Pathways to Housing

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					  Ending Homelessness
through Housing FIRST
 Tom Lorello, Shelter,
  Harvard University November 31,
 Homelessness is a “Revolving Door”
 Point in Time vs. Longer Time Frame
 800,000 PIT vs. 2.2-3.5 million annually
 Identified 3 Subgroups
          * Transient
          * Episodic
          * Chronic
          CULHANE’ S
 Transient: 80% of overall population,
  single, economically caused episode, low
  rates of illness
 Episodic: 10 % of overall population,
  multiple episodes of homelessness over
 Chronic: 10% of overall population,
  multiple, complex problems, long term
   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
 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
   10% of population, using over 50% of the
 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
 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
 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(maybe)

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

                       Safe haven
Clinician’s Priorities:
Treatment and Services

    -Primary Role of Outreach and
    transitional along the
    -Treatment and sobriety to get
    consumer housing ready
Two hurdles in Early Stages of
 Threshold expectations (sobriety-
  abstinence, 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
 Relapse (SA or MH) may lead to housing
  change or eviction
    Consumer’s Priorities
   Housing then Services           (maybe)

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

Housing then Treatment   (maybe)
        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
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
 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
   Obtaining the skills needed to perform that role
   Using natural and professional supports as needed
   Emphasizes choice, the dignity of risk, de-emphasizes
    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
 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
   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
 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