The Strategic Framework for Ending Chronic Homelessness in Nashville

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					    The Strategic Framework for
  Ending Chronic Homelessness in
                 Presented by
The Mayor’s Task Force to End Chronic Homelessness

             September 23, 2004

                                      Compiled by

                         Task Force Members
         Chair: Dorothy Shell Berry, Director Metro Social Services
           Facilitated by: Douglas Perkins, Vanderbilt University

                  Howard Allen, Homeless Rep, Power Project
            Dr. Stephanie Bailey, Director, Metro Health Department
                 Kevin Barbieux, Homeless Rep, Power Project
               James Bearden, CEO, Gresham, Smith & Partners
           Bill Coke, Community Volunteer, Christ Church Cathedral
                       Mark Desmond, CEO, United Way
                    Cynthia Durant, Vice President, US Bank
             Howard Gentry, Vice Mayor, Metropolitan Government
         John Gupton, Attorney, Baker, Donelson, Caldwell & Berkowitz
              David Guth, CEO, Centerstone Mental Health Center
              Steve Halford, Director Chief, Metro Fire Department
               Hank Helton, Mayors Office of Affordable Housing
               Judge Andrei Lee, Judge, General Sessions Court
          Rev. Kenneth Locke, Pastor, Downtown Presbyterian Church
        John Lozier, Director, Nat'l Health Care for the Homeless Council
Steven Meinbresse, Community Volunteer, TN Dept. of Human Services (formerly)
            Mike Neal, CEO, Nashville Area Chamber of Commerce
       Dr. David Pennington, Director, VA-TN Valley Health Care System
                Ed Pringle, Director, HUD-Nashville Field Office
                      Phil Ryan, Executive Director, MDHA
          Father Joseph Sanches, Pastor, Holy Name Catholic Church
              Brenda Sanderson, Owner, Broadway Entertainment
                 Ronal Serpas, Chief, Metro Police Department
              Dr. Roxane Spitzer, CEO, Nashville General Hospital
          Charles Strobel, Director, Campus for Human Development
                 Rader Walker, CEO, Nashville Rescue Mission
        Rev. Kaki Friskics-Warren, Community Foundation of Middle TN
                   Pam Womack, Mental Health Cooperative

                                               Work Group Members
            Health                             Housing                   Economic Stability                System Coordination
             Chair                                 Chair                           Chair                                Chair
           John Lozier                     Kaki Friskics-Warren               Steve Meinbresse                      Mark Des mond

     Task Force Members                   Task Force Members                Task Force Members                  Task Force Members
       Stephanie Bailey                       How ard Allen                    Kevin Barbieux                      Kevin Barbieux
          David Guth                         Kevin Barbieux                    James Bearden                      David Pennington
         Steve Halford                       Cynthia Durant                     John Gupton                           Bill Coke
        Roxane Spitzer                       How ard Gentry                      Mike Neal                          Ronal Serpas
        Pam Womack                           Kenneth Locke                    Joseph Sanches                         Andrei Lee
                                               Ed Pringle                    Brenda Sanderson
     Core Team Members                       Charles Strobel                                                    Core Team Members
  Theresa Armstead, Vanderbilt                Rader Walker                   Core Team Members                Kimberly Bess, Vanderbilt
   Scott Orman, Metro Health                                               Brenda Gill, Metro Action            Mary Gormley, MDHA
          Department                     Core Team Members                       Commission                   Scott Orman, Metro Health
  Pam Sylakowski, Metro Social        Theresa Armstead, Vanderbilt         Carrie Hanlin, Vanderbilt                 Department
           Services                    Brian Christens, Vanderbilt          Diana Jones, Vanderbilt            Doug Perkins, Vanderbilt
                                         Mary Gormley, MDHA               Lisa Pote, Nashville Career      Brenda Ross, Metro Social Svs.
Community Members/Resource                Paul Johnson, MDHA                 Advancement Center                  Suzie Tolmie, MDHA
              Persons                                                          Phil Ryan, MDHA
    Bart Perkey, Metro Health        Community Members/Resource                                           Community Members/Resource
            Department                              Persons            Community Members/Resource                          Persons
Russanne Buchi-Fotre, Downtown         Bill Barnes, Community Activist              Persons                     Angela Bard, Centerstone
               Clinic                   Bill Burleigh, Operation Stand    Christine Bradley, Nashville           Angela Bauer, MH Court
 Michael Cartwright, Foundations                      Dow n               Career Advancement Center             Jeff Blum, Sheriff’s Office
             Associates                 Penny Campbell, Park Center         Terry Horgan, Woodbine        Joe Brown, Operation Stand Down
   Joy Cook, TN Department of                   Pat Clark, MDHA             Community Organization           Russanne Buchi-Fotre', Metro
               Health                       Bob Currie, Park Center         Betty Johnson, Goodw ill                Health Department
 Doel Fuentes, Nashville Rescue               Brian Dion, TDMHDD          Dani Lieberman, United Way                  Pat Clark, MDHA
              Mission                        Kathy Dodd, Woodbine       Darryl Murray, Welc ome Home           Rae Ann Coughlin, TN Dept.
    Estelle Garner, Samaritan               Community Organization                  Ministries                            Correction
       Recovery Community             Charlie Finchum, Salvation Army      Ed Ow ens, Gresham Smith           Linda Cross, Veterans Affairs
    David Grimes, Centerstone         Jennifer Jones, Operation Stand                Partners              Bob Davenport, Veterans Affairs
   Jim Holzemer, Nashville Fire                       Dow n              Derrell Payne, Social Security    Margo Fortney, MH Cooperative
            Department                 Ed Latimer, Affordable Housing            Administration                 Andy Garrett, Metro Police
Linda Klinefelter, TN Protection &                 Resources            John Poole, Campus for Human      Bill Gupton, TN Dpt. of Corrections
             Advocacy                 Rusty Lawrence, Urban Housing               Development             Tony Halton, National Health Care
    William Luttrell, Campus for                    Solutions          Shelby White, Nashville Chamber           for the Homeless Council
       Human Development             Jessica LeVeen, Federal Reserve              of Commerce                Donald Haw kins, Metro Police
Sandra McMahan, Metro General                         Bank               Don Worrell, Nashville Rescue     Mary Ann Hea, Public Defenders
              Hospital                       Terry Livingston, HUD                   Mission                   Mike Hodge, Neighborhood
  James Martin, Homeless Rep         Loretta Owens, Nashville Housing                                                 Resource Center
 Marion Mosby, HCA Healthcare                         Fund                                                  Doc Hooks, Metro Health Dept.
Sean Muldoon, Nashville CARES               Ralph Perry, FannieMae                                         Harmon Hunsicker, Metro Police
  Karl Smithson, Homeless Rep                 Carol Ridner, MDHA                                             Brian Huskey, Urban Housing
          Linda Thomsen                Don Worrell, Nashville Rescue                                            Ben Jacobs, Metro Health
 Pam White, Nashville Prevention                     Mission                                                  Dani Lieberman, United Way
            Partnership                                                                                    Darlene McClung, Project Return
 John York, Samaritan Recovery                                                                             Sandra McMahan, Metro General
            Community                                                                                                      Hospital
                                                                                                              Pamela May, New Hope Fdn
                                                                                                                    Lee Mitchell, MDHA
                                                                                                                 Charlene Murphy, MDHA
                                                                                                            Bruce Newport, Nashville Safe
                                                                                                                   Haven Family Shelter
                                                                                                               Steve Pharris, Metro Health
                                                                                                                  Larry Prisco, Vanderbilt
                                                                                                             Stacey Richards, Centerstone
                                                                                                                  Theresa Robinson, VA
                                                                                                           Michelle Steele, Mayor's Offic e of
                                                                                                             Benn Stebleton, Oasis Center
                                                                                                             Marsha Travis, Sheriff's Dept.
                                                                                                             Regina Williams, Centerstone
                                                                                                                   Bill York, Metro Police


