The State of Homelessness in Los Angeles County

Metropolitan Service Planning Area Health Office (SPA 4)

SPA 4 PROFILE

THE STATE OF HOMELESSNESS IN LOS ANGELES COUNTY:

The Need for a Multi-Dimensional Approach

SPA 4 BEST PRACTICE COLLECTION RELIABLE INFORMATION FOR EFFECTIVE COMMUNITY HEALTH PLANS, PROGRAMS AND POLICIES

M. RICARDO CALDERÓN, SERIES EDITOR

June 2002

Los Angeles County Department of Health Services • Public Health

At a Glance METROPOLITAN SERVICE PLANNING AREA HEALTH OFFICE (SPA 4)

241 North Figueroa Street, Room 312 Los Angeles, California 90012 (213) 240-8049

The Best Practice Collection is a publication of the Metropolitan Service Planning Area (SPA 4). The opinions expressed herein are those of the editor and writer(s) and do not necessarily reflect the official position or views of the Los Angeles County Department of Health Services. Excerpts from this document may be freely reproduced, quoted or translated, in part or in full, acknowledging SPA 4 as the source.

Internet: http://www.lapublichealth.org/SPA 4

LOS ANGELES COUNTY BOARD OF SUPERVISORS

Gloria Molina, First District Yvonne Brathwaite Burke, Second District Zev Yaroslavsky, Third District Don Knabe, Fourth District Michael D. Antonovich, Fifth District DEPARTMENT OF HEALTH SERVICES

The SPA 4 Best Practice Collection fulfills the Los Angeles County Department of Health Services (DHS) local level goal to restructure and improve health services by “establishing and effectively disseminating to all concerned stakeholders comprehensive data and information on the health status, health risks, and health care utilization of Angelinos and definable subpopulations”.1 It is a program activity of the SPA 4 Information Dissemination Initiative created with the following goals in mind: To highlight lessons learned regarding the design, implementation, management and evaluation of public health programs To serve as a brief theoretical and practical reference for program planners and managers, community leaders, government officials, community based organizations, health care providers, policy makers and funding agencies regarding health promotion and disease prevention and control To share information and lessons learned in SPA 4 for community health planning purposes including adaptation or replication in other SPA’s, counties or states To advocate a holistic and multidimensional approach to effectively address gaps and disparities in order to improve the health and well-being of populations The SPA 4 Information Dissemination Initiative is an adaptation of the Joint United Nations Program on HIV/AIDS (UNAIDS) Best Practice Collection concept. Topics will normally include the following: 1. SPA 4 Viewpoint: An advocacy document aimed primarily at policy and decision-makers that outlines challenges and problems and proposes options and solutions.

Thomas L. Garthwaite, MD.

Director and Chief Medical Officer, Department of Health Services

Jonathan E. Fielding, MD, MPH, MBA. Director of Public Health and County Health Officer

James Haughton, MD, MPH. Medical Director, Public Health

BEST PRACTICE COLLECTION TEAM M. Ricardo Calderón, Series Editor Manuscript Author & SPA 4 Area Health Officer

Angela Salazar, MPH. Manuscript Author & Program Director, Health Education

Carina Lopez, MPH.

Project Manager, Information Dissemination Initiative

2. SPA 4 Profile: A technical overview of a topic that provides information and data needed by public, private and personal health care providers for program development, implementation and evaluation.

3. SPA 4 Case Study: A detailed real-life example of policies, strategies or projects that provide important lessons learned in restructuring health care delivery systems and/or improving the health and well being of populations.

4. SPA 4 Key Materials: A range of materials designed for educational or training purposes with up-to-date authoritative thinking and knowhow on a topic or an example of a best practice.

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THE STATE OF HOMELESSNESS IN LOS ANGELES COUNTY

Table of Contents I. INTRODUCTION

1. Definitions of Homelessness

2. How many people are Homeless?

The Numbers

3. Who is Homeless?

Families

Children

Adults

Veterans

4. Who is Homeless in Los Angeles County

II. REASONS FOR HOMELESSNESS

1. The Multi-Dimensional Framework for Homelessness

Indivdual

Environmental

Structural

Superstructural

4 5 6 6 55 55 7 7 12

III. HEALTH AND WELLBEING

1. Statistics

Mortality

Mental health and substance abuse

Physical health

Infectious dieseases

Barriers to care

13 14

IV.

17 17 17

SERVICES FOR THE HOMELESS 1. Stewart B. Mckinney Homeless Assistance Act of 1987

2. Federal Assistance Programs

Food stamp Program

Public Housing and Section 8 Tenant-based Assistance

Employment and Training Services

Supplemental Security Income

Community Health Centers

Substance Abuse Prevention and Treatment Block Grant Program

Medicaid

3. State and County Assistance Programs

The Department of Health Services Programs

Alcohol and Drug Program Administration (ADPA)

Tuberculosis Control Program

Office of AIDS Policy and Programs (OAPP) V.

15

14 19

DISCUSSION: THE MULTI-DIMENSIONAL APPROACH TO ADDRESS HOMELESSNESS

VI. CONCLUSIONS

19

21 23

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INTRODUCTION

I. INTRODUCTION In the past decade, the United States has seen enormous economic growth. While this growth has substantially improved the financial well being of many, there remains a bleak reality: the number of persons in extreme poverty has risen along with the number of homeless persons across the US. Moreover, the economy’s success has driven up the cost of living making housing more unaffordable.

Goals of The State of Homelessness in Los Angeles County: Describe characteristics of the homeless population and who utilizes homeless services in Los Angeles County and SPA 4

Understand the reasons for homelessness using the Multi-Dimensional Framework for Homelessness

Skid Row, officially known as Central City East,1 is an area of Downtown Los Angeles between 3rd and 7th streets and Alameda and Main Streets. As of the 2000 census, there were 17,740 people and 2,410 households residing in the neighborhood.

Describe health problems and issues relating to health care in the homeless population

Outline major services available to the homeless population

Homelessness is clearly a national problem.

However, homeless persons across the US are not homogenous. Homelessness varies across geographical areas and it is becoming more apparent that there is no single face of homelessness. Homelessness is occurring in various ethnic minority groups, females, and children at increasing rates. It is important that each community understand its etiology of homelessness in efforts to better serve the unique needs of local homeless people.

