The slow road to an effective homeless crisis response, part 1

This is the first  installment of a two-part report on last week’s big announcements around the city’s response to the homeless crisis in Seattle and King County. Part 2 can be found here.

Last week we all finally got to see the long-awaited and much-delayed report from consultant Barb Poppe on Seattle’s response to its homeless crisis. And it immediately became clear why it took so long to see the light of day.

The Poppe report was only one of three 60+ page documents released by the city yesterday. The second was a detailed assessment of the larger homeless response in Seattle and King County commissioned by All Home, King County, the City of Seattle, and United Way (the four big funders of programs to address the homeless crisis) and written by consultancy Focus Strategies.

The third document was Pathways Home, an update to the city’s Human Services Division (HSD) strategy for addressing homelessness that is clearly in response to critiques raised in the Poppe and Focus reports.

All of this was neatly wrapped up in a city web page declaring a bold new initiative with a fact sheet and timeline, with pretty graphics and everything else we’d need to believe that they’re really serious this time.  As a testament to how carefully this was orchestrated, across the two reports and the Mayor’s plan I found no points of disagreement — major or minor — on any topic. The chance of that happening independently on an issue as controversial as homelessness is precisely zero.

Back in June, I wrote this article laying out what needed to change in the city’s homeless crisis response.  It is eerily similar to what was announced yesterday. I raise this not to suggest that I’m full of brilliant insights and everyone should just do what I say; just the opposite. I wrote that piece because at the beginning of the summer it was already painfully obvious, even to someone unskilled in the field (i.e. me), exactly what steps must be taken. The city, the City Council, and the community had already talked this to death. And yet, the Mayor’s Office and HSD held the two reports while they worked with the two consultants to massage their findings to be mutually consistent (Poppe’s report relies heavily on the findings in the Focus report), and to buy them time to write their own new strategy. On the latter point, I don’t blame them; it’s obvious that the Mayor and HSD Director Catherine Lester didn’t want to spend the summer answering hard questions about all the things the report says they were doing wrong without being able to talk to what they will do to fix them. And to their credit, they are trying to address many of the strongest critiques in their new strategy. But no one should be fooled here: this was a major PR undertaking to manage the downside of a pair of critical reports, and tie a pretty bow around it to re-establish some sense of leadership in a homeless response effort that has shown little or no substantial success. The Murray administration buried bad news for two and a half months until it could put some semblance of a happy face on it.

The Focus assessment report raises three key issues with the current homeless response.

  1. The current response — both in Seattle and regionally — is not driven by funders; it’s driven by providers. That has created a big, inefficient mess that spends lots of money on the wrong programs.

All Home, the organization tasked by Seattle, King County, and United Way to be the regional coordination point for homeless services, has a completely broken governance structure. While it has a Funder Alignment Committee, according to Focus “its role is unclear and it has limited decision-making authority.” The Executive Committee and the Coordinating Board, which hold the decision-making power, are primarily filled with providers, and the co-chairs of both committees are providers. Further, Focus says:

“The All Home Charter is set up to require consensus decision-making in most cases and has relatively loose conflict of interest provisions, so individual providers have a large ability to sway decisions. When system design work is done in this collaborative way, it rarely leads to significant changes and rather tends to reinforce maintaining the status quo.”

For its part, HSD has hundreds of contracts with providers worth tens of millions of dollars. Individually, many of them are doing good work, but it has created a web of individual programs that is impossible to navigate. And those programs continue to get individually funded without any requirements to meet a performance standard or to contribute to a larger coordination effort to ensure that money is well spent and the full capacity of the system is utilized.

Let’s look at one example raised by the Focus report. According to their research, 12% of the homeless population is families. But 21% of the investment in programs and services, and thus 22% of the capacity, is for families.

capacity-single-adults-vs-families

The result of that is a collective system where resources are under-utilized — and the messy, bottom-up provider-driven system both creates and hides that result. Family emergency shelter capacity across the region is only at 69% utilization.

utilization-rate-for-programs

Further: it turns out that a significant fraction (around 35%) of the emergency shelter capacity in the region is going to people who are not actually unsheltered or in imminent danger of becoming unsheltered. In the summer that isn’t a critical issue, but in the Seattle winter when emergency shelters are at capacity it’s a life-or-death matter as to whether we are prioritizing shelter space for those with no alternative source of shelter.

rate-of-entry-from-homelessness

Transitional and permanent supportive housing are both heavily utilized in the system, but that belies another underlying truth: transitional housing, at least the programs in existence today, are not the most efficient use of funds to move people from homelessness back into permanent housing.  Stays in transitional housing tend to be very long, particularly compared to Rapid Rehousing programs:

length-of-stay

Because of that, transitional housing is much more expensive, particularly compared to rapid rehousing:

cost-of-exit-to-permanent-housing

Transitional housing in the Seattle/King County region has a slightly better success rate than rapid rehousing (though in their verbal report, Focus pointed out that these stats are as of May 2016, and since then some new RRH programs have come on line that are performing much better and raising the success rate):

rate-of-exit-to-permanent-housing

But because rapid rehousing is so much cheaper than transitional housing, in terms of the outcomes it is still a far better investment than transitional housing: investing the money in rapid re-housing results in more people successfully exiting to permanent housing. It’s worth pointing out though that not all TH projects are failures; a relative handful are performing highly, and the ones that do deliver high outcomes as well. But it’s far from the majority, and the difference in outcomes between the high performers and the rest is substantial.

th-projects-and-performance

th-exit-rates-by-performance-level

Regionally, almost $20 million is spent on transitional housing (and far less on rapid rehousing).

program-funding

In Seattle, HSD has already realized that RRH is a better deal and has started shifting money toward it (aside: the timeframes are different in the two charts, which is why Seattle’s RRH spend is higher than the all-region number)

hsd-program-investments

Now, Focus did something simultaneously clever and stupid in their report: they made the case that if the funding for transitional housing was reduced by about $15 million and that money redirected into more cost effective programs, if existing programs hit their performance targets (including refocusing emergency shelters on the truly unsheltered), and if the “coordinated entry” system (for designing personalized interventions for the homeless at the time they enter the system to get them the help they need) were well implemented, then the region would have the capacity to shelter all homeless adults and families within a year.

capacity-to-shelter-all-unsheltered-households

As a theoretical exercise in the benefits of re-allocating money not being spent well, it’s a useful thought exercise. But as a practical step it’s not only completely unrealistic but actually damaging to the overall effort because it leads people to think that the homeless problem is actually solvable in the next year — and it drives stupid headlines saying precisely that.  First of all, most of that $15 million is tied up in contracts, many of which extend to the end of 2017. Second, as has been pointed out repeatedly, the emergency shelter system is fundamentally broken in that most of it has high barriers to entry: people with pets, possessions, or unmarried partners are not welcome, nor are people with mental health or substance abuse issues. Yes, there is a lot of capacity, but there is a complete mismatch between that capacity and what is actually needed to shelter the homeless in Seattle and King County.

Since Focus put that suggestion out there, the head of LIHI (a large provider of publicly-funded transitional housing) has felt the need to make public statements defending transitional housing for fear of losing her funding source. And that also hurts the cause: we won’t make progress on reforming the broken, provider-driven system we have in place today if every funding decision is tried in the court of public opinion by providers at risk of losing their funding, rather than through data-driven performance evaluations and competitive bidding where the best programs with the best outcomes get funded.  Which brings us to the second point:

2.  The effort is neither data-driven nor performance driven.

For all of HSD Director Catherine Lester’s big talk (and reputation) for a change to a metric-driven culture over her five years in leadership at HSD, the truth is anything but that. And in fairness, that’s equally true for the larger efforts in King County. There is a county-wide effort to move to a new HMIS system — a central IT system for tracking and sharing information about those in the homeless system that would be the basis of the new “Coordinated Entry for All” (CEA) system and allow providers to capture and share information about homeless people to better align outreach and service delivery. But there has been little effort to-date to drive accurate and useful collection of data by providers. Focus reported that  the data in the current HMIS system shows providers inputting data in order to be nominally compliant while choosing to do so in a way that provides little useful information or insights — usually by simply choosing “unknown.”

missing-data

If the system is done right, not only does it enable an effective coordinated entry system but it creates other important opportunities. Focus (and Poppe) suggests that three new teams be created to manage issues that are falling through the cracks today: a Family Impact Team to ensure that families are appropriately assessed, prioritized and admitted based on their situation and any immediate health and safety issues; a Housing Resource Center to connect landlords with service providers who want to refer homeless people to housing opportunities; and an Outreach Planning Team to ensure that outreach providers are coordinating with each other on whom they approach and what steps they take. All three of these teams would manage a “by name list,” extracted from the HMIS system, of high-priority individuals and families who have been in the system for a long period of time and/or have high barriers to exit and need special attention to successfully transition out.  Those lists don’t exist today.

Having a working HMIS system which providers are required to participate in also allows for funders such as HSD to generate reports on how the system is working. That would include daily reports on simple statistics such as how many people are in the system, weekly or monthly reports on bed capacity and shelter utilization, and regular reports on which providers are hitting their performance goals.

At a more fundamental level, it allows for funders to make their contracts performance driven, because it provides a source for metrics by which a provider’s performance can be evaluated — something which largely doesn’t exist today. There is essentially no accountability in the provider system today: no salient performance metrics in the providers’ funding contracts, nor any means for enforcing collection of those metrics with which to evaluate the providers’ performance. Without the ability to evaluate performance, it’s impossible to fix the things that are broken in the existing system. And that brings us to the third issue that Focus raised:

3. The shelter system is very, very broken.

Regionally, over $20.5 million is spent annually on shelters. HSD is spending $11.7milion, plus another $8 million on day centers, hygiene centers, and other complementary services for the homeless. But the evidence shows that the money is not being spent well. A litany of problems exist, some of which I’ve already mentioned as issues for the entire homeless response system.

