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Los Angeles County’s Enterprise Linkages Project: An Example of the Use of Integrated Data Systems in Making Data-Driven Policy and Program Decisions

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DOI 10.1515/cjpp-2012-0005   Calif. J. Politics Policy 2012; 4(2): 95–112
Research Article
Thomas Byrne*, Stephen Metraux, Manuel Moreno, Dennis
P. Culhane, Halil Toros, Max Stevens
Los Angeles County’s Enterprise Linkages
Project: An Example of the Use of Integrated
Data Systems in Making Data-Driven Policy
and Program Decisions
Abstract: Governments at all levels are tasked with administering public pro-
grams that serve large numbers of people. The use of integrated data systems
(IDS), which can be used to link administrative records from multiple public
agencies into one database, offer a unique mechanism for providing the type
of comprehensive information that is important for understanding the complex
needs of vulnerable populations and for making data-based policy and program
decisions that translate into more effective and efficient policies. In this paper,
we draw on recent efforts to restructure Los Angeles County’s General Relief (GR)
Program – a cash assistance program for indigent adults – as an example of how
the effective use of IDS can play a crucial role in generating evidence that can
guide important program and policy decisions.
Keywords: administrative data; Los Angeles County; social policy
*Corresponding author: Thomas Byrne, School of Social Policy and Practice, University of
Pennsylvania, e-mail:
Stephen Metraux, Mayes College of Healthcare Business and Policy, University of the Sciences,
Manuel Moreno, Research and Evaluation Services, Chief Executive Office, Los Angeles County,
Dennis P. Culhane, School of Social Policy and Practice, University of Pennsylvania,
Halil Toros, Research and Evaluation Services, Chief Executive Office, Los Angeles County,
Max Stevens, Research and Evaluation Services, Chief Executive Office, Los Angeles County,
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96  Thomas Byrne et al.
1 Introduction
Governments at all levels are tasked with administering public programs that
serve large numbers of people. The ability of policymakers and program manag-
ers to make optimal policy and program decisions depends in no small part on
the quality of relevant information at their disposal. However, as recipients of
services from one public agency may use additional public services, policymak-
ers often require information from across multiple public systems so as to coor-
dinate the delivery of effective and efficient public programs and services. This is
especially true when considering how to best meet the often complex and over-
lapping social, economic and health needs of vulnerable populations. The use of
integrated data systems (IDS), which can be used to link administrative records
from multiple public agencies into one database, offers a unique mechanism for
providing the type of comprehensive information that is important for under-
standing complicated problems or the complex needs of vulnerable populations.
In turn, this information can be used in making data-based policy and program
decisions that translate into more effective and efficient policies.
In this paper, we draw on recent efforts to restructure Los Angeles County’s
General Relief (GR) Program – a cash assistance program for indigent adults – as
an example of how the effective use of IDS can play a crucial role in generating evi-
dence that can guide important program and policy decisions. After providing some
background on the concept of IDS, the rationale for the usage of such systems and an
example of how IDS have been used to inform homeless assistance policy, we then
shift our attention to examining the Enterprise Linkages Project (formerly known
as the Adult Linkages Project), an exemplary IDS that tracks public health, mental
health, criminal justice and other social services used by GR Program participants
and participants in other public programs in Los Angeles County. We then briefly
summarize important findings from two studies that used Enterprise Linkages Project
data and subsequently proceed to examine the key role that these studies played in
shaping proposals to restructure the GR Program. In doing so, we arrive at some con-
clusions about factors that are necessary for helping IDS achieve their potential as
tools for making data-driven, evidence-based policy and program decisions.
2 Background on Integrated Data Systems (IDS)
Administrative data are the computerized records of service users and services
used that are compiled cumulatively on a day-to-day basis by service providers.
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Los Angeles County’s Enterprise Linkages Project  97
These records are usually collected in order to meet local, state and Federal
program reporting requirements, or for billing and other operational purposes.
The recent expansion of automated record-keeping systems has made such
data more ubiquitous and better-suited for evaluating programs or policies
and conducting research on use of public services. Using administrative data
is far less expensive than primary data collection, especially because the cost
of collecting data is often part of the day-to-day operating budgets of agencies
or programs. Therefore, studies using administrative data can use much larger
samples, in a more timely fashion, at a much smaller cost, than would be pos-
sible through primary data collection. Given the availability of many years of
continuously collected data often available in administrative databases, lon-
gitudinal studies can be completed in a matter of months as opposed to over
the course of several years. As time-sensitive policy and program decisions
often cannot wait for the results of a multi-year study or evaluation, adminis-
trative data represents a powerful tool for providing quick, quality information
to decision-makers.
Administrative data can be used to identify the prevalence and patterns of
service utilization within an agency or program, factors associated with differ-
ential program and service use, and costs that correspond to patterns of service
utilization. All of these factors make analysis of administrative data from a single
public agency or program a powerful tool, and integrating records from multiple
agencies or programs offers an even greater capacity for engaging in evidence-
based decision-making. Merging administrative records from several sources
allows for the identification and tracking of individuals and populations across
different service systems. This can provide a better understanding of: the patterns
by which people use multiple systems (either concurrently or sequentially); the
relationships between different systems; and unforeseen or previously unknown
relationships or phenomena.
Given all this, the integration of administrative data has a broad range of
potential applications for conducting research to answer pressing policy or pro-
grammatic questions (Culhane and Metraux 1997; Duran et al. 2005; Culhane
et al. 2010). The role of administrative data in policy toward homelessness is a
good example of this. Findings from this body of research, which would have
been exceedingly difficult to conduct in the absence of the availability of adminis-
trative data from one or more public systems, have been used to guide important
homelessness policy and program decisions. In what follows, we provide a brief
overview of studies in this area.
Using administrative data from New York City and Philadelphia shelters,
Culhane et al. (1994) showed how the homeless population was considerably
larger when assessed over the course of a year as opposed to the predominant
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98  Thomas Byrne et al.
point-in-time prevalence counts that were then being conducted. Culhane and
his colleagues also used this data to demonstrate a typology for homeless indi-
viduals (Kuhn and Culhane 1998), based on their use of shelter. A key finding
from this study was the identification of a “chronic” sub-group of shelter users,
who while only comprising about 10% of all individuals who use shelter, use
about half of all shelter resources, because of their long-term use of shelters.
