Home > The Hidden Costs of Homelessness in Nashville: A report on the
Vanderbilt University Center for Community Studies
Douglas D. Perkins, Ph.D., Director Email: d.perkins@vanderbilt.edu
Peabody College, Box 90 http://peabody.vanderbilt.edu/ccs/
Nashville, TN 37203-5701 Voice: (615) 322-3386
The Hidden Costs of Homelessness in Nashville:
A Report
to the Nashville Metro Homelessness Commission
By Courte C.W.
Voorhees, Scott R. Brown & Douglas D. Perkins
EXECUTIVE SUMMARY
The costs of homelessness, in terms of services and systems of care, must be understood to better inform policy-making. Currently those costs are generally unknown because they are spread across many public and private agencies that do not readily share cost and budget information or do not separate costs for serving the homeless population; some may be difficult to quantify; mostly costs of homelessness are elusive because people experiencing homelessness themselves tend to be “hidden.” Also, the methods and resources to track, analyze and report costs have not been standardized or made transparent and regularly reported.
This study aims to shed light on the economics of homelessness in Nashville. We draw on, and where possible try to improve upon, the data sources and analytic approaches of similar studies in other cities across the U.S. In addition, for comparative purposes, we estimated the costs of providing permanent housing for homeless persons, both including and not including supportive services, and the differences in expenditure for all options to provide a cost-efficiency analysis.
Methods. Six trained Vanderbilt students conducted interviews with homeless people, service providers, and outreach workers throughout Nashville. Archival data were also used to construct costs directly and to estimate unavailable figures. Homeless participants were only excluded from the study if they were under 18 years old, were unable to understand the consent form, or did not speak English. Once the initial convenience sample was gathered, an effort was made to make the final sample (n = 105) as demographically representative of the 2,227 homeless persons identified in the 2008 Nashville Homelessness Count as possible. Respondents were, on average, 45 years old; had lived in Nashville an average of 35.5 years (median 12 years); 75% were male; 62% self-identified as African-American; almost all were single, divorced or widowed. Only 2.7% were veterans of the armed forces, which likely under-represents the adult homeless veteran population. Median income for respondents was $2,800 (mean $4,641); 71.4% of participants had been homeless for one year or more prior to the interview; participants had spent an average of 3-5 years on the streets or in shelters; 52% met the criteria for chronic homelessness. We believe this percentage in the sample to be representative of the Nashville count, regardless of some estimates that chronic homelessness makes up about 10% of homelessness nationally. Participants were interviewed at shelters, on the street, and in advocacy centers.
Key informants (n=17 outreach and service workers, program administrators) were interviewed (by phone, email or in person) to determine or help estimate costs of providing services for people experiencing homelessness in Nashville. Service costs were sought for addiction treatment, advocacy, case management/referrals, child care and education, clothing, communications, counseling, documents, education, emergency care/transport, financial services, food, health care, housing/shelter, incarceration, job training, laundry, legal/courts, mental/behavioral health, pastoral care, personal care items, and transportation. Unavailable costs were estimated based on existing data or excluded from the total.
Three semi-structured interview protocols were used in this study (See Appendix). One asked service providers about their services, costs, numbers served, and their record keeping. The second protocol was a long-form interview of homeless persons to determine whether they are chronically homeless, which services they use and how often, and demographic information. This protocol was pilot tested with 8 homeless persons and then modified based on feedback. Long form interviews were recorded and transcribed. Homeless participants were paid $10 as compensation. The third protocol was a shortened version of the long-form interview.
Results. The total cost associated with homelessness in Nashville from 11 service provider agencies and archival/provider estimates is $16,784,020. This is likely an underestimate, given the omission of many other “hidden” costs that were beyond the scope of this study. The estimated total cost associated with chronic homelessness in Nashville is $10,034,426. That works out to $7,537 per average homeless person in our sample and $10,624 for the average chronic homeless person in the sample. Both of the total cost and per person figures should be treated as lower bounds for the cost of homelessness in Nashville. Different methods were required to calculate the separate costs of each of the following service categories, as detailed in the report.
Conclusion: In contrast
to current costs related to average and chronic homelessness, the annual
cost to provide permanent housing (including a reduction in existing
services) is estimated at $5,907-7,618 per person, or a
net per-person savings of between
$1,630-3,007. The annual cost of housing plus
wrap-around services is $11,500, which would be largely, but not entirely,
subsidized by the reduction in existing service costs.
INTRODUCTION
As Federal responsibility for addressing homelessness has devolved to local and state governments, the need for cities to understand and accurately estimate the true costs of homelessness has become vital. These costs must be seen in terms of public as well as private services, systems, and goods provided. Many of these costs are currently unknown because some may be difficult to quantify, but mostly because so many homeless persons themselves are “hidden.” Also, finding the methods and resources to track, analyze and report costs have not been standardized or regularly budgeted.
Due to geography, weather, and an increasingly upscale housing market, Nashville has many of the variables that lead to a growing homeless population (Lee, 1989). The 2008 homelessness count in Nashville yielded 2,227 people on the streets, in shelters, and in camps. Due to the intrinsic nature of a single point-in-time count, the total is likely a significant underestimate – without even taking into account those people that have been or will be homeless in their lifetime (Shinn & Tsemberis, 1998). Homelessness is also not just a problem for the stereotypical adult males in Nashville, as out of the 74,000 children in Nashville public schools, about 1,700 served each year are homeless (Alapo, 2007). Numerous studies remind us that homelessness is linked with economic issues far more than mental health or substance abuse, making jobs and housing major foci; with federal cuts significantly lowering section 8 vouchers, around 1,500 families in Nashville will be unable to afford the modest accommodations that were previously attainable (Paine, 2004). This abstraction of policy from its real consequences is not uncommon; government agencies often artificially separate poverty and homelessness – leading to myopic strategies to deal with homelessness (Shinn & Gillespie, 1994). In short, to prevent and ameliorate homelessness in Nashville, we must understand the scope, cost, and context of a constellation of issues. To this end, this study aims to shed light on the economic topography of homelessness in Nashville.
Based on Clasen's (2006) study of the hidden costs of homelessness in Durham, North Carolina and studies conducted across the United States, we have determined the extent of the externalized costs of homelessness in Nashville – for the people experiencing homelessness, the community, and the government. The purpose of this study is to determine the full costs of homelessness in Nashville using current practices, the estimated cost for permanent supported housing for people experiencing homelessness, the cost for housing first in Nashville, and the relative difference in expenditure for all options. This study has conducted semi-structured interviews with people experiencing homelessness, service providers, and outreach workers in Nashville. Archival data were also used to construct costs directly and to estimate unavailable figures. These data are then compared to information about permanent supportive housing and services that has been collected by various research groups and agencies to conduct a cost-efficiency analysis.
Background on Homelessness
Although homelessness has likely been a problem for U.S. communities since our nation was formed, the 1980's saw a rise in people on the streets and society's consciousness of the issues surrounding their plight. During the 80's, the number of people on the streets and the causes for their homelessness rose sharply – changing the strategies necessary to alleviate homelessness (Lee, 1989). Through the surge of research in this period, we learned how complicated homelessness is and what the myriad outcomes of being on the streets are; homelessness is associated with problem behaviors in children, strained family relationships, increased exposure to trauma, increased anger and depression, and greater social stigma (Biswas-Diener & Diener, 2006).
