Transitions to Housing among Homeless Adults: A Pilot Study Presented by:

1. Transitions to Housing among Homeless Adults: A Pilot Study Presented by: Harmony Rhoades, Ph.D. and Hsun-Ta Hsu, M.S.W. Study Team: Suzanne L. Wenzel, Ph.D., Eric Rice, Ph.D., Ben Henwood, Ph.D., Harmony Rhoades, Ph.D., and Hsun-Ta Hsu, M.S.W. Acknowledgments: Skid Row Housing Trust Staff and Clients

2. Methods • Interviews with 33 adults transitioning into permanent supportive housing (PSH) at SRHT • Interviewed before moving in to housing • Average of 18 days prior to move-in date • Follow-up interview 3 months later • Average time between baseline and follow-up interview: 3.25 months • 25 people completed follow-up interviews • One refusal • Three never moved into housing • Three could not be reached at follow-up • 3 interview parts • Quantitative: Demographic questions, behavior, health & happiness • Social network interview: Characteristics of important people in their lives/those they have been in contact with in past 3 months (called ‘alters’) • Qualitative: Open-ended questions asking how the respondents felt about the moving process, how things would/did change, what types of services they might use, etc.

3. Respondent Characteristics • Average age 50 years • 68% male • 72% African American, 20% Latino • 48% had at least a high school diploma or GED • All self-reported as heterosexual • 54% reported being diagnosed with schizophrenia • 40% were looking for work • 84% owned a cell phone • 44% married or in a serious relationship • 12% were military veterans

4. Baseline Housing Characteristics • Location stayed most in past 3 months (prior to moving into PSH) • 63% shelter • 8% home of friend, family or stranger • 8% transitional living facility • 8% outside • Remainder: Substance • abuse facility, abandoned • building/squat, or • convalescent home

5. Baseline HIV Testing & Sexual Activity • 96% ever tested for HIV; 54% in the past 3 months • 100% of respondents received their last test result • 44% reported being sexually active in the past 3 months • Average of 1.4 partners • 62% of partners were steady (vs. casual or one-time) • 46% reported unprotected sex

6. Baseline Health, Mental Health & Happiness • General health: 48% reported health as good or very good • Competing needs: 46% reported at least some difficulty in: • Finding a safe place to sleep, getting enough to eat, keeping in touch with friends or family, keeping healthy, spending time how want, getting help with mental health problems, substance abuse, or physical health. • Life satisfaction: 65% reported feeling a lot or all of the time: • Enjoying living, feeling a strong will to live, being content with life, feeling in control of life, feeling good about oneself, feeling motivated, satisfied with social activity, and being pleased with health. • 61% exhibited moderate to severe symptoms • of depression • 65% reported symptoms of PTSD

7. Baseline Violence & Alcohol Use • 58% drank any alcohol in past 3 months • 4% reported binge drinking • 12% threatened or injured with a weapon • 42% had things stolen or were robbed • 21% afraid of being robbed or having things stolen • 50% afraid of being beaten up • 29% afraid of being sexually assaulted

8. Baseline Service Utilization (past 3 months) • 95% utilized mental health services • 96% had taken a prescription medication for mental health problem • 83% were currently taking medication for mental health problem • Only 4% (one person) reported unmet need for mental health care • 59% substance abuse treatment • No one reported unmet need • 71% had lifetime substance abuse treatment utilization • 79% utilized physical health treatment • 8% had unmet need • 29% used legal services • 25% unmet need • 21% used employment services • 29% unmet need

9. Baseline Social Network Characteristics • On average, respondents had weekly contact with 66% of their social network • 39% were known before they became homeless • 54% had jobs • 16% had been homeless themselves • 22% were housing service providers; 12% other service providers; 7% outreach workers • Had in-person contact with 68%, 50% by phone, 22% written • Felt emotionally close to 26%, went to 43% for advice, could confide in 28%, and could borrow $100 from 17% • Talked about housing issues with 68% • Drank with 10%, 16% had been drunk in past 3 months, and 10% used drugs • 10% had risky sex • 13% had ever been sex partners, 6% were current sex partners • Had unprotected vaginal sex with 5% (<1% UAI)

10. Changes at Follow-Up: Basic Characteristics • Baseline • 40% were looking for work • 84% owned a cell phone • 44% married or in a serious relationship • Follow-up • 36% were looking for work • 76% owned a cell phone • 40% married or in a serious relationship • 3 people left relationships; 2 developed new relationships

11. Follow-Up Housing Characteristics • Baseline • Where stayed most in past 3 months (prior to moving into PSH) • 63% shelter • 8% home of friend, family or stranger • 8% transitional living facility • 8% outside • Remainder: Substance abuse facility, abandoned building/squat, or convalescent home • Follow-Up • Where stayed most in past 3 months (after moving into PSH) • 96% own place • 4% shelter • PSH move-in had been delayed