This document is one in a series of articles to be published by the SPA 4 Area Health Office in The Best Practice Collection. The primary purpose of this document is to provide extensive information regarding the state of homelessness in Los Angeles County, with special attention to SPA 4 health issues and services available to the homeless population; but, the information provided goes beyond simply the numbers. This document introduces and advocates the use of The Multi-Dimensional Framework for Homelessness, a model intended to

Explain the role of The Multi-Dimensional Framework for Homelessness in developing comprehensive strategies for homelessness

Advocate the use of The Multi-Dimensional Framework for Homelessness describe the multifaceted etiologies of homelessness and to provide the backbone for developing a comprehensive strategy to end homelessness. Adopting The Multi-Dimensional Framework for Homelessness is integral in creating a system that advocates for multi-sectoral coordination and action to create more effective community programming and planning in the area of homelessness in our communities.

3

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DEFINITION OF HOMELESSNESS

1. DEFINITION OF HOMELESSNESS By the early 1980’s, there was a crisis in the United States: thousands of Americans found themselves without a home or without shelter due to a variety of reasons that will be later discussed. The public reacted because it was not since the Great Depression that the US had seen so many families living in shelters, on the streets, or with family and friends.1

On any given night in America, anywhere from 700,000 to 2 million people are homeless, according to estimates of the National Law Center on Homelessness and Poverty.

The term "homeless" was created around this time, intending it to be an inoffensive way of referring to persons living on the streets and in shelters.2 Although the adoption of this term brought public awareness to an otherwise indistinct group of people and circumstances, the term still remains multifaceted and can take on a variety of meanings.

Homelessness can mean anything on a continuum that ranges from the lack of basic shelter to being precariously housed (Table 1).1,2

There is debate over where the definition of homelessness lies along this continuum. Currently, definitions almost always leave out the precariously housed, primarily because identifying persons who are living in doubled-up or shared housing situations is difficult in practical terms. Furthermore, grouping those who are in shared housing situations with those who are without a home may obfuscate the specific needs and concerns of these distinct populations. Hence, researchers most often use an operational definition of homeless limited to persons in shelters, on the streets and those using services such as soup kitchens and mobile clinics.1 Unless otherwise noted in this document, the numbers/figures come from research that has used such operational definitions in obtaining the data.

A largely accepted formal definition of homelessness comes from the Stewart B. McKinney Homeless Assistance Act of 1987, a Federal legislation which created a series of targeted homeless assistance programs.3 In the Act, a homeless person is: (1) an individual who lacks fixed, regular and adequate nighttime residence (2) an individual whose primary residence is one of the following: i. a temporary place for people about to be institutionalized ii. any place not meant for human habitation iii. a supervised shelter.

Researchers most often use an operational definition of homeless limited to persons in shelters, on the streets and those using services such as soup kitchens and mobile clinics.1

Table 1. Definition of Homelessness on a Continuum based on Housing Arrangements

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HOMELESSNESS: DEMOGRAPHICS

2. HOW MANY PEOPLE ARE HOMELESS? Not surprisingly, putting a figure to the number of homeless persons in the US has been a challenging task for researchers. Estimates have varied from less than half a million to more than two million each year.1 The differences in estimates are due to various definitions of homelessness, different counting techniques and the use of different time periods.

Homeless persons are counted using either direct or indirect methods.

Direct counts are made by obtaining numbers from the streets, shelters, and service programs.

Indirect counts include telephone surveys and inter views of a portion of the population.

Homeless persons are counted using either direct or indirect methods.

Direct counts are made by obtaining numbers from the streets, shelters, and service programs. Indirect counts include telephone surveys and interviews of a portion of the population, which are used as representative samples that approximate the entire population.4 Similarly, homeless counts can occur at either one point in time (point prevalence, i.e. each night) or over a period of time (period prevalence, i.e. in the past 5 years).1,4 These estimates can vary substantially. For instance, when some people experience homelessness only briefly causing the period prevalence to be

many times greater than the point prevalence. Because homelessness most often occurs in short episodes, using a period prevalence measure is more appropriate.1

The Numbers It is estimated that 3.5 million people are currently without a home in the United States.5 Yet, this number is an incomplete picture of a problem that is more serious: it is estimated that 14% of the U.S. population (26 million people) have been homeless at some time in their lives and 5% (8.5 million people) have been homeless within the past five years.6 With an area that spans four thousand square miles and accommodates over nine million people, Los Angeles County has a large homeless population. Up to 84,000 people are homeless each night in the country amounting to close to 236,400 people being homeless over the course of the year.7 The city of Los Angeles is home to approximately 41,500 homeless people each night.

SPA 4, with one of the most dense and diverse populations in the county, encompasses areas with a high degree of homelessness such as downtown/Skid Row, Hollywood, and parts of East Los Angeles. According to the Los Angeles County Health Survey, SPA 4 had the greatest percentage of adults who were homeless within the past five years.

Interestingly, SPA 4’s three health districts, Central, Hollywood/Wilshire and Northeast, have homeless populations that are unique to each district; that is, homeless persons tend to differ substantially between the SPA’s three districts. About 375,000

adults have experienced homelessness in the past five years.8

“There are many risk factors for becoming homeless, such as disputes and relationship breakdown, physical or sexual abuse, lack of qualifications, unemployment, alcohol or drug misuse, mental health problems, contact with the criminal justice system, debt, lack of a social support network and institutionalization or the death of a parent during childhood” World Health Organization

3. WHO IS HOMELESS? The face of homelessness is changing.

While homelessness has traditionally been associated with single white males, the trend is changing to the extent that ethnic minorities make up the greatest share of the nation’s homeless population and there is increasing prevalence of homelessness in women, families, and youth.5,9

Families Families represent approximately 3437% of the national homeless population.4 With costs of living increasing nationwide, it is becoming more difficult to raise children with one source of income and most homeless families are single-parents. About 84% of homeless families are headed by mothers and have an average of 2.2 children.4 Most families become homeless due to a housing crisis, making housing their primary need.10

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HOMELESSNESS: DEMOGRAPHICS The increasing prevalence of homeless families is primarily a concern for SPA 4’s Northeast Health District.

