“Housing-First” Models in Philadelphia

1. “Housing-First” Models in Philadelphia David Dunbeck, MSW Director of Homeless Services Horizon House, Inc. Philadelphia November 30, 2005

2. What is Housing First? • Housing First is a program model that assists chronically homeless individuals by immediately offering needed rental subsides and permanent housing • Supports are continuous throughout the engagement process and through placement into permanent housing to assist the individual in maintaining his/her housing

3. Why Housing First? • Need • Moral Issues • Financial Issues

4. Statistics on Homelessness • Nationally: • Between 700,000 and 800,000 people are homeless on any given night. • 81% enter and exit the system quickly • 9% of users of emergency shelter enter and exit repeatedly • (These are the CHRONICALLY HOMELESS) • Philadelphia • Most recent street census: 429 living on CC streets • 3,000 men, women, and children in shelter (110% of capacity)

5. Statistics on Homelessness • Federal definition of Chronically Homeless includes individuals with a significant disability and either: • 1 continuous year of homelessness or • 4 episodes of homelessness in the past 3 years.

6. Moral Issues • Everyone deserves a safe, permanent place to live. • People don’t earn the right to housing. • “Why do you ask a homeless person if they are “housing ready”? Do you ask a hungry person if they are “food ready”? Tanya Tull, Shelter Now, LA

7. Financial Issues • Dennis Culhane’s NY/NY study. • Daily Cost of Services used by the Homeless • Permanent Supportive Housing $28 • Emergency Shelter $36 • Home First/New Keys $58 • Prison $75 • Non-hospital rehab $120 • Detox $200 • Emergency room/crisis visit $200 • Psychiatric hospital $700 • Inpatient hospital stay $1,285

8. Goals Bring chronically homeless street and shelter dwelling individuals with co-occurring substance abuse and mental illness disorders into permanent independent housing with intensive behavioral healthcare support.

9. Objectives • More individuals who are the most severely disadvantaged homeless will be in independent housing. • These individuals will: • be more likely to participate in ongoing outpatient behavioral health services. • have more positive attitudes about the value of behavioral health services. • have increased family and social contacts. • be in better health, mentally and physically. • These individuals will have reduced admission to shelter, prison, drug treatment, ER, acute care units, criminal justice system.

10. Service Model • Modeled on the Pathways to Housing Program in New York City • Includes the following components: • The “evidence-based” practice of Assertive Community Treatment (ACT) • The “best” practice of immediate access to Supported Housing • Harm Reduction Model of Recovery

11. Multi-Disciplinary Teams 24/7 Hour Availability and Coverage Small Caseloads: 1:10 staff:client ratios The team provides all treatment except inpatient Assertive Outreach Essential Ingredients of Assertive Community Treatment Lachance, K., & Santos, A.B. (1995). Modifying the PACT model: preserving critical elements. Psychiatric Services, 46:601-604 .

12. Essential Ingredients of Assertive Community Treatment • Community Locus of Care - integrated case management model and treatment following consumers through shelters, streets, prisons, and any other site • 80% of the time spent in the community with consumers • Long term engagement model

13. ACT Team Composition • Team Leader • Psychiatrist (0.5 FTE) • Psychiatric and Physical Health Nurses • BS and MS-level Clinical Case Managers • Mental Health Specialist(s) • Drug and Alcohol Specialist(s) • Vocational Specialist(s) • Case Aide/Peer Support Specialists • Supported by Clinical Director

14. Housing Two ground rules for housing: • Client must let Horizon House be payee • Client must agree to home visits • One-bedroom apartments • Scattered Sites • 30% of income for rent

15. HARM Reduction Model of Recovery • Assumes that any decrease in substance use is a positive step that must be supported • Assumes that some individuals will only attain clean and sober status, with supports through a long term engagement process

16. Philadelphia’s Two Housing First Programs New Keys: • Targets chronically street homeless with serious mental illness and substance abuse disorders. Home First: • Targets chronically homeless shelter users with serious mental illness and substance abuse disorders.