12. Follow-Up HIV Testing & Sexual Activity • Follow-Up • 56% tested in the past 3 months • 100% received last test result • 52% sexually active in the past 3 months • Average of 1.5 partners • 79% of partners were steady • 85% reported unprotected sex • Baseline • 54% tested in the past 3 months • 100% received last test result • 44% sexually active in the past 3 months • Average of 1.4 partners • 62% of partners were steady • 46% reported unprotected sex

13. Follow-Up Health, Mental Health & Happiness • Baseline • General health • 48% reported health as good or very good • Competing needs • 46% reported at least some difficultymeeting needs • Life satisfaction • 65% reported feeling satisfied a lotor all of the time. • 61% exhibited moderate to severe symptoms of depression • 65% reported symptoms of PTSD • Follow-Up • General health • 64% reported health as good, very good, or excellent • 30% increased health status • Competing needs: Only 28% reported some difficulty meeting these needs. 75% reported a decrease in overall difficulty meeting needs. • Life satisfaction: 78% reported feeling satisfied a lot or all of the time. 62% reported some increase in life satisfaction. • 33% exhibited moderate to severe symptoms of depression (36% moved out of this category) • 43% reported symptoms of PTSD (19% of people moved out of this category)

14. Follow-Up Violence & Alcohol Use • Baseline • 58% drank any alcohol in past 3 months • 11% reported binge drinking • 12% threatened or injured with a weapon • 42% had things stolen or were robbed • 21% afraid of being robbed or having things stolen • 50% afraid of being beaten up • 29% afraid of being sexually assaulted • Follow-Up • 50% drank any alcohol in past 3 months • 8 people decreased drinking frequency; 8 increased • 8% reported binge drinking; 1 stopped, 2 started • 24% threatened or injured with a weapon • 20% had things stolen or were robbed • 11% afraid of being robbed or having things stolen • 32% afraid of being beaten up • 24% afraid of being sexually assaulted (50% of women) • Overall, 63% experienced decreased fear of violence

15. Follow-Up Service Utilization (past 3 months) • Baseline • 95% utilized mental health services • 96% had prescription • 83% currently taking medication • Only 4% reported unmet need • 59% substance abuse treatment • No unmet need • 79% utilized physical health treatment • 8% had unmet need • 29% used legal services • 25% unmet need • 21% used employment services • 29% unmet need • Follow-Up • 90% utilized mental health services • 83% currently taking medication for mental health needs • No one reported unmet need for mental health care • 65% substance abuse treatment • 4% reported unmet need • 71% utilized physical health treatment • 12% had unmet need • 28% used legal services • 12% unmet need • 20% used employment services • 24% unmet need

16. Follow-Up Social Network Characteristics • Baseline • Weekly contact with 66% • 39% known before became homeless • 54% had jobs • 16% had been homeless • 22% housing service providers; 12% other service providers; 7% outreach workers • In-person contact with 68%, 50% by phone, 22% written • Emotionally close to 26%, went to 43% for advice, could confide in 28%; could borrow $100 from 17% • Talked about housing issues with 68% • Drank with 10%, 16% had been drunk, and 10% used drugs • 10% had risky sex • 13% had ever been sex partners, 6% were current sex partners • Had unprotected vaginal sex with 5% (<1 UAI) • Follow-Up • Weekly contact with 73% of their social network • 41% were known before they became homeless • 49% had jobs • 18% had been homeless themselves • 12% housing providers; 5% other providers; 1% outreach workers • Had in-person contact with 72%, 50% by phone, 22% written • Felt emotionally close to 26%, went to 27% for advice, could confide in 31%, and could borrow $100 from 34% • Talked about housing issues with 58% • Drank with 14%, 15% had been drunk since R moved in, and 16% used drugs. • 8% had risky sex • 19% had ever been sex partners, 12% were current sex partners • Had unprotected vaginal sex with 10% (4% UAI)

17. Feelings about Moving in at Baseline • Happy, excited, nervous, & grateful for different reasons: • Achievement • Ownership • Safety • Have control over his/her life • Fulfill basic needs • Better access to services "I’ve been out living like less than a human being for quite some time now. And this is giving me an opportunity to join the human race again, so to speak.“ "For one thing having a safe place to sleep…And also to kind of navigate my way through services that I needed to take advantage…although they were available before they were harder to access and to process because of unstable, or lack of, housing, shall I say?"