Financial stress is causing many families, often with young children, to live in shared housing situations (doubled-up), out of cars, in local hotels and shelters, or even on the streets. Often, women and children are made homeless due to domestic violence. It has been estimated that about half of the nation’s homeless women are fleeing from domestic violence situations.11

Children Most homeless children are part of homeless family units. It is estimated that 38% of those who experience homelessness over the course of a year are children.10 Unaccompanied minors (i.e. runaway or displaced children) amount to about 3-7% of all homeless persons.12 These youngsters have issues distinct to their adult counterparts that need to be addressed. For instance, many homeless minors are victims of abuse, may have extensive drug problems, and are at particularly high risk of sexually transmitted diseases and HIV infections.1,11,12 For decades, runaway youth fleeing from problems at home or in search of glamour found themselves on the sidewalks and abandoned buildings of Hollywood. In 1997, the Children’s Hospital estimated that as many as 8,000 youths lived on Hollywood streets over the course of a year.13 A recent impetus to revitalize Hollywood by creating offices, apartments and restaurants out of abandoned buildings is displacing scores of young people, many who lived in

vacant building squats. Not surprisingly, more young people are sleeping on sidewalks, in alleyways, and under freeway overpasses.14 With so many young homeless people without roofs over their heads, the situation is bound to become more severe. Many homeless youth discover that exchanging sex for basic needs such as food, clothing, shelter, or protection can be their key to survival. A study conducted on Hollywood youth revealed that 26% of runaways reported involvement in "survival sex" compared to only 0.2% among non-runaway youth. Furthermore, rates of depression, alcohol and substance abuse, post-traumatic stress disorder and attempted suicide are major concerns for these youth.1,15

Adults Approximately 66% of people who experience homelessness over the course of a year are single adults, most entering and exiting the situation fairly rapidly. The remainder live in the homeless assistance system or in a combination of shelters, hospitals, streets and jails. About 81% of homeless single adults are between 25 and 54 years while 10% are between 17 and 24 years and another 9% are over 55 years.4 The homeless population in downtown Los Angeles is largely made up of single adult males of African American descent.16 With close to 11,000 homeless on downtown’s Skid Row, a 50-block area east of downtown bordered by 3rd and 7th streets and Alameda and Main streets, there is a considerable amount of attention given to this population.17

Veterans While 13% of the general population are United States veterans, 23% of the homeless are veterans.9 According to the U.S. Department of Veterans Affairs, a large proportion of homeless veterans are single, from disadvantaged communities, suffer from mental illness, and have substance abuse problems. Close to half of homeless veterans served during the Vietnam Era.18

4. WHO IS HOMELESS IN LOS ANGELES COUNTY? The data presented in this section come from three different research studies conducted in Los Angeles County: (1) The Los Angeles County Health Survey, 1997, (2) The UCLA Homeless Women’s Health Study, 1997 and (3) The RAND Course of Homelessness Study, 1991.

According to a December 2000 report of the US Conference of Mayors: • Single men comprise 44 percent of the homeless, single women 13 percent, families with children 36 percent, and unaccompanied minors seven percent.

• The homeless population is about 50 percent AfricanAmerican, 35 percent white, 12 percent Hispanic, 2 percent Native American and 1 percent Asian.

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THE LOS ANGELES COUNTY HEALTH SURVEY

The Los Angeles County Health Survey 8 In 1997, the Los Angeles County Health Survey assessed homelessness within the county using a telephone survey of households within the county.

Homelessness within the past 5 years was assessed using a definition of homelessness that includes the precariously housed (i.e. doubled-up or shared housing situations with friends or family).

Figure 1. Percent of adults who were homeless within the last 5 years by Service Planning Area (SPA)

Figure 2. Ethnicity of adults who were homeless within the last five years in Los Angeles County

Figure 3. Employment status of adults who were homeless within the last five years in Los Angeles County

Figure 4. Education level of adults who were homeless within the last five years in Los Angeles County

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UCLA HOMELESS WOMEN’S HEALTH STUDY

The UCLA Homeless Women’s Health Study 19 The UCLA Homeless Women’s Health Study was conducted to assess the health status of homeless women in Los Angeles County using service-based sampling. Unlike the Los Angeles County Health Survey, this study excluded precariously housed individuals (persons doubled up or in shared living arrangements with friends or family members). As stated previously, this definition is most commonly used in homelessness research and separates the precariously housed from the definition of homelessness.

The ethnic breakdown of the sample population of homeless women from Los Angeles County (N=964) versus ethnic breakdown of sample population of homeless women from SPA 4 (N=505) can be found in figure 5.

Figure 5. Ethnic Break down of the sample population of homeless women from Los Angeles County

Figure 6. Age structure of the sample population of homeless women from Los Angeles County (N= 960)

Figure 7. Number of years since being last stably housed among sample population of homeless women from Los Angeles County (N= 966)

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THE RAND COURSE OF HOMELESSNESS STUDY

The RAND Course of Homelessness Study 20

Figure 8. Ethnic breakdown of the sample population of homeless indivduals in Downtown and Westside (N = 1563)

The RAND Course of Homelessness Study was a prospective study of homeless persons in Los Angeles Downtown and Westside. This survey was conducted using both servicebased sampling and probability sample of homeless persons. This study excluded precariously housed individuals (persons doubled up or in shared living arrangements with friends or family members).

Figure 9. Ethnic Breakdown of the sample population of homelesss indivduals by gender (N = 1563)

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THE RAND COURSE OF HOMELESSNESS STUDY

Figure 10. Education level of the sample population of homeless indivduals in Downtown and Westside ( N = 1563)

Figure 11. Ethnic breaksown of the sample population of homeless indivduals by gender (N = 1563)

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REASONS FOR HOMELESSNESS

II. REASONS FOR HOMELESSNESS

1. THE MULTI-DIMENSIONAL FRAMEWORK FOR HOMELESSNESS There is not a simple answer to the question of why there are homeless persons. Like many other social issues, homelessness has a multitude of causes.

In order to better understand the etiologies of homelessness, the needs of homeless persons and to provide effective services, we must understand all factors that influence homelessness on a holistic level. This can be best achieved using the Multi-Dimensional Framework for Homelessness. This model is adapted from a framework for HIV in developing countries.21 It identifies four levels of causation involved in homelessness. Table 3 summarizes each causal level.

