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Gregg Pieples Greater Cincinnati Behavioral Health Services Andy Hutzel Over-the-Rhine Community Housing Fred Baxter.

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Presentation on theme: "Gregg Pieples Greater Cincinnati Behavioral Health Services Andy Hutzel Over-the-Rhine Community Housing Fred Baxter."— Presentation transcript:

1 Gregg Pieples Greater Cincinnati Behavioral Health Services Andy Hutzel Over-the-Rhine Community Housing Fred Baxter Greater Cincinnati Behavioral Health Services

2  Community Mental Health Agency  Founded in 1971  350 employees  Serves approximately 6000 individuals per year  Services offered:  Psychiatric  Care Management  Specialized Care Management (Homeless, Court)  Counseling  Vocational  Day Program  Integrated Health Care – Nursing, medical care, pharmacy services

3  Projects for Assistance in Transition from Homelessness (PATH) – Homeless Outreach PATHS TO RECOVERY Uses Housing First Approach IDDT/ACT Team Integrated Behavioral Health Counselors in Health Care for Homeless Site  Housing First ACT Team Uses Housing First Approach

4  Mental Health  Greater Cincinnati Behavioral  Substance Abuse  Alcoholism Council  Housing  OTRCH  Evaluation  SARDI - Wright State University

5 Scattered Site Jimmy Heath House GCB Care Management Counseling Groups OTRCH S+C Front Desk Owner / Landlord Housing Voucher Front Desk Staff

6 93 Admissions to date 75 current units of housing 25 Congregate units (JHH) 48 Scattered-site units Chronically homeless Chronic Public Inebriates Official Start Date: October 2009  Multiple arrests  Failed Treatment Hx  Non-service connected  Currently using  Currently homeless

7  A consumer driven housing and support service that offers people who are homeless immediate access to an apartment of their own and the services needed for recovery.

8  The direct, low barrier placement into permanent housing  No requirement to complete another program first  Provision of intensive, readily available support services  Although participation in these services is not required  Sobriety is not a requirement  Use of Evidence based practices (EBP)  Continued services regardless of previous or continued failures  Consumer driven

9  SAMHSA / HUD priority  Housing First is an "evidence-based practice,“ ◦ Multiple research studies report that HF programs consistently show significant positive impact on its target population  Longer stays in Housing  Reduced substance use  Less hospitalizations and incarcerations  Impact of using a Housing First methodology at Pathways to Housing ◦ Showed significant housing retention rates and lower substance use rates as compared with traditional Contiuum of Care programs. ◦ Autonomy & Control. Perceived choice was much higher in Housing First.  The Streets to Homes program in Toronto ◦ housed more than 1,500 people since inception ◦ 87 percent have remained housed. ◦ Reduction in the use of …  Substances, emergency services such as 911, emergency rooms, ambulance, fire, police detox, and jail

10 "Some people think when you give housing away that you’re actually enabling people as opposed to helping them get better. Our experience has been that the offer of housing first, and then treatment, actually has more effective results in reducing addiction and mental health symptoms, than trying to do it the other way. The other way works for some people, but it hasn’t worked for the people who are chronically homeless." Sam Tsemberis Founder & CEO Pathways to Housing

11  Variations occur in…  service type & intensity  housing type  Outcomes show consistency in Housing retention but vary in other areas  Seattle vs. New York Models

12  Separation of Housing & Treatment  Client Choice of Housing & Services  Intensive Treatment Services  A Recovery Philosophy

13 Requires a change in Thinking

14 Housing Services Treatment Services  Apply for housing subsidy  Find apartment  Sign lease  Maintain housing (abide by a lease)  Supportive housing contact weekly  Treatment and Support services ◦ Using ACT or other Intensive Case Management  Relapse (either MH or SA) is expected ◦ Does not result in housing loss

15 Traditional Perspective Housing First Perspective  Need to learn pro housing behavior (transitional housing required)  Acceptable ADL’s, sober, motivated to work a “plan”  Take medication  Until proven housing ready still homeless  If didn’t cooperate terminated due to non compliance  Judging people to be incapable of having an apartment  Case Manager views self as expert and determines what is best for client  Client oriented  Everyone has a right to housing  Client can choose housing  Immediately placed into housing  Housing not contingent on treatment compliance  Expectation that client will sign lease and abide by it  Supportive Housing Visit  Treatment is offered not required

16 ACT or Intensive Case Management Service

17 Traditional Perspective of SA Treatment IDDT Perspective of SA Treatment  Demands treatment prior to move in  Any exception viewed as enabling  Expected that clients will keep appointments, no outreach  If client doesn’t keep appointments CM will terminate services due to poor follow up  Case managers repeatedly point out bad consequences of using and traditional substance abuse treatment is only viable option  Integration of SA and MH treatments  Flexibility of staff  Assertive outreach  Recognition of client preference  Close monitoring  Comprehensive services  Stage-wise treatment(i.e pre- contemplation)  Recognizes accomplishments  Conveys optimism

