Housing Chronically Homeless People: HOUSING FIRST Programs in Philadelphia

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Housing ChronicallyHomeless PeopleHOUSING
FIRST Programs in Philadelphia
National Alliance To End Homelessness Ending
Homelessness Plan, Act, Succeed
Presented by David Dunbeck Horizon House,
Inc. July 18, 2006
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Housing First ProgramsNew Keys and Home First

• Replicated the model used by the Pathways to
  Housing Program
• Quick access to subsidized apartments
• Intensive clinical support services using an
  Assertive Community Treatment (ACT) Team (accept
  5 individuals per month)
• Recovery using a Harm Reduction Model
• Consumer choice is key
• Representative payee home visits

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New Keys

• Started March, 2003
• Funding
• Services
• SAMHSA Treatment for Homeless grant (3
  years-ended 2005)
• Medicaid fee-for service billing through
  city/state Targeted Case Management Systems
• Housing
• HUD SHP grant 25 units (3 years, renewable)
• HUD SPC grant 35 units (5 years, renewable)

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New Keys Target Population

• Chronically street homeless
• Dual diagnosis serious mental illness and
  drug/alcohol addiction
• Housing and services for up to 65 consumers
• Intentionally took the consumers who had not been
  successful in any other treatment programs
• Most frequent contact with outreach
• Highest number of refusals of service

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Home First

• Started January, 2004
• Chronic Homeless Initiative grant
• Services
• SAMHSA (3 years)
• VA (year-to-year) expire 2006
• HRSA (3 years)
• Medicaid fee for services through city/state
  Targeted Case Management systems (at end of
  grants)
• Housing
• HUD SHP grant 70 units (3 years, renewable)

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Home First Target Population

• Chronically homeless, shelter users
• Serious mental illness. May have co-occurring
  drug/alcohol addictions, physical disabilities
• Capacity Services for 90, housing for 75
• Intentionally took the consumers who had not been
  successful in any other housing or treatment
  programs and had high system utilization

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Housing First Outcomes

• Currently, we have 152 consumers assigned to New
  Keys and Home First
• 113 are housed in their own apartments
• 18 are in housing process and living in shelter
• 9 are being engaged through outreach
• 7 are incarcerated (2 still have apartments)
• 4 are in long-term hospitalization
• 2 are in nursing homes
• 1 is living with family

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Housing First Outcomes

• As of 2/28/06
• 126 clients had lived in at least one apartment
• 1st apartment
• 70/126 were successful in their 1st apartment
  (56)
• 2nd apartment
• 24/47 were successful in their 2nd apartment
  (51)
• Cumulatively, 94/126 successful in their 2nd apt.
  (75)
• 3rd apartment
• 12/14 were successful in their 3rd apartment
  (86)
• Cumulatively, 106/126 successful by their 3rd
  apt. (84)

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Housing First Outcomes

• Impact of Housing on Mental Health
• Of those ever housed (and receiving services)
• 79 showed improvement
• 18 stayed the same
• 3 deteriorated
• Of those not housed (but receiving services)
• 20 showed improvement
• 70 stayed the same
• 10 deteriorated

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Housing First Outcomes

• Impact of Housing on Substance Use
• Of those ever housed (and receiving services)
• 57 showed improvement
• 34 stayed the same
• 4 deteriorated
• Of those not housed (but receiving services)
• 15 showed improvement
• 70 stayed the same
• 15 deteriorated

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Housing First Outcomes

• Impact of Housing on Overall Life Status
• Of those ever housed (and receiving services)
• 84 showed improvement
• 12 stayed the same
• 4 deteriorated
• Of those not housed (but receiving services)
• 50 showed improvement
• 35 stayed the same
• 15 deteriorated

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Things Weve learned! (Usually the hard way!)
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Safety
Staffing
Housing
Managing expectations/ pressures
Behavioral Health
Maintaining the model
Funding
The forest/the trees
Employment
Physical Health Needs
Costs
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Things Weve Learned

• Housing First ACT
• is not the same as
• ACT

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Things Weve Learned

• These programs are expensive and there are a lot
  of hidden costs
• Staffing costs
• Cost for furnishings
• Apartment damages
• Unpaid rents
• Exorbitant utilities
• Socialization costs
• Research/data analysis

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BUT

• Housing First is still a good investment!

• Preliminary analysis shows significant (gt50)
  reduction in inpatient hospitalizations, detox,
  and rehab after engaging in services and/or
  getting housing.

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Things Weve Learned

• Its a challenge to introduce 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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Things Weve Learned

• There are advantages and disadvantages to having
  housing services in a different agency than
  treatment services
• Good cop/bad cop
• Values
• Harm reduction
• Client choice
• Landlord issues
• Damages

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Things Weve Learned (or are still trying to
figure out)

• Money Management
• Is it really therapeutic to be representative
  payee for your consumers?
• Or would it be better to let another agency be
  the representative payee?

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Things Weve Learned

• SAFETY
• must be a critical consideration
• when implementing a
• housing-first program.
• FACT You are controlling (some of) the money of
  an active substance user who also has a diagnosis
  of serious mental illness.

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Things Weve Learned

• Address Safety concerns by
• Establishing
• Boundaries, behavior expectations for consumers
• Policies and procedures for staff
• Consequences (i.e., discharge)
• Training Staff
• Proactively considering safety in your space
  planning

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Things Weve Learned

• Safety training Understanding behavior
  intervening before behavior escalates.
• Lalemand Behavior Scale
• Agitated
• Disruptive
• Destructive
• Dangerous
• Threat of Lethal
• From the Non-Aggressive Psychological and
  Physical Intervention (NAPPI, Inc.)

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Things Weve Learned

• Good assessments are a good investment!
• Take the time to perform a thorough assessment
  (including physical health) at the beginning.
• Dont drop the physical health ball use your
  nurses!
• Dealing with long unmet physical health needs can
  be a powerful engagement tool!

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Things Weve Learned

• Staffing
• It takes special people to do housing first
• Hiring good staff
• 120 turnover in first year
• Maintaining the revolution
• Keeping good staff
• TRAIN, LISTEN, SUPPORT

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Things Weve Learned

• We built sustainability into our grants.but, we
  still werent prepared for the transition
• Its always going to be a painful process, but
  dont wait until you need to bill fee-for-service
  to begin the transition
• Pull the bandage off
• Do the necessary procedures, paperwork, etc.
  fully from the beginning its easier to
  transition with only 5, 10, or 20 consumers (and
  associated paperwork) than with 155 consumers!

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Things Weve Learned

• My new mantra
• Defend the program,
• but dont become defensive

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The Goal
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Housing First Future Growth

• Welcome Home
• Start-up December 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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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
• Carla Williams, Director of ACT,
  carla.williams_at_hhinc.org