Homelessness can be understood using a framework that uses these levels of causation (Figure 12). Included in the figure are issues to be further discussed in this document. Lack of affordable housing and poverty are highlighted because they have been identified as major contributing factors to the rise in homelessness over the past two decades.22,23

Table 2. Time of current episode of homelessness and total time of homelessness among sampled indivduals (N=1563).

Table 3. Causal Level of the Multi-Dimensional Model

Figure 12. The Multi-Dimensional Framework for Homelessness INDIVIDUAL – substance abuse, mental illness, perception of the services system

ENVIRONMENTAL – lack of affordable housing, low paying jobs, domestic violence

STRUCTURAL – changes to public assistance, lack of comprehensive policies to prevent homelessness

SUPERSTRUCTURAL –poverty, racism, gender issues

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REASONS FOR HOMELESSNESS

II. REASONS FOR HOMELESNESS CON’T

for aid and consequently have begun experiencing homelessness in increasing numbers.24

Individual

Superstructural

Homeless persons experience mental illness and substance abuse at levels higher than the general public. Mental illness and substance abuse may cause homelessness but it is more probable that they contribute to the inability to be freed from homelessness.1

Poverty is an important superstructural factor contributing to homelessness.

Poor persons must decide where to allocate resources for even the most basic needs including housing, food, childcare, health care and education.

Because housing drains most of an individual’s resources, it is often the first thing that is relinquished.1

Environmental A lack of affordable housing is a major contributor to the current housing crisis and to homelessness.

Affordable housing has become increasingly scarce and is beyond the reach of many poor persons because they are forced to contribute increasingly larger proportions of their income toward housing. Likewise, once they are homeless it is increasingly difficult to locate affordable housing.1

Structural There have been changes to the public assistance system that has resulted in more persons becoming or remaining homeless. One of the major changes occurred in 1996 with the federal welfare reform law that replaced the Aid to Families with Dependent Children (AFDC) program with a block grant program called Temporary Assistance to Needy Families (TANF). This change has significantly decreased the aid given to poor persons.23 There is cause for concern because in some communities families are no longer eligible

While the number of poor people has not changed much in recent years, the number of people living in extreme poverty has increased. These people are the most vulnerable to becoming homeless.1

It is estimated that 20-25% of the homeless population have mental health conditions, such as schizophrenia, depression and bipolar disorder.30 III. HEALTH AND WELL-BEING According to the World Health Organization (WHO), health is not merely the absence of disease; rather, it encompasses physical, mental and social well-being. Since the state of homelessness encroaches upon all three of these areas of well-being, homeless persons are especially vulnerable to poor health status.

Poor health status not only causes significant problems for those already homeless but it can also be a cause for homelessness due to a variety of reasons including physical, emotional and financial strain. A survey conducted in the 1980s revealed that poor physical health was a factor for becoming homeless in 13% of homeless patients.25,26 As the number of persons without health coverage continues to rise, the situation remains grim. Homeless persons experience high rates of both chronic and acute health problems. Many homeless people lack health insurance, do not have a regular source of care, and are under-treated for common medical problems; hence, amplifying their poor health. In addition, they are at high risk for injuries and crowded living situations may contribute to outbreaks of disease.

Conditions requiring regular, continuous treatment, such as tuberculosis, HIV/AIDS, diabetes, hypertension, addictive disorders, and mental disorders are difficult to manage among those without adequate housing.26

“Homeless people constitute a heterogeneous population characterized by multiple morbidity (primarily alcohol and drug dependence, and mental disorders) and premature mortality. The problems need to be addressed by many measures, requiring a focused primary health care system and multi-agency cooperation”.

World Health Organization

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STATISTICS OF HOMELESSNESS

Many homeless persons experience multiple health problems. Often a direct consequence of homelessness, frostbite, skin conditions, leg ulcers and upper respiratory infections are common.11 Moreover, homeless people are at greater risk of trauma frequently resulting from rape, muggings and other street violence.11,26 To make matters worse, homelessness precludes even basic care, such as nutrition, personal hygiene and first aid.

It is also becoming more apparent that self-medication occurs among some homeless people through the use of prescription drugs, illicit drugs and alcohol.26

Homeless children are especially at risk of poor health due to low immunization rates, inadequate nutrition, unsuitable living conditions, and little health care.11,26

Homeless children are especially at risk of poor health due to low immunization rates, inadequate nutrition, unsuitable living conditions, and little health care.11,26 In a study conducted in a population of homeless children in New York City, it was revealed that 61% of homeless children had not received their proper immunizations; 38% of homeless children in shelters have asthma (an asthma rate four times that for all New York City children and the highest prevalence rate of any child population in the United States); and that homeless children suffer from middle ear infections double the national rate, which can adversely impact their language development.26,27

1. STATISTICS The following statistics are derived from various research studies. They reflect the health issues facing the nation’s homeless population.

Mortality Homeless persons face substantially higher mortality rates than the general population. From studies conducted in homeless populations, it has been estimated that mortality in adults is approximately three to four times greater than the general population and mortality in children is two times greater.11,28,29 The most frequent cause of death among homeless in the 19-24 years age group is homicide, for the individuals ages 25-44 years it is AIDS, and for the 45-64 years group it is heart disease and cancer. Similarly, the risk factors for death in the homeless includes AIDS and renal disease (including hypertension and diabetes).11

Mental Health & Substance Abuse It is estimated that 20-25% of the homeless population have mental health conditions such as schizophrenia, depression, and bipolar disorder.30 Mental health disorders cause disruption in even the most basic aspects of daily life, such as self-care, household chores and socialization. Research has revealed that homeless persons with mental illness remain homeless for longer periods of time and have less contact with family and friends.

Moreover, they are more likely to encounter barriers to employment, are in poorer physical health, and have

more contact with the legal system than homeless persons without mental illness.31

The most frequent cause of death among homeless in the 19-24 years age group is homicide, for the individuals ages 25-44 years it is AIDS, and for the 45-64 years group it is heart disease and cancer.

Because mental disorders require chronic management, people with little access to mental health care have considerably poor mental well-being. Nevertheless, most people with mental disorders do not need hospitalization, and even fewer require long-term institutional care. It is estimated that only 5-7% of homeless persons with mental illness require institutionalization; most can live in the community with proper supportive housing.31 Despite the critical need for supportive housing for homeless persons with mental illness, there is a dearth of appropriate community-based treatment services or supportive housing services.1,31 Addictive disorders often lead to severe alcohol or drug abuse in homeless persons. Among homeless adults, 31-50% use alcohol and/ or other drugs.4 Often, alcohol and other drugs serve as a form of selfmedication for people with untreated concurrent mental disorders.32 Unfortunately, there are limited services for people with addiction disorders who are in need of affordable/supportive housing and health care.

