Seba Alwayel517 Catawba circle Columbia, SC 29201 · 8032372950.docx

Seba Alwayel
517 Catawba circle Columbia, SC 29201 · 8032372950
Sebaalwayel.gmail.com · personal summary
Organized registration information, product warranties, end user
agreements, program user codes, and other data essential to
effective software acquisitions, resource distribution, and asset
utilization.
Keeping to inform future software acquisitions, resource
distribution, and asset utilization. Trusted IT team member
articulated technology forecasts to company directors.
Experience01-01-2014 to 11-12-2014
STC company in Dammam, Saudi Arabia
-translator
- answerd customar quations related to proudacts, servises or
their specific account.
- translate conversations from English to Arbic.
Education
Bachler’s degree in Information technology “IT” major
University of south Carolina.
Graduation date” 09-05-2020
Skills
Speak two languages.
Good communication skills.
Good at persuasion.
Good leader.
Good in bargaining.
Nice behaviors.

2
O R I G I N A L P A P E R
A Transitional Living Program for Homeless
Adolescents: A Case Study
Elissa D. Giffords Æ Christina Alonso Æ Richard Bell
Published online: 7 July 2007
� Springer Science+Business Media, LLC 2007
Abstract Under the Runaway, Homeless, and Missing Children
Protection Act in (P.L.
108-96), Congress authorized the Transitional Living Program
for Older Homeless Youth
(TLP). TLP provides grants to community and faith-based non-
profit and public organi-
zations for longer-term residential supports (up to 18 months) to
youth ages 16–21 in order
to promote their successful transition to adulthood and self-
sufficiency (National Network
for Youth, Issue brief: Runaway and homeless youth act
reauthorization [Available online
at
http://www.nn4youth.org/site/DocServer/NNYandVOAFinalUpd
ate.pdf?docID=304],
2007). This article describes a transitional living program in
Long Island, New York

designed to enable youth in a residential setting (ages 16–21) to
develop and internalize
independent living skills through the provision of shelter and
support services which
prepare them for living independently in the community.
Keywords Independent living � Foster care � Self-sufficiency
� Adolescent youth �
Homeless � Runaway
E. D. Giffords (&)
Social Work Department, Long Island University, CW Post
Campus, Northern Blvd, Brookville, NY
11548, USA
e-mail: [email protected]
C. Alonso � R. Bell
Family and Children’s Association, 100 East Old Country Road,
Mineola, NY 11501, USA
C. Alonso
e-mail: [email protected]
R. Bell
e-mail: RBel[email protected]
123
Child Youth Care Forum (2007) 36:141–151
DOI 10.1007/s10566-007-9036-0
Introduction
In the 1980s the number of Independent living programs to

assist formerly homeless
adolescents and foster youth to develop the skills they need to
sustain themselves in the
community increased significantly nationwide (for, e.g., see
Brickman et al. 1991; Kroner
1988; Lindsey and Ahmed 1999). Many of these programs
received their funding from the
Runaway and Homeless Youth Act (RHYA). The RHYA was
first enacted as Title III of
the Juvenile Justice and Delinquency Prevention Act of 1974
(JJDPA, P.L. 93–415) and
was last reauthorized as part of the Runaway, Homeless, and
Missing Children Protection
Act in October of 2003 (P.L. 108–96). Under this legislation,
Congress authorized the
Transitional Living Program for Older Homeless Youth (TLP),
which continues to provide
grants to community and faith-based non-profit and public
organizations for longer-term
residential supports (up to 18 months) to youth ages 16–21 to
promote their successful
transition to adulthood and self-sufficiency (National Network
for Youth 2007).
Hammer, Finkelhor, and Sedlak (2002) estimated that in 1999,

‘‘1,682,900 youth had a
runaway/thrownaway episode. Of these youth, 37% were
missing from their caretakers and
21% were reported to authorities for purposes of locating them’’
(p. 2). According to the
US Conference of Mayors, unaccompanied youth account for
3% of the urban homeless
population (US Conference of Mayors 1998). The National
Coalition for the Homeless
(NCH 1999) states the reasons that youth become homeless fall
into three inter-related
categories: Family problems, economic problems, and
residential instability. They explain
that many homeless youth leave home after years of physical
and sexual abuse, strained
relationships, addiction of a family member, and parental
neglect. Some youth may also
become homeless following a family’s financial crises from lack
of affordable housing,
limited employment opportunities, insufficient wages, no
medical insurance, or inadequate
welfare benefits. Collins (2001) explains that while recent child
welfare practice empha-
sizes family based services and temporarily removing children

from their homes, in reality
large numbers of youth spend a considerable amount of time in
substitute care, where they
remain until they age-out of the juvenile justice and/or foster
care system. Notably, find-
ings from a study that examined the relationship between foster
care and homelessness
demonstrate an over-representation of people with a foster care
history in the homeless
population (Roman and Wolfe 1995).
According to the Adoption and Foster Care Analysis and
Reporting System (AFCARS
2006), in September 2005 there were 513,000 youth in foster
care nationwide. In 2005,
more than 24,000 youth left or ‘‘aged out’’ of foster care at the
age of 18. This is a 41%
increase since 1998 (The Pew Charitable Trust 2007).
According to studies of young people discharged to themselves
in different states:
12–30% struggled with homelessness; 40–63% did not complete
high school; 25–
55% were unemployed; those employed had average earnings
below the poverty

level, and only 38% of those employed were still working after
1 year; 30–62% had
trouble accessing health care due to inadequate finances or lack
of insurance; 32–
40% were forced to rely on some form of public assistance and
50% experienced
extreme financial hardship; 31–42% were arrested; 18–26%
were incarcerated; and
40–60% of the young women were pregnant within 12–18
months of leaving foster
care (The Children’s Aid Society 2007, p. 2).
As this group matures and ages out of the child welfare system,
‘‘they will confront issues
of independent living, bereavement and trauma, unhealthy
relationships, substance abuse
and domestic violence, sex and sexuality, and anger
management’’ (Children’s Aid Society
142 Child Youth Care Forum (2007) 36:141–151
123
2007, p. 3). Consequently comprehensive services, including
health and mental health,
must be consistently available and adapted for youth at various

stages of their development
and maturation to assist this group make a successful transition
to adulthood (Children’s
Aid Society 2007).
Independent living services are a viable alternative for youth
not quite ready for
emancipation. These services include special programs such as
counseling and training
designed to prepare youth for eventual independence (Hardin
1988). In 1989, the Child
Welfare League of America (CWLA) created standards for
Independent-Living Services
that focus on planning and providing services through a
collaborative effort among
non-profit and public child welfare agencies. CWLA suggests
organizations use a com-
prehensive long-term plan that integrates the activities
necessary to prepare an adolescent
for eventual self-sufficiency. Based on this framework,
programs have developed to assist
this group of at-risk youth with services such as housing,
financial need, mentoring,
community referrals, education, employment, and supportive
counseling.

