Pathways to Housing by kGA19c

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									     Pathways’ Housing First:
Ending homelessness and supporting
   recovery for people with co-
        occurring diagnoses

        Sam Tsemberis. Ph.D.
           Founder and CEO
       Pathways to Housing, Inc.
   Stsemberis@pathwaystohousin.org
   4 Essential Elements

Of the Pathways Housing First
           Program
         Housing First

 Whatis housing first?
 Why was it developed?
 Who does it serve?
 How does it operate?
 How do you know it is working?
How does Pathways’ Housing First
 Relate to 10-Year Plans to End
         Homelessness?

 The National Alliance to End Homelessness
    advocates for Cities and States to develop 10-year
    plans to END HOMELESSNESS
   Almost all plans include a housing first
    component or approach
   The US Interagency Council on the Homeless
    advocates for using housing first to End Chronic
    Homelessness (in 2003 issued a $35M RFP)
Partial Listing of Housing First Programs in the USA & Canada

                                 Calgary
          Seattle, WA
                                                                    Toronto
     Portland, OR                                                                      Worcester, MA
                                                                                 NYC

                        Salt Lake City,                              Philadelphia           Hartford
                                           Chicago, IL               PA                     CT
                        UT
     San                                                 Columbus                          Annapolis
     Francisco, CA                                       OH                                &
                                Denver,                              Richmond,             Baltimore
                                CO                                   VA                    MD
         Los Angeles, CA                       Chattanooga,
                                               TN                                   Washington
                                                                                    DC

                                                                              Charlotte
                                                                              County, FL
                                                   Fort Lauderdale, FL

                                            Housing First Sites that received technical
                                            assistance from Pathways to Housing, Inc
                                              Housing First Sites established 2003-2007
     Pathways’ HF 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
   or case management (CM) services
3 unwarranted
assumptions of
                           Map of traditional homeless
this system:
a. Referrals work
                                services programs:
b. skills learned in   Typically defined by a series of steps
different settings              (assumes consumers need to be “housing ready”)
are transferable;
c. People need                                                Permanent
treatment before*
housing                                                       Housing
                                          Transitional
                                          Housing
                          Drop-in,
                          Shelter,
                          Safe haven
       Outreach
Current system results in enormous
       misuse of resources
 Shelters:    10% of the chronically homeless utilize
    50% of the system resources
   Hospitals/Detoxes: 3% of clients use 28% of all
    Medicaid funding for acute care services
   Jail/Prison: Extremely high rates of incarceration
    and recidivism rates for people who are mentally
    ill and homeless
   Outreach/Drop-in: e.g., see M. Gladwell’s Million
    Dollar Murray in the The New Yorker
      Pathways HF program:
    Quick and Efficient Way to
    End Chronic Homelessness

 Immediate access to permanent affordable
  housing (one’s own apartment) with support
  and treatment services
 Immediate program start up: Program rents
  existing units from community landlords
     Pathways HF program:
    Cost Effective Way to End
     Chronic Homelessness
 Total annual program cost:
 1) housing: annual rent at fair market of modest
  studio or one bedroom (approx. $12K per year);
 2) support and treatment service support; ranges
  between $10 and $15K depending on intensity);
 In NYC cost per person per year approx $24K
  (compared to $28K to $35K per year for a shelter
  cot with services)
    Pathways’ HF Program Ends the
     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., why can’t we write a prescription for housing
    covered by Medicaid if the person we are treating
    has as a psychiatric disability, acute and chronic
    health problems, and is homeless?
 Possible Sources of Funding
      for HF programs
COST: Approx $20K (range $15-$25)
Support /Clinical Services
  - Medicaid
  - Contracts (most efficient are contracts for
    housing and services
Housing- rental support
  - HUD-S+C; SHP (Supported Housing) ;
  - Section 8 or other Vouchers (tenant based are
    best funding option for several reasons)
  - State or City SH funds
    Current Referral Sources
     for Pathways program

 Homeless Outreach Teams
 Shelters (long stay clients). Drop-ins
 Criminal Justice ( ATI and Post-Release)
 Psychiatric Hospitals( State and Local)
 Drug Treatment Services, self referrals, and
  others
        4 Elements of
        Housing First
 1. Consumer Choice
 2. Separation of Housing and
     Services
 3. Recovery Orientation
 4. Effectiveness
  1. Consumer Choice as the
   foundation of the program
There is a vast disconnect between what most
  supportive housing providers offer and what
  consumers say they want
Most supportive housing programs require clients to
  demonstrate ‘housing readiness’, i.e.,
  1) psychiatric treatment, 2) a period of sobriety,
  and 3) agree to observe program rules (ongoing
  treatment, curfews, guests, etc.)
Essentially, treatment and sobriety before housing
    What do consumers want?
        Housing, first!
  When asked, people who are homeless
  almost always say they want housing first;
 “A place of my own”
 Do not want to participate in psychiatric
  treatment or attain a period of sobriety as a
  precondition for housing
 (This refusal to participate in pretreatment
  does not mean people are ‘treatment
  resistant’ or they ‘want’ to remain homeless
      Pathways’ Housing First
     Honors Consumer Choice