              A Call to Action

Homelessness       –   especially    chronic        In the 2004 count of homeless in Nashville,
homelessness – constitutes a multi-faceted          volunteers and Metro officials counted 1,800
challenge facing communities across our             homeless individuals, including 900 who
nation.      The homeless are a visible             met the Department of Housing and Urban
reminder that some citizens do not possess          Development’s definition of chronically
one of the most basic ingredients of human          homeless.
existence – shelter from the elements.
Homelessness arises from multiple causes
and its complexity can easily confound the
government, law enforcement, health care,
                                                        The U.S. Department of Housing and Urban
and social service agencies.            And         Development defines a chronically homeless person
homelessness affects us all – it is, by               as an unaccompanied hom eless individual with a
definition, human suffering that takes place        disabling condition who has either b een continuously
in public: a daily tragedy of the few that          homeless for a year or more or has had at least four
                                                     (4) episodes of homelessness in the past three (3)
touches the many.                                      years. To b e considered chronically homeless,
                                                       persons must have b een sleeping in a place not
In a city like Nashville, recognized across         meant for human hab itation (e.g., living on the streets)
the nation for its excellent quality of life, the   and/or in an emergency homeless shelter during that
plight of our chronically            homeless                               time.
population is especially poignant and                    The UnitedStates Interagency Council on
problematic. It is not that our community            Homelessness estimates that chronically homeless
has ignored the problem – far from it. But,          persons make up about 10 percent of all homeless
at the end of the day, research and                    persons, b ut consume 50 percent of availab le
programs of the past have not marshaled
the commitment, resources, and level of
coordination       required       to       solve
homelessness in Nashville.
                                                    Nashville boasts a 20-year history of
                                                    research and planning that has generated
It is time to take up the challenge of chronic
                                                    increased services for the homeless
homelessness in Nashville. Our federal
                                                    population. These achievements have been
government has set the goal of ending
                                                    critical yet limited in scope and often
chronic homelessness. In April of 2004,
                                                    fragmented. This ten-year plan will give
Mayor Bill Purcell appointed a task force
                                                    Nashville a guide to end chronic
charged with making certain Nashville
                                                    homelessness, improving the lives of many
meets the federal goal within ten years. By
                                                    and improving our community. This is the
bringing community leaders, government,
                                                    first time that a broad representation of the
and service agencies together to take on
                                                    Nashville community has convened to
the multiple components of chronic
                                                    create a vision and concrete plan to end
homelessness, Nashville will map a
                                                    chronic homelessness.
coordinated system to address this
important issue.

Introduction: The Planning Approach

Mayor Purcell named a task force that           Additionally, job training, readiness and
includes public officials; business and faith   placement are needed for chronically
communities; social service agency              homeless persons who are able to work.
representation; homeless individuals and                Systems Coordination
committed citizens to a five-month job of       In addition to the components already
designing the plan. Individuals who are         discussed, the broad system of services
chronically homeless do not fit one general     and housing must be as seamless and
description. However, they do share             coordinated as possible. Nashville must
common needs, including affordable              continue to develop a system that
housing, adequate income, and health care.      encourages chronically homeless
Given those common needs, the task force        individuals to enter permanent housing and
divided the planning into four work groups:     access services. Service providers must
housing, health, economic stability, and        coordinate and communicate to avoid
syste ms coordination.
                                                duplication and utilize resources effectively.

                 Housing                        The four work groups were comprised of
A variety of housing options that ensure        key individuals from across the city and
long-term stability must be available to and    were charged with creating a set of
affordable for, chronically homeless            recommended goals. To create such a plan
persons. Permanent supportive housing is        requires commitment and ownership from
critical. But to move from chronic              those Task Force work group members as
homelessness, there must be adequate            well as from other stakeholders. The four
emergency and transitional housing options      work groups sought input from the
as well.                                        homeless, business, faith community, and
                                                service providers. They researched other
                  Health                        city’s plans and investigated best practices.
Individuals who experience chronic              They assessed current and past efforts in
homelessness need access to a range of          Nashville to impact chronic homelessness.
comprehensive services that respond to          And finally, they agreed to a finite set of
their complex and multiple health and           recommended goals for the ten-year plan.
behavioral health care needs. Homeless
individuals who meet HUD’s definition of
chronically homeless may need services
such as mental health case management or
drug treatment in order to remain in stable      By focusing on the chronically homeless,
housing and maintain employment.                  population and working to end chronic
                                                homelessness all the homeless populations
                                                            are better served.
           Economic Stability
Most individuals who become homeless
are eligible for assistance from public
and private systems of care, including
benefits that can assure steady
incomes, these systems are fraught with
obstacles that impede access.

Introduction: National Perspective on Homelessness

  Who Experiences Homelessness?
According to the National Alliance to End
Homelessness, over the course of a year,
as many 3.5 million individuals or nearly
11% of the poor population become
homeless. “A Status Report on Hunger and            Recent studies in New York and
Homelessness in America’s Cities 2002”, a                    Philadelphia
25-city survey published by the U.S.
Conference of Mayors documented a 19%              Studies in New York and Philadelphia
increase in homelessness, the steepest rise     identified three patterns of homelessness:
in a decade.                                        chronic, episodic, and transitional.
                   Age                          Transitional Homelessness describes a
The 2003 U.S. Conference of Mayors’              single episode of homelessness that is
survey of hunger and homelessness in 25        relatively short and often occurs in times of
cities found that families with children           economic hardship and/or temporary
accounted for 40% of the homeless               housing loss. The majority of individuals
population.      It  also   found    that       who fit into this category are families and
unaccompanied minors constitute 5% of the                       single adults.
urban homeless population.
                                                   Episodic Homelessness refers to
                                                   recurrent periods of homelessness.
         Gender and Ethnicity                   Typically individuals who experience this
Most studies show that single homeless          are younger and use the shelter system,
adults are more likely to be male than            and often have substance addictions.
female. In the 2003 U.S. Conference of          Research indicates that 9 percent of the
Mayor’s survey, single men accounted for         single adult homeless population fit the
41% of the urban homeless population while          pattern of episodic homelessness.
single women accounted for 14%.
                                                   Chronic Homelessness refers to an
Like the total U.S. population, the ethnic       extended episode generally lasting two or
makeup of homeless populations varies by           more years. Homeless persons in this
geographic location. In its 2003 survey, the    category are more likely to have a serious
U.S. Conference of Mayors found that the          mental illness, sometimes along with a
homeless population in the 25 cities            substance addiction, unstable employment
surveyed was 49% African-American, 35%         histories, and histories of hospitalization and
Caucasian, 13% Hispanic, 2% Native                            or incarceration.
American and 1% Asian.

Introduction: Local Perspective on Homelessness

           Count of Homeless
On March 24, 2004, volunteers in Nashville
helped to identify 447 individuals sleeping              Conditions of the Homeless
outside. On that night, shelter providers         When describing the conditions of chronic
throughout the city provided a count of           homelessness, it’s important to understand
1,358 individuals residing in their facilities.   that some of this population will periodically,
Together, a total of 1,805 individuals were       or even frequently, stay in shelters, while
counted as homeless during this point-in-         others will often live outdoors. Of the
time survey.                                      sheltered single homeless population
                                                  counted on March 24, there is a
Surveying all homeless persons at a point in      prevalence of chronicity, substance abuse
time is inherently limited by:                    and mental illness.      In the professional
  o The transient nature of homelessness          estimates of shelter providers responding to
  o The change in camp locations                  MDHA’s point-in-time survey, 42% of the
  o Incomplete numbers due to cheap motel         homeless single persons sheltered that
    rental by multiple homeless persons           night met the HUD definition of “chronic”.
  o Homeless families in cars moving
    further out of the central service area       All of the shelter programs serving single
  o The expansive geographic area of              individuals indicated that 55% or more of
    Davidson County as a count area               their residents had substance abuse issues.
                                                  Of the 13 programs, 11 estimated the
                                                  incidence to be 74% or higher and 6 out of
          Gender and Ethnicity                    the 13 programs said that 100% of their
In the March 2004 count, the majority of          residents are dealing with these issues.
individuals sleeping outdoors were males.         Estimates of single persons sheltered that
Although it was not always possible for           evening who suffer from mental illness
volunteers to ascertain gender, 68% of the        averaged 37%.
unsheltered population was estimated to be
male.                                             The pervasiveness of addiction and mental
                                                  illness was not only unique to the shelters
As in national data, individuals of color were    serving single homeless individuals, but was
over-represented among the homeless in            also noted in shelters serving women and
both the outdoor count and the count of           children. In shelters serving single women
homeless individuals residing in shelter          and families with children, estimates of
programs. At least 38% of the individuals         persons who suffer from mental illness
sleeping outdoors were confirmed to be            averaged 27%. In these family shelter
African American. 50% of the homeless             programs, an average of 51% of the
individuals in shelters were African              residents were estimated to have substance
American. Data from the 2000 Census               abuse problems.
reports the percentage of African American
in Nashville-Davidson County to be 25.9%.         Of the 1,358 persons counted in "shelter"
                                                  programs, 296 fell into the “family/ children”
                                                  heading which is not quite 22% of the total.

