Key Issues in Managing Permanent Supportive Housing

1. Key Issues in Managing Permanent Supportive Housing Anne CoryCorporation for Supportive HousingApril 30, 2010www.csh.org

2. Introductions • Introduce yourself: • Name • Agency • Job Title • Experience with supportive housing • What do you hope to get out of today’s training?

3. Introduction to CSH • The Corporation for Supportive Housing is a national nonprofit organization and Community Development Financial Institution that helps communities create permanent housing with services to prevent and end homelessness.

4. CSH Products and Services • Project-Specific Financing and Expertise to help create supportive housing • Capacity Buildingto strengthen and expand the supportive housing industry • Public Policy Reformto build an efficient system for producing and financing supportive housing

5. Define Supportive Housing • A cost-effective combination of permanent, affordable housing with services that helps people live more stable, productive lives.

6. Supportive Housing is for People Who: • Are chronically homeless • Cycle through institutional and emergency systems and are at risk of long-term homelessness • Are being discharged from institutions and systems of care • Without housing, cannot access and make effective use of treatment and supportive services

7. Housing & Services • HOUSING • PERMANENT: Not time limited, not transitional; • AFFORDABLE: For people coming out of homelessness; and • INDEPENDENT: Tenant holds lease with normal rights and responsibilities. • SERVICES • FLEXIBLE: Designed to be responsive to tenants’ needs; • VOLUNTARY: Participation is not a condition of tenancy; and • INDEPENDENT: Focus of services is on maintaining housing stability.

8. Supportive Housing Types • Buildings developed or rehabilitated as special needs housing • Rent-subsidized apartments • Mixed-income buildings • Long-term set asides • Single-family homes • Master-leased buildings or units

9. Definition and Overview Elements of Managing Permanent Supportive Housing

10. Elements of Managing Permanent Supportive Housing • Housing First • Voluntary Service Model • Harm Reduction • Coordination of Property Management and Supportive Services

11. What is Housing First? • The direct, or nearly direct, placement of targeted homeless people into permanent housing. While supportive services are to be offered and made readily available, the program does not require participation in these services to remain in the housing. • The use of assertive outreach to engage and offer housing to homeless people with mental illness who are reluctant to enter shelters or engage in services.

12. What is Housing First?(continued) • Once in housing, a low demand approach accommodates client’s alcohol and substance use, so that relapse will not result in the client losing housing. • The continued effort to provide case management and to hold housing for clients, even if they leave their program housing for short periods.

13. Housing First • A housing first approach rests on two central premises: • The best way to end homelessness is to help people move into permanent housing as quickly as possible • Once in housing, formerly homeless people may require some level of services to help them stabilize, link to long-term supports, and prevent a recurrence.

14. Defining Housing First Philosophies • Safe, affordable housing as a right and a prerequisite for effective services • Provide permanent housing opportunity as soon as possible • Do not focus on “housing readiness” or sobriety as a prerequisite • Facilitate easy access to housing • Housing stability is primary objective: services support housing retention • Quality of life and well-being measure success

15. Core Elements of Housing First  • Crisis Intervention: Helps stabilize participants while they are acquiring permanent housing. • Permanent Housing Services: Helps participants obtain permanent housing. Assist with move-in and other costs associated with becoming rehoused, including short-term rent subsidy. • Case Management/Wraparound Services: Helps to stabilize participants once they are housed.

16. Housing First Strategies • Assessment-based targeting • Assistance locating housing • Assistance with costs of housing • Housing is NOT time-limited • Tenants hold leases & have full rights • On-going case management to ensure housing opportunity is stable • Service intensity dependent upon needs of household – varies household to household and over time

17. Housing First: What we have learned • Some homeless people cannot or choose not to navigate the Continuum of Care. They do not or cannot comply with program requirements and get screened out or kicked out of shelters, day centers, transitional housing programs   • Homeless people/families who meet all the program requirements can get “stuck” in transitional programs because there is no exit—no affordable permanent housing options are available. • People with serious psychiatric problems and/or substance use can maintain stable housing without going through stages in the Continuum of Care approach; without being “housing ready”.

18. Consistent Findings Housing + Services Make a Difference • More than 80% of supportive housing tenants are able to maintain housing for at least 12 months • Most supportive housing tenants engage in services, even when participation is not a condition of tenancy • Use of the most costly (and restrictive) services in homeless, health care, and criminal justice systems declines • Nearly any combination of housing + services is more effective than services alone • “Housing First” models with adequate support services can be effective for people who don’t meet conventional criteria for “housing readiness”

19. Supportive Housing: It Works summary of key findings from a range of studies • ER visits down 57% • Emergency detox services down 85% • Incarceration rate down 50% • 50% increase in earned income • 40% rise in rate of employment when employment services are provided • More than 80% stay housed for at least one year

20. Start Up Challenges • Accepting the Housing First approach – that the first priority is to house people not fix them. • Accepting that some community resources will eventually shift from crisis/emergency services such as shelters to permanent housing • Accepting that services focus on maintaining housing, not “treatment” • Selecting an appropriate site or locating landlords willing to participate in the program • Recruiting landlords and maintaining good relations • Encouraging shelters and transitional programs to refer clients immediately to minimize time spent in emergency setting (rapid rehousing) • Hiring or re-training staff to play new/different roles, including engaging tenants in voluntary services

21. Sustaining Housing First • Biggest challenge is locating enough affordable housing to meet the tenant demand • Requires at least one or probably several of the following: • Housing subsidies –e.g. tenant based Housing Choice vouchers or other forms of subsidy • Developing strong relationships with landlords and negotiating reasonable rents • Focus on increasing tenant incomes so they can afford to pay more rent • Developing new affordable housing that is financed in such a way that the rents are affordable to extremely low-income tenants

22. Questions? • Questions on Housing First?

23. Voluntary Service Model • Definition: • Housing is not contingent on acceptance of services • Does NOT mean services are not offered/not important • Engagement strategies are key

24. Supportive Servicesin Voluntary Model • Offer services tenants want and need • Market services to tenants • Be creative in engaging tenants • Be persistent in engaging tenants

25. Engagement Strategies Engagement sets the stage for formal case management and treatment sessions where in-depth assessments, counseling, and referrals can occur on an individualized basis.