A similar analysis was conducted using administrative data from family shel-
ters (Culhane et al. 2007) and findings from these studies were used to propose
different approaches for rehousing the resulting homeless subgroups (Culhane
and Metraux 2008).
Additional research has made use of administrative data to examine the use
of non-shelter health, behavioral health, criminal justice and social services by
persons experiencing homelessness. Studies in this vein have shown that relative
to their housed counterparts, homeless persons make more extensive and more
costly use of inpatient hospitalizations and emergency department (ED) services,
as well as of behavioral health services (Salit et al. 1998; Kuno et al. 2000; Kushel
et al. 2001, 2002). In addition, by linking administrative data from public shelter
systems with data from criminal justice systems, it has been shown that nearly
one-quarter of individuals in a public shelter at a given point in time had expe-
rienced an episode of incarceration in the prior 2 years (Metraux and Culhane
As a further extension of this research, shelter data have been merged with
data from multiple public service systems to show the cost-effectiveness of pro-
viding services-enriched housing for the most difficult to serve and disabled
homeless persons (Culhane et al. 2002). Additional studies have taken a similar
approach in using administrative data from several public health, behavioral
health and criminal justice systems to show that providing housing interventions
to high-need sub-groups of the homeless population can result in substantial
reductions in the utilization of such services subsequent to an individual’s place-
ment in housing (Rosenheck et al. 2003; Martinez and Burt 2006; Mondello et
al. 2007; Larimer et al. 2009; Sadowski et al. 2009; McLaughlin 2011). In using
administrative data to inform novel insights and practical approaches, this
research has been influential in guiding homelessness policy over the previous
decade (Kosa 2009; McGray 2004).
Nonetheless, one disadvantage of these studies is their ad hoc nature,
meaning that these studies were usually the product of administrative data that
were obtained for specific projects. Even with a sole data source, this requires
repeating a cumbersome acquisition process outlining the specific terms of
access, including the scope of the research, protocols for maintaining record
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Los Angeles County’s Enterprise Linkages Project  99
confidentiality, and data storage and transfer procedures. Each new project
entails setting up new arrangements, leading to a process that is prone to bureau-
cratic and legal delays that add considerable time to such research, especially
when multiple data systems are involved. Such delay threatens to mitigate one
of the primary advantages of administrative data, its potential to provide close to
real-time results on large populations in an expedient manner.
To streamline data acquisition, a number of state and local governments as
well as universities have created IDS – data repositories that combine adminis-
trative records from multiple agencies or programs. An IDS does not eliminate
data acquisition issues; indeed, there are a number of legal, ethical, techni-
cal, economic and administrative challenges in creating an IDS, which are dis-
cussed more fully by Culhane et al. (2010). What is different, however, is that in
an IDS, data from multiple sources are stored in a single data repository that is
available to interested and eligible parties under a streamlined and routinized
acquisition process. Furthermore, data can be merged and de-identified before
it leaves the IDS, which removes potentially thorny confidentiality issues. The
data can then be routinely updated by the IDS from data contributed by the
participating services systems without having to go through a reacquisition
Three brief examples of IDS illustrate the capabilities of such a setup. The
first is South Carolina, which merges data from several state systems including
Medicaid, the Department of Mental Health, the Department of Education and
the Department of Social Services. Using these data, the state identified 340,000
children having “special healthcare needs,” a figure that far exceeded the 10,000
children that had previously been identified by using datasets from single-service
systems (Bailey 2003). Chapin Hall at the University of Chicago is a research and
policy center focusing on children, youth and family issues. Their Center for State
Foster Care and Adoption Data maintains a database of child welfare records from
15 states. With these data, state welfare agencies can generate standard reports,
and researchers can perform more complex analyses. In an example of the latter,
George et al. (2010) examined the services use, and corresponding costs, for mul-
tiple systems users among Illinois families across the foster care, mental health,
substance abuse treatment, and juvenile and adult correction systems. Finally,
the State of Michigan maintains the Statewide Homeless Assistance Data online
Warehouse (SHADoW), a collection of data from the state’s homeless manage-
ment information systems and supplemented with data from human services,
housing, health and criminal justice systems. The object of this data warehouse is
to facilitate longitudinal and cost-based studies related to homelessness in Michi-
gan (Ritter and Davis 2007).
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100  Thomas Byrne et al.
3 The Enterprise Linkages Project:
an Exemplary IDS
In 2007, nine Los Angeles County Departments entered into an agreement to
implement the Adult Linkages Project (ALP). The initial aim of the ALP was to
provide comprehensive information on the multi-system service utilization pat-
terns of persons participating in the GR Program, a county-funded cash assis-
tance program administered by the Department of Public Social Services (DPSS)
that serves more than 100,000 indigent adults who are ineligible for federal or
state-level assistance program. Recently, the ALP has been expanded to include
information not only about GR participants, but about participants in other
public programs as well. As a reflection of this broadening scope of emphasis and
the accompanying expansion in its range of possible applications, the ALP is now
known as the Enterprise Linkages Project (ELP).
The ELP tracks the service utilization of GR and other public program
participants across a spectrum of publicly funded health, mental health,
social and corrections services. The ELP also tracks the costs associated with
such service utilization, allowing for the formulation of a complete picture of
county resources expended upon participants in the GR and other public pro-
grams. The tracking of costs of public service use also creates the potential for
conducting cost–benefit analysis using ELP data. In addition to records main-
tained by DPSS, the ELP integrates records from the Departments of Commu-
nity and Senior Services (CSS), Health Services (DHS), Mental Health (DMH),
Public Health (DPH), Children and Family Services (DCFS), as well as the Pro-
bation and Sheriff Departments. Given its capacity to track the service use of
GR recipients and other persons across different county agencies, analysis of
ELP data can help foster collaboration between county agencies, and identify
redundancies in services, resulting in the potential for cost avoidance and
cost savings.