Nashville’s Perspective

         What’s In Place Now?                                 Outreach Services
Over the past 20 years much has been and         Outreach workers canvass areas known to
continues to be done to address the              be frequented by homeless persons as well
housing and service needs of homeless            as area shelters and feeding programs.
individuals. As a result of public and private   Outreach services are provided through
funds and the commitment of hundreds of          local agencies including:
generous volunteers, the spectrum of                Metropolitan Health Department
homeless programs is broader. In spite of           Metropolitan Development and
these efforts, there are still chronically             Housing Agency
homeless persons.                                   Mental Health Cooperative
                                                    Operation Stand Down
    Shelter Beds and Transitional                   Oasis Center
              Housing                               Nashville CARES
Emergency shelter beds in Nashville for
homeless families, youth and single women                   Supportive Services
currently number 230. Current available          Services available to homeless individuals
shelter beds for single adult males total        in Nashville include emergency services,
approximately 912. Bed availability for all      feeding     programs,     assessment      and
homeless individuals is reduced each spring      treatment for mental health issues, alcohol
due to the seasonal nature of the Room in        and drug addictions, case management,
the Inn program which shelters up to 200         health     care,    employment      services,
homeless individuals each night at area          educational      services,    child      care,
congregations and is closed mid-April to         transportation, information and referral, and
mid-November. Nashville’s stock of longer-       financial assistance.
term transitional housing is scarcer: 251
units of transitional housing exist for              Peter B. is a 58-year-old who suffers from
homeless individuals, and 130 units for             severe mental illness. Peter comes to the
homeless families.                                      Lodge for shelter and food and is often
                                                   delusional and off his medicine. Because of
          Permanent Housing                       insurance limitations, Peter is denied inpatient
Nashville currently has an inventory of 807      psychiatric treatment. Without his medicine, he
permanent housing opportunities that are          will not seek outpatient treatment. Not a great
                                                     deal is k nown about Peter because of his
targeted for homeless individuals. 56 units
                                                      inability to articulate his history with any
are under development.                              cohesiveness. He believes he is a country
                                                 music star. He sings and plays the guitar poorly.
          Prevention Services                     He says he has a house somewhere in a rural
Efforts to prevent homelessness focus            Tennessee town that he can’t stay in because it
primarily on financial assistance to pay rent    bothers him to be confined. He owns an old car
and utility arrearages. Several agencies         that he drove to Nas hville. According to him, he
offer this form of assistance to individuals     has work ed all his life and now a lawyer handles
                                                   his financial affairs. He can’t understand this
and families facing imminent threat of
                                                     and in telling about it often reacts in angry
homelessness. Key players include Metro
                                                 outbursts. It is not k nown if he has family or has
Social Services, Metro Action Commission         ever been married, but it doesn’t appear he has
and the Campus for Human Development.             anyone to care for him. He is a lost and lonely
Area churches, Big Brothers and Ladies of        man who appears physically as well as mentally
Charity also contribute to this prevention        sick er with each visit. He has been coming to
effort.                                                the Lodge, on and off, for about a year.

Nashville’s Perspective: Past Planning Efforts
This strategic framework for addressing chronic homelessness builds on a long history of
planning for the homeless in Nashville. Since 1984, several plans or studies have been
conducted on issues related to homelessness.
                                                   1998 The Metropolitan Health
1984 Council of Community Services                 Department’s Voice of the Homeless
  o Broad based effort                             Survey
 o Creation of Nashville Coalition for the         o Surveyed 630 homeless persons at 20
   Homeless                                          sites over a two month period of time
 o Resulted in the creation of the Downtown        o Found that 60% of those surveyed had
   Clinic which was funded by Robert Wood            lived in Nashville before becoming
   Johnson and Pew Memorial Trust                    homeless
                                                   o Found that 60% reported being first time
1986 MDHA’s Task Force on                            homeless
Homelessness                                       o Demonstrated that only a small
 o Detailed the demographics of the                  percentage of those surveyed received
   homeless population                               mainstream benefits
 o Recommendation made resulting in
   creation of the Guest House and the            2001 Downtown Homeless Outreach
   Campus for Human Development                   Initiative Report to the Inter-
 o Encouraged Metro to adopt a policy             Departmental Task Force on the
   statement taking responsibility for the        Homeless
   homeless in Nashville                           o Included outreach efforts focused on
 o Recognized the need for more affordable           downtown Nashville
   housing and for a central database of           o Focused on the chronically homeless
   homeless population                               population
                                                   o Attempted to formally liaison with the
1986 and 1987 The Nashville Coalition                downtown business community
for the Homeless and Center City
Committee “Plan for Nashville”                    2002 The Metropolitan Health
 o Addressed issues of housing, mental            Department Needs Assessment
   illness, substance abuse, employment and        o Recognized many of the same needs
   loss of community among the homeless              identified in 1986
 o Defined homeless sub-populations               2003 The Providers Survey
 o Recognized the need for additional              o Suggested the reestablishment of the
   outreach and case management, for                 Nashville Coalition for the Homeless
   affordable housing, for improved access to      o Recommended creating 100 new
   mainstream services (SSI) and for                 permanent housing units for homeless
   services for developmentally disabled             individuals
   homeless persons                                o Recommended increasing the shelter
                                                     beds for families with older children
1989 Task Force on Affordable Housing              o Recommend simplifying the enrollment
 o Set goal to reduce Nashville’s affordable         process for benefits such as SSI, food
   housing gap by 50% by 2000 and produce            stamps, and TennCare
   14,000 units of affordable housing              o Recommended quantifying the extent of
 o Recommended the creation of Affordable            homelessness in Nashville
   Housing Inc.
 o Recognized the need for increasing
   housing opportunities for special needs

