1. Pathways to Housing, Inc. Housing First: Ending homelessness and supporting recovery Sam Tsemberis. Ph.D. Founder and Executive Director

2. Are they the homeless mentally ill or the mentally ill homeless? Do people who are homeless and mentally have more in common because they are homeless or because they have a mental illness?

3. What is Housing First? Is it an intervention that serves people who are mentally ill. The model has implications for how we address homelessness.

4. Housing First Why was it developed? What is housing first? How does it work? Is it effective?

5. Annapolis & Baltimore MD Hartford CT 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

6. How Housing First Relates to 10- Year Plans to End Homelessness The National Alliance to End Homelessness advocating for Cities and States to develop 10-year plans to END HOMELESSNESS The US Interagency Council on the Homeless focus on Ending Chronic Homelessness ($35M Initiative)

7. Current System Housing and service programs: A series of steps Permanent Housing Transitional Housing Drop-in, Shelter Outreach WHY Housing First?

8. 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

9. 3 Assumptions of the Housing Readiness (or treatment first) Model Referrals between agencies work – they dont Learning to live in congregate settings prepares you for independent living – it doesnt People need to be psychiatrically stable and clean and sober before before they can mange independent apartments

10. Misuse of resources by people who remain chronically homeless 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 Outreach/Drop-in: e.g., Million Dollar Murray- The New Yorker

11. Housing First Ends Cycling Through Acute Care Systems Permanent Supported Housing ends homelessness for people cycling throughout the institutional circuit Stopping this cycle has cost implications and possibilities for reinvestment, e.g., what if we could write a prescription for housing covered by the national insurance plan if the person we are treating has as a psychiatric disability, acute and chronic health problems, and is homeless?

12. 4 Essential Elements of Housing First 1. Consumer Choice 2. Separation of Housing and Services 3. Recovery Orientation 4. Effectiveness

13. 1. Consumer Choice is the foundation of this program Program started with a psychiatric rehabilitation approach to street homelessness (taking psych rehab to the streets –d shern et. al) There is is a vast disconnect between what most supportive housing providers offer and what consumers say they want Essentially, treatment and sobriety before housing

14. What do consumers want? Housing, first! When asked, almost every person who is homeless (w or w/o mi) says they want housing first; Will accept immediate access to permanent independent housing; a place of their own Do not want to participate in psychiatric treatment or attain a period of sobriety as a precondition for housing

15. Housing First Honors Consumer Choice Once housed, consumers continue to choose the type, sequence and intensity of services (or no services) All must agree to weekly visit

16. 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

17. 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

18. HOUSING FIRST PROGRAM Main Components 1. Housing: Scatter site independent apartments rented from community landlords 2. Treatment: Treatment and support services provided using Assertive Community Treatment (ACT) Teams, CM or other off site services

19. Treatment and support services: ACT teams/CM Teams Multidisciplinary team (MD, MSW, CSAC, RN, etc) Serves people with highest needs (severe mental illness; substance abuse; homeless, 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 and assist with community integration

20. Case Management teams: Brokerage Service Model CM services – higher case load ratios Must broker other needed services Follow through and continuity of care among systems 7-24 on call Consumer driven philosophy and interventions

21. Matching Housing and Support and Treatment Services with Client Needs Most people need the same things in housing (mih or hmi) Their service and support needs vary Ensure services are unlimited Ensure they are consumer driven and evidence based

22. 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

23. Landlords as program partners: Landlord, agency, and tenant have a common goal Landlord, agency, all want quality, safe, well managed apartments Agency that ensure rent is paid on time and is responsive to landlord concerns Agency wants landlord to contact agency the minute a problem occur Agency responsible for damages Agency housing staff on call for landlord

24. 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) Observing the terms of the lease

25. LIMITS to consumer choice on clinical services There are limits to choice in these instances 1) Danger to self or others 2) Must agree to weekly visit by support team 3) Others (abuse, violence, legal issues, etc.)

26. 3. Recovery oriented services We now know that people who are diagnosed with severe mental illness (and co-occurring SA) can live full and independent lives in the community (Harding study definition). How do we support more individuals to achieve this goal?

27. Programs elements that support recovery Design the housing a vision of recovery in mind: people living fully integrated into the community, Rent and/or develop housing that looks like normal housing not a program Design the program so that the services can walk away from the person who no longer needs them (or return if necessary)

28. Recovery focused support services Provide services that support recovery: supported employment, education, wellness management, etc., in at least equal proportion to mental health and drug treatment services Provide access to housing in a manner that that can change o accommodate positive family developments

29. Recovery focused services… Convey hope, offer choice after choice, are respectful, patient, nurturing, compassionate, seek and discover capabilities and create new possibilities

30. How is program funded? COST: local costs vary – e.g., FMR Support /Clinical Services - Medicaid/contracts Housing- rental support - HUD-S+C; SHP; Vouchers - State or City Supported Housing funds or local vouchers

31. 4. Effectiveness CQI and documentation of Program Effectiveness

32. Why evaluation and research? Want to build the new models based on empirical evidence -- not on assumptions, special interest, dramatic cases, or political obligations Research provides scientific basis to inform policy and advocacy for system transformation

33. Research Evidence: Building and evidence based practice New York Housing Study Funded by SAMHSA, CSAT and NYSOMH

34. 36 month longitudinal randomized control trial Study 3: Comparing Pathways to Housing with Standard Treatment-Housing Programs in NYC

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

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

37. 36-month follow up: Selected Domains Literal Homelessness Choice and Psychiatric Symptoms Residential Stability

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

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

40. 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

41. County Level Evaluation: Westchester County halves number of homeless in 5 years Westchester County: (New York Times, Feb 26, 2006) Combining rent subsidies, eviction prevention grants, and housing first the county has reduced homelessness by two-thirds since Jan. 1998 Cost $23K for HF compared to $28-$36K shelter with services County is considering a top-to bottom shift to the housing-first model

42. Cross site studies – 10cities same measures: VA evaluates chronic homelessness initiative - VA: 11 cities funded by ICH show about 85% housing retention rates after first year

43. Cross site studies – 6 cities same measures: HUD commissions study to evaluate Housing First - HUD Housing First: found 84% retention rate across six study sites

44. Intra-departmental cost study: DHS Cost by service type

45. SAMHSA NREBPP Pathways Housing First On SAMHSA web site National Registry of Evidence Based Programs (NREPP)

46. System Transformation Reversing the existing system of providing homeless services Using transitional programs in a different way: e.g., if for consumers cant mange independent apartments

47. System Transformation Agency and staff training in system transformation Pilot Housing First program

48. THANK YOU! stsemberis@pathwaystohousing.org www.pathwaystohousing.org