One day every winter, Wake County, N.C., counts its homeless. In the wee hours of the morning on that appointed day, staff from the county Human Services Department and Raleigh-area nonprofit and faith-based organizations load up their cars with food and clothing, and head to highway underpasses, cemeteries and campsites hidden in the woods behind the rail yard. They add the people they find there to the numbers spending the night in area shelters. It’s difficult work, says David Harris, the county’s director of housing services. The temperature hovers around freezing. Sometimes it rains. But mostly it’s that the homeless don’t want to be counted—most are drug addicts, upward of 20 percent have mental illness and they generally want to protect the last shred of privacy they have left. Last year local newspapers publicized the count ahead of time. “The homeless hid,” says Harris. “They knew we were coming.” As a result, the 2005 count netted only 1,106 individuals, a finding that severely underestimated what the community knew about its homeless problem.
The less-publicized 2004 count found 1,235 homeless people, yet all the evidence indicates that Wake County’s homeless population is growing, not shrinking. In Raleigh, someone earning the $5.15 an hour minimum wage would need to work 119 hours a week in order to afford a two-bedroom apartment at fair-market rent. Census data indicates that 15,000-plus Wake County residents are living with friends or family because they can’t afford a place of their own. Studies show that this group is at extreme risk for homelessness, and many drift in and out of shelters and transitional housing at some point in the year. The result is that family homelessness in Wake County is rising 11 percent a year (and overall homelessness by about 20 percent a year). “The one-night count isn’t just inaccurate, it’s inadequate,” says Richard Fitzgerald, resource consultant for the Raleigh Rescue Mission.
Yet the face-to-face count has long been the only way to ensure that the same person isn’t counted twice. In order to get a more accurate sense of its homeless population, county officials and representatives from area nonprofit and faith-based organizations developed a plan to improve collaboration among the various agencies that serve the homeless, the jobless, the poor and anyone else considered at risk. At the heart of this goal is a homeless management information system (HMIS) that government and nongovernmental groups alike can use to create a single view of each homeless person in Wake County, track these people across the breadth of resources they use, and provide more informed and targeted services. Slightly more than a year after its October 2004 launch, 16 organizations are using the HMIS, and additional organizations, including local schools and hospitals, will be using it soon. And while Wake County will still hit the streets to count its homeless this winter (the one-night count is a U.S. Department of Housing and Urban Development requirement), county officials now have real numbers from the HMIS they can use to obtain the appropriate level of resources from government and private-sector contributors.
Between those additional grants and improved efficiency, the HMIS is poised to save Wake County millions of dollars. In addition, other communities nationwide are turning to Wake County as a model, not just for its database system, but for how to get different groups with different agendas to work together.
Despite its success, this collaboration project almost didn’t get off the ground. Concerns about the confidentiality of homeless people in the system, distrust of the county departments that were leading the project and a reluctance to change the long-followed process were all issues that nearly stopped the project dead in its tracks. While many of these concerns predated the HMIS, the project’s leaders realized that they needed to deal with these issues before they could make any further progress. So rather than forcing a system on reluctant users, the project leaders confronted each of these issues head-on and designed the system to meet the community members’ concerns. The Wake County story contains important change management lessons for any CIO implementing a major IT project.
“A system can be an easy scapegoat,” says David Stratton, the IT manager for Wake County’s Human Services Department. “Projects like this tend to be a lightning rod for any unresolved issues in a community.”
A History Lesson
In 1996 HUD radically changed the way it gave funding to agencies that provide services to the homeless. Instead of considering grant applications from each agency, it decided to consider applications that came from the larger communities, local groups that HUD dubbed Continuums of Care (CoC). The change forced the various organizations dealing with the homeless within each community to collaborate. Today there are more than 400 CoCs covering the entire country.
The extent of the actual collaboration varies wildly, however. Martha Burt, a principle research associate at the Urban Institute who reviewed the CoC concept for HUD in 2002, says that about half of all CoCs just get together to write grants, and another third do some low-level yearlong planning as well. Only rarely do these community groups actually work together to provide care that could objectively be called continuous.
The Wake County CoC has 30 members, ranging in size from the county’s Human Services department, which has 1,700 employees and nine buildings, to the Interfaith Food Shuttle, which has only one case manager and some volunteer drivers. Members of the Wake CoC had been meeting informally since the early ’90s and had good working relationships. But these would be put to the test by a 2001 HUD mandate requiring that CoCs implement information systems capable of tracking at least 50 percent of a community’s beds by October 2004. (Technically, HUD doesn’t issue mandates as much as give suggestions for what would make a good grant application, says Burt. But because HUD funding is so competitive, local groups feel compelled to comply with the federal recommendations.) It was a tall order.
