Transcript Pathways to Housing - Coalition for the Homeless

Pathways’ to Housing, Inc.
Housing First:
Ending homelessness and supporting
recovery
Sam Tsemberis. Ph.D.
Founder and Executive Director
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?
What is Housing First?
 Is
it an intervention that serves
people who are mentally ill.
 The model has implications for
how we address homelessness.
Housing First
 Why
was it developed?
 What is housing first?
 How does it work?
 Is it effective?
Pathways’ Housing First Programs in the USA & Canada
Calgary
Seattle, WA
Toronto
Portland, OR
Worcester, MA
NYC
Oakland, CA
Salt Lake City,
UT
Philadelphia
PA
Chicago, IL
Hartford
CT
Columbus
OH
Los Angeles, CA
Denver,
CO
Chattanooga,
TN
Annapolis
&
Baltimore
MD
Richmond,
VA
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
How Housing First Relates to 10Year 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)
WHY Housing
First?
Current System
Housing and service programs:
A series of steps
Permanent
Housing
Transitional
Housing
Drop-in,
Shelter
Outreach
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
3 Assumptions of the Housing
Readiness (or treatment first)
Model
 Referrals between agencies work – they don’t
 Learning to live in congregate settings prepares

you for independent living – it doesn’t
People need to be psychiatrically stable and clean
and sober before before they can mange
independent apartments
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 MurrayThe New Yorker
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?
4 Essential Elements of
Housing First
 1.
Consumer Choice
 2. Separation of Housing and
Services
 3. Recovery Orientation
 4. Effectiveness
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
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
Housing First
Honors Consumer Choice

Once housed, consumers continue to
choose the type, sequence and intensity of
services (or no services)
 All must agree to weekly visit
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
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
HOUSING FIRST PROGRAM
Main Components
Housing: Scatter site independent
apartments rented from community
landlords
2. Treatment: Treatment and support
services provided using Assertive
Community Treatment (ACT) Teams,
CM or other off site services
1.
Treatment and support services:
ACT 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, 70-80%of the time in the
community
7-24 on call

Teams use a recovery focus and assist with community
integration
Case Management teams:
Brokerage 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
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
Housing Component: Independent
apartments integrated into the
community*
1.
2.
3.
4.
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
Landlords as program partners:
Landlord, 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
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
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.)
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?
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)
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
Recovery focused services…

Convey hope, offer choice after choice, are
respectful, patient, nurturing,
compassionate, seek and discover
capabilities and create new possibilities
How is program funded?
COST: local costs vary – e.g., FMR
Support /Clinical Services
- Medicaid/contracts
Housing- rental support
- HUD-S+C; SHP; Vouchers
- State or City Supported Housing funds or local
vouchers
4. Effectiveness
CQI and documentation of Program
Effectiveness
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
Research Evidence:
Building and evidence
based practice
New York Housing
Study
Funded by SAMHSA, CSAT and NYSOMH
Study 3: Comparing
Pathways to Housing
with Standard
Treatment-Housing
Programs in NYC
36 month longitudinal
randomized control trial
Study Design
-
Longitudinal Random Assignment
- N=225
Experimental (Pathways)
99
- Control (Other NYC programs) 126
-
Follow-up Rates
Entire Sample
6month
12month
18month
24month
30month
36month
96%
94%
92%
90%
86%
86%
36-month follow up:
Selected Domains
 Literal
Homelessness
 Choice
and
Psychiatric
Symptoms
 Residential
Stability
Proportion of Time
Literally Homeless
Proportion
1
0.8
0.6
Experimental
Control
0.4
0.2
B
as
el
in
e
6M
on
12 th
-M
on
th
18
-M
on
th
24
-M
on
30 th
-M
on
th
36
-M
on
th
0
Time
Note. Significant at 6-, 12-, 18-, 24-, 30-, and 36-month.
Proportion of Time
Stably Housed
1
Proportion
0.8
0.6
Experimental
Control
0.4
0.2
0
e
in
l
e
s
a
B
6
t
on
-M
h
12
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on
-M
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18
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h
24
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on
-M
h
30
t
on
-M
h
36
t
on
-M
h
Time
Note. Significant at 6-, 12-, 18-, 24-, 30-, and 36-month.
Housing First Programs, Choice
& Psychiatric Symptoms
reduction
Program
Assignment
Choice
Proportion
of time
homeless
Adapted from Greenwood et al, 2005.
Personal
Mastery
reduction Psychiatric
Symptoms
increase
County Level Evaluation:
“Westchester County
halves 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
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
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
Intra-departmental cost study:
DHS Cost by service type
SAMHSA NREBPP
Pathways’ Housing First
On
SAMHSA web site National Registry of
Evidence Based Programs (NREPP)
System Transformation

Reversing the existing system of providing
homeless services

Using transitional programs in a different
way: e.g., if for consumers can’t mange
independent apartments
System Transformation
 Agency
and staff training in system
transformation
 Pilot
Housing First program
THANK
YOU!
[email protected]
www.pathwaystohousing.org