Pathways’ to Housing, Inc. Housing First: Ending homelessness and supporting recovery

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Pathways to Housing, Inc.Housing FirstEnding
homelessness and supporting recovery

• Sam Tsemberis. Ph.D.
• Founder and Executive Director

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Are they the homeless mentally ill or the
mentally ill homeless?

• Do people who are homeless and mentally have more
  in common because they are homeless or because
  they have a mental illness?

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What is Housing First?

• Is it an intervention that serves people who are
  mentally ill.
• The model has implications for how we address
  homelessness.

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Housing First

• Why was it developed?
• What is housing first?
• How does it work?
• Is it effective?

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Pathways Housing First Programs in the USA
Canada
Calgary
Seattle, WA
Toronto
Worcester, MA
Portland, OR
NYC
Hartford CT
Philadelphia PA
Oakland, CA
Salt Lake City, UT
Chicago, IL
ColumbusOH
Annapolis BaltimoreMD
Denver, CO
Richmond, VA
Los Angeles, CA
Chattanooga, TN
Washington DC
Charlotte County, FL
Fort Lauderdale, FL
Housing First Sites that received technical
assistance from Pathways to Housing, Inc
Housing First Sites established 2003-2007
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How Housing First Relates to 10-Year Plans to End
Homelessness

• The National Alliance to End Homelessness
  advocating for Cities and States to develop
  10-year plans to END HOMELESSNESS
• The US Interagency Council on the Homeless focus
  on Ending Chronic Homelessness (35M Initiative)

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Current SystemHousing and service programs A
series of steps
WHY Housing First?
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Eligibility criteria for supportive housing
(NYC Survey of providers in 2005)

• Clean time 92.5 of Providers require
• Methadone 11 exclude
• Insight into mental illness
• Compliance with treatment
• Criminal background
• Sex offenders 82 exclude
• History of arson 80 exclude
• Credit checks

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3 Assumptions of the Housing Readiness (or
treatment first) Model

• Referrals between agencies work they dont
• Learning to live in congregate settings prepares
  you for independent living it doesnt
• People need to be psychiatrically stable and
  clean and sober before before they can mange
  independent apartments

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Misuse of resources by people who remain
chronically homeless

• Shelters 10 of the chronically homeless
  utilize 50 of the system resources
• Hospitals/Detoxes 3 of clients use 28 of all
  Medicaid funding for these services
• Jail/Prison High rates of incarceration and
  recidivism rates for people who are mentally ill
  and homeless
• Outreach/Drop-in e.g., Million Dollar Murray-The
  New Yorker

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Housing First Ends Cycling Through Acute Care
Systems

• Permanent Supported Housing ends homelessness for
  people cycling throughout the institutional
  circuit
• Stopping this cycle has cost implications and
  possibilities for reinvestment,
• e.g., what if we could write a prescription for
  housing covered by the national insurance plan if
  the person we are treating has as a psychiatric
  disability, acute and chronic health problems,
  and is homeless?

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4 Essential Elements ofHousing First

• 1. Consumer Choice
• 2. Separation of Housing and Services
• 3. Recovery Orientation
• 4. Effectiveness

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1. Consumer Choice is the foundation of this
program

• Program started with a psychiatric rehabilitation
  approach to street homelessness (taking psych
  rehab to the streets d shern et. al)
• There is is a vast disconnect between what most
  supportive housing providers offer and what
  consumers say they want
• Essentially, treatment and sobriety before
  housing

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What do consumers want?Housing, first!

• When asked, almost every person who is homeless
  (w or w/o mi) says they want housing first
• Will accept immediate access to permanent
  independent housing a place of their own
• Do not want to participate in psychiatric
  treatment or attain a period of sobriety as a
  precondition for housing

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Housing FirstHonors Consumer Choice

• Once housed, consumers continue to choose the
  type, sequence and intensity of services (or no
  services)
• All must agree to weekly visit

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Consumer choice as a continuous process in
Housing First programs

• Choices include the right to risk people make
  mistakes and learn from that experience, dignity
  of failure
• Continued practice in making choices leads to
  making the right choices and the experience of
  success

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2. Separation of Housing and Clinical Services

• Housing Services To find apartments, sign
  lease, and maintain all aspects of housing
  including facilitating relations with building
  staff
• Treatment and support services Offered not
  required Relapse (SA or MH) is expected and does
  not result in housing loss and housing loss does
  not result in discharge from clinical services

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HOUSING FIRST PROGRAMMain Components

• Housing Scatter site independent apartments
  rented from community landlords
• Treatment Treatment and support services
  provided using Assertive Community Treatment
  (ACT) Teams, CM or other off site services

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Treatment and support servicesACT teams/CM
Teams

• Multidisciplinary team (MD, MSW, CSAC, RN, etc)
• Serves people with highest needs (severe mental
  illness substance abuse homeless, long periods
  of hospitalization, criminal justice involuntary
  commitment orders, etc.)
• Services are provided directly, 70-80of the time
  in the community
• 7-24 on call
• Teams use a recovery focus and assist with
  community integration

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Case Management teamsBrokerage Service Model