Nashville’s Perspective: Past Planning Efforts

2003 Homeless Individuals in Nashville-           Root Causes of Homelessness in
Pinpointing Numbers and Needs in                       Nashville, Tennessee
Davidson County by Vanderbilt                  This extensive, but not exhaustive, list of factors must
University                                     be considered when dealing with the chronically
 o Recommended a focused coordinated           homeless.
                                               Lack of Affordable Housing Nashville’s housing
   strategic plan to be implemented
                                               market does not provide enough units affordable to
 o Recommended the development of a            those on disability, Temporary Assistance for Needy
   technology based tracking system to store   Families or who work minimum wage jobs.
   critical information                        Physical Disability Profound injuries, illness, or birth
 o Recommended the creation of a common        defects. Socially debilitating physical traits such as
   intake form for all services to the         disfigurement, dental deficiencies, or obesity.
   homeless                                    Mental Illness Schizophrenia, bipolar disorder,
                                               chronic depression and other severe and persistent
                                               mental illnesses.
                                               Developmental Disabilities Low IQ or head injury
     All these efforts had their merit in      that hinder intellectual functioning.
informing the city, creating segments of       Severe Trauma A history of domestic violence,
                                               abuse, combat, catastrophic loss of family, or a
  needed infrastructure and improving
                                               similar traumatic event.
 pockets of services. In looking back at       Educational Deficiencies The inability to read/write,
 all this work, it is evident that to have a   the lack of basic academic skills or no high school
 significant impact, a clear focus has to      diploma.
   be determined, the vision has to be         Learning Disabilities Dyslexia, ADD and other
                                               disorders which interfere with educational and life
       longer than 3-5 years, and the          functioning.
     commitment to the plan has to be          Addiction Drugs, alcohol, sex, gambling and other
expanded to include the entire city. The       addictions.
    work done dating back to 1984 has          Domestic Violence partner abuse forces victims out
                                               of their homes and into shelters or on the streets.
 brought Nashville to this point where a
                                               Severe Family Dysfunction Abusive parents, broken
 unified coordinated 10-year plan is the       homes, multiple residences/caregivers.
             logical next move.                No Family or Significant Support System Total lack
                                               of family support due to death, alienation, or
                                               institutional childhood.
                                               Criminal History The existence of a criminal record
                                               that seriously limits opportunity.
                                               Limited Occupational Skill Set The inability to do
                                               anything beyond the most basic manual labor.
                                               Life Skill Deficienc y The inability to manage the
                                               most basic life functions such as hygiene, housing,
                                               transportation, finances, and relationships.
                                               Transportation Deficiencies The inability to
                                               purchase, maintain, insure, or legally drive a car or
                                               obtain transportation through public or private means.
                                               Prior Long Term Institutionalization An extended
                                               stay in juvenile institutions, mental hospitals, prison or
                                               other institution.
                                               Generational Poverty Two or more generations
                                               dependent on public assistance or charity for basic
                                               living needs that has fostered an attitude of
                                                          Nashville Coalition for the Homeless
                                                                    PO Box 280988
                                                                  Nashville, TN 37208
                                                                 615-242-1070 ext 640
                                                    *Based on document from Campus for Human

                  Mayor’s Task Force to End Chronic Homelessness
                                Strategic Framework

Our vision: Within 10 years, Nashville will be a community without chronic homelessness by
assuring access to safe, affordable and permanent housing with a comprehensive array of
supportive services.
                                      Guiding Principles

1.       Permanent Supportive Housing is            5.      Community Ownership is
a priority – individuals moving into housing        understanding that homelessness impacts
as quickly as possible                              the whole community – every individual,
                                                    agency, and business – particularly those
                                                    operating in the central city. Solutions to
2.       Continuum of Supportive                    end homelessness can and must be found
Services including health, mental health,           in every public and private sector entity.
substance abuse, outreach and other
services are available, tailored to meet an         6.       Voice and Choice of homeless
individual’s need and recognize a person’s          individuals is a must, both in their individual
ability to change. Services are essential to        circumstances and in the systems that
achieving long-term housing stability.              affect them.

                                                    7.       Results-Driven must be imbedded
3.      Systems Coordination and                    in all our services, programs, and
collaboration between public and private            endeavors. Success must be clearly defined
sector service providers is critical and            and measured. Only services proven
necessary for long-term success.                    effective will be funded.

                                                    8.      Prevention, funded, coordinated,
4.     Self Sufficiency includes access to          and well functioning systems of housing
income assistance (SSI, SSDI,) and/or               with social and economic supports for
employment opportunities and is the best            individuals at risk of homelessness is the
way to assure individuals ability to maintain       only lasting and cost-effective solutions to
housing and live independently.                     chronic homelessness.

In creating a set of recommendations, work groups focused on a standardized series of tasks.
These tasks included defining key terms and identifying the relevance of the work group area to
the guiding principals. Additional research was conducted on the current status of the work
group topic in Nashville, existing gaps and barriers, and best practices implemented in other
cities. Taking all this into consideration, each work group identified a set of recommendations.
The findings and recommendations of the work group efforts are reflected in the following
sections of this framework, Housing, Health, Economic Stability, and Systems Coordination.

“Everyone has the right to a standard of living adequate for the health and well -being of
    themselves and their family, including food, clothing, housing, medical care and
  necessary social services.” Universal Declaration of Human Rights, United Nations

Strategic Framework: Housing

                                                             Gaps and Barriers
Homelessness is linked to a shortage of        Addressing barriers to developing housing
housing for individuals and families with      will be essential to the successful expansion
very low incomes. The vast majority of         of affordable housing for homeless
individuals experiencing homelessness          individuals. Barriers include:
have incomes that fall far below the typical
threshold calculated for most affordable        Harsh attitudes toward homeless
housing. Monthly rents of $0 to $160 are the       individuals from the larger Nashville
maximum that can be paid by most                   community
homeless individuals. Nashville's housing         The "Not in my back yard" syndrome
sector for homeless individuals has                makes it difficult to locate housing for
experienced minimal development in the             homeless and chronically homeless
past two decades.                                  individuals
                                                  The will to create structures and systems
                                                   that support housing development for
                                                   homeless individuals has been limited in
                                                   Nashville to this point
                                                  Land use policy and zoning restrictions
                                                   have created costly obstacles
            Key Definitions                       Hopelessness (chronically homeless
                                                   individuals often are early in the "stages of
Affordable housing is the term used to             change" process, which means that
describe housing opportunities that are            motivation for life-change can be low)
                                                  Chronically homeless individuals are
available to households earning 80% or less
                                                   resistant to the current systems of care; at
of median family income that do not cost
                                                   the same time, systems of care have not
more than 30% of gross monthly income.
                                                   found successful engagement methods
                                                  Requirements of current housing and
Permanent Supportive Housing (PSH) is
                                                   shelters do not accommodate chronically
the term used to describe permanent,               homeless individuals who are "treatment
affordable housing linked to health, mental        resistant" or in early stages of change
health, employment and other support               (i.e., rules and regulations and program
services.                                          expectations)
                                                  Resources needed for very low income
                                                   housing development have been
                                                   extremely limited

Strategic Framework: Housing

                   Best Practices
Permanent supportive housing (PSH) was                     The most comprehensive case for
implemented     in   the    early     1990's.              supportive housing is made by the
Demonstration studies showed that PSH                      University of Pennsylvania's Center for
was very successful at stabilizing tenants in              Mental Health Policy and Services
housing with retention rates at about 85%                  Research. Researchers tracked mentally ill
after two or more years. The following are                 individuals who were homeless in New York
common tenets of PSH programs:                             City for two years. Among their conclusions
                                                           was that supportive permanent housing
1. The housing is affordable for individuals               created an average annual savings of
with SSI income.                                           $16,282 per person by reducing the use of
2. The housing is permanent                                public services, including: 72% savings
(tenant/landlord laws apply, refusal to                    resulting from a decline in the use of public
participate in services is not grounds for                 health services; and 23% savings from a
eviction).                                                 decline in shelter use.
3. The housing is linked to a broad base of
support services.
4. The supportive services are flexible and
individualized, not program driven.
5. PSH is grounded in the principles of
integration of services, personal control,
accessibility, and autonomy.

  Chronic Homeless Production Chart
         Housing Activity              Need    Estim ated Cost                      Assum ptions
Development of new ly constructed
permanent supportiv e housing units      486         $19,440,000    1.      Need is based on March 2004 Homeless
Rehabilitation/Conversion activities                                2.      Chronic includes those found during the
yielding new permanent supportive        486         $14,580,000       2004 Count to either be unsheltered or in a
housing units                                                          homeless facility and identified by the provider
                                                                       as chronically homeless
Rental assistance/subsidies              972          $5,832,000    3.      New construction cost is based on $40,000
                                                                       per unit
                                                                    4.      Rehab/Conversion cost is based on
                                                                       $30,000 per unit
                                               TOTAL $39,852,000    5.      Rental assistance cost is based on $6000
                                                                       per individual

  Non-Chronic Homeless Production Chart
         Housing Activity              Need     Estim ated Cost                       Assum ptions
Development of new ly constructed
permanent supportiv e housing units      397          $15,880,000   1.      Need is based on March 2004 Homeless
Rehabilitation/Conversion activities                                2.      Non-chronic includes those found during the
yielding new permanent supportive        397          $11,910,000      2004 count who do not meet the HUD definition
housing units                                                          of chronic homelessness
                                                                    3.      New construction cost is based on $40,000
Rental assistance/subsidies              794           $4,764,000      per unit
                                                                    4.      Rehab/Conversion cost is based on $30,000
                                                                       per unit
                                               TOTAL $32,554,000    5.      Rental assistance cost is based on $6000
                                                                       per individual

