Housing-Focused Responses to Unsheltered Homelessness: Spotlight on Jackson/West Tennessee

About the Jackson/West Tennessee Continuum of Care

The Jackson/West Tennessee Continuum of Care (CoC) serves 23 counties, ranging in population from 7,000 in Lake County to nearly 100,000 in Madison County. This vast territory, mostly rural, also encompasses cities like Jackson and Dyersburg.

Jackson-Madison County General Hospital, a public hospital, is the collaborative applicant for federal funding through the U.S. Department of Housing and Urban Development (HUD). This is unique: only a handful of CoCs are led by healthcare entities like public hospitals or health departments.

Tennessee Homeless Solutions (THS), a nonprofit providing emergency shelter, permanent housing, and other services to people experiencing homelessness in the area, also runs the CoC’s data system, or Homeless Management Information System (HMIS). The CoC operates a Homeless Hotline as an access point for homeless services and also provides CoC-wide street outreach.

Since July 2021, the CoC housed more than 800 people in Rapid Re-Housing (RRH) projects, about 250 in Permanent Supportive Housing (PSH) projects, almost 300 with Emergency Housing Vouchers, and many more through other permanent housing subsidies and domestic violence programs.

The CoC has served about 750 people in its homelessness prevention programs since July 2021, especially through pandemic-era assistance. Despite this remarkable rate of re-housing, unsheltered homelessness decreased only incrementally over this period as more and more people entered homelessness.

Scaling Up Housing and Services Throughout Rural Areas in the 23-County CoC

Twenty years ago, homeless services in the area were thin. Since then, the Jackson/West Tennessee CoC worked steadily to add system capacity, especially through permanent housing programs. Now, the CoC operates street outreach and housing programs in all 23 counties. CoC stakeholders emphasized the centrality of close cross-agency collaboration to making this possible: this is no easy feat, particularly in rural areas. Additional federal funding during the COVID-19 pandemic helped the CoC operate more than 500 units of permanent housing in 2022.

The following year, HUD awarded the CoC funding through the competitive Supplemental Notice of Funding Opportunity to Address Rural and Unsheltered Homelessness (SNOFO). The CoC allocated nearly all its award to RRH, aiming to scale up available housing resources and decrease the length of time it takes for someone to enter housing from homelessness. For those who can enter a permanent housing program in the CoC, success is high: consistently, the CoC sees 98–99% of people in housing programs maintain their housing.

The end of pandemic funding severely challenged the CoC’s housing capacity, causing a loss of almost half of all permanent housing units. Only about 275 units were left in 2023 and 2024. The CoC has worked hard to rebuild capacity, which should be reflected in future data.

“[Winning the special funding from HUD] made a difference. Especially after the COVID-19 dollars went away, we could have seen a huge spike in homelessness. The SNOFO made a big difference in preventing it from increasing.”

— CoC stakeholder

Homeless services providers see the benefits of maintaining a larger presence throughout the CoC, including in its small towns. For example, about 25–30 people lived unsheltered for a while in a town with a population of about 16,000. After opening a day shelter in the town in summer 2020, one provider quickly facilitated housing connections for about three-quarters of the unhoused population, including everyone experiencing chronic homelessness. Daily touch points via the drop-in center helped this process: “getting to know people personally made it easier to offer them the type of housing program they might need,” depending on factors like their income and service needs, said one provider. This provider leveraged any available assistance suitable to facilitate housing access, including RRH and PSH funded by HUD’s Emergency Solutions Grants and CoC Programs, Emergency Housing Vouchers, and using SOAR (SSI/SSDI Outreach, Access, and Recovery) to help people connect with Social Security disability benefits. (Notably, Emergency Housing Vouchers are currently at risk of losing funding unless Congress intervenes.)

Ensuring Housing Connections Through Outreach and Navigation

Street outreach staff and housing navigators work throughout the CoC to ensure housing and services are accessible across the 23-county area including the more rural parts. The CoC hired its first housing navigator in 2021. The team now consists of eight people, including a lead housing navigator and three people specifically focused on youth. The team divvies up their work by geographic region, each covering a group of counties close to where they reside. This approach ensures they can reach every single county, which is not often the case in rural CoCs.

Housing navigators have an expansive role in the CoC, wearing several hats: they conduct homelessness prevention, street outreach, case management, and aftercare, and in counties with no emergency shelter, they connect people to a motel voucher program. They work with people who come into contact with the homelessness response system by calling the Homeless Hotline, by clicking the “need help” button on the CoC’s website and completing a one-page form, through community referrals, or through other means. Their role requires relationship-building and a deep knowledge of the community. The CoC’s housing navigators spend most of their time in the field, either conducting outreach to people experiencing homelessness (which they do 3–4 times per week) or reaching out to and solidifying relationships with other community partners.