This article describes one transitional living program that
provides young people (ages
16–21) with shelter and services for up to 18 months in order to
prepare them for living
independently in the community. The tangible and non-tangible
services provided by this
organization assist runaway and homeless youth obtain the
critical knowledge and skills
needed for self-sufficiency.
Family and Children’s Association: Walkabout Programs
Agency Background
Family and Children’s Association (FCA) is accredited by the
Council on Accreditation
(COA), and is one of the largest not-for-profit human service
agencies on Long Island, with
a 45-member Board of Trustees, a staff of 350 employees,
assisted by 250 volunteers, and a
budget of $24 million. The agency was formed in January 1998
as a merger of two non-
profit, secular, community-based human service agencies-
Children’s House (founded as an
orphanage in 1884) and Family Service Association of Nassau
County (founded as a

counseling agency in 1958). Its mission is to protect children, to
help families, and to
strengthen communities by offering assistance to those who are
experiencing social,
emotional or economic difficulties. Agency services are
available to abused and neglected
children from birth through adolescence, homeless or abandoned
teenagers and young
adults and families in crisis. The agency also offers services to
people with mental health
or substance abuse problems, and provides an array of services
for senior citizens. Resi-
dents of the Runaway and Homeless Youth programs utilize
various agency services,
primarily vocational and educational, mental health, and
substance abuse programs.
The Walkabout Programs
Two of FCAs’ independent living programs are Walkabout for
Young Men and Women
and Walkabout II. The ‘‘Walkabouts’’ are transitional,
community-based homes for
homeless adolescents between the ages of 16 and 21. The
programs offer continued

housing and support to young adults with the intent of helping
them live and work inde-
pendently in the community. They provide independent living
skills and money
Child Youth Care Forum (2007) 36:141–151 143
123
management training, vocational and education planning,
assessment, and assistance.
Youth receive individual and group counseling weekly and on
request, family intervention.
Mental health and medical services are offered through other
Family and Children’s
Association’s programs.
Walkabout for Young Men and Women began in 1974 as an
outgrowth of a community
need to house and help adolescents who were homeless and in
crisis. Funding for Walk-
about for Young Men and Women comes from the Nassau
County Youth Board, a Nassau
County Emergency Shelter grant, and the State Food and
Nutrition program. Walkabout II
receives its entire funding from a United States Department of

Health and Human Services
Grant. FCA also raises private donations for the Walkabouts.
While the programs currently
meet all compliance standards, as determined by the Office of
Children and Family Ser-
vices, like many other organizations, the programs would
benefit from additional staff
resources. Current program funding provides for only two
professional social work posi-
tions. All other workers are paraprofessionals with the
responsibility of supplying the
greatest number of client contact hours. This group consists of
eleven residential coun-
selors-two staff each 8-h shift—Six part time weekend, and five
full time staff members.
The staff team at Walkabout for Young Men and Women
maintains minimally a 2:10 staff
client ratio. The six youth at Walkabout II work with a Resident
Assistant, a former client,
who serves as a role model and peer mentor. Program staff
members of the Walkabout for
Young Men and Women are also available to provide ongoing
supportive services and life
skills monitoring to the youth at Walkabout II if needed.

Unfortunately, there is high turnover among the residential staff
members. Keeping this
employee group stable is a challenge for any manager in this
area of practice, since
unwanted staff turnover can potentially interfere with the
program’s continuity and sta-
bility. This group monitors client case plans and oversees the
residence on a regular basis.
Additional financial resources would enable the agency to
increase the number of cre-
dentialed staff and provide greater salaries and professional
development opportunities for
both paraprofessionals and social workers. This may minimize
the cost of staff turnover
and ensure optimal care and growth of each client. Also,
additional funding would benefit
clients’ aftercare and supportive services. While Walkabout’s
aftercare services provide
former residents with numerous supports, including assistance
securing and maintaining
permanent housing, further financial resources would be useful.
For instance, once clients
no longer need housing and 24-h supervision, they may still
require various supportive

services such as counseling, vocational, and educational
assistance. At the current levels of
funding, it is challenging to offer these services.
Referrals to the Walkabout Programs
Typically, youth are referred to the Walkabout Programs from
emergency shelters, schools
(i.e., guidance counselors, social workers, and principals),
community-based organizations,
crisis hotlines, the Department of Social Services, Probation
Department, local police
departments, graduates from drug and alcohol rehabilitation
programs, and self-referred.
As presented in the literature, youth who are referred to FCA
Walkabout Programs are
often experiencing conflicts in their home environment with
their parental figures,
significant others, family members, etc. Sometimes these youth
act out in their homes
because of this conflict and are asked to leave. Often their home
environment is unsafe
because of mental health and drug and alcohol use, thus this
population would benefit from
counseling services.

123
In some cases, families experiencing economic difficulties ask
their 17- or 18-year-old
youth to leave home because supportive housing requirements
often do not permit other
adults to live in housing programs or because financially, the
family cannot afford to
support them. Other youth are referred to Walkabout after living
on the streets following
poor discharge planning from foster care. Lack of affordable
housing in Nassau County
substantially contributes to the difficulties older youth face
when attempting to live
independently with limited or no resources and may find
themselves homeless.
Youth often come to the Walkabouts with a myriad of problems,
including anger
management issues, based on oppressive or abusive home
environments, or filled with
frustration with ‘‘the system’’ that has failed them. Frequently
these youth possess low self-

esteem resulting from a lack of positive relationships or stable
home environments, or
because of sexual or physical abuse. Many of the young women
in the Walkabout pro-
grams are involved in promiscuous behavior and/or abusive
relationships. This is attributed
to several causes including youth not having positive male role
models, or a lack of
positive affirmation in their formative years, as well as the need
for human contact and
acceptance. Many of the youth that are involved in the program
commonly have trust
issues because of past betrayals, including the perception that
prior caseworkers or adults
in their lives made poor decisions on their behalf or that they
failed them in some way.
Clients work one on one with a life skills counselor which helps
to develop their inter-
personal skills.
There is much difficulty securing Medicaid, which creates a
barrier for those youth
requiring ongoing medication. As well, the number of youth in
the Runaway and Homeless

Youth system requiring mental health services has consistently
increased over the past
several years. It is unlikely youth can achieve in this
environment without receiving timely
medication in a consistent ongoing basis.
One goal of the program staff is to work with clients so that
they may become more
resilient, develop healthy attachments, and increase their self-
esteem. Ongoing obstacles
the program faces in meeting this goal are that the
paraprofessionals do not always possess
formal education regarding this at-risk population.
Walkabout Goals and Objectives
The Walkabout programs’ goals are as follows:
• To enable residents to develop and internalize independent
living skills.
• To assist residents in the identification of long range goals.
• To develop belief and commitment that they can accomplish
these long-range goals.
The program has objectives derived from its goals that are as
follows:
• To help residents identify and implement individual
educational/skills training or
employment plans.

• To help residents learn Independent living skills.
• To teach youth to maximize interpersonal relationships and
systems negotiations.
• To help residents learn responsible time management.
• To teach residents how to manage their nutritional needs.
• To teach youth general housekeeping responsibilities, personal
hygiene, and health.
• To expand residents’ individual level of recreational
activities, in order for them to
learn teamwork and to develop healthy outside interests.
123
• To develop moral values by evaluating the pros and cons of
‘‘social norms’’ as defined
by the Walkabout Program.
• To further enhance individual residents’ self-esteem.
Staff members use a Life Skills Assessment Scale to evaluate
and record individual
adolescents’ skills. The Life Skills Inventory Rating Scale
incorporates 13 categories that
the youth are expected to master, including money management,
food management, hy-
giene and health, housekeeping, housing, transportation,
educational planning, job seeking
skills, job maintenance skills, emergency and safety skills,

knowledge of community re-
sources, interpersonal skills, and legal skills. It is expected that
youth will become profi-
cient in all of these areas during their year of housing.
Contracts and Program Phases
When youth enter the Walkabout Programs they sign a contract
agreement that clearly
specifies what their responsibilities are as clients and what
responsibilities they must fulfill
in order to remain in the program. Walkabout agrees to provide
room and board for up to
1 year, counseling services, vocational and educational
planning, information and referral,
and advocacy. The contract explicitly defines the program
guidelines and provides detailed
information about the staff, orientation period, use of contracts,
program criterion, money
management, food preparation, house meetings, curfews,
chores, and other related
requirements.
There are three primary phases of the program. During the
initial phase, individual
clients meet with the social worker for an assessment to develop

a goal plan for all areas of
their lives. An Individual Service Plan is prepared with each
resident within the first
2 weeks of entry, which is reviewed monthly and modified
accordingly for the duration of
the individual’s stay. Beginning with this phase, clients meet
with the social worker for
weekly sessions for the duration of their stay. Clients also meet
with a career counselor
during this time for a vocational/educational evaluation and to
create an employment,
money management, and educational goal plan, which is also
regularly reviewed and
modified. Clients are offered various supportive services to help
them to work toward their
plan. For example, clients may receive scholarships, participate
in resume writing and
interviewing skills workshops, receive help enrolling in school,
and receive GED/SAT
study guides, books, or tutorial assistance.
The middle phase continues the important work established
earlier. Clients generally
maintain their plan efforts and work toward achieving the short-
term goals and skills they

will need to attain their longer-term goal of independent living.
Responsibilities gradually
increase as youth acquire skills, to give them an opportunity to
practice what they have
learned. These opportunities can include food shopping,
opening a bank account, meal
preparation, and help with household chores.
Since the primary goal of the program is to prepare youth for
independent living,
Walkabout staff focus on discharge planning from the moment
clients enter the program.
During the final phase of a client’s stay, 3 months prior to
discharge, the social worker
begins termination of the clinical relationship while the career
and life skills counselors
begin to set up discharge plans based on individual client goals.
Staff members also offer
information and referral services including familiarizing youth
with community resources,
searching for housing, beginning higher education, employment
relocation, and/or
transportation.

