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Benefits of Supported Housing for People with Psychiatric Disabilities

Benefits of Supported Housing for People with Psychiatric Disabilities. Conclusions based on a systematic review of published research studies.

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Benefits of Supported Housing for People with Psychiatric Disabilities

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  1. Benefits of Supported Housing for People with Psychiatric Disabilities Conclusions based on a systematic review of published research studies Compiled by the Supported Housing Study Group at Boston University Center for Psychiatric Rehabilitation.  Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006)

  2. Learning Objective: Increased Understanding About…. • Characteristics and principles of supported housing • Factors that contribute to positive supported housing outcomes • Positive outcomes for people with psychiatric disabilities who receive supported housing services

  3. Learning Activities • Review of Trainee Supported Housing Knowledge and Experiences • Presentation & Exercise: Supported Housing Principles • Presentation and Exercise: Factors that Positively Effect Supported Housing Outcomes • Presentation and Exercise: Supported Housing Benefits to the Individual

  4. Review of Supported Housing Knowledge and Experiences • Successes and Challenges • Experiences with Supported Housing • Characteristics of Supported Housing

  5. Supported Housing Principles

  6. Supported Housing Principles • Housing is permanent. • Individuals either own their homes or have a lease in their own name. • Permanence has the same meaning as it does for anyone else renting a house or apartment in the community. Rog, Debra J., (2004). The Evidence of Supported Housing. Psychiatric Rehabilitation Journal, 27 (4), 334-343.

  7. Supported Housing Principles • Housing is distinct and separate from other services. • Housing and service agencies are legally and functionally separate. Rog, Debra J., (2004). The Evidence of Supported Housing. Psychiatric Rehabilitation Journal, 27 (4), 334-343.

  8. Supported Housing Principles • Housing is integrated into the community. • Apartments or houses are located among other houses and apartments that one would find in the community. Rog, Debra J., (2004). The Evidence of Supported Housing. Psychiatric Rehabilitation Journal, 27 (4), 334-343.

  9. Supported Housing Principles • Housing is affordable. • No more than 40% of the individuals adjusted gross income is required for rent or mortgage payments. Rog, Debra J., (2004). The Evidence of Supported Housing. Psychiatric Rehabilitation Journal, 27 (4), 334-343.

  10. Supported Housing Principles • Mental health services are offered, not mandated. • The individual does not have to avail her/himself of any services, including medication, in order to participate in the program. • Services are flexible, individualized, and voluntary that come and go depending on the individual’s needs and preferences. Rog, Debra J., (2004). The Evidence of Supported Housing. Psychiatric Rehabilitation Journal, 27 (4), 334-343.

  11. Supported Housing Principles • The individual chooses the housing and mental health services. • Individuals are offered options about where s/he wants to live and from whom s/he wants services, if any. • Although the person’s ideal choice can’t be guaranteed, the place that s/he lives in must be based on whether s/he chooses to live there or not. Rog, Debra J., (2004). The Evidence of Supported Housing. Psychiatric Rehabilitation Journal, 27 (4), 334-343.

  12. Supported Housing Principles • Services are community based. • There are no live in staff. Rog, Debra J., (2004). The Evidence of Supported Housing. Psychiatric Rehabilitation Journal, 27 (4), 334-343.

  13. Supported Housing Principles • Crises services are available. • Crises services are available 24 hours per day, 7 days a week. Rog, Debra J., (2004). The Evidence of Supported Housing. Psychiatric Rehabilitation Journal, 27 (4), 334-343.