18 Choice is the foundation of Housing First

19  Dignity of Choices  Right to risk  People make mistakes and learn from the experience  Learn to ask what clients want  Offer what housing options you have  Client makes choice  Clients typically want their own apartment  Treatment Services are offered; not required

20 Landlord, Agency and Tenant have common goal Agency makes sure rent is on time Agency is responsive to landlord concerns  Tenant Rights and Responsibilities-there are limits to choice ◦ Must sign lease ◦ Pay portion of Rent ◦ Abide by Lease

21 Traditional Perspective Housing First Perspective  Clients with many needs require group settings  Group settings often have supervision 24/7  Client has no choice in housing option ◦ case manager knows what is in the clients best interest  Clients can fully integrate into community  Can be indistinguishable from everyone else  Feels part of society and has increased sense of self worth  Can feel they truly have own home

22 Traditional Perspective Housing First Perspective  Case manager views self as the expert ◦ determines what is best for client  Manipulating client through coercion ◦ no real choice  Must take meds to get into housing  Can’t work on any treatment goals unless sober  Must express they want treatment before moving into housing  Cant transport if smells like alcohol  Clients do not see consequences as their responsibility if they don’t see their choice  Client chooses treatment goals & services  Client may reject any services ◦ except supportive housing visit  Client determines frequency of service & sequence of service  Focus on establishing trust by meeting needs as presented by client  No strings attached  Teaches responsibility ◦ use consequence of behavior as opportunity to learn

23 Recovery is possible

24  Convey Hope  Offer choice after Choice  Are respectful, patient, nurturing, compassionate  Are strength based and client centered  Move client toward independence  Allows SA clients to determine what recovery is to them

25 Importance of Evidenced Best Practices  Housing First  Integrated Dual Diagnosis Treatment  Motivational Interviewing  Trauma Informed Care  Strengths Based Case Management

26 Goes hand in hand with the Housing First Model

27 A collaborative, person-centered form of guiding to elicit and strengthen motivation for change February 2009 Revised definition Center for Evidence Based Practices Ohio SAMI CCOE

28  Listening with empathic understanding  Evoking client’s own concerns/motivations  Reducing resistance  Nurturing hope & optimism

29  Express Empathy  Develop Discrepancy  Roll with Resistance  Support Self-Efficacy It’s about connecting to individuals that have made a habit out of not connecting

30 Ohio SAMI CCOE Regional Training Stages of Change  Precontemplation  Contemplation  Preparation  Action  Maintenance/Relapse Prevention Prochaska and DeClementi, Miller and Rollnick 1991

31 Why do People change? Pre- Contemplation Contemplation Preparation Action Relapse Maintenance

32 Ohio SAMI CCOE Regional Training Stages of Change & Stages of Treatment  Pre-contemplation  Engagement  Contemplation & Preparation  Persuasion  Action  Active treatment  Maintenance  Relapse Prevention

33 Ohio SAMI CCOE Regional Training Example: Decisional Balance NOT CHANGING Using drugs, not taking meds, skipping group tx CHANGING Getting sober, taking meds, attending groups Benefits“Pros” Costs“Cons”

34 Fred Baxter MSW, LSW Clinical Counselor

35 TeamServices  5 FTE’s  Program Manager  Counselor  Two Care Managers  Peer Specialist  Data person  Housing Support  Care Management  Counseling  Crisis Intervention  Groups  Peer Mentoring

36  Basic Needs  Housing Support  Cleanliness  Safety  Communication with Landlord  Lease obligations  Benefits  Food  Clothing  Medical care  Vocational  Social Supports

37 Non-Traditional  Setting ◦ Often not in office  Style ◦ Rarely a sit-down  Length ◦ Very short sessions

38 Engagement Strategies  Dialogue & Topic commonality  Rapport Building  Trust through demonstration  Assessment  Groups  Treatment Referrals  Individual

39  Engagement by Nature  Support and Education  Coordination of Services

40  Respect Others  Able to participate ◦ Intoxicated members ◦ Highly symptomatic members

41 Topics  Welcome  Connection  Announcements  Coordination  News  Educational Segment  Open  Flexible  Examples  What is hope?  Cultural Diversity  Community Safety Structure

42  Group is voluntary  Relational  Staff and client connected Group patterns and counseling must consider the members interest, motivation and cognitive ability

43 A review of the population

44  Chronic homelessness  Chronic alcoholism  Multiple arrests  Failed Treatment Hx  Non-service connected  Currently using  Currently homeless

45 Selection CommitteeCommittee Members  Monthly Meeting  All potential Clients  Reviewed  Prioritized  DIC  HIP Team  Cincinnati Police  DCI (Chico / Valerie)  OTRCH  PATH