123
Clients that still need supportive services enter Walkabout II,
FCA’s second transitional
program. It offers youth an opportunity to demonstrate the skills
acquired at the original
Walkabout program with monitoring and a safety net for error.
Walkabout II is characterized
by less formal structure and supervision, requiring more
responsibility on the part of program
youth. The residents are required to purchase and prepare their
own food, maintain their own
schedules, and pay ‘‘rent’’ to their own bank accounts. The
original program assists youth in
acquiring life skills, whereas Walkabout II enables youth to
apply these skills.
All clients that graduate from Walkabout are eligible for
aftercare services. Youth are
encouraged to come back for assistance with financial aid,
scholarships, banking and
budgeting, workshops, counseling, tax forms, participation in
holiday meals and gifts, and
referrals for food, clothing, and other services as needed. Staff

members are not required to
follow clients beyond 6 months, however many of the youth
remained estranged from
family and counselors often stay connected to former residents
for years, providing an
opportunity for youth to engage in long-term positive
relationships and support. Youth
need these types of services, however challenges in obtaining
adequate funding limits the
amount of staff and resources formally used to provide ongoing
supportive services.
Continuous Quality Improvement and Outcome Measurement
Finding out what works and what does not work for youth is
important to help youth
successfully achieve long-term self-sufficiency. Indeed, it is not
enough to offer services; a
youth’s capacity to become functionally independent relies on
services that work! FCA’s
Walkabout Programs use a continuous quality and performance
improvement (CQPI)
strategic plan, to help managers and staff adapt the program to
its current environment;
clarify the needs of its clients; and set priorities to better meet
its mission. As such, FCA

views CQPI as a commitment to urgently and continually
improve all aspects of the
organization’s functioning as a process that identifies important
improvement opportunities
and involves various stakeholders in the planning and
implementation of these changes.
FCA considers this plan an assurance to the community that
what it is doing is effective
and efficient. Formal quality and performance improvement
planning have demonstrated
that the organization’s services produce positive outcomes for
clients; and the organization
is efficient in the use of its resources (Giffords and Dina 2004).
The CQPI process is
ongoing and explores whether programs such as Walkabouts I
and II have a positive
impact on the lives of those who use their services.
As part of the CQPI plan FCA requires outcome success, quality
assurance monitoring,
and management of the Walkabout programs. FCA has
identified a correlation between
staff productivity, client census, and client success. Program
managers are required to

monitor and record data, and then modify the program and
services accordingly. For this
reason, as seen in Table 1, the Walkabout Programs have
identified Outcome Indicators, to
assess the program’s goal. Client records are reviewed monthly
for milestone independent
living skill achievements, such as money management and
clients’ ability to secure and
maintain employment or pursue educational opportunities. Once
clients have completed
their life skills curriculum and graduate from the Walkabout
Program, FCA provides after
care services for a minimum of 6 months to ensure clients are
able to sustain themselves
in an appropriate discharge setting. For statistical purposes,
FCA records clients as
‘‘successful’’ once this is accomplished.
A review of the outcome indicators as seen in Table 2, reveal
the programs provided
transitional living services to 44 youth in 2005 and non-
residential services to another 168.
123

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123
Walkabout I exceeded projected outcome goals for all indicators
and overall program goal
during the 2005 contract year. Walkabout II achieved a 100%
success rate in both indi-
cators and overall program goal. This suggests youth benefit
from the extended transitional
program service model, where they have the opportunity to
practice their newly acquired
independent living skills.
The following cases illustrate how youth become more
functionally independent as they
move throughout the program:
Diego, a 18-year-old Hispanic male, has had no contact with his
biological father and
very little contact with his mother. He was placed in Lakeview
House, Community
Residence at FCA, when his grandmother became unable to take
proper care of him.
During this time Diego was diagnosed with Bi-Polar and

Borderline Personality
disorder, ADHD and was hospitalized for depression. He was
persuaded to drop out
of High School and attend GED classes in order to keep up with
his graduating class.
He was referred to Walkabout for Young Men and Women after
reaching his goals at
Lakeview House. At the time, Diego was not enrolled in High
School or GED
classes, he was unable to cook or prepare food, and had never
been responsible for
himself. While living at Walkabout, Diego was taken off all
medication and shows
no sign of negative or depressive behaviors. Diego took and
passed his GED and has
since obtained and maintained full-time employment. He
learned to cook and ful-
filled all the requirements of the program including chores,
meetings, and curfews.
Diego shows a high level of maturity at this stage in his life. He
has managed to
maintain savings through excellent money management skills
and the help of the
Life Skills Counselor, which will prove to be helpful upon his

discharge. As with all
entering residents, Diego began on orientation level. During his
stay, he soared up
the behavioral level classification system earning him junior
level status. With the
support of the Walkabout staff, Diego decided to apply to
SUNY Albany in hopes of
being in the entering class of fall 2006.
Vignette #2:
Antoine is a 20-year-old Haitian male who moved to the US 5
years ago at the urging
of his father, after his grandmother’s death. Antoine reluctantly
obliged. He
frequently found himself at odds with his father and new
stepmother. Antoine
Table 2 Program outcomes
Program goal: In a safe, nurturing environment, homeless youth
will acquire the independent living skills
needed to live independently
2005 Outcome indicators 2005
Count
% of census
I-1 Number of youth who acquired or continued to practice

independent living
skills such as: Banking/money mgt; nutrition; time mgt;
personal hygiene;
health; socialization skills
41 93%
I-2 Number of youth who, over the past quarter, attended
school, vocational
training, or were employed
40 91%
I-3 Number of discharged youth who, over the past quarter,
moved into an
appropriate setting for independent living
34 87% of
discharges
I-4 Number of non-residential youth who continued maintaining
independent
living and/or were referred to appropriate housing.
168 NA
123
reported that his father threw him out due to poor school
attendance, although he
stated this was because he was working to support himself as

his father refused to
give him money. Antoine moved in with a friend until the
family moved to Florida.
The family offered to take him with them, but he chose to stay
behind in an attempt
to make a life of his own. Antoine’s guidance counselor at
school recognized that
Antoine was struggling. He soon entered the Walkabout
program. Counselors in this
program recognized that Antoine was unaware of proper
personal hygiene, such as
showering. Antoine also was unable to prepare food/meals
properly and was seen
eating raw meat. With the assistance and guidance of program
staff, Antoine has
become one of the most accomplished residents. Now he is
clean, dresses well, able
to cook full meals, maintain full-time employment, and saved
over $6,000. He is
working toward his GED and attending an FCA
Vocational/Educational Program. He
is eager to begin attending college this fall. Antoine harbors
much anger and
resentment toward his father. However, he expresses interest in

