Housing First: So what?

A Critical Review of the International Literature and Case Studies

Michele LancioneUniversity of Cambridge

ml710@cam.ac.uk

Layout

1 Basics• Success• Results• Critics

2 Models• Overview• PHF• CHF• HFL + RrH• Support• Recap

3 Cases• Overview• Sweden• London• Scotland

4 So what?

• Models• Cases• So what?

• Basics

Success/1Housing First Rocks

'Housing First ends homelessness. It's that simple' (Sam Tsemberis)

[We'll come back to this]

The HF approach has been replicated all over the US. Documented experiences can be found from Seattle (DESC 2008) to Boston (MHSA 2014); from Maine

(Mondello et al. 2009) to Colorado (Perlman et al. 2006); from Rhode Island (Hitsh and Glasser 2007) to New Mexico (Guerin 2011) and more...

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comT.B., Chronic homeless person in NY The block of his new flat, in Spanish Harlem Buying cookware with case worker

Walking to flat with another case worker

Inside the flat T.B. with Tsemberis in the flat

Success/2Housing First Adaptations

• 100,000 homes

The 100,000 Homes Campaign is a national movement of over 175 communities working

together to find permanent homes for 100,000 chronic and medically vulnerable

homeless Americans by July 2014

Source: http://100khomes.org - See also (100000 Homes Campaign 2011)

1) Identify every homeless person on their streets by name - Questionnaires with 'Vulnerability Index'

2) All communities are working toward housing at least 2.5% of their chronic and vulnerable neighbors each month

3) Communities are committed to pulling together their multiple service systems into a single housing placement

Success/3Beyond Housing First

• Programs for Veteran Homeless people

• Rapid re-housing (RrH) for families

'So I want to know if more mayors can challenge each other on this issue. Can you challenge a neighboring mayor or governor to see who can get all their vets

into housing first? That’s the kind of challenge -- can you challenge yourself to be the first to end veterans homelessness in the Midwest or in the South? Take a

region, get it done. Can each of you get just one more mayor or one more governor to sign up?'

Source: United States Interagency Council on Homelessness, 4 June 2014, http://usich.gov

Rapid re-housing has become a major emphasis in communities’ strategies to end homelessness. Rapid re-housing is also an emphasis in the Homeless Emergency Assistance and Rapid

Transition to Housing (HEARTH) Act, signed in 2009 by President Obama.

Source: National Alliance to End Homelessness, http://www.endhomelessness.org

• It is targeted to families• It originated before PtH (Beyond Shelter,

1989, in L.A. by Tanya Tull)• It is 'big' in the US

• It provides a limited ammount of 'care'[more in what follows]

Success/4Housing First in the World

The Finnish National Programme to Reduce

Long-Term Homelessness

(Busch-Geertsema 2010; Tainio and Fredriksson 2009)

Sweden Housing First(Knutagård and Kristiansen 2013)

Australian Housing First(Johnson 2012; Johson

et al. 2012)

France Housing First(Houard 2011;

Republique Francaise 2010)

2008 Danish first national Homelessness Strategy (1,000 people in HF) (Benjaminsen 2013b)

PROGRESS program from 2011 to 2013 (see Busch-Geertsema, 2011; 2012a-b; 2013). Local

reports from 5 test sites and 5 peer sites (Test sites:

Amsterdam - Wewerinke et al. 2013; Copenhagen -

Benjaminsen 2013a; Glasgow - Johnsen and Fitzpatrick 2013; Lisbon - Ornelas 2013; and Budapest - Fehér and Balogi

2013)

'At home/Chez sois' project in Canada; $110 million, 4

years, 5 cities, 2,148 individuals -> to evaluate if HF works (Goering et al.

2012; 2014)

Results/1Cost savings

Use and cost of services (jail bookings, days incarcer- ated, shelter and sobering center use, hospital-based medical services, publicly funded alcohol and drug detoxification and treatment, emergency

medical services, and Medicaid-funded services)

Median monthly costs was $4066 per person per month and decreased to $1492 and $958 after 6 and 12 months in housing, respectively -> cost rate reduction of 53% for housed participants relative to wait-list controls

- Larimer et al. 2009 (based on Seattle case study 1811 Eastlake)

- Sadowski et al. 2009 (randomised control trial in a no-profit hospital in Chicago)

Costs savings is one of the central argument brought forward by the supporter of HF (and RrH). Culhane (a major US scholar on homelessness) has strongly argued in favor of this position (Culhane 2008; Culhane and

Byrne 2010; Culhane et al. 2002)

It compares the pergentage of people using hospitalization services in two different groups: people that received a house and case management, confronted to people in usual care. The one that received a house had fewer hospital days and emergency department visits compared to the ones in usual care.

