Using Critical Time Intervention as a Scalable Solution to Crisis Homelessness

We have made meaningful progress over the past decade in addressing chronic homelessness in the United States, as evidenced by a 35% reduction between 2007 and 2016 in the number of persons experiencing chronic homelessness on a single night. The significant expansion of permanent supportive housing (PSH) over this time period is rightly credited as driving this progress and helps illustrate what is possible if resources are directed towards evidence-based, housing-focused solutions.

Yet, PSH should not be understood as a one-size fits all solution to homelessness. With annual costs that can exceed $15,000, it is a resource-intensive intervention, and it may not be feasible or necessary to provide such an intensive intervention to all persons experiencing homelessness. Alternative solutions that are less resource intensive, but equally effective as PSH, are therefore sorely needed for the bulk of the homeless population who experience short-term or “crisis” homelessness. For these individuals (who make up about 85% of the overall sheltered homeless population), an episode of homelessness is often triggered by an event such as an eviction, dissolution of a relationship, or transition out of an institutional living arrangement, such as foster care, prison, inpatient hospitalization, or substance abuse treatment. Unfortunately, progress in addressing crisis homelessness has not kept pace with that made on chronic homelessness: after subtracting out reductions in chronic homelessness, between 2007 and 2015, there was only a 6% decline in homelessness among single adults.

Fortunately, the emergence of a new paradigm in the homelessness assistance sector focused on housing stabilization, coupled with recent Medicaid policy developments, provides a unique opening for substantial progress to be made in reducing crisis homelessness. Recognizing this opportunity, my colleague Dennis Culhane and I recently presented a proposal to leverage the evidence-based intervention Critical Time Intervention (CTI) as a means to expand the availability of rapid re-housing—a promising new strategy that focuses on providing short-term, highly flexible assistance to help homeless households quickly achieve housing stabilization—for persons experiencing crisis homelessness.

Adapting CTI into a large-scale rapid re-housing intervention would make for a sound and feasible policy response to crisis homelessness for several reasons. First, the CTI and rapid re-housing conceptual and program models align nearly perfectly, meaning that a CTI-based rapid re-housing program model would be fairly straightforward to implement. Second, CTI has a strong evidence base as an effective intervention for reducing homelessness, and an integration of rapid re-housing and CTI could therefore amplify the impact of existing rapid re-housing programs. Third, recent guidance issued by the Centers for Medicaid and Medicare Services (CMS) suggests that most of the services at the core of a CTI-based rapid re-housing program could be reimbursed by state Medicaid programs, thereby providing the necessary funding to scale-up the approach with federal resources.

Implementing a CTI-based rapid re-housing at a large scale would have benefits at multiple levels. First, at the individual level, the housing stability and connections to community-based treatment and supports afforded by CTI would lead to improved health, economic, and social outcomes. Second, from the perspective of health care systems, and Medicaid in particular, the expansion of CTI-based rapid re-housing services could lead to more efficient and effective use of health care dollars.  Third, the implementation of our proposal would have a number of potential benefits to society, the most notable of which would be a substantial reduction in overall homelessness. Society would also benefit from reduced utilization of criminal justice system resources, public assistance, and other public services, as CTI has been linked with reductions in such services.

To be sure, there are challenges that would need to be addressed in implementing this idea. These include the need to appropriately tailor CTI for those experiencing crisis homelessness; having a trained workforce in place to deliver CTI-based rapid re-housing at scale; determining the best mechanism for states to include CTI in their Medicaid benefit package; and resolving how to pay for the temporary financial assistance component of rapid re-housing.

Fortunately, there is important work already being done to address these challenges and figure out how best to integrate CTI and rapid re-housing. Most notably, in a project supported by the Melville Charitable Trust, the Center for the Advancement of Critical Time Intervention is partnering with the National Alliance to End Homelessness to develop and test an integration of CTI into rapid re-housing programs in Connecticut. Such work is crucially important and holds great promise. To make real progress in addressing crisis homelessness similar work should be actively encouraged.Byrne_photo

About the Author: Tom Byrne is an Assistant Professor of Social Welfare Policy at the Boston University School of Social Work.  He is also an Investigator at the U.S. Department of Veterans Affairs’ National Center on Homelessness Among Veterans. 

Innovative Model of Integrated Health Care for the Homeless (Denver, CO)

Last month, the Colorado Coalition for the Homeless opened a new health clinic that integrates comprehensive health care and housing. The Stout Street Health Clinic offers a range of services, including medical, dental, vision, pharmaceutical, and behavioral health care, and also includes over 70 supportive housing apartment units.

The previous clinic was unable to meet the health care demands of the city’s homeless population, and routinely turned away patients and had long waitlists. With the increased capacity of this new clinic, they expect to serve 50% more people. The clinic is also expected to reduce overall state and local costs for emergency health care and other services.

In addition to an increase in capacity to provide adequate care, the health center offers two particularly important features. First, the co-location of multiple health services (e.g. physical, mental, vision, dental, etc.) provides patients with a one-stop option for health, and allows for practitioners to instantly connect patients to additional services. Second, combining apartments and health care in one complex provides supportive housing options that may be more appropriate for individuals with significant medical vulnerabilities.

This program is one of the most innovative, advanced, and integrated approaches to helping people experiencing homelessness that we have encountered. Of particular note, the entire agency, including architecture and human resource functions, is guided by trauma-informed care principles.

This is an excellent example of how states can seize opportunities made possible under the Affordable Care Act (ACA).

Photo from Colorado Coalition for the Homeless website.
Photo from Colorado Coalition for the Homeless website.

The Stout Street Health Center was built in part with ACA capital funds. Further, with the Medicaid expansion in Colorado, an estimated 65% of patients served are now covered by Medicaid. This is an increase from roughly 15% prior to the expansion.

To learn more about how the ACA and Medicaid expansion can be used to strengthen homeless services, read the Center’s recent paper on the topic here.

Blog Post Author: Amanda Aykanian, Research and Project Lead at the National Center

The National Center Releases a White Paper on Using Medicaid and the Affordable Care Act to Strengthen Homeless Services

Reliable funding streams to help people experiencing homelessness are greatly needed. The Patient Protection and Affordable Care Act (the ACA) and Medicaid offer substantial opportunities for such funding. This is made possible primarily through the optional expansion of Medicaid and adoption of Medicaid waiver services and state plan amendments.

With this paper, we provide information about Medicaid and non-Medicaid provisions that states can implement to increase access to services and to expand the types of services available to people experiencing homelessness. This includes components established by the ACA as well as pre-existing provisions. We also present examples of how some states have already taken advantage of these opportunities. Finally, we provide homeless service agencies with guidance on how best to advocate for change in their state.

Download the paper here: Strengthening Homeless Services: Funding Streams and Emerging Opportunities in Medicaid and the Affordable Care Act

Blog Post Author: Amanda Aykanian, Research and Project Lead at the National Center