As one navigator put it, “the role of housing navigation is frontline defense.” Whenever they can, navigators help people who are not yet homeless but imminently at risk of entering homelessness. Navigators start by asking the person what it is they need to improve their life and achieve what they want. Then, they start connecting them with resources to address these needs, whether it’s food, clothing, shelter, income, or something else.

Over the years, navigators have built up relationships with area institutions like churches, school systems, other aid organizations, law enforcement, and landlords. Cultivating these relationships is so critical to their work because it opens doors to resources for residents experiencing homelessness. Still, providers note that housing is the hardest resource to find. Navigators help people fill out paperwork for government-assisted housing but often they have more success finding units through relationships they previously created with local landlords. These personal relationships go a long way to motivate landlords to rent to people who might have an eviction or other barrier in their background. Soon, navigators will have access to funding to pay for discrete costs that help stabilize someone in housing, like first month’s rent. Qualifying young people can also access funding to cover up to six months in rental arrears through HUD’s Youth Homelessness Demonstration Project (YHDP) grants.

“A typical day could look like: I’m getting referrals from all these places, I’m reaching out to folks, I have appointments set up, I’m trying to get people into shelter, I’m verifying homelessness. In any downtime I have, I’m doing outreach, or being on the lookout for more resources to help people out. No day ever looks the same out of 5.”

— Housing Navigator

Successful housing navigation requires consistency and follow-through. The job of the navigator does not stop after a resource need is filled. Sometimes, people continue calling navigators for years after becoming stably housed to check in or because they need a new resource. Managing new referrals alongside existing relationships is a lot to juggle. It requires the navigators to prioritize their time appropriately and lean on partners where possible.

Implementing an Efficient Coordinated Entry (CE) System

If someone meets HUD’s definition of homelessness, the navigators will verify their homelessness, conduct an assessment, and connect them with CE. The Jackson/West TN CoC’s CE assessment is a questionnaire designed by people with lived experience to prioritize people most in need and achieve equitable access to housing and services. The CoC designed their CE system to assess residents within one week of contacting the system, no matter which entry point they come through. Once people complete the CE assessment, navigators enter them into HMIS.

Once people are assessed through CE, they can be referred to housing programs including PSH and RRH. All veterans are assessed for eligibility for the Supportive Services for Veteran Families Program, which serves over 100 households yearly, all across the CoC’s 23 counties. Caseworkers, including housing navigators and housing program case managers, meet biweekly to make referrals for open housing programs. A separate group meets afterwards to focus on people who are survivors of domestic violence to ensure they do not fall through the cracks. This system works to ensure housing referrals, when available, are made as quickly as possible. For example, for people housed in RRH programs between 2021-2024, the average length of time from referral to move-in was 38 days (worsening housing market conditions have since caused this number to increase).

Proactively Engaging Encampment Residents Through Quarterly Outreach Events

In addition to regular street outreach, the CoC began intensive outreach with encampments in 2024 through quarterly events. West Tennessee Healthcare coordinates these events with the assistance of volunteers and donated supplies (like hygiene bags) from the West Tennessee Healthcare Hope and Healing Foundation. Volunteers include homeless services staff of all levels and several providers with other community partners like the Code Department, Fire Department, West Tennessee Legal Services, and Regional Opioid Prevention. They canvass downtown Jackson equipped with hygiene products, Narcan, and bus passes. Each volunteer matches with a person experiencing unsheltered homelessness, helps them complete an intake for homeless services and work towards housing. For example, volunteers might help people submit an application to the Public Housing Authority, obtain a driver’s license, or connect to legal services.

The first event served 53 people, 51 of whom were no longer experiencing unsheltered homelessness by the time of the next outreach event. The second outreach event served 18 people, 8 of whom had not previously connected with a program. Each person that is eligible for HUD housing programs is put on the CE list and followed up with by a housing navigator or other CoC staff.

Leading with Data and Lived Experience to Inform Programming and Funding Decisions

Most people experiencing unsheltered homelessness in the CoC are in the larger cities, including Jackson and Dyersburg, but many reside in rural areas like Henry County. The CoC tries to ensure services are available throughout its vast geography according to evolving needs. The CoC uses both qualitative and quantitative data to determine geographic and programmatic areas of need and scale up accordingly. The CoC partners with people with lived experience to collect, interpret, and actualize insights from quantitative and qualitative data. The Youth Action Board (YAB) is one example of such partnerships. YAB members are paid $15/hour for their work and participate in monthly activities.

Regularly focusing on data quality helps ensure CoC leaders can have confidence in the program data they use to drive decisions and strategic priorities. Staff at the HMIS lead agency run monthly data quality reports for CoC grantees and regularly provide feedback and support to the staff who enter data.

