Presentation on theme: "Homelessness and Substance Abuse: SAMHSA–CSAT Response"— Presentation transcript:
1 Homelessness and Substance Abuse: SAMHSA–CSAT Response H. Westley Clark, MD, JD, MPH, CAS, FASAMDirectorCenter for Substance Abuse TreatmentSubstance Abuse and Mental Health Services AdministrationU.S. Department of Health and Human ServicesOakland, CA, February 8, 2007
2 SAMHSAThe 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.Vision: A life in the community for everyoneMission: 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)
5 Co-Occurring Disorders, and Family Homelessness Substance Abuse,Co-Occurring Disorders, and Family Homelessness
6 Cities Participating in the US Conference of Mayors Hunger and Homelessness Survey BostonCharlestonCharlotteChicagoClevelandDenverDes MoinesDetroitKansas CityLos AngelesLouisville MetroMiamiNashvilleNorfolkPhiladelphiaPhoenixPortlandSalt Lake CitySan FranciscoSanta MonicaSeattleSt. PaulTrentonThe 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 PercentageThe US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006
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 Factors associated with homelessness are diverse, complex and interrelated. Causes identified by the survey cities include:Mental illness and the lack of needed servicesLack of affordable housingSubstance abuse and the lack of needed servicesJobsDomestic violencePrisoner re-entryUnemploymentPovertyThe 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 HomelessnessBostonCharlestonChicagoClevelandDenverLos AngelesLouisville MetroMiamiNashvilleNorfolkPhoenixPortlandSalt Lake CitySan FranciscoSanta MonicaSeattleSt. PaulTrenton√√√√√√√√√Receives a SAMHSA Grant in this areaThe US Conference of Mayors 23-City Survey: Hunger and Homelessness, December 2006
13 16 Survey Cities Identified Substance Abuse and the lack of needed services as a Primary Cause of HomelessnessChicagoClevelandLos AngelesLouisville MetroMiamiNashvilleNorfolkPhiladelphiaPhoenixPortlandSalt Lake CitySan FranciscoSanta MonicaSeattleSt. PaulTrenton√√√√√√√√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 BostonCharlestonClevelandDenverDes MoinesLos AngelesLouisville MetroMiamiPhiladelphiaPhoenixPortlandSalt Lake CitySan FranciscoSanta MonicaSeattleSt. PaulTrentonThe 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 PhiladelphiaPhoenixPortlandSalt Lake CitySan FranciscoSt. PaulTrentonBostonChicagoClevelandDenverLouisville MetroNorfolkThe 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 BostonClevelandDenverLos AngelesLouisville MetroPhoenixSan FranciscoDomestic ViolenceCharlestonChicagoKansas CityLos AngelesSalt Lake CitySan FranciscoSeattle√√√√√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 CharlestonChicagoDenverDes MoinesLos AngelesPovertyClevelandPhoenixSeattleSt. PaulTrentonThe 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.
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 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.
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.
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.
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 Substance Use Disorder Co-Occurrence of Serious Psychological Distress (SPD) and Substance Use Disorders Among Adults, Aged 18 or Older: 200522.2 Million24.6MillionCo-OccurringDisordersSubstance Use DisorderSPD5.2 Million* NSDUH 2005
26 What do we know about substance abuse and homelessness? Half of all homeless adults have substance use disorders.113 percent of those in substance abuse treatment were homeless at the time of admission (up from 10% in 2000).2More than 120,000 people admitted for substance abuse treatment are homeless at the time of admission.31 Blueprint for Change, CMHS, SAMHSA.2 The DASIS Report: Characteristics of Homeless Female Admissions to Substance Abuse Treatment, Drug and Alcohol Services Information System (DASIS), SAMHSA, OAS.3 The DASIS Report: Characteristics of Homeless Admissions to Substance Abuse Treatment, Drug and Alcohol Services Information System (DASIS), SAMHSA, OAS.
