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Housing-First Models in Philadelphia

• David Dunbeck, MSW
• Director of Homeless Services
• Horizon House, Inc.
• Philadelphia

November 30, 2005
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What is Housing First?

• Housing First is a program model that assists
  chronically homeless individuals by immediately
  offering needed rental subsides and permanent
  housing
• Supports are continuous throughout the engagement
  process and through placement into permanent
  housing to assist the individual in maintaining
  his/her housing

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Why Housing First?

• Need
• Moral Issues
• Financial Issues

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Statistics on Homelessness

• Nationally
• Between 700,000 and 800,000 people are homeless
  on any given night.
• 81 enter and exit the system quickly
• 9 of users of emergency shelter enter and exit
  repeatedly
• (These are the CHRONICALLY HOMELESS)
• Philadelphia
• Most recent street census 429 living on CC
  streets
• 3,000 men, women, and children in shelter (110
  of capacity)

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Statistics on Homelessness

• Federal definition of Chronically Homeless
  includes individuals with a significant
  disability and either
• 1 continuous year of homelessness or
• 4 episodes of homelessness in the past 3 years.

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Moral Issues

• Everyone deserves a safe, permanent place to
  live.
• People dont earn the right to housing.
• Why do you ask a homeless person if they are
  housing ready? Do you ask a hungry person if
  they are food ready?

Tanya Tull, Shelter Now, LA
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Financial Issues

• Dennis Culhanes NY/NY study.
• Daily Cost of Services used by the Homeless
• Permanent Supportive Housing 28
• Emergency Shelter 36
• Home First/New Keys 58
• Prison 75
• Non-hospital rehab 120
• Detox 200
• Emergency room/crisis visit 200
• Psychiatric hospital 700
• Inpatient hospital stay 1,285

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Goals

• Bring chronically homeless street and shelter
  dwelling individuals with co-occurring substance
  abuse and mental illness disorders into permanent
  independent housing with intensive behavioral
  healthcare support.

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Objectives

• More individuals who are the most severely
  disadvantaged homeless will be in independent
  housing.
• These individuals will
• be more likely to participate in ongoing
  outpatient behavioral health services.
• have more positive attitudes about the value of
  behavioral health services.
• have increased family and social contacts.
• be in better health, mentally and physically.
• These individuals will have reduced admission to
  shelter, prison, drug treatment, ER, acute care
  units, criminal justice system.

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Service Model

• Modeled on the Pathways to Housing Program in New
  York City
• Includes the following components
• The evidence-based practice of Assertive
  Community Treatment (ACT)
• The best practice of immediate access to
  Supported Housing
• Harm Reduction Model of Recovery

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Essential Ingredients of Assertive Community
Treatment

• Multi-Disciplinary Teams
• 24/7 Hour Availability and Coverage
• Small Caseloads 110 staffclient ratios
• The team provides all treatment except inpatient
• Assertive Outreach

Lachance, K., Santos, A.B. (1995). Modifying
the PACT model preserving critical elements.
Psychiatric Services, 46601-604 .
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Essential Ingredients of Assertive Community
Treatment

• Community Locus of Care - integrated case
  management model and treatment following
  consumers through shelters, streets, prisons, and
  any other site
• 80 of the time spent in the community with
  consumers
• Long term engagement model

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ACT Team Composition

• Team Leader
• Psychiatrist (0.5 FTE)
• Psychiatric and Physical Health Nurses
• BS and MS-level Clinical Case Managers
• Mental Health Specialist(s)
• Drug and Alcohol Specialist(s)
• Vocational Specialist(s)
• Case Aide/Peer Support Specialists
• Supported by Clinical Director

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Housing

• Two ground rules for housing
• Client must let Horizon House be payee
• Client must agree to home visits
• One-bedroom apartments
• Scattered Sites
• 30 of income for rent

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HARM Reduction Model of Recovery

• Assumes that any decrease in substance use is a
  positive step that must be supported
• Assumes that some individuals will only attain
  clean and sober status, with supports through a
  long term engagement process

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Philadelphias Two Housing First Programs

• New Keys
• Targets chronically street homeless with serious
  mental illness and substance abuse disorders.
• Home First
• Targets chronically homeless shelter users with
  serious mental illness and substance abuse
  disorders.

