Evaluating Maryland's Homelessness Solutions Program: A Research Proposal

Background and Rationale for the Evaluation

The proposed evaluation focuses on homelessness. The 2009 Homeless Emergency Assistance and Rapid Transition to Housing (HEARTH) Act defines homelessness as a situation where a family or individual lacks an adequate, regular, and fixed nighttime residence (Substance Abuse and Mental Health Services Administration [SAMHSA], 2023). This definition includes persons living in transitional housing, emergency shelters, abandoned buildings, the streets, and other places not meant for habitation. Individuals who stand to lose their nighttime residence within 14 days, or who are fleeing domestic violence and lack the resources to obtain alternative housing, are also considered homeless under the HEARTH Act of 2009 (SAMHSA, 2023).

Data from the National Alliance to End Homelessness shows that the number of homeless people in the United States has risen by approximately 6 percent since 2017 (SAMHSA, 2023). Contrary to expectations, the COVID-19 pandemic that peaked in 2020 had no significant effect on the U.S. homelessness rate (National Alliance to End Homelessness, 2023). According to a report by the Maryland Interagency Council on Homelessness (2022), this is due to the increase in economic assistance programs and efforts to de-congregate shelters in line with social distancing requirements. Nonetheless, a point-in-time count conducted in 2022 showed that over 582,000 people — approximately 9 in every 5,000 — were homeless across the United States (National Alliance to End Homelessness, 2023). Individual adults made up 72 percent of this population, while 28 percent lived in the streets and other unfit environments with their children (National Alliance to End Homelessness, 2023).

In Maryland, point-in-time count data from 2020 showed that slightly over 6,300 people were homeless statewide, with Baltimore City accounting for the highest rates of homelessness at 35 percent (Maryland Interagency Council on Homelessness, 2022). Generally, the statewide annual count showed that Maryland had approximately 28,288 homeless people in 2020 (Maryland Interagency Council on Homelessness, 2022). Unfortunately, homelessness disproportionately affects special populations, including persons with disability, mentally ill individuals, veterans, unaccompanied in-parenting youth, and victims of domestic violence (Maryland Interagency Council on Homelessness, 2022). Twenty-one percent of homeless people in the state, as per the 2020 point-in-time count, were chronically homeless individuals who had been homeless for over a year and struggled with a physical disability, substance use disorder, or severe mental illness (Maryland Interagency Council on Homelessness, 2022). Homeless veterans made up 7.5 percent of the homeless population, while individuals experiencing domestic violence and unaccompanied homeless youth made up 5 percent and 4 percent of the homeless population, respectively (Maryland Interagency Council on Homelessness, 2022).

Policymakers across the U.S. need to institute ways of addressing homelessness because it increases the risk of mortality and reduces the average life expectancy of affected populations (Maryland Interagency Council on Homelessness, 2022). Studies have shown that homeless people report higher rates of injury-related death and violence than the general population (Maryland Interagency Council on Homelessness, 2022). Data from the Office of the Chief Medical Examiner (as cited in Maryland Interagency Council on Homelessness, 2022) shows that approximately 243 homeless people died in Maryland in 2020. This translates to a death rate of 3,835 per 100,000 people for homeless populations, which is three times the death rate of the general Maryland population (Maryland Interagency Council on Homelessness, 2022). On average, homelessness reduces an individual's life expectancy by 30 years relative to the average person (Maryland Interagency Council on Homelessness, 2022).

Besides mortality, homelessness is associated with a myriad of other adverse health outcomes. The most commonly studied health outcomes among homeless populations include cardiovascular diseases (CVD), HIV and other infectious diseases, communicable diseases, opioid-related overdose, mental health problems, and mortality. A systematic review by Al-Shakarchi et al. (2020) sought to compare the risk of CVD in homeless and non-homeless populations using data from studies drawn from North America and Europe. The findings showed that the risk of CVD and CVD-related mortality among homeless populations was three times greater than that of non-homeless populations (Al-Shakarchi et al., 2020). Sources attribute this to the high prevalence of CVD-related risk factors among homeless populations, including smoking, use of illicit substances, and high cholesterol levels (Al-Shakarchi et al., 2020).

Studies have also found a positive association between homelessness and the risk of HIV, sexually transmitted diseases, and Hepatitis C (Arum et al., 2021). This is because homeless individuals are more likely to engage in risky behaviors such as sharing drug-injection needles and unsafe sexual behavior (Arum et al., 2021). At the same time, homelessness increases the risk of communicable diseases such as influenza, tuberculosis, mosquito-borne illnesses, skin infections, and Hepatitis A because of limited access to vaccination, low health literacy levels, living in congregate settings, and low levels of personal hygiene (Liu et al., 2020). Homeless populations are also associated with higher use of illicit substances, opioid overdose, and opioid-related deaths (Fine et al., 2022). For instance, 65 percent of deaths reported among homeless individuals in 2020 were due to drug overdose and related complications, with opioid overdoses accounting for 88 percent of these deaths (Maryland Interagency Council on Homelessness, 2022). In a study by Fine et al. (2022) examining mortality rates among 60,092 homeless adults between 2003 and 2018, 12 percent of participants died during the study period, with drug overdoses accounting for 25 percent of reported deaths.

Studies have also found homeless individuals to have a higher prevalence of mental health disorders than their non-homeless counterparts (Gutwinski et al., 2021). A systematic review by Gutwinski et al. (2021) found that approximately 12 percent of homeless individuals had either schizophrenia spectrum disorders or major depression, compared to 0.7 percent of the non-homeless population. The study also found a higher risk of mortality among homeless individuals with mental health disorders compared to the general population (Gutwinski et al., 2021). These adverse health outcomes necessitate programs and policies aimed at reducing homelessness, which are often implemented by government agencies or non-governmental organizations.

Many studies have sought to evaluate the effectiveness of interventions that focus on preventing or reducing homelessness. To inform this evaluation, a systematic review of peer-reviewed articles on homelessness prevention interventions was conducted. The search strategy targeted databases such as Cochrane, PubMed, and Science Direct, with inclusion criteria limited to studies published in the last ten years, conducted in the U.S., and evaluating homelessness prevention or intervention programs. The review identified several studies that evaluated programs similar to the HSP (Dwyer et al., 2023; Philips & Sullivan, 2022; Aubry et al., 2020).

Generally, the studies found that homelessness prevention programs and interventions were effective in preventing and reducing homelessness (Dwyer et al., 2023; Philips & Sullivan, 2022; Aubry et al., 2020). However, the studies also found some interventions, or combinations of interventions, to be more effective than others. For instance, Dwyer et al. (2023) evaluated the impact of unconditional cash transfers and coaching support programs on increasing housing stability among homeless individuals. The study found that unconditional cash transfers, coupled with coaching supports and workshops on plan-making, goal-setting, and self-affirmation, improved housing stability within three months better than cash transfer programs alone. Similarly, Philips and Sullivan (2022) evaluated the effectiveness of financial assistance and case management programs in reducing and preventing homelessness among vulnerable populations. The study found that financial assistance coupled with case management increased housing stability and reduced evictions more than monetary assistance programs alone. The primary weakness of these evaluations is that they focus on income intervention programs alone and disregard supportive housing programs, which are also quite common.

In their systematic review, Aubry et al. (2020) address this weakness by studying the impact of both housing support and income assistance interventions targeting homeless individuals. The study found that compared to usual care, housing support programs increase long-term housing stability at a rate of 1.13. At the same time, income assistance coupled with case management improved the number of days a homeless individual is housed by eight days relative to usual care (Aubry et al., 2020).

The primary strength of this body of work is that the studies use comprehensive data collection methods and include rigorous evaluation designs, both of which enhance the credibility of the findings. However, the reviewed studies have a limited scope, focusing on one or two interventions. The proposed evaluation seeks to assess the HSP, which incorporates a range of diverse interventions targeted at homeless people. Moreover, the reviewed studies do not focus specifically on Maryland, and it would be instructive to examine whether findings from studies conducted in other environments can be replicated in the state.

References

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Appendices

Appendix 1: Budget Table for the HSP Evaluation Project

Staffing Expenses

Project Director — $139,109.00. The project director will be responsible for managing and coordinating all project activities. Per Indeed, the average annual salary for a Maryland program director is $139,109.

Project Assistant (1) — $51,776.00. Full-time employee assists the project director and case managers in coordinating and scheduling training, distributing vouchers, maintaining records and accounting, and handling data entry. Per Indeed, the annual base salary for a project assistant in Maryland is $51,776.00.

Case Managers (10) — $296,870.40. Part-time employees provide case management services to the homeless population in Maryland, conduct assessments, assist with housing applications, and arrange transportation to potential housing sites. Per Indeed, the average pay rate in Maryland is $25.77/hr. ($25.77 × 24 hr/week = $618.48 × 4 weeks/month = $2,473.92 × 12 months = $29,687.04 × 10 people = $296,870.40).

Program Analyst — $35,763.84. Collects, runs, and validates data; completes program assessments; and monitors the program to determine its success. Per Indeed, the average pay rate in Maryland is $62.09/hr. ($62.09 × 24 hr/week = $1,490.16 × 2 weeks/month = $2,980.32 × 12 months = $35,763.84).

Staffing Subtotal: $523,519.24

Benefits

Project Director — $41,732.70. Fringe benefits at 30% of salary for full-time employees: $139,109.00 × 0.30 = $41,732.70.

Project Assistant (1) — $15,532.80. Fringe benefits at 30% of salary: $51,776.00 × 0.30 = $15,532.80.

Case Managers (10) — $35,624.40. Fringe benefits at 12% of salary for part-time employees: $29,687.04 × 0.12 = $3,562.44 × 10 = $35,624.40.

Program Analyst — $4,291.66. Fringe benefits at 12% of salary: $35,763.84 × 0.12 = $4,291.66.

Benefits Subtotal: $97,181.56

Training

Consultant Fees — $4,000.00. A flat fee of $500 per class for eight classes on financial literacy and locating and applying for housing: $500 × 8 = $4,000.00.

Training Lunch — $1,600.00. Box lunches during training classes: $20 × 10 participants = $200 × 8 classes = $1,600.00.

Training Subtotal: $5,600.00

Equipment and Supplies

Emergency Food or Clothing Vouchers — $22,500.00. To provide emergency food and clothing vouchers to homeless participants (one per participant if needed): $150 × 150 participants = $22,500.00.

Rental Assistance Vouchers — $10,000.00. One-time payment to assist participants with rent; funds will be drawn upon until exhausted per year.

Furniture and Housing Supplies Vouchers — $10,000.00. To assist participants with furniture and housing supplies when moving from homelessness to permanent residency; funds will be drawn upon until exhausted per year.

Participant Incentives — $500.00. Ten participants will be randomly selected to provide an in-depth interview and will receive $50 each: $50 × 10 = $500.00.

Equipment and Supplies Subtotal: $43,000.00

Total Cost: $669,300.80

Appendix 2: Gantt Chart (Activity Timeline for HSP Evaluation Project)

The activity timeline Gantt chart is provided as a separate exhibit within the appendices section.

Appendix C: Client Satisfaction Questionnaire (CSQ-8)

Client Satisfaction Questionnaire (CSQ-8, v. TMS-180S) (Larsen et al., 1979)

Instructions for participants: Please help us improve our service by answering some questions about the help that you have received. We are interested in your honest opinions, whether they are positive or negative. Please answer all of the questions. We also welcome your comments and suggestions. Thank you very much.

1. How would you rate the quality of service you received? Excellent (4) / Good (3) / Fair (2) / Poor (1)

2. Did you get the kind of service you wanted? No, definitely not (1) / No, not really (2) / Yes, generally (3) / Yes, definitely (4)

3. To what extent has our service met your needs? Almost all of my needs have been met (4) / Most of my needs have been met (3) / Only a few of my needs have been met (2) / None of my needs have been met (1)

4. If a friend were in need of similar help, would you recommend our service to him or her? No, definitely not (1) / No, I don't think so (2) / Yes, I think so (3) / Yes, definitely (4)

5. How satisfied are you with the amount of help you received? Quite dissatisfied (1) / Indifferent or mildly dissatisfied (2) / Mostly satisfied (3) / Very satisfied (4)

6. Have the services you received helped you to deal more effectively with your problems? Yes, they helped a great deal (4) / Yes, they helped somewhat (3) / No, they really didn't help (2) / No, they seemed to make things worse (1)

7. In an overall, general sense, how satisfied are you with the service you received? Very satisfied (4) / Mostly satisfied (3) / Indifferent or mildly dissatisfied (2) / Quite dissatisfied (1)

8. If you were to seek help again, would you come back to our service? No, definitely not (1) / No, I don't think so (2) / Yes, I think so (3) / Yes, definitely (4)

Scoring: Scores are summed across all items. Items 2, 4, 5, and 8 are reverse scored. Total scores range from 8 to 32, with higher numbers indicating greater satisfaction.

Appendix D: Financial Well-Being Scale

CFPB Financial Well-Being Scale — Questionnaire

Part 1: How well does this statement describe you or your situation?

Response options: Completely / Very well / Somewhat / Very little / Not at all

1. I could handle a major unexpected expense.

2. I am securing my financial future.

3. Because of my money situation, I feel like I will never have the things I want in life.

4. I can enjoy life because of the way I'm managing my money.

5. I am just getting by financially.

6. I am concerned that the money I have or will save won't last.

Part 2: How often does this statement apply to you?

Response options: Always / Often / Sometimes / Rarely / Never

7. Giving a gift for a wedding, birthday, or other occasion would put a strain on my finances for the month.

8. I have money left over at the end of the month.

9. I am behind with my finances.

10. My finances control my life.

Part 3: Tell us about yourself.

11. How old are you? 18–61 / 62+

12. How did you take the questionnaire? I read the questions / Someone read the questions to me

CFPB Financial Well-Being Scale — Scoring Worksheet

Part 1 scoring (response values): Items 1, 2, 4: Completely=4 / Very well=3 / Somewhat=2 / Very little=1 / Not at all=0. Items 3, 5, 6: Completely=0 / Very well=1 / Somewhat=2 / Very little=3 / Not at all=4.

Part 2 scoring (response values): Item 8: Always=4 / Often=3 / Sometimes=2 / Rarely=1 / Never=0. Items 7, 9, 10: Always=0 / Often=1 / Sometimes=2 / Rarely=3 / Never=4.

Total response value = Part 1 subtotal + Part 2 subtotal.

Appendix E: VI-SPDAT Tool V 2.0 for Single Adults

The VI-SPDAT (Vulnerability Index–Service Prioritization Decision Assistance Tool) Version 2.0 for single adults is included as a separate exhibit within the appendices section.