Housing First 101: Is it housing only?

1. Housing First 101: Is it housing only?

2. Objectives • Define Housing First principles • Recognize Housing First Best Practices • Distinguish expectations of Veterans in housing • Identify Tenant rights and obligations

3. Agenda • Housing First Defined • Implementation of the Practice • Using the Structure of the Lease • Summary/Close • Q&A

4. I. Housing First Defined

5. “Housing First is a major change of clinical philosophy and a giant logistic change at the same time, it takes housing and treats it as a human right instead of a reward for doing well.” • Based on overwhelming evidence that all people experiencing homelessness can achieve stability in permanent housing if provided with the appropriate levels of services. Stefan Kertesz, M.D., Birmingham VA Medical Center

6. Housing First: Definition • Quickly and successfully connect individuals and families experiencing homelessness to permanent housing without preconditions and barriers to entry, such as sobriety, treatment or service participation requirements. • Supportive services are offered to maximize housing stability and prevent returns to homelessness as opposed to addressing predetermined treatment goals prior to permanent housing entry.

7. Housing First holds that homeless Veterans with physical and mental health issues, including substance use disorders, require the fundamental safety and security that permanent housing provides, without first having to “earn” or prove a readiness for housing by complying with or completing other treatment programs. HUD-VASH Resource Guide, 2012

8. Housing First (HF) • HF is a paradigm shift from the traditional housing ready approach. It follows a basic principle—that everyone is ready for housing, regardless of the complexity or severity of their needs. Services are wrapped around them.

9. Housing First • HF is not one size fits all • Part of housing choice is that an individual can choose to go to treatment before housing or that they can get treatment while in housing

10. Key Evidence • High housing retention rates (Mares & Rosenheck, 2011) • Fewer hospitalizations (Sadowski et al., 2009) • Higher perceived choice in services (Greenwood et al., 2005; Tsemberis, Gulcur, & Nakae, 2004) • Reduced substance use and abuse (Padgett et al., 2011) • Reduced involvement in criminal activity (DeSilva, Manworren, & Targonski, 2011)

11. Housing First Principles

12. Housing First Best Practices • Assertive engagement using motivational techniques • Comprehensive assessment and housing stabilization planning • Person-centered and recovery oriented; teach tenancy skills • Based in the community and in the home • Links to Community Supports: social, spiritual, libraries, sports, arts, recreation

13. Housing First is NOT… HOUSING FIRST HOUSING ONLY

14. Housing First vs. “Treatment First” Housing First Treatment First/Abstinence Higher rates of dropout Less likely to engage the Veteran successfully Higher rates of substance use and substance abuse treatment utilization • Demonstrate much lower rates in use of substance abuse treatment services • More likely to stay engaged in the homeless program and be stably housed • Demonstrate a greater control over drug and alcohol use Padgett et al.

15. Housing First: Key Principles • Housing as a basic human right • Respect, warmth, compassion for all Veterans • A commitment to Veterans • Scattered site housing • Separation of housing and services • Veteran choice and self-determination • Recovery orientation • Harm reduction

17. Housing First: Essential Practice Elements • Low threshold admissions policy • Harm reduction-based policies and practices • Separation of housing and services • Reduced service requirements • Eviction prevention • Consumer education

18. Misperceptions Lead to Low Expectations “Research about the low expectations of mental health professionals in relation to people with mental health conditions gaining employment is now very well documented. These expectations are often underpinned by concern about issues of risk, stress and relapse. Such low expectations … can result in them and their families receiving very cautious messages from mental health professionals about gaining employment.” Rinaldi et al., 2010

19. II. Implementation of the Practice

20. Lack of replication guidelines (every program looks different) Strength of abstinence-based philosophy in local programs/communities Lack of clear understanding of: Harm reduction Low demand services Strength of abstinence-based philosophy embedded in historical VA Healthcare culture Program-level barriers Problems with Adoption: Why is it so hard?!

21. Potential Barriers • Lack of understanding about what Housing First really means • “Jack-of-all-trades” expectations of staff • Providing non-Veteran-centered services • Lack of buy-in from some service providers • Lack of buy-in from some team members • Landlord resistance

22. What about alack of buy-in? • Recognize that not everyone shares the same values as Housing First • Look for opportunities to build partnerships with the “non-believers” • Refer to your Veteran-centered approach

23. Strategize ways to be flexible within limits of outside rules Can the Veteran use substances away from property? Develop individualized risk management plans If funding requires treatment: Do notforce Veterans to engage in more than the minimum Offer a wide range of service choices Are you able to maneuver Veterans between properties? Do notprotect Veterans from natural consequences Strategies to Overcome Barriers