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.1As 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.220 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.21 National Resource Center on Homelessness and Mental Illness2 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.1Among homeless veterans, one-third to one-half have co-occurring mental illnesses and substance use disorders.2Among detainees with mental illnesses, 72 percent also have a co-occurring substance use disorder.21 The DASIS Report: Characteristics of Homeless Admissions to Substance Abuse Treatment, 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 time25 percent are homeless more than a year, half in transitional housing29 percent were homeless for first time before age 1825 percent experienced out-of-home placement before age 18Family 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., Based on women with children.
30 What do we know about homeless families? 84 percent are single mothersAverage age: late 20sAverage 2–3 children, most under age 666 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 Medicaid27 percent needed medical treatment in the past year45 percent had one or more chronic health conditionIn 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 alcohol27 percent—Problems with drugs44 percent—Mental health problems (primarily depression, anxiety, PTSD)58 percent—One or more of the above*Burt et al., Based on women with children; self-report of problems within past year.
33 Experience of Violence* 67 percent—Severe childhood physical abuse43 percent—Childhood sexual abuse63 percent—Severe violence by adult intimate partner(s)*Bassuk et al., Based on women with children.
34 Needs of ChildrenHomeless 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 ChallengesHomeless individuals with alcohol/substance use disorders pose substantial challenges to the substance abuse treatment community…
38 Service System Challenges Inadequate screening and assessmentFragmented servicesCategorical fundingLack of discharge planningPoor integration of careOther fiscal and coverage limitations
39 Societal Challenges Stigma Oppression and racism Discrimination PovertyHousing costsLack of employment
40 Treatment Challenges Engagement Retention Relapse Interagency collaborationNeeds versus access to servicesTreatment philosophiesPolicy and financing
41 Challenges to Successful Engagement Social isolationDistrust of authoritiesMobilityMultiplicity of needs
42 Meeting the Challenges: Engagement Challenges Outreach (aggressive/assertive)Providing housing or other practical assistanceCreating a safe, nonthreatening environmentStrategies to increase motivationFamily-based treatment engagement strategyPeer 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 resourcesHighly complexNecessary to reduce fragmentation of careLinkage vs. Integrated Treatment—Which is better?Research on this question is mostly descriptiveControlled comparisons are prohibitive
46 Challenges to Integrating Services Well-established programs and a specialized work forceInteragency turf battlesFunding limitationsLack of technology and resources to support information needsLack of available servicesSize and complexity of the service systemLack of political will and mechanisms to channel public supportLegislative and political opposition
47 “No Wrong Door” PolicyEach 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 neededFollow up on referrals to ensure clients received proper care
49 Federal Response to Homelessness Targeted Homeless Assistance ProgramsResourcesCoordination/LinkagesTreatment for Homeless ProgramHomeless Family ProgramCollaborative Initiative to Help End Chronic HomelessnessPolicy AcademiesFederal Leadership
50 Creating a Comprehensive Service System for Homelessness Support concept of “No Wrong Door” to servicesProvide services determined by evidence to be effectiveChange ineffective policies or regulationsLeverage existing resourcesUse mainstream resourcesPursue new resources
51 Steps to Achieving a Comprehensive Service System Involve key stakeholdersEstablish a formal planBuild linkages and partnerships from top-down and bottom-upEnhance funding and other resourcesStreamline the administration of fundingPerform ongoing monitoring and quality assurance
52 Federal Spending FY 2005 FY 2006 Agency Totals Enacted Enacted Targeted Homeless Assistance Programs (Budget Authority in Millions of Dollars)FY FY 2006Agency Totals Enacted EnactedHUD 1, ,327.0VA 1,HHSUSDAFEMAEDUCATIONDOLICHSSATOTAL 3, ,593.9The reason the budget looks lower in 2006 than 2005 is due to a VA budgeting issue- OMB has removed the VA healthcare funds that serve homeless persons in their mainstream programs, since they are not technically "targeted dollars" as all of the other figures are.