Strategic Framework: Housing

1.      Develop Permanent Supportive                2. Identify All Existing Funding Sources
Housing       (PSH)     Opportunities    for        while developing new funding initiatives to
Homeless Individuals and Families. PSH              finance the permanent supportive housing.
is housing made affordable to homeless               When considering financing for permanent
individuals that has links to health, mental        supportive housing, three distinct costs must
health, employment and other social                 be kept in mind: funds for housing
services. By providing homeless individuals         development (rehab and new construction),
with a way out of expensive emergency               funds for rental subsidies (ongoing), and funds
public services and back into their own             for support services (ongoing).
homes, PSH not only improves the lives of
                                                    Funding Opportunities to explore:
its residents but also generates significant
                                                      Property transfer tax for housing
public savings. Currently Nashville has an             development (THDA -HOUSE Program)
affordable housing inventory of 807 housing           Support from THDA to develop an
opportunities    targeted    to    homeless            innovative pilot housing project that could be
individuals.                                           used as a state model or "best practice" of
                                                       homeless housing
PSH development includes the following                Local housing trust fund with a recurring,
features:                                              dedicated funding source
  Successful housing options for the homeless        Tennessee's federal HOME dollars for
   population must include a variety of options        Community Housing Development
   to promote choice and "goodness of fit"             Organizations specifically developing
  Adequate development along the housing              housing for homeless population
   continuum includes a combination of                HUD 811, 202, 221 (d) and 236 housing
   scattered-site (single units, duplexes, etc.),      development programs
   modular, congregate living and single room         Community Development Block Grant
   occupancy units                                     (CDBG) and HOME allocations to the
  Development can be accomplished through             Nashville area
   construction, renovation, or master leasing        HOPWA, Ryan White, and SAMHSA federal
   of existing housing stock                           funding
  Low-density, de-concentrat ed sites are            THDA low income housing tax credits
   preferred. The Housing Work Group defines           (LIHTC) and bond financing programs
   low density as fewer than 20 units per             Federal Home Loan Bank of Cincinnati and
   development. As the density of housing              Atlanta under the Affordable Housing
   increases (up to 20 units), supportive              Program
   services will need to increase in proportion.      Local allocation for low-income housing
  PSH must have access to public                      development
   transportation, and be located within walking      HUD Continuum funding
   distance of essential services and amenities       Instate local development fee for housing
   (food, laundry facilities, bus routes, etc.)        development
  Establishment of community as peer support         Development financing through the
   is linked to long-t erm housing stability           Nashville Housing Fund as well as local and
  Ongoing assessment and evaluation of                regional banks
   adequate housing development for                   Faith-based community initiatives and
   homeless persons will be conducted utilizing        investments
   annual counts and other monitoring efforts

Strategic Framework: Housing

3) Establish leadership committee to               6) Apply to the Nashville Civic Design
secure lead private gifts for housing             Center for consultation on housing
development. This initiative will be              design that can meet homeless resident
directed by leaders in the public and private     and neighborhood needs.
sectors. This fund could be administered
within an existing nonprofit (i.e., The United    7) Establish an emergency fund for the
Way or The Community Foundation of                purpose of preventing chronic homeless
Middle Tennessee). The faith community,           individuals and families from relapsing
business community, foundations,                  into homelessness after they move into
corporations and individuals will be              permanent housing.
educated on this philanthropic opportunity.       These interventions would be limited to
Philanthropic gifts would be focused on the       chronically homeless individuals who are
one-time expense of housing development.          already in the coordinated system of care
                                                  developed for support services.
4) Develop a community education                  Interventions could include supportive
initiative regarding homelessness in              services, rental assistance, homemaker
Nashville. The Housing Committee                  services, addiction and mental health
identified public attitude as a primary barrier   treatment. Keeping people in housing is
to housing development. Community                 easer and less costly than reestablishing
education on the permanent supportive             them in housing.
housing model will be essential to
successful implementation. A broad
                                                  8) Train service providers on the
community education campaign should be
                                                  permanent supportive housing model.
initiated early in the housing development
                                                  Permanent Supportive Housing is a new
phase. To effectively penetrate
                                                  concept for many Nashville service
discrimination, this education campaign will
                                                  providers. Training will be needed at the
include; the root causes of homelessness,
                                                  local level to assist providers with
extent of homelessness, human and public
                                                  implementation and management skills
cost of homelessness and cost
                                                  necessary to develop this new service
effectiveness of best practice interventions.
                                                  approach. The training needs to include:
                                                  stages of change, motivational interviewing,
5) Address discrimination against                 harm reduction intervention models, low
homeless individuals, which violates              demand housing operations and
human rights and dignity. If Nashville is         management.
to be “One City All People” and housing
opportunities are to be developed,
discrimination issues must be addressed.
We recommend that the Metro Human
Relations Commission address homeless
discrimination issues including the
criminalization of homelessness.

Strategic Framework: Health and Behavioral Health Care

Homeless persons have all the same                                 Profile of Health Care Needs of
physical and behavioral health problems as                         Homeless Persons in Nashville
individuals with homes, but at greatly                        Metro Public Health Department analyzed
elevated rates, with multiple diagnoses and                   calendar year 2003 encounter data from its
disabling conditions being common. By                         Downtown Clinic for the Homeless and
“health” this report refers to the full complex               encounter data for homeless persons
of physical health, mental health and                         served by Bridges to Care, a program that
substance abuse problems. Homelessness                        links uninsured persons in Nashville to
inevitably causes or worsens serious health                   safety net providers and hospitals. While
problems.                                                     not representative of all, these data provide
 Undetected and untreated                                    information about the health care needs of a
    communicable diseases including                           substantial portion of the homeless. As the
    HIV/AIDS and tuberculosis threaten the                    table below shows, these homeless persons
    health of other homeless individuals in                   averaged 4 health care encounters per year
    particular and of the public in general.                  and behavioral health problems (substance
 Trauma resulting from violence and                          abuse and mental health) were among the
    conditions caused by exposure to the                      top diagnostic groups. Dental problems
    elements are also common among                            were also prevalent.
    homeless individuals.
 Twenty-five percent (25%) of homeless
    persons have some form of physical
    disability or disabling health condition.
 Approximately 20% of homeless
    persons have a serious mental illness.
 At least 40% have substance use
    disorders (Blueprint for Change, DHHS
    Pub. No. SMA-04-3870 2003).

                                 Homeless Patients -- Calendar Year 2003
                                         Downtown Clinic                                       Bridges to Care
Av. # Visits/Person     4.1                                                 3.9
Gender                  Males = 83%                                         Males = 66%
                        Females = 17%                                       Females = 33%
Race                    Black = 54%                                         Black = 45%
                        White = 41%                                         White = 54%
                        Other = 5%                                          Other = 1%
Age                     18 – 34 (24%) 45 – 54 (31%) 65 and > (2%)           18 – 34 (26%) 45 – 54 (30%) 65 and > (0%)
                        35 – 44 (36%) 55 – 64 (7%)                          35 – 44 (36%) 55 – 64 (7%)
Top Ten Diagnostic      Substance abuse = 23%                               Substance abuse = 12%
Groups (ICD- 9          Mental illness & mental health screening = 16%      Mental illness & mental health screening = 10%
Codes) based on         Physical Health Conditions = 34.5%                  Physical Health Conditions = 27.5%
primary diagnosis (1)             Dental = 15%                                         Dental = 7.5%
                                  H ypertension = 8%                                   H ypertension = 5%
                                  Respiratory infection = 4%                           Respiratory infection = 3%
                                  Diabetes = 3%                                        Diabetes = 4%
                                  COPD = 2.5%                                          COPD = 2%
                                  Injury = 2%                                          Injury = 6%
(1) This is the primary problem for which the patient was treated during the visit and therefore does not represent all
    possible health and behavioral health conditions a person may have at the time.

