Transcript Pathways to Housing - Community development
Pathways’ Housing First: Ending homelessness and supporting recovery for people with co occurring diagnoses
Sam Tsemberis. Ph.D.
Founder and CEO Pathways to Housing, Inc.
4 Essential Elements Of the Pathways Housing First Program
Housing First
What is housing first?
Why was it developed?
Who does it serve?
How does it operate?
How do you know it is working?
How does Pathways’ Housing First Relate to 10-Year Plans to End Homelessness?
The National Alliance to End Homelessness advocates for Cities and States to develop 10-year plans to END HOMELESSNESS Almost all plans include a housing first component or approach The US Interagency Council on the Homeless advocates for using housing first to End Chronic Homelessness (in 2003 issued a $35M RFP)
Partial Listing of Housing First Programs in the USA & Canada Calgary Seattle, WA Portland, OR Salt Lake City, UT San Francisco, CA Los Angeles, CA Denver, CO Chicago, IL Columbus OH Toronto NYC Philadelphia PA Richmond, VA Worcester, MA Hartford CT Annapolis & Baltimore MD Chattanooga, TN 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
Pathways’ HF PROGRAM
Main Components
1.
2.
Housing: Scatter site independent apartments rented from community landlords Treatment: Treatment and support services provided using Assertive Community Treatment (ACT) Teams or case management (CM) services
3 unwarranted assumptions of this system:
a. Referrals work b. skills learned in different settings are transferable;
Map of traditional homeless services programs: Typically defined by a series of steps (assumes consumers need to be “housing ready”) Permanent
c. People need treatment before* housing
Housing Transitional Housing Drop-in, Shelter, Safe haven Outreach
Current system results in enormous misuse of resources Shelters: 10% of the chronically homeless utilize 50% of the system resources Hospitals/Detoxes: 3% of clients use 28% of all Medicaid funding for acute care services Jail/Prison: Extremely high rates of incarceration and recidivism rates for people who are mentally ill and homeless Outreach/Drop-in: e.g., see M. Gladwell’s
Million Dollar Murray
in the The New Yorker
Pathways HF program: Quick and Efficient Way to End Chronic Homelessness
Immediate access to permanent affordable housing (one’s own apartment) with support and treatment services Immediate program start up: Program rents existing units from community landlords
Pathways HF program: Cost Effective Way to End Chronic Homelessness
Total annual program cost: 1) housing: annual rent at fair market of modest studio or one bedroom (approx. $12K per year); 2) support and treatment service support; ranges between $10 and $15K depending on intensity); In NYC cost per person per year approx $24K (compared to $28K to $35K per year for a shelter cot with services)
Pathways’ HF Program Ends the 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., why can’t we write a prescription for housing covered by Medicaid if the person we are treating has as a psychiatric disability, acute and chronic health problems, and is homeless?
Possible Sources of Funding for HF programs
COST: Approx $20K (range $15-$25) Support /Clinical Services Medicaid Contracts (most efficient are contracts for housing and services Housing- rental support HUD-
S+C; SHP (Supported Housing)
; Section 8 or other Vouchers (tenant based are best funding option for several reasons) State or City SH funds
Current Referral Sources for Pathways program
Homeless Outreach Teams Shelters (long stay clients). Drop-ins Criminal Justice ( ATI and Post-Release) Psychiatric Hospitals( State and Local) Drug Treatment Services, self referrals, and others
4 Elements of Housing First
1. Consumer Choice 2. Separation of Housing and Services 3. Recovery Orientation 4. Effectiveness
1. Consumer Choice as the foundation of the program
There is a vast disconnect between what most supportive housing providers offer and what consumers say they want Most supportive housing programs require clients to demonstrate ‘housing readiness’, i.e., 1) psychiatric treatment, 2) a period of sobriety, and 3) agree to observe program rules (ongoing treatment, curfews, guests, etc.) Essentially,
treatment and sobriety before housing
What do consumers want?
Housing,
first!