letting go, openly
participating in all social work sessions. This is particularly
notable, because An-
toine’s prior history includes gang involvement, which has
ceased, since he entered
the FCA programs. Antoine remains committed toward his
personal goal of inde-
pendent living and hopes to move on to Walkabout II upon
completion of this
program.
Conclusion
Transitional living programs for older homeless youth assist
them to acquire independent
resources and skills, empowering them to make the difficult
transition to self-sufficiency.
The greatest challenge to providing successful services for this
population is to secure
adequate resources. The costs associated with providing
residential care, and supportive
services necessary to ensure client success continue to escalate
on Long Island. However,
funding has decreased through the years for this group, limiting
the range of services and

available beds, provided by the Walkabout programs. Data on
homeless, runaway, and
throwaway youth (for, e.g., see NCH 1999) suggest a high
proportion of these youth are
living on the streets. Independent living programs offer these
youth an opportunity to make
a successful transition to adulthood. Despite the challenges
faced by many youth before
they entered the program, Walkabout clients are thriving.
Interdisciplinary case manage-
ment services help to ensure youths’ preparedness to live on
their own in the community.
For example, social workers provide psychosocial assessment
and supportive counseling,
adult and peer mentors provide stability and role models, and
employment counselors help
youth to develop work related skills. While program staff and
administrators would like to
do more, the clients are successful. Even with limited resources,
the program assists young
people gain independence through skill building that fosters
pro-social behaviors and
empowers clients to work to their full potential.
Outcome assessment tools enable staff and administrators to

constantly assess and
re-evaluate program goals and services. This is important so
that the program personnel
can formulate strategies to meet the needs of their clients. Staff
members that are aware of
the factors that contribute to youths’ ability to gain the
knowledge and skills they need to
function independently in the community may be able to create
an environment where they
can adapt their program to improve the overall quality of the
services provided to homeless
and at-risk youth by their organization.
123
Future research that addresses both qualitative and quantitative
factors may provide
additional insight into the services that are most effective with
this population and help
provide more evidence that supports increase-funding resources
for independent living
services. Longitudinal research that includes several
organizations may also be valuable in

assisting practitioners and social planners in evaluating the
effectiveness of Independent
Living program. The delicate and complex relationship between
older homeless youth and
transitional, community-based homes like FCA Walkabout
Programs are crucial in the
lives of this population of at-risk young adults.
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http://www.acf.dhhs.gov/programs/cb/stats_research/afcars/tar/r
eport13.pdf
http://www.childrensaidsociety.org/files/Foster_Care.pdf
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http://www.endhomelessness.org/pub/fostercare/webrept.htm
The Journal of Sociology & Social Welfare
Volume 28
Issue 4 December
Article 6
December 2001
Serving the Homeless: Evaluating the Effectiveness
of Homeless Shelter Services
George M. Glisson
University of Georgia
Robert L. Fischer
Bruce A. Thyer
Families First
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Recommended Citation
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(2001) "Serving the Homeless: Evaluating the Effectiveness of
Homeless
Shelter Services," The Journal of Sociology & Social Welfare:
Vol. 28 : Iss. 4 , Article 6.
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Serving the Homeless: Evaluating the
Effectiveness of Homeless Shelter Services
GEORGE M. GLISSON
BRUCE A. THYER
School of Social Work
ROBERT L. FISCHER
Families First
The effects of homeless assistance services at the local level are
tremendously
difficult to ascertain. In this study, a four-month sample of
homeless

persons served by a local homeless shelter and case
management program
were contacted nine to eleven months after receiving services.
The findings
suggest that the program had some initial success in assisting
the homeless
clients to locate housing within the first year after leaving the
shelter.
However, the housing costs paid by these formerly homeless
were quite
high, with nearly three-quarters of them spending forty percent
or more of
their income on housing.
Homelessness continues to be a major social issue facing the
United States. Depending on the criteria used to operationally
define homelessness, the national incidence of the problem has
been estimated to range from a low of 300,000 homeless
persons
to a high of 3.5 million homeless persons (Cordray & Pion,
1990;
Rossi, P., Wright, J., Fisher, B., & Willis, G., 1987). In all, an
es-
timated 34 percent of homeless service users are members of
homeless families, and 23 percent are minor children
(Interagency
Council on the Homeless, 1999).
Policy Context
While the multiple causes of homelessness can be attributed in
part to the scarcity of low-income housing and the inadequacy
of
Journal of Sociology and Social Welfare, December, 2001,
Volume XXVIII, Number 4

90 Journal of Sociology & Social Welfare
income supports for the poor, clearly there are specific groups
of
homeless persons who are in need of special services (Burt,
1999;
Jencks, 1994; Rossi, 1989; Rossi, 1994). These groups include
those
with chronic mental illness, alcohol and drug abusers, persons
with HIV disease, and families with small children (Cohen,
1989;
Cohen & Burt, 1990; Fischer, 1989; Homes for the Homeless,
1998;
Lamb & Lamb, 1990).
While the debate over the principal causes of has continued
several key findings have been identified. First, there is a per-
sistent group of the poorest members of the population, and
among the poorest are children, with some 13 million living in
poverty in contemporary America (A. Johnson, 1989) and an
estimated 1.5 million homeless youth age 12-17 each year
(Ring-
walt, Greene, Robertson, & McPheeters, 1998). Fifty percent of
African-American children and forty percent of Hispanic
children
live in poverty, and the single-parent African-American family
constitutes the fastest-growing segment of the nation's poor and
homeless populations (A. Johnson, 1989). Second, the number
of African-Americans who are homeless is disproportionately
higher than the percentage of African-Americans in the general
population in this country. It has been estimated that, nation-
wide, nearly 60 percent of all homeless persons are African-
American (Homes for the Homeless, 1998), while statistics from

the metropolitan Atlanta Area indicate that approximately 80
per-
cent of all local homeless persons are African-American
(Atlanta
Task Force for the Homeless, 1992). Third, the gap in available
housing for the poor versus the number of households in need of
low-income housing has widened. In 1993, an estimated 10.6
mil-
lion units of low-income housing were available for 14.3
million
households (Low Income Housing Information Service, 1988).
Between 1995 and 1997, the number of affordable units
available
to low-income households nationwide dropped from 44 units
per 100 families to 36 units per 100 families (U.S. Department
of Housing and Urban Development, 2000).
Prior Evaluations of Homeless Services
The amount of research devoted to evaluating programs
aimed at preventing or remedying the problem of homelessness
is exceeded by the numbers of purely descriptive or qualitative
Serving the Homeless 91
studies (Blankertz, Cnaan, & Saunders, 1992; Johnson, &
Cnaan,
1995). Some recent work has focused on services for particular
categories of the homeless, for example, the homeless mentally
ill (Caton, Wyatt, Felix, Grunberg & Dominguez, 1993; Segal &
Kotler, 1993), and homeless families (Fischer, 2000; Rog,
Holupka,
& McCombs-Thornton, 1995; Rog, McCombs-Thornton,
Gilbert-