More specifically, information from the ELP can help produce both a more
accurate characterization of the comprehensive needs of GR and other public
program participants as well as a more complete understanding of the extent
and cost of their interactions with multiple public service systems. This is par-
ticularly important in the case of GR participants, who, because of their complex
health, social and economic needs, are frequent users of county health, mental
health and additional services and constitute some of the most vulnerable resi-
dents of Los Angeles County. Indeed, roughly 60% of the GR caseload is home-
less, underscoring the vulnerability and frequently substantial service needs of
GR participants.
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Los Angeles County’s Enterprise Linkages Project  101
ELP data not only provide information about service utilization patterns, but
also include individual-level demographic and other relevant characteristics about
recipients of public services. For GR participants, ELP data provide an indicator of
disability status, which is important given the fairly high rate of disability among GR
participants. Moreover, the longitudinal structure of the ELP allows for the tracking
and comparison over time of different cohorts of participants in public program
(e.g. long-term vs. first-time GR participants). This is quite useful as it allows for the
identification of important characteristics or factors that may be associated with
certain patterns of utilization of county services. In turn, these factors or charac-
teristics may serve as the basis for the targeting of special interventions towards
certain groups of GR recipients or other participants in public programs.
Given the collaborative efforts of a large number of county departments to
share data and the correspondingly wide range of public service systems that it
includes, the ELP is an IDS initiative that creates opportunities for conducting a
broad swath of investigations that might be used to guide important policy and
program decisions. In the remainder of this paper, we describe how some of the
initial studies using ELP data took full advantage of its wide-ranging capabilities
and were subsequently put to near immediate use to inform an ongoing process
to restructure GR program practices and policies.
4 Key ELP Studies
GR participants frequently experience homelessness, have a disability or face
other challenges that require housing and additional forms of assistance beyond
the monthly GR cash grant of $221 to help them transition from GR towards greater
self-sufficiency. In recognition of this, efforts to restructure the GR program into
a form of assistance that leads to better outcomes for GR participants have been
developing since the late 1990s. Over the course of roughly a decade, a number
of important supplemental programs that provide substance abuse treatment,
employment and vocational assistance, and housing services to certain GR par-
ticipants were gradually introduced alongside the basic monthly GR cash grant.
The ongoing efforts to restructure the GR program also included making use
of the ELP to help develop data-driven enhancements to the GR program and
identify areas where increased collaboration between county agencies might lead
to more efficient and effective delivery of services to GR participants. Therefore
the County’s Research and Evaluation Services (RES), a unit within the Service
Integration Branch (SIB) of the Chief Executive Office (CEO), commissioned one
study (Metraux and Culhane 2009) that used ELP data to examine the extent and
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102  Thomas Byrne et al.
cost of service utilization of GR participants and specific sub-groups of GR across
a number of county departments. A second study conducted by RES staff evalu-
ated the GR Housing Subsidy and Case Management Pilot Project (Moreno et al.
2009). The aim of the evaluation was to determine whether providing homeless
GR participants with subsidized housing and supportive services would lead to
positive outcomes for GR participants and cost savings for the county.
As these studies both involved tracking the utilization of multiple county ser-
vices by large numbers of GR participants over the course of several years, they
would have proved exceedingly difficult if not impossible to conduct without the
ELP. Moreover, although they analyzed years of administrative data, these studies
were completed over the course of several months. Thus, the ELP was used to
answer important questions and provide valuable information to inform the
restructuring of the GR program in a timely manner that otherwise would have
been unavailable. In turn, the results of these two studies were ultimately of great
importance in shaping plans to comprehensively restructure the GR program that
were developed in late 2009 and early 2010. Before examining in detail the role
that these studies have played in the GR restructuring process, we briefly sum-
marize their key findings below.
5 Using Adult Linkages Project Data for
Determining Patterns and Costs of Services
Use by General Relief Recipients in Los Angeles
Completed in July 2009 before the ALP became the ELP, the study entitled Using
Adult Linkages Project Data For Determining Patterns And Costs Of Services Use
By General Relief Recipients In Los Angeles County (hereafter “The ALP Study”),
sought to improve understanding of how GR recipients interact with a spectrum
of services provided by a number of county departments. The ALP Study was
a longitudinal study that examined cost and extent of county service use by
roughly 13,000 GR participants over a 3-year period from 2005 until 2007. The
ALP Study focused on four main areas: examining the characteristics of GR
participants; analyzing the cost and extent of service use by GR participants
within individual county departments; analyzing the cost and extent of service
use by GR participants across multiple county departments; and analyzing the
cost and extent of the multi-department service use of certain sub-group of GR
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Los Angeles County’s Enterprise Linkages Project  103
First, in terms of characteristics, the study found high rates of disability
among GR participants with 30–40% of GR participants being identified through
the GR application process as having a disability. In addition, one out of every six
GR enrollees had a treatment history for a mental illness in one or more county
departments, and most of those involved diagnoses that could qualify as “severe
mental disorders.” Moreover, over half of GR participants were homeless at some
point while receiving GR, and about 15% of persons remained on GR cumula-
tively for more than 1 year. About two-thirds of this extended user group had a
disability, and about one in six had been treated for a mental illness. All of these
findings underscore the often complex needs facing GR participants that present
obstacles to their ability in transitioning towards greater self-sufficiency.
Second, the ALP Study examined the extent and cost of services use by GR
participants within seven individual county departments: DPSS, DHS, DMH, the
Alcohol and Drug Program Administration (ADPA), which is housed within DPH,
Sheriff, Probation and DCFS. GR participants made substantial use of county ser-
vices, with about three-quarters of GR recipients using services in at least one
county department in addition to receiving GR from DPSS. The highest rates of
utilization were in health services provided by DHS and in Sheriff Department jail
stays, with 40–50% of GR participants using each type of service. The cost of DHS
health services utilization totaled $70.6million over a 3-year period from 2005
until 2007, with more than two-thirds of that amount accounted for by inpatient
hospitalizations. Jail stays for GR participants included in the ELP cost the county
a combined $131.3million over a 3-year period, which was more than six times the
cost of the monthly GR grants paid by DPSS. Overall, health services and jail stays
accounted for about 83% of the overall cost of county services used over a 3-year
period by GR recipients included in the ELP.
