1. National Alliance To End Homelessness
Ending Homelessness: Plan, Act, Succeed
Housing Chronically Homeless People: HOUSING FIRST Programs in Philadelphia
Presented by: David Dunbeck
Horizon House, Inc.
July 18, 2006

2. Housing First Programs “New Keys” and “Home First”
Replicated the model used by the Pathways to Housing Program
Quick access to subsidized apartments
Intensive clinical support services using an Assertive Community Treatment (ACT) Team (accept 5 individuals per month)
Recovery using a Harm Reduction Model
Consumer choice is key
Representative payee; home visits

3. New Keys Started March, 2003 Funding: Services – Housing –
SAMHSA Treatment for Homeless grant (3 years-ended 2005)
Medicaid fee-for service billing through city/state Targeted Case Management Systems
Housing –
HUD SHP grant – 25 units (3 years, renewable)
HUD SPC grant – 35 units (5 years, renewable)

4. New Keys Target Population
Chronically street homeless
Dual diagnosis – serious mental illness and drug/alcohol addiction
Housing and services for up to 65 consumers
Intentionally took the consumers who had not been successful in any other treatment programs
Most frequent contact with outreach
Highest number of refusals of service

5. Home First Started January, 2004 Chronic Homeless Initiative grant:
Services –
SAMHSA (3 years)
VA (year-to-year) expire 2006
HRSA (3 years)
Medicaid fee for services through city/state Targeted Case Management systems (at end of grants)
Housing –
HUD SHP grant – 70 units (3 years, renewable)

6. Home First Target Population
Chronically homeless, shelter users
Serious mental illness. May have co-occurring drug/alcohol addictions, physical disabilities
Capacity: Services for 90, housing for 75
Intentionally took the consumers who had not been successful in any other housing or treatment programs and had high system utilization

7. Housing First Outcomes
Currently, we have 152 consumers assigned to New Keys and Home First:
113 are housed in their own apartments
18 are in housing process and living in shelter
9 are being engaged through outreach
7 are incarcerated (2 still have apartments)
4 are in long-term hospitalization
2 are in nursing homes
1 is living with family

8. Housing First Outcomes
As of 2/28/06:
126 clients had lived in at least one apartment
1st apartment
70/126 were successful in their 1st apartment (56%)
2nd apartment
24/47 were successful in their 2nd apartment (51%)
Cumulatively, 94/126 successful in their 2nd apt. (75%)
3rd apartment
12/14 were successful in their 3rd apartment (86%)
Cumulatively, 106/126 successful by their 3rd apt. (84%)

9. Housing First Outcomes
Impact of Housing on Mental Health:
Of those ever housed (and receiving services):
79% showed improvement
18% stayed the same
3% deteriorated
Of those not housed (but receiving services):
20% showed improvement
70% stayed the same
10% deteriorated

10. Housing First Outcomes
Impact of Housing on Substance Use:
Of those ever housed (and receiving services):
57% showed improvement
34% stayed the same
4% deteriorated
Of those not housed (but receiving services):
15% showed improvement
70% stayed the same
15% deteriorated

11. Housing First Outcomes
Impact of Housing on Overall Life Status:
Of those ever housed (and receiving services):
84% showed improvement
12% stayed the same
4% deteriorated
Of those not housed (but receiving services):
50% showed improvement
35% stayed the same
15% deteriorated

12. Things We’ve learned! (Usually the hard way!)

13. Safety
Staffing
Housing
Managing expectations/
pressures
Behavioral Health
Maintaining the model
Funding
The forest/the trees
Physical Health Needs
Employment
Costs

14. Things We’ve Learned:
“Housing First + ACT”
is not the same as
“ACT”

15. These programs are expensive and there are a lot of hidden costs:
Things We’ve Learned:
These programs are expensive and there are a lot of hidden costs:
Staffing costs
Cost for furnishings
Apartment damages
Unpaid rents
Exorbitant utilities
Socialization costs
Research/data analysis

16. BUT… Housing First is still a good investment!
Preliminary analysis shows significant (>50%) reduction in inpatient hospitalizations, detox, and rehab after engaging in services and/or getting housing.

17. Things We’ve Learned:
It’s a challenge to introduce “housing first” in an agency and division that also provide “traditional” homeless and treatment services:
Values
Harm reduction
Client choice
Hiring
Co-location of facilities

18. Things We’ve Learned:
There are advantages and disadvantages to having housing services in a different agency than treatment services:
Good cop/bad cop
Values
Harm reduction
Client choice
Landlord issues
Damages

19. Things We’ve Learned (or are still trying to figure out):
Money Management:
Is it really therapeutic to be representative payee for your consumers?
Or would it be better to let another agency be the representative payee?

20. Things We’ve Learned: SAFETY must be a critical consideration
when implementing a
housing-first program.
FACT: You are controlling (some of) the money of an active substance user who also has a diagnosis of serious mental illness.

21. Things We’ve Learned: Address Safety concerns by: Establishing:
Boundaries, behavior expectations for consumers
Policies and procedures for staff
Consequences (i.e., discharge)
Training Staff
Proactively considering safety in your space planning

22. Things We’ve Learned:
Safety training: Understanding behavior; intervening before behavior escalates.
Lalemand Behavior Scale:*
Agitated
Disruptive
Destructive
Dangerous
Threat of Lethal
* From the Non-Aggressive Psychological and Physical Intervention (NAPPI, Inc.)

23. Things We’ve Learned: Good assessments are a good investment!
Take the time to perform a thorough assessment (including physical health) at the beginning.
Don’t drop the “physical health” ball – use your nurses!
Dealing with long unmet physical health needs can be a powerful engagement tool!

24. Things We’ve Learned: Staffing
It takes special people to do housing first:
Hiring good staff
120% turnover in first year
Maintaining the “revolution”
Keeping good staff
TRAIN, LISTEN, SUPPORT

25. Things We’ve Learned:
We built sustainability into our grants….but, we still weren’t prepared for the transition:
It’s always going to be a painful process, but don’t wait until you need to bill fee-for-service to begin the transition:
“Pull the bandage off”
Do the necessary procedures, paperwork, etc. fully from the beginning – it’s easier to transition with only 5, 10, or 20 consumers (and associated paperwork) than with 155 consumers!

26. but don’t become defensive”
Things We’ve Learned:
My new mantra:
“Defend the program,
but don’t become defensive”

27. The Goal:

28. Housing First – Future Growth
“Welcome Home”
Start-up December 2006
Services and housing for 60
Philadelphia 10-Year Plan to End Homelessness
Proposes “housing first” for 360 (currently at 150)

29. Contact Information
Horizon House, Inc.
1201 Chestnut St., 12th floor
Philadelphia, PA
David Dunbeck, Director of Homeless Services,
Carla Williams, Director of ACT,