Mongelli, Brito, & Holupka, 1995). In addition, the challenges
of conducting research with homeless and formerly homeless
clients continues to be examined (Orwin, Sonnefeld, Garrison-
Mogren, & Smith, 1994). Overall, the existing research on
housing
outcomes of homeless shelter services consists of primarily
small-
scale samples of clients, obtained from single communities, and
with considerable attrition in the sample at follow-up.
Program Context
Homeless shelter services in northeast Georgia have ex-
panded considerably during the last two decades. In 1974 only
four shelters for homeless persons could be found in the metro-
politan Atlanta Area, whereas presently approximately one hun-
dred shelters are available (Atlanta Task Force for the
Homeless,
1992; Research Atlanta, Inc., 1997). In the local area of Athens,
Georgia, during the period of this study, over 3,300 persons
were
at risk of living in the streets, in shelters, and in overcrowded
living circumstances, and thirty-six percent of persons that
stayed
in area shelters were children under the age of eighteen
(Glisson,
1992). The primary local shelter for the homeless in Athens,
Georgia, is the Athens Area Homeless Shelter (AAHS). The
AAHS
placed over 250 persons into permanent housing through its
case
management services and shelter program during the year in
which this study was conducted. However, follow-up informa-
tion on formerly homeless persons regarding the "durability" of
these placements has not been available. An exploratory
program

evaluation of the AAHS was undertaken in an attempt to deter-
mine what happens to the former clients of the homeless shelter
after they leave the facility.
Method and Procedures
The present study involved an effort to evaluate homeless
shelter services at the local level. The research included a
review
of program case records and a post-program follow-up with a
sample of formerly homeless individuals.
Homeless Shelter Site and Program Services
The Athens Area Homeless Shelter (AAHS) was established
in December 1986 and can accommodate up to 32 individual
homeless persons in a dormitory-style arrangement, with sep-
arate dorms for men and women. Parents and their children
can reside in three separate private rooms, each sleeping up to
persons.
The intervention used with these homeless individuals con-
sisted of a comprehensive set of services including physical
shel-
ter, meals, employment counseling, case management services,
supportive counseling, health care referral, clothing supply, and
other social services. The primary goal of the AAHS program
is to assist clients in obtaining safe, affordable and relatively
permanent housing following their departure from the shelter.
Secondary goals include assisting shelter clients to obtain em-
ployment and to improve their health through proper nutrition

and medical care.
Research Design
The base client sample consists of all persons who received
AAHS residential services during a four-month period (June to
September, 1991), and had a history of residing in the vicinity
of Athens, Georgia. Attempts were made to contact all these
individuals by telephone or by personal interview approximately
9-11 months following their departure from the Shelter.
A one-page semi-structured interview protocol was devel-
oped to assess the following aspects of the lives of former
AAHS
clients: respondent's current living situation, living costs, length
of time at current address, employment and income, perceptions
about the safety of their home, and views regarding the AAHS
services they had received. The post-test-only design used in
this evaluation enables a determination as to what happened
to former shelter clients, but not an unambiguous attribution of
causation for any positive outcomes, due to the lack of controls
inherent in such a research design. Nevertheless, since the
AAHS
(and most other homeless shelters) had little systematic
informa-
tion on the housing disposition of their clients after they left the
shelter, the present inquiry was seen as a valuable first step in
documenting the possible outcomes of shelter services.
Survey Results
For the purpose of this study, the unit of analysis is a "head-

of-household" and represents either an individual person who
sought shelter services solely for him/herself, or the head of
a family (e.g., a husband/wife, or a single parent with one or
more children). A total of 124 households (individuals or heads
of
families accompanied by family members) representing 166
men,
women and children had received residential services during the
sampling time frame. Based on client records maintained by the
AAHS, at entry into the program, 75 percent of the sample
group's
earnings were below the federal poverty line for the relevant
size of household groups. Sixty-six percent of the sample group
members were African-American, 30% were white, 4% were
His-
panic, and less than one percent was Asian. Although African-
Americans make up the majority of homeless persons served at
the AAHS (as well as of our sample group), African Americans
comprise only approximately one-quarter of the general popu-
lation in the Athens metropolitan area. The sample groups' stay
in the AAHS averaged nearly three weeks, but ranged from one
night to six months.
Of the 124 households, intake information indicated that 100
households (81%) had a history of residing in the Athens
vicinity.
The researchers with the assistance of AAHS staff sought out
these individuals and families for the purpose of conducting a
follow-up interview. The follow-up efforts resulted in contact
with 71 of the 100 Athens-resident households (71% response
rate) for follow-up interviews. The remaining 24 households
were
not contacted due to a lack of information in their client file
and were unable to be traced. Thus, the housing circumstances
of these 24 nonrespondent households are unknown. However,

a follow-up contact rate of 71% is a substantially higher than
would be expected, considering the nature of homelessness (A.
K.
Johnson, 1989).
At follow-up, which ranged from 9-11 months (average of
38 weeks) following the client's departure from the AAHS, 41
of the 71 former clients (58%) held contractual agreements (i.e.,
leases) in their own name, indicating that they occupied
relatively
permanent housing. The former clients had, on average, resided
in their current home for eighteen weeks, with a range from one
week to 50 weeks. Some of the housing characteristics and
living
circumstances of the former AAHS clients are presented in
Table 1.
Nearly a third (31%) of the clients had maintained their follow-
up home for six or more months, and 35% had lived in their
home
the entire period of time since leaving the AAHS.
Data on monthly housing costs were obtained from 51 of
the 71 former clients (72%); the remaining 20 persons did not
provide this information or had no direct housing costs, such
as instances in which the individual was living with a relative.
For these 51 respondents, their monthly rent averaged $186 and
utilities averaged $47, for a mean total monthly housing cost of
$233 (range = $50 to $645). Monthly income for the 51 clients
reporting housing costs averaged $503, and thus these individ-
uals expended approximately 46% of their monthly income on

Table 1
Housing Environment and Living Circumstances of Shelter
Clients
Contacted at Follow-Up (n = 71)
Housing Type at Follow-up
Apartment 36.6%
Mobile home 15.5%
Single-family home 12.7%
Duplex 8.5%
Rented room 8.5%
Living Circumstances at Follow-up
Living alone 18.3%
Living with relatives 16.9%
Living with own child(ren) 14.1%
Living with friend(s) 12.7%
Living with boy friend 9.9%
Living with spouse 5.6%
Living with roommate 4.2%
Other circumstances* 18.3%
includes living on the streets, in a 3helter, etc.
housing. Of the 51 households reporting, 39 households were
residing in private housing and 12 households were in public
housing. Overall, 20 households' (28%) percentage of monthly
income spent on housing costs was over 50 percent.
Surprisingly,
6 of the 12 households living in public housing (50 percent) re-

ported spending 50 percent or more of their income on monthly
housing costs. Although the clients' rents were set at 30 per-
cent of their monthly income, utility costs pushed half of these
persons' monthly housing costs above the 50 percent threshold.
Additionally, 14 of the 39 private housing households (36%) re-
ported monthly housing costs of over 50 percent of one's
monthly
income. Sixty of the 71 respondents provided information about
their monthly income, and according to these data, 55 of the 60
households (92%) earned less than the federal poverty standard
($9,100 for a single individual in 1992; $13,700 for a family of
three). For the African-American households reporting housing
costs, monthly housing costs consumed 50% of their monthly
income, while for the white households these costs amounted to
39% of their income. White and African-American households
had entered into contractual housing agreements (i.e., leases)
in approximately the same proportion (60%). African-American
households moved fewer times (M =.88 times) than white
house-
holds (M = 1.4 times) and, on average, the 51 African-American
households had lived in their present living arrangements for 18
weeks while white households had done so for 16 weeks.
One key dimension of a desirable housing situation for home-
less individuals and families is the level of safety. Overall, the
clients' average perceived safety rating of their present home
was 3.0 (O.K.), but a difference was present in that those living
in public housing (n = 12) provided an average safety rating of
2.3 while that for the 32 respondents residing in private housing
gave a mean rating of 3.2. Clearly former clients living in
public
housing projects felt less safe in their home and environment
than
those in private circumstances.
Discussion

The findings presented here can be cautiously seen as posi-
tive. A majority of the respondents (58%) were residing in
stable
housing situations at the time of the follow-up interview, and
nearly half (45%) had resided in their current dwelling for about
four months since their departure from the homeless shelter. On
average, the formerly homeless persons rate the safety of their
homes as acceptable.
In relative terms, the housing costs of these formerly homeless
individuals and families are high: 36 of 51 respondents (71%)
spend 40% or more of their income towards housing costs, well
above the U.S. Department of Housing and Urban
Development's
standard of 30% as an appropriate proportion of one's income
which should apply towards housing. Only 6 of the 51 respon-
dents (12%) paid less for housing than this federal standard.
Thus,
it would seem that most of the AAHS clients remained at-risk in
terms of their ability to maintain a stable home situation, given
the large proportion of their income going towards housing
costs.
After a short stay in the homeless shelter, the majority of these
individuals are able to locate relatively safe, affordable and
stable
homes. It should be noted, however, that the majority of the
AAHS
former clients continued to live in poverty and perilously on the
verge of a return to homelessness.