  14. Factors that Positively Impact Supported Housing Outcomes

  15. Factors that Appear to Positively Impact Supported Housing Outcomes • Choice of housing • Having more than one housing option increases the individual’s desire to stay and leads to a better functional match between the person and the housing. (Srebnik et al, 1995) • Greater information about housing options during the process of choosing housing is related to desire to stay in residence.(Srebnik et al, 1995) Compiled by the Supported Housing Study Group at Boston University Center for Psychiatric Rehabilitation.  Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006)

  16. Factors that Appear to Positively Impact Supported Housing Outcomes • Rapid entry into housing • Facilitating entry into housing quickly increases the likelihood that the individual will stick with services and achieve independent housing. (Mares, Kasprow, & Rosenheck, 2004) Compiled by the Supported Housing Study Group at Boston University Center for Psychiatric Rehabilitation.  Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006)

  17. Factors that Appear to Positively Impact Supported Housing Outcomes • Housing subsidies and vouchers • When housing is affordable, there is a more direct and quicker exit from homelessness and stable independent living is more likely. (Hurlburt, et al., 1996) • Subsidies and vouchers enable individuals access to higher quality housing, which positively impacts keeping people housed and satisfied with their housing. (Hurlburt, et al., 1996) Compiled by the Supported Housing Study Group at Boston University Center for Psychiatric Rehabilitation.  Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006)

  18. Factors that Appear to Positively Impact Supported Housing Outcomes • Intensive services • Regular case management is no better than services as usual – intensive services are needed. (Rosenheck, et al., 2003) • ACT case management leads to greater satisfaction, greater contact with service providers, reduced symptoms, and greater stability in the community. (Morse, et al., 1997; Fletcher, et al., 2008) • Individuals receiving intensive case management are less likely to terminate services, which can lead to better housing outcomes. (Clark & Rick, 2003) Compiled by the Supported Housing Study Group at Boston University Center for Psychiatric Rehabilitation.  Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006)

  19. Factors that Appear to Positively Impact Supported Housing Outcomes • Integrated services • A nine site, four year study found that agencies with improved inter-organization integration of services had greater improvement in housing status outcomes than those that did not.. (Rosenheck, 2002) Compiled by the Supported Housing Study Group at Boston University Center for Psychiatric Rehabilitation.  Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006)

  20. Factors that Appear to Positively Impact Supported Housing Outcomes • Practical services • Help with day to day tasks, e.g., house keeping, shopping, budgeting, is needed to increase housing stability. Compiled by the Supported Housing Study Group at Boston University Center for Psychiatric Rehabilitation.  Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006)

  21. Supported Housing Benefits for the Individual

  22. Supported Housing Benefits to the Individual • Residential status can be significantly improved. • Living situations for individuals who are psychiatrically disabled, with a psychiatric disability and homeless (or at risk of becoming homeless) and with substance abuse problems can be significantly improved. (Tsemberis, et al., 2004; Gulcur, et al., 2003; Shern et al., 1997; Rosenheck, et al., 2003; Goldfinger, et al., 1999; Morse, et al., 2006) • Experimental studies have found that the proportion of individuals who were housed in a community setting (not the streets, a shelter, or an institution) was higher by an average of 15% than those in control groups. (Tsemberis, et al., 2004; Gulcur, et al., 2003; Shern et al., 1997; Rosenheck, et al., 2003; Goldfinger, et al., 1999; Morse, et al., 2006). • Studies have shown significantly faster decreases in homelessness for individuals participating in supported housing. (Tsemberis, et al., 2004) Compiled by the Supported Housing Study Group at Boston University Center for Psychiatric Rehabilitation.  Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006)

  23. Supported Housing Benefits to the Individual • Housing stability can be improved to rates of 80% or more. (Goldfinger, et al., 1999) • Individuals in supported housing tend to have significantly fewer moves and thus less disruption in their lives. • More than one controlled study measuring the % of time individuals remained housed during follow-up attained the 80% rate. • Follow-up periods ranged from 90 days to over 1 year , in one case, 5 years. Compiled by the Supported Housing Study Group at Boston University Center for Psychiatric Rehabilitation.  Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006)

  24. Supported Housing Benefits to the Individual • Quality of life can be increased. (O’Connell, et al., 2008) • Living in a place of preference is correlated with the individual’s rating of quality of life. (Nelson, et al., 1998) • Individuals with psychiatric disabilities report wanting independent housing, in non-congregate settings by a wide margin. (Middelboe, et al., 1998) • Clinicians are more likely to recommend settings with higher levels of supervision than individual’s prefer, e.g., group homes versus independent housing. (Goldfinger & Schutt, 1996) Compiled by the Supported Housing Study Group at Boston University Center for Psychiatric Rehabilitation.  Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006)