26. Goals of Engagement • Care for immediate needs • Develop a trusting relationship • Provide services and resources • Connect to mainstream services and social networks to maximize independence • Help people stay housed

27. Supportive Services in Voluntary Model • Flexible • Flexible in type • Different tenants may need/want different types of services • Tenants may need/want different types of services at different times in their lives

28. Supportive Services in Voluntary Model • Flexible • Flexible in intensity • Some need/want many services during first 6 months/year, then step down • Some need/want many services during entire tenancy • Some need/want many services intermittently/episodically

29. Supportive Services in Voluntary Model • Flexible • Flexible in delivery • Where do tenants want to receive services? • How do tenants want to receive services? • From whom do tenants want to receive services?

30. Voluntary Services Work • Homeless Families Evaluations in Minnesota and California • 2 programs with mandatory services and sobriety requirements had a housing retention rate of 70% after one year. • 2 programs with voluntary services and no sobriety requirement had a housing retention rate of 95% at the one-year mark

31. Supportive Housing/Voluntary Service Strategies • Assertive and patient engagement • To overcome barriers resulting from isolation and symptoms of mental illness or addiction • Trauma informed services • Establish trust • Recovery oriented • Ask tenants where they want to be living and what kind of work they want to be doing in 5 years • Practical support to meet basic needs and respond to individual preferences and goals

32. Supportive Housing/Voluntary Service Strategies (continued) • Training and help with basic living skills, hygiene • Assistance with benefits including eligibility for other (permanent) housing to meet changing needs • Mental health and/or substance use treatment services flexible and available where people live & when they need help • Enhancing motivation to change • Re-engagement in services during relapse and crisis • Linkages to primary health care

33. Voluntary Service Model • Questions about voluntary service model?

34. Harm Reduction • Harm reduction is a set of practical clinical strategies that reduce negative consequences of drug use or other activities, incorporating a spectrum of strategies from safer use, to managed use, to abstinence.

35. Harm Reduction Principles • People have the right to make decisions about their lives and actions. Harm Reduction is about educating them to make the best decisions for themselves. • The user takes responsibility for his/her choices and behavior. • The individual sets his/her own goals in collaboration with the service provider. • There are no punitive sanctions for what someone chooses to put/not put in his/her body. • When we create punitive sanctions, people will lie. • Incremental change is normal. • Quality of life and well-being measure success.

36. Some Examples of Harm Reduction • Methadone maintenance • Following prescription protocols • Support groups • Education on drugs and drug interactions • Permanent housing with voluntary services

37. Harm Reduction • Never underestimate the power of people to make changes in their lives; and never underestimate our ambivalence about change. Patt Denning Harm Reduction Therapy Center

38. Successful Engagement Strategies • Be there from the start • Use the lease itself as an engagement tool • Knock on the door • Design engagement materials thoughtfully • Check in often: prevent isolation • Learn what tenants like/want/need

39. Successful Engagement Strategies • Provide needed resources, address basic needs • Encourage community building • Employment goals • Use violations of lease or house rules as a trigger for engagement

40. Motivational Interviewing • A client-centered approach to help people resolve ambivalence and make change. • A process of developing a relationship with a person and building trust so that we become influential toward positive change. • Motivation is fluid and can be influenced.

41. Motivational Interviewing • Express Empathy - communicate respect and acceptance. • Develop Discrepancy - distinguish tenant’s goals from current behavior and talk through likely consequences of current behavior (“predictables and inevitables”) • Roll with Resistance - change your direction or listen more carefully. • Embrace Optimism - believe in the tenant’s ability to change.

42. Effective Communication Techniques • Ask Open-Ended Questions • Listen Reflectively • Summarize • Affirm • Empathize

43. Effective Communication Techniques • Review a typical day • Look back – life before “the problem” • Summarize what you hear/concerns • Explore pros and cons (present and future) • Normalize ambivalence • Explore expectations of the change and provide non-biased information

44. From Cause to Response • Cause > Symptom > Behavior > Response • Example • Cause:Alcoholism • Symptom:Intoxication • Behavior:Lost keys • Immediate Response:Property management keeps the key at the front desk • Long Term Response:Services staff works with the tenant, who then drinks less in order to take better care of his/her things.

45. Designing House Rules • Emphasis on Behavior • Clear Purpose and Rationales Stated • “No Rules without Relationship” • Enforceable • Legal • Less is More • Tenant Input • Keep Current and Revise • Education of Tenants • Clear, Consistent Consequences

46. Lease Enforcement • NOT “Anything Goes” • Quick, consistent response is critical • Balanced with concerns for safety • Incident reporting • Lease violation notices • Coordination with supportive services staff • Legal issues related to substance abuse and lease enforcement

47. Eviction Prevention • Eviction is a last resort only undertaken in only the most extreme circumstances • Be able to document that all preventive measures were taken • Coordination with Supportive Services

48. Eviction and Substance Use • Difference between Clean and Sober and Harm Reduction • Tenancy laws are the same, whatever you call your housing model!

49. Harm Reduction • Questions on Harm Reduction?

50. Coordination of Property Management and Supportive Services • One of the defining characteristics of permanent supportive housing is the coordination of property management and supportive services to support the goal of housing retention for tenants. • For effective coordination, it is critical to have clear definitions of roles.