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The Journal of Sociology & Social WelfareDecember
2001Serving the Homeless: Evaluating the Effectiveness of
Homeless Shelter ServicesGeorge M. GlissonRobert L.
FischerBruce A. ThyerRecommended CitationServing the
Homeless: Evaluating the Effectiveness of Homeless Shelter
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Co-Location of Health Care Services for Homeless
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Jessica Blue-Howells LCSW , Jim McGuire PhD LCSW & John
Nakashima PhD
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WSHC0098-13891541-034XSocial Work in Health Care, Vol.
47, No. 3, June 2008: pp. 1–20Social Work in Health Care

Co-Location of Health Care Services for
Homeless Veterans: A Case Study of
Innovation in Program Implementation
Blue-Howells, McGuire, and NakashimaSOCIAL WORK IN
HEALTH CARE
Jessica Blue-Howells, LCSW
Jim McGuire, PhD, LCSW
John Nakashima, PhD, MSW
ABSTRACT. This case study examines how the Veterans
Affairs
Greater Los Angeles Healthcare System (GLA) improved
homeless vet-
eran service utilization through program innovation that
addressed service
fragmentation. The new program offered same-day co-located
mental
health, medical, and homeless services with a coordinated
intake system.
Jessica Blue-Howells is Study Coordinator, the VA Greater Los
Angeles
Healthcare System, West Los Angeles Healthcare Center, Los
Angeles, California.
Jim McGuire is VA Program Manager, Homelessness Prevention
and Incarcer-
ated Veterans Programs, and VA NEPEC Project Director,
CHALENG Evalua-
tion, at Department of Veterans Affairs Northeast Program
Evaluation Center
(NEPEC) and UCLA School of Public Policy and Social
Research, West Los

Angeles Healthcare Center, Los Angeles, California.
John Nakashima is Program Analyst, Veterans Affairs Greater
Los Angeles
Healthcare System, West Los Angeles Healthcare Center, Los
Angeles, California.
The authors acknowledge the program innovators at Veterans
Affairs Greater
Los Angeles Healthcare System: Steve Berman, MSW, Robert
Ely, PhD, William
Daniels, MSW, Debbie Dyckoff, RN, MSN, Mariquita McBride,
MSW, Joan
Brosnan, RN, PhD, and Gloria Martinez, RN, and the dedicated
primary care,
homeless, and mental health staff who implemented the
innovation and made high
quality service to homeless veterans a reality.
Address correspondence to: Jessica Blue-Howells, VA Greater
Los Angeles
Healthcare System, West Los Angeles Healthcare Center, 11301
Wilshire Blvd.,
Mail code 10H-5, Building 206, room 112A, Los Angeles, CA
90073 (E-mail:
[email protected]).
220 SOCIAL WORK IN HEALTH CARE
The program is analyzed using a framework proposed by
Rosenheck
(2001) that has four phases: the decision to implement, initial
implementa-
tion, sustained maintenance, and termination or transformation.

GLA was
able to successfully implement a new program that remains in
the sustained
maintenance phase five years after the initial decision to
implement. Key
factors from the Rosenheck innovation model in the program’s
success
included coalition building, linking the project to legitimate
goals, program
monitoring, and developing communities of practicing
clinicians. The key
lesson from the case study is the need for a coalition to
persistently
problem solve and act as advocates for the program, even after
successful
initial implementation. Social work leadership was critical in all
phases of
program implementation.
KEYWORDS. Program innovation, program implementation,
homeless,
veterans
INTRODUCTION
People who are homeless have many health needs (Institute of
Medicine,
1988; Interagency Council on the Homeless, 1992; O’Connell,
2004;
Randolph, Balinsky, Leginski, Parker, & Goldman, 1997; Wood,
1992).
Homeless people are at higher risk than non-homeless
populations for med-
ical problems such as hypertension, diabetes mellitus, upper
respiratory
infections, gastrointestinal problems, and podiatry problems

(Gallagher,
Anderson, Koegel, & Gelberg, 1997; Wright & Weber, 1987).
Although
people who are homeless have great need for health care
services, they
often underutilize health care (Kushel, Vittinghoff, & Haas,
2001). Barriers
to care can be divided into two types: patient-related (e.g., lack
of personal
health insurance, competing survival needs) and institution-
related (e.g.,
negative provider attitudes toward the homeless, limited
services, cost of
health care coverage) (Gelberg, Gallagher, Anderson, & Kogel,
1997;
Kushel et al., 2001).
One major institutional barrier is service fragmentation, in
which ser-
vices are provided at different locations, and have separate
admission pro-
cedures (Dennis, Cocozza, & Steadman, 1998; Drury, 2003;
Interagency
Council on the Homeless, 1992). An example of service
fragmentation
was the homeless veteran service provision by the Veterans
Affairs (VA)
Greater Los Angeles Healthcare System (GLA) in the 1990s.
Los Angeles
has the largest concentration of homeless veterans in the United
States:
Blue-Howells, McGuire, and Nakashima 221

There are an estimated 21,424 homeless veterans in the GLA
service area
(Nakashima, Burnette, McGuire, & Edwards, 2006). By the late
1990s,
GLA had developed many transitional housing and
rehabilitation pro-
grams for homeless veterans (Nakashima, McGuire, Berman, &
Daniels,
2004). Yet in 2000 a review of medical care utilization found
that
GLA-enrolled homeless veterans had only one-third of the
medical visits
that non-homeless enrolled veterans did, and 22% of homeless
veterans
enrolled at GLA had never received a full physical or mental
status exam
(McGuire, Blue-Howells, & Nakashima, 2003)
An important reason for this underutilization was service
fragmenta-
tion. Services for homeless veterans were offered by separate
departments
(homeless, mental health, ambulatory care) in different
buildings on the
campus that were half a mile apart. The existing referral and
scheduling
systems resulted in wait times of several months for specialty
care and
even routine examinations. It was believed that these distance
and time
barriers promoted service underutilization, especially for
homeless
patients who suffered from serious medical or cognitive
disabilities.
Clearly, GLA had service access issues.

CASE STUDY PURPOSE
There are two purposes to this article. The first is to examine
how GLA
improved homeless veteran service utilization by addressing
service frag-
mentation through program innovation. Program innovation at
GLA was
based on a model developed at the West Haven VA that
integrated medical
and mental health care at one clinic location for mental health
patients and
established the effectiveness of that model (Druss, Rohrbaugh,
Levinson,
& Rosenheck, 2001). GLA’s program was innovative in two
ways: (1) it
modified the West Haven model to address the specific needs of
homeless
patients by co-locating medical, mental health, and homeless
services
(such as housing and vocational rehabilitation), and (2) it
created an
access center for homeless veterans that conducted screening,
assessment,
and referral to all services on a one-stop basis to promote
continuity and
rapidity of care. (Note: results from a formal evaluation of
patient
outcomes will be presented in a separate article.)
The second purpose of this article is to examine the
implementation
process of the new program. This case study is important
because while
other health care systems have co-located or integrated services
for spe-

cific patient populations, there are few descriptions of the
challenging
implementation process in the literature (Kirchner, Cody,
Thrush,
Sullivan, & Rapp, 2004; Wilde, Albanese, Rennells, & Bullock,
2004).
One recent example of integrating services offered by Indyk and
Rier
(2006) examined a linkage approach for multiple providers to
address
HIV/AIDS services. Our article examines both facilitating
factors and
barriers faced using a framework articulated by Rosenheck
(2001) who
synthesized multiple organizational theories to explain the
translation of
research to practice within complex, bureaucratic organizations.
Rosenheck identifies four phases in program implementation:
(1) the
decision to implement, (2) initial implementation, (3) sustained
mainte-
nance, and (4) termination or transformation. Key strategies for
successful
implementation during these phases are coalition building,
linking the
new program to legitimate organizational goals, program
monitoring, and
creating communities of practicing clinicians.
Implementation begins with the decision to implement, in which

