1. Reflections on the Finnish Experience from a US Perspective Dennis P. Culhane University of Pennsylvania

2. Overview  Housing First! In the US: Policy or Program?  Current Debates on Siting  Emerging Models for Floating Support  Structural and Policy Perspectives

3. Housing First: Policy or Program?  Consumer-led Movement by People with SMI  Became an Evidence-based Practice in Pathways  Adopted as Official US Policy in 2009  Applies to Chronic and Crisis Homelessness  In field – as much a philosophy as a policy – room for interpretation

4. Current Debates on Siting  Model has emphasized “consumer choice” and “housing as housing” not a residential program  Congregate siting emerged in NYC and elsewhere  “Olmstead” Supreme Court Decision – states are interpreting unit concentration threshold  Consumers continue to advocate choice and “normalized” apartments  Experience has shown some need and want more structure: “Permanent” Safe Haven Models

5. Emerging Models for Floating Support  HF model originated with Assertive Community Treatment (ACT)  Recent research finds ACT no better than intensive case management (ICM), and ICM no better than Peer Support (quite lower cost)  High fixed costs for support limits growth in units  Critical Time Intervention as bridge to mainstream supports – Possibility for sustainable growth

6. Structural and Policy Perspectives  Commitment to HF! Policy – but Scaling Issues Remain  Cost Argument has been Critical to Policy Adoption  Aging of Adult Homeless Population is Key Factor for Future  Integrating Evaluation into Programs Necessary for Sustaining Political Support

7. Commitment to HF! But Scaling Issues Remain  Approximately 100,000 CH in the US  Flat HUD Homeless Budgets from 2010 to present  Veterans are the Exception: 70,000 units since 2009: Veteran Homelessness down 35%  Affordable Care Act (ACA) with Medicaid Expansion Holds Major Promise for Services Funding (But States Must Adopt and Adapt)  Gap: Who will pay housing cost for nonVets?

8. Cost Offsets Critical to Policy Adoption  Research has indicated that especially for people with SMI, PSH/HF may be budget neutral over time  For people with chronic substance abuse – evidence is less robust  For people in service-poor states, not likely offsets  For aging homeless population, case may be stronger

9. Aging of Adult Homeless Population a Key Factor for Future  Adult Homelessness in the US reflects an “Easterlin Cohort Effect”  Increased Costs Predicted with Aging  Cost Offset Opportunities Increase – Avoidance of Unnecessary Nursing Home Care  US Budget Provision Allows Accounting for Cost Avoidance in Allocating New Housing Expenditure

10. A Cohort Phenomenon 31-3340-42 49- 51 Source: Culhane et al. (2013)/ U.S. Census Bureau Decennial Census Special Tabulation

11. Integrating Evaluation into Programs Necessary for Political Support  Evidence and Cost Research has been key to Sustaining Political Support  Mandatory Data Collection for Homeless Programs (HMIS) Has Created Infrastructure  Mandatory Performance Measurement Immanent (Housing Placement Rates and Returns to Homelessness- at Program & Community Levels)  Data Integration – Linking HMIS and Mainstream Service Data – a Growing Capacity with Impact

12. Concluding Thoughts  “Olmstead” (Supreme Court ruling) may drive siting issue debates, but some structured environments appear needed  New and low cost service models needed: CTI, Peers, and Mainstream Supports?  Federal housing spending a problem for capacity  Aging issue a key factor for future  Integrating data collection into programs, and linking data across systems a future potential