06/07/2013 - In Order To Bend the Curve, We Must First Abandon the Line

“First come, first serve” is a concept we learn from the earliest age and is reinforced throughout our whole lives—from the moment we stand in the school lunch line to receiving our driver’s license at the DMV. Placing people in a line (or ‘queue’ to use another technical term), has been programmed into our everyday thinking such that “first come, first serve” is the default approach we use to distribute goods or services or provide help. In some contexts it seems fair, but is it the right way to end homelessness?
In my new role at the U.S. Interagency Council on Homelessness (USICH), I work on coordinating the Federal interagency effort to achieve the goal of ending chronic homelessness by 2015. This goal lured me to this job in the first place, and since coming here, my conviction that we can indeed end chronic homelessness has only increased. At the same time, I remain troubled at the current scale of the problem and at the slowness of our collective progress in reducing this number. According to the most recent Point-in-Time count from 2012, the number of people experiencing chronic homelessness on any given night is still nearly 100,000. While this number is below 100,000 for the first time in history, it’s far from zero, and we have less than three years to go. 
Our lack of progress on ending chronic homelessness comes not from a lack of knowing what to do. In fact, we’ve known the solution to chronic homelessness for many years—permanent supportive housing. We’ve known for years that when permanent supportive housing is made available to people experiencing chronic homelessness, the result is not only improvement in the length and quality of human lives, but also the reduced burden on public services and taxpayers alike. The evidence makes clear that permanent supportive housing, when targeted at the most vulnerable and high-cost people experiencing chronic homelessness, may result in significant public cost offsets. No public policy in history has made as much sense, both morally and fiscally, as that of ending chronic homelessness through permanent supportive housing. 
Why then are we still so far from reaching our goal of ending chronic homelessness? 
One of the answers to that question may be the persistence of a “first come, first serve” mentality. (Other answers are likely related to admission requirements that impose treatment compliance, income, and criminal checks, but that’s a topic for another day...) Today my focus is on the role of “first come, first serve”.  In most communities today, access to housing, including permanent supportive housing, is still typically managed through the “first come, first serve” approach. People who apply for permanent supportive housing, once deemed eligible, are placed on a waiting list, and then offered housing in the order in which they applied and were approved. The predominance of “first come, first serve” could explain why only 45 percent of the 166,000 units of permanent supportive housing for single individuals are targeted at people experiencing chronic homelessness. While providing supportive housing on a “first come, first serve” basis may seem a fair way to allocate a scarce resource—and permanent supportive housing is certainly in short supply—this view of fairness fails to take into account that many of the individuals in desperate need of permanent supportive housing are the very same individuals whose challenges make it hard for them to get to that line in the first place.
A wise person once said, “If you do not ask the right questions, you do not get the right answers.”  We need to recognize that that the right question for ending chronic homelessness is not “What is the fairest way to allocate scarce resources?,” but rather “How do we respond to a national crisis?” In situations of crisis, like natural disasters, help and assistance are not provided “first come, first serve,” but rather through a triage approach: the most urgent, acute, highest-need cases are addressed first, followed by moderate cases, and finally by the lowest need cases. Triage is not about choosing winners and losers, but rather determining who needs help first and most urgently. Triage ensures that everyone gets helped in their turn, while also ensuring that the most devastating and tragic losses are averted.
Chronic homelessness is indeed a crisis and should be responded to through triage, not a queue.  Perhaps the only reason we have failed to recognize chronic homelessness as a crisis is because it is one that we have lived with for so long. But make no mistake: for the men and women who experience life on the streets, in shelters, and through the revolving door of emergency rooms, hospital beds, jails, detox, psychiatric centers, and more, every day is a crisis.
A triage approach prioritizes people for housing on the basis of the length and persistence of homelessness and the severity of need. This approach must happen at both the program level as well as at the community level. Permanent supportive housing providers can adopt policies that offer available housing units first to eligible individuals who have the longest lengths of homelessness and/or the highest needs as evidenced by their assessed vulnerability or their involvement in crisis service systems, followed by people with long lengths of stay who have less severe needs, followed by other eligible individuals. Communities should mobilize their crisis response and outreach services to proactively identify and engage individuals who have the longest lengths of homelessness and highest needs and connect them immediately to permanent supportive housing. Communities that have centralized waiting lists for permanent supportive housing should adopt community-level prioritization policies that ensure help is offered to people based on the length of their homelessness and their severity of needs.
We know that in this resource-constrained environment, many communities do not have enough permanent supportive housing to assist everyone who would benefit from it. New resources and investments are certainly needed to expand the supply of permanent supportive housing. Our case for new investments is stronger when we can demonstrate that we are making the best use of existing resources and show tangible results in terms of decreased use of emergency services and overall reductions in homelessness. Replacing “first come, first serve” with a triage approach holds promise to accelerate momentum. We can do this if we mobilize a nationally coordinated push to prioritize and house people experiencing chronic homelessness who have the longest lengths of homelessness and the most severe challenges. Let’s bend the curve on chronic homelessness (and other public costs) and show that investing in more permanent supportive housing is indeed a winning strategy.  That is how we will end this crisis once and for all.

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