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Pathways’ to Housing, Inc. Housing First : Ending homelessness and supporting recovery

Pathways’ to Housing, Inc. Housing First : Ending homelessness and supporting recovery. Sam Tsemberis. Ph.D. Founder and Executive Director. Are they the homeless mentally ill or the mentally ill homeless?.

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Pathways’ to Housing, Inc. Housing First : Ending homelessness and supporting recovery

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  1. Pathways’ to Housing, Inc.Housing First:Ending homelessness and supporting recovery Sam Tsemberis. Ph.D. Founder and Executive Director

  2. Are they the homeless mentally ill or the mentally ill homeless? • Do people who are homeless and mentally have more in common because they are homeless or because they have a mental illness?

  3. What is Housing First? • Is it an intervention that serves people who are mentally ill. • The model has implications for how we address homelessness.

  4. Housing First • Why was it developed? • What is housing first? • How does it work? • Is it effective?

  5. Pathways’ Housing First Programs in the USA & Canada <1s2buzzll3@comcast.net>  Calgary Seattle, WA Toronto Portland, OR Worcester, MA NYC Philadelphia PA Hartford CT Oakland, CA Salt Lake City, UT Chicago, IL ColumbusOH Annapolis & BaltimoreMD Denver, CO Richmond, VA Los Angeles, CA Chattanooga, TN Washington DC Charlotte County, FL Fort Lauderdale, FL Housing First Sites that received technical assistance from Pathways to Housing, Inc Housing First Sites established 2003-2007

  6. How Housing First Relates to 10-Year Plans to End Homelessness • The National Alliance to End Homelessness advocating for Cities and States to develop 10-year plans to END HOMELESSNESS • The US Interagency Council on the Homeless focus on Ending Chronic Homelessness ($35M Initiative)

  7. WHY Housing First? Current SystemHousing and service programs: A series of steps

  8. Eligibility criteria for supportive housing: (NYC Survey of providers in 2005) • Clean time –92.5% of Providers require • Methadone – 11 % exclude • Insight into mental illness • Compliance with treatment • Criminal background • Sex offenders – 82% exclude • History of arson – 80% exclude • Credit checks

  9. 3 Assumptions of the Housing Readiness (or treatment first) Model • Referrals between agencies work – they don’t • Learning to live in congregate settings prepares you for independent living – it doesn’t • People need to be psychiatrically stable and clean and sober before before they can mange independent apartments

  10. Misuse of resources by people who remain chronically homeless • Shelters:10% of the chronically homeless utilize 50% of the system resources • Hospitals/Detoxes: 3% of clients use 28% of all Medicaid funding for these services • Jail/Prison: High rates of incarceration and recidivism rates for people who are mentally ill and homeless • Outreach/Drop-in: e.g., Million Dollar Murray-The New Yorker

  11. Housing First Ends Cycling Through Acute Care Systems • Permanent Supported Housing ends homelessness for people cycling throughout the “institutional circuit” • Stopping this cycle has cost implications and possibilities for reinvestment, • e.g., what if we could write a prescription for housing covered by the national insurance plan if the person we are treating has as a psychiatric disability, acute and chronic health problems, and is homeless?

  12. 4 Essential Elements ofHousing First • 1. Consumer Choice • 2. Separation of Housing and Services • 3. Recovery Orientation • 4. Effectiveness

  13. 1. Consumer Choice is the foundation of this program Program started with a psychiatric rehabilitation approach to street homelessness (taking psych rehab to the streets –d shern et. al) There is is a vast disconnect between what most supportive housing providers offer and what consumers say they want Essentially, treatment and sobriety before housing

  14. What do consumers want?Housing, first! • When asked, almost every person who is homeless (w or w/o mi) says they want housing first; • Will accept immediate access to permanent independent housing; a place of their own • Do not want to participate in psychiatric treatment or attain a period of sobriety as a precondition for housing

  15. Housing FirstHonors Consumer Choice • Once housed, consumers continue to choose the type, sequence and intensity of services (or no services) • All must agree to weekly visit

  16. Consumer choice as a continuous process in Housing First programs • Choices include the right to risk; people make mistakes and learn from that experience, dignity of failure • Continued practice in making choices leads to making the right choices and the experience of success

  17. 2. Separation of Housing and Clinical Services • Housing Services: To find apartments, sign lease, and maintain all aspects of housing including facilitating relations with building staff • Treatment and support services: Offered not required;Relapse (SA or MH) is expected and does not result in housing loss and housing loss does not result in discharge from clinical services

  18. HOUSING FIRST PROGRAMMain Components • Housing: Scatter site independent apartments rented from community landlords • Treatment: Treatment and support services provided using Assertive Community Treatment (ACT) Teams, CM or other off site services

  19. Treatment and support services:ACT teams/CM Teams • Multidisciplinary team (MD, MSW, CSAC, RN, etc) • Serves people with highest needs (severe mental illness; substance abuse; homeless, long periods of hospitalization, criminal justice; involuntary commitment orders, etc.) • Services are provided directly, 70-80%of the time in the community 7-24 on call • Teams use a recovery focus and assist with community integration

