Pathways to Housing

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					Ending Homelessness through Housing FIRST

Tom Lorello, Shelter, Inc.
Harvard University November 31, 2006

Homelessness is a “Revolving Door” Phenomenon  Point in Time vs. Longer Time Frame  800,000 PIT vs. 2.2-3.5 million annually  Identified 3 Subgroups * Transient * Episodic * Chronic


Transient: 80% of overall population, single, economically caused episode, low rates of illness  Episodic: 10 % of overall population, multiple episodes of homelessness over time  Chronic: 10% of overall population, multiple, complex problems, long term homelessness


Transient: emphasis on prevention, rental assist, landlord advocacy, affordable housing, jobs
Episodic: supportive housing Chronic: aggressive outreach, long term commitment and intensive, flexible supports, supported housing

 

Culhane: Implications re: Causes of Homelessness

Is homelessness caused by mental illness, or addictions?  Manifestation of extreme poverty in the context of our current economy.  Fewer jobs for unskilled labor  Shrinking value of wages for unskilled  Soaring Housing Costs

Chronic Homelessness: A Summary of the Research
    

Unattached Adults Long Term Homelessness: a year or more or multiple times over a several year period Disabled by addiction, mental illness, physical illness- often multiple disorders Frequent hospitalization, incarceration, unstable employment 10% of population, using over 50% of the resources

Challenges to Helping People in Chronic Homelessness

Mistrust is common  Focus on immediate needs, survival  transiency  Multiple complex needs (mental illness, substance abuse, medical, trauma)  Demoralized helplessness, hopelessness  Fragmented systems of care  Significant Access Barriers

“Failure”: A Time for Innovation

Is there a different way to think about this?  Is there a new way of approaching people living on streets that would result in better housing and other outcomes?

Evolution of Strategies to End Chronic Homelessness

Outreach  Safe Havens  Housing First  Employment

Guiding Principles

Flexible Approach, Prioritizing Outreach to “Nontraditional” Settings and Trust Building  Taking a Long Term View of Success  Respecting their Pace, Priorities  Taking Expressed Preferences Seriously: provide concrete assistance, blankets, etc.  Establish credibility, familiarity  Respect needs for independence, control

Guiding Principles (continued)

Advocate for Accessibility of Mainstream Services  Holistic (or integrated) Approach-MSC’s  Using Principles of Motivational Enhancement, Stages of Behavior Change  Tolerating, expecting multiple set backs over time  Using set backs as learning opportunities

Safe Havens

Extension of Outreach  A Form of Low Threshold Supportive Housing that serves Hard to Reach persons with Severe Mental Illness, living on the Street, and unable/willing to participate in Support Services  A Portal of Entry to the Homeless and Mental Health Service Systems

Sequence One
Treatment then Housing Demonstrating Readiness


Continuum of Care
(assumes skills learned in present setting can prepare consumers to live in the next setting)

Permanent Housing
Transitional Housing Drop-in Safe haven


Clinician’s Priorities: Treatment and Services
-Primary Role of Outreach and transitional along the continuum: -Treatment and sobriety to get consumer housing ready

Two hurdles in Early Stages of Continuum

Threshold expectations (sobrietyabstinence, psychiatric medication, curfews)  Subtle but taxing demands on consumer’s social skills (making and breaking ties along the way)

Problems of Access and Retention in Continuum of Care

Housing is linked to clinical status  Sobriety and treatment are preconditions for admission  Relapse (SA or MH) may lead to housing change or eviction

Consumer’s Priorities Housing then Services
 Immediate


access to permanent housing  No requirement for sobriety or treatment  Set own service priorities: A job and a relationship

Sequence Two
Housing then Treatment

Housing First Is…..

Immediate, direct access to psh  No requirements for mh, sa treatment  Services available but voluntary  Basic agreements include rep payee, 2 visits per mo.  Tenant has rights and responsabilites as in a standard lease

Housing First Is…..

Mix of scattered site, project based units  Has been successful with chronic homeless  A form of low threshold intervention  Philosophical approach and staff culture consistent with principles of harm reduction, role recovery

Two Program Requirements:
1. Tenants agree to pay 30% of their income (usually SSI) for rent; mostly through rep payee money management program 2. Tenants agree to two apartment visits per month

Harm Reduction

Accepts that people engage in harmful behaviors such as drug use and works to minimize its harmful effects.  Alternative to waiting to “hit bottom” or cohersion.  Examples include condom use, needle exchange, decreasing use, nutrition, housing (?).

Role Recovery is….

Obtaining and sustaining a valued role as a:
– – – –

Worker Friend Homeowner/tenant Partner, etc.

   

By overcoming personal losses, setbacks, obstacles, and limitations Obtaining the skills needed to perform that role

Using natural and professional supports as needed
Emphasizes choice, the dignity of risk, de-emphasizes pathology.

Ending Chronic Homelessness

Housing First: immediate, low threshold access to housing, with supportive services available and potentially intensive.  PSH works, and is cost effective at the level of the community.  Savings in use of expensive services, i.e, ER visits, ambulance, incarceration.

New York City
Data on 4,679 people who were homeless with psychiatric disorders who had been placed in supportive housing in New York City between 1989 and 1997 showed a marked decrease in shelter use, hospitalizations, length of stay in hospital and time incarcerated. Savings after housing placements included:  $16, 282 per person in services  $3,779 per person in shelter costs These savings funded 95% of the cost of building, operating and providing supportive services for housing.

San Diego
In San Diego, service usage of 227 individuals was tracked for 18 months. The total cost incurred by these individuals included:
 

$6 million in health care. 2,358 hospital visits. 1,745 ambulance trips.

Implementation of a targeted program achieved the following results:
   

58% had no police contact for a year 26% achieved continuous sobriety 50% decrease in ER visits (a total savings of $18,120 per month). $180,223 per month savings in hospitalizations

Washington State
SAMHSA followed the 24 highest utilizers of services in 2003 and found that they cost $49,489 per person in detox, substance abuse treatment, hospitalization, emergency room visits and incarceration.

Dr. James O’Connell analyzed medical service utilization data of 119 homeless individuals between 1999-2003. He found the following cost and utilization rates:

18,384 emergency room visits  871 medical hospitalizations  Total Medicaid cost of $13 million  Per person Medicaid cost $25,000

It is noteworthy that this study did not include health, incarceration and police data.

Housing First Validates

Taking Expressed Needs Seriously  Harm Reduction  Outreach to “Non-traditional Settings”  Respecting Need for Independence and Control  Power of Immediate Access: Instilling Hope  Context Matters

Housing First Modifies Our View of……

Taking a Long Term View of Success  Need for Motivational Enhancement  Assumptions re: Sequencing and Readiness  Separates Clinical picture from Housing Readiness


The most significant predictor of treatment success for people with co-occurring disorders is the presence of an empathic, hopeful, continuous, treatment relationship in which integrated treatment and coordination of care can take place through multiple treatment episodes (Minkoff)

Can We Really End Homelessness?

We know what works.  The most significant challenge will be developing housing to a sufficient scale  Leadership to provide incentives to developers to create affordable housing for 30% median and below.  Partnerships with non-profits and government