Third, to provide a more complete picture of the county service utilization
patterns of GR recipients, the ALP Study also examined the extent of services use
across multiple county departments. Roughly 40% of GR participants received
services in two or more county departments in addition to receiving their GR
grant from DPSS, while nearly one-quarter used three or more county depart-
ments in addition to DPSS. Receipt of services from DHS and the Sheriff Depart-
ment represented the most frequently used pattern of two or more departments,
with 20–30% of GR participants using this combination. Also of interest was the
finding that more than one-quarter of both cohorts had some type of inpatient
stay through DHS or ADPA over a 3-year period.
Finally, the ALP Study examined the service use of seven sub-populations
of GR recipients whose multi-system service use costs were substantially higher
than the average for the GR population as a whole. These groups included indi-
viduals with a history of expensive service use in the year prior to their initial
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104  Thomas Byrne et al.
certification or re-certification for receipt of GR, individuals with a disability,
those with a mental illness, the long-term homeless, frequent jail users, and
employable GR participants. Among these groups, the service costs for persons
with a disability were more than double that of the average GR participant.
In summary, the study offered a fairly comprehensive portrait of the char-
acteristics, service use and overall financial impact of GR recipients. Moreover,
the county’s Research and Evaluation Services (RES) is the only agency in the
state of California to have undertaken such a comprehensive data-driven study,
and in so doing the findings from the ALP Study serve as a prime example of the
type of project that is possible to execute with an IDS, but would not be feasible
otherwise. In particular, the study made it clear that the cost of providing services
to GR recipients extends beyond county outlays on monthly GR grants. In fact,
findings indicated that for every dollar spent by DPSS on GR grants, other county
departments spent $4.34 on GR recipients.
6 The General Relief Housing Subsidy and Case
Management Pilot Project: an Evaluation of
Participant Outcomes and Cost Savings
Started in 2006, the GR Housing Subsidy and Case Management Pilot Project
(hereafter “The Pilot Project”) provided a $300 per month housing subsidy and
case management services to 900 homeless GR participants at any given time.
The evaluation of the Pilot Project (hereafter “The Pilot Evaluation”) was com-
pleted in September 2009 by researchers in the county’s RES and relies in part on
data from the ELP. The aim of the evaluation was to determine whether providing
homeless GR participants with subsidized housing and supportive services would
lead to positive outcomes including reduced homelessness, increased employ-
ment and increased receipt of Supplemental Security Income (SSI). In addition,
The Pilot Evaluation sought to examine whether the Pilot Project generated cost
savings resulting from reductions in the utilization of county services by Pilot
Project participants subsequent to housing placement.
A number of positive outcomes were found for Pilot Project participants.
More than two-thirds of Pilot Project participants remained at the same address
during their time in the pilot and, after exiting the pilot, participants experienced
a dramatic drop in the amount of time spent homeless. Moreover, participation
in the Pilot Project led to increased employment, as employable Pilot Project par-
ticipants were almost twice as likely to obtain employment in comparison to a
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Los Angeles County’s Enterprise Linkages Project  105
control group made up of GR recipients who did not participate in the Pilot Project.
Disabled Pilot Project participants filed applications for SSI at a much higher rate
than their counterparts in the non-participant control group (85% vs. 32%) and
the SSI approval rate among Pilot Project participants who had filed and received
a decision on an SSI application, was twice that of the control group. Finally, the
Pilot Evaluation examined the extent and cost of health, mental health, and crim-
inal justice service utilization in multiple county agencies to determine whether
participation in the Pilot Project was associated with reductions in service utili-
zation. The Pilot Evaluation estimated that, as a result of lower levels of service
use following housing placement, the county would save a net $11million over
2 years by housing 900 GR recipients through the pilot program. What is more,
the evaluation projected net cost savings of about $19million over a 2-year period
resulting from a hypothetical targeting of the pilot project to 900 disabled GR
recipients, an estimate that was considered conservative.
7 The Impact of ELP Studies on GR Program
While the county had been making gradual enhancements to the GR program
since the late 1990s, the importance of undertaking comprehensive efforts to
restructure the GR program was given new urgency amidst the economic reces-
sion that began in late 2007. Between June 2007 and June 2009, the unemploy-
ment rate in Los Angles County jumped from about 5% to nearly 12%. During the
same time period, as many out-of-work persons sought unemployment benefits
and other forms of public assistance, the GR caseload grew by nearly 40% from
60,447 to 82,524 persons (Moreno et al. 2009), and by July of 2011 had risen to
roughly 107,000. An expansion in the GR caseload size came at a substantial cost
to the county as the net cost of the GR program grew from $133million during
the 2006–2007 fiscal year to $222 million for the 2009–2010 fiscal year, a 67%
increase (County of Los Angeles 2010). The increase in funding obligations for
the GR program was accompanied by mounting fiscal challenges facing the state
and county. Gaps in the state budget resulted in a $150million loss in revenue
for Los Angeles County for the 2008–2009 fiscal year and a $465.3million loss
for the 2009–2010 fiscal year. As declining home values were a large driver of
the recession, county property tax revenues also declined significantly from their
pre-recession levels. In addition, falling consumer demand for goods and ser-
vices resulted in a drop in revenue from a number of key sales taxes, including
the Proposition 172 sales tax and the Realignment sales tax. All told, the county
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106  Thomas Byrne et al.
faced budget shortfalls of $300million for the 2009–2010 fiscal year and roughly
$220million for the 2011–2012 fiscal year, creating uncertainty around the con-
tinued viability and funding of the increasingly expensive GR program as well as
other county programs.