 Provides immediate access to a furnished
  independent apartment -- (no psychiatric
  treatment or sobriety prerequisite)
 Once housed, consumers continue to
  choose the type, sequence and intensity of
  services and all program participants must
  agree to weekly visit
        Consumer choice as a
    continuous process in Housing
            First programs

 Choices include the right to make
  mistakes – ‘dignity of failure’ – people
  learn from mistakes and make better
  choices in their next step…
 (this is a continuous process – choice, trial
  and error -- that leads to learning to make
  the right choice and experience success
    2. Separation of Housing from
          Clinical Services

 Separation of housing from treatment
 To obtain housing and to keep housing tenants
  must pay rent (30% of income – SSI) and observe
  rules of a standard lease

   Relapse does not result in housing loss or
    discharge from clinical services (In instances
    where a consumer is evicted from an apartment
    the team will help find another)
     Housing Component: Independent
      apartments integrated into the
               community*

1.    Rent units available on the open market (normal
      rental housing)
2.    Rent less than 20% of the total* number of units
      in any one building
3.    Tenants have same rights and responsibilities as
      any other lease holder

      *depending on availability of housing stock in
      different places there are many other housing
      options
 Landlords as program partners:
  Landlord (are considered a 3rd
program component of this model)

   Landlord, agency, all want quality, safe,
    well managed apartments
 Agency assures landlord that rent is paid on time
 Agency staff are responsive to landlord concerns
 Landlord is encouraged to contact agency if
  problems arise with tenant
 Good communication prevents eviction and also
  prevents problems from developing into crises
         ACT teams:
Treatment and support services
   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, 80% in the community
    7-24-365
   Team practices with Consumers Consumer driven
    philosophy (Consumer Choice & Focus on Recovery)
    – goal is community integration
     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
LIMITS to consumer choice in
           housing

Consumers must comply with the following:
   1) Must sign lease or sublease or
         complete housing applications
   2) Pay their portion of rent (30%)
   3) Observing the terms of the lease
LIMITS to consumer choice on
      clinical services

The teams clinical authority will override
  consumers’ choice in instances where:

     1) Person is considered a danger to self or
             others
     2) In cases of domestic violence, child
             abuse/neglect or other legal issues
3. Providing Recovery Oriented
             services:
     Assuring a values based
             practice
 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.
 How do we support more individuals to
  achieve this goal?
       Programs elements that
          support recovery
 Design the housing and services with a vision of
  recovery in mind: fully integrated into the
  community, indistinguishable from anyone else’s
  place
 Rent and/or develop housing that looks like
  normal housing (e.g., mixed income housing; 80-
  20 etc.) not a facility based supportive program
  program
 Design the program so that the person can stay
  housed and the services can walk away from the
  person who no longer needs them
    If, programs support recovery,
                then…
 Services: Provide services that support
  recovery: such as supported employment,
  wellness management recovery, shared
  decision making; etc.
 Housing: Be sure the housing you provide
  can accommodate changes such as marriage
  or having a child or other positive
  individual and family developments
 If, programs support recovery,
             then…


 Convey hope, offer choice, be respectful;
 Seek and discover capabilities;
 Create new possibilities
4. Research and Program Effectiveness:
Developing an Evidence Based Practice


   Program conducts continuous quality
    improvement studies
   Program conducts research and program
    evaluation
                   Proportion of Time
                   Literally Homeless

              1
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Proportion




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

Note. Significant at 6-, 12-, 18-, 24-, 30-, and 36-month.
 Having More Choice Improves
    Psychiatric Symptoms
                                                   reduction
 Program
Assignment

                                        Personal   reduction Psychiatric
                             Choice
                                        Mastery              Symptoms

Proportion
  of time                                           increase
 homeless


  Adapted from Greenwood et al, 2005.
           Other studies
    (VA Chronic Homelessness
         Initiative & HUD)
- VA: 11 cities funded by ICH show
  about 85% housing retention rates
  after first year
- HUD Housing First: 84%
  retention rate across several study
  sites
 System Transformation
          -1-
End the existing step by step system

Give everyone their own apartment and
 use existing facility based housing with
 services on site for those who a)
 choose it or B) need more support than
 the scatter site apartment model can
 provide
 System Transformation
          -2-
Providing people with psychiatric disabilities
  a home only cures their homelessness, they
  need support and treatment to help cure or
  manage their illness

Scatter site and facility based programs are
  only models of how to deal with people
  whoa re homeless they are not the solution
  to the nation’s homelessness problem
 System Transformation
          -3-

The solution to homelessness is for
 the government to reinvest in
 building many thousands of units
 of affordable and mixed income
 housing
       For additional
        information
See
www.pathwaystohousing.org

See also:

Pathways’ Housing First on the SAMHSA web
   site under NREPP (National Registry of
   Evidence Based Programs)
          THANK
             YOU!

stsemberis@pathwaystohousing.org

								
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