When asked, people who are homeless almost always say they want housing
first
; “A place of my own” Do not want to participate in psychiatric treatment or attain a period of sobriety
as a precondition
for housing (This refusal to participate in pretreatment does not mean people are ‘treatment resistant’ or they ‘want’ to remain homeless
Pathways’ Housing First Honors Consumer Choice Provides immediate access to a furnished independent apartment -- (no psychiatric treatment or sobriety prerequisite) Once housed, consumers
continue to choose
the type, sequence and intensity of services and all program participants must agree to weekly visit
Consumer choice as a continuous process in Housing First programs Choices include the
right to make mistakes – ‘
dignity of failure’ – people learn from mistakes and make better choices in their next step… (this is a continuous process – choice, trial and error -- that leads to learning to make the right choice and e
xperience success
2. Separation of Housing from Clinical Services
Separation of housing from treatment
To obtain housing and to keep housing tenants must pay rent (30% of income – SSI) and observe rules of a standard lease
Relapse does not result in housing loss or discharge from clinical services
(In instances where a consumer is evicted from an apartment the team will help find another)
Housing Component: Independent apartments integrated into the community* 1.
2.
3.
Rent units available on the open market (normal rental housing) Rent less than 20% of the total* number of units in any one building Tenants have same rights and responsibilities as any other lease holder *depending on availability of housing stock in different places there are many other housing options
Landlords as program partners: Landlord (are considered a 3 rd program component of this model) Landlord, agency, all want quality, safe, well managed apartments Agency assures landlord that rent is paid on time Agency staff are responsive to landlord concerns Landlord is encouraged to contact agency if problems arise with tenant Good communication prevents eviction and also prevents problems from developing into crises
ACT teams: Treatment and support services
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, 80% in the community 7-24-365 Team practices with Consumers Consumer driven philosophy (
Consumer Choice & Focus on Recovery)
– goal is 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
LIMITS to consumer choice in housing
Consumers must comply with the following: 1) Must sign lease or sublease or complete housing applications 2) Pay their portion of rent (30%) 3) Observing the terms of the lease
LIMITS to consumer choice on clinical services
The teams clinical authority will override consumers’ choice in instances where: 1) Person is considered a danger to self or others 2) In cases of domestic violence, child abuse/neglect or other legal issues
3. Providing Recovery Oriented services: Assuring a values based practice 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. How do we support more individuals to achieve this goal?
Programs elements that support recovery
Design the housing and services with a vision of recovery in mind: fully integrated into the community, indistinguishable from anyone else’s place
Rent and/or develop housing that looks like normal housing (e.g., mixed income housing; 80 20 etc.) not a facility based supportive program program
Design the program so that the person can stay housed and the services can walk away from the person who no longer needs them
If, programs support recovery, then…
Services: Provide services that support recovery: such as supported employment, wellness management recovery, shared decision making; etc.
Housing: Be sure the housing you provide can accommodate changes such as marriage or having a child or other positive individual and family developments
If, programs support recovery, then…
Convey hope
, offer choice, be respectful; Seek and discover capabilities; Create new possibilities
4
. Research and Program Effectiveness: Developing an Evidence Based Practice Program conducts continuous quality improvement studies Program conducts research and program evaluation
Proportion of Time Literally Homeless
1 0.8
0.6
0.4
0.2
0 Ba se lin e 6 M on th 12 -M on th 18 -M on th 24 -M on th 30 -M on th 36 -M on th
Time
Note
. Significant at 6-, 12-, 18-, 24-, 30-, and 36-month. Experimental Control
Proportion of Time Stably Housed
1 0.8
0.6
0.4
0.2
0 Ba se lin e 6 M on th 12 -M on th 18 -M on th 24 -M on th 30 -M on th 36 -M on th
Time
Note
. Significant at 6-, 12-, 18-, 24-, 30-, and 36-month.
Experimental Control
Having More Choice Improves Psychiatric Symptoms
reduction
Program Assignment Proportion of time homeless Choice Personal Mastery
reduction
Psychiatric Symptoms
increase
Adapted from Greenwood et al, 2005.
Other studies (VA Chronic Homelessness Initiative & HUD) -
VA
: 11 cities funded by ICH show about 85% housing retention rates after first year -
HUD Housing First
: 84% retention rate across several study sites
System Transformation
-1 End the existing step by step system Give everyone their own apartment and use existing facility based housing with services on site for those who a) choose it or B) need more support than the scatter site apartment model can provide
System Transformation -2-
Providing people with psychiatric disabilities a home only cures their homelessness, they need support and treatment to help cure or manage their illness Scatter site and facility based programs are only models of how to deal with people whoa re homeless they are not the solution to the nation’s homelessness problem
System Transformation -3-
The solution to homelessness is for the government to reinvest in building many thousands of units of affordable and mixed income housing
For additional information
See www.pathwaystohousing.org
See also: Pathways’ Housing First on the SAMHSA web site under NREPP (National Registry of Evidence Based Programs)