24. Strategy: Honor Veteran’s Voice and Choice • “At the very least, the strengths perspective obligates workers to understand that, no matter however downtrodden and sick, individuals have survived and (in some cases) thrived. They have taken steps, summoned up resources and coped. We need to know what they have done, how they have done it, what they have learned from doing it, what resources, inner and outer were available in their struggle to surmount their troubles.” Dennis Saleebey, “The Strengths Perspective in Social Work Practice”

25. Separation of Housing and Services • Functional separation between Housing and Services • Not a different reality from other housing in the community • Allows each Veteran to fully participate in the clinical services offered • Property Manager can focus on the contract of the lease • Each Veteran is assisted to manage the full rights and responsibilities of tenancy

26. Preparation • Targeting: Low barrier approach – Every Veteran deserves housing • High expectations: Veterans have the same rights and responsibilities in relation to housing as anyone else in the community • No special rules for a homeless population

27. Preparation • Each Veteran is expected to follow a lease • Case Management is focused on every Veteran assuming full rights and responsibilities of tenancy • Engage: look for comfort and goals

28. Strategy: Honor Veteran’s Voice and Choice • Strengths Perspective • The Veteran is the resident expert on his/ her own life • Let go of assumptions • What are their wants and needs; what is their perspective on where they are? • The Veteran has strengths and experiences that are valuable and essential to their success • What has worked in the past; what has not worked? • What do they think would work this time?

29. Motivation and Change • Motivation is behavior specific (people have different responses to different issues) • Each person is motivated to change by unique factors • Compliance does not equal change • Change that occurs because of external pressure tends to be short-lived • More that someone “owns” (internalizes) the reasons for change, the more likely change will endure • Change is always hard and motivation gets you through it

30. Motivation & Change • Motivation fluctuates from one time and situation to another; not a fixed trait • Motivation can be influenced by outside influence; it does not reside solely in the person

31. Motivational Interviewing (MI) and Stages of Change

32. Harm Reduction Plan – Example

33. III. Using the Structure of the Lease

34. Using the Lease to Structure the Work: • One of the goals of Housing First is for each person to be stably housed. To reach this goal, the Veteran needs to learn how to manage tenancy obligations. • Key to achieving this goal is the active coordination between landlords/property management and support services staff, while maintaining the functional separation of these two staffs.

35. Using the Lease to Structure the Work: • Having separation of functions helps tenants learn by being treated no differently from any other tenant. (Don’t want to create alternate reality) • Problems that threaten tenancy may motivate tenants to use services in order to keep their housing.

36. Key Roles: Property Management -Services • Property Management has a key role in helping people understand their obligations and comply with them. (Assertive approach) • Establish the expectations for the tenant • The case management staff provide and arrange for services needed to maintain housing and also function as advocates for the tenant. • Assist the tenant to meet the expectations of tenancy

37. Tenant Rights

38. Obligations of Tenancy

39. Obligations of Tenancy

40. IV. Summary/Closing

41. Closing • Housing First makes it possible for every Veteran to stabilize in their communities by eliminating the barriers to housing access and providing the support needed to maintain housing • Housing First is goal-oriented and client-driven • Housing First has the same rules as all other rental housing and uses case management to assist each tenant to meet these expectations • It takes a village and depends on quality supports and assertive landlords • Choice is only real in the context of each Veteran’s goals, knowledge , and consistent expectations

42. V. Q & A

43. Resources • http://www.blogs.va.gov/VAntage/35220/helping-homeless-veterans-not-end-housing/ • Stefan Kertesz, M.D., Birmingham VA Medical Center, Discussion on Veterans and homelessness, The Birmingham VA Medical Center’s marking of National VA Research Week, May, 2016. • HUD-VASH Resource Guide for Permanent Housing and Clinical Care, NCHAV, 2012. • Mares AS, Rosenheck RA. (2011) A comparison of treatment outcomes among chronically homeless adults receiving comprehensive housing and health care services versus usual local care. Adm Policy Ment Health. 38: 459– 475. • Sadowski LS, Kee RA, VanderWeele TJ, Buchanan D. (2009) Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. JAMA. 301: 1771– 1778. • Tsemberis S. (2010) Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction. Center City: Hazelden. • Tsemberis S, Gulcur L, Nakae M. (2004) Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Am J Public Health. 94: 651– 656. • Padgett, D.K., Stanhope, V., Henwood, B.F. and Stefanic, A. (2011) Substance Use Outcomes Among Homeless Clients with Serious Mental Illness: Comparing Housing First with Treatment First Programmes, Community Mental Health 47(2) pp.227-232. • M. B. DeSilva, J. Manworren, and P. Targonski, “Impact of a housing first program on health utilization outcomes among chronically homeless persons,” Journal of Primary Care & Community Health, vol. 2, no. 1, pp. 16–20, 2011 • 10 Fundamental Components of a Successful Recovery, www.recovery.org • Dennis Saleebey; The Strengths Perspective in Social Work Practice: Extensions and Cautions. Soc Work 1996; 41 (3): 296-305.