Understanding the “Support” in Supportive

Housing

Richard Cho

100,000 Homes Campaign

“All Hands on Deck” Call

September 14, 2011

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Corporation for Supportive Housing

CSH is a national non-profit organization that helps communities create permanent housing with services to

prevent and end homelessness.

CSH advances its mission through advocacy, expertise, innovation, lending, and grant-making.

Key Questions

What is supportive housing?

What are the services in supportive housing?

How can we pay for the services in supportive housing?

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What is Supportive Housing?

Supportive housing is permanent, affordable

housingcombined with

a range of supportive services

that help people with special

needslive stable and independent lives.

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People who:

But for housing cannot access and make effective use of treatment and supportive services in the community;

and

But for supportive services cannot access and maintain stable housing in the community.

Who is Supportive Housing For?

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Supportive Housing Comes in Many Forms

Apartment buildings exclusively housing formerly homeless individuals and/or families.

Rent subsidized apartments leased in open market.

Apartment buildings with mixed income households, including the formerly homeless.

Long-term set aside of units within privately owned buildings.

Services integrated within existing affordable housing developments.

Single family homes, including shared housing environments.

More than Housing + Services

Simply pairing rent subsidies or affordable housing units with services does not make supportive housing

In supportive housing, housing and services linked such that whole is greater than sum of parts (synergistic effect):– Services informs housing/property management– Housing’s function viewed as platform for

improving outcomes for most vulnerable Not just any services – Supportive housing

entails specific approach to services

What is the Services Model in Supportive Housing?

Ironically, the “support” in supportive housing is most difficult aspect of the model to describe

Usual approaches fall short:– The “laundry list”– Titles like “case manager,” “services coordinator”– Staffing ratios (e.g. “1:20” or “1:15”)– Terms and phrases like “flexible,”

“comprehensive,” “voluntary vs. mandatory” Need better deconstruction of services in

supportive housing

What Do We Know About the People Supportive Housing Tries to Reach?

Chronic behavioral health challenges (mental illness, substance use, often co-occurring)

Physical health/medical challenges Long histories of homelessness (lack of recent

experience living in housing) and instability Likely to engage in “risky” behaviors Often involved in multiple public service settings May be “resistant” to services and change

Mismatch of Various Service Modalities

Services Modality

What It Is Reaction

Treatment/ therapeutic emphasis

Services are clinical and focus on treatment of mental illness or substance use

Housing refusal, early attrition or termination, return to homelessness

Brokered case management

Services as “yellow pages”; referrals out to various community-based or mainstream services

Low trust of case manager, low engagement from services, lease violations

“Self-help” or behavioral modification

Services emphasize self-awareness and behavioral change

High failure rate, low engagement in services

Why Do These Approaches Fail?

Presume same “needs hierarchy” between services provider and tenant

Fail to recognize tenant’s past negative experiences with services

Assume that tenant’s own behaviors, patterns, actions are the main source of pathology

Expectation of change in short-term despite long history and pattern of instability

Competing Need Hierarchies?

Behavioral Health

Physical Health

Housing

IncomeFamily/

Relationships

Independence

Independence

IncomeFamily/

Relationships

Housing

Physical Health

Behavioral Health

Provider’s Assumed Hierarchy of Tenant’s Needs

Tenant’s Actual Hierarchy of Own Needs

Implications for Services

Having pre-determined and proscribed set of service goals will lead to disappointment

Requiring services participation as condition of tenancy does not work if tenant values independence greater than housing– Given long history of having no housing, individuals may not

feel the “value” of housing immediately Judgmental attitude towards behaviors will

encourage tenants to lie or disengage Services must overcome perception of negativity Recognize that change will take a long time, will be

incremental, and non-linear

Key Considerations for Effective Services in Supportive Housing

Emphasis on engagement, rapport building Goal of services should be to help individuals remain

housed through problem-solving– Help them retain housing at least long enough to help them

rebuild attachment and develop healthy fear of losing housing again

Place tenant in driver seat of goal setting Non-judgmental attitude increases open

communication and ability to anticipate problems Allow for incremental change Cultivate sense of self-care and wellness through

compassion not condescension or coercion

A Simple Theory of Change for Supportive Housing

Tenants are chronically homeless, have complex health conditions, and are

resistant to change

Prioritization and Placement in

Housing

Troubleshooting of Housing Problems /

Lease Violations

Housing Stability

Engagement and Rapport

Building

Motivational Enhancement

and Empowerment

Services Goal

Setting

Connection to and Coordination of

Needed Services (Health, Behavioral

Health, Employment)

Improved Health and Social Outcomes (Recovery)

Three Functions of Services

Tenants are chronically homeless, have complex health conditions, and are

resistant to change

Prioritization and Placement in

Housing

Troubleshooting of Housing Problems /

Lease Violations

Housing Stability

Engagement and Rapport

Building

Motivational Enhancement

and Empowerment

Services Goal

Setting

Connection to and Coordination of

Needed Services (Health, Behavioral

Health, Employment)

Improved Health and Social Outcomes (Recovery)

Revisioning the Services in Supportive Housing as Three “Stool Legs”

Housing Stability Supports

•Focused on ensuring housing stability•Troubleshooting housing-related issues•Preventing lease violations and eviction

Care Management•Focused on improving health care access and coordination and shifting service use from inpatient/crisis to outpatient/preventive•Health care assessment, planning, coordination of services•Can incorporate Wellness Self-Management

Rehabilitative/ Recovery Services

•Focused on skill-building around activities of daily living•Education about behavioral health, medications•Peer supports•Recovery readiness services•Relapse prevention

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Enables Understanding of Link to New Payment Systems Under Medicaid

Housing Stability Supports

•Not Medicaid eligible

Care Management

•Consistent with services model under Health Homes State plan option

Rehabilitative/ Recovery Services

•Eligible under Home and Community Based Services (1915c or 1915i)

Most Services in SH Match Medicaid Eligible Services

Analysis “crosswalking” services in supportive housing with 1915c Home and Community Based Services found that:

– 61% of services matched HCBS by category/type

– 85% of service hours delivered were of those types that matched HCBS

The Future

In the future, will supportive housing’s services model be assembled in a modular fashion and through new organizational?– Linkage to Health Homes (e.g. FQHCs) to pay for

care management?– Home and Community Based Services to

reimburse rehabilitative services?– State grant or federal MH or SA block grant funds

to pay for housing stability supports?

Shift in Emphasis and Capacity of Supportive Housing Services?C

are Management

Rehabilitative Supports

Housing Stability Supports

Care management

Rehabilitative Services

Housing Stability Supports

Contact

Richard Cho

Director, Innovations & Research

Richard.cho@csh.org