  25. Supported Housing Benefits to the Individual • Psychiatric hospitalizations are less likely. • Several studies show a reduction of hospitalization while individuals were housed even though clinical outcomes are more difficult to affect than housing outcomes. (Lipton, et al., 1988; Culhane et al., 2002) Compiled by the Supported Housing Study Group at Boston University Center for Psychiatric Rehabilitation.  Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006)

  26. Other Conclusions • Provision of supported housing services may reduce other service-related costs. (Culhane, et al., 2002) • Supported housing approaches may be more expensive than other residential service delivery, but the cost offsets may make the cost benefit equation more palatable when compared to other options. (Culhane, et al., 2002) • Substance abuse, unsuccessful housing history, and criminal arrests are associated with poorer housing outcomes. (Hurlbert, et al, 1996; Kenny, et al., 2004) Compiled by the Supported Housing Study Group at Boston University Center for Psychiatric Rehabilitation.  Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006)

  27. Other Conclusions • It is unclear whether substance abuse and psychiatric symptoms are positively effected by successful supported housing outcomes. (O’Connell, 2008) • Some studies suggest that psychiatric diagnosis is not a factor in residential stability and some suggest that it is(Rosenheck, et al., 2003, Hurlbert, et al., 1996). Compiled by the Supported Housing Study Group at Boston University Center for Psychiatric Rehabilitation.  Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006)

  28. References Dickey, B., Gonzalez, O., Latimer, E., Powers, K., Schutt, R., & Goldfinger, SM, 1996. Use of mental health services by formerly homeless adults residing in group and independent housing. Psychiatric Services, 47: 152. Fletcher, T. D., Cunningham, J. L.,Calsyn, R. J., Morse, G. A., Klinkenberg, W. D., 2008. Evaluation of treatment programs for dual disorder individuals: Modeling longitudinal and mediation effects. Administration and Policy in Mental Health and Mental Health Services Research, 35: 319-336. Forchuk, C, Nelson, G. & Hall, B., 2006. “It’s Important to be Proud of the Place You Live In": Housing Problems and Preferences of Psychiatric Survivors. Perspectives in Psychiatric Care, 42: 42-52. Goering, P., Wasylenki D., Lindsay, S., Lemire, D., & Rhodes, A., 1997. Process and outcome in hostel outreach program for homeless clients with severe mental illness.. American Journal of Orthopsychiatry, 67: 607-617. Goldfinger, S., & R. Schutt, 1996. Comparison of Clinicians' Housing Recommendations and Preferences of Homeless Mentally Ill Persons. Psychiatric Services, 47: 413-415. Goldfinger, S. M., R.K., Tolomiczenko, G.S., Seidman, L., Penk, W.E., Turner, W., & Caplan, B., 1999. Housing placement and subsequent days homeless among formerly homeless adults with mental illness. Psychiatric Services, 50: 647-679. Greenwood, R.M., Schaefer-McDaniel, N., Winkel, G., & Tsemberis, S, 2005. Decreasing psychiatric symptoms by increasing choice in services for adults with histories of homelessness.. American Journal of Community Psychology, 36: 223-238.