As the stereotype of the homeless person started to fade, research focused on understanding the real face of homelessness and the incidence of homelessness within the population. According to a 1990 phone poll, 7.4% of people had been homeless at some point in their life and 3.1% of respondents had been homeless within the previous 5 years (Shinn & Tsemberis, 1998). These data defy the image of lifelong, mentally-ill, substance abusing men that previously dominated the nation's vision of homelessness and tell us that a large and wide segment of the U.S. population face the streets at some point in their life. Although the 90's saw a reduction in national political focus on homelessness, in 2002 the Federal Interagency Council on Homelessness reinvigorated its efforts toward prevention of homelessness (Burt, 2003). The national resurgence in the interest to cure homelessness has led to many cities adopting and enacting a 10 year plan to end homelessness. Nashville has taken this plan seriously, creating a homelessness commission and conducting research to understand and end homelessness in the metro area.
Definitions of Homelessness
Perhaps due to the diverse causes, contexts, and results of homelessness, there are a variety of available definitions. According to the original McKinney Act, a person is homeless if they lack, “a fixed, regular, and adequate nighttime residence,” or sleep in, “a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings," as well as those sleeping in shelters for the homeless (quoted in Burt, 2003). Although this definition captures the essence of homelessness, government agencies needed a more specific definition that was easier to operationalize in order to categorize people for services. Therefore, the U.S. Interagency Council on Homelessness defined chronic homelessness as "an unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year or more, or has had at least four episodes of homelessness in the past three years" (2003).
Although narrowing the scope of homelessness to chronic homelessness makes operationalizing the definition easier, it obscures many people on the streets and denies purely economic homelessness. This problematic definition leaves out at least half of the homeless population and de-emphasizes families, youth, and children. The 2003 U.S. Conference of Mayors’ survey determined that 40 % of the homeless population is made up of families with children and that 5% of the urban homeless population are unaccompanied minors (Mayor's Task Force to End Chronic Homelessness , 2004). According to the Metropolitan Health Department of Nashville and Davidson County (1998) report on homelessness, 60% of respondents were experiencing homelessness for the first time and 20% were experiencing homelessness for the second time. Unless these periods are especially long (over one year), the majority of Nashville's homeless do not meet the definition for chronically homeless. Additionally, people that are homeless purely due to economic hardship would not qualify for this definition as they have no “disabling condition.”
Causes of Homelessness
Perceptions of the causes of homelessness can generally be broken down into three camps: a) personal/individual, such as psychological deficiencies or bad choices; b) structural, such as low opportunities for jobs and housing, racism, or educational deficiencies; c) a combination of individual and structural issues. Although homelessness is likely a complex version of the latter option, the majority of the research on homelessness is on the personal characteristics of people experiencing homelessness and not the context surrounding their plight or interactions between the spheres of influence. This has often led to the erroneous assumption that personal characteristics and choices are causal. As an example, although it is difficult to determine whether alcohol and drug dependence are causes or symptoms of homelessness, instance of these disorders are significantly higher in men and women who are homeless when compared to similar low-income people (Caton, Hasin, Shrout, Opler, Hirshfield, Dominguez, & Felix, 2000). This should lead policy makers and organizations working with homelessness to adopt drug and alcohol treatment as an important part of supportive housing and wrap-around services, rather than blaming homelessness on individual decisions to drink or do drugs.
Shinn & Tsemberis (1998) note that the correlation between homelessness and mental illness and other personal factors is overexaggerated and less strong than the correlation between homelessness and economic factors – pointing toward more structural etiology. In a study of the antecedents of homelessness in Boston, MA, Crane, et al. (2005) found that economic factors were the most common cause of homelessness, followed by almost equal contribution by mental health issues and relationship breakdowns, then health problems and then many other causes; the most common causes (in order) given by people experiencing homelessness for loss of their housing were economic difficulty paying rent or mortgage, housing sold or converted, breakdown of cohabitational relationship, death of a relative or friend, and disputes with the landlord, co-tenants, or neighbors (Crane, et al., 2005). Locally, three fifths of people in Nashville believe that homelessness is caused by structural issues (Lee, Jones, & Lewis, 1990) – while 90% of people believe that there are multiple causes of homelessness, including luck. According to the Metro Homelessness Commission's Economic Stability Committee report on employment for individuals who are homeless (2007), the majority of people experiencing homelessness interviewed in Nashville (93.5%) have been employed, about two thirds (62.6%) are earning money in some capacity, and the majority are willing to work. Most interviewees were employed temporarily, are not full time, and receive low or substandard wages. This employment situation may be a cause or catalyst to homelessness or people remaining homeless.
Different research literatures also approach causes of homelessness in divergent manners. The economic literature primarily approaches homelessness as a failure in the housing (and sometimes the labor) market where housing prices become too expensive for certain people to afford, and thus these people become homeless (Allgood & Warren 2003; Bohanon 1991; Early 2004). Analyses of the cost of homelessness are primarily focused on the costs and effectiveness of subsidized and public housing. Yet, this line of analysis excludes possible non-demographic factors that could render people unable to live in housing at all, regardless of cost. The psychology literature includes a greater focus on the mental and physical health issues surrounding homelessness in addition to examining the issue of affordable housing from a social perspective (Levine, Perkins, & Perkins 2005; Rosenheck & Seibyl 1998; Shinn & Tsemberis 1998).
Still, perceptions of individualistic causes of homelessness are persistent. In 2006, Chattanooga Mayor Ron Littlefield took people experiencing homelessness to see the film The Pursuit of Happiness to encourage them to pull themselves up by their bootstraps – essentially ignoring structural causes for homelessness and highlighting an extremely rare case of rags-to-riches success (Wang, 2006). Irregardless, the public generally view people experiencing homelessness more negatively than those living in poverty or living with mental illness – regardless of where they place the blame for homelessness (Lee, Farrell, & Link, 2004).
Although structural causes are important to address, Shinn and Tsemberis (1998) remind us that people experiencing homelessness still have a higher rate of disability than the rest of the population. Beyond alcohol and drug use, other personal characteristics still have bearing on homelessness; Herman, Susser, Struening, and Link (1997) demonstrate that adverse childhood experiences – like lack of parental care and physical abuse – are powerful risk factors and common precursors to adult homelessness. The Metro Nashville Health Department (1998) report also states that 37% of respondents report that a health professional told them they have a drug and/or alcohol problem and 22% were told that they have a psychiatric problem. The literature and local knowledge points to solutions that focus on both structural and personal issues to prevent and ameliorate homelessness.
Costs of Homelessness
Researchers’ explanation of the cause of homelessness, whether explicit or implicit, strongly affects the approach taken to studying the costs of homelessness and how resources are targeted, especially with respect to preventing homelessness. The two main explanations identified in the research literature on the costs of homelessness are failures in the housing market, seen primarily in the economic literature (see Allgood & Warren 2003; Bohanon 1991), and mental or physical health issues, prevalent in the psychological literature (see Levine, Perkins, & Perkins 2005; Rosenheck & Seibyl 1998; Shinn & Tsemberis 1998). The economics approach tends to neglect psychological, health, or social problems that could result in people becoming homeless even with a sufficient supply of affordably priced housing. While the psychological literature gives more attention to the social problems that result in people becoming homeless, it often fails to provide solid cost-benefit analyses that would allow for a better comparison of policy alternatives.
Most past studies on the costs of homelessness in the have either a) studied characteristics of those who become homeless or b) studied the traits that mediate the duration of homelessness. The first approach conducts demographic analyses with the intention of improving the efficiency of existing resource use by identifying who is most likely to become homeless and targeting preventative resources at these key at-risk groups. Early (2002) took this approach by studying demographic characteristics, constructing an economic model for homelessness, and using the model to estimate what percentage of people currently living in subsidized housing would become homeless if the subsidy were removed. On the other hand, some researchers study determinants of the duration of homelessness, assuming that those who remain homeless for longer spells use larger amounts of services (Allgood & Warren 2003). These studies examine the characteristics of people who successfully exit homelessness against the characteristics of those who are “chronically homeless.” While a few cost studies of service provision have been completed (see Clasen 2006; Lewin Group 2004), there is a general lack of studies that attempt to comprehensively estimate the average daily cost of an individual being homeless. Without a comprehensive survey of costs, it is difficult to accurately estimate evaluate the cost-effectiveness of policy alternatives to reduce homelessness.
However, the lack of comprehensive empirical studies on the costs of homelessness may be due to two major challenges in conducting this type of research. First, due to the homeless population’s high degree of mobility and unreliable access to communication devices, any attempt to track a specific group of homeless people for an extended period of time runs into severe data collection problems and faces the higher costs associated with long-term studies. Second, in estimating usage of services by contacting service providers, one runs into the problem of repeat clients as some agencies track encounters but not the unique number of individuals that use their services, another variation of the tracking problem. Given these challenges, it has been very difficult for researchers to assess whether costs of homelessness are being driven by a smaller group that use large quantities of services or of larger numbers of users that use fewer quantities of resources.
Thus, from an economic cost perspective, two conclusions can be drawn about issues surrounding the effectiveness of the attempts to improve the efficiency of services provided to the homeless through better targeting. First, the studies that use this approach expose that a strict focus on homelessness as a housing shortage frequently fail to take into account the demographics of those who use the housing and those who are excluded from it. Second, the concept of using income alone to target who should receive housing is a double-edged sword: if income is used prior to demographic analyses as the primary criterion for entry, inefficiency is created by supplying housing to lower risk low-income earners who take spots that could be used to house those at greater risk of becoming homeless without subsidized housing. However, using income to prioritize who receives housing within demographically at-risk groups can increase efficiency by replacing the typical first-come, first-serve or hardship approaches.
Current Strategies
In some respect, all current major strategies to ameliorate homelessness aim to house people who are now on the streets. Housing first strategies simply put homeless people in housing without major restrictions; supportive and wraparound housing strategies place people in housing with integrated services; services first strategies aim to ameliorate immediate problems and personal deficiencies that proponents believe must be solved before someone can be stable in housing. Each of these strategies has its strong points and may be the right solution for some situations, but all may seem expensive to the government and the public. Burt (2003) reminds us that although housing and serving the homeless is expensive, homelessness is expensive regardless – and the solutions we choose greatly affect the quality of life of those experiencing homelessness. Research overwhelmingly supports housing first and supportive housing over services first approaches, so these options will be explored in more depth. It is also important to realize the diversity of approaches within housing strategies. Some emphasize more centralized plans while others aim to decentralize housing for people experiencing homelessness. As one consequence of approach, Lee, Farrell, and Link (2004) demonstrate that exposure to homelessness leads to public motivation to reduce homelessness and shift policy accordingly. Mixed housing and decentralized strategies emphasizing broader exposure may reduce existing outgroup stereotypes that stigmatize the homeless, increase willingness to support policies to alleviate homelessness, and shift perceived blame from individual to structural causes for those exposed to people experiencing homelessness (Lee, Farrell, & Link, 2004). Centralized strategies – although not exposing the broader community – may create stronger exposure to better achieve the same goals for a smaller population. It is important to weigh these possibilities for sustainable strategies since positive public attitudes about homelessness in Nashville translate into support for policies that alleviate homelessness.
With primary strategies focusing on housing, the issue of efficiency has boiled down to how to most effectively target low-income or subsidized housing to those who are most likely to become homeless without it. Thus, there have been a significant number of studies and analyses done based on the demographic data available about the homeless population in order to determine what the primary determinants of homelessness are in order to create the most effective entry requirements for low-income housing (Allgood & Warren, 2003; Bohanon, 1991; Early, 2002).
Early (2002) created a housing model that incorporated both income-based targeting and household demographic characteristics. The model indicates that the upper income limits currently in place needed to be lowered in order to increase the effectiveness of low-income housing, as a significant number of families living in subsidized housing would not become homeless if their subsidies were removed. Early (2002) argues that this is primarily due to low-income housing officials basing access on policies of first-come, first-serve or hardship and recommends using absolute income as an appropriate measure for differentiating among low-income households to increase effectiveness in targeting (and thus reducing the cost incurred by subsidizing housing for those who have the means to live elsewhere).
Yet income alone overlooks other factors that may put an individual at greater risk for homelessness, such as mental health problems. Allgood & Warren (2003) also found that eligibility criteria for subsidized and public housing favors drug-free, single women with young children, a cluster which is less likely to experience extended homelessness, while single men and those with behavioral problems actually form a larger demographic proportion of the homeless population. While this does not necessarily mean that low-income housing is entirely ineffective, those seeking to lower the costs and incidence of homelessness must recognize that single men and individuals with behavioral problems require different types of housing or services which must use different eligibility requirements to target these clusters than the current system of subsidized or public housing.
Housing First Strategies. Housing first strategies are based on the notion that people are homeless because they do not have a home, not because of personal deficiencies that transcend housing status. As stated previously, 7.4% of people had been homeless at some point in their life and 3.1% of people have been homeless within the previous 5 years (Shinn & Tsemberis, 1998). This means that more people are experiencing homelessness and that homelessness is far more temporary than previously suspected – indicating that homelessness is a temporary state, rather than a permanent trait (Shinn & Tsemberis, 1998). An experiment in New York City demonstrates that housing first programs (i.e., Pathways to Housing) get people off the streets faster, reduce health costs when compared to continuum of care programs and the control group, and generally cost less (Gulcur, Stefancic, Shinn, Tsemberis, and Fischer, 2003). Tsemberis and Eisenberg (2000) showed that residents with psychiatric disorders placed in housing first programs in NYC had a higher housing retention rate (88%) than residential treatment (47%) after 5 years. Overall, housing first has been the most successful option to reduce homelessness for people on the streets and in psychiatric hospitals in New York City(Gulcur, Stefancic, Shinn, Tsemberis, and Fischer, 2003; Stefancic & Tsemberis, 2007).
Burt (2003) suggests housing subsidies as the most straightforward and fast strategy for reducing homelessness, coupled with education and job training for those living in poverty. Shinn and Tsemberis (1998) tentatively claim that in many cases subsidized housing is sufficient to end homelessness for families. Additionally, Shinn (2007) showed that 80% of sheltered families in New York City that received housing subsidies remained stable – versus 18% stability for those who did not receive subsidies.
Even people that fit the stereotype of chronic homelessness can be well served by housing first. Clients with severe psychiatric disabilities can obtain and maintain housing when given the opportunity and necessary supports (Tsemberis & Eisenberg, 2000) – greatly reducing the resources necessary for serving this population. As far as abusers and addicts – the mainstay of the services first argument – Padgett, Gulcur, and Tsemberis (2006) found no significant difference in substance use between treatment first and housing first users. It is even possible that services first approaches are doing some harm, as services without housing can keep people experiencing homelessness from using mainstream health services instead of expensive emergency care (Shinn & Tsemberis, 1998).
Supportive Housing. Permanent supportive housing (PSH) is one of the 4 guiding principles in the Strategic Framework for Ending Chronic Homelessness in Nashville (The Mayor’s Task Force to End Chronic Homelessness, 2004). PSH is defined in the Strategic Framework as “permanent, affordable housing linked to health, mental health, employment and other support services” (p. 12). A client in PSH has direct access to all of their health needs, including transportation, economic support, community support, and healthy social networks. Solid social networks and organizational ties are associated with better health outcomes, higher self-esteem, social support, and social capital (Cattell, 2001). This also supports decentralized, integrated housing, wherein people who are formerly homeless are given access to established social networks. It is likely that any housing strategy should include some facilities for PSH.
Culhane, Metraux, and Hadley (2002) found that placing homeless individuals with severe mental illnesses in supportive housing experienced a marked reduction in shelter use, hospitalizations, length of stay per hospitalization, and time incarcerated. Costs of services used totaled an average of $40,451 per person per year prior to entering supportive housing and $16,281 less after placement in supportive housing compared with a control group not placed in such housing. With the annual cost of placement being $17,277, the net annual cost of providing housing to these individuals was only $995. In addition, upwards of 70% of the individuals placed in supportive housing retained their housing.
Martinez,
Burt, and Burt (2006) documented a 56% drop in use of acute health care
for people sheltered in supportive housing. Wright (2006) found a 75.2%
decrease in physical and mental health care costs after the institution
of wraparound services for people with co-occurring mental health and
substance use disorders. Proscio (ND) notes that people experiencing
homelessness placed in supportive housing reduced residential mental
health service use to zero within one year. Comprehensive supportive
housing in Nashville currently costs $11,500 per person and already
shows similar reductions in service use and costs for clients.
METHODS
Methodological Issues
Tracking the expenses of homelessness and determining reduction in costs is inherently problematic. The numerous studies across the nation have used many different methods to create their numbers – each based on contextually valid logic and available knowledge and examples. Some studies have had access to comprehensive HMIS databases and medical records and have tracked individual people. Other studies have found citywide costs and divided them by the homeless count. Others have taken service provider data and made estimates based on average client costs. Ideally, these studies would track individuals and the greater population over time to form a longitudinal study measuring the actual and direct costs for a community. Given the transitory nature of the homeless population and resulting problems in tracking and contacting specific homeless individuals, it has thus far been extremely difficult to construct the type of longitudinal study of the homeless population that would shed light on patterns of individual service usage over time and key services or factors that lead to an exit from the state of homelessness (Allgood & Warren 2003). Also, taking into account the higher costs of such longitudinal studies, most studies to date have been based on cross-sectional data, which are limited in their ability to account for temporal factors in the problem of homelessness and tend to capture those who are homeless for an extended period of time (Early 2002). This study uses a hybrid of several other designs to conform to the needs and realities of Metro Nashville. It is impractical and expensive to create a longitudinal study so a cross-sectional design has been used. As the Nashville HMIS lacks comprehensive tracking of individuals through services, this study used data from service providers, people experiencing homelessness, and archival data to create average costs per individual or total community costs that are divided by the homeless count estimate.
The main weakness of using averages that are not directly attached to specific individuals is determining whether a few people are using many services and therefore incurring much of the costs or if the service use is distributed more evenly. The survey provides data supporting our methodology – in that services are spread out relatively evenly, even though there are some “frequent flyers.” Still, considering the relative cost and effectiveness of the methods used, the hybrid design for this study has captured as many good features from other studies as possible. The main goal is to create numbers that can be used with confidence that are not inflated due to poor methodology or selection bias for people tracked consistently in an HMIS.
Procedures
Sampling. Homeless participants were first selected using a convenience sample of people experiencing homelessness in Nashville wherein no ethnicity, gender, adult age, or other demographic factor was used to target or exclude participants. Participants were only excluded from the study if they were under 18, they were cognitively unable to understand the risks and/or the content of the study, or if they did not speak English. Participants were interviewed at shelters, on the street, and in advocacy centers. Once the initial sample was gathered (n ≈ 75), specific demographic markers (gender, age, ethnicity, probable living situation) were targeted using snowball sampling to make the sample more representative of the likely population of people experiencing homelessness in Nashville. The final sample size (n = 105) is based on a predicted level of theoretical saturation (Strauss & Corbin, 1998), wherein new data from a representative sample does not vary results significantly.
Sample demographics gathered in the interviews are as follows: The average age of respondents was 45.33 (median 47) years old; 75% of interviewees were male, 25% were female; 62.16% of participants self-identified as Black/African American, 29.73% self-identified as White/Caucasian, and 8.10% self-identified as other/mixed-ethnicity; 54% were single, 2.7% were married, 21.6% were divorced, and 13.5% were widowed (8% no response); Respondents have lived in Nashville for an average of 35.49 years (median 12 years); 2.7% state that they are veterans of the armed forces; Median income for respondents was $2,800 (mean $4,641.30); 71.4% of participants had been homeless for one year or more prior to the interview; Participants had spent an average of 4.96 years (median 3 years) on the streets or in shelters; 83.78% of respondents live alone (unaccompanied). Overall, 52% of interviewees meet the criteria for chronic homelessness.
Key informants (outreach and service workers, program administrators) were interviewed, to determine service usage and operating costs to estimate the costs of providing services for people experiencing homelessness in Nashville. Based on an initial list from Clifton Harris and known community resources, a snowball sampling procedure was used to determine further service providers. Service costs were sought for addiction treatment, advocacy, case management/referrals, child care and education, clothing, communications (telephone, internet, etc.), counseling, documents, education, emergency care/transport, financial services, food, health care, housing/shelter, incarceration, job training, laundry, legal/courts, mental/behavioral health, pastoral care, personal care items, and transportation. Some costs were located as separate sums while others were part of indivisible budgets. Some costs were not available and had to be estimated based on existing data or excluded from the total.
Interviews. Three interview protocols were used in this study (See Appendix). Interviews with people experiencing homelessness and service providers were conducted by 6 trained interviewers. The first protocol (semi-structured) was for service providers which asked what services they provide, how much those services cost, how many people they serve, if they keep records of the identities of clients, and numerous detailed prompts. Service provider interviews were conducted in person and via e-mail.
The second protocol was the long-form interview. This semi-structured protocol was created using questions based on literature and the service provider list. Questions were designed to determine whether participants qualified as chronically homeless, which services they use and how often, demographic information, and numerous detailed prompts. The protocol was piloted using cognitive interviews with 8 people experiencing homelessness and then modified based on feedback from the cognitive interview sessions. Interviewer provided potential participants with a brief description of the study, its potential benefits, and potential risks. Interested potential participants were read the informed consent document and were assessed for inclusion criteria (homeless, age, mental status, English speaking). Long form interviews were recorded on tape and transcribed. Homeless participants were paid ten dollars as compensation.
The third protocol was the short form interview. This semi-structured protocol is an abridged version of the long form protocol. The short form contained less in-depth questions and prompts as well as less demographic questions. The short form responses were recorded on paper. Otherwise, the interview process was the same as for the long form.
Analyses. Data were recorded and analyzed in Microsoft Excel and StarOffice Calc. Service provider data were remitted in varied forms, including individual costs per day, total cost per service, cost per person, or total budget. Costs were divided to obtain a per person, per service figure. These figures where then multiplied by reported service use by people experiencing homelessness and then multiplied by the percentage of people experiencing homelessness that use the particular service. If a per person, per service figure was unattainable, the total budget or total service cost was divided by the homeless count to determine a best estimate figure. When data were insufficient for an estimate or specific data were unavailable, figures where sparingly used from an existing study with the most similar region, population, and goals avaiable – Clasen's (2006) study of the hidden costs of homelessness in Durham, NC. Each figure will be discussed in the results section.
RESULTS
Service Providers
The total cost associated with homelessness in Nashville from service provider agencies and archival/provider estimates is $16,784,020.15. This is likely an underestimate, given the omission of externalities such as lost work time, lost potential tax revenue, partial costs of civic projects, survival crime, etc. that are extremely difficult to measure or estimate. The total cost associated with chronic homelessness in Nashville is $10,034,425.68. The per-person estimate for the cost of homelessness in Nashville is $7,536.61 and the per-person estimate for the cost of chronic homelessness in Nashville is $10,624.72. Both of the total cost and per person figures for homelessness and chronic homelessness should be treated as lower bounds for the costs of homelessness in Nashville.
The total cost of homelessness was derived by finding the total cost of these service categories: hospital, clinic, emergency medical services (EMS)/emergency transport, veterans affairs (VA) costs, social services, shelter services, police, jail, courts, drug and alcohol treatment, and advocacy costs. Chronic homeless costs were determined by multiplying the basic per-person cost by the percentage of total use by chronic homeless individuals determined by the survey, then divided by the percentage of chronic homeless individuals relative to the total sample. Slightly different methods were required to calculate the cost of each category, which the following paragraphs will explain in detail.
Hospital costs. 74.28% of respondents use hospital services for physical and mental health, with an average of 9.05(median 2) visits per year. Of those visits, only 28.34% included overnight stays; respondents overwhelmingly felt that being hurried out of the hospital negatively affected their health and likely lead to repeated outpatient visits. Hospital costs were found by multiplying the per-person average cost of providing services to a homeless individual by an estimated count of the number of homeless that used hospital services in the past year. The estimate of the total number of homeless that used hospital services was derived by multiplying the percentage of homeless individuals in our interview survey that reported using hospital services within the past year by an estimate of the total number of homeless in Nashville taken from the count of homeless individuals conducted in January 2008. The average per-person cost for providing health care to people experiencing homelessness is $1,561.49 and the cost for medical care for chronically homeless individuals is $1,875.10. The total estimated cost for providing health care for people on the streets is $3,477,430.55 and for chronically homeless is $2,187,303.81.
Clinic costs. 72% of participants visit a medical clinic for care with an average of 9.24 (median 2) visits per year. Clinic costs were estimated using the same method (multiplying the per-person services cost of clinics by an estimate of the count derived from our interview survey and the 2008 total count). Clinic costs were estimated to be $389.18 per homeless person and $449.36 for a chronically homeless person. This totals $866,703.53 for homelessness and $524,182.29 for chronic homelessness.
Emergency medical services costs. EMS costs were estimated using Nashville interview data and indirect cost information. To do so, we obtained an estimate of the percentage of the homeless population in an analog city (Clasen, 2006) who had used EMS services to obtain a percentage for Nashville (25%) – as interview responses were insufficiently specific for an estimate. The archival total cost of EMS services to homeless individuals was divided by the analog city's sample to obtain an estimated per-person user cost ($389). We then multiplied the per-person cost by the estimated percentage of homeless that used EMS services in Nashville, obtaining a per-person cost of $97.22, a chronically homeless per-person cost of $185.61, a total cost of $216,513.89.
Veterans Affairs (VA) costs. VA costs were estimated by calculating a per person cost for service users from an analog city (Clasen, 2006) and by dividing the cost for supplying case management and services to veterans experiencing homelessness by the number served. This figure ($9,345.65) is then multiplied by the percentage of participants in the interviews that qualify for and use these services (2.7%). This yielded a per person experiencing homelessness average of $252.33. By adjusting this figure for chronic homeless using VA services, the Chronic homeless per person cost is $481.73. The per-person figure was multiplied by the 2008 count number to create a Nashville Metro total estimate of $561,938.91 (100% of A eligible interviewees qualify as chronically homeless).
Social Services (SS) costs. SS were determined by utilizing the social services costs for homeless people in an analog city (Clasen, 2006). This figure ($754) is the estimated cost for homeless and chronically homeless individuals and was corrected using the Nashville count for a total cost of $1,679,158 and a chronic homelessness total cost of $879,541.
Shelter services costs. With shelters in particular, per person cost data can vary according to the extent of services provided and unique individual usage data is not usually kept on the individual service level – with many organizations instead opting to keep track of total encounters. This makes it difficult to disaggregate shelter costs to derive a per-person cost by service provided within a shelter to make an estimate across all shelters as to the total cost of homeless shelter usage to Nashville. However, by targeting the largest shelters , the total cost figure should capture a good portion of the total shelter costs.
Thus, the total cost is a conservative estimate based heavily on the total expenditures of the most widely used and largest shelters with some smaller shelters included as well. The total cost of each shelter was obtained either through financial statements and/or through interviews with key personnel in the organization, and our lower bound total estimate from the shelters surveyed is $4,888,851. This includes worker salaries and operating costs in addition to the direct costs of food, shelter, clothing, etc. This low-bound total was then divided by the 2008 count, resulting in a per-person cost of $2,195.26. There was no significant difference in reported use of shelters between chronic homeless individuals and non chronic homeless individuals. The total shelter cost ($4,888,851) was then multiplied by the straight percentage of chronically homeless from the interview sample to determine a chronic homelessness shelter total of $2,542,202.56.
Police costs. Police costs for pick up were estimated using an analog figure (Clasen, 2006) for pick up cost multiplied by the number of homeless arrests in a year ($823,494). This figure is then divided by the total number from the count to create a per person cost of $369.78.
Jail costs. 55.24% of respondents have been arrested in the past year with an average number of 40.54 nights in jail per arrest reported. This means an average of 88.4 (median 2) nights in jail per year for the whole sample. 76% of those arrested stayed for more than three nights per visit. Initially, total and per-person jail costs were estimated by first calculating the average number of days an average homeless individual spent in jail per year (9.9). The total cost was derived by multiplying 9.9 days per arrest by the cost per night in jail ($72). This comes to a $720 annual cost per homeless person. This figure was multiplied by the jail’s count of unique homeless individuals arrested to find a total cost of $1,697,760. Secondarily, we used the same methodology as used to estimate clinic costs (multiplying the per-person services cost of the jail by an estimate of the count derived from our interview survey and the 2008 count) to estimate the total cost of all jails’ services and found the total cost to be $881,892. This estimate was lower than our initial calculation based on the jail data, which could be explained by two factors. First, our interview sample may have under-reported the amount or duration in which they stayed in jail. Second, the jail may have overestimated the number of people arrested who were actually homeless – which may be possible given that the unique number of inmates identified as homeless were greater than the total homeless count. Since we were working to form the lower bound on costs, we selected the lower of the two estimates. Selecting the higher estimate would add $815,868 to the total cost. Thus, the per-person cost is $396, the per person chronic homelessness cost is $347.77, and the total jail cost for people who are chronically homeless is $405,670.32. The jail costs for non-chronic homeless individuals is higher because non-chronic respondents tended to be held in custody longer per arrest and total than chronic arrestees.
Court costs. Court costs were estimated using the same method as police costs. The number of arrests of people that the Nashville metro jail listed as homeless (5,602) was multiplied by an average court encounter ($145.25) from an analog city (Clasen, 2006), then divided by the 2008 count. The per-person cost figure is $365.38 and the chronic homelessness per-person cost is $449.23. The total cost is $813,690.50 and the chronic homelessness total cost is $426,210.13.
Addiction treatment costs. 41.9% of participants report that they received drug or alcohol treatment within the last three years with an average 1.952 visits per year with an average of 44.697 nights stayed per year. 70.45% of respondents who received drug and alcohol treatment stayed overnight while the remaining 29.55% received outpatient treatment. Drug and alcohol treatment costs were obtained directly from providers, with an average per-person annual cost of $1,033.47 and a per-person chronic homelessness cost of $3,258.65. The Nashville metro total is $2,301,547.71 and the chronic homelessness total is $1,658,717.56. These figures were derived by averaging the daily cost of service provision of multiple providers, multiplying it by the 45 night average stay in a drug or alcohol treatment facility calculated in our interview survey, and then finally weighting that number by 83%, the percentage of homeless individuals who indicated in the survey to have had recent drug or alcohol treatment.
Advocacy costs. Advocacy costs were included as a total cost simply by the organization’s total expenses, which totaled $272,800. Again this estimate is a lower bound as there may be groups advocating for homeless individuals and helping them obtain services, documentation, etc. outside of our sample. To obtain an individual cost, we divided the total cost of advocacy by the total number of homeless to obtain the per-person cost of $122.50. For chronic homelessness, the total cost is $200,800. and the per person cost is $172.63.
Some potential problems where estimation was used were the possibilities of the agency costs being non-representative of other agencies and potential self-reporting bias in situations where usage data was derived from our interviews with the homeless. Additionally, the total count of 2227 homeless individuals is likely a lower bound, as it was a one night survey and likely underestimated under the number of people not in shelters on a particular night. A higher count of homeless individuals would result in a greater total cost of homelessness, but would have differential effects on the per-person cost estimate. Where the count was used as a divisor for a fixed, aggregate service cost (e.g., meals, medication), a higher count number would reduce the per person cost. Where the count was used as a divisor for a fixed structural cost (e.g., building costs, staff), the per person cost would likely not be affected, assuming service providers had sufficient capacity or expanded to absorb the greater demand. For estimates where the count was used as both multiplier and divisor, no change would take place in the cost amount.
Table 1. Total and Per-person Costs for Services to Homeless People in Nashville, TN (2007)
| Service | Per-Person Cost | Chronic Per-Person Cost | Total Cost | Chronic Total Cost |
| Hospital | $1,561.49 | $1,875.10 | $3,477,430.55 | $2,187,303.81 |
| Clinic | $389.18 | $449.36 | $866,703.53 | $524,182.29 |
| EMS | $97.22 | $185.61 | $216,513.89 | $216,513.89 |
| Veterans Affairs | $252.13 | $481.73 | $561,938.91 | $561,938.91 |
| Social Services | $754.00 | $754.00 | $1,679,158.00 | $879,541.00 |
| Shelter Services | $2,195.26 | $2,195.26 | $4,888,851.00 | $2,542,202.56 |
| Police | $369.78 | $455.38 | $823,494.00 | $431,345.20 |
| Jail | $396 | $347.77 | $881,892.00 | $405,670.32 |
| Court | $365.38 | $449.23 | $813,690.50 | $426,210.13 |
| Addiction Treatment | $1,033.47 | $3,258.65 | $2,301,547.71 | $1,658,717.56 |
| Advocacy | $122.50 | $172.63 | $272,800.00 | $200,800.00 |
| Totals: | $7,536.61 | $10,624.72 | $16,784,020.15 | $10,034,425.68 |
Housing Costs
The following are cost estimates to provide housing using two housing first strategies and a supportive housing strategy. All housing is assumed to require tenant contributions of 30% of income, as per HUD convention. Utilities are not included in any cost, as the $75-175/month is normally paid for by the tenant.
Housing first. The cost to provide housing for people experiencing homelessness can be either figured from development of property or the use of rent subsidies. The main cost difference between the two is that development requires more initial capital and credit while the rental likely costs more over the long term. Nashville housing and rent cost data are from a local non-profit housing developer who is familiar with the current Nashville market. Inflation and rent increase estimates are based on HUD (2008) figures.
The developed, non-profit owned costs are as follows: For an efficiency/one bedroom dwelling, the cost would be $35-45,000 for rehabbing or constructing a new unit and would cost a total of $7080 a year to own and operate the unit. For a 2 bedroom home suitable for couples or small families, the cost would be $45-85,000 for rehabbing or constructing a new unit and would cost a total of $7,500 a year to own and operate the unit. For a 3 bedroom home suitable for larger families, the estimated cost would be $85-100,000 for rehabbing or constructing a new unit and would cost a total of $8,436.
Using HUD (2008) guidelines
for occupancy (1.5 persons average per bedroom) and local estimates
of likely occupancy for individuals experiencing homelessness, the following
figures display a total estimate for developed housing first: 1 bedroom:
60% use * ($340 mortgage + $250 operating costs) = $354 weighted total;
2 bedroom: 20% use * ($375 mortgage + $250 operating costs) / 3 occupancy
modifier = $41.67 weighted total; 3 bedroom: 20% use * ($453 mortgage
+ $250 operating costs) / 4.5 occupancy modifier = $31.24 weighted
total; Total: $354 + $41.67 + $31.24 = $426.91 Monthly and $5,122.93
Yearly.
Current market rate in Nashville to rent similar dwellings is about $500 a month and $6,000 a year for an efficiency/one bedroom dwelling, about $600 a month and $7,200 a year for a 2 bedroom dwelling, and about $725 a month and $8,700 a year for a 3 bedroom dwelling. Weighting these costs (as with the developed units using a percentage of use and an occupancy modifier for multi-bedroom homes) yields a single cost: 1 bedroom: 60% use * $500 rent = $300 weighted total; 2 bedroom: 20% use * $600 rent / 3 occupancy modifier = $40 weighted total; 3 bedroom: 20% use * $725 rent / 4.5 occupancy modifier = $32.22 weighted total; Total: $300 + $40 + $32.22 = $372.22 Monthly and $4,466.64 yearly. It should be noted that although the immediate monthly cost of rent is lower than developing property, by calculating rent increase over 20 years (HUD, 2008) versus a stable mortgage with cost inflation for management and maintenance over 20 years yields an average cost for developed, non-profit owned units of $6,057.84 per year and $7,384.69 for rented units – saving $1,326.85 per year on average.
Assuming subsidies pay all of the rent but 30% of the tenant's income, subsidies would cover cost, minus an average of $840 per year (median yearly income from survey, $2,800 * 30%). This would yield yearly costs of $4282.93 for non-profit owned/developed housing and $3,626.64 for rentals.
Supportive housing.
Aside from being one of the 4 guiding principles in the Strategic Framework
for Ending Chronic Homelessness in Nashville (The Mayor’s Task Force
to End Chronic Homelessness, 2004). PSH is a widely accepted means of
getting people experiencing homelessness off of the streets and into
a home that they stick with. Supportive housing may be the best option
for severely mentally or physically disabled individuals and may be
a stepping stone toward basic housing or independent living for some
people on the streets or in shelters. Currently, the cost to provide
wraparound services and housing in Nashville is $11,500 Yearly or
$958.33 Monthly. Although this study notes a net loss (see table
2) for permanent supportive housing (PSH), a local PSH provider reports
a net savings of $3,646.21 per individual. Supportive housing provides
quality of life and access to services that may be necessary or preferred
by some people experiencing homelessness.
Table 2. Costs for Housing First and Permanent Supportive Housing in Nashville, TN (2007)
| Yearly Costs: | Current Cost | Cost, reduced by Housing | Housing Cost (subsidized) | Reduced Cost + Housing | Savings/ (loss) |
| Homeless NP Developed | $7,536.41 | $2,280.25 | $4,282.93 | $6,263.29 | $973.23 |
| Chronic Homeless NP Developed | $10,624.72 | $3,334.78 | $4,282.93 | $7,617.71 (upper bound) | $3,007.01 |
| Homeless Rent subsidy | $7,536.41 | $2,280.25 | $3,626.64 | $5,906.89 (lower bound) | $1,629.52 |
| Chronic Homeless Rent subsidy | $10,624.72 | $3,334.78 | $3,983.04 | $7,317.82 | $3,306.90 |
| Homeless PSH | $7,536.41 | $1,587.07 | $11,500.00 | $13,087.07 | ($5,550.66) |
| Chronic Homeless PSH | $10,624.72 | $2,282.67 | $11,500.00 | $13,782.67 | ($3,157.95) |
Housing costs compared. Utilizing reduction in service use figures from existing housing efforts (Culhane, Metraux, and Hadley, 2002; Martinez, Burt, & Burt, 2006; Meschede, 2007; Mondello, Gass, McLaughlin, & Shore, 2007; Padgett, Gulcur, & Tsemberis, 2006; Perlman & Parvensky, 2006; Shinn & Tsemberis, 1998; Tsemberis & Eisenberg, 2000; Wright, 2006), we estimated drop amounts for each service category, chronic homeless and homeless (see table 2). Then, cost totals (service costs reduced by housing estimates + housing subsidy cost) were calculated for each category and subtracted from the costs of homelessness generated by this project. Non-profit developed housing for people experiencing homelessness has an estimated yearly savings of $973.23. Non-profit developed housing for chronically homeless people has an estimated yearly savings of $3,007.01. Rent subsidized housing for people experiencing homelessness has an estimated yearly savings of $1,629.52. Rent subsidized housing for chronically homeless people has an estimated yearly savings of $3,306.90. Supportive/wraparound housing for people experiencing homelessness generates a yearly loss of $5,550.66. Supportive/wraparound housing for chronically homeless people generates a yearly loss of $3,157.95. Although a net loss for supportive housing may seem like a negative outcome, in the scope of a larger effort to house people on the streets, diverse housing options could balance each other out; for instance, a housing program for chronically homeless people could be split almost evenly between Non-profit developed units and supportive housing – with just a small leaning toward housing first units, breaking even or yielding a slight total savings. Since the point of housing is to get people off of the streets, not to make a profit, such a balanced scheme seems tenable.
Conclusions
Out of the many interviews generated by this study, the words from one person experiencing homelessness exemplifies the frustration of many: “...the city of Nashville...need[s] to...stop spending so much money on tacky artwork – like $330,000 – and get some vacant houses that they are kicking some of these people out of that need these houses and fix them up and put these people in the houses and stop taking care of downtown for the rich folks...we're human beings too.” If you believe that housing is a right, a privilege, or somewhere in between, this study still strongly indicates that housing people experiencing homelessness makes economic sense for Nashville. It is evidenced by this research that all housing first options are less expensive than accepting the status quo and a balanced use of supportive housing and housing first efforts are still as affordable as our current state of urban decay. Whether shifting public and non-profit perspectives toward housing over services or locating subsidies and other funding for housing, our next task to end homelessness – chronic and otherwise – is to create dwelling options and continue the measurement of costs associated with services and housing.
Beyond
economic questions, housing people on the streets is a question of quality
of life, or even life itself; In the earnest words of one homeless respondent:
“Everybody needs a house or an apartment or something, because it's
getting real hard here out on the streets. People are dying, it's so
hot.” This study certainly does not intend to reduce homelessness
to dollar figures. We hope that the results of this research simply
show that money is not our greatest obstacle in the struggle for human
rights and humane housing.
References
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Appendices
Interview
Protocols:
Homelessness Interview Protocol:
Key Informant
Hello. My name is ______ and
I'm doing a study on housing and the experience of homelessness. I am
from the Center for Community Studies at Peabody College where we are
interested in permanent supportive housing for people who are on the
streets or in shelters. Can I ask you a few questions about your work
for this study? The interview will last about 30 minutes and I'll record
the interview. I won't include your name or any information that would
make your answers identifiable. If you'll take part in this interview,
I will read an agreement to you that explains possible benefits and
risks for you and the community. Or, if you prefer, you can read it
yourself. You will need to sign a copy and can keep a copy if you'd
like. The signed copy will be kept separate from your interview answers.
Thank you for your time.
Thank you for your time.
If you have any questions, please contact me using the information on
the confidentiality agreement.
Homelessness Interview Protocol: Person Experiencing Homelessness
Hello. My name is Courte and
I'm doing a study on housing and the experience of homelessness. I am
from the Center for Community Studies at Peabody College where we are
interested in permanent supportive housing for people who are on the
streets or in shelters. Can I ask you a few questions about your experiences
for this study? The interview will last about 30 minutes and I'll record
the interview. I won't include your name or any information that would
make your answers identifiable. If you'll take part in this interview,
I will read an agreement to you that explains possible benefits and
risks for you and the community. Or, if you prefer, you can read it
yourself. You will need to sign a copy and can keep a copy if you'd
like. The signed copy will be kept separate from your interview answers.