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STATISTICS OF HOMELESSNESS

Physical Health Several studies have found that onethird to one-half of homeless adults have some form of physical illness.33 Although arthritis, rheumatism and joint problems are some of the most common self-reported problems, it has been evaluated that upper respiratory tract infections, trauma, female genitourinary problems, hypertension, skin and ear disorders, gastrointestinal diseases, peripheral vascular disease, musculoskeletal problems, dental problems, and vision problems are the most common conditions affecting homeless persons.11,33,34

Homeless adults and children are twelve times more likely to have dental problems than the general US population. The conditions of high incidence are periodontal disease (gum disease), complete tooth loss and oral cancers.35 Homeless adults and children suffer from a variety of dental health problems. It is estimated that they are twelve times more likely to have dental problems than the general US population; the conditions of high incidence are considerably more serious, such as periodontal disease (gum disease), edentulism (complete tooth loss) and oral cancers.35 A variety of conditions associated with homelessness contribute to poor dental health, they include: lack of access to dental care, nutritional deficiencies, inability to practice good dental hygiene, alcoholism and other substance abuse.33,35

Similarly, vision problems contribute considerably to the poor health status of homeless persons. Little access to optometric care contributes to a situation where many homeless people live with poor eyesight and a variety of eye disorders.33 Close to half of the homeless persons surveyed by the Interagency Council on the Homeless in 1997 reported at least one chronic health problem. The most common chronic conditions were arthritis and related disorders, high blood pressure, and some type of physical disability (i.e. lost limb, trouble walking).5 The high prevalence of chronic disorders among homeless people is especially important because of its relation to long-term disability and inability to work or engage in other activities.36 There remains a severe need to address issues of homeless persons with chronic disabilities through accessible housing units, supportive services, and proper health care.

Approximately two-thirds of the problems homeless people have are acute illnesses which most are the direct result of being homeless.33 The three most common acute illnesses that affect homeless people are respiratory infections (i.e. colds, influenza, pneumonia), trauma (i.e. lacerations,

wounds, sprains, contusions, fractures, burns), and minor skin ailments (i.e. sunburn, contact dermatitis, psoriasis, corns and calluses).11,33

Infectious Diseases Both acute and chronic infectious diseases cause significant morbidity in the homeless. Nationally, 26% of the homeless reported an acute infection, specifically chest infections, coughs or bronchitis.5 There is high prevalence of chronic infections in the nation’s homeless population, posing great threat to them and others around them (see Table 4).11,33

Barriers to Health Care The City of Los Angeles has the lowest health insurance coverage rate in California with 2.8 million uninsured people.37 Compared with California, Los Angeles has fewer free community health systems per 100,000 people.38 Hence, the major sources of health care for homeless people come from public hospitals, hospital emergency rooms, and free clinics.

The homeless experience high rates of hospitalization and re-hospitalization since they often delay seeking medical attention for their conditions.11

Table 4. Prevalence of infectious diseases in homeless people.

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STATISTICS OF HOMELESSNESS

According to a recent study conducted in Los Angeles,39 57% of homeless persons reported a regular source of health care. Homeless persons with a regular source of care were asked to reveal their source. They responded as follows: 30% hospital outpatient department, 25% community or homeless clinic, 23% hospital emergency room, 14% government-run clinic, and 9% private physician.

The three most common acute illnesses that affect homeless people are: respiratory infections (i.e. colds, influenza, pneumonia), trauma (i.e. lacerations, wounds, sprains, contusions, fractures, burns) minor skin ailments (i.e. sunburn, contact dermatitis, psoriasis, corns and calluses).11,33

The homeless face a number of barriers to health care.11,38 These barriers are diverse and can be illustrated using the four Levels of Causation from The Multi-Dimensional Framework for Homelessness. Examples of barriers to health care are illustrated below:

Individual: the low perceived need of health care by homeless persons; that is, health care is not a top priority for homeless persons trying to fulfill

basic needs such as housing and food.

Homeless persons may also have little trust in medical establishments.11,38

homeless persons, poor attitude about caring for homeless, or lack of experience working for homeless persons. 11

Environmental: financial constraints and lack of transportation.

The inadequate service of health care for homeless persons creates a system that does not have the capacity to provide continuous, comprehensive health care necessary for the multifaceted problems of homeless people.

To make matters more difficult, there is a lack of recuperative services available to homeless persons once they are discharged from medical establishments.11

Structural: lack of medical facilities for homeless persons. Few clinics have walk-in services or have complicated enrollment procedures. Regimens requiring actions such as bed rest or refrigeration of medications. 11,38 Superstructural: discrimination or improper care from medical providers due to lack of experience caring for

HOMELESSNESS FACTS: INTERNATIONAL “Homeslessness is a complex concept embracing states of rooflessness, houselessness, living in insecure accommodation, or living in inadequate accommodation Roofless includes rough sleepers, newly arrived immigrants and victims of fire, floods or severe harassment or violence.

Houseless includes those living in emergency or temporary accommodation such as night shelters, hostels and refuges and those released from long-term institutions such as psychiatric hospitals, prisons, detention centers, community or foster homes with nowhere to go upon release.

Living in insecure accommodation describes people who are staying with friends or relatives on a temporary or involuntary basis, tenants under notice to quit, those whose security is threatened by violence of threats of violence, or squatters.

Living in inadequate accommodation includes overcrowded or substandard accommodation�

World Health Organization

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IV. SERVICES Most urban centers in the US have had missions, flophouses and soup kitchens serving the poor for over a century. These institutions, along with government and non-profit agencies and private individuals, provide integral services to homeless persons.

While this makes for a broad arena of services, there is little coordination or communication between service providers creating a fragmented system of services. Resources for homeless services largely come from private and federal grants. The federal government serves homeless people with two types of programs: (i) programs for the homeless authorized under the McKinney Act, and (ii) programs for all low income people.