Strategic Framework: Health and Behavioral Health Care

The harsh reality is that homeless persons           Gaps in the Service System and
are often faced with co-occurring or multiple                Barriers to Care
health and behavioral health problems that        Although there are multiple providers of
increase the difficulty of overcoming their       health and behavioral health care in the
homelessness. Homelessness is prolonged           community who have served the homeless
for persons who cannot stabilize and              population for many years, there continue to
manage their health conditions and who are        be barriers to care and significant gaps in
consequently less likely to maintain their        the existing health care delivery systems in
housing or job.       Moreover, health care       Davidson County. There are several key
services are markedly less effective when         factors that prohibit or limit homeless
delivered to persons without the basic            persons from receiving proper health care.
protections afforded by a home (protection
from the elements, sanitary conditions,           1. Housing shortage. Housing is health
opportunity to rest, refrigeration for food and   care. Many of the health problems of
medicines): housing is health care.               homeless individuals relate directly to their
                                                  lack of housing.
        Current Service System                    2. Lack of access to health insurance
The current homeless service system in            and health and behavioral health care.
Davidson County is comprised of a variety         Homeless individuals often are uninsured
of organizations that provide some type of        and therefore lack access to comprehensive
health or behavioral health care or service       health care. Often they go without care until
to homeless persons. The types of entities        relatively    minor       problems     become
include:                                          expensive medical emergencies.
  Entities whose sole purpose is to serve        3.      Lengthy disability determination
   the homeless population (e.g., homeless        process. The length of time for a person to
   shelters and the Downtown Clinic)              complete the eligibility process for
  Entities that offer a range of services but    Supplemental Security Income (SSI) or
   have a component of their service that is      Social Security Disability Insurance (SSDI)
   targeted to the homeless population (e.g.,     is a major barrier to the receipt of benefits,
   a homeless outreach service of a               which include health insurance and monthly
   community mental health provider)
                                                  income.      Regrettably,      persons    with
  Entities that do not target the homeless       substance abuse disorders are often not
   population but due to the nature of their
                                                  eligible under current federal law. However,
   service provide care to homeless persons       many homeless persons appear to be
   (e.g., hospitals, emergency rooms, safety
                                                  eligible but are not receiving disability
   net medical clinics, community mental
   health centers, substance abuse                benefits which could help resolve their
   providers, community social service            homelessness.
   agencies). Emergency rooms in particular       4.      Fragmented, uncoordinated and
   are the most expensive level of care but       unorganized system of care. Persons
   are frequently utilized inappropriately by     trying to access needed services often face
   homeless and other uninsured persons.          a service system that is not organized
  Entities that provide a public service and     effectively or efficiently. They consequently
   in the course of their work must respond       have difficulty knowing what “mainstream”
   to the needs of the homeless population        or “homeless-specific” services and benefits
   (e.g. EMTs-Fire Department).                   are available, or how to navigate the system
                                                  in order to access services.

5. Lack of single point of accountability         11. Lack of knowledge regarding needs
for homeless persons with mental                  of homeless persons suffering from
illnesses. Fragmentation and lack of clear        mental         retardation        or     other
responsibility within the service delivery        developmental disabilities. There is little
system inhibits service providers from            available data on the incidence rate of
providing optimal care.                           homeless       persons      suffering   mental
6. Lack of Needed Services. Certain               retardation      or    other     developmental
services are not available to meet the            disabilities, though service providers
current needs of homeless and other poor          frequently observe these conditions.
persons (e.g., detoxification, dental care,       Therefore little is known about this
respite care after discharge from a hospital,     population and their service needs.
specialty health care, substance abuse            12. Criminalization of behavior related to
treatment).                                       a mental health or substance abuse
7.    Lack of services that allow for             disorder.       Criminal sanctions including
relapse. The nature of mental illness and         incarceration are ineffective responses that
substance abuse disorders is that                 do not comprehend or help to resolve the
individuals will relapse. Zero tolerance          underlying health problems.
policies in some current treatment and            13. Stigma. Homeless persons, persons
housing programs reflect the lack of              with a mental illness and persons with a
understanding of these disorders.                 substance abuse disorder are often
8. Lack of access to services that                stereotyped, viewed inaccurately by the
incorporate an understanding of dual              public, in print or other media. Stigma often
diagnosis and co-occurring conditions.            leads to barriers in assuring the availability
The multiple diagnoses of many homeless           of and access to services, or unfair
persons (involving physical, mental and           discrimination or practices.
addiction disorders) require sophisticated        14.      Funding, funding, and funding.
care that does not focus on one condition of      There is a need for additional funding to
an individual separately from other               support the development or enhancement of
conditions.                                       needed services.
9. Limited outreach and engagement
between the service system and
homeless persons. The service system is
not always responsive to the needs of the
homeless persons and the homeless
persons are not always ready to receive
services. Additionally, outreach efforts of the
system are poorly coordinated.
10. The nature of certain illnesses keeps
some persons from accessing or
maintaining contact with services. So-
called “treatment avoidance” is often
symptomatic of addictions and mental
illnesses, and is aggravated for many
homeless persons by prior bad experiences
within the treatment system.

Strategic Framework: Health and Behavioral Health Care

     Elements of an Effective and              10. Expedited assessment and eligibility
         Responsive System                     determinations for mainstream benefits,
Key elements of an effective and responsive    especially disability and health insurance
health and behavioral health care system       benefits. Benefits assistance services
that will help homeless persons get well and   include education, assessment, application
move out of homelessness include:              assistance,           documentation/records
                                               procurement, and advocacy.
1.      Mechanisms that facilitate a
coordinated and integrated service                            Key Definitions
delivery system. Persons who are               Outreach Services – An array of therapeutic
homeless have complex problems that            services delivered directly to the individual
require comprehensive services that are        outside of traditional service delivery locations,
well coordinated.                              as well as connecting individuals to existing
2. Aggressive outreach. Outreach is now        service providers. It typically focuses on those
                                               persons who are not aware of vital services or
considered the first and most important step   who are prevented by a variety of factors from
in providing access for homeless individuals   accessing services.
to needed mental health, substance abuse       Assertive Community Treatment – A service
and social services, and to housing            delivery model that provides comprehensive,
(Blueprint for Change, DHHS Pub. No.           community based treatment to individuals with
SMA-04-3870 2003).                             serious and persistent mental illness. It is a
3. Engagement is essential to develop the      multidisciplinary team of staff that provid es crisis
trust, the rapport and the relationship        intervention, medication monitoring, case
needed to help individuals accept more         management, rehabilitation, substance abuse
                                               treatment and support to those who are the
long-term services, the ultimate goal of
                                               most seriously ill who require this intensive level
outreach efforts. (Interagency Council on      of care. The team is accessible 24 hours a day,
the Homeless, 1991; McMurray-Avila,            7 days a week and delivers services in the
1997).                                         community and not in the office. Case loads are
4. Assertive Community Treatment. ACT          small and usually do not exceed more than a
provides a full range of community- based      ratio of 1:10. The ACT model has proven
integrated services to persons 24 hours per    effective for certain populations including those
day, 7 days a week.                            individuals who are homeless and who have a
5. Treatment services for persons with co-     serious mental illness.
occurring disorders and multiple health        Primary Health Care – The "medical home" for
conditions.                                    a patient, ideally providing continuity and
                                               integration of health care. All family physicians
6. Prevention strategies. Health services
                                               and most pediatricians and internists are in
that address the known risk factors for        primary care. The aim of primary care is to
homelessness.                                  provide the patient with a broad spectrum of
7.      Easy and quick access to               care, both preventive and curative, over a period
detoxification services                        of time and to coordinate all of the care the
8. Service principles and values that          patient receives.
respect consumer’s voice and right to          Specialty Health Care – Refers to medical
self-determination and actively involve        services provided by physicians upon referral by
consumers in service planning and              a primary care physician. Examples would
                                               include orthopedics, dermatology, cardiology,
provision of service.
                                               neurology, gastroenterology, gynecology, etc
9.      Low-demand approach.             The
recognition that participation in treatment
and receipt of services should not be
required in order to gain access to housing.

