1. + Pathways Housing First: Ronni Michelle Greenwood PhD University of Limerick Psychology Department 12 February 2013 Philosophy Practice Principles Proof

2. + Overview Describe Pathways Housing First Philosophy Program Operations Describe Key Principles Consumer Choice Separation of Housing & Services Recovery Orientation Community Integration Demonstrate that it works Costs argument Recovery argument Try to answer your questions

3. + Introductions: Getting to Know You How did it come about that you are taking this course? What kinds of experiences do you have working with homeless people? What do you think causes homelessness? What do you think causes people to stay homeless? What are your opinions of homeless people? (deficits, strengths, skills, judgment, insight)

4. + Let’s take a quiz Two short questionnaires; Short explanation for how to think about the answers; Answer quickly & honestly; Add up your scores and divide by number of items.

5. + Let’s talk about ‘choice’ Your score indicates how much choice you have in some every day aspects of your life. Since you are key workers, you might have thought about these things before. But have you thought about them in terms of your life? (We tend to take them for granted) What does ‘choice’ do for you? What happens when it is taken away? How do your experiences (if any) of low choice differ from those of homeless services recipients? Why do I think it’s important that you maximize choice for homeless or formerly homeless people?

6. + Client Stories

7. + Overview: Simple, Revolutionary Idea Pathways to Housing: It reversed the order of service delivery It relocated service choice from provider to consumer It is infused with a harm reduction approach It’s revolutionized the way we go about ending homelessness

8. Housing First Basics Housing First Basics  Housing First provides immediate access to a home – in most cases an apartment of one’s own  Does not require treatment or sobriety as a precondition for housing off-site  Does provide intensive community based – off-site – services to help keep housing and facilitate treatment and recovery

9. + Who does HF serve? People who are literally homeless for years, multiply diagnosed – among the most vulnerable Other providers typically call this group the ‘hard to house’, ‘treatment resistant’, or ‘not housing ready’ It’s true, they aren’t ‘easy’ to work with; They often don’t do what we tell them to do; ‘We’ know best, and they obviously do not, else they wouldn’t be in the situation they are in. Consumers call these providers ‘strict’ Consumer advocates call the providers ‘creamers’

10. + 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

11. + Continuum of Care Housing and service programs: A series of steps Permanent Housing Transitional Housing Drop-in, Shelter Outreach

12. + Continuum of Care: ‘An Institutional Circuit’ Permanent Housing Transitional Housing Drop-in, Shelter Outreachhomeless

13. + Let’s stop & talk: What does the continuum of care look like in Dublin? Is there an ‘institutional circuit’? What are some typical eligibility criteria? Exclusionary criteria? How easy is it for service providers to refuse services or housing to somebody in need? What are some common reasons why a homeless person is refused housing? What do providers think is going to happen to them? How much responsibility do providers accept for this?

14. For those who remain homeless: Enormous misuse of resources 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  Million Dollar Murray – Malcom Gladwell  “It cost us one million dollars not to do something about Murray,” O’Bryan said.  In contrast, the average cost of PHF is $57 per day

15. + Housing First Ends Homelessness  Housing First provides immediate access to a home  Does not require treatment or sobriety as a precondition for housing  Provides intensive community based – off site – services to help keep housing and facilitate treatment and recovery

16. + 5 Essential Elements of Housing First 1. Consumer Choice 2. Separation of Housing and Services 3. Recovery Orientation 4. Community Integration 5. Program Evaluation

17. Consumer Choice is the foundation of this program Consumer choice is absolutely essential to this approach for housing and services Eliminates the disconnect between what providers offer and what consumers want Honors dignity & self-determination Right to make mistakes Learning is part of recovery

18. 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 The right to make mistakes and learn is key to recovery

19. + What do consumers choose? Housing, first! When asked, almost every person who is homeless (w or w/o mi) says they choose housing first; Will accept housing and their own terms Very effective with so called ‘hard to house’ or ‘treatment resistant’

20. + Housing First Honors Consumer Choice Once housed, consumers continue to choose the type, sequence and intensity of services (or no services) However, all must agree to weekly visit (It’s Housing First, NOT Housing Only)

21. LIMITS to consumer choice: practical and clinically informed; not absolute Of course there are clinical and legal limits to choice: 1) Danger to self or others 2) Must agree to weekly visit by support team 3) Others (abuse, violence, legal issues, etc.)

22. + Let’s stop and talk: How much choice do ‘difficult to serve’ service users have? Reflect on the questionnaires you filled in a few minutes ago. Isn’t it often a choice between ‘my way or the highway’? What are some of the reasons that choice is restricted in the continuum of care? Do you try to maximize choice in your delivery of services? How? Is it difficult? Why? How might you increase consumer choice? What are the barriers you might face to implementing choice?