"[O]ur most conservative analyses suggest a 29% reduction in hospital

days and a 24% reduction in emergency department visits"

(Sadowski et al., 2009:1776)

Results/2Housing retention (HR)

This is definitely the point on which the evidence (of effectiveness) is strongest.

Gulcur et al. 2003 (based on NY Housing Study) -> HR is higher in HF than in Continuum of care*• Pearson et al. 2007 (comparison of 3 HF programs) -> HR is high in all cases (see also Pearson et al. 2009)• Tsai et al. 2010 (compare Residential Treatment First with Housing First) -> People in HF have spent more days in their own place than RTF• Tsemberis et al. 2004 (bases on NY Housing Study) -> HR is higher in HF than in Continuum of care -> around 80% HR rate (see also Tsemberis and Eisenberg 2000)• -> In Europe -> 88% HR over four years in the Danish case (Benjaminsen 2013a-b)

* In the US literature, 'Continuum of Care', 'Treatment First' and 'Staircase model' are often used as synonimous

Source: Charles M. Schulz

Results/3Health and wellbeing

Appel et al. 2012 (comparison of people in HF and Continuum of Care) -> Methadone treatment retention is higher for people in HF -> 51% vs 20%• Collins et al. 2012 (the sample was specific to the 1811 project in Seattle)* -> Consistent reduction on alcohol consumption -> 7% every three months • Padgett et al. 2011 (compare people in HF with people in Treatment First) ->HF participants have lower rate of substance abuse (see also Padgett et al. 2006)• Greenwood et al. 2005 (based on the New York Housing Study) -> People in HF perceive greater choice over people in Continuum of Care -> this is assumed to be good for psychiatric symptoms• Padgett 2007 (expanded version of New York HOusing Study) -> People in HF show (limited) markers of ontological security

* The 1811 project in Seattle is made of a single estate with on-site services. It is a form of Communal Housing First (CHF) rather than PHF.

Benefits of HF on health and substance abuse (as well as on social and economic integration) are limited and

contested [see after]

Source: M. Lancione

Critics/1Studies are limited

• Groton 2013 compares 7 major studies on HF: 'Low retention rates, failure to collect data consistently across experimental conditions, and vulnerability to recall bias all weaken the current studies’ ability to fairly assess Housing First programs' (61)• Waegemakers Shiff and Rook 2012 (from Canada): ''With relatively sparse external scientific evidence or research on the model, it is nonetheless supported by [...] HUD and has been declared a “best practice” by [...] USICH. [...] Declaring the Housing first model a best practice appears to be a political decision rather than a scientific research decision" (16-17)---> both lament strong research affiliation with the Housing First agencies being evaluated (i.e. PTH)

Source: Waegemakers Shiff and Rook 2012

Source: Waegemakers Shiff and Rook 2012

Critics/2On effect beyond housing stability

-> There is few solid evidence due to study bias (see example above) • Kertesz et al. 2009: '[T]he Housing First and voucher trials appear to have recruited severely mentally ill homeless persons whose addiction severity at housing entry was lower than normally seen in many homeless persons' (61) (see also Kertesz and Weiner 2009)-> Overall HF has not yet proove to be particularly beneficial on socio-economic integration and health/substance abuse• McNaughton and Atherton 2011: ''[T]he evidence as to further benefits from Housing First, beyond that of maintaining housing (albeit an important outcome) remains underwhelming. It may be expected a priori that providing housing leads to people no longer being homeless, but if their personal circumstances remain potentially mired in difficulty [...] can the outcome be viewed as a ‘success’ [?]" (74-75)

Source: Padgett 2011 - Note study bias at baseline

Critics/3On transferability

Source: www.mcnc.org

• Johnsen 2012 speaking about the UK: '[P]olicy transfer can (and sometimes does) go very wrong, if borrowing countries omit components crucial to programme effectiveness in the nation of origin or pay insufficient attention to socio-political differences between contexts' (197) • Johnson 2012 speaking about the Australian experience: 'Given the different conditions it would operate under, the direct transference of the Pathways to Housing approach would therefore be problematic' (185) -> He refers to differences in welfare, housing market, state regulations, etc. (see also Johson et al. 2012)

Policy transfer is all but automatic.

