Pathways to Housing

HOUSING FIRST: Ending Homelessness and Transforming Lives

Sam Tsemberis, PhDFounder and CEO Pathways to Housing

September 30, 2013

www.pathwaystohousing.org

Presentation Outline

1. Program Philosophy

2. Program Operations

3. Policy and Systems Change

4. Program Effectiveness

5. Implementation and Dissemination

Who is served by Housing First?HomelessMental health

problems Addiction and abuse

Health problemsPovertyIsolationStigmaPTSD/Trauma

GINI (Social Disparity)Housing First is also an economic intervention

Why Focus on Chronic Homelessness? Most in Need/VulnerableHigh Rates of Service Utilization (Aubrey

12% use 50%)Public Health Concerns – most visibleCommunity ConsensusMost Challenging for Traditional System to

Engage

Traditional system

Homeless

Shelter placement

Transitional housing

Permanent housing

Lev

el o

f in

dep

end

ence

Treatment compliance + psychiatric stability + abstinence

System Renovation Using Housing First

Homeless

Shelter placement

Transitional housing

Permanent housing

Lev

el o

f in

dep

end

ence

Treatment compliance + psychiatric stability + abstinence

1A. Consumer Choice in Housing Matching the housing type to the person’s needs

Consumer Choice drives the provision of housing

Consumers choose among housing types, rental market and social housing

Choose neighborhoods, size of unit, furnishings and other household items for their apartments

Tenants rights and responsibilities (terms and conditions of standard lease)

Rent contribution about 30% of income

Housing Choice: Independent apartments in community settings (Scatter Site Housing Model)

Most consumers prefer own place in normal settings

Independent aptCreate sense of

homeIntegrated housing Services are off site

Pathways has served:22 People in Washington County46 People in Chittenden County18 People in Windham. Etc.

Pathways tenants live in 4 counties and 8 different cities

60 Tenants, 60 Apartments, 2 Counties, 6 Cities, 31 Landlords: Housing Retention Rate 90.5%

Pathways VT: Housing First In Rural Areas

Some Operations Issues for the Housing Component of the Program

Separation of Housing and Services: Commitment is to the person

Choice in location, unit, and life style

Developing and Managing Relationships with Private Market Community Landlords

Repairs, Relocations and Relatives

After housing…

Health &Wellness/Weight Loss/Exercise

Finances/Budgeting/Money Management

Alcohol/Drug -- Use Abuse

Mental Health Issues

JOB, JOB, JOB

eviction

Services Provided Directly or Brokered

choice Spiritual

Wellness/Nutrition

Arts /Creativity

HOUSING

Addiction

PEERSUPPORT

Income Entitlements

Employment/education

MentalHealth

Friends & Family

ant

ACT Team providesmost servicesdirectly ;Transdisciplinary practice.ICM teams broker services.

ClientsNo wrongDoor – Immediate access—Client directed

CLIENT

RN/MD

Clinical and Support Services for Housing First: ACT, ICM, and CM Teams

Consumer choice in type, frequency and intensity of services

Team meeting - (1-5 times a week)

Team structure and team philosophy

Art and science of the Home Visit

Working as a team: “We have each other’s back”, geographic coverage, cross coverage, etc. Rural variations include teleconferencing between 2 or more smaller teams

Managing the 7/24 on-call

Team Operation Logistics

Google groups, teleconferencing morning meeting

Outlook coordinated calendars

Team approach to case management

Smaller teams

Teaching online skills to tenants – telemedicine

Managing the 7/24 on-call

Housing First Program Fidelity5 Domains/Factors

I) CHOICE in Housing and Services

II) Separation of Housing and Services

III) Service Philosophy

IV) Service Array

V) Program Structure

Operations:Lessons learned

Match services to client needThere’s no place like homeThe importance of hiring peersHF is not only a new program it is a

culture change

HomelessRapid-rehousing

prevention

Low support Low needs(families)

Moderate support &

moderate needs

High support & high needs

Relationship of housing and supports:Depends on who we serve.

• Poverty must be addressed as a component of recovery

• Programs must address client’s practical concerns (e.g., it’s not housing it’s making a home –furniture, phone, tv, etc.)

• Employment, education, meaningful activity

Economic Recovery – It’s not housing it’s a home

Housing First Treatment Philosophy: Recovery Focused Mental Health Services

Relationships are foundationalPeer supportKnowledge and skills to self- manageEmphasis on welcoming, hopeful, inspiring culture

• • Moving forward

requires taking risks Harm reduction, lease co-signs, head lease, etc.

Balancing risk and

Responsibility

Housing First As Systems Change and Program Effectiveness

Begin with the assumption of capabilityLess transitional and emergency and more

permanent with supportsNYU study of staff time and energyCanadian study program and cost outcomes

Street/shelter/hosp/jail

Community Placement

Transitional Housing

Permanent housing

Ongoing, flexible support

Harm Reduction

Housing First Model

Community-based, Residential Treatment (on-site clinical staff)

Permanent Single Site (on-site services)

Permanent housing

(scatter-site, off site services)

Redesigning the System: System Transformation

Longer term Institutional Care

Least restrictive to more restrictive setting

Front-Line Practice

Differing Provider Perspectives by Program Model: A Program Implementation Paradox

TF providers were consumed by the pursuit of housingHF providers focused on clinical concerns

Housing First Model

Treatment First Model

Focus on Housing

Focus on Treatment

Stanhope, V., Henwood, B.F. & Padgett, D.K. (2009). Understanding service disengagement

from the perspective of case managers. Psychiatric Services, 60, 459-464.

MENTAL HEALTH COMMISSION OF CANADA (2009):AT HOME/CHEZ SOI -- 5 CITIES, RCT N=2,215

MHCC At Home / Chez Soi5 Cities

Moncton, Montreal, Toronto, Winnipeg, Vancouver

Housing First (n=1267)

Client Interviews every 3 months:

Residential stability, mental health,

addiction, quality of life, social integration

Treatment as Usual (n=990)

Lessons in Implementation and Dissemination Science

• 1. Program – is the intervention well understood?• 2. Outer setting - economic, political, and social• context• 3. Inner setting – org experience, staff stability, org• culture• 4. Individuals - attitudes towards intervention, believe it will work or I necessary, leadership, • 5. Process - planning, engaging, executing

• Prevention must be an integral part of the strategy to end homelessness

• Employment, education, and other meaningful activity

• Poverty must be addressed as a component of recovery

There is much more to do:

We cannot afford not to end homelessness for those on the streets.

For additional information

Please visit our website:

www.pathwaystohousing.orgOr send an email to:

stsemberis@pathwaystohousing.org