Thank you for your time.
How long have you been living on the streets or in shelters?
The next few questions are asking about you experience while homeless. Please only include information regarding time in a shelter, on the streets, in a car, or crashing with friends for free.
While you were homeless, did you ever go to the hospital, clinics, doctors, or seek medical care from anyone?
While you were homeless, were you ever a patient in a mental hospital or clinic?
While you were homeless, were you ever a patient in a drug or alcohol treatment facility?
Are there any other kinds of services you have used while you were homeless?
While you were homeless, were you ever locked-up or arrested?
If you could have a home with access to all of the places and services that you need, would you live there?
Do you currently have a job?
What has led to you being homeless?
Do you live alone or with family members?
Have you ever been diagnosed with a mental illness, alcohol dependence or abuse, or substance dependence or abuse?
Have you ever been a victim of domestic abuse or institutional abuse?
Do you have access to a bank?
What do you think people need to get off the street?
I have just a few more questions to help us get a fuller picture of the kinds of people who are homeless in Nashville.
What year were you born?
Would you define yourself as:
How long have you lived in Nashville?
Are you a veteran of the armed forces?
What is your yearly income?
Are you single, married, divorced, widowed?
[Time permitting]Please describe a usual day for you, including people and places that you encounter
Do you have anything else to
add to this interview?
Thank you for your time. If you have any questions, please contact me using the information on the confidentiality agreement.
[MARK SEX: MALE/FEMALE]
Informed Consent Forms
Key Informant.
Name of participant: _________________________________________________________
Age: ___________
This letter
is to tell you about this study and your part in it. Please listen
carefully and feel free to ask any questions at any time. You
will be given a copy of this letter to keep.
Taking part in this study is by choice. You can stop this at any time or skip any question. If I learn something that changes the possible risks or benefits of this study, I will tell you right away so that you can decide if you want to continue.
The purpose of this study is to find out costs of homelessness to people who are homeless and to the community. The results may be used to support permanent housing and services for people who are homeless in Nashville. The results may also be used in other U.S. cities and may be published in an article. The results of this study will be included in a report to the Metro Nashville Homelessness Commission.
You are being asked to take part in this study because your answers can help us to provide housing and services for the homeless. No one will share your name with anyone and no one will share your individual answers. I will not ask you or anyone else for your name or any information to identify you. The records of this interview will be kept separate from the form that you sign so that no one will know what you have answered.
The interview should take about 30 minutes. You can skip any question or stop the interview at any time. There is a small risk that you could be identified. We will do everything that we can to prevent this from happening. The possible benefits to you from this study are more information to create and support housing and services for people who are homelessness in Nashville. This study may result in more services and housing that could benefit people experiencing homelessness in Nashville. This study may help us figure out some causes of homelessness and what we can do to prevent and cure homelessness. You will not receive money for doing this interview. There is no penalty for you to stop this interview. If I think that you do not understand the risks of this study at any time, I will stop the interview. If I find out that you are under 18 years old at any time, I will stop the interview.
We will do all that we can to keep your name and answers private, but total privacy cannot be guaranteed. Your name will never be written down. Your signature will be kept separate from the records of this interview. This letter and the interview will be kept secure. Your information may be shared if you or someone else is in danger or if we are required to do so by law. In this case, we will share your information with Vanderbilt or the government, such as the Vanderbilt University Institutional Review Board, Federal Government Office for Human Research Protections, and/or representatives of the Metropolitan Nashville Homelessness Commission.
If you have
any questions or feel that you have been harmed by doing this interview,
please contact the principal investigator, Courte C. W. Voorhees
at (615) 428-4421 or the Faculty Advisor, Dr. Douglas
D. Perkins at (615) 322-3386., or the Vanderbilt University
Institutional Review Board Office at (615) 322-2918 or toll free
at (866) 224-8273.
STATEMENT BY PERSON AGREEING TO PARTICIPATE IN THIS STUDY
☐ I have read this letter or it has
been read to me. The information in it has been explained to me verbally.
All my questions have been answered, and I freely and voluntarily choose
to participate.
Date Signature
of volunteer
Consent obtained by:
Date Signature
Printed Name and Title
Person experiencing homelessness.
Name of participant: _________________________________________________________
Age: ___________
This letter is to tell you about this study and your part in it.
Please listen carefully and feel free to ask any questions at any time.
You will be given a copy of this letter to keep.
Taking part in this study is by choice. You can stop this at any time or skip any question. If I learn something that changes the possible risks or benefits of this study, I will tell you right away
so that you can decide if you want to continue.
The purpose of this study is
to find out costs of homelessness to people who are homeless and to the community. The results may be used to support permanent housing and services for people who are homeles
s in Nashville. The results may also be used in other U.S. cities and may be published in an article. The results of this study will be included in a report to the Metro Nashville Homelessness Commission.
You are being asked to take part in this study beca
use your answers can help us to provide housing and services for the homeless. No one will share your name with anyone and no one will share your individual answers. I will not ask you or anyone else for your name or any information to identify you. The ta
pe recording of this interview will be kept separate from the form that you sign so that no one will know what you have answered.
The interview should take about 30 minutes. There may be questions that make you uncomfortable. You can skip any question or
stop the interview at any time. There is a small risk that you could be identified. We will do everything that we can to prevent this from happening.
Participation in this study does not mean that you will get better housing. This study may help us figure
out some causes of homelessness and what we can do to prevent and cure homelessness. This study may also help us to build housing for people who are homeless. You will receive ten dollars for doing this interview. There is no penalty for you to stop this
interview.
If I think that you do not understand the risks of this study at any time, I will stop the interview. If I find out that you are under 18 years old at any time, I will stop the interview.
We will do all that we can to keep your name and answers
private, but total privacy cannot be guaranteed. Your name will never be written down. Your signature will be kept separate from the audio tape of this interview. This letter and the interview will be kept locked-up.
Your information may be shared
i
f you o
r someone else is in danger or if we are required to do so by law. In this case, we will share your information with Vanderbilt or the government, such as the Vanderbilt University Institutional Review Board, Federal Government Office for Human Research Pr
otections, and/or representatives of the Metropolitan Nashville Homelessness Commission.
If you have any questions or feel that you have been hurt by doing this interview, please contact me,
Courte C. W. Voorhees
at
(615) 428-4421
or my Faculty Advisor
, Dr. Douglas D. Perkins
at
(615) 322-3386
., or the
Vanderbilt University Institutional Review Board Office
at
(615) 322-2918 or toll free at (866) 224-8273.
STATEMENT BY PERSON AGREEING TO PARTICIPATE IN THIS STUDY
☐
I have read this letter
or it has been read to me. The information in it has been explained
to me verbally. All my questions have been answered, and I freely
and voluntarily choose to participate.
Date Signature of volunteer
Consent
obtained by:
Date Signature
Printed Name and Title
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