Housing Chronically Homeless People: HOUSING FIRST Programs in Philadelphia

1. National Alliance To End Homelessness Ending Homelessness: Plan, Act, Succeed Housing ChronicallyHomeless People:HOUSING FIRST Programs in Philadelphia Presented by: David Dunbeck Horizon House, Inc. July 18, 2006

2. Housing First Programs“New 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

3. 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)

4. 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 New Keys Target Population

5. 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)

6. 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 Home First Target Population

7. 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 Housing First Outcomes

8. 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%) Housing First Outcomes

9. 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 Housing First Outcomes

10. 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 Housing First Outcomes

11. 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 Housing First Outcomes

12. Things We’ve learned! (Usually the hard way!)

13. Safety Staffing Housing Managing expectations/ pressures Behavioral Health Maintaining the model Funding The forest/the trees Physical Health Needs Employment Costs

14. “Housing First + ACT” is not the same as “ACT” Things We’ve Learned:

15. 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 Things We’ve Learned:

16. Housing First is still a good investment! BUT… • Preliminary analysis shows significant (>50%) reduction in inpatient hospitalizations, detox, and rehab after engaging in services and/or getting housing.

17. It’s 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 Things We’ve Learned:

18. 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 Things We’ve Learned:

19. 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? Things We’ve Learned (or are still trying to figure out):

20. 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. Things We’ve Learned:

21. 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 Things We’ve Learned:

22. 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.) Things We’ve Learned:

23. Good assessments are a good investment! Take the time to perform a thorough assessment (including physical health) at the beginning. Don’t drop the “physical health” ball – use your nurses! Dealing with long unmet physical health needs can be a powerful engagement tool! Things We’ve Learned:

24. 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 Things We’ve Learned:

25. We built sustainability into our grants….but, we still weren’t prepared for the transition: It’s always going to be a painful process, but don’t 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 – it’s easier to transition with only 5, 10, or 20 consumers (and associated paperwork) than with 155 consumers! Things We’ve Learned:

26. My new mantra: “Defend the program, but don’t become defensive” Things We’ve Learned:

27. The Goal:

28. “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) Housing First – Future Growth

29. Horizon House, Inc. 1201 Chestnut St., 12th floor Philadelphia, PA 19107 215-636-0606 David Dunbeck, Director of Homeless Services, david.dunbeck@hhinc.org Carla Williams, Director of ACT, carla.williams@hhinc.org Contact Information