In 1999, 50 federal programs provided services to homeless people. Of these 50 programs, 16 were specifically targeted to homeless persons and 34 were mainstream programs designed for all low income people. The federal government set aside $1.2 billion for programs for the homeless. In comparison, $215 billion was set aside for mainstream programs in 1997.40

1. STEWART B. MCKINNEY HOMELESS ASSISTANCE ACT OF 1987 There has been relatively little action taken by the Federal government in establishing comprehensive legislation responding to homelessness.

The Stewart B. McKinney Homeless Assistance Act of 1987 was the government’s first attempt at such legislation and it remains the only one. The Act was created in response to the growing homeless problem in the 1980s and was most recently amended in

1994 to further expand the scope of the legislation. The McKinney Act contains nine titles summarized in Table 5 (see page 18). This Act is responsible for funding various homeless programs seen at the local level.

Even though the McKinney programs have been successful for helping homeless persons, resources granted to the programs are not enough to meet demand. Furthermore, critics argue that the McKinney Act fails to respond to the causes of homelessness; that is, the Act is designed to help only those who are already homeless and does not reach out to those who are on the verge of homelessness.41

2. FEDERAL ASSISTANCE PROGRAMS Federal assistance programs are designed for all low income individuals, including homeless persons. They provide a wide range of assistance such as housing, food, health care, transportation, and job training (see Table 6, page 18).

There has been increasing concern that these programs have not met the needs of homeless persons. In a Report to Congressional Requesters, the United States General Accounting Office (GAO) assessed the barriers to federal assistance programs encountered by homeless persons.40 The following is a description of each program and barriers reported by the GAO.

Food Stamp Program: The Food Stamp Program, administered by the U.S. Department of Agriculture, provides low income persons with coupons that can be redeemed for food items at authorized food stores. In 1999 this state-administered

program provided 18.2 million people with an average of $72 in food stamps each month. Only 37% of homeless people received these benefits in 1996.

Obstacles to obtaining food stamps include: misinformation about the program, administrative difficulties, and lack of outreach. In addition, homeless persons may not be able to use food stamps effectively because they often lack facilities for food refrigeration, storage and preparation.

Public Housing and Section 8 TenantBased Assistance: The Department of Housing and Urban Development oversees and funds public housing and Section 8 tenantbased assistance. These programs house more than 6 million people.

While public housing is owned and operated by a local housing authority, Section 8 assistance is federally subsidized privately owned housing. Scarcity of public housing and dearth of private landlords who accept Section 8 vouchers are the most fundamental problems to accessing these programs.

Similarly, applying for these programs includes long waiting periods during which homeless persons may be lost to follow up due to lack of stable address or telephone number.

Employment and Training Services: The Workforce Investment act of 1998 provides the framework for the federal government’s employment and training activities. This legislation requires states to establish workforce installment boards that develop employment and training systems in their communities. Job training is provided through vouchers, which are used to obtain services from community providers. There is concern that this program limits a homeless person’s access to training since: the dollar value

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Table 5. The Stewart B. Mckinney Homeless Asstistance Act

Table 6. Federal Assistance Programs

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of the voucher may not be sufficient to meet the training needs of homeless persons who require intensive services and community providers may not be qualified to serve special needs of homeless persons.

Supplemental Security Income: The Social Security Administration administers the Supplementary Security Income program, which provides cash benefits to blind, disabled (physical and mental), and aged persons who are below certain income levels. In 1999, 6.3 million people received a monthly average of $341 in SSI benefits. Only 11% of homeless persons received SSI in 1996 despite the large number of homeless persons who qualify for these benefits. The low participation may be attributed to the complex application process that requires extensive documentation regarding issues such as living arrangements, income and medical history.

Obtaining medical documentation can be especially difficult since homeless persons often do not have a single service provider.

Community Health Centers: Administered by the Department of Health and Human Services, the Community Health Center program, funds primary and preventative health care services in medically underserved areas. The Program funds communitybased public and private nonprofit organizations. Homeless persons were approximately 2 percent of centers’ patrons in 1996. The barriers to accessing the centers’ services are essentially the same as barriers to health care in general, as previously discussed.

Substance Abuse Prevention and Treatment Block Grant Program: The Health and Human Services’ Substance Abuse and Mental Health Services Administration (SAMHSA) is responsible for the Substance Abuse Prevention and Treatment Block Grant Program, which funds substance abuse programs directed by states and territories. There is cause for concern because these substance abuse treatment programs often do not address the special needs of homeless persons, who are especially in need of such services. Examples of barriers to these programs include: long waiting lists that result in lost to follow up of homeless persons; strict requirements, such as access to telephone; and, outpatient treatment rather than residential treatment.

Medicaid: Medicaid, a joint federal-state program, provides health care coverage to low income individuals. In California, Medi-Cal is available to persons who meet income limits or fall into “medically indigent” groups. Although most homeless persons are eligible for MediCal, few homeless people actually have this insurance. A major obstacle in obtaining Medi-Cal is the application process, which requires an interview at which documentation of income, residency, and medical history must be provided. Further, individuals on Medi-Cal must recertify their eligibility annually. Without assistance, obtaining Medi-Cal can be extremely difficult for a homeless person.

3. STATE AND COUNTY ASSISTANCE PROGRAMS Homeless persons may be eligible for the state of California’s welfare program, CalWorks, and the county General Relief program. These programs provide cash assistance to families and the very low income, respectively. Barriers to these programs include similar programmatic obstacles discussed above.

Services for homeless persons in Los Angeles County are mainly concentrated within the downtown area.

Services range from housing agencies to substance abuse programs. There has been criticism that the system is fragmented, with little coordination or communication between service providers. There exists a major need to identify all services in Los Angeles County and evaluate the effectiveness of the services system. Furthermore, a multi-disciplinary approach to providing services to homeless persons, namely health care services, is long overdue. For instance, a homeless person who comes into a health facility should be assessed for housing status so that proper housing arrangements can be made upon discharge; moreover, he/she can be enrolled in adequate recuperative services and be referred to other agencies.

According to a study conducted

by Shelter Partnership7, 153 agencies operate 331 short-term housing programs for homeless people, providing a total of 13,632 beds in Los Angeles County. These beds are primarily located (62%) in the City of Los Angeles. More than one-third of the County’s beds are intended for the single adult homeless population.

Beds for families amount to about

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SERVICES FOR THE HOMELESS

17% and beds for persons with substance abuse problems comprise 22% of the County’s total beds.