23. + 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

24. + 2. Separation of Housing and Clinical Services 1. Housing: Scatter site independent apartments rented from community landlords 2. Treatment: Treatment and support services provided using Assertive Community Treatment (ACT) Teams, ICM or other off site services

25. Treatment and support services: ACT (Assertive Community Treatment) Team  Multidisciplinary team (MD, MSW, CSAC, RN, etc)  Serves people with highest needs (severe mental illness; substance abuse; 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, a harm reduction focus, and assist with community integration

26. Treatment and support services: Case Management teams & the Brokerage Service Model  CM services  Consumers with fewer or less challenging needs  Higher case load ratios  Broker other needed services  Provide follow through and continuity of care among various systems  7-24 on call  Consumer-driven, harm reduction, recovery philosophies

27. Match Housing, Support & Treatment Services to Client Needs  Most people need the same things in housing (mih or hmi)  But their service and support needs vary  Ensure services are unlimited  Ensure they are consumer driven and evidence based (ACT is EBP)

28. Housing Component: “Home” versus “Housing” Providing a home increases “ontological security” well-being that arises from constancy in material environment: daily routines, privacy, secure base for identity (re)development Improves mental health and reduces harm Rental units allow for life changes (relationships, kids, etc)

29. Housing Component: Independent apartments integrated into the 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 holder 4. Affordability: Apartments are subsidized; tenants pay 30% of income towards rent

30. Landlords are program partners: Landlord, agency, and tenant have a common goal Landlord, agency, all want quality, safe, well-managed apartments Agency and landlord communication -- responsive to landlord concerns Agency responsible for damages Agency ensures that rent is paid on time No rent loss for vacancies

31. Tenant rights and responsibilities: 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) Observe the terms of the lease

32. + Let’s stop and talk: How are services & housing tied together in Dublin? How do people access physical/mental/educational etc services? What happens to families? What happens to children and partners or when family constellation changes? What happens when people want to move to another location? What happens when people don’t want to engage in services? What happens when they “graduate” from services? What are local barriers to decoupling services from housing? What would be the advantages? Would there be disadvantages?

33. 3. Recovery oriented services We know that people who are diagnosed with severe mental illness can recover and live full and independent lives in their community (Courtney Harding) 62 to 68 percent significantly improved or fully recovered across multiple domains of functioning: loss of many schizophrenic symptoms, work, social relationships, self-care. So we provide services that support recovery: supported employment, education, wellness management, etc., in at least equal proportion to psychiatric and substance abuse treatment services

34. 3. Recovery focused services… Convey hope Potential to grow, develop, change Introduce experiences outside the mentally ill identity Seek to discover capabilities Gardening, peer support, working, art Create new possibilities Community involvement, occupations, talents

35. + Let’s stop & talk about recovery: Recovery from MI/recovery from SA/recovery from trauma (of homelessness) Is recovery a topic of planning in the Holistic Needs Assessment? How is recovery talked about amongst service providers? What do you think the typical key worker thinks about recovery ‘on the ground’? Where are services getting it right? Where could services do more to bring about recovery?

36. 4. Community Integration: key to recovery Help develop natural supports in the community (Re)build social network Reconnect with family & friends Establish new relationships Natural supports: Learn to use community resources Social, recreation, political, religious activities

37. 4. Community Integration Housing that is normal housing -- not a program The services can walk away from the person who no longer needs them (& return if necessary) < 20% of a given building; reduces stigma, visibility, concerns about crime

38. + Let’s stop and talk about community integration How important is community integration in the planning and assessment done by service providers in Dublin? How is community integration promoted or hindered in the ways that housing services are provided? What are some of the social and political barriers to community integration? What could you do in your practice to promote community integration? How does the label ‘anti-social behaviour’ undermine community integration?

39. + Any questions so far?

40. 5. Effectiveness

41. + The Revolution Provide immediate independent permanent housing and effective supports for persons with mental illness &/or substance misuse Transform existing housing and treatment systems to align with consumer preferences and values Challenge & change beliefs about this population’s capabilities

42. + The Resistance: “Housing First Won’t Work” Psychiatric decompensation without treatment requirements Moral Worth “You can’t give these people housing and ask for nothing in return” Exaggerating Differences: “Our city is nothing like New York”, “Our housing is different”, “Our population of consumers is different” Exaggerating Similarities: “We already have programs that provide treatment and housing, it’s just that the sequence is different” Competing with existing providers for limited funds: “You’ll put us out of business.”

43. + The strategy: Show the sceptics that it works 1. Use experimental research designs 2. Choose diverse outcomes important to multiple stakeholders 3. Partner with academic institutions, 4. Demonstrate implementation feasibility and replicate outcomes in diverse settings 5. Commit to publish and publicize results to maximize audience reach.