The CoC then uses these quantitative and qualitative data sources during the CoC Notice of Funding Opportunity process, which is different than the SNOFO application discussed above. The CoC prioritizes projects for federal funding based on clearly defined criteria and direction from people with lived experience. These criteria include whether the project(s) perform well in the following categories:

1. Geographic need: The project is located in an area with a clearly identified service need.
2. Strategic priority: The project meets one of the CoC’s goals of: 1) ending chronic homelessness; 2) ending family homelessness; 3) serving people with the highest needs and longest histories of homelessness; 4) increasing permanent housing units; and 5) improving street outreach.
3. Past performance: If it is a renewal project, the project historically met certain outcomes, like ensuring all subpopulations have access to housing and services.
4. Committee review: All projects are reviewed by a committee. In the last CoC competition, six of eight committee members were YAB members with lived experience of homelessness.

In applying the criteria to the 2024 CoC funding competition, committee members with lived experience advocated to deprioritize projects that did not fully spend their money in the past to make room for other projects they believed, based on their experiences and the data they reviewed, would make a difference in the CoC. One such new project, which did receive HUD funding, will hire a new street outreach worker to connect people in downtown Jackson to RRH. The feedback from committee members with lived experience helped maximize the use — and benefits from — the limited federal funds available.

Leveraging strategic community partnerships

The CoC emphasizes the importance of partnerships throughout their work, including with health entities. As the CoC lead applicant and a large public hospital, West Tennessee Healthcare operates several initiatives to identify and meet the housing needs of hospital patients. For example, people are screened for their housing status upon entry. There are programs to provide food bags and hygiene kits to people who need them, no questions asked.

West Tennessee Healthcare also contracts Tennessee Homeless Solutions to serve people who are discharged from the hospital and would otherwise have nowhere to go in a RRH program. A hospital social worker first initiates a referral to the program, and then an outreach worker follows up to conduct a CE assessment and confirm eligibility. Program participants then move into their own home (with the help of a rental subsidy). They are connected to a case manager and other services they might need, like wound care or home healthcare. Due to the severity of health issues, people often move from there to a nursing facility or pass away. If they do not need long-term healthcare support, they can transfer to PSH or a long-term voucher through the housing authority.

Ultimately, the CoC believes that the program saves the hospital money (potentially millions of dollars) and saves lives. As one staff member said, “I can’t imagine how many people would have died on a street if we did not have that program.” This is especially true as the population of people experiencing homelessness ages.

“I want to reiterate teamwork. It’s all about keeping your eye on the ball — and the ball is helping the folks who need it.”

— CoC Lead Agency Staff

Confronting Challenges Ahead

After five consecutive years of decreases in unsheltered homelessness between 2019–2023, numbers began increasing again in 2024 and are anticipated to increase again in 2025. The CoC suffered a major setback in losing almost half its permanent housing capacity when COVID-19 relief funding expired, which had enabled the CoC to massively scale up housing assistance. The devastation of this loss in funding is amplified by the simultaneous reality of worsening housing affordability — according to HUD rent data, average rents in the Jackson metro area rose 33% in the last two years.

Mirroring national patterns, the unhoused population is trending older according to Point in Time data. Providers believe this to be attributed to people who are on fixed incomes (e.g., receiving Social Security benefits or Supplemental Security Income) facing increasingly unaffordable rents. Providers are also noticing an increase in evictions and a decrease in landlords who are willing to rent to voucher holders. According to local performance data submitted to HUD, fewer people in emergency shelters or other temporary housing programs have been able to exit to long-term housing.

Public sentiment against increasing homelessness has posed a challenge. The public often misunderstands the root causes of homelessness and solutions to address them. One prominent example of this has been the delay of Jackson’s new shelter due to public complaints and local politics. Simultaneously, providers are grappling with the impact of state and local ordinances that ban camping on public land and panhandling in certain areas. Criminalization laws like these can disrupt service ties between people who are unsheltered and their case managers. Forcing homeless services providers to respond to complaints from business owners takes time away from developing and implementing long-term solutions.

To meet these challenges, the CoC is:

• focusing on broader housing market issues, homelessness prevention strategies, and natural disaster preparedness in their upcoming strategic plan. This will help the CoC stem the tide of new entrants into homelessness;
• building relationships with landlords and developers to expand the number of units available to people housed through local programs;
• working to bolster supportive services for people, especially those with mental health conditions, through healthcare’s prominent role in the CoC; and
• educating the public and local elected officials about homelessness and the impact of their work.

The CoC’s previous success with reducing unsheltered homelessness was made possible through competitive federal funding opportunities (including COVID relief dollars) and creative local partnerships. Additional local, state, and federal support, that is stable and consistent, could enable the CoC to finally end unsheltered homelessness.

Acknowledgements 

The Alliance is grateful to the service providers and community leaders in the Jackson/West Tennessee CoC for their time and partnership.