'The accommodation they [North American service providers] were comparing these good models with

were dire. I mean really dire. You don’t have anything, or not much left in the UK as bad as that standard. So these

models, they sung out, you know what I mean, as being great in comparison. (UK homelessness service provider)'(Source: Johnsen and Teixeira 2012, 196)

Critics/4On HF philosophy

Source: Pathways to Housing 2013

• Stanhope and Dunn 2011 -> On costs -> The paper argues that the research on HF has been of a positivist kind, narrowing down an issue and producing targeted and selective welfare programs. This approach is related to particular ways of understanding care: from justice to economic discourses and calculus.• Löfstrand and Juhila 2012 -> On consumer and choice: '[A]lthough empowerment is linked to the strengthening of clients’ own choice-making capabilities, it does entail professional efforts to reform the conduct of clients in relation to the norms of the PHF model' (63) -> choice is governed and neoliberal subjects biopolitically produced (see also Klodawsky 2009)

• Pleace 2011; Löfstrand 2012 -> On risk of 'over-emphasising': 'As the Housing First movement [...] spreads across the US and into the EU, securing the attention of policy-makers and media [...] it brings with it a particular image of what ‘homelessness’ is. [...] This is a potentially dangerous image if it is presented in isolation, because it presents a very restricted picture of what homelessness is' (Pleace 2011, 122)

Think critically!

'The challenge facing [...] policy-makers and advocates of a Housing First approach is to embrace a more critical and reflective approach [...] As it currently stands, expectations

about Housing First are high and quite possibly unrealistic.

(Johson 2012, 188)

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• Models• Cases• So what?

• Basics

• Pleace (2012b) has identified 3 kinds of 'Housing First' programs (see also Pleace and Bretherton 2012):– Pathways Housing First (PHF)– Communal Housing First (CHF)– Housing Fist Light (HFL)

• The latter has been subsequentally deemed 'Housing Led' and not 'Housing First' (ECCH 2010; Pleace and Bretherton 2013b) -> The approach is similar to Rapid re-Housing (RrH)

• Understanding the differences allows you to better assess your needs

OverviewWelcome in Wonderland

PHF/1Pathways Housing First

PtH virtual media campaign, Source: https://www.facebook.com/pathwaystohousing

• Target: Chronically homeless people (long term+alcohol and drug+mental health issues)• Aims: Housing stability; Reduction of substance abuse; Improvement in physical and mental health; Re-engagement with social life• Philosophy: Scattered housing; Separation of services; Self-determination; Harm reduction and recovery orientation; Respect, warmth and compassion• Delivery: The service is unlimited in time; Assertive Community Treatment (ACT) and Intensive Case Management (ICM)

Key contributions to understand the philosophy of PHF are: Tsemberis and Asmussen 1999; Tsemberis and

Elfenbein 1999; Tsemberis 2010a-b; Tsemberis 2012

Evidence on Housing Stability and costs (US), Ontological security, Limited other outcomes

PHF/2Pathways Housing First

Source: Stefancic and Tsemberis 2007

• Stefancic and Tsemberis 2007 have compared two program of HF (PHF and Consortium): ''The Consortium’s lower retention rate suggests that their discharge policies may not reflect the practice of separating housing from treatment' and 'The large number of participants engaged by the Consortium may suggest that these agencies were extremely rigorous in their efforts to screen-out ineligible applicants' (275)

Continous support and separation of housing and service are key elements of PHF. PHF was originally called 'Consumer Preference Supported Housing'!

(Tsemberis and Asmussen 1999)

CHFCommunal Housing First

The case of Finland provides a good example of CHF (Pleace 2012b; Tainio and

Fredriksson 2009). In the US, see the 1811 project in Seattle (DESC 2008).

In Finland 'A key part of the strategy was to redesign and modify what were defined as

‘residential homes’ (i.e. institutional communal

accommodation with on site services) to make them into

‘residential units’ that would be supported using services

that followed a Housing First philosophy.' (Pleace 2012b, 25)

• Target: Chronically homeless people (long term+alcohol and drug+mental health issues)• Aims: Housing stability; Reduction of substance abuse; Improvement in physical and mental health; Re-engagement with social life• Philosophy: Communal housing (also adaptations of existing shelters); Separation of services; Limited self-determination; Harm reduction and recovery orientation; Respect, warmth and compassion• Delivery: The service is unlimited in time; It offers on site drug and alcohol and mental services.

Evidence on Housing Stability, Possibly costs, Limited other outcomes

HFL + RrHHousing First 'Light' and Rapid re-Housing

• Target: Chronically homeless people, people at risk of homelessness, families, other groups• Aims: Housing stability; Reduction of substance abuse; Improvement in physical and mental health; Re-engagement with social life• Philosophy: Housing 'first'; Separation of services; Limited self-determination; Harm reduction and recovery orientation; Respect, warmth and compassion• Delivery: The service is limited in time and based on service brokerage

Source: Rodriguez 2013 (on Georgia, US); For a UK case see Crane et al 2012.