“When I first saw the mandate I thought, This is wonderful in theory because it will help end the controversy on the number of homeless people we have,” says Rev. James Galloway, former executive director of the PLM Families Together, which offers transitional housing for single mothers and their children. “My practical response was, ‘Oh, bleep.’”
Wake County had actually tried to build a common system for all its agencies once before. In the early ’90s, the Triangle Community Foundation gave a grant to a local software developer to network the area’s shelters together and write an application all of them could use. At the time, the participating agencies were concerned that the system might intrude on homeless people’s privacy: The data would be saved on floppy disks and processed in an office in Chapel Hill, and there was no plan to safeguard the information or limit who had access to it. But before these concerns could be addressed, the grant money ran out and the project was abandoned. “It didn’t end well,” says Fitzgerald of the Rescue Mission. “We did just enough to make everybody mad.” With the system no longer on the agenda, the confidentiality concerns receded below the surface. Business went on as usual.
When confronted with the HUD mandate for an HMIS, some members of the CoC advocated waiting, anticipating the government would withdraw the request. But as time went by and HUD stuck to its guns, the Wake County CoC developed a project proposal. The plan called for a Web-based application that all the agencies could use. Each homeless or at-risk person in the system would have a unique ID in order to avoid duplication, and service providers at different agencies would be able to access information about the client captured at other agencies. The whole thing would be hosted by the vendor (Softscape) in order to cut down on long-term maintenance. Wake County’s e-steering committee, led by CIO Lib Wanner, approved the project that July, agreeing to pay $211,000 on top of $20,000 from the Human Services budget and an $80,000 HUD grant and $111,000 from Wake County’s Automation CIP fund. Wanner says the approval was a no-brainer; Wake County received about $2.6 million from HUD in 2004, and if an IT project could help preserve that funding then the county was willing to invest. Wake County ranks proposed IT projects on a 0 to 280 scale, with projects needing a 122 or higher to get a green light. The HMIS proposal received a 199.6.
As it became clear to members of the CoC that the HMIS was going to happen, old tensions began to resurface. “The first meetings had a lot of smart people with loud voices saying there was no way to make this system safe or secure,” Galloway says. Client confidentiality was the biggest issue. The agencies collect all sorts of private information, including criminal records, history of drug use and domestic violence, and HIV status. Many were concerned that if the records were available online, unauthorized users such as law enforcement, county officials and agency staff who didn’t need to know the information would be able to gain access to it. “There was a lot of suspicion of the people who were strongly for [the HMIS],” says Galloway. A visit from a HUD official sent to explain the benefits of an HMIS didn’t help. Some of the CoC members were experienced computer users, but others had never touched a keyboard or used the Internet. The HUD representative tried to explain that an HMIS system would have built-in security that would ensure that only authorized users could view client records, but he came off like a computer nerd who didn’t suffer fools lightly. “It was like raising a red flag in front of a bunch of bulls,” says Galloway. The domestic violence prevention group was so frustrated that it actually left the CoC, forfeiting access to federal funding from HUD in the process.
By March 2004, the situation was desperate. Realizing that the project was on the brink of collapse, Stratton, Human Services’ IT manager, decided to hire a project manager. Because of the growing sentiment against the county, Stratton wanted to bring in someone independent, outside the county. He settled on Phil Conen, an independent IT consultant with a British accent that seems hopelessly out of place in North Carolina.
At the first CoC meeting, Conen just listened. The frustration was palpable. Conen announced that he was going to hold a meeting just to discuss confidentiality issues and asked each agency to send a representative. Twenty people showed up. During the four-hour meeting, Conen listened to people’s concerns and translated computer security terms like permission-based access into plain English. Conen told the audience that the computer stores two pieces of information—who you are and what you are allowed to do—and that the CoC could set whatever parameters it wanted for individual access to client information. At the end of the meeting Conen suggested that each agency make a list of all the types of information they thought should be considered confidential, and he said that he would take the list to the vendor to ensure that every concern was met.
Conen broke the information he received into 11 comprehensive categories, such as health, mental health, substance abuse history, job status and education. Softscape in turn designed the system so that information captured in each of these categories was a separate data element that could either be shared or not shared independently from the other 10 elements. A counselor at the agency the homeless person first visits captures all the information on an electronic intake form, but then the client—the homeless person—decides which information to share with which agency. For example, someone who didn’t finish high school could elect to share education information with a GED program, yet keep their medical history private; all he would have to do is click the boxes next to the data he wants to share and the program with which to share it. The same person could choose not to share education information with any other agency. All the data in the system could also be stripped of identifiable information and used by organizations to run reports or spot trends, preserving one of the key benefits of the shared system.
In order to further reassure the CoC members, both Wake County and Softscape signed a contract promising that unauthorized users would not be able to access identifiable data. The CoC finally had a confidentiality model it could work with.