53 FY ‘06 HHS Funding for Mainstream and Homeless Specific Service Programs Relevant to Homelessness (dollars in millions)HHS Mainstream Programs (listed alphabetically) FY06 AppropriationAccess to RecoveryCommunity Mental Health Services Block GrantCommunity Services Block GrantConsolidated Health Centers (CHC)Head StartMaternal & Child Health Services Block GrantMedicaidRyan White CARE ActSocial Services Block GrantState Children’s Health Insurance ProgramSubstance Abuse Prevention & Treatment Block GrantTemporary Assistance for Needy FamiliesTotal $ for HHS Mainstream ProgramsHHS Homeless Specific Service Programs (listed alphabetically)Treatment for Homeless GrantsHealth Care for the HomelessPrograms for Runaway & Homeless YouthProjects for Assistance in Transition from HomelessnessSurplus Property/ Title VOther Targeted Homeless ActivitiesTotal $ 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* 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) CMHS200420052006PATH$49.8$54.8$ 54.2Treatment for Homeless$ 3.3$ 6.1$ 5.8CHI$ 3.6$ 3.4$ 3.7Best Practices$ 4.9$ 2.5$ 2.6Subtotal$ 61.6$ 66.8$ 66.3CSATTreatment for Homeless$ 29.9$ 29.7$ 30.4CHI$ 4.3$ 4.2$ 3.6Other$ 0.2---$ 0.5Subtotal$34.4$33.9$ 34.5TOTAL$96.0$100.8
55 SAMHSA Resources to Address Homelessness (Dollars in Millions) CMHS20062007(CR)2008(Pres)PATH$54.2254.26$ 54.26Homelessness PRNS$ 9.49$ 8.49$Best Practices$ 2.61Subtotal$ 66.32$ 65.36$ 58.68CSATGrants to Benefit Homeless Individuals$ 34.52$ 32.59Subtotal$34.52TOTAL$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 personsGrantees are embedded within an integrated, comprehensive, community-based systemGrantees conduct followup outcome evaluations137 grants awarded since 200187 active grantees (23 new grantees were awarded in September 2006)
57 Treatment for Homeless Awards Three-Year Grant Period17 grants funded for $9.8M in 200119 grants funded for $10.9M in 200214 grants funded for $7.8M in 2003Five-Year Grant Period34 grants funded for $13.5M in 200430 grants funded for $11.9M in 200523 grants funded for $9.0M in 2006TOTAL = $62.9M (first-year awards only)
58 Number of Treatment for Homeless Grants Funded 2001 to 2006 AK1WA 1NYMA 8OR 2WI16CT 2MI 34NJ 2PA 1OHDE 1NV 1IN14ILWVMD 3DC 2CACOMO613KY 1225TN 5AZ2NMOK 2SC 1AR 1AL23GA3TX10FL10U.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% ChangeIncrease % of adults receiving services who:Did not use alcohol or illegal drugs49.6%71.5%44.0%Had no/reduced involvement with CJS92.1%96.3%4.6%Were currently employed or attending school14.4%33.8%133.9%Had no alcohol or illegal drug related health consequences45.7%57.5%25.9%Were socially connected80.5%84.5%5.0%Had a permanent place to live in the community8.8%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% ChangeIncrease % of adults receiving services who:Did not use alcohol or illegal drugs44.8%79.8%78.0%Had no/reduced involvement with CJS90.7%97.2%7.2%Were currently employed or attending school8.0%31.4%292.3%Had no alcohol or illegal drug-related health consequences49.4%71.7%45.0%Were socially connected90.5%93.4%3.2%Had a permanent place to live in the community9.3%14.3%54.8%
61 Homeless Families Program CSAT/CMHS collaborationA 5-year knowledge development initiative that documented and evaluated intervention models targeted to homeless mothers who have psychiatric, substance use, or co-occurring disordersThis 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 phasesPhase I began FY 1999; consisted of 14 sitesPhase 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 homelessnessIncrease housing stabilityPromote family preservation/reunificationDecrease substance useImprove mental healthImprove social functioningPhase 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 servicesPsychiatric symptoms among the women declined significantly at 9 and 15 months after entryIllegal 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 PlansConducted in collaboration with HUD and Departments of Labor, Education, Justice, Agriculture, Veterans Affairs, and Interagency Council on HomelessnessHigh-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 childrenTwo 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, WashingtonState and Territory Action Plans can be viewed at
66 SAMHSA/CSAT Information SHIN for publication ordering or information on funding opportunities– TDD lineHELP – SAMHSA’s National Helpline (average # of tx calls per mo.- 24,000)