17. PROGRAM CAPACITY: 60 Accepted first 5 clients in March 2003 Housed first 2 clients in May 2003 New Keys

18. New Keys Funding • Services: • 3-year Health and Human Services (HHS) grant • Substance Abuse and Mental Health Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT) grant ($1.8 million) • Housing: • 3 year HUD Supportive Housing Program grant (25 units) ($650,000) • 5-year HUD Shelter Plus Care grant (35 units) ($1.5 million)

19. New Keys Partners • Horizon House, Inc. • 1260 Housing Development Corporation • University of Pennsylvania Center for Mental Health Policy and Services Research • City of Philadelphia – OBH, OAS

20. Currently have 60 consumers assigned to New Keys: 45 are housed in their own apartments 1 is in an interim unit 2 are in hospital 5 are incarcerated 7 are being engaged through outreach New Keys Outcomes

21. PROGRAM CAPACITY: 70 Accepted first 5 clients in January 2004 Housed first client in February 2004 Home First

22. Home First Funding • Services: • 3-year Health and Human Services (HHS) grant • Substance Abuse and Mental Health Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT) grant ($1.6 million) • 3-year Health and Human Services (HHS) grant • Health Resources and Services Administration (HRSA) grant ($900,00) • Veterans Administration grant • Housing: • 3 year HUD Supportive Housing Program grant (70 units) ($1.9 million)

23. Home First Partners • City of Philadelphia – OBH and OAS • Horizon House, Inc. • 1260 Housing Development Corporation • Philadelphia Health Management Corporation • Veterans Administration

24. Currently have 90 identified: 65 are housed in their own apartments 8 are in shelter or safe haven 4 are hospitalized 5 are currently difficult to locate; outreach 5 are incarcerated 3 are in interim units Home First Outcomes

25. Of the 39 consumers housed as of 3/1/05: 37 were entered in OESS database before 2000. 27 were homeless for over 10 years. Averaged 15.5 inpatient admissions* over last 5 years (3 per year), ranging from 0 to 68. * detox, rehab, or psychiatric inpatient treatment After engagement by ACT team, there was an almost 60% reduction in inpatient admissions. After housing, there was a 78% reduction in inpatient admissions. Home First Outcomes

26. WM is a 52 y.o. female Homeless since 1998 Diagnosed with bipolar disorder and alcohol addictions New Keys Case Study: WM

27. In 3 years prior to New Keys: 11 psych. hospitalizations (207 inpatient days) In 1 year prior to New Keys: 2 psych. hospitalizations (107 inpatient days) 67 street outreach contacts New Keys Case Study: WM

28. Since being housed (last 22 months): No hospitalizations No street outreach contacts Is still in her first apartment New Keys Case Study: WM

29. HG is a 52 y.o. female Homeless since 1993 – bouncing between streets, shelters, institutions Diagnosed with schizophrenia, multiple addictions Home First Case Study: HG

30. In 5 years prior to Home First: 66 admissions to shelter 46 admissions to detox, D&A or psychiatric inpatient treatment (average 9.2 per year) Home First Case Study: HG

31. Since being housed (last 19 months): 0 admissions to shelter 1 inpatient psychiatric hospitalization No inpatient treatment in last 15 months Had problems in first apartment, and moved successfully to another apartment (15 months) Has greatly reduced her drug use Home First Case Study: HG

32. Introducing “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 Housing First Challenges

33. Having housing services in a different agency than ACT services (advantages/disadvantages): Good cop/bad cop Values Harm reduction Client choice Landlord issues Damages Housing First Challenges

34. Safety – where do you draw the line? Money management Physical health needs Staff burnout VA payeeship issues Housing First Challenges

35. Services: Transition to MA fee-for-service reimbursement – July 25, 2005 Housing HUD renewal funding through McKinney Continuum of Care process Housing First - Sustainability

36. “Welcome Home” Start-up Spring 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

37. References • Culhane, Metraux, and Hadley, Public Service Reductions Associated with Placement of Homeless Persons with Severe Mental Illness in Supportive Housing, Housing Policy Debate, Vol. 13, Issue 1, Fannie Mae Foundation, 2002. • McCarroll, Christina, Pathways to housing the homeless, The Christian Science Monitor, May 1, 2002. • Tsemberis and Eisenberg, Pathways to Housing: Supported Housing for Street-Dwelling Homeless Individuals with Psychiatric Disabilities, Psychiatric Services, Volume 51, No. 4, April 2000.

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