• CM services higher case load ratios
• Must broker other needed services
• Follow through and continuity of care among
  systems
• 7-24 on call
• Consumer driven philosophy and interventions

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Matching Housing and Support and Treatment
Services with Client Needs

• Most people need the same things in housing (mih
  or hmi)
• Their service and support needs vary
• Ensure services are unlimited
• Ensure they are consumer driven and evidence based

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Housing Component Independent apartments
integrated into the community

• Rental units available on the open market (normal
  rental housing)
• Integration Rent less than 20 of the total
  number of units in any one building
• Permanence Tenants have same rights and
  responsibilities as any other lease holder
• Affordability Apartments are subsidized
  tenants pay 30 of income towards rent

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Landlords as program partnersLandlord, agency,
and tenant have a common goal

• Landlord, agency, all want quality, safe, well
  managed apartments
• Agency that ensure rent is paid on time and is
  responsive to landlord concerns
• Agency wants landlord to contact agency the
  minute a problem occur
• Agency responsible for damages
• Agency housing staff on call for landlord

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LIMITS to consumer choice in housing issues

• There are limits to choice in these instances
• 1) Must sign lease or sublease
• 2) Pay portion of rent (30)
• 3) Observing the terms of the lease

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LIMITS to consumer choice on clinical services

• There are limits to choice in these instances
• 1) Danger to self or others
• 2) Must agree to weekly visit by support team
• 3) Others (abuse, violence, legal issues, etc.)

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3. Recovery oriented services

• We now know that people who are diagnosed with
  severe mental illness (and co-occurring SA) can
  live full and independent lives in the community
  (Harding study definition).
• How do we support more individuals to achieve
  this goal?

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Programs elements that support recovery

• Design the housing a vision of recovery in mind
  people living fully integrated into the
  community,
• Rent and/or develop housing that looks like
  normal housing not a program
• Design the program so that the services can walk
  away from the person who no longer needs them
  (or return if necessary)

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Recovery focused support services

• Provide services that support recovery supported
  employment, education, wellness management, etc.,
  in at least equal proportion to mental health and
  drug treatment services
• Provide access to housing in a manner that that
  can change o accommodate positive family
  developments

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Recovery focused services

• Convey hope, offer choice after choice, are
  respectful, patient, nurturing, compassionate,
  seek and discover capabilities and create new
  possibilities

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How is program funded?

• COST local costs vary e.g., FMR
• Support /Clinical Services
• Medicaid/contracts
• Housing- rental support
• HUD-SC SHP Vouchers
• State or City Supported Housing funds or local
  vouchers

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4. Effectiveness

• CQI and documentation of Program Effectiveness

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Why evaluation and research?

• Want to build the new models based on empirical
  evidence -- not on assumptions, special
  interest, dramatic cases, or political
  obligations
• Research provides scientific basis to inform
  policy and advocacy for system transformation

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Research EvidenceBuilding and evidence based
practice

• New York Housing Study
• Funded by SAMHSA, CSAT and NYSOMH

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Study 3 Comparing Pathways to Housing with
Standard Treatment-Housing Programs in NYC

• 36 month longitudinal randomized control trial

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Study Design

• Longitudinal Random Assignment
• N225
• Experimental (Pathways) 99
• Control (Other NYC programs) 126

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Follow-up RatesEntire Sample
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36-month follow up Selected Domains

• Literal Homelessness
• Choice and Psychiatric Symptoms

• Residential Stability

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Proportion of Time Literally Homeless
Note. Significant at 6-, 12-, 18-, 24-, 30-, and
36-month.
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Proportion of Time Stably Housed
Note. Significant at 6-, 12-, 18-, 24-, 30-, and
36-month.
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Housing First Programs, Choice Psychiatric
Symptoms
ProgramAssignment
reduction
PsychiatricSymptoms
Choice
PersonalMastery
reduction
Proportionof timehomeless
increase
Adapted from Greenwood et al, 2005.
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County Level EvaluationWestchester
Countyhalves number of homeless in 5 years

• Westchester County (New York Times, Feb 26,
  2006)
• Combining rent subsidies, eviction prevention
  grants, and housing first the county has reduced
  homelessness by two-thirds since Jan. 1998
• Cost 23K for HF compared to 28-36K shelter
  with services
• County is considering a top-to bottom shift to
  the housing-first model

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Cross site studies 10cities same measures VA
evaluates chronic homelessness initiative

• VA 11 cities funded by ICH show about 85
  housing retention rates after first year

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Cross site studies 6 cities same measures HUD
commissions study to evaluate Housing First

• HUD Housing First found 84 retention rate
  across six study sites

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Intra-departmental cost studyDHS Cost by
service type
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SAMHSA NREBPP

• Pathways Housing First
• On
• SAMHSA web site National Registry of Evidence
  Based Programs (NREPP)

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System Transformation

• Reversing the existing system of providing
  homeless services
• Using transitional programs in a different way
  e.g., if for consumers cant mange independent
  apartments

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System Transformation

• Agency and staff training in system
  transformation
• Pilot Housing First program

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THANK

• YOU!
• stsemberis_at_pathwaystohousing.org
• www.pathwaystohousing.org