Understanding the “Support” in Supportive Housing

Richard Cho 100,000 Homes Campaign “All Hands on Deck” Call September 14, 2011

Corporation for Supportive Housing

2 CSH is a national non-profit organization that helps communities create permanent housing with services to prevent and end homelessness. CSH advances its mission through

advocacy

,

expertise

,

innovation

,

lending,

and

grant-making

.

Key Questions

 What is supportive housing?

 What are the services in supportive housing?

 How can we pay for the services in supportive housing?

4

What is Supportive Housing?

Supportive housing is

permanent, affordable housing

combined with a range of

supportive services

that help

people with special needs

live stable and independent lives.

Who is Supportive Housing For?

People who:



But for housing

cannot access and make effective use of treatment and supportive services in the community;

and



But for supportive services

and maintain community.

stable cannot access housing in the 5

Supportive Housing Comes in Many Forms

6   Rent subsidized apartments leased in open market.

 Apartment buildings exclusively housing formerly homeless individuals and/or families. Apartment buildings with mixed income households, including the formerly homeless.

 Long-term set aside of units within privately owned buildings.

 Services integrated within existing affordable housing developments.  Single family homes, including shared housing environments.

More than Housing + Services

   Simply pairing rent subsidies or affordable housing units with services does not make supportive housing In supportive housing, housing and services linked such that whole is greater than sum of parts (synergistic effect): – Services informs housing/property management – Housing’s function viewed as platform for improving outcomes for most vulnerable Not just any services – Supportive housing entails specific approach to services

What is the Services Model in Supportive Housing?

   Ironically, the “support” in supportive housing is most difficult aspect of the model to describe Usual approaches fall short: – The “laundry list” – Titles like “case manager,” “services coordinator” – Staffing ratios (e.g. “1:20” or “1:15”) – Terms and phrases like “flexible,” “comprehensive,” “voluntary vs. mandatory” Need better deconstruction of services in supportive housing

What Do We Know About the People Supportive Housing Tries to Reach?

      Chronic behavioral health challenges (mental illness, substance use, often co-occurring) Physical health/medical challenges Long histories of homelessness (lack of recent experience living in housing) and instability Likely to engage in “risky” behaviors Often involved in multiple public service settings May be “resistant” to services and change

Mismatch of Various Service Modalities Services Modality

Treatment/ therapeutic emphasis Brokered case management “Self-help” or behavioral modification

What It Is Reaction

Services are clinical and focus on treatment of mental illness or substance use Services as “yellow pages”; referrals out to various community based or mainstream services Housing refusal, early attrition or termination, return to homelessness Low trust of case manager, low engagement from services, lease violations Services emphasize self-awareness and behavioral change High failure rate, low engagement in services

Why Do These Approaches Fail?

 Presume same “needs hierarchy” between services provider and tenant  Fail to recognize tenant’s past negative experiences with services  Assume that tenant’s own behaviors, patterns, actions are the main source of pathology  Expectation of change in short-term despite long history and pattern of instability

Competing Need Hierarchies?

Provider’s Assumed Hierarchy of Tenant’s Needs Tenant’s Actual Hierarchy of Own Needs

Behavioral Health Physical Health Housing Income Family/Relationships Independence Independence Income Family/Relationships Housing Physical Health Behavioral Health

Implications for Services

     Having pre-determined and proscribed set of service goals will lead to disappointment Requiring services participation as condition of tenancy does not work if tenant values independence greater than housing – Given long history of having no housing, individuals may not feel the “value” of housing immediately Judgmental attitude towards behaviors will encourage tenants to lie or disengage Services must overcome perception of negativity Recognize that change will take a long time, will be incremental, and non-linear

Key Considerations for Effective Services in Supportive Housing

      Emphasis on engagement, rapport building Goal of services should be to help individuals remain housed through problem-solving – Help them retain housing at least long enough to help them rebuild attachment and develop healthy fear of losing housing again Place tenant in driver seat of goal setting Non-judgmental attitude increases open communication and ability to anticipate problems Allow for incremental change Cultivate sense of self-care and wellness through compassion not condescension or coercion

A Simple Theory of Change for Supportive Housing

Tenants are chronically homeless, have complex health conditions, and are resistant to change

Prioritization and Placement in Housing Troubleshooting of Housing Problems / Lease Violations

Housing Stability

Engagement and Rapport Building Motivational Enhancement and Empowerment Services Goal Setting Connection to and Coordination of Needed Services (Health, Behavioral Health, Employment)

Improved Health and Social Outcomes (Recovery)

Three Functions of Services

Tenants are chronically homeless, have complex health conditions, and are resistant to change

Prioritization and Placement in Housing Troubleshooting of Housing Problems / Lease Violations

Housing Stability

Engagement and Rapport Building Motivational Enhancement and Empowerment Services Goal Setting Connection to and Coordination of Needed Services (Health, Behavioral Health, Employment)

Improved Health and Social Outcomes (Recovery)

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Revisioning the Services in Supportive Housing as Three “Stool Legs” Housing Stability Supports

• Focused on ensuring housing stability • Troubleshooting housing-related issues • Preventing lease violations and eviction

Care Management

• Focused on improving health care access and coordination and shifting service use from inpatient/crisis to outpatient/preventive • Health care assessment, planning, coordination of services • Can incorporate Wellness Self Management

Rehabilitative/ Recovery Services

• Focused on skill building around activities of daily living • Education about behavioral health, medications • Peer supports • Recovery readiness services • Relapse prevention

Enables Understanding of Link to New Payment Systems Under Medicaid Housing Stability Supports

• Not Medicaid eligible

Care Management

• Consistent with services model under Health Homes State plan option

Rehabilitative/ Recovery Services

• Eligible under Home and Community Based Services (1915c or 1915i)

Most Services in SH Match Medicaid Eligible Services

 Analysis “crosswalking” services in supportive housing with 1915c Home and Community Based Services found that: – 61% of services matched HCBS by category/type – 85% of service hours delivered were of those types that matched HCBS

The Future

 In the future, will supportive housing’s services model be assembled in a modular fashion and through new organizational?

– Linkage to Health Homes (e.g. FQHCs) to pay for care management?

– Home and Community Based Services to reimburse rehabilitative services?

– State grant or federal MH or SA block grant funds to pay for housing stability supports?

Shift in Emphasis and Capacity of Supportive Housing Services?

Care Management Rehabilitative Supports Housing Stability Supports Care management Rehabilitative Services Housing Stability Supports

Contact

Richard Cho Director, Innovations & Research [email protected]