Pathways’ Housing First:Ending homelessness and supporting recovery for people with psychiatric disabilities and addiction diagnoses

Sam Tsemberis. Ph.D.Founder and Executive Director

Pathways to Housing, Inc.

Are they the homeless Are they the homeless mentally ill or the mentally ill mentally ill or the mentally ill

homeless?homeless? Do people who are homeless and

mentally have more in common because they are homeless or because they have a mental illness?

What is Housing First?What is Housing First?

Is it an intervention that serves

people who are mentally ill.The model has implications for

how we address homelessness.

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

Annapolis & BaltimoreMD

Hartford CT

Pathways’ Housing First Programs in the USA & Canada

Worcester, MA

Oakland, CA Salt Lake City, UT

Denver, CO

Chattanooga, TN

Charlotte County, FL

Philadelphia PA

NYC

Housing First Sites that received technical assistance from Pathways to Housing, Inc

Washington DC

Housing First Sites established 2003-2007

ColumbusOH

Richmond, VA

Portland, OR

Seattle, WA

Chicago, IL

Calgary

Toronto

Los Angeles, CA

Fort Lauderdale, FL

How Housing First Relates to 10-How Housing First Relates to 10-Year Plans to End HomelessnessYear 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)

Current SystemCurrent SystemHousing and service programs: Housing and service programs:

A series of steps A series of steps

PermanentHousing

TransitionalHousing

Drop-in,Shelter

Outreach

Eligibility criteria for supportive Eligibility criteria for supportive housing: housing:

(NYC Survey of providers in 2005)(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

3 Assumptions of the Housing 3 Assumptions of the Housing Readiness (or treatment first) Readiness (or treatment first)

ModelModel

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

Misuse of resources by people who Misuse of resources by people who remain chronically homelessremain 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

Housing First Ends Cycling Housing First Ends Cycling Through Acute Care Systems 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?

4 Essential Elements of4 Essential Elements ofHousing FirstHousing First

1. Consumer Choice2. Separation of Housing and

Services3. Recovery Orientation4. Effectiveness

1. Consumer Choice is the 1. Consumer Choice is the foundation of this programfoundation 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

What do consumers want?What do consumers want?Housing, Housing, first!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

Housing FirstHousing FirstHonors Consumer ChoiceHonors Consumer Choice

Once housed, consumers continue to choose the type, sequence and intensity of services (or no services)

All must agree to weekly visit

Consumer choice as a Consumer choice as a continuous process in Housing continuous process in Housing

First programsFirst 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

2. 2. Separation of Housing Separation of Housing and Clinical Servicesand 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

HOUSING FIRST PROGRAMHOUSING FIRST PROGRAMMain ComponentsMain Components

1. Housing: Scatter site independent apartments rented from community landlords

2. Treatment: Treatment and support services provided using Assertive Community Treatment (ACT) Teams, CM or other off site services

Treatment and support services:Treatment and support services:ACT teams/CM TeamsACT 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

Case Management teams:Case Management teams:Brokerage Service ModelBrokerage 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

Matching Housing and Support Matching Housing and Support and Treatment Services with and Treatment Services with

Client NeedsClient 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

Housing Component: Independent Housing Component: Independent apartments integrated into the apartments integrated into the

community*community* 1. Rental units available on the open market

(normal rental housing)2. Integration: Rent less than 20% of the total*

number of units in any one building 3. Permanence: Tenants have same rights and

responsibilities as any other lease holder4. Affordability: Apartments are subsidized;

tenants pay 30% of income towards rent

Landlords as program partners:Landlords as program partners:Landlord, agency, and tenant have a Landlord, agency, and tenant have a

common goal 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

LIMITS to consumer choice in LIMITS to consumer choice in housing issueshousing 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

LIMITS to consumer choice on LIMITS to consumer choice on clinical servicesclinical 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.)

3. 3. Recovery oriented Recovery oriented servicesservices

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?

Programs elements that Programs elements that support recoverysupport 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)

Recovery focused support Recovery focused support servicesservices

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

Recovery focused services… Recovery focused services…

Convey hope, offer choice after choice, are respectful, patient, nurturing, compassionate, seek and discover capabilities and create new possibilities

How is program funded?How is program funded?

COST: Approx $22K for ACT (ICM $15K)

Support /Clinical Services- Medicaid/contracts

Housing- rental support- HUD-S+C; SHP; Vouchers- State or City Supported Housing funds or local

vouchers

4. Effectiveness4. Effectiveness

CQI and documentation of Program Effectiveness

Why evaluation and Why evaluation and research?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

Research Evidence:Research Evidence:Building and evidence Building and evidence

based practicebased practiceNew York Housing

StudyFunded by SAMHSA, CSAT and NYSOMH

36 month longitudinal 36 month longitudinal randomized control trial randomized control trial

Study 3: Comparing Study 3: Comparing Pathways to HousingPathways to Housing

with Standard with Standard Treatment-Housing Treatment-Housing Programs in NYCPrograms in NYC

Study DesignStudy Design

- Longitudinal Random Assignment- N=225

- Experimental (Pathways) 99- Control (Other NYC programs) 126

Follow-up RatesFollow-up RatesEntire SampleEntire Sample

6-month

12-month

18-month

24-month

30-month

36-month

96% 94% 92% 90% 86% 86%

36-month follow up: 36-month follow up: Selected DomainsSelected Domains

Literal Homelessness

Choice and Psychiatric Symptoms

Residential Stability

Proportion of Time Proportion of Time Literally HomelessLiterally Homeless

Note. Significant at 6-, 12-, 18-, 24-, 30-, and 36-month.

00.20.4

0.60.8

1

Time

Prop

ortio

n

ExperimentalControl

Proportion of Time Proportion of Time Stably HousedStably Housed

Note. Significant at 6-, 12-, 18-, 24-, 30-, and 36-month.

0

0.2

0.4

0.6

0.8

1

Time

Prop

ortio

n

ExperimentalControl

Housing First Programs, Choice Housing First Programs, Choice & Psychiatric Symptoms& Psychiatric Symptoms

PsychiatricSymptoms

Adapted from Greenwood et al, 2005.

reduction

increase

reduction

ProgramAssignment

Proportionof time

homeless

Choice PersonalMastery

County Level Evaluation:County Level Evaluation:“Westchester County“Westchester County

halves number of homeless in 5 years”halves 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

Cross site studies – 10cities Cross site studies – 10cities same measures: VA evaluates same measures: VA evaluates chronic homelessness initiative chronic homelessness initiative

- VA: 11 cities funded by ICH show about 85% housing retention rates after first year

Cross site studies – 6 cities same Cross site studies – 6 cities same measures: HUD commissions measures: HUD commissions

study to evaluate Housing First study to evaluate Housing First

- HUD Housing First: found 84%

retention rate across six study sites

Intra-departmental cost Intra-departmental cost study:study:

DHS Cost by service typeDHS Cost by service type

SAMHSA NREBPPSAMHSA NREBPP

Pathways’ Housing First

OnSAMHSA web site National Registry of

Evidence Based Programs (NREPP)

System TransformationSystem Transformation

Reversing the existing and use transitional programs if for consumers can’t mange independent apartments

Develop plans to END Homelessness

Convene Interagency Council

System TransformationSystem Transformation

Agency and staff training in system transformation

Pilot Housing First program

60 second60 secondpsapsa

www.pathwaystohousing.org

THANKTHANK

YOU!

stsemberis@pathwaystohousing.org