The rapid uptick in the size and cost of the GR program challenged county
officials to look for ways to close a sizeable budget gap. In April 2009, the Los
Angeles County Board of Supervisors asked the County CEO and DPSS to create
a GR program that would better meet the need of GR recipients and make more
efficient use of county resources. The GR Restructuring Workgroup that was
established to develop a comprehensive plan for GR reform was composed of rep-
resentatives from 11 county departments and 10 community stakeholder groups.
The workgroup benefitted from its ability to draw on the important findings of
both the ALP Study and the Pilot Evaluation in developing a set of 27 recommen-
dations for changes to the GR program that were delivered to the County Board
of Supervisors in September 2009 and an additional set of 15 recommendations
presented in January 2010. The 42 recommendations were designed to reduce the
GR caseload over time by focusing services on housing assistance, Supplemental
Security Income (SSI) advocacy, and employment preparation.
As a whole, the comprehensive restructuring of the GR program outlined
by GR Restructuring Workgroup’s recommendations serves as a terrific example
of making data-based decisions about how to improve programs and policies.
Indeed, a number of key recommendations were drawn directly from the findings
of the ALP Study and the Pilot Evaluation. Results from these studies were cited
as clear evidence that, if implemented, the proposed changes to the GR program
would generate cost savings for the county and result in better outcomes for GR
participants. Four areas of proposed reform are particularly worth exploring in
order to highlight the impact of the ALP Study and the Pilot Evaluation.
First, the GR Restructuring Workgroup recommended expanding the GR
Housing Subsidy and Case Management Pilot Project, to provide housing sub-
sidies to 10,000 homeless GR recipients by 2014. This recommendation was con-
sistent with findings from the Pilot Evaluation, which found reduced homeless-
ness, increased employment, increased receipt of SSI benefits and significant
cost savings for the county associated with the Pilot Project. What is more, the
GR Restructuring Workgroup recommended that housing subsidies be targeted to
disabled homeless GR participants who could apply for SSI. This was a strategy
suggested by the Pilot Evaluation, which projected even greater cost savings in
targeting disabled GR participants, as the county would receive federal Interim
Assistance Reimbursement (IAR) for the full cost of housing subsidies provided
to successful SSI applicants for the time during which their SSI application is
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Los Angeles County’s Enterprise Linkages Project  107
Second, a number of key recommendations outlined how the county should
engage in more comprehensive and systematic efforts to help disabled GR partici-
pants transition from GR to SSI. Several of these recommendations were aimed at
increasing both the application and approval rate for SSI among GR participants.
Some dealt with helping establish eligibility for SSI (e.g. assistance in obtain-
ing health records to document a disability) while others focused on helping
GR participants navigate the application process itself. The stated goal was to
increase the approval rate for SSI among disabled GR recipients from 40% in the
2008–2009 fiscal year to 70% in the 2012–2013 fiscal year. The decision to focus
heavily on obtaining SSI benefits for eligible GR participants was influenced in
part by the ALP Study’s finding that a significant proportion of GR participants
(30–40%) had disabilities and that disabled persons made use of county services
at double the rate and cost of the average GR participant. Therefore, as the ALP
Study suggested, assisting disabled GR participants in applying for SSI carried
with it the potential to yield cost savings for the county. Not only would caseload
sizes decrease as more disabled GR recipients transitioned onto SSI, but the
county would save on health costs, as the medical expenses for SSI beneficiaries
would be covered by Med-Cal, the state Medicaid program.
Third, the GR Restructuring Workgroup recommended that, within the limits
of confidentiality requirements, the ELP data structure be used to examine the
county service use history of GR participants with the aim of appropriately tar-
geting services to match unique needs. This proposal drew on findings from
the ALP Study that demonstrated a great deal of variation in the service utili-
zation patterns of GR participants, suggesting a corresponding variation in the
type and amount of services needed. In particular, the ALP Study examined the
service utilization patterns of specific sub-groups of GR participants who made
disproportionate use of county services. For example, the ALP Study was able to
show that 10% of GR participants who made the most extensive use of county
services were responsible for about 40% of the overall cost of services used by all
GR participants. Such findings formed part of the basis for the GR Restructuring
Workgroup’s suggestion of targeting assistance to GR participants on the basis of
their service utilization patterns. In doing so, the county might potentially gener-
ate substantial cost savings through increased employment for employable GR
participants, higher levels of SSI approval for disabled GR recipients, and reduc-
tions in expensive acute care service utilization for GR participants who make the
heaviest use of county services.
Finally, a number of recommendations made by the GR Restructuring Work-
group called for increased collaboration between county agencies in providing
services to GR participants. The need for the development of a more integrated
service delivery model for the GR program was made apparent by the ALP Study
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108  Thomas Byrne et al.
and the Pilot Evaluation, which both detailed the often substantial, and some-
times redundant, utilization of services by GR participants across multiple county
departments. Indeed, the ALP Study found that 40–50%of GR participants made
use of services in two or more county departments and that 20–30% made tandem
use of county health and criminal justice services. In providing clear evidence of
the nature, extent and cost of multi-system service use by GR participants the
ALP Study and the Pilot Evaluation provided a clear, data-based rationale for
pursuing greater cooperation between agencies in meeting the needs of the GR
The recommendations for restructuring the GR program were designed not
only with the intent of implementing programs tailored to the needs of sub-
populations of GR participants and reducing the number of GR participants by
helping them to transition to other more suitable forms of assistance such as SSI,
but to create significant cost savings for the county as well. Results from the ALP
Study and the Pilot Evaluation offer solid evidence that the prospects for realizing
the projected savings are quite good. However, the GR Restructuring Workgroup
did not intend for the implementation of its plan to be financed through savings
generated by GR restructuring itself. Instead, the GR Restructuring Workgroup
recommended that reform of the GR program be funded through the redirection
of existing county funds in the GR budget, tapping into new federal funding
sources such as the County Services Block Grant – Health Related, and through
recouping the cost of providing subsidized housing to GR participants who are
approved for SSI via the Interim Assistance Reimbursement. In addition, the GR
Restructuring Workgroup outlined how to use a one-time infusion of $7.2million
in county funds that had previously been set aside for the purpose of jumpstart-
ing GR restructuring efforts.
