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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