National Initiatives to End Homelessness

This chapter presents two large-scale governmental efforts to implement community-level projects to improve the availability of and access to housing and support services for homeless people with severe mental illness. It’s one thing to have “evidence-based” housing and support services available, and another thing to try to bring them to scale in real- world community settings. How well do these community-level approaches work? Lessons learned from these efforts can help to guide future dissemination of evidence-based housing and support services.


Homeless people with severe mental illness require services from multiple systems of care to achieve stable tenure in the community. The fragmented and poorly coordinated community services for the severely mentally ill have been a concern from the earliest days of the deinstitutionalization movement. The 1992 report of the Federal Task Force on Homelessness and Chronic Mental Illness, Outcasts on Main Street, recommended the development of a demonstration program to coordinate services. The Center for Mental Health Services funded five-year demonstration projects in 1992 to test whether a more integrated system of care could be developed that would provide service recipients greater services integration by increasing collaboration and cooperation among agencies providing mental health and substance abuse treatment, health care, income support, and housing (Randolph et al., 2002). Of the 25 states that vied for the initiative, nine were selected through a process of peer review to participate in the $17 million demonstration project. Each state selected two communities that had similar numbers of homeless people with mental illness and were comparable in terms of population size, housing, and median income.

Nine experimental communities were randomly chosen to receive funding and technical support to develop systems-integration strategies, such as forming interagency coalitions, co-l ocating services, developing interagency information systems, joint funding, and establishing interagency service delivery teams (Randolph et al., 2002). Nine communities in the same states served as comparison sites. Funding for assertive community treatment teams was provided to both experimental and comparison communities to serve 400 individuals at each site. Outcome of systems- change strategies was assessed through site visits and interviews with key representatives from community service organizations. To determine if systems-change strategies improved the service and behavioral outcomes of individual clients, over 7,000 homeless individuals in experimental and comparison communities were evaluated at study entry and over the follow-up year.

The study found that the ACCESS effort did not lead to greater service integration in the nine experimental sites. Although service integration did not improve across multiple human services agencies system-wide, the experimental sites had better services integration at the individual project level, giving clients greater access to the range of services available in the community (Goldman et al., 2002; Morrissey et al., 2002). Health status, community adjustment, and service-use outcomes improved for individuals in both the experimental and comparison groups, but greater efforts to implement systems-integration strategies in the experimental sites did not result in better client outcomes. Regardless of whether a site was experimental or comparison, however, individuals in sites with greater service system integration had better housing outcomes (Rosenheck et al., 2002).

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