  20. Case Management teams:Brokerage Service Model • CM services – higher case load ratios • Must broker other needed services • Follow through and continuity of care among systems • 7-24 on call • Consumer driven philosophy and interventions

  21. Matching Housing and Support and Treatment Services with Client Needs • Most people need the same things in housing (mih or hmi) • Their service and support needs vary • Ensure services are unlimited • Ensure they are consumer driven and evidence based

  22. Housing Component: Independent apartments integrated into the community* • Rental units available on the open market (normal rental housing) • Integration: Rent less than 20% of the total* number of units in any one building • Permanence: Tenants have same rights and responsibilities as any other lease holder • Affordability: Apartments are subsidized; tenants pay 30% of income towards rent

  23. Landlords as program partners:Landlord, agency, and tenant have a common goal • Landlord, agency, all want quality, safe, well managed apartments • Agency that ensure rent is paid on time and is responsive to landlord concerns • Agency wants landlord to contact agency the minute a problem occur • Agency responsible for damages • Agency housing staff on call for landlord

  24. LIMITS to consumer choice in housing issues • There are limits to choice in these instances • 1) Must sign lease or sublease • 2) Pay portion of rent (30%) • 3) Observing the terms of the lease

  25. LIMITS to consumer choice on clinical services • There are limits to choice in these instances • 1) Danger to self or others • 2) Must agree to weekly visit by support team • 3) Others (abuse, violence, legal issues, etc.)

  26. 3. Recovery oriented services • We now know that people who are diagnosed with severe mental illness (and co-occurring SA) can live full and independent lives in the community (Harding study definition). • How do we support more individuals to achieve this goal?

  27. Programs elements that support recovery • Design the housing a vision of recovery in mind: people living fully integrated into the community, • Rent and/or develop housing that looks like normal housing not a program • Design the program so that the services can walk away from the person who no longer needs them (or return if necessary)

  28. Recovery focused support services • Provide services that support recovery: supported employment, education, wellness management, etc., in at least equal proportion to mental health and drug treatment services • Provide access to housing in a manner that that can change o accommodate positive family developments

  29. Recovery focused services… • Convey hope, offer choice after choice, are respectful, patient, nurturing, compassionate, seek and discover capabilities and create new possibilities

  30. How is program funded? COST: local costs vary – e.g., FMR Support /Clinical Services • Medicaid/contracts Housing- rental support • HUD-S+C; SHP; Vouchers • State or City Supported Housing funds or local vouchers

  31. 4. Effectiveness CQI and documentation of Program Effectiveness

  32. Why evaluation and research? • Want to build the new models based on empirical evidence -- not on assumptions, special interest, dramatic cases, or political obligations • Research provides scientific basis to inform policy and advocacy for system transformation

  33. Research Evidence:Building and evidence based practice New York Housing Study Funded by SAMHSA, CSAT and NYSOMH

  34. Study 3: Comparing Pathways to Housing with Standard Treatment-Housing Programs in NYC 36 month longitudinal randomized control trial

  35. Study Design • Longitudinal Random Assignment • N=225 • Experimental (Pathways) 99 • Control (Other NYC programs) 126

  36. Follow-up RatesEntire Sample

  37. Literal Homelessness Choice and Psychiatric Symptoms Residential Stability 36-month follow up: Selected Domains

  38. Proportion of Time Literally Homeless Note. Significant at 6-, 12-, 18-, 24-, 30-, and 36-month.

  39. Proportion of Time Stably Housed Note. Significant at 6-, 12-, 18-, 24-, 30-, and 36-month.

  40. Housing First Programs, Choice & Psychiatric Symptoms ProgramAssignment reduction PsychiatricSymptoms Choice PersonalMastery reduction Proportionof timehomeless increase Adapted from Greenwood et al, 2005.

  41. County Level Evaluation:“Westchester Countyhalves number of homeless in 5 years” • Westchester County: (New York Times, Feb 26, 2006) • Combining rent subsidies, eviction prevention grants, and housing first the county has reduced homelessness by two-thirds since Jan. 1998 • Cost $23K for HF compared to $28-$36K shelter with services • County is considering a top-to bottom shift to the housing-first model

  42. Cross site studies – 10cities same measures: VA evaluates chronic homelessness initiative • VA: 11 cities funded by ICH show about 85% housing retention rates after first year

  43. Cross site studies – 6 cities same measures: HUD commissions study to evaluate Housing First • HUD Housing First: found 84% retention rate across six study sites

  44. Intra-departmental cost study:DHS Cost by service type

  45. SAMHSA NREBPP Pathways’ Housing First On SAMHSA web site National Registry of Evidence Based Programs (NREPP)

  46. System Transformation • Reversing the existing system of providing homeless services • Using transitional programs in a different way: e.g., if for consumers can’t mange independent apartments

  47. System Transformation • Agency and staff training in system transformation • Pilot Housing First program

  48. THANK YOU! stsemberis@pathwaystohousing.org www.pathwaystohousing.org

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