  • The vast majority of shelters do not operate 24/7: they take people in at 7pm, and kick them back out onto the street at 6am the next morning.
  • They generally do not accept people with significant possessions, nor do they provide safe storage for possessions.
  • They generally do not accept people with pets.
  • They generally do not accept unmarried couples together.
  • Many shelters do not accept people with active mental health or substance abuse issues.
  • A significant portion of the shelter capacity is given to people who are not literally unsheltered. There will always be some people in that category who urgently need to be taken in, but it’s currently 35% of the people staying in shelters. In the winter this is a critical issue.
  • “Long-term shelter stayers” (referred to as LTSS) who are stuck in the system consume a large fraction of the shelter capacity.  Focus estimated that 40% of shelter stayers consume 74% of the capacity.
  • Many shelters are not using the Seattle/King County HMIS system, not participating in the CEA coordinated entry system.
  • To the extent that the shelters have outreach staff trying to connect homeless people to services, many are not integrated with the larger system of providers that can offer services. This creates a system where homeless people’s success in getting services is dependent upon luck and the specific outreach staff person who reaches out to them.
  • Overall, shelter quality and performance is not good. Focus’s assessment of regional shelters determined that of 50 shelters assessed, 12 were performing at a high level, 24 at a moderate level, and 14 were performing at a low level. This makes a big difference, because the low performers  cost far more to achieve a successful outcome.

shelter-performance

shelter-exit-cost-by-performance-level

 

In a nutshell: the shelter system is failing the people it was intended to help. Many people are turned away; the ones who are accepted must give up pets, possessions and partners. Outreach to offer services is poorly coordinated, and in the end nearly everyone is out on the street again at 6am. This is why so many people refuse offers of emergency shelter: because the personal cost of entry is far higher than the benefits received.

Focus raised several other issues, including:

  • With the critical lack of affordable housing, the current stock of publicly-funded affordable housing is not being used strategically to shelter the homeless.
  • There is no current emphasis on successfully transitioning people out of permanent supportive housing once their issues have stabilized.
  • Their analysis of race, ethnic, gender and age disparities put numbers to what was already generally known, particularly that homelessness has a disparate impact on people of color and the disabled.

disparities

 

Poppe’s report doesn’t add a lot beyond what Focus provided, though it provides interesting “color commentary” and highlights some additional recommendations for Seattle and King County to consider. She emphasizes the importance of a competitive bidding process, inherent in which is the notion that some current providers will lose funding in the future.

Poppe also discusses the importance of a “person centered” response system, which is essentially the same as a “funder driven” system. Unlike today’s provider-driven “boutique” system where each provider chooses what services they want to offer and to whom, in a person-centered system the homeless person’s experience of the system is not determined by the provider that the person happens to interact with first; instead it is customized to that person’s specific needs and pulls in the providers best able to help.

And Poppe also emphasizes the importance of a “housing first” approach, recognizing that once someone is stabilized into dependable shelter, it then becomes possible to address the other issues that person may have such as mental health or substance abuse issues. But that also raises the corollary: anyone excluded from the homeless response system because of other issues will not resolve those issues on their own and suddenly become eligible to enter the system.

Poppe made a big deal about the criteria used to prioritize housing interventions. Seattle and King County have standardized on a “vulnerability index” assessment. While it seems like a humane approach, it creates a situation where a constant stream of vulnerable people “jump the line” in front of a homeless person with lower vulnerability. Under the assessment rules, a person who has been homeless for one year receives the same ranking as someone continuously homeless for ten years or more: a single point, the same ranking as for most other items in the vulnerability index such as “family legal issues.” This results in people becoming chronically homeless because they never get prioritized high enough to gain access to housing services. And there are two outcomes of that: first, the longer someone is homeless the higher the likelihood that they will develop other issues such as mental health or substance abuse — and the higher the barriers become to eventually re-housing them. Second, as we have already discussed, long-term emergency shelter stayers consume an oversized share of shelter resources, and successfully transitioning them out frees up those resources to help others.  Poppe argues that Seattle and King County should change their criteria to prioritize housing interventions based upon length of time someone has been homeless, following the new best practice adopted by most other cities. This is a highly technical argument and easily misunderstood, as it can sound harsh and unsympathetic. There will always be people with immediate needs, at high risk for severe health or safety consequences, who will take priority.  But the system today practically ensures that a straight white male in his 30’s will never get permanent housing assistance and will be stuck indefinitely in the emergency shelter system (consuming lots of resources) until he develops enough other issues — as a side effect of being homeless — to boost his vulnerability index. That is also not an acceptable outcome. Poppe makes a similar argument for abandoning the vulnerability index assessment for prioritizing admission into emergency shelters, especially for families. She argues that the top priority must be given to those at high risk for health and safety issues, such as families with newborns and children under the age of four. The current vulnerability index system does not necessarily prioritize their admission over others either.

Together, the Focus and Poppe reports paint a picture of a deeply dysfunctional  regional response to the homeless crisis, and recommend large-scale changes to try to right the ship.

Next up in Part 2: the city’s response, and what it means.

 

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