Application of Implementation Science for Homeless Interventions

The Federal Strategic Plan to Prevent and End Homelessness, Opening Doors, developed by the US Interagency Council on Homelessness,¹ offers a national vision and direction to address homelessness at a federal level, building upon coalitions and partnerships and developing coordinated and cost-effective local service efforts. For managers implementing programs, the initiative requires an assessment of existing homeless services and exploration of systematic approaches to evaluate and develop new and enhanced models of care that respond to the unique characteristics of their local homeless populations. Both the immediacy and the importance of the initiative require systematic, effective approaches to ensure that best practices lead to common practices.

Through the years, interventions and practices that address the causes and effects of homelessness have been offered by a multitude of service providers such as churches, nonprofit entities, community groups, and city and county agencies. Programs have ranged from shelters and soup kitchens to transitional housing and rent and housing subsidies. Funding for these services has come through diversified, and at times mixed, sources including donations, community agency allocations, local and state authorities, or federal regulation or statute.

With limited resources and persistent need, it is imperative that we use evidence-based, cost-effective interventions to get people stably housed and that we disseminate these practices as widely as possible. Service providers should carefully consider implementation designs when operationalizing programs.

IMPLEMENTATION OF SERVICES

Implementation research is the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice designed to improve the quality and effectiveness of health services and care.² Dissemination of new intervention models that researchers find promising and translating those models to practical applications for managers and practitioners of homeless services often proves challenging. Many models have been proposed and applied with modest empirical support.^3–5 Additionally, different model frameworks have more reasonable application for various settings or program designs.

Addressing homelessness is complex, and solutions are multifaceted. Research demonstrates that prevention initiatives—as well as those interventions that promote and lead to safe, stable, and permanent housing within the community—reduce homelessness and are cost-effective. The successful dissemination of these programs requires a deliberate method of development, implementation, monitoring, and evaluation. It is also imperative that service delivery methods include mechanisms for ongoing, consistent, reliable, and retested responses from the field. This feedback is critical to informing practice changes that can modify program design and ultimately improve services.

INTERACTIVE SYSTEMS FRAMEWORK

Originally designed to operate in the prevention field to improve implementation of community-centered programs, the Interactive Systems Framework for Dissemination and Implementation (ISF)⁶ offers a foundation for homeless intervention services. However, because homeless services are implemented by a multitude of providers, through various programs, with diverse funding sources, an enhanced framework is necessary to ensure consistency in adoption as well as the flexibility to modify key program principles or augment services with innovative components.

Implementation framework models encompass identification of program operational principles and components including intent, population targets, expected treatment regimens, outcomes, and utilization. The ISF incorporates these components and involves interrelated systems: (1) synthesis, to distill knowledge about practice interventions; (2) translation for model sites, to convert this knowledge to practical application; (3) delivery of the intervention model, through analysis of suitable sites and obtaining stakeholder commitment; and (4) support and technical assistance to provide ongoing guidance to ensure model adoption and fidelity.

Enhanced for homeless populations, implementation frameworks must also include specific processes for:

• identifying practice evidence applicability for various settings and homeless populations or subpopulations;

• reviewing local, state, and federal funding and funding authorities;

• assessing community infrastructure for capacity and evidence of commitment and collaboration among stakeholders;

• evaluating community provider staff knowledge, abilities, and skills; and

• developing program principles that address the hard-to-reach homeless person while providing services that lead to permanent housing.

Enhanced homeless service implementation frameworks must be dynamic and interactive and recognize the consistent feedback available from providers and managers through various mediums including site visits, Web-based applications, and phone or in-person forums. Ongoing support for programs must be adjusted to various levels of need and diverse expertise of staff providing services such as administrative personnel, discipline specific providers, and paraprofessionals. The framework should be developed to evaluate the technical assistance provided through assessment of knowledge gained and the impact on program process and outcome measures. As necessary, the program design must be modified or adjusted to adapt to local considerations such as need, populations or subpopulations, and availability of services. Interaction with the direct service providers is key and offers realistic perspectives on feasibility of all aspects of the program design, from principle program components, funding, and process and outcome measures to educational requirements of staff.

THE FRAMEWORK’S ROLE IN MODEL REFINEMENT

An inherent component of any enhanced implementation framework is how it promotes the flexibility to allow change “from” and “across” the sites as well as “up” to program managers. It is this important feedback from service providers that contributes significantly to practice informed modifications incorporated into the program design. Information from the interactive and diverse technical support methods serves as a bidirectional evaluation process to make program modifications. Additionally, an enhanced framework recognizes the value of program staff contributions to development of the educational curriculum and the importance of promoting these modifications and translating them to additional sites.

Making modifications in program designs specifically applicable to the services provided promotes practical, reasonable, and quality care. An enhanced implementation framework is currently used as a basis to develop several homeless service intervention models under the US Department of Veterans Affairs, National Center on Homelessness Among Veterans, including Safe Haven-Low Demand residential bridge programs, Housing First Programs⁷ and community-based, one-stop service centers. As projects develop, both management and clinical aspects of the program are modified or enhanced to improve or expand services. Program adjustments developed at individual sites have been adopted at other locations. These adjustments included specific practice-informed components put in place at sites by line-level staff as a result of identifying gaps in current services, including processes for site inspections, medication supervision, case management reviews, and assessing former program participants for readmission. These program components were shared by individual sites through technical support forums and adopted by other sites when appropriate. Additionally, these program components were added to operational guidance forums, disseminated through virtual conferences and poster presentations, and included in fidelity review instruments.

Traditional implementation frameworks may, in some cases, minimize implementation site accommodation. Intervention services are developed based on research findings and other evidence-based practice research known at the time. However, the program designs that are ultimately implemented must recognize the line- and midlevel staff who are providing services and the importance of their contributions to deliver programs that best serve their populations.

IMPLICATIONS FOR POLICY AND FUTURE RESEARCH

To develop new and enhanced interventions for homeless populations, implementation frameworks must be adopted that provide a systematic method for dissemination of services in community-based settings. Interventions should be developed not only from the available research and evidence-based practices, but also the practical application of the service. Ending homelessness, the goal of the federal plan, requires clear vision and direction; strong partnerships among federal, state, and local agencies; and service provider commitment. To develop the most effective services toward this end, direct service providers must ensure that those programs, developed to move homeless populations to community permanency, are implemented based on deliberate models and research, and also modified and adopted to recognize and accommodate the needs of the homeless individual.

Policy recommendations regarding expansion of services must acknowledge this practical application of intervention, ensuring that all levels of staff are included in an ongoing evaluation of service delivery and that feedback from sites continually drives program design adjustments. While an enhanced implementation framework has been successfully used as a model for community-based interventions with homeless veteran populations within a federal funding environment, further research is needed to determine the effectiveness of this framework with other interventions, populations, and settings.