44. The Evidence Outcome VariableResults Housing retention rateHF more time stably housed Proportion of time homelessHF less time homeless Use of alcohol and drugsNo sig. difference or HF lower rate Participation in SA treatment TF higher use Participation in MH treatment TF higher use Psychiatric symptomsNo sig. difference Consumer choiceHF more perceived choice CostHF decreased costs, cost-effective

45. + The Champions Individuals who had the courage - at some personal risk – to advocate for, fund, or implement this seemingly risk-laden approach to solving a high- profile problem. City, County, State Administrators Policymakers Politicians Providers Advocates

46. + The Result Revolution in homelessness service delivery – world wide! Hundreds of cities in the U.S. & Canada, in Europe and Japan Homelessness ended for thousands of “difficult to serve” Millions of $/€/£ saved annually by circumventing the circuit

47. + Unintended Consequences Bandwagons: Adopt the HF label, but not the philosophy Low fidelity to the model HF “immediately” upon sobriety HF in form of temporary/emergency accommodation Housing “only” Research: Include “weak” HF programs Validity of outcomes

48. + Research Evidence: Building an evidence based practice Stable Housing Psychiatric symptoms/mental health Alcohol & Substance Use Costs

49. New York Housing Study Funded by SAMHSA, CSAT and NYSOMH

50. 48 month longitudinal randomized control trial Comparing Pathways to Housing with Standard Treatment-Housing Programs in NYC

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

52. Follow-up Rates Entire Sample 6- month 12- month 18- month 24- month 30- month 36- month 96%94%92%90%86%

53. 36-month follow up: Selected Domains Residential Stability Literal Homelessness Choice Psychiatric Symptoms Substance abuse

54. HF experience significantly more choice Note. Significant at 6-, 12-, 18-, 24-, 30-, and 36-month.

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

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

57. Cross site studies of HF - HUD : - 6 cities same measures: - 84% retention rate across six study sites - VA: - 11 cities, same measures: funded by ICH show about 85% housing retention rates after first year

58. Mental Health & Substance Misuse Research from the New York Housing Study examined two predictors of mental health and alcohol/substance use Time spent in permanent housing Perceived choice over residential and treatment decisions

59. Housing First Programs, Choice & Psychiatric Symptoms Psychiatric Symptoms Adapted from Greenwood et al, 2005. reduction increase reduction Program Assignment Proportion of time homeless Choice Personal Mastery

60. Mental Health Time spent in permanent housing 6 - 12 months prior to the current assessment period was associated with fewer psychiatric symptoms (Time-Lagged Effect) Greater perceived choice over residential and treatment decisions was associated with fewer psychiatric symptoms and greater self-esteem (concurrent effect)

61. Alcohol/Substance Use Permanent housing was related to less alcohol use (concurrent effect) In the short-term, greater choice was related to less alcohol use (concurrent effect) Over the long-term, choice was related to greater alcohol and illegal substance use although actual use was quite low (Time-lagged effect)

62. Summary and Implications Two key components of program (permanent housing and choice driven services) are beneficial to mental health Permanent housing was associated with less alcohol use Over time, choice may increase alcohol and substance use, but not to high rates, and in the context of harm reduction strategies

63. Cost studies New York City: 2-year follow-up: PHF lower costs than treatment as usual (Gulcur et al., 2003) Denver: Net cost savings of $4,745 per person per year (Perlman & Parvensky) Rhode Island: Net savings pp $8839 (Hirsch & Glasser, 2008)

64. + Cost Studies Seattle: aggregate reduction in cost of $3.2million (Srebnik, 2007) Chicago: “health care savings far exceed costs of the Housing First intervention” (National AIDS Housing Coalition, 2008)

65. Beyond the ‘Tipping Point’  The National Alliance to End Homelessness advocated for Cities and States to develop 10- year plans to END HOMELESSNESS  The US Interagency Council on the Homeless $35M Initiative Ending Chronic Homelessness

66. + Beyond ‘The Tipping Point’ 11 agencies funded, 9 adopted HF 24+ cities moved forward without funding to implement housing first Up to now 250+ cities have developed 10- year plans to end chronic homelessness Virtually all use some sort of HF approach

67. Annapolis & Baltimore MD Hartford CT Some Pathways’ Housing First Programs in the USA & Canada Worcester, MA Oakland, CASalt 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 Columbus OH Richmond, VA Portland, OR Seattle, WA Chicago, IL Calgary Toronto Los Angeles, CA Fort Lauderdale, FL

68. + European Housing First

69. + European (Pathways) Housing First What’s next? Implementation & Evaluation Flexibility & Fidelity Fit the model to different governmental/policy structures But insist on 5 Essential Elements With program fidelity, success is practically guaranteed!

70. + Thank you for listening. Ronni.Greenwood@ul.ie www.pathwaystohousing.org