coalition building (mobilizing stakeholder support) and linking
the new
program to legitimate organizational goals (i.e., validating the
necessity
of the program) are critical. Next, in the initial implementation
phase, the
model specifies pursuing and securing commitment of resources
(funding,
staffing, physical plant, etc.) as the strategy that allows the
program to
begin. Program monitoring (process evaluation) during this
phase facili-
tates implementation by ensuring the new program adheres to
program
design and goals.
As the program matures, the model indicates that sustained
mainte-
nance requires a strategy of maintaining continued institutional
support
for funding and other resources. Also critical is participation
from new
communities of practicing clinicians. These communities are
providers
from different disciplines and clinics who coalesce into a team
committed
to improving and maintaining the program. Thus, the program
innovation
becomes institutionalized as its stakeholders accept the new
program as a
standard of care.
Sustained maintenance is a desirable end goal. Some programs,
however,
enter a final stage, termination or transformation, in which the
program

closes or its goals and practices are radically altered so it no
longer resem-
bles its original form. Reasons for program
termination/transformation
include: shifts in organizational goals/objectives, de-emphasis
of certain pro-
gram elements, and lack of successful outcomes to justify its
continuation.
The following sections follow the Rosenheck implementation
frame-
work with its key concepts to explain GLA’s program
innovation in
serving homeless veterans.
THE DECISION TO IMPLEMENT
The leader of the implementation effort was GLA’s Community
Care
Careline director, a social worker, whose responsibilities
included the
medical center’s homeless programs. At GLA, he had developed
a reputa-
tion for creating innovative programs that addressed patient
need and
reduced medical center costs through greater efficiency
(Nakashima et al.,
2004). In early 2000, the Community Care director and his staff
devel-
oped a VA grant proposal to create an integrated system of
clinics for
homeless veterans to be housed in one building. The proposed

program
would be based on a primary care/mental health model piloted
at the West
Haven VA.
As a crucial first step, the Community Care director built a
coalition of
decision makers. Coalition members were identified based on
their exper-
tise and their authority over important resources (such as mental
health
and substance abuse services). Importantly, the GLA Medical
Center
director was informally part of the coalition. The Medical
Center director
believed the new program would better meet the health needs of
homeless
veterans, a legitimate organizational goal because homeless
veterans were
a national VA priority, special needs population. Also, from an
efficiency
perspective, the new integrated program would free up general
primary
care resources for GLA to serve non-homeless veterans. The
program was
also in line with VA’s new Advanced Clinic Access program,
which pro-
moted increased efficiency by matching patient demand with
clinic
resources.
The proposed program’s merit and its support from the GLA
Medical
Center director and other managers made the proposal attractive
to VA
Central Office (VACO) funders. In January 2001, the proposal

was
approved for $1.5 million for 2 years of VACO funding to be
matched by
$2.2 million in local funds to launch the innovation.
Importantly, the new program faced pre-implementation barriers
because of finances. The Medical Center was running an annual
budget
deficit of $10–15 million. Although the program had grant
funding, it still
needed resources from other GLA departments for
implementation. Many
of these financially strained departments were reluctant to
commit
resources. For example, Ambulatory Care managers were afraid
they
would have to temporarily assign existing primary care staff to
the new
program (an overall GLA hiring freeze in 2002 delayed the
hiring of new
staff—even when grant funding was available for the new
position). In
response, the coalition explained to Ambulatory Care managers
how the
new program would reduce the overall demand on Ambulatory
Care by
providing primary care services for homeless veterans (about
6,000
patients receive homeless services annually at GLA). After
some discus-
sion, Ambulatory Care agreed to assign a primary care

physician provider
for the new program’s startup.
The coalition also had difficulty in getting cooperation from
Engineering,
which controlled building usage. The proposed program site, a
three-story
building on the West Los Angeles campus, needed costly
renovation
including flooring, re-wiring, and installation of a new
cooling/heating
system. To address budget concerns about the renovation, the
coalition
met several times with Engineering managers. Ways to
efficiently use
existing physical resources were identified and agreements
reached.
Eventually, building renovations were completed.
INITIAL IMPLEMENTATION
In July 2002, the integrated clinic opened. The goal of the new
program
was to integrate patient care by co-locating programs and
services in one
building. At this facility a veteran could receive medical,
mental health,
substance abuse, and housing services—all in one day, thus
reducing the
chance of appointment no-show. This process was facilitated by
a central
intake and assessment office (called the Access Center) that
evaluated the
veteran’s needs and directed the client to appropriate providers
in the
building. Clinics now co-located in one building (homeless,

mental health,
primary care) agreed to honor the Access Center’s assessment
and provide
services on a same-day basis. There was also a future plan to
add a medical
case manager. This case manager would follow patients with
chronic con-
ditions to facilitate their ongoing VA care after their initial
visit.
One innovation in the program’s early operation was a new
model of
primary care delivery. Traditionally, GLA assigned each patient
a primary
care provider to coordinate both general internal medicine and
specialty
referral needs (Veterans Health Administration, 1998);
unfortunately,
waiting times for the initial primary care provider visit could
take several
weeks. In the new program, homeless veterans now had a
primary care
provider they could see on a same-day basis. Further, the new
primary care
model focused on services and disease-specific clinical
practices applica-
ble to a homeless population, including infectious disease
screening and
treatment, chronic pain management, and hypertension
management
(Healthcare for the Homeless Information Resource Center,
2004).

Another success was the effective use of program monitoring in
guiding
the initial implementation. Social work research staff developed
a three-
year longitudinal comprehensive program evaluation and a
periodic moni-
toring process that reviewed the chart of each patient to ensure
that
services were offered in an appropriate and timely manner. The
monitoring
information was reported to a weekly operations meeting of
clinic manag-
ers who used the trended data to identify problem areas, make
corrective
adjustments in staffing and programming, and assess the impact
of the
adjustments. For example, based on aggregate information
regarding
patient traffic flow and need, clinic managers arranged the
schedules of the
Primary Care Clinic providers to accommodate more walk-in
patients, and
instituted an on-call system to offer same-day psychiatry
assessments.
The new program also found creative ways to work with other
GLA
clinics. For example, some homeless patients needed specialty
services at
the GLA Optometry and Dental Clinics. These clinics, however,
were still
on a traditional consult/appointment-based system that could
require a
several-week to several-month wait. To increase access, the
program

established a same-day system with the specialty clinics. When
a home-
less veteran needed services, the specialty clinic was called
directly; if
there was a slot available due to an appointment cancellation or
no-show,
the homeless veteran was seen immediately.
Despite its early successes the new program faced many
challenges. As in
the pre-implementation phase, GLA’s ongoing budget crisis was
the major
issue. A proposed plan to add a Dental Clinic was cancelled
because there
were insufficient supplemental Medical Center funds. Blanket,
cost-saving
freezes stalled all hiring— even for the new program, which had
set-aside,
grant funding for staffing. For example, the Primary Care Clinic
could not
immediately implement same-day physical exams and walk-in
appointments
because it did not have a doctor to consult with nurse
practitioner staff, and
could not institute a nursing triage function due to a nursing
shortage. The
clinic was also unable to hire the medical case manager as
planned in the
program model. In response, the program’s coalition
persistently presented
their staffing requests to the Medical Center executive staff who
used their
influence with GLA’s Human Resources Department to expedite
the hiring
process. Eventually, the program did meet many, but not all, of
its staffing

requirements. (The case manager position remained unfilled and
thus the
patient medical case management component was not
implemented.)
Another significant challenge was the clash of cultures between
clinic
staffs. For example, the Access Center was staffed with
Homeless Clinic
paraprofessional technicians who implemented the initial
assessment
plan. Homeless Clinic managers felt that paraprofessional
staff—many
who were former homeless veterans—engaged patients well and
dis-
cerned manipulative patient behavior that affected the
usefulness of the
initial assessment plan. Mental Health and Primary Care Clinic
managers,
however, believed that the plans should be overseen by licensed
staff due
to the complex nature of adding medical and psychiatric
assessments to
the case plan. The issue was resolved by having a clinical social
work
coordinator oversee all cases and assign the most complex cases
to pro-
fessional-level staff. Paraprofessional staff were still involved
in most
cases, resulting in an optimal blend of staff expertise and
experience.

Finally, safety was an important consideration. Staff
accustomed to
working with homeless patients were fearful of mental health
patients and
staff accustomed to mental health patients were fearful of
homeless
patients. In response, clinic managers implemented a series of
actions
including: Professional Assault Response Training (PART) for
staff,
installation of a building panic alarm system, and establishing a
rapid
response arrangement with VA campus police. Also, through
negotiation
with the VA campus police chief and the Medical Center
Director, a full-
time contract security guard was assigned to the program.
In sum, the program in its initial implementation phase was
successful
in modifying and adapting its programs and procedures to
address the
needs of its patients. Challenges such as staffing, clinic culture
clashes,
and safety concerns were addressed by coalition members
meeting,
changing practice as necessary, and presenting issues to medical
center
leadership on an ongoing basis.
SUSTAINED MAINTENANCE OF THE PROGRAM
The sustained maintenance phase of a program’s implementation
is
characterized by ongoing commitment to its existence by

stakeholders
including staff and the institution. Stakeholder commitment to
GLA’s
program innovation came in the form of new communities of
practice,
GLA management’s approval of the program’s performance, and
resource
commitment by VA.
Communities of Practice
A key component of sustaining the program was developing
communi-
ties of practice where clinicians from different disciplines and
clinics
coalesced into a team committed to maintaining and improving
the pro-
gram. Social workers played a key role in facilitating
communication and
collaboration between workers, which resulted in communities
of practic-
ing clinicians. For example, Primary Care Clinic staff worked
closely
with staff from an on-campus private nonprofit homeless
veteran residen-
tial program so many of its residents could use the Access
Center for their
ongoing mental health and medical needs without tying up
resources for
new, walk-in clients. Another example was Homeless and
Mental Health

Clinic staffs working together to develop an effective process
for same-day
psychiatric screening for homeless patients.
GLA Management Approval
The program innovation’s performance convinced GLA
management
of its value. The program’s patient volume was large. During
the four
years between opening in July 2002 and March 2006, the new
program
saw over 9,000 veterans in over 45,000 visits. Although the
population
was more complex than the general primary care population, the
pro-
gram’s primary care clinic provider panels were maintained at
the same
level as the general primary care clinic, with 900 patients
assigned to a
full-time nurse practitioner and 1,200 assigned to a full-time
doctor. In
terms of quality, during this same period, the program’s primary
care
providers were completing recommended health screening and
proce-
dures at a higher rate than providers at Ambulatory Care
services,
which provided primary care for the general GLA population.
Regard-
ing patient safety, there were no incidents of staff members
being
assaulted or injured by patients during the two years of project
pilot
funding.

Also, the new integrated homeless program helped attract new
patients
to GLA. This was important because of VA’s current capitated
financing
system, which pays each VA medical center a minimum of
approximately
$3,000 for every patient enrolled and assessed.
Resource Commitment to the Program
Impressed by the program’s success, the VA Central Office
added an
additional year of funding at the end of the two-year pilot grant.
In a short
time, the program became institutionalized by VA; that is, it
was now
considered by the Veterans Health Administration (VHA) to be
a standard
of care for homeless veterans. The VHA Mental Health
Strategic Plan
(2005) recommended replication of the homeless veterans
integrated care
model at VA sites nationwide and GLA received numerous
inquiries from
other VAs on how to implement a similar program.
TERMINATION OR TRANSFORMATION?
As noted in the Rosenheck framework some programs remain in
a sus-
tained maintenance phase; others terminate or transform into

something
different from the original model. Now in its fifth year (in
2007), the GLA
program innovation is still in a sustained maintenance phase.
The basic
model of providing co-located services with a central access and
intake
system was executed faithfully and will likely remain in
operation, given
ongoing institutional support and the legitimization of the
model in the
VHA Mental Health Strategic Plan.
PROGRAM AND CASE STUDY SUMMARY
This case study describes an innovative program designed to
address
lack of timely access to services for homeless veterans by co-
locating
clinics in one building and creating an access center to
coordinate entry to
all needed services. Rosenheck’s stage model helped identify
significant
elements at each stage of its development. The program was
successfully
implemented and is currently being sustained at GLA.
In terms of program innovation, the GLA integrated homeless
project
addressed service fragmentation for homeless veterans due to
institutional
barriers like geographic distance and waiting time. It offered
co-located
mental health, medical, and homeless services, which were
coordinated
through one intake system and offered on a same-day basis. The

program’s
staff developed new innovations like blending traditional
primary care
and homeless care, which resulted in coordinated and quicker
services for
veterans. Since its inception, the program has served thousands
of home-
less veterans, and improved their access to medical care, mental
health
treatment, and social services. The program has been recognized
as a best
practice and its profiling in the Veterans Health Administration
current
mental health strategic plan may result in its replication
throughout the
national system.
Creation of a coalition and linking the project to legitimate VA-
wide
goals (i.e., serving homeless veterans) was crucial in getting the
program
approved by GLA and funded by the VA Central Office.
Initially,
program implementation was fostered by creative problem
solving and
ongoing program monitoring that helped modify the program to
meet the
needs of patients. The program’s sustained maintenance can be
attributed
to stakeholder commitment in terms of providers coalescing into
a team

of advocates for the program (communities of practice), the
Veterans
Health Administration (VHA) acknowledging and
institutionalizing the
program as a best practices model, and VHA and GLA
dedicating
resources to maintain the program.
Nevertheless, implementation goals were not fully realized or
were
severely delayed—due mainly to a climate of fiscal restraint at
a deficit-
burdened medical center. A case management system for
assisting veter-
ans with chronic illnesses to interface more effectively with
specialty
clinics was unable to be implemented. Most needed medical
center
resources and cooperation were obtained, but this required
several
rounds of lengthy discussion and negotiation with GLA
managers. Coali-
tion leaders repeatedly and successfully argued that treating
homeless
veterans and getting them off the streets was an essential
institutional
goal for GLA.
The most important lesson from this case study is the need for a
dedi-
cated coalition of leaders to persistently problem solve
throughout the
implementation process. The GLA coalition was critical in
gathering
resources needed in addition to grant funding such as staffing,
and building

renovations and repairs. Building a coalition is an important
first step to a
successful implementation. Coalition members should be
selected for their
expertise, their authority (power) in the organization, and their
diligence.
In this project, social workers took the lead in identifying the
need for
the clinic— that a vulnerable population lacked access to
critically needed
health care. Social workers recognized that a project of this
scope could
not succeed without intensive collaboration over time with other
disci-
plines, such as nursing, medicine, and psychiatry. Social work
engaged
these disciplines in the multiple tasks leading to the
implementation and
operation of the new program, managing interdisciplinary
conflict as it
arose. Social work leadership was critical in sustaining program
mainte-
nance, providing process evaluation as the program was
implemented,
and organizing and encouraging development of communities of
practic-
ing clinicians. Social work researchers developed and executed
the pro-
gram evaluation. These core social work values and skills aided
organizational change and guided and sustained this innovative
program
that ensured that this underserved veteran patient population
actually
obtained the services they needed.

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DATE RECEIVED: February 23, 2007
ACCEPTED FOR PUBLICATION: April 9, 2007
The Journal of Sociology & Social Welfare
Volume 37
Issue 1 March Article 8

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