The majority of homeless services are offered by non-profit organizations, some of which are religiously affiliated. Services may have requirements and rules or contingencies that are strictly upheld. Such a system often promotes negative attitude toward the services system because it encroaches upon a person’s freedom.

For instance, it is estimated that skid row has about 200 shelter beds open many nights. Many homeless persons do not use such services because they do not want restrictions or do not feel that they are treated with respect.43 The Los Angeles Homeless Services Authority (LAHSA) is an important player in the arena of service delivery for homeless persons in Los Angeles County.44 The Los Angeles County Board of Supervisors and the Mayor and City Council of Los Angeles created LAHSA in 1993 to provide funding and guidance for local, non-profit agencies working with homeless persons in areas such as housing, case management, counseling, advocacy, and substance abuse programs.

LAHSA is governed by a politically appointed, 10-member commission of which five members are selected by the County Board of Supervisors and five are chosen by the Mayor and City council. Through a competitive application process (Request for Proposal), LAHSA distributes between $45 and $60 million of public funds to approximately 80 agencies and over 120 programs throughout the City and County of Los Angeles each year. In addition to allocating funds, LAHSA coordinates its own direct services to homeless persons, such as the Los Angeles Winter Shelter Program.

The Department of Health Services programs The County of Los Angeles Department of Health Services’ public health units play an important role in providing services to homeless persons in Los Angeles County by collaborating with other County and non-County agencies. The Alcohol and Drug Program Administration, TB Control Program, and Office of AIDS Policy and Programs have been involved in the area of homelessness through a variety of programs.

Alcohol and Drug Program Administration (ADPA): ADPA provides several residential and non-residential alcohol/drug recovery and treatment services through contracts with various community organizations. ADPA contractors provided services to over 35,000 people, 24% of whom were homeless at the time of admission in FY 1998-1999. ADPA is also involved in a number of jointly funded programs that serve homeless persons, such as: (1) Services for General Relief and CalWORKS participants – screening, assessment and treatment for participants with drug and alcohol problems (2) Community Assessment and Service Centers – substance abuse clinical assessments, mental health clinical assessments, and referrals to treatment, screening for contagious diseases and linking to other services (3) Los Angeles Men’s Program – residential recovery program for dually diagnosed homeless men in downtown Los Angeles (4) Alcohol and drug prevention program in Skid Row – community alcohol and drug prevention program, providing drug-free environments.

proper completion of therapeutic regimens by homeless persons with tuberculosis. The Program administers the TB Control Incentive/Enabler Project, which provides a variety of amenities such as housing vouchers, meal vouchers, and transportation assistance to homeless and other indigent persons with tuberculosis.

Office of AIDS Policy and Programs (OAPP): Through a combination of Federal Ryan White CARE and County funds, OAPP supports housing services for persons with HIV. Furthermore, CARE funds provide involvement in programs that identify homeless persons with HIV, offer psychosocial assessment, counsel and enroll persons in comprehensive care.

HOW TO END HOMELESSNESS: THE TEN ESSENTIALS 1. Plan 2. Data 3. Emergency Prevention 4. Systems Prevention 5. Outreach 6. Shorten Homelessness 7. Rapid Re-housing 8. Services 9. Permanent Housing 10. Income

TB Control Program: The TB Control Program provides and facilitates the

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DISCUSSION: THE NEED FOR A MULTI-DIMENSIONAL APPROACH

V. DISCUSSION: THE NEED FOR A MULTI-DIMENSIONAL APPROACH As discussed earlier, in order to better understand the etiologies of homelessness and the needs of homeless people we must understand all factors that cause and influence homelessness.

Homelessness is an extremely difficult socioeconomic problem to resolve and there has been no dramatic improvement in the state of homelessness over the past couple of decades. There is a critical need for a comprehensive planning strategy that approaches the problem from all angles and perspectives. Homelessness requires a wide-ranging, integrated, systems approach to address complex, multiple and competing priorities and needs. In Los Angeles County, just as in the rest of the nation and many countries around the world, there are countless governmental programs and non-governmental organizations dealing with specific homeless issues often times in isolation of each other. In some places, duplication of efforts and redundancy of programs and services is common. In other places, interventions are scarce or ineffective, do not address the real causes of homelessness, are limited to a few group of beneficiaries or contribute directly or indirectly to exacerbate the problem. In many settings, an inordinate amount of funding is available for homeless services. Nevertheless, the homeless situation continues to worsen instead of improving. In addition, this situation is compounded in some places by the fact that many social and health governmental and

non-governmental organizations owe their existence and sustainability to the maintenance of the homelessness problem. If in fact, there are bureaucracies that support large infrastructures and staff maintaining status quo interventions and lacking cost-effective programs and services.

The state of homeless in any county, state or country cannot be resolved without a unified strategic plan in which all sectors of society –public, private and non-profit—actively contribute, participate and, most importantly, share the vision, values, resources, programs, services and responsibilities in a complementary fashion. Therefore, a framework to plan, manage, implement and evaluate all efforts to end homelessness is of utmost importance. Consequently, the SPA 4 Area Health Office proposes The Multidimensional Framework to Address Homelessness as a tool to plan, organize, manage, implement and evaluate all efforts to end homelessness. This framework is an adaptation of the Four Levels of Causation of Disease and the

Multidimensional Model to Prevent and Control HIV/AIDS promoted by the Regional Office for Latin America and the Caribbean of Family Health International during the period 1992 – 1997. As has been discussed, homelessness is a complex problem with many levels of causation ranging from individual behaviors to social, economic and political conditions (see Figure 12).

The SPA 4 Area Health Office proposes the same levels of causation of HIV/ AIDS as the levels of causation of homelessness –individual, environmental, structural and superstructural. “Superstructural factors include macrosocial and macropolitical arrangements, physical and resource characteristics and other elements such as economic underdevelopment, sexism, racism that often evolve over the long term. Mechanisms for change at this level include social movements, revolutions, land distribution and war. Structural factors include laws, policies and standard operating procedures. Mechanisms for change

Causation Levels of Homelessness* Causation Levels of Homelessness*

INDIVIDUAL

ENVIRONMENTAL

STRUCTURAL

SUPERSTRUCTURAL

* SPA 4 Area Health Office

*SPA 4 Area Health Office

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DISCUSSION: THE NEED FOR A MULTI-DIMENSIONAL APPROACH Figure 13. How Areas of Concern fit into The Mutli-Dimensional Framework for Homelessness INDIVIDUAL – healthcare seeking behaviors: homeless people do

ENVIRONMENTAL – lack of adequate sanitation on Skid Row, lack of areas of recreation or fitness centers for exercise, few affordable housing untis.