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New Keys

• PROGRAM CAPACITY 60
• Accepted first 5 clients in March 2003
• Housed first 2 clients in May 2003

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New Keys Funding

• Services
• 3-year Health and Human Services (HHS) grant
• Substance Abuse and Mental Health Administration
  (SAMHSA) Center for Substance Abuse Treatment
  (CSAT) grant (1.8 million)
• Housing
• 3 year HUD Supportive Housing Program grant (25
  units) (650,000)
• 5-year HUD Shelter Plus Care grant (35 units)
  (1.5 million)

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New Keys Partners

• Horizon House, Inc.
• 1260 Housing Development Corporation
• University of Pennsylvania Center for Mental
  Health Policy and Services Research
• City of Philadelphia OBH, OAS

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New Keys Outcomes

• Currently have 60 consumers assigned to New Keys
• 45 are housed in their own apartments
• 1 is in an interim unit
• 2 are in hospital
• 5 are incarcerated
• 7 are being engaged through outreach

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Home First

• PROGRAM CAPACITY 70
• Accepted first 5 clients in January 2004
• Housed first client in February 2004

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Home First Funding

• Services
• 3-year Health and Human Services (HHS) grant
• Substance Abuse and Mental Health Administration
  (SAMHSA) Center for Substance Abuse Treatment
  (CSAT) grant (1.6 million)
• 3-year Health and Human Services (HHS) grant
• Health Resources and Services Administration
  (HRSA) grant (900,00)
• Veterans Administration grant
• Housing
• 3 year HUD Supportive Housing Program grant (70
  units) (1.9 million)

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Home First Partners

• City of Philadelphia OBH and OAS
• Horizon House, Inc.
• 1260 Housing Development Corporation
• Philadelphia Health Management Corporation
• Veterans Administration

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Home First Outcomes

• Currently have 90 identified
• 65 are housed in their own apartments
• 8 are in shelter or safe haven
• 4 are hospitalized
• 5 are currently difficult to locate outreach
• 5 are incarcerated
• 3 are in interim units

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Home First Outcomes

• Of the 39 consumers housed as of 3/1/05
• 37 were entered in OESS database before 2000.
• 27 were homeless for over 10 years.
• Averaged 15.5 inpatient admissions over last 5
  years (3 per year), ranging from 0 to 68.
• detox, rehab, or psychiatric inpatient
  treatment
• After engagement by ACT team, there was an almost
  60 reduction in inpatient admissions.
• After housing, there was a 78 reduction in
  inpatient admissions.

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New Keys Case Study WM

• WM is a 52 y.o. female
• Homeless since 1998
• Diagnosed with bipolar disorder and alcohol
  addictions

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New Keys Case Study WM

• In 3 years prior to New Keys
• 11 psych. hospitalizations (207 inpatient days)
• In 1 year prior to New Keys
• 2 psych. hospitalizations (107 inpatient days)
• 67 street outreach contacts

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New Keys Case Study WM

• Since being housed (last 22 months)
• No hospitalizations
• No street outreach contacts
• Is still in her first apartment

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Home First Case Study HG

• HG is a 52 y.o. female
• Homeless since 1993 bouncing between streets,
  shelters, institutions
• Diagnosed with schizophrenia, multiple addictions

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Home First Case Study HG

• In 5 years prior to Home First
• 66 admissions to shelter
• 46 admissions to detox, DA or psychiatric
  inpatient treatment (average 9.2 per year)

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Home First Case Study HG

• Since being housed (last 19 months)
• 0 admissions to shelter
• 1 inpatient psychiatric hospitalization
• No inpatient treatment in last 15 months
• Had problems in first apartment, and moved
  successfully to another apartment (15 months)
• Has greatly reduced her drug use

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Housing First Challenges

• Introducing housing first in an agency and
  division that also provide traditional homeless
  and treatment services
• Values
• Harm reduction
• Client choice
• Hiring
• Co-location of facilities

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Housing First Challenges

• Having housing services in a different agency
  than ACT services (advantages/disadvantages)
• Good cop/bad cop
• Values
• Harm reduction
• Client choice
• Landlord issues
• Damages

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Housing First Challenges

• Safety where do you draw the line?
• Money management
• Physical health needs
• Staff burnout
• VA payeeship issues

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Housing First - Sustainability

• Services
• Transition to MA fee-for-service reimbursement
  July 25, 2005
• Housing
• HUD renewal funding through McKinney Continuum of
  Care process

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Housing First Future Growth

• Welcome Home
• Start-up Spring 2006
• Services and housing for 60
• Philadelphia 10-Year Plan to End Homelessness
• Proposes housing first for 360 (currently at
  150)

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References

• Culhane, Metraux, and Hadley, Public Service
  Reductions Associated with Placement of Homeless
  Persons with Severe Mental Illness in Supportive
  Housing, Housing Policy Debate, Vol. 13, Issue 1,
  Fannie Mae Foundation, 2002.
• McCarroll, Christina, Pathways to housing the
  homeless, The Christian Science Monitor, May 1,
  2002.
• Tsemberis and Eisenberg, Pathways to Housing
  Supported Housing for Street-Dwelling Homeless
  Individuals with Psychiatric Disabilities,
  Psychiatric Services, Volume 51, No. 4, April
  2000.

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Contact Information

• Horizon House, Inc.
• 1201 Chestnut St., 12th floor
• Philadelphia, PA 19107
• 215-636-0606
• David Dunbeck, Director of Homeless Services,
  david.dunbeck_at_hhinc.org