In sum, the GR Restructuring Workgroup’s recommendations highlight the
potential of using IDS to provide quality information that can be used to make
important decisions in addressing pressing problems. With the help of evidence
from the ALP Study and the Pilot Evaluation, the GR Restructuring Workgroup
was able to develop a comprehensive set of data-driven recommendations for cre-
ating a more effective GR program that would not require the commitment of new
county resources.
In February 2010, the Los Angeles County Board of Supervisors approved
the GR Restructuring Workgroup’s recommendations and implementation plan
for restructuring the GR program. As a result, the GR program, whose continued
viability was threatened by a nearly unparalleled fiscal climate and potential cuts
in social spending, was given new life and a new direction.
Since approval of the GR Restructuring Workgroup’s recommendations,
a number of recommendations have been implemented. For example, the GR
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Los Angeles County’s Enterprise Linkages Project  109
Housing Subsidy and Case Management Pilot Project has expanded beyond the
pilot stage and is now known as the GR Housing Subsidy Program. In addition,
drawing on one of the suggestions from the ALP Study, DPSS staff are currently
collecting informed consent from GR participants which would allow information
about their service utilization to be released to county workers. In turn, beginning
in mid 2012, social workers at DPSS will be able to identify and target for special
interventions those GR participants who use a disproportionate amount of public
As efforts to revise GR program policies and procedures continue to unfold
and evolve, officials in Los Angeles County continue to make use of data to inform
decisions. In doing so and by using data-driven decision making, the GR Program
that emerges as a result of restructuring efforts will be one that, while still main-
taining its crucial safety net function, will better meet the housing, health,
income and employment needs of indigent adults while making more prudent
and efficient use of public funds.
8 Conclusion
At the outset of this paper we argued that IDS represent a promising and power-
ful mechanism for fashioning data and evidence-based policy responses to com-
plicated problems. The example of GR program reform in Los Angeles County is
encouraging as it provides validity for this argument. However, the experience in
Los Angeles also shows that the mere existence of the administrative and tech-
nological infrastructure necessary to support IDS is not enough to translate its
potential promise as a policy tool into reality. If information from IDS is to be
successful in shaping policy and program decisions, a few additional factors are
First, trained researchers need to be able to access IDS data and use it to
answer important research questions that would be difficult or impossible to
answer in a timely manner without IDS. Similarly, studies conducted using IDS
must produce information in a timely manner that is useful to agency executives,
program directors, policymakers and other stakeholders. It is here that the efforts
of the County CEO and the RES unit in Los Angeles County were quite impor-
tant in the GR restructuring process. The County CEO and RES staff formulated
a conceptual framework that was a driving force in seeing the ELP come to frui-
tion. Likewise, RES staff oversaw the implementation of the ELP as well as both
the ALP Study and the Pilot Evaluation. These two studies made full use of the
unique capacity of ELP data to answer questions that would have proven difficult
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110  Thomas Byrne et al.
to answer otherwise. Moreover, findings from the ALP Study and the Pilot Evalu-
ation were directly relevant to efforts to restructure the GR program. More spe-
cifically, both studies were geared towards better understanding the extent and
cost of county services used by GR recipients and examining ways in which more
effective services could be provided at a lower cost to the county. In turn, this type
of information was of clear and immediate use to policymakers.
Second, it is important to clearly convey the results and implications of studies
that are conducted using IDS. Even if IDS are used to produce timely, relevant and
valuable information, such information is most likely to be translated into policy
and program changes if it is presented in a fashion that clearly points to a par-
ticular course of action. In Los Angeles County, many of the recommendations
for changes to the GR program made by the GR Restructuring Workgroup were
clearly linked to findings from the ALP Study and the Pilot Evaluation. This was
evident in the recommendation to dramatically expand the GR Housing Subsidy
and Case Management Pilot Project. The results of the Pilot Evaluation demon-
strated that such an expansion would lead to better outcomes for GR participants
and substantial cost savings to the county, which provided a strong rationale for
the recommended course of action.
Governments on all levels are often presented with complex problems that
must be addressed in a time-sensitive manner. What is more, in the context of the
fiscal challenges that many local and state governments currently face and are
likely to continue to face in the near future, there is a need for data-driven deci-
sions about how to make the most efficient use of public resources. Having access
to the type of comprehensive information about a problem or issue that IDS can
provide facilitates the process of making optimal program and policy decisions.
In addition, complicated problems often require coordinated responses from
multiple agencies or systems and data from IDS can be used to foster meaningful
and effective collaboration. Although the costs and administrative challenges of
creating an IDS can be significant, as the example from Los Angeles County dem-
onstrates, local and state governments have much to gain by way of effective and
efficient policies and programs in doing so.
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... The San Francisco Department of Public Health maintains a Coordinated Care Management System that integrates medical, homeless services, criminal, mental health, and substance abuse records, and links all patient data for patient surveillance and health services utilization [13,14]. LA County has similarly linked HMIS data with homeless services data to guide policy and resource allocation [15]. During the COVID-19 pandemic, LA County performed daily matches of HMIS client profiles to the COVID-19 surveillance database to identify COVID-19 patients who were potentially experiencing homelessness at the time of their infection. ...
Background Variable and incomplete reporting of housing status creates challenges in the surveillance of coronavirus disease 2019 (COVID-19) among the homeless population in Los Angeles County (LA County) and nationwide. Methods We developed standard investigation procedures to assess the housing status of LA County COVID-19 patients. Using data sharing procedures, we matched COVID-19 patients to Homeless Management Information System (HMIS) client profiles and supplemented with additional data sources for contributory data points and to further housing status ascertainment. Results We identified 10 586 COVID-19 patients among people experiencing homelessness (PEH) between 30 March 2020 and 30 December 2021; 2801 (26.5%) patients were first identified from HMIS profile matches, 1877 (17.7%) from quarantine/isolation housing intake rosters, 573 (5.4%) from hospital records, 749 (7.1%) from case and contact interviews, 3659 (34.6%) directly from PEH medical and service providers, and 927 (8.8%) had unknown sources. Among COVID-19 patients matched to HMIS profiles, 5351 (42.5%) were confirmed to be PEH at the time of COVID-19 diagnosis. Conclusions Interoperability between public health data, HMIS, and external partners have been critical components in evaluating the impact of COVID-19 among the LA County homeless population. No one data source was complete for COVID-19 surveillance in this population.