STRUCTURAL – no policies or protocols for adequate discharge

SUPERSTRUCTURAL – Homeless people have no social, economic or political power; the media and the public at large are insensitive to homeless people and their issues

not seek services because of poor customer services provided by the personal, public and mental health systems.

from medical facilities, no comprehensive release plan from prisions, financial assistance procedures making funding inaccessible, lack of a comprehensive local, state or national plan.

at the structural level include constitutional and legal reform, civil and human rights activism, legislative lobbying and voting. Environmental factors include living conditions, resources, social pressures and opportunities, examples of which include forced relocation/migration in pursuit of employment and urbanization. Processes for change at the environmental level range from community organization and legal action to the provision of services. The individual level factors relate to how the environment is experienced and acted upon by individuals and may include, amongst others, isolation, boredom and low perception of risk.

Change at the individual level is most often achieved through education, counseling, reward and punishment, and the provision of information”.29 Therefore, in order for homelessness programs and services to be effective, a holistic approach is required encompassing all the levels of society and the economy.

The Multidimensional Framework to Address Homelessness can be applied

to local efforts in Los Angeles County to deal with the issue. For example, on January 30, 2001, LAHSA called upon homeless service providers and homeless people to facilitate a discussion regarding homelessness and homeless services. Among those involved in the discussion were Los Angeles County and City representatives, law enforcement personnel, community members and governmental and nongovernmental employees. Los Angeles County Sheriff Lee Baca led the group discussion identifying areas of need. The issues were extensive, representing political, social and personal concerns. Some of the issues identified can be placed into the Multidimensional Framework for Homelessness (see figure 13) The core message of the Multidimensional Framework for Homelessness is that efforts to address homelessness at any of its four levels of causation are not a collection of independent activities, but rather a system of integrated planning, implementation and evaluation practices. Los Angeles County, as a whole, must manage these practices

or components and oversee their successful integration to better address homelessness issues and achieve outstanding performance. The four levels of causation of homelessness represents more than isolated components and even more than individual levels with each one leading to the next. Rather, they symbolize a cohesive model or framework in which each level supports and is supported by every other. The connected levels reflect a framework for a system in which: (a) all parts are integrated and altering one will affect all the rest, and (b) assessing an issue in any level requires examining the linkages with all the other functions and the multidimensional framework as a whole.

“Successful and sustained public health interventions of the past have relied on changes at each of the causation levels described.

The massive effort in the United States to reduce cigarette smoking is an example of an intervention that worked at many levels and ultimately succeeded in lowering cigarette consumption. Initial efforts targeted the individual smoker

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CONCLUSION

and eventually evolved to include structural changes, such as cigarette taxes, banning smoking in public places and designating special sections in airplanes for smokers. On the environmental level, smokers have been stigmatized and labeled as outcasts and forced out onto sidewalks to smoke, further reinforcing these messages. The combination of structural and environmental pressures intensified the response of the individual and produced results beyond what would have been attained through purely and individual approach�. Other examples include the prevention of vehicle-related morbidity and mortality through mandated seat-belt usage programs along with water fluoridation, enriching foods with micronutrients, increasing educational opportunities for women resulting in lower fertility rates, syphilis screening on all hospital admissions of reproductive age women, and motorcycle helmet laws.

An additional example of the effective application of multidimensional approaches is the 100% Condom Brothel Program in Thailand which reduced the level of unprotected sex and the incidence of sexually transmitted infections and HIV/ AIDS. More specifically, individual interventions included information, education and training of commercial sex workers. Structural internvetions included non-compliance fines and closure of brothels. Environmental interventions included mass media campaigns, condom availability and brothel owners’ buy-in and support, and superstructural interventions included macro level societal efforts on poverty reduction, socioeconomic improvement, gender equity, women’s empowerment, etc.

Unfortunately, a homelessness approach in Los Angeles County operating on the referenced complementary levels are rare or do not exist. However, reinforcing and multilevel strategies can achieve results beyond those attainable through purely individualistic governmental and non-governmental approaches. Clearly, to end homelessness in Los Angeles County, as well as in any other place, a strategic approach based on individual, environmental, structural and superstructural interventions is needed to address the causes and conditions that facilitate homelessness.

VI. CONCLUSION Homelessness is a reality around the world in developing and developed countries even in a booming economy.

Homelessness in Los Angeles County has been and continues to be a major societal problem. There are thousands of people who live in substandard conditions each night placing them in vulnerable and high risk conditions.

Homeless people face a variety of social, economic, mental and health problems including chronic diseases, injures and violence.

the homeless. Current underlying assumptions to end homelessness are guiding programs in a direction that can be counter-productive or not cost-effective. Therefore, The Multidimensional Approach to Address Homelessness offers a model to shift current planning, management, implementation and evaluation efforts and perspectives to end homelessness. It is a framework to facilitate innovation and change, better utilize available resources, and launch concerted public, private and non-profit sector actions to address the root causes of homelessness. It is also a strategy to plan comprehensive programs and services, organize and deploy services, support policymaking and improve the health status and wellbeing of homeless people in Los Angeles County, the state and the nation as a whole.

While a number of federal, state and local services exist, there are multiple unmet needs due to the lack of a single, comprehensive strategic plan comprising all public, private and non-profit stakeholders in Los Angeles County. The State of Homelessness in Los Angeles County must be addressed at the broadest biological, social, economic and political levels.

New perspectives must be embraced to change current mental models to develop programs and services for

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Practical Lessons: The 1998 National Symposium on Homelessness Research. The U.S Department of Housing and Urban Development and the U.S. Department of Health and Human Services, August 1999.

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Metropolitan Service Planning Area (SPA 4) 241 North Figueroa Street, Room 312 Los Angeles, California 90012 Tel: (213) 240-8049 Fax: (213) 202-6096 www.lapublichealth.org Š 2002 SPA 4

The State of Homelessness in Los Angeles County: SPA 4 Profile

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