18. Feelings about being Housed at Follow up • Grateful and feel blessed for being housed: • A sense of security • Less stressed • Fulfill subsistence needs • Solitude space for meditation and think about future "I guess what's made me happy is that I'm in a place that I can consider mine that I don't have to worry about, you know, who's going to sit beside me or "sleep beside me" or who's just going to randomly walk up to me because I have nowhere else to go, that I have my own space...being able to shower when I want to shower, eat when I want to eat, sleep when I want to sleep and not having to go by somebody's schedule or worry about how I'm going to "survive" the day or night."

19. Building Perspectives • Most participants like the building and their places: • Clean • Really renovated • Quiet • Nice staff members • The only concerns: • Shared facilities • Hot during summer • Interaction with neighbors

20. Neighborhood Perspectives • Outside of Skid Row: • Convenient • Quiet • Laidback • Heart of Skid Row: • Drug infested • Illegal activities are prevalent • Remind participants of their previous experiences

21. Expected and Actual Changes in Life • At baseline, participants’ anticipated changes in life: • More settled and stable • A better quality if life • A place to put important documents or personal items • At follow up, the actual changes in life move to higher level • Become healthier • Enjoy hobbies • Think more about future • Making appointments and interviews • Motivated • Positive attitudes and higher self esteem "I didn’t have the energy to sit there and deal with them. Now I have the energy to sit there. And I’m coming in on time. And talk with my psychiatrist. And I have patience."

22. Anticipated Service Use vs. Actual Service Use • Major services interested in at baseline: • Mental health • Physical health • Recovery from substance use • Legal aids • Job training • Education • Major services used at follow-up: • Mental health • Physical health • Recovery from substance use

23. Housing Impacts on Family Relationships • The results are mixed, and may be influenced by: • Previous experiences with families • Neighborhood location • Family location Baseline: "Now, my blood, family relations, as I said, I’m going to have a place for them to come visit me and have a place to stay... " Follow-Up: "We was more in contact when I wasn’t housed. I thought about that the other day too."

24. Housing Impacts on Associates/Friends • Housing influence on participants’ friendships: • Most of the participants expressed losing contacts at follow-up, no matter whether they expected it happening at baseline or not • Those lost contacts were considered "negative influences“ • Previous contacts might be jealous on participants having housing • Most of the participants expressed gaining new contacts at baseline, and did do at follow-up • These new contacts were usually neighbors, staff members, and people who also attended the same recovery groups • Still some enjoyed the solitude that the housing provide, and choose to stay in his/her place.

25. Housing Impacts on Romantic Partners • At baseline: • Housing could help facilitate and sustain romantic relationships • Privacy • Place for dinner date • Place for partners to stay over • At follow-up: • Participants expressed not having relationships, and intimate relationships was not their primary focus • Health and job issues are the primary focus • The partners in the neighborhood are not "good enough" • Having a primary partner is still a goal, but no in the near future or in Skid Row • Some expressed complicated relationships, and possible sex trades

26. Housing Impacts on Romantic Partners Cont. At baseline: "cause having a place, I’ve met women and they’re asking me where do you live. I can’t tell them anything. But I have my own place, you’re more acceptable to women." At follow-up: "the women down here they’re pretty bad. A lot of them are messed up, so that’s the reason why I haven’t found any." Future goal: "[chuckles] To get a job. [big sigh] My goal is to get a job. That’s the number one. Get a driver’s license. Goal: driver’s license. And get a good woman."

27. Typical Day at Baseline • The major features of participants’ daily life before housed • Getting up very early (as early as 3 am) • Take showers in lines • Have meals at shelters • Go to libraries or parks • Make some appointments

28. Typical Day at Follow-up • The major features of participants’ daily life after housed • Rest more • Not in constant moving • Attend appointments • Making their own food • Participate in social outings or gardening groups • Watch TV • Exercise more • Think more about how to better themselves and • what is the next step

29. Future Goals • Life does not stop at PSH: • Find a stable job, and save money • Get education or retrieve licenses • Moving out of Skid Row once stabilized • Find a serious romantic partner

30. Conclusions • Increased life satisfaction, ease of meeting basic needs and general health • Decreased fear of violence and victimization • Reports of actual victimization increased • No changes in uptake of HIV testing • Some evidence of increased substance abuse treatment service utilization • Also some physical health treatment unmet need • Increase in sexual activity • Particularly unprotected sex • Social networks increasingly comprised of sex partners • Conflicting evidence about changes in substance use • Some respondents decreased alcohol use, while just as many increased • Some increase in drug using alters, and alters with whom they drink • Many fewer service providers within their social networks • Social support • Decrease in alters who provide advice • Fewer alters whom they contact weekly • Hope to learn more in proposed NIH-funded study