Efficient targeting of homelessness prevention services for families.

OBJECTIVES: We developed and evaluated a model to target homelessness prevention services to families more efficiently. METHODS: We followed 11,105 families who applied for community-based services to prevent homelessness in New York City from October 1, 2004, to June 30, 2008, through administrative records, using Cox regression to predict shelter entry. RESULTS: Over 3 years, 12.8% of applicants entered shelter. Both the complete Cox regression and a short screening model based on 15 risk factors derived from it were superior to worker judgments, with substantially higher hit rates at the same level of false alarms. We found no evidence that some families were too risky to be helped or that specific risk factors were particularly amenable to amelioration. CONCLUSIONS: Despite some limitations, an empirical risk model can increase the efficiency of homelessness prevention services. Serving the same proportion of applicants but selecting those at highest risk according to the model would have increased correct targeting of families entering shelter by 26% and reduced misses by almost two thirds. Parallel models could be developed elsewhere.

The impact of shelter use and housing placement on mortality hazard for unaccompanied adults and adults in family households entering New York City shelters: 1990-2002.

This study examines mortality among New York City (NYC) homeless shelter users, assessing the relationships between mortality hazard and time in shelter, patterns of homelessness, and subsequent housing exits for both adults in families and single adults. Administrative records from the NYC shelter system were matched with death records from the Social Security Administration for 160,525 persons. Crude mortality rates and life tables were calculated, and survival analyses were undertaken using these data. Life expectancy was 64.2 and 68.6 years for single adult males and single adult females, respectively, and among adults in families, life expectancy was 67.2 and 70.1 years for males and females, respectively. For both groups, exits to stable housing (subsidized or non-subsidized) were associated with reduced mortality hazard. And while mortality hazard was substantially reduced for the time adults were in shelters, extended shelter use patterns were associated with increased mortality hazard. Differences between single homelessness and family homelessness extend to disparities in mortality rates. Although causal links cannot be established here, results suggest that, for both subgroups of the homeless population, prompt resolution of homelessness and availability of housing interventions may contribute to reduced mortality.

A population-based assessment of the health of homeless families in New York City, 2001-2003.

OBJECTIVES: We compared estimated population-based health outcomes for New York City (NYC) homeless families with NYC residents overall and in low-income neighborhoods. METHODS: We matched a NYC family shelter user registry to mortality, tuberculosis, HIV/AIDS, and blood lead test registries maintained by the NYC Department of Health and Mental Hygiene (2001-2003). RESULTS: Overall adult age-adjusted death rates were similar among the 3 populations. HIV/AIDS and substance-use deaths were 3 and 5 times higher for homeless adults than for the general population; only substance-use deaths were higher than for low-income adults. Children who experienced homelessness appeared to be at an elevated risk of mortality (41.3 vs 22.5 per 100,000; P < .05). Seven in 10 adult and child deaths occurred outside shelter. Adult HIV/AIDS diagnosis rates were more than twice citywide rates but comparable with low-income rates, whereas tuberculosis rates were 3 times higher than in both populations. Homeless children had lower blood lead testing rates and a higher proportion of lead levels over 10 micrograms per deciliter than did both comparison populations. CONCLUSIONS: Morbidity and mortality levels were comparable between homeless and low-income adults; homeless children's slightly higher risk on some measures possibly reflects the impact of poverty and poor-quality, unstable housing.

Health and social characteristics of homeless adults in Manhattan who were chronically or not chronically unsheltered.

OBJECTIVE: This study compared health and social characteristics of two groups of homeless adults in Manhattan--those who were chronically unsheltered and those who were not. METHODS: Outreach workers conducted brief, structured interviews with 1,093 unsheltered homeless adults. Respondents were later categorized as being chronically unsheltered on the basis of New York City criteria (sleeping without shelter at least nine of the previous 24 months). RESULTS: The sample had high rates of substance abuse (65%), serious medical issues (42%), and repeated trauma (51%) and low rates of medical insurance (47%) and income entitlements (26%) entitlements. Sixty-seven percent were chronically unsheltered, and these respondents had significantly higher rates on several measures, including military service, incarceration, and mental illness. CONCLUSIONS: The sick and aged nature of this population suggests that more aggressive efforts are needed to enroll unsheltered homeless people in income and health benefits and to create adequate housing opportunities with appropriate support services.

The use of data to assist in the design of a new service system for homeless veterans in New York City.

OBJECTIVE: Operation Home is an agreement between the City of New York and the US Department of Veterans Affairs to design a new service system to help end veteran homelessness in New York City. The authors' task was to obtain data to inform the design of this new system. METHODS: A variety of methods were used. The group reviewed relevant literature and data from street homeless survey samples, analyzed shelter data, and consulted with VA homeless program staff on the findings. We then surveyed case managers at a veterans' shelter regarding their clients and determined their housing eligibility using a standardized logic model, and led two focus groups of veterans at this shelter regarding their views of the current shelter system and services for homeless veterans and how these might be improved. RESULTS: Among those resident in shelters during 2006, 37.2% of self-identified veterans compared to 0.9% of others reported their prior residence as supported housing, suggesting the need for more intensive case management at veterans' supported housing sites to help them sustain their tenure. The lack of interconnectedness among the various information systems made it more difficult to collect and analyze pertinent data. To begin to address this, a data match was undertaken to estimate the proportion of veterans resident in the veterans' shelter who were not in receipt of VA benefits to which they may be entitled. CONCLUSION: The data obtained through collaboration between staff from NYC's Department of Homelessness Services, US Department of Veterans Affairs facilities in the New York/New Jersey region and Common Ground Community led to information that informed the evaluation design of the new system. The identification of gaps in available data on homeless veterans will lead to projects both to improve and share data.