Summary

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Chapter 11. Do Certain Interventions Work Better When

11.4 Summary

It is clear that families in this study experience high numbers of psychosocial challenges and even higher numbers of barri - ers to housing. This result was by design: the study enrolled families only after they had spent at least 7 days in shelter.

At the same time, the examination of potential moderator effects of difficulties of this sort does not provide evidence that any of the interventions studied works comparatively better for families who have greater psychosocial challenges or housing barriers than for families who face fewer difficulties.

We cannot completely rule out the possibility of differential effects—doing so would require larger sample sizes than are available in the study. At this point, however, the main study results on impacts across all families provide the study’s clearest guidance for policy and practice.

Exhibit 11-4. Impacts Moderated by Housing Barriers Index

Outcome SUB vs. UC CBRR vs. UC PBTH vs. UC SUB vs. CBRR SUB vs. PBTH CBRR vs. PBTH Impact at Low vs. High

Housing Barriers Low High Low High Low High Low High Low High Low High

Housing stability

At least 1 night homelessa or doubled up in past 6 months or in shelter in past 12 months (%)

– 30.30 – 25.32 – 9.51 – 0.22 – 4.67 – 7.09 – 24.30 – 30.16 – 30.75 – 30.40 – 3.54 13.31*

At least 1 night homelessa or

doubled up in past 6 months (%) – 24.50 – 23.49 – 6.65 – 1.82 3.32 – 8.99 – 17.29 – 24.00 – 29.62 – 23.00 – 3.37 15.80*

Number of places lived in past

6 months – 0.39 – 0.32 – 0.13 – 0.06 0.02 – 0.13 – 0.17 – 0.32 – 0.32 – 0.43 – 0.14 0.14

Any stay in emergency shelter in

months 7 to 18 after RA (%) – 16.92 – 11.00 – 7.93 2.37* – 11.19 – 5.64 – 13.77 – 13.61 – 13.30 – 13.46 – 2.93 5.38 Family preservation

Family has at least one child

separated in past 6 monthsb (%) – 5.96 – 7.85 1.51 – 4.82 0.75 – 1.55 – 1.96 – 0.46 – 4.79 – 8.20 3.19 – 3.05 Spouse/partner separated in past

6 months, of those with spouse/

partner present at RAc (%)

– 5.51 7.44 16.23 2.41 – 0.55 0.68 – 14.33 – 18.29 – 13.00 7.81 5.67 7.68

Family has at least one child reunified, of those families with at least one child absent at RAd (%)

1.75 8.91 15.52 1.74 – 0.58 5.63 – 11.16 7.55 13.03 33.27 3.50 4.72

Adult well-being

Health in past 30 days was poor

or fair (%) 0.72 – 0.62 – 2.69 – 5.20 – 0.06 3.40 1.39 – 1.27 – 1.89 – 6.16 – 2.52 – 15.52

Psychological distresse – 1.03 – 0.81 – 1.55 – 0.02** – 0.62 0.08 0.45 – 1.04* – 1.08 – 1.77 – 1.84 – 1.99 Alcohol dependence or drug

abusef (%) – 4.46 – 4.52 – 2.39 – 4.92 – 0.50 1.35 1.78 – 0.78 – 0.55 – 11.70 – 6.86 – 8.17

Experienced intimate partner

violence in past 6 months (%) – 8.17 – 5.29 – 0.59 – 2.56 – 0.96 – 2.77 – 5.76 – 7.92 – 8.11 0.27 – 5.81 3.50 Child well-being

Number of schools attended since

RAg – 0.15 – 0.25 0.00 – 0.08 – 0.02 – 0.10 – 0.13 – 0.33 – 0.04 – 0.23 0.05 – 0.05

Childcare or school absences in

last monthh – 0.19 – 0.12 – 0.17 – 0.11 – 0.08 0.16 – 0.03 – 0.01 0.18 – 0.33*** 0.08 – 0.33**

Poor or fair health (%) – 0.37 0.90 0.03 – 0.22 0.47 4.13 – 0.37 – 0.62 – 3.48 0.70 – 4.05 – 4.60 Behavior problemsi – 0.20 – 0.08 – 0.26 – 0.03 – 0.25 – 0.04 0.18 0.00 0.23 0.07 – 0.03 – 0.01 Self-sufficiency

Work for pay in week before

survey (%) – 6.65 – 3.44 – 0.23 1.80 – 1.11 11.62* – 2.07 – 6.87 – 6.55 – 15.58 – 2.16 – 13.35 Total family income ($) – $779 – $111 $1,193 $1,020 $973 $1,071 – $1,515 – $693 – $1,658 – $1,424 $217 $389 Household is food insecure (%) – 10.84 – 8.20 – 10.37 – 4.60 – 5.16 1.83 – 4.04 – 4.70 1.23 – 13.96* – 1.04 – 14.45 CBRR = community-based rapid rehousing. PBTH = project-based transitional housing. SUB = permanent housing subsidy. UC = usual care.

RA = random assignment.

*/**/*** Impact magnitude varies significantly with level of housing barriers at the .10, .05, and .01 levels, respectively, using a two-tailed t-test.

a The definition of homeless in this report includes stays in emergency shelters and places not meant for human habitation. It excludes transitional housing.

b Percentage of families in which a child who was with the family at baseline became separated from the family in the 6 months before the 18-month survey.

c Percentage of families in which a spouse or partner who was with the family at baseline became separated from the family in the 6 months before the 18-month survey.

d Percentage of families in which at least one child was separated from the family at baseline and no child was reunited with the family at the time of the 18-month survey.

e Psychological distress is measured with the Kessler 6 (K6) scale and ranges from 0 to 24, with higher scores indicating greater distress. Impacts shown as standardized effect sizes. Effect sizes were standardized by dividing impacts by standard deviation for the UC group.

f Measures evidence of alcohol dependence or drug abuse using responses to the Rapid Alcohol Problems Screen (RAPS-4) and six items from the Drug Abuse Screening Test (DAST-10).

g Number of schools outcome is topcoded at four or more schools.

h Absences outcome is defined as 0 = no absences in past month; 1 = one–two absences; 2 = three—five absences; 3 = six or more absences.

i Behavior problems outcome is measured as the standardized Total Difficulties score from the Strengths and Difficulties Questionnaire, or SDQ.

Notes: The Low estimate is calculated at the 20th percentile of the moderator in the full sample and the High estimate is calculated at the 80th percentile of the moderator. Impact mean difference estimates are regression-adjusted for baseline characteristics and are weighted to adjust for survey nonresponse. See Chapter 5 and Appendix B for outcome definitions.

Source: Family Options Study 18-month followup survey

Short-Term Impacts of Housing and Services Interventions for Homeless Families 134

CHAPTER 12.

INTERVENTION COSTS

T

his chapter of the report documents the costs of providing the housing or shelter and supportive services in the programs associated with the inter - ventions in the Family Options Study, including the cost of remaining in emergency shelter. For decisionmakers de - signing and implementing policy to address homelessness among families, understanding the relative costs of the active interventions in this study is a critical complement to un - derstanding their relative impacts. This chapter begins by introducing the concepts and methods used to analyze and describe program costs and then providing a high-level summary of the cost estimates (Section 12.1).

To assess the relative costs of the interventions, it is crucial to understand the cost per month for each program, but also to look at costs from two other perspectives: (1) the cost dur - ing the period the family uses the program (the “program stay”) and (2) the overall cost to all providers of shelter and housing assistance of giving families priority access to a particular type of program. Following the Introduction and Summary section, the next sections (12.2 through 12.5) present in detail the costs per month of the programs that provided the permanent housing subsidy (SUB), community- based rapid re-housing (CBRR), and project-based transitional housing (PBTH) interventions and of emergency shelter. Those sections also present the average costs per program stay for the families assigned to the active interventions and the costs for the stay in emergency shelter that followed random assign - ment of families to usual care (UC). Section 12.6 compares monthly costs and costs per stay across the three active in -terventions and emergency shelter. Section 12.7 compares the costs of all use of shelter and housing programs in the followup period after random assignment by families given priority access to each intervention. Finally, Section 12.8 compares the average costs per month of all use of shelter and housing programs used at the time of the followup sur-vey by families given priority access to each intervention.

12.1 Introduction and Summary

The objective of the Family Options Study is to provide evi - dence to support decisions of policymakers, planners, and practitioners addressing homelessness among families. Al-though much of the study is focused on estimating relative effects of different types of interventions, such estimates are only one input into decisions about homelessness policy.

Another input is the cost of the interventions. Because of differences in the type of housing or shelter provided, the duration of assistance, and the range and intensity of sup-portive services offered, the programs associated with each active intervention vary in cost. With respect to duration, housing assistance provided by CBRR and PBTH programs is temporary; subsidies provided by SUB programs are indefinite, as long as regular eligibility requirements for the subsidy are maintained. Regarding the intensity of supportive services, programs without supportive services will usually require fewer resources for a given duration than those offer - ing such services.

This chapter reports on the costs of providing the housing and services in the programs associated with the three active interventions: CBRR, PBTH, and SUB. The chapter also reports costs for emergency shelter programs to provide information on the cost of the initial stay in emergency shelter during which families were enrolled in the study and also any sub-sequent return to shelter during the period between random assignment and the followup survey.135

We present analyses for four concepts of costs: (1) per-family monthly program cost, (2) program cost per stay during the followup period, (3) cost of all program use during the followup period, and (4) monthly cost of all program use at the time of the followup survey.

1. Per-family monthly program cost: The cost of all resources used to provide shelter or housing and services to a family during the course of a month because they are receiving

135 The UC intervention includes whatever housing subsidies or supportive services families were able to obtain without study assistance. Because it was not feasible to determine the extent and costs of any assistance beyond what was provided by the emergency shelter program, for per-family monthly program costs and program cost per stay during the followup period, we report costs associated with emergency shelter only rather than all costs associated with the UC intervention—in particular, for assis-tance that families may have received after leaving shelter. The third cost measure, the cost of all program use during the followup period does estimate the cost of other program use for all intervention types, including UC.

assistance through a particular program. We estimate per- family monthly program costs of CBRR, PBTH, and emergency shelter programs by cataloging and valuing the housing or shelter dimension of each program (capital and operating costs or rent) and also the services dimension (the personnel, space, and materials used to provide services) in each of 81 study programs. We estimate costs of SUB in each of the 10 sites providing SUB using administrative data. Household-level administrative data provide information on household-level monthly housing assistance payments (HAPs) and housing authority financial reports supply site-level costs of adminis-tering the Housing Choice Voucher program.136

2. Program cost per stay during the followup period: The cost of all resources used to provide shelter or housing and supportive services to a family by the program to which they were given priority access during the time between random assignment and the family’s followup survey.137 We estimate program costs per stay by multiplying per-family monthly program costs by the average number of months of assistance received by families assigned to that program type in the program’s site. Combining the monthly cost measure of intensity of assistance with the duration of receipt provides a single measure of the amount of housing or shelter and services provided to families at a study intervention.

3. Cost of all program use during the followup period: The cost of all program use during the followup period accounts for costs of all programs families used during the followup period. Families given priority access to a particular type of program through random assignment nonetheless used multiple programs—both the program type to which they were randomized and other program types. Random assign-ment to one program makes it more likely that a family will use that program, but also either more or less likely that the family will use other housing or shelter programs (see Exhibits 6-2, 7-4, and 8-6). When comparing program costs, it is useful for decisionmakers within the homeless services and housing assistance systems to consider the costs of all

program use during the followup period for which this study estimates impacts. As in the cost per stay, this cost includes the expense of providing housing or shelter and related assis - tance (services) to study families during the time between random assignment and the followup survey. We estimate the cost of all program use by multiplying the average site- level per-family monthly program cost for each program type by the number of months of assistance of each respective type provided to each family, as observed in the Family Options Study Program Usage Data. The cost of all program use during the followup period is the sum of these monthly costs times months of assistance. This chapter reports averages of this amount (calculated using the same nonresponse weights used in the impact analyses) for each of the study’s pairwise comparisons. Thus, this estimate provides a total cost of housing or shelter and services that reflects the different mixes of program types used that resulted from a family’s being provided priority access to a particular program type.138 4. Monthly cost of all program use at the followup survey:

The monthly cost of all program use at the followup survey considers the average per-family monthly program cost of programs from which families were receiving assistance at the time of the followup survey. Initial random assignment to one program type may make it more or less likely that the family will use other housing or shelter programs in the medium and long terms. As a result, giving families priority access to a particular program type today can change the cost of assistance they receive months and years into the future. These subsequent costs will be analyzed for a longer timeframe and reported in the 36-month report along with impacts measured at 36 months. This chapter reports averages of this point-in-time cost calculated for each of the study’s pairwise comparisons.

Each of the four cost measures provides useful, but different, information to a decisionmaker evaluating the relative costs and benefits of CBRR, PBTH, and SUB. A decisionmaker con - sidering the relative cost of funding one particular program

136 Gubits et al. (2013) described the type and extent of services linked to the housing or shelter provided by the programs participating in each intervention. This cost analysis adds to that information by estimating the value of the resources that programs and their partners expend on those services per family per month, which can serve as one measure of the depth or intensity of the services.

137 The length of time between random assignment and the followup survey varied across families, with a median of 20 months. Weighted averages of duration of assistance receipt are calculated at both the study level and site level from the Program Usage Data (see Chapter 4, Exhibit 4-2) using nonresponse weights. All observed months of use of a program of the type to which a family was randomly assigned are counted for families assigned to CBRR, PBTH, and SUB. Emergency shelter durations are calculated as the average duration in the first observed shelter stay, the stay during which families were randomly assigned. Subsequent returns to shelter are not included in this cost measure, but they are captured in the cost of all program use during the followup period.

138 Many families accessed shelter or housing and related services from programs not in the cost study. All stays at programs that matched a “type” from a study were valued at the site-level average of the per-family monthly program cost. So, assistance from any rapid re-housing program was valued at the sites’ average CBRR per-family monthly program cost, and assistance from any transitional housing program was valued at the site’s average PBTH per-family monthly program cost. Study families also received assistance from programs the study classifies as permanent supportive housing, public housing, or project-based housing assistance (project-based vouchers or Section 8 projects), for which we have no direct cost estimates. Under the assumption that they have similar program and cost structures, we use site-level average PBTH costs to estimate permanent supportive housing costs and SUB costs to estimate public housing and project-based assistance costs.

Short-Term Impacts of Housing and Services Interventions for Homeless Families 136 Chapter 12. Intervention Costs

type versus another would use per-family monthly costs and program costs per stay to assess the costs associated with serving a family with a particular type of intervention and over a given length of time. For example, the analysis below in Section 12.1.2 shows that the ongoing cost per month of providing a family with CBRR, on average, is lower than the cost of providing either PBTH or SUB and is substantially lower than the cost of continued stay in emergency shelter.

Costs per stay within the followup period after random as - signment add the consideration that ongoing costs are limited to the duration of the assistance. Continuing our example, CBRR assistance is of shorter duration than PBTH or SUB, and the per-stay cost of providing a family with CBRR is sub - stantially lower than costs for the longer assistance episodes observed for SUB and PBTH. (These computations, however, ignore the possibility that, at the end of this stay in this pro - gram, the individual might begin a stay in some other program.

The third and fourth measures address that possibility and also the possibility that someone assigned to one program uses another program instead.)

The third measure, the cost of all program use during the followup period, incorporates the reality that a family ran-domly assigned to one program might nevertheless use a different program at some point over the followup period.

The intervention to which a family is assigned also has an indirect effect on the family’s use of programs not associated with the intervention. For example, this study finds that SUB results in improved housing stability, meaning fewer subsequent stays in costly emergency shelters. As a result of avoiding those stays in emergency shelter, the estimated per-family cost of all program use since random assignment is only $1,478 higher for families assigned to SUB as com-pared with families assigned to CBRR, even though costs per stay for CBRR are less than one-half as large as costs per stay for SUB.

This third measure of costs represents the total cost of the housing and services provided by the homeless services and housing assistance systems to study families given priority access to each of the active interventions. The costs can then be assessed in the context of the relative impacts of the interventions (reported in Chapters 6 through 9), which the study measured during the same period.

The fourth measure is a first look estimate of how the third measure of all program use might continue to accumulate during a longer time horizon. If families were to continue to use the mix of programs they are observed using at the time

of the followup survey, then each month the average cost of all program use by families assigned to each intervention would grow by this monthly amount.

This approach to estimating costs is different from previous studies that calculate the costs of homelessness. Many studies in recent decades sought to compare the cost of supportive housing for chronically homeless individuals or families with mainstream healthcare and public safety costs of managing this population in the absence of supportive housing.139 By contrast, this analysis focuses on the costs incurred, not by other systems or services, but by the programs that consti-tute the interventions in the study. Thus, it is very different from this “cost offset” literature. Instead, this study makes a careful distinction between services that are an integral part of the program and other services that the families random-ized to any of the four treatment groups might have received from mainstream systems or from specialized systems but not because they were participating in the SUB, CBRR, and PBTH

This approach to estimating costs is different from previous studies that calculate the costs of homelessness. Many studies in recent decades sought to compare the cost of supportive housing for chronically homeless individuals or families with mainstream healthcare and public safety costs of managing this population in the absence of supportive housing.139 By contrast, this analysis focuses on the costs incurred, not by other systems or services, but by the programs that consti-tute the interventions in the study. Thus, it is very different from this “cost offset” literature. Instead, this study makes a careful distinction between services that are an integral part of the program and other services that the families random-ized to any of the four treatment groups might have received from mainstream systems or from specialized systems but not because they were participating in the SUB, CBRR, and PBTH

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