  29. References Burnam, A., Morton, S., McGlynn, E., Petersen, L., Stecher, B., Hayes, C. & J. Vaccaro, 1995. An Experimental Evaluation of Residential and Nonresidential for Dually Diagnosed Homeless Adults: The Effectiveness of Social Interventions for Homeless Substance Abusers. Journal of Addiction Disorders, 14: 111-134. Casper, E. & Clark, D., 2004. Service Utilization, incidents, and hospitalizations among people with mental illnesses and incarceration histories in supportive housing program. Psychiatric Rehabilitation, 28: 181-184. Cheng A-L, Lin H, Kasprow W, Rosenheck RA., 2007. Impact of Supported Housing on Clinical Outcomes: Analysis of a Randomized Trial Using Multiple Imputation Technique. Journal of Nervous and Mental Disease, 95: 83-88. Clark, C & Rich, A, 2003. Outcomes of homeless adults with mental illness in a housing program and in case management only. Psychiatric Services, 54: 78-83. Cooper, B. K. & A. A. Pearce, 1996. The short term effects of relocation on continuing care clients with a psychiatric disability. Research on Social Work Practice, 6: 179-192. Culhane, D. P. , Metraux, S. & Hadley, T., 2001. The impact of supportive housing for homeless people with severe mental illness on the utilization of the public health, corrections, and emergency shelter systems: The New York initiative. Washington DC. Fannie Mae Foundation, 49: 1-49. Culhane, D. P., Metraux, S. & Hadley, T., 2002. Public service reductions associated with placement of homeless persons with severe mental illness in supportive housing. Housing Policy Debate, 13: 107-163. Dickey, B., Latimer, E., Powers K, Gonzalez, O, et al, 1997. Housing costs for adults who are mentally ill and formerly homeless. Journal of Mental Health Administration, 24: 291-305.

  30. References Gulcur, L., Stefanicic, A., Shinn, M., Tsemberis, S., & S. Fischer, S.N., 2003. Housing, Hospitalization, and Cost Outcomes for Homeless Individuals with Psychiatric Disabilities Participating in Continuum of Care and Housing First Programs. Journal of Community & Applied Social Psychology, 13: 171-186. Harahan, P., Luchins, D., & Savage, C., Goldman, H., 2001. Housing satisfaction and service use by mentally ill persons in community integrated living arrangements. Psychiatric Services, 52: 1206-1209. Hanrahan, P., McCoy, M., Cloninger, L., J. Dincin, M. Zeitz, T. A. Simpatico, & D.J. Luchins, 2005. The mothers' project for homeless mothers with mental illnesses and their children: A pilot study. Psychiatric Rehabilitation, 28: 291-294. Harkness, J., Newman, S., & D. Salkever, 2004. The cost effectiveness of independent housing for the chronically mentally ill. Health Services Research, 39: 1341-1360. Hurlburt, M., Wood, PA., & Hough, RL., 1996. Providing Independent Housing for the Homeless Mentally Ill. Journal of Community Psychology, 24: 291-310. Hurlburt, M. S. , Hough, R.L., & Wood, P.A., 1996. Effects of substance abuse on housing stability of homeless mentally ill persons in supported housing. Psychiatric Services, 47: 731-736. Jarbrink, K., Hallam, A, & Knapp M, 2001. Costs and outcomes management in supported housing. Journal of Mental Health, 10: 99-108.

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  33. References Nelson, G., Hall, B. & R. Walsh-Bowers, 1998. The Relationship Between Housing Characteristics, Emotional Well- Being and the Personal Empowerment of Psychiatric Consumer/ Survivors. Community Mental Health Journal, 34: 57-69. Newman, S. J., Reschovsky, J.D., Kaneda, K. et al, 1994. The effects of independent living on persons with chronic mental illness: An assessment of the Section 8 certificate program. Milbank Quarterly, 72: 171-198. O'Connell M, Rosenheck R, Kasprow W, Frisman L, 2006. An examination of fulfilled housing preferences and quality of life among homeless persons with mental illness and/or substance abuse. The Journal of Behavioral Health Services and Research, 33: 354-365. O'Connell MJ, Kasprow W, Rosenheck RA, 2008. Rates and risk factors for homelessness after successful housing in a sample of formerly homeless veterans. Psychiatric Services, 59: 268-275. Padgett, D.K., Gulcur, L. & Tsemberis, S., 2006. Housing First Services for People Who Are Homeless With Co-Occurring Serious Mental Illness and Substance Abuse. Research on Social Work Practice, 16: 74-83. Pollio, D., Spitznagel, E., North, C., Thompson, S. & D. Foster, 2000. Service Use over Time and Achievement of Stable Housing in a Mentally Ill Homeless Population. Psychiatric Services, 51: 1536-1543. Rosenheck, R., Morrissey, J., Lam, J., et al, 2001. Services delivery and community: social capital, service systems integration, and outcomes among homeless persons with severe mental illness. Health Services Research, 36: 691-710. Rosenheck, R., Kasprow, W., Frisman, L. & W. Liu-Mares, 2003. Cost-effectiveness of Supported Housing for Homeless Persons With Mental Illness. Archives of General Psychiatry, 60: 940-951.