... The second data source was the County's integrated Enterprise Linkages Project (ELP) database (see Bryne, et al., 2012), 19 which includes records of services provided to County clients by the departments of Children and Family Services (DCFS), Health Services (DHS), Mental Health (DMH), and Public Health (DPH). In addition, incarceration and adult probation histories of individuals were available. ...
... 113 One will note that on November 2014, the sample would have been under PRCS for any length of 110 For more information, see (Countywide Criminal Justice Coordination Committee, 2016). 111 For more information, see (Byrne et al., 2012). 112 This data only goes back to 2006 when the ELP was created. ...
While much is known about governance models for research informatics programs in academic medical centers and similarly situated cancer centers, community and public health systems have been less well-characterized. As part of implementing an enterprise research governance framework, leaders in the Los Angeles County Department of Health Services established a research informatics program, including research data warehousing. The strategy is focused on high-priority, patient-centered research that leverages the investment in health IT and an efficient, sustained contribution from 2 affiliated Clinical Translational Sciences Institutes. This case study describes the foundational governance framework and policies that were developed. We share the results of several years of planning, implementation, and operations of an academically funded research informatics service core embedded in a large, multicenter county health system. We include herein a Supplementary Appendix of governance documents that may serve as pragmatic models for similar initiatives.
Executive leaders in the federal government have for decades called for the increased monitoring of public spending and greater assurances that spending goals are being met. This mandate was formalized in federal law with the Government Performance and Results Act (GPRA) in 1993, and was reauthorized through the GPRA Modernization Act in 2010. The revamped GPRA addresses a frustration in Congress and the White House Office of Management and Budget (OMB) with lengthy and diffuse lists of goals and performance measures that were routinely set by federal agencies but less often managed. Thus the updated GPRA goes beyond the original in pressing for assessment of the highest priority goals of federal agencies and for more concerted attention by agency leadership (including newly designated positions for monitoring) to be transparent about the outcomes and indicators that are associated with these aims. Agency leaders are further directed to identify more timely measures of success (within one or two years of goals being set), and to identify priorities that cut across federal agencies. The new agenda’s increased focus on priority items, the appointment of specific personnel, and greater attention to time-sensitive and quality metrics is hoped to increase the rigor and effectiveness of oversight.
The chapters in this volume have provided researchers and practitioners with a theoretical framework to understand the shared components of a mature integrated data system. While this information is critical to individuals who are engaged in this work, it does little to explain the evolution of how these integrated data systems (IDSs) developed over time or the distinct practices to build, use, and sustain these systems. This chapter provides a qualitative analysis of interview data and key documents gathered during a series of case studies of ten AISP network sites. Identified through a national survey of the most promising IDS sites in the country, the ten AISP network sites are connected by a common set of elements, but as this study shows, these sites have developed distinct organizational models and IDS practices to fit their unique context and program needs. The analysis presented in this chapter reveals three key models in the AISP network—executive-based, agency-based, and university-based models—and provides critical information about the evolution of these practices for others interested in developing their own IDS in the future.
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Previous estimates of the size and composition of the U.S. homeless population have been based on cross-sectional survey methodologies. National enumeration efforts have yielded point-prevalence estimates ranging from 0.11 to 0.25 percent of the population. This study reports data from shelter databases in Philadelphia and New York City that record identifiers for all persons admitted and so make possible unduplicated counts of users. Unduplicated counts of shelter users yield annual rates for 1992 of about 1 percent for both cities and rates near 3 percent over three years in Philadelphia (1990–92) and over five years (1988–92) in New York City. The annual rates are three times greater than rates documented by point-prevalence studies. Shelter bed turnover rates are reported, as are average monthly first admission and readmission counts over a two-year period. Implications for future research and public policy are discussed.
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Problem: At present, homelessness in the United States is primarily addressed by providing emergency and transitional shelter facilities. These programs do not directly address the causes of homelessness, and residents are exposed to victimization and trauma during stays. We need an alternative that is more humane, as well as more efficient and effective at achieving outcomes. Purpose: This article uses research on homelessness to devise alternative forms of emergency assistance that could reduce the prevalence and/or duration of episodes of homelessness and much of the need for emergency shelter. Methods: We review analyses of shelter utilization patterns to identify subgroups of homeless single adults and families with minor children, and propose alternative program models aimed at the particular situations of each of these subgroups. Results and conclusions: We argue that it would be both more efficient and more humane to reallocate resources currently devoted to shelters. We propose the development of community-based programs that instead would focus on helping those with housing emergencies to remain housed or to quickly return to housing, and be served by mainstream social welfare programs. We advocate providing shelter on a limited basis and reserving transitional housing for individuals recently discharged from institutions. Chronic homelessness should be addressed by permanent supportive housing.
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This study tests a typology of family homelessness based on patterns of public shelter utilization and examines whether family characteristics are associated with those patterns. The results indicate that a substantial majority of homeless families stay in public shelters for relatively brief periods, exit, and do not return. Approximately 20 percent stay for long periods. A small but noteworthy proportion cycles in and out of shelters repeatedly. In general, families with long stays are no more likely than families with short stays to have intensive behavioral health treatment histories, to be disabled, or to be unemployed. Families with repeat stays have the highest rates of intensive behavioral health treatment, placement of children in foster care, disability, and unemployment. The results suggest that policy and program factors, rather than family characteristics, are responsible for long shelter stays. An alternative conceptual framework for providing emergency assistance to homeless families is discussed.
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This study examined incarceration histories and shelter use patterns of 7,022 persons staying in public shelters in New York City. Through matching administrative shelter records with data on releases from New York State prisons and New York City jails, 23.1% of a point-prevalent shelter population was identified as having had an incarceration within the previous two-year period. Persons entering shelter following a jail episode (17.0%) exhibited different shelter stay patterns than those having exited a prison episode (7.7%), leading to the conclusion that different dynamics predominate and different interventions are called for in preventing homelessness among persons released from jail and from prison.
