1. Understanding the “Support” in Supportive Housing Richard Cho 100,000 Homes Campaign “All Hands on Deck” Call September 14, 2011

2. 2 Corporation for Supportive Housing CSH is a national non-profit organization that helps communities create permanent housing with services to prevent and end homelessness. CSH advances its mission through advocacy, expertise, innovation, lending, and grant-making.

3. Key Questions What is supportive housing? What are the services in supportive housing? How can we pay for the services in supportive housing?

4. 4 What is Supportive Housing? Supportive housing is permanent, affordable housing combined with a range of supportive services that help people with special needs live stable and independent lives.

5. 5 People who: But for housing cannot access and make effective use of treatment and supportive services in the community; and But for supportive services cannot access and maintain stable housing in the community. Who is Supportive Housing For?

6. 6 Supportive Housing Comes in Many Forms  Apartment buildings exclusively housing formerly homeless individuals and/or families.  Rent subsidized apartments leased in open market.  Apartment buildings with mixed income households, including the formerly homeless.  Long-term set aside of units within privately owned buildings.  Services integrated within existing affordable housing developments.  Single family homes, including shared housing environments.

7. More than Housing + Services Simply pairing rent subsidies or affordable housing units with services does not make supportive housing In supportive housing, housing and services linked such that whole is greater than sum of parts (synergistic effect): –Services informs housing/property management –Housing’s function viewed as platform for improving outcomes for most vulnerable Not just any services – Supportive housing entails specific approach to services

8. What is the Services Model in Supportive Housing? Ironically, the “support” in supportive housing is most difficult aspect of the model to describe Usual approaches fall short: –The “laundry list” –Titles like “case manager,” “services coordinator” –Staffing ratios (e.g. “1:20” or “1:15”) –Terms and phrases like “flexible,” “comprehensive,” “voluntary vs. mandatory” Need better deconstruction of services in supportive housing

9. What Do We Know About the People Supportive Housing Tries to Reach? Chronic behavioral health challenges (mental illness, substance use, often co-occurring) Physical health/medical challenges Long histories of homelessness (lack of recent experience living in housing) and instability Likely to engage in “risky” behaviors Often involved in multiple public service settings May be “resistant” to services and change

10. Mismatch of Various Service Modalities Services Modality What It IsReaction Treatment/ therapeutic emphasis Services are clinical and focus on treatment of mental illness or substance use Housing refusal, early attrition or termination, return to homelessness Brokered case management Services as “yellow pages”; referrals out to various community- based or mainstream services Low trust of case manager, low engagement from services, lease violations “Self-help” or behavioral modification Services emphasize self-awareness and behavioral change High failure rate, low engagement in services

11. Why Do These Approaches Fail? Presume same “needs hierarchy” between services provider and tenant Fail to recognize tenant’s past negative experiences with services Assume that tenant’s own behaviors, patterns, actions are the main source of pathology Expectation of change in short-term despite long history and pattern of instability

12. Competing Need Hierarchies? Behavioral HealthPhysical HealthHousingIncomeFamily/RelationshipsIndependence IncomeFamily/RelationshipsHousingPhysical HealthBehavioral Health Provider’s Assumed Hierarchy of Tenant’s Needs Tenant’s Actual Hierarchy of Own Needs

13. Implications for Services Having pre-determined and proscribed set of service goals will lead to disappointment Requiring services participation as condition of tenancy does not work if tenant values independence greater than housing –Given long history of having no housing, individuals may not feel the “value” of housing immediately Judgmental attitude towards behaviors will encourage tenants to lie or disengage Services must overcome perception of negativity Recognize that change will take a long time, will be incremental, and non-linear

14. Key Considerations for Effective Services in Supportive Housing Emphasis on engagement, rapport building Goal of services should be to help individuals remain housed through problem-solving –Help them retain housing at least long enough to help them rebuild attachment and develop healthy fear of losing housing again Place tenant in driver seat of goal setting Non-judgmental attitude increases open communication and ability to anticipate problems Allow for incremental change Cultivate sense of self-care and wellness through compassion not condescension or coercion

15. A Simple Theory of Change for Supportive Housing Tenants are chronically homeless, have complex health conditions, and are resistant to change Prioritization and Placement in Housing Troubleshooting of Housing Problems / Lease Violations Housing Stability Engagement and Rapport Building Motivational Enhancement and Empowerment Services Goal Setting Connection to and Coordination of Needed Services (Health, Behavioral Health, Employment) Improved Health and Social Outcomes (Recovery)

16. Three Functions of Services Tenants are chronically homeless, have complex health conditions, and are resistant to change Prioritization and Placement in Housing Troubleshooting of Housing Problems / Lease Violations Housing Stability Engagement and Rapport Building Motivational Enhancement and Empowerment Services Goal Setting Connection to and Coordination of Needed Services (Health, Behavioral Health, Employment) Improved Health and Social Outcomes (Recovery)

17. Revisioning the Services in Supportive Housing as Three “Stool Legs” Housing Stability Supports Focused on ensuring housing stability Troubleshooting housing-related issues Preventing lease violations and eviction Care Management Focused on improving health care access and coordination and shifting service use from inpatient/crisis to outpatient/preventive Health care assessment, planning, coordination of services Can incorporate Wellness Self- Management Rehabilitative/ Recovery Services Focused on skill- building around activities of daily living Education about behavioral health, medications Peer supports Recovery readiness services Relapse prevention 17

18. Enables Understanding of Link to New Payment Systems Under Medicaid Housing Stability Supports Not Medicaid eligible Care Management Consistent with services model under Health Homes State plan option Rehabilitative/ Recovery Services Eligible under Home and Community Based Services (1915c or 1915i)

19. Most Services in SH Match Medicaid Eligible Services Analysis “crosswalking” services in supportive housing with 1915c Home and Community Based Services found that: –61% of services matched HCBS by category/type –85% of service hours delivered were of those types that matched HCBS

20. The Future In the future, will supportive housing’s services model be assembled in a modular fashion and through new organizational? –Linkage to Health Homes (e.g. FQHCs) to pay for care management? –Home and Community Based Services to reimburse rehabilitative services? –State grant or federal MH or SA block grant funds to pay for housing stability supports?

21. Shift in Emphasis and Capacity of Supportive Housing Services? Care Management Rehabilitative Supports Housing Stability Supports Care management Rehabilitative Services Housing Stability Supports

22. Contact Richard Cho Director, Innovations & Research Richard.cho@csh.org