  34. References Rosenheck, R., Morrissey, J., Lam, J., Calloway, M., Johnsen, M., Goldman, H. Randolph, F. , Blasinsky, M., Fontana, A., Calsyn, R. & G. Teague, 1998. Service system integration, access to services, and housing outcomes in a program for homeless persons with severe mental illness. American Journal of Public Health, 88: 1610-1615. Rosenheck, R. et al., 2002. Service Systems Integration and Outcomes for Mentally Ill Homeless Persons in the ACCESS Program. Psychiatric Services, 53: 958-966. Rosenheck, R. A., & Lam, J., 1997. Homeless Mentally Ill Clients' and Providers' Perceptions of Service Needs and Clients' Use of Services. Psychiatric Services, 48: 381-386. Rosenheck, R., & Lam, J, 1997. Individual and community level variation in intensity and diversity of service utilization by homeless persons with serious mental illness. Journal of Nervous and Mental Disease, 185: 633-638. Rosenheck, R. A. & Dennis, D., 2001. Time-Limited Assertive Community Treatment for Homeless Persons With Severe Mental Illness. Archives of General Psychiatry, 58: 1073-1080. Siegel, C. E.; Samuels, J.; Tang, D.; Berg, I.; Jones, K. & K. Hopper, 2006. Tenant Outcomes in Supported Housing and Community Residences in New York City. Psychiatric Services, 57: 982-991. Srebnik, D. Livingston, J., Gordon, L., et al, 1995. Housing choice and community success for individuals with serious and persistent mental illness. Community Mental Health Journal, 31: 139-152. Stefancic, A. & Tsemberis, S., 2007. Housing First for Long-Term Shelter Dwellers with Psychiatric Disabilities in a Suburban County: A Four-Year Study of Housing Access and Retention. Journal of Primary Prevention, 28: 265-279.

  35. References Susser, E., Valencia, E., Conover, S., Felix, A., Tsai, W. & J. Wyatt, 1997. Preventing Recurrent Homelessness among Mentally Ill Men: A "Critical Time" Intervention after Discharge from a Shelter. American Journal of Public Health, 87: 256-262. Tsemberis, S., 1999. From Streets to Homes: An Innovative Approach to Supported Housing for Homeless Adults with Psychiatric Disabilities. Journal of Community Psychology, 27: 225-241. Tsemberis, S. E. R. & R. F. Eisenberg, 2000. Pathways to housing: supported housing for street-dwelling homeless individuals with psychiatric disabilities. Psychiatric Services, 51: 487-493. Tsemberis, S., Gulcur, L., & Nakae, M., 2004. Housing first, consumer choice, and harm reduction for individuals who are homeless with dual diagnoses: A 24 month clinical trial. American Journal of Public Health, 94: 651-656. Wolff, N., Helminiak, T., Morse, G., Calsyn, R., Klinkenberg, D. & Trusty, M., 1997. Cost-Effectiveness Evaluation of Three Approaches to Case Management for Homeless Mentally Ill Clients. American Journal of Psychiatry, 154: 341-348. Yin-Ling Irene Wong, Stephen R. Poulin, Sungeun Leeb, Morris R. Davis, and Trevor R. Hadley, . Tracking residential outcomes of supported independent living programs for persons with serious mental illness. Evaluation and Program Planning.

  36. References Yanos, P.T.; Barrow, S.M.; Tsemberis, S., 2004. Community Integration in the Early Phase of Housing Among Homeless Persons Diagnosed with Severe Mental Illness: Successes and Challenges. Community Mental Health Journal, 40: 134-150. Yanos, P., Felton, B., Tsemberis, S., Frye, V., 2007. Exploring the role of housing type, neighborhood characteristics, and lifestyle factors in the community integration of formerly homeless persons diagnosed with mental illness. Journal of Mental Health, 16: 703-717.

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