Strategic Framework: Health and Behavioral Health Care

Each year, many individuals in Nashville are   2. Conduct a comprehensive assessment
homeless and are in desperate need of          of health care system capacity and need,
health care, behavioral health care and        to indicate additional areas for expansion or
social services. In order to achieve the       rescission.    Assessment should include
overarching goal that untreated health         careful review of programs and service
conditions, illnesses and injuries will no     designs developed in other cities. The
longer cause or prolong homelessness in        requirements of such a study exceeded the
Nashville, the Health Work Group provides      resources available to the Work Group.
the following recommendations.
                                               3. Service        system characteristics.
1.   Establish new/expanded services.          Assure that existing health and behavioral
Complement existing health care services       health services for homeless persons
by adding the following capabilities:          incorporate the following characteristics:

  Permanent supportive housing, with            Involvement of consumers in service
   primary care, behavioral health care and       planning and delivery of services.
   case management services available on         Protection of confidential information
   site.                                          about homeless consumers and respect
  Aggressive outreach to assess need,            of their right of self-determination.
   engage and re-engage homeless                 Integration of treatment for co-occurring
   persons into systems of care; includes         mental health and substance abuse
   service-oriented outreach teams to             disorders.
   intervene in cases of disruptive behavior     Incorporation of relapse tolerance into
  Expedited enrollment procedures for            housing and service programs.
   SSI, SSDI, TennCare and other public          Provision of transportation to assure
   benefits                                       effective access to health and
  Single-agency responsibility for               behavioral health services not available
   homeless persons with mental illnesses         on site.
  Assertive Community Treatment teams           Evaluation of programs according to
   that provide on-going treatment and            outcomes.
   case management without time                  On-going community education
   limitations                                    regarding the needs of homeless
  24/7 alcohol and drug detoxification,          persons and available resources.
   screening and assessment                      Improved community partnerships to
  Increased residential substance abuse          promote an effective service delivery
   treatment for indigent and uninsured           system.
  Respite Care setting(s) for recuperation
   of persons without homes after hospital

Strategic Framework: Economic Stability

It is well documented that the chronically      Local employers lack uniform and
homeless, many of whom are mentally ill,        comprehensive information about available
often with co-occurring diseases, consume       tax credit and incentive programs for
inordinate levels of resources. Dennis          training and hiring marginalized populations.
Culhane’s University of Pennsylvania-
supported 2001 landmark study is often          Stigma, discrimination, and misperceptions
cited as the benchmark on the effects of        by the larger community about the
homelessness       and     service-enriched     chronically    homeless      will   impact
housing on mentally ill individual’s use of     implementation strategies without a strong
publicly funded services. While focusing on     top-down, long-term commitment by local
New York City data, it is representative of     government, the private sector and faith-
the impact of offering supported housing        based community leadership.
options    to a chronically       homeless
population.                                     Local homeless and specialized job training
                                                and employment-related activities are often
In general, once placed in supportive           population-specific and may include specific
housing, a homeless mentally ill person         funder requirements or dis-incentives to
reduced his or her use of publicly funded       working with a chronically homeless
services by 30%.          This reduction in     population.
utilization paid for 95% of the costs of
building, operating and providing services in                     Sample Initiative
supportive housing. The service reduction       Chrysalis was founded in 1984 to creat e and
resulted      in    fewer     and     shorter   locate employment opportunities to help
hospitalizations, reduced shelter use, and      homeless and ot her disadvantaged individuals
                                                become self-supporting.         The program has
reduced use of medical and mental health
                                                received numerous awards and recognition for
                                                successfully bringing private sector business
                                                models to a difficult social service issue. Initially
             Current Status                     a homeless employment day center, Chrysalis
Nashville currently offers a variety of low-    went on to develop and operate a temporary
income job training and employment              employment agency and multiple businesses
activities for which homeless individuals are   that serve as training and market wage
eligible. However, specific and effective       employment for homeless individuals. Their
outcome-based assessment, training, and         approach is to create and offer employment
                                                programs that foster individual initiative and
employment services for the chronically
                                                independence within an environment that is very
homeless are basically non-existent.            similar to privat e sector work. The intent is to
                                                instill a positive work ethic and good work habits
     Identified Gaps and Barriers               applicable to any employment setting. Chrysalis
Low income service providers offering job       promotes itself as preparing a motivated low-
training and employability programs have        income work force, wit h strong supervisory
not sufficiently engaged the business           oversight and post placement oversight.
community      in   effectively   developing    Chrysalis utilizes a “work first” philosophy that
outcome-based activities for difficult to       helps individuals maintain and upgrade
serve populations, especially the chronically   employment after finding a job.          Chrysalis
                                                acknowledges job retention as a primary
homeless willing and able to work.              problem and has instituted an enhanced case
                                                management system to improve retention.
                                                516 South Main Street, Los Angeles, CA 90013
                                                (310) 392-4117, Lesley Goldberg, VP of

Strategic Framework: Economic Stability

           Recommendations                         5. Nashville will aggressively seek new
1. Nashville will utilize an outcome               funding for job training and employment
based funding approach to be monitored             programs. This could include discretionary
at least annually for any continued                Workforce Development grants that target
homeless funding generated through                 homeless individuals through the federal
Metro government. Calls for proposals will         Department of Labor (Office of Disability
follow agreed upon criteria established by         Employment Policy, Employment and Training
open committees comprised of both service          Administration), as well as state administered
providers and other interested parties such as     programs     from    the     Department      of
the Chamber of Commerce and the                    Labor/Workforce        Development,        the
Downtown Partnership. An inability to meet         Department of Human Services, and the
performance targets could lead to de-              Department of Mental Health.
funding. All programs working with the             6. Nashville should obtain the services of
chronically homeless would be encouraged to        a    full  time   homeless      programs
develop milestones and performance target          development director to maximize resource
measurement structures regardless of the           development for the chronically homeless. (A
funding source.                                    Development Director could also explore new
2.   Nashville will develop a formal               or underutilized program options such as
“Income Maintenance – Training –                   Americorp or partnering with Metro Action
Employment Continuum.” The focus will              Commission to apply for discretionary CSBG
be to meet the needs of the homeless               funds.)
individual with accountability, as they are        7. Nashville should establish a pilot
ready and able to participate.                     project to facilitate access to basic local
3. Nashville will develop formal                   banking      services     for    homeless
Memorandums of Understanding with                  individuals such as free basic checking
key public service providers. Key                  accounts and debit cards as are provided to
providers will include the local Social Security   high school students.
Office, the State Office of Disability             8. Nashville will conduct an analysis of
Determination Services, the Department of          the public transportation barriers that
Human Services, the TennCare Bureau,               prevent homeless individuals from
Tennessee Department of Labor and others to        participating in job training programs or
ensure full early access by homeless               maintaining employment. The analysis
individuals to all publicly funded benefit and     done by Metropolitan Transit Authority will
service programs.                                  include the participation of service providers,
4. Nashville will develop at least one             homeless individuals, low-income employment
results-based chronically homeless job             and training agencies, major employers of
readiness/ training/ employment pilot              low-income individuals and other interested
project.   This project will involve the           parties.
Chamber      of    Commerce,      Metropolitan          Nashville does not have sufficient detailed
Development and Housing Agency, the                  demographics on the make-up of its chronically
                                                   homeless population. While we know it is primarily
Downtown Partnership, the Convention and
                                                        adult men, we do not know much about the
Visitors   Bureau,     Metropolitan    Transit       existence of families, the elderly, or the specific
Authority, Metro Action Commission, the             nature and frequency of disabilities. As such, this
Nashville Career Advancement Center, Metro         limits the community’s ability to effectively prioritize
Social Services, Park Center, Matthew 25,             new or targeted job training and employment
Goodwill Industries, and others.                         services for this population. It is critical to
                                                     understand where Nashville’s chronic homeless
                                                     population is along the “income maintenance –
                                                    employability continuum” before new services are

