88$91.27

56 Treatment for Homeless Program (CSAT/CMHS) Provides services linkages among SA/MH services with housing programs/other services for homeless persons Grantees are embedded within an integrated, comprehensive, community-based system Grantees conduct followup outcome evaluations 137 grants awarded since 2001 87 active grantees (23 new grantees were awarded in September 2006)

57 Treatment for Homeless Awards Three-Year Grant Period 17 grants funded for $9.8M in 2001 19 grants funded for $10.9M in 2002 14 grants funded for $7.8M in 2003 Five-Year Grant Period 34 grants funded for $13.5M in 2004 30 grants funded for $11.9M in 2005 23 grants funded for $9.0M in 2006 TOTAL = 137 $62.9M (first-year awards only)

58 Number of Treatment for Homeless Grants Funded 2001 to 2006 22 CO 10 NM TX 10 GA MO WI IL IN 1 OH PA 1 NY 16 TN 5 5 3 4 6 OR 2 4 3 MI 3 MA 8 CT 2 MD 3 DE 1 DC 2 3 OK 2 AK 1 AZ 2 FL WV 1 CA AL 2 NJ 2 WA 1 KY 1 NV 1 SC 1 AR 1 U.S.V.I. 1

59 Results: GPRA Intake to 6-month Follow-up: All Active Grants N=87 GPRA Measures % at Intake % at 6-Mth Follow-up % Change Increase % of adults receiving services who: Did not use alcohol or illegal drugs 49.6%71.5%44.0% Had no/reduced involvement with CJS 92.1%96.3%4.6% Were currently employed or attending school 14.4%33.8%133.9% Had no alcohol or illegal drug related health consequences 45.7%57.5%25.9% Were socially connected 80.5%84.5%5.0% Had a permanent place to live in the community 8.8%24.2%173.9%

60 Results: GPRA Intake to 6-Month Followup: All Active California Grants N=18 GPRA Measures % at Intake % at 6-Mth Follow-up % Change Increase % of adults receiving services who: Did not use alcohol or illegal drugs 44.8%79.8%78.0% Had no/reduced involvement with CJS 90.7%97.2%7.2% Were currently employed or attending school 8.0%31.4%292.3% Had no alcohol or illegal drug-related health consequences 49.4%71.7%45.0% Were socially connected 90.5%93.4%3.2% Had a permanent place to live in the community 9.3%14.3%54.8%

61 Homeless Families Program CSAT/CMHS collaboration A 5-year knowledge development initiative that documented and evaluated intervention models targeted to homeless mothers who have psychiatric, substance use, or co-occurring disorders This is the first multi-site study to focus on interventions for homeless families in which the mothers have psychiatric and/or substance abuse disorders. Conducted in two phases –Phase I began FY 1999; consisted of 14 sites –Phase II began in FY 2001; consisted of 8 sites

62 Homeless Families Program Phase I consisted of cross-site outcome study to explore and describe effective program interventions that: –Reduce homelessness –Increase housing stability –Promote family preservation/reunification –Decrease substance use –Improve mental health –Improve social functioning Phase II consisted of site-specific evaluation and cross-site outcome evaluations that provide new knowledge about serving homeless mothers with dependent children.

63 Homeless Families Program—Preliminary Findings Approximately 1,600 women and their families received services Psychiatric symptoms among the women declined significantly at 9 and 15 months after entry Illegal drug use declined from 25 to 14 percent from baseline to 15 months

64 Homeless Policy Academies Purpose: To enhance State capacity to develop Homelessness Action Plans Conducted in collaboration with HUD and Departments of Labor, Education, Justice, Agriculture, Veterans Affairs, and Interagency Council on Homelessness High-level stakeholder attendance: State Medicaid directors, substance abuse agencies, providers, community representatives, etc. All States have attended as well as D.C., Puerto Rico, U.S. Virgin Islands, Pacific Territories

65 Homeless Policy Academies 9 Academies conducted: 5 focused on chronic homelessness, 4 on families and children Two mini-Policy Academies for the Pacific Basin focusing on individuals and families with children who are homeless were convened in Pago Pago, American Samoa, and in Tumon, Guam (with a team from the Commonwealth of the Northern Mariana Islands participating) An In-State Policy Academy focusing on chronic homelessness was convened in Olympia, Washington State and Territory Action Plans can be viewed at http://www.hrsa.gov/homeless

66 SAMHSA/CSAT Information www.samhsa.gov SHIN 1-800-729-6686 for publication ordering or information on funding opportunities –800-487-4889 – TDD line 1-800-662-HELP – SAMHSA’s National Helpline (average # of tx calls per mo.- 24,000)

67 Questions & Answers


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