Over the next 28 days Conen held 33 meetings with CoC members on many other topics ranging from case management to shelter intake. The meetings were held at different agencies—a couple meetings took place in an affordable housing developer’s garage—in order to further establish that this was a CoC project. It also allowed Conen to make a personal connection with the agency staff and clients, and permitted members of the CoC to see how their peers worked before they started collaborating through the system. Whenever Conen introduced a topic area, he would work with the group to develop a common definition for the term in question and use that definition going forward. As with confidentiality, he let the group develop the requirements and made the vendor redesign the system accordingly. The HMIS contract included time for design revisions, so the vendor was willing to make the changes without charging more.
The Road to User Friendly
On the outskirts of Raleigh, a converted warehouse serves as the South Wilmington Street Center, a men’s shelter that helped 1,895 men in 2004. It sits across six lanes of traffic from an adult bookstore. Homeless people start to congregate outside the shelter around noon. Doors open at four. Workers have to check in and assign beds to up to 234 homeless people each evening—more when the temperature drops below freezing. On those nights, meeting rooms and the cafeteria are converted into emergency dorms using mats.
Carson Dean, director of the center and chair of the CoC’s HMIS subcommittee, told Conen that the check-in process had to be fast, and Softscape’s developers came up with something they called quick check-in, which took about 30 seconds. It wasn’t fast enough. The men in line are easily agitated. The staff checking them in also has to confiscate drinks, work tools and sometimes weapons, and explain why they can’t hand out extra laundry tokens. Quick check-in using the system took hours and the software itself was difficult to maneuver. “It took four or five screens,” says Dean. “We needed something like two screens.”
Conen decided to bring the Softscape developers to the shelter to watch the check-in. “It was eye-opening,” says Doug Wright, Softscape’s VP of professional services. His team redesigned the system so that it took only two steps: Enter the name, click on a bed number. Pop-up alerts notify a worker if there is new information about the client, if he has mail or if he was involved in a violent episode the previous night.
The HMIS has been in place for more than a year now, and members of the CoC say that it has not only saved them time and money but has improved the level of care that they provide. Most obviously, the system has helped Wake County retain millions of dollars in annual HUD grants that it may otherwise have lost. The HMIS also generates reports in seconds that would take individuals up to 40 hours to prepare previously. This in turn allows users to spot trends.
At PLM Families Together, for instance, Galloway was able to generate reports showing that while 95 percent of the women who stay with his program for at least four months stay sober and eventually attain permanent housing, that rate dropped precipitously for women who have a child returned to them from protective custody. The mother may have had a substance abuse problem that caused the child to be taken away, Galloway explains. After several months in the program, once the mother has sobered up and stayed clean, the state may decide to return custody of the child to the mother. But that can cause other problems, particularly in families where an older child was taken into custody and the mother gave birth to another child when she was clean.
“When the older child sees how much better off the younger one is, he blames mom, and the whole family decompensates [falls apart],” says Galloway. Based on the information from the HMIS, the organization changed its policy and no longer allows reunions unless the family has attained permanent housing or passes a more careful screening. “The HMIS pinpointed this,” he says. “We wouldn’t have seen it otherwise.”
Bringing area hospitals onboard with the HMIS will also help reduce the cost to care for the county’s homeless. Hospitals don’t like to discharge people who don’t have anywhere to go, so the homeless often end up spending more nights in public hospitals than their condition warrants, and hospitals charge the county for that free care. When the hospital comes online with the HMIS, it will be able to reserve a shelter bed for a patient and discharge him more promptly to the shelter. (A night at Dorothea Dix Hospital costs the county $594, compared with $23 a night at the South Wilmington Street Center.)
There are still issues to resolve. The domestic violence agency has not rejoined the CoC. And no one has figured out a model that will allow runaway minors to legally consent to sharing their personal data, since they can’t get parental permission. And there remain a handful of agencies in the Wake County CoC that do not use the system.
The CoC also put off resolving one big issue: who pays for the HMIS. The county and the CoC were happy to foot the initial bill, while making it clear that the agencies that use the system would ultimately be responsible for its maintenance and user fees. In September the CoC voted unanimously to incorporate as its own entity, which will allow it to make payments and accept donations directly. “Six months ago everyone thought [the HMIS] was a ridiculous idea,” says Galloway. But the HMIS has brought them closer together. Members of the CoC also say that the data they can derive from the HMIS—and the benchmarks and metrics that it will provide—will help attract private-sector donors who can now make contributions to a central organization.
In the meantime, Wake County has become a model for other CoCs implementing an HMIS. In New York City, Department of Homeless Services CIO Dilip Kulkarni says that his CoC—by far the largest in the country—looked at Wake County’s HMIS before beginning its own project this year. And incidentally, the HMIS has helped the CoC get a better sense of its homeless problem. Between October 2004 and September 2005 the system processed 4,100 unique homeless and at-risk individuals, nearly four times the number in last year’s one-night count.