47 20042007

48 Community Task Force InterAct for Health HUD SSH Funds Awarded 2006 Housing & Developers 3CDC OTRCH Congregate site located 2007 Site Financing HUD SHP Federal Home Loan Bank City HOME funds, Local foundations 2008

49 SAMHSA Grant Services Agencies Design & Implementation 2009 First Client Housed Jimmy Heath House Opened Dec 2010 2010 Local foundations Today


51 ◦ 91.2% male ◦ 52.7% African American / 45.1% Caucasian ◦ Average age = 50.11 years ◦ 11.0% Veterans ◦ 60.4% completed 12 th grade ◦ 97.8% unemployed







58  Arrest and confinement data ◦ Obtained from the Hamilton County Clerk of Courts ◦ 57 clients  Criminal justice data ◦ Obtained for the 24-month period before and after housing placement

59  60% reduction in arrests (335) between the pre- and post-housing periods Time Period# of Arrests% of Total Arrests Pre-housing period56371.2% Post-housing period22828.8% Total791100%

60  Statistically significant reduction in arrests Pre-housing period Post-housing period Level of significance Average # of arrests 9.884.00.000

61  44% reduction in jail days between the pre- and post-housing periods  642 fewer jail days in the post-housing period Time Period# Days Confined% of Total Confinement Pre-housing period145664.1% Post-housing period81435.9% Total2270100%

62 ◦ No statistically significant reduction in jail days

63  Examined the relationship between  service dosage & changes in alcohol and mental health outcomes  Clients with greater baseline alcohol use & more individual counseling sessions  had reduced alcohol consumption  between baseline & 6-month follow-up  (F = 15.98, p =.000)  Strong Regression  29.7% of the change in alcohol use explained by the model

64  Excellent housing retention  Sustained reductions in alcohol use  Reduced criminal justice activity  Low staff turnover  Strong, continued partnerships  Active participation in services

65 Operations

66 Traditional Property MgmtProperty Mgmt in HF Application process is first come, first serve Selection Committee determines most vulnerable Property manager makes decisionsBlended management committee makes decisions Eviction notices if late on rentHousing retention and payment plans if late on rent 3 strict compliance letters = eviction6 or more strict compliance letters depending on act Substance use not toleratedSubstance use discussed openly and attempt to address Rules are rulesRules can be guidelines May or may not have supportive services Extensive supportive services, engaged in all No front desk staffFront desk staff are eyes & ears for all Clear roles with service providerMany roles overlap with services

67 Scattered-SiteCongregate Many, diverse landlordsOne landlord Ability to transferTough it out No house rules or front desk staff House rules, 24 hr staff & monitoring, incl video cameras Transportation issuesKnow where to find residents Typically 4-6 unit buildingsMore people and units Less expensiveMore expensive Less servicesMore services, on site staff Volunteer groups, activities


69 Lessons Learned  Communication and teamwork  Measure success in years, not weeks or months  Housing First for the 10 th time  Difficult decisions  Every Housing First project is a bit different  Be creative in addressing issues  Chronic illness much greater than anticipated  Patience is critical  Staff morale is ongoing concern

70  Try to be a helper rather than a policeman.  Even when dealing with very difficult behavior, most people are doing the best they can (at the moment). They are up against their limitations. “When I knew better, I did better”  Services need to be individualized and focus on the particular needs of the client. Clients can demonstrate the same behavior with very different etiologies.  Trauma and mental illness are often the occult cause of negative behavior, substance abuse may take center stage and be the most apparent issue but it may not be the source of the issue.  It is difficult for homeless individuals to transition into permanent housing. We frequently see men and women who have been “housed” for years remain a “Homeless Person” in their mind.

71  Assess carefully –clients are frequently having cognitive issues or suffering from dementia from long term substance abuse.  Harm Reduction needs to be the center of the approach to individuals in housing first programs  When working with actively using addicts, interventions should first focus on the negative behavior, not the addiction it’s self. It’s not the substance abuse in and of it’s self, it’s the behavior.  Not all negative behavior is based on addiction. One should look at social skills, competency, physical limitations, cognitive abilities. Many clients do not have basic coping skills or ability to manage a household.  Chronic means chronic issues will reoccur

72 And small group exercise

73 1. Centers for Disease Control and Prevention. (1999). Framework for Program Evaluation in Public Health. Morbidity and Mortality Weekly Report, 48(RR11), 1-40.

74 1. Substance Abuse and Mental Health Services Administration. Permanent Supportive Housing: Evaluating Your Program. HHS Pub. No. SMA- 10-4509, Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, 2010. 2. Burt, M.A. (2004). The Do-It-Yourself Cost- Study Guide. Assessing Public Costs Before and After Permanent Supportive Housing: A Guide for State and Local Jurisdictions. Corporation for Supportive Housing.

75  Most difficult to house client  What are the barriers to successful housing?  What are some strategies to overcome those barriers  Would any HF principles assist in the process?

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