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This article assesses the impact of public investment in supportive housing for homeless persons with severe mental disabilities. Data on 4,679 people placed in such housing in New York City between 1989 and 1997 were merged with data on the utilization of public shelters, public and private hospitals, and correctional facilities. A series of matched controls who were homeless but not placed in housing were similarly tracked.Regression results reveal that persons placed in supportive housing experience marked reductions in shelter use, hospitalizations, length of stay per hospitalization, and time incarcerated. Before placement, homeless people with severe mental illness used about $40,451 per person per year in services (1999 dollars). Placement was associated with a reduction in services use of $16,281 per housing unit per year. Annual unit costs are estimated at $17,277, for a net cost of $995 per unit per year over the first two years.
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This article outlines a policy research agenda based on the analysis of administrative data. Computerized records of client characteristics and their related shelter utilization patterns offer researchers a rich source of longitudinal data that makes possible a wide range of investigations and can be analyzed by using an array of multivariate statistical tools. Specifically, this article discusses the contributions administrative data can make to (1) enumerating and determining the characteristics of the homeless population, (2) understanding the effect of homelessness on related public systems, (3) gauging the effect of policy interventions on the use of homeless services, (4) evaluating the effectiveness of system-level delivery of homeless services, and (5) measuring the performance of individual homeless service providers. The article concludes by commenting on several issues that policy makers might consider regarding the implementation of automated information systems among homeless service providers.
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This article explores the use of integrated administrative data systems in support of policy reform through interagency collaboration and research. The legal, ethical, scientific and economic challenges of interagency data sharing are examined. A survey of eight integrated data systems, including states, local governments and university-based efforts, explores how the developers have addressed these challenges. Some exemplary uses of the systems are provided to illustrate the range, usefulness and import of these systems for policy and program reform. Recommendations are offered for the broader adoption of these systems and for their expanded use by various stakeholders.
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Chronically homeless individuals with severe alcohol problems often have multiple medical and psychiatric problems and use costly health and criminal justice services at high rates. To evaluate association of a "Housing First" intervention for chronically homeless individuals with severe alcohol problems with health care use and costs. Quasi-experimental design comparing 95 housed participants (with drinking permitted) with 39 wait-list control participants enrolled between November 2005 and March 2007 in Seattle, Washington. Use and cost of services (jail bookings, days incarcerated, shelter and sobering center use, hospital-based medical services, publicly funded alcohol and drug detoxification and treatment, emergency medical services, and Medicaid-funded services) for Housing First participants relative to wait-list controls. Housing First participants had total costs of $8,175,922 in the year prior to the study, or median costs of $4066 per person per month (interquartile range [IQR], $2067-$8264). Median monthly costs decreased to $1492 (IQR, $337-$5709) and $958 (IQR, $98-$3200) after 6 and 12 months in housing, respectively. Poisson generalized estimating equation regressions using propensity score adjustments showed total cost rate reduction of 53% for housed participants relative to wait-list controls (rate ratio, 0.47; 95% confidence interval, 0.25-0.88) over the first 6 months. Total cost offsets for Housing First participants relative to controls averaged $2449 per person per month after accounting for housing program costs. In this population of chronically homeless individuals with high service use and costs, a Housing First program was associated with a relative decrease in costs after 6 months. These benefits increased to the extent that participants were retained in housing longer.
This article examines the cost-effectiveness of providing permanent supported housing to homeless people with mental illness. Through the use of billing records and frequency of use charts, researchers were able to map the service usage of a cohort of 268 homeless individuals from both urban and rural communities. The results suggest that significant cost savings can be achieved by establishing supportive housing programs from the homeless rather than forcing them to rely on emergency services. Data from this study can inform policy changes at both the State and Federal level. It can also provide for the introduction of common themes of money and cost-effectiveness which all of the stakeholders in the service funding debate can use. Further recommendations and uses for the data are described and discussed.
Homeless adults, especially those with chronic medical illnesses, are frequent users of costly medical services, especially emergency department and hospital services. To assess the effectiveness of a case management and housing program in reducing use of urgent medical services among homeless adults with chronic medical illnesses. Randomized controlled trial conducted at a public teaching hospital and a private, nonprofit hospital in Chicago, Illinois. Participants were 407 social worker-referred homeless adults with chronic medical illnesses (89% of referrals) from September 2003 until May 2006, with follow-up through December 2007. Analysis was by intention-to-treat. Housing offered as transitional housing after hospitalization discharge, followed by placement in long-term housing; case management offered on-site at primary study sites, transitional housing, and stable housing sites. Usual care participants received standard discharge planning from hospital social workers. Hospitalizations, hospital days, and emergency department visits measured using electronic surveillance, medical records, and interviews. Models were adjusted for baseline differences in demographics, insurance status, prior hospitalization or emergency department visit, human immunodeficiency virus infection, current use of alcohol or other drugs, mental health symptoms, and other factors. The analytic sample (n = 405 [n = 201 for the intervention group, n = 204 for the usual care group]) was 78% men and 78% African American, with a median duration of homelessness of 30 months. After 18 months, 73% of participants had at least 1 hospitalization or emergency department visit. Compared with the usual care group, the intervention group had unadjusted annualized mean reductions of 0.5 hospitalizations (95% confidence interval [CI], -1.2 to 0.2), 2.7 fewer hospital days (95% CI, -5.6 to 0.2), and 1.2 fewer emergency department visits (95% CI, -2.4 to 0.03). Adjusting for baseline covariates, compared with the usual care group, the intervention group had a relative reduction of 29% in hospitalizations (95% CI, 10% to 44%), 29% in hospital days (95% CI, 8% to 45%), and 24% in emergency department visits (95% CI, 3% to 40%). After adjustment, offering housing and case management to a population of homeless adults with chronic medical illnesses resulted in fewer hospital days and emergency department visits, compared with usual care. Identifier: NCT00490581.