Strategic Framework: Systems Coordination

An array of distinct components is              The definition of discharge planning taken
necessary to construct an effective             from the Massachusetts Housing and
response     to     chronically  homeless       Shelter Alliance is “the process to prepare a
individuals. We must assure that the broad      person in an institution for return or re-entry
system of services and housing available to     into the community and linkage of the
homeless individuals is as seamless and         individual to needed community services
coordinated as possible. Among the many         and supports.”
and often complex issues under the
systems coordination umbrella, the Work
Group divided into subcommittees to focus
on three main topics:                                         Sample Initiative
                                                Via State General Funds, California
                Outreach                        operates programs in 24 counties and two
Nashville must have an engagement system        cities that provide integrated services to
that effectively encourages chronically         persons who are mentally ill and homeless,
homeless individuals to enter permanent         at risk of homelessness, and or at imminent
housing and access appropriate services.        risk of being incarcerated. Known as the
                                                “AB 2034” programs (2034 is the number
Webster Dictionary defines outreach “as an      of the Assembly Bill that authorized the
effort to build connections from one person     funding), they have demonstrated success
or group to another”. It is these connections   in breaking the cycle of chronic
that offer street homeless individuals the      homelessness for individuals with serious
opportunity to be linked with other segments    mental illnesses. The State gives broad
of the social service system, and ultimately,   discretion to the county contractors that
an end to their homelessness.                   administer the programs, but makes
                                                performance the basis for payment -- not
         Collect Accurate Data                  services provided. Higher payments are
                                                given to counties that show the greatest
Service providers must coordinate and           reduction in homelessness, incarceration,
communicate to assure no duplication and        etc.        (National  Alliance   to   End
utilize limited resources effectively.  A
comprehensive homeless management
information system (“HMIS”) will be a key
component of this systems framework.

   Coordinate Discharge Planning
We must work to prevent the discharge of
persons exiting publicly funded institutions
from     immediately        resulting      in

Strategic Framework: Systems Coordination- Outreach

  Lack of geographical coordination and          3. Provide Formal Training for Outreach
   information sharing between outreach           Workers that should be required of all
   providers                                      outreach workers including specifics on
  Current outreach system is ineffective at      local resources, building trust, how to
   reducing street homeless                       engage clients, understanding community
       o Not enough street outreach               resources, and worker safety.
       o Too much ineffective floating
         outreach                                 4. Develop a Community Court, where
  Lack of formal training provided to            alternative sentencing is used to prevent the
   outreach workers                               creation of a criminal record for many
  Constant cycling of chronically                homeless individuals in Nashville, and to
   homeless in and out of criminal justice        address the underlying causes that led them
   system                                         to homelessness. Community courts utilize
                                                  a non-traditional approach to working with
           Recommendations                        offenders, using sentencing alternatives and
1.     Create a Centralized Outreach              legal sanctions to promote rehabilitation and
Coordination Center (OCC) belonging to a          address the deeper issues of criminality.
single entity, (possibly Metro government)
should be designated, and charged to                             Sample Initiative
coordinate outreach efforts across various        At the community court in Austin, TX,
agencies in Nashville. With the full backing      when a defendant presents at the initial
of the city, housing providers, mental health     court hearing, it is first determined if they
agencies, substance abuse agencies and            are a candidate for treatment.         When
the Metropolitan Police Department the            treatment is deemed necessary, a referral is
OCC would be responsible for providing            made to the court’s clinical evaluator for
strategic direction of outreach efforts as well   assessment and recommendations. When
as defining objectives and goals for              mental illness and/or substance abuse are
reducing street homeless on an annual             identified as contributing factors to the
basis.                                            defendant’s criminal behavior, the court
                                                  then makes a referral to the resources that
2.    Create an Interdisciplinary Street          will best serve the defendant.            The
Outreach       Team     by    re-configuring/     defendant’s participation in treatment then
expanding existing outreach services into a       becomes part of their sentencing. For those
“dream team” including a city-wide                not needing formal treatment, the judge can
coordinator, social workers, a Nurse              craft rehabilitative sentencing to include a
Practitioner, a Licensed Alcohol and Drug         range of social services such as counseling,
counselor, a mental health professional and       work training, outpatient day treatment, etc.
a dedicated Metro Nashville police officer.       The referral to these social services is
The team would be housed at one location,         coordinated and followed-up by court-based
preferably the OCC and be directly                social workers.
accountable to its hiring agency. The team
would be flexible in terms of days/times out      .htm
on the street.

Strategic Framework: Systems Coordination - Data Collection

Nashville has a broad network of homeless
service providers that offer homeless                       Recommendations
services ranging from           outreach to       1. Implement the Homeless Management
permanent supportive housing. Among the           Information System (HMIS) currently
challenges faced by the city is how to collect    under development by the Metropolitan
comprehensive data on individuals who are         Health Department. Nashville needs a
homeless and served at many points in the         centralized system to gather information on
system. To paint an accurate picture of the       homeless services.
problem and evaluate efforts to address it,
we must coordinate all of these services in a     2.       Mandate that All City-Funded
way that promotes and rewards data                Homeless Programs Participate in HMIS.
collection and information sharing within         Currently, only those agencies assisted by
and between service providers.                    HUD’s Continuum of Care homeless
                                                  funding are required to participate in HMIS.
                                                  The Systems Coordination Work Group
A Homeless Management Information                 recommends        that   Nashville-Davidson
System (HMIS) provides a means of                 County broaden this mandate to include all
generating an unduplicated count of               city-funded programs that serve homeless
homeless individuals, as well as analyzing        individuals. Agencies that are privately
service use and the effectiveness of local        funded and those that receive no
systems at reducing homelessness. HUD             government funding must also be urged to
has been directed by Congress to work with        participate in HMIS, in order to glean
jurisdictions to gather homeless data across      optimal benefits.
the country. The standard features:

    • Provide an unduplicated count of            3.   Conduct Point-In-Time Count of
persons served                                    Homeless Individuals No Less than
    • Track data on individuals who enter         Every 2 Years. This will help the community
the homeless system, including                    monitor progress on outcomes related to
demographics, where they were prior to            reducing homelessness.
entry, what services they access while in
the system and how they exit the system
    • Track bed registry, incident
    • Facilitate case management across
agencies in a centralized manner through
the use of case management notes
    • Provide reports and data on
homelessness in Nashville, including the
number of chronically homeless
    •Require one entry of initial data into the
system so that both service providers and
homeless individuals save time that is now
wasted in intake processes at multiple

Strategic Framework: Systems Coordination - Coordinated Discharge Planning

            Gaps and Barriers
  Internal Policies or Practices of              3.     Establish criteria for exemplary
   Institutions Discharging Homeless              discharge     planning    practices for
  Institutions may deny or delay treatment       individuals who are homeless and those
   to chronically homeless No Institutional       who are at risk of being homeless
   Follow-Up      of   Implementation    of
   Discharge Plan                                 4. Assure pre-release assistance with
  Lack of Services for Homeless Without          enrollment and    public   assistance
   Diagnosed Disability                           programs
  No Services Available during the
  Lack of Available Housing

1.      Identify a comprehensive list of
discharge related staff at institutions and
facilities state-wide that serve a high
                                                               Sample Initiative
number of individuals who are homeless
and at risk of being homeless. Begin              The Massachusetts Housing and Shelter
                                                  Alliance (MHSA) developed Discharge
involving them in a planning process by
                                                  Planning Protocols in Massachusetts, a
having them complete the discharge
                                                  set of strategies that centers on the
planning survey, and use the results to
                                                  prevention of homelessness, especially for
assess and analyze the extent of the
                                                  those at risk of chronic homelessness.
                                                  MHSA documents the connection between
2.     Educate and coordinate with key            growing homelessness and discharge from
administrators and discharge personnel            public systems of care, to create resources,
from      hospitals,      mental       health,    and to develop a comprehensive strategy of
correctional, and residential treatment           homeless      prevention     that   assures
facilities in order to reduce rates of            successful discharge to the community.
recidivism       among      the     homeless      (Interagency Council on Homelessness)
population. Develop training curricula and
implement an on-going series of regional
training workshops and technical assistance
to institutions and facilities.        Specific
educational topics should include:           a)
homeless discharge planning protocols; b)
benefits facilitation and acquisition; c) data
collection and discharge review tools; d)
community resources and referral process;
e) cross-training and communication; f)
service planning and linkage; and g) client