Begin at Home A Housing First Pilot Program

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Begin at Home A Housing First Pilot Program

• Debra Srebnik, Ph.D
• King County Mental Health, Chemical Abuse and
  Dependency Services Division
• Co-Occurring Disorders Conference
• Yakima, WashingtonOct 2, 2007

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HOUSING FIRST MODEL

• Direct placement in housing from the streets
• No sobriety or readiness requirements to begin
  or remain in housing
• Services are voluntary, intensive, and easily
  accessible
• Focus on harm reduction, relapse prevention and
  recovery from mental illness, substance use, and
  medical conditions and behaviors needed to
  manage responsibilities of being in housing
• Tenants hold lease and have full
  rights/obligations of tenancy
• Housing considered permanent
• Units held up to a 90-day absence
• Eviction is a last resort

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HOUSING STOCK

• Plymouth Housing Group (a Seattle agency
  offering permanent supportive housing and
  services for homeless single adults) provided 20
  private, Section 8 studio apartments for the
  project.

Below, the twelve properties owned and managed by
PHG
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FUNDING

• Braided funding from the following sources
• 160,000 - Seattle Housing Authority (section
  8 vouchers)
• 180,000 - City of Seattle Human Services
  housing case managers
• 32,000 - City of Seattle General fund
  nursing
• 372,000 annually
• -Other Housing First projects include
  funding from
• United Way and King County

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TARGET POPULATION

• 1) Single adults 18yrs old meeting HUD
  definition
• for chronic homelessness
• 12 consecutive months homeless or 4 episodes
  within last 3 years PLUS physical and/or
  psychiatric condition with impaired functioning
• AND
• a) Referred from Medical Respite Service
  (24-hour beds with nursing, MH, CD services for
  homeless whove had acute medical event and need
  daily nursing) with at least 10,000 in inpatient
  Harborview Medical Center costs in previous 12
  months (N14), OR
• b) Referred from REACH (intensive case
  management for homeless chronic public
  inebriates) with 60 visits to the Dutch Schisler
  Sobering Center within last 12 months (N6)

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SERVICES

• Housing case managers provide intensive housing
  stabilization (121 ratio) and counseling
  on-site and referrals when needed
• One housing case manager is a chemical dependency
  specialist
• A Registered Nurse is on-site to provide services
  14 hours/week
• Services include medical care, mental health and
  substance use relapse prevention/harm reduction
  and recovery services, income support, and
  teaching skills for independent living
• Tenants moved in June - August, 2006

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EVALUATION DESIGN Process

• Participant demographics, homelessness history,
  disabling conditions
• Primary care contact after admission
• Contact with in-housing chemical dependency
  specialist
• Application for DSHS benefits and insurance
• Participant-reported program satisfaction (6 mos.
  after move-in)
• Stakeholder focus groups 6 months after program
  start

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EVALUATION DESIGN Outcome

• One-year Pre / Post move-in comparing BAH
  (N20) with non-program residents (N43) in same
  building
• Program tenure and disposition at exit
• Medical Respite admissions/days
• Dutch Schisler Sobering Center contacts
• King County jail bookings and jail days
• Harborview emergency room and inpatient
  contacts/days
• Income and income sources
• Employment status
• Participant self-reported program impact

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PARTICIPANT CHARACTERISTICS

• 75 male
• 77 Caucasian (N13)
• Average age 49.9 yrs (SD7.8) range 29 to 62
  years old
• 9 receiving GAU, 6 receiving SSI or SSDI
• Average 40.9 months homeless (SD31.6) range
  2-120 months
• 74 with mental health issues, 68 with
  alcohol/drug problems
• 53 with mobility, functional, physical, or
  sensory disability
• Average 4.2 chronic medical conditions (SD3.3)

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MEDICAL CONDITIONS N
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PROCESS EVALUATIONClient-reported strengths

• staff to talk to open to listen talk w/o an
  appointment (3x)
• having a home place to live (3x)
• food food vouchers (2x)
• can set-up room the way I want funds for it (2x)
• own place to shower and nobody bothers me
• not riding bus around all night
• place to stay to recover from crushing effects of
  addiction
• allow family to visit
• feel secure because of a place to go
• attention to all concerns resulting in better
  structure of daily life

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PROCESS EVALUATIONClient-reported areas for
improvement

• more lighting outside backup staff to let you in
• own key to front door
• more move-in for K-mart
• more access to TV room (not always watching
  sports)
• 1-3 days of food and vitamins at move-in
• mandatory hygiene and housekeeping videos before
  move-in
• WI-FI
• more meetings in-house and softball team

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PROCESS EVALUATION Stakeholder-reported strengths

• Participants are very happy
• Participants remained housed (everyone 6 months)
• Rules are working - reward for progress (e.g.,
  start with weekly room checks and no guests - and
  earn less frequent checks and daytime then
  evening guests)
• Nursing on-site for non-urgent issues and
  prevention prepares and motivates people to go
  to appointments
• Rapid housing allows clients to believe in the
  program

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PROCESS EVALUATIONStakeholder-reported areas
for improvement

• Barriers to rapid placement - criminal history
  screening and housing eligibility paperwork
• Nursing had inadequate space/privacy and no sink
• Should have conducted medical assessment at time
  of referral
• Needed earlier dialogue with housing authority
  regarding anticipated applicant pool and how
  they could be prioritized

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OUTCOME EVALUATIONProgram tenure disposition

• Out of 20 Begin at Home (BAH) participants
• -2 died (one heart attack one xx)
• -1 evicted
• -17 still in housing 1 yr
• Comparison group all who consented (n19) are
  still in housing (23 didnt consent to data
  collection)

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OUTCOME EVALUATIONMedical respite

• Begin at Home (BAH)
• Pre 27 stays 1107 days 254,610
  
• Post no stays
• -- Ineligible for Medical Respite
  if housed
• Comparison group no stays either pre or post

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OUTCOME EVALUATIONSobering Center
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OUTCOME EVALUATIONJail bookings
- Jail days similar pattern
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OUTCOME EVALUATIONHarborview Emergency
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OUTCOME EVALUATIONHarborview Inpatient
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OUTCOME EVALUATIONHarborview charges
BAH charges reduced by 1.2 million Comparison
80,000
Even after removing the two most expensive
patients (possible outliers), charges were
reduced 595,832 for BAH
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OUTCOME EVALUATIONClient-reported impacts
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SUMMARY

• BAH implemented a Housing First model with low
  barriers to housing access using braided funding
• Targeted high need, high cost, medically-vulnerabl
  e
• Housing retention was strong
• Participant and stakeholder satisfaction was high
• 1.5 million savings in first year far
  outweighed 372,000 cost
• Hospital, Medical Respite, and Sobering Center
  reductions were greater for BAH participants than
  comparison group