Evidence on Housing Stability (contested in NY, see ICPH 2013)

RecapSupport is central in HF

Source: Pleace and Bretherton 2012

• ACT (Assertive Community Treatment): intensive; complex team; low participant-to-staff ratio (7 to 1); in vivo interventions; long-term• ICM (Intensive Case Management): simplier service; small team; higher participant-to-staff ratio (20 to 1); ≠ interventions; long-term• CTI (Critical Time Intervention): like ICM but very short term (9 months)

HF is not cheap: delivering 'high quality, intensive support services on an open-ended basis, it is still

quite expensive to run' (Pleace 2011, 120)

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Target is key to define support, and neither is ever stable,

obvious or cheap.

'A new politics of homelessness should start from [understanding

homeless people] not only as human beings (another static category), but

as more-than-human becoming subjects' (Lancione 2013, 363)

• Models• Cases• So what?

• Basics

OverviewHousing First in Europe

• Very brief overview of– Sweden HF (4 cities)– Camden Housing First (CAMHF)

– Scotland 'Turning Point' (TPS)

• Small pilot studies to help you reflect on your context

Souce: http://client.globecartoon.com

SwedenHF in different contexs

Source: Knutagård and Kristiansen 2013

• No national strategy• Municipal fundings• ≠ than PHF: in Helsingborg, Malmö and Stockholm there are entry requirements and there is a trial period (2 years) before tenants get a lease of their own• ≠ than PHF: no ACT, only case management• Housing retention: 80%• Core elements:a) immediate housingb) separation of housing and supportc) harm reduction d) non-judgemental

Not by the book: 'The core elements of the philosophy have been adopted, but the services provided have been adapted differently depending on the local

resources within the organi- sational field' (Knutagård and Kristiansen 2013, 107)

LondonHF @ Camden

Stopping homelessness: 'CAMHF was housing chronically homeless people whom

other homelessness services had repeatedly assessed [...] as being unable to live in ordinary housing' (Pleace

and Bretherton 2013, 69)

• No national strategy on HF• Municipal fundings• Scattered housing in private market• Designed to support a staircase service (Camden Hostels Pathway, CHP)• Target: CHP people with highest needs

• ≠ than PHF: no ACT, 2 people in ICM• ≠ than PHF: support limited in time because of limited fundings• 75 days to house someone • 7 people house in one year• Good HR; few evidence on other points

Source: Pleace and Bretherton 2013

ScotlandHF @ Glasgow

• No national strategy• Various fundings• ≠ than PHF: no ACT, only case management with service brokerage• Housing: scattered but provided by housing associations• Team: composed by 6 people (full time) of which 3 peer supporter• Target: 22 homeless people with severe needs• Good housing retention• Good health recovery• Diminished engagement with justice system

Support is key: 'the effectiveness of the Housing First approach lies as much (if not more) in the provision of high quality, flexible and non-time-limited support as it does the allocation of stable independent housing

per se' (Johnsen 2014, viii)

Source: Johnsen 2014

'HF and other supportive housing interventions may end homelessness

but do not cure psychiatric disability, addiction, or poverty.

These programs, it might be said, help individuals

graduate from the trauma of homelessness into the normal everyday misery

of extreme poverty, stigma, and

unemployment' (Tsemberis 2010a, 52)

Success depends on goals. If 'ending homelessness' means providing 'housing

stability' then these policies seem to work.

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• Sistemi• Casi• So what?

• Basics

So what?/1The policy-making version

Context (simplified)

Institutional intervention Outcomes

Homeless person = Costs for taxpayers

Institution = Illuminate and wise intervention

Housing = The market provides solutions

Homelessness is over (But little is said on other aspects, e.g. '100,000 Homes campaign')

Support = Barely mentioned

Huge costs outsets(But it lacks long-term

evidence)

DREADFUL!1st lesson: Do not create a mediatic bubble

It is not about ending homelessness.

So what?/2The PHF version

Context (simplified)

Institutional intervention

Outcomes

PtH = Well supported and organised; Respect,

warmth and compassion; Harm Reduction model ->

choice

Housing = Scattered housing

The homeless person is 'housed' (evidence)

Support = ACT and ICM (intensive)

Homeless person = Chronic homeless people with mental health

issues and substance abuse

The evidence on recovery is still thin

Savings compared to 'treatment first' but depends on context (i.e. welfare)

PARTIAL!2nd lesson: You can't simply replicate

PHF works with specific target and context

So what?/3Understand the problem

Context Institutional intervention Outcomes

Homeless person = Who?!Your organisation =

illuminate and wise but possibly pennyless

Housing = Private housing? Communal

housing? Is it enough to 'house' homeless people?

THINK!3rd lesson: You have a choice

Think about target, goals, and critical aspects

Support = How much? