A key component of jurisdictionally-led, community- based, business-oriented 10 Year Plans to end chronic homelessness has been the emergence of local cost benefit research to identify the cost to basic public infrastructure of frequent use of acute treatment, emergency rooms, EMS, and law enforcement services by persons who are chronically homeless. An important example of cost research is from the City and County of San Diego, whose focus on 15 chronic inebriates on the streets over 18 months was revealed to have cost the City and County $3 million without changing the vulnerable and costly situation of the 15 individuals.

In addition to the financial impact was San Diego data that showed just how heavy utilization often was. As cited in a Law Enforcement Quarterly journal article by key partners Joan F. Dawson and Officer John Liening, "The Volunteers Of America Inebriate Reception Center (Detox) - the first stop for most individuals who are arrested for being 'drunk in public' - averages about 10,000 intakes a year. Forty- three percent of these individuals are repeat offenders, averaging thirty to forty intakes a year." Further: "The problem is more than just a financial one. Some chronic public inebriates abuse hospital emergency rooms daily. According to staff at UCSD Medical Center, it was common to see one 'chronic' eight to ten times in a weekend. This individual was taking limited bed space in the emergency room getting sobered up before he could be released, only to start drinking again once he was back out on the street."

San Diego partners, including the San Diego City Attorney's Office, the agency responsible for prosecuting misdemeanors in the City of San Diego, and the San Diego Superior Court - ultimately created the Serial Inebriate Program, or SIP, a collaborative diversion effort involving police, prosecutors, the court, and alcohol treatment providers. The expansive list of stakeholders recognized that an effective solution would need to involve all agencies and people affected: City of San Diego's Fire and Life Safety Services/Emergency Medical Services, the San Diego Police Department, the San Diego Sheriff's Department Detention Facilities, the Volunteers Of America Inebriate Reception Center (Detox), the San Diego City Attorney's Office, the Office of the Public Defender, the San Diego Superior Court, San Diego County Drug and Alcohol Services, the communities of San Diego, and the individuals themselves.

Noted the authors of the expectation of new outcomes: "City and County officials were open to any cost effective program that would divert the chronic inebriate off the street and into treatment."

SIP's early model of data followed by policy and investment changes followed by new results now is the standard of expectation. Just as the research of Dr. Dennis Culhane revealed the profile of people who are chronically homeless as a costly, finite population with disabilities living long term on the streets and languishing in shelters, the research provided the basis for new federal commitment and investment targeted to what that research revealed. Innovators emerged to shape new solutions ranging from Housing First to Project Homeless Connect to engage and move individuals from homelessness to stability. Good for the community, good for taxpayers, good for the homeless person - a rare trifecta in public policy.

With a demographic profile and budget impact as new defining elements for creating a trajectory of new solutions has come new targeted federal investment to identify "what works." New federal investment initiatives targeted to chronic homelessness were followed by a new $10 million permanent supportive housing demonstration initiative targeted to people who are chronically homeless and addicted to alcohol. The impetus was the cost benefit research of San Diego's Serial Inebriate Program (SIP).

To be an eligible applicant for the federal investment initiative, a community had to have at least 100 individuals who fit the profile of being on the streets for at least 365 days over the last five years, not in shelter or transitional housing in that time, and who also had a long-term addiction to alcohol. Eligible activities were limited to leasing of housing and limited housing search and administrative expenses.

Grantees were to have strong partnership with local law enforcement and court systems and other relevant institutions to identify eligible clients for the program. Grantees also had to demonstrate existing relationships with service providers, including grassroots community- based organizations including faith-based organizations, to ensure the comprehensive supportive services needs of the clients are addressed through other funds.

It was the intent of Congress that funds awarded under this NOFA support innovative solutions, which frequently result when local community organizations work together. Building upon existing collaborations, grantees were expected to work in conjunction with local law enforcement agencies and courts, including the police department, sheriffs department, superior court, city attorney, and/or city council, to identify and refer eligible clients to projects funded by this program. After clients are identified the provider could determine, on a case-by-case basis, if they needed to be stabilized in programs (not funded through this initiative), such as a residential treatment center, detoxification center or other jail diversion program, for up to six months prior to being placed into permanent supportive housing (funded through this initiative).

HUD expected that approximately half of the projects awarded would provide grants for leasing for project- based initiatives, though almost no grantees did project-based sites. Comprehensive alcoholism treatment services, along with other relevant services, must be provided in a manner deemed appropriate by the grantee and are subject to requirements of the Supportive Housing Program regulations and other applicable laws and regulations. Clients must be assisted in accessing relevant mainstream service delivery systems, Food Stamps, Supplemental Security Income (SSI), and Medicaid, for example.

Data analysis of San Diego's SIP initiative, published as "Evaluation of Impact of the San Diego Serial Inebriate Program (SIP) on Utilization of Healthcare Resources" and led by James Dunford, MD., City of San Diego EMS Medical Director, showed the benefit to the community, to taxpayers, and to homeless individuals of the collaborative effort for solutions.

548 individuals met the definition of a SIP client between Jan.1, 2000 and March 2, 2004.

Resource utilization by these 548 individuals showed 2,736 paramedic ambulance transports, $1.5 million in charges, with 87% uncompensated.

Data showed 3,846 visits to UCSD Medical Center or Scripps Mercy Hospital Emergency Department, with $2.9 million in charges, of which 85% was uncompensated.

There were 4,094 in-patient days at UCSD Medical Center or Scripps Mercy Hospital, with $15.3 million in charges, of which 81% was uncompensated.

According to the analysis, EMS/ED use decreased by 50% for those entered San Diego's program. For the 443 individuals who used EMS and ED services, there was a combined average decrease of $18,120 per month in charges for these types of services after entering SIP. For the 83 people who needed hospitalization, there was an average decrease of $180,223 per month in charges for these types of services with a 62% reduction in average rate of monthly hospitalization after entering SIP.

Taxpayers and the community benefit when the most vulnerable and costly population of people experiencing chronic homelessness move from streets and shelters to the stability of housing, ending their costly random ricocheting between acute treatment systems and law enforcement

Public systems benefit as they partner for housing solutions that move their systems from demoralization and costly frequent use by people experiencing chronic homelessness

Awardees from the twelve federal SIP housing demonstration sites in eleven cites and counties coast to coast joined in December in an inaugural audio conference convened by the United States Interagency Council on Homelessness and hosted by Council Director Philip Mangano to share results and insights from the innovative 2-year $10 million demonstration program funded to identify effective housing strategies for people who are chronically homeless and addicted to alcohol. The initiative, developed at the direction of Congress and with the specific interest of Representative Allen Mollohan of West Virginia, was the result of collaboration between the Council and the U.S. Department of Housing and Urban Development.

Noted Director Mangano, ""The Council and HUD as federal partners once again worked together to create a new approach to investing for results, to reach outside of existing models so that we can reach inside the population of those most deeply in need of innovative housing solutions, and most deeply in need of our partnership. The innovators in this initiative have much to tell us about what's working, and what's not to end the homelessness of these vulnerable neighbors." Among the topics discussed by the partners were housing results which will be explored in depth in ongoing calls, housing retention, housing market issues in partnering to create opportunity for a complex population, and unexpected insights and outcomes for clients.

Early insights identified during the initial discussion included rates of housing retention consistent with other Housing First initiatives, ranging from 85% upward, and the role of the 6-month opportunity for treatment or stabilization in achieving higher retention. Most sites reported a few deaths among their residents, due to serious physical health issues, and most also reported affirmation by new residents of the housing opportunity. There were few reports of difficulties in accessing units for the initiative.

Awardees were: Pathways to Housing DC, Housing for Serial Inebriates, Washington DC; Contra Costa, CA Health Services - Project Coming Home AAA; Colorado Coalition for the Homeless - Denver Homeless Alcoholic Recovery Program; Project Renewal, Inc. - Bowery Project, New York, NY; San Francisco Department of Public Health - Direct Access to Housing for Chronic Alcoholics; City of Santa Monica, CA - Serial Inebriate Program; Santa Cruz County, CA Health Services Agency - Meaningful Answers to Chronic Homelessness; Common Ground Community, Inc. -Street to Home Initiative for Chronically Homeless, New York, NY; ECH Lifebuilders - Off the Streets for Alcohol Addicts, San Jose, CA; Community Mental Health Council, Inc. - Project Wraparound, Chicago, IL; Emergency Services and Homeless Coalition of Jacksonville - Home Safe, Jacksonville, FL; and South East Tennessee Human Resource Agency - Regional Partnership to End Chronic Homelessness, Chattanooga, TN.

The expansive partnership of San Diego City and County demonstrates the variety of stakeholders committed to innovative solutions. San Diego's Ten Year Plan is now in implementation under the leadership of business champion Dene Oliver, who co-chaired the Plan's development with United Way of San Diego CEO Doug Sawyer.

As Medical Director of the City of San Diego EMS system and associated with the University of California at San Diego Medical Center, Dr. James Dunford took early notice of the revolving door involving jail, detox facilities, and hospitalization for chronically homeless inebriates and the resulting costs. With partners Officer Liening, Sergeant Schnell, Scripps Hospital and other community collaborators, progress has been made through the SIP initiative.

Learn more about United Way of San Diego's homelessness initiatives.

Learn more about San Diego's Homeless Outreach Teams.

Learn more about San DIego's 10 Year Planning partnership.

This issue conludes our 08 in 08 special series.

We hope you enjoyed this 08 in 08 Innovation series . . . and, if you missed any episodes, you can always access the Council's "on demand" service and catch up. Just visit our web site at www.usich.gov/innovations. You can also see the Council's previous Innovations series - 20 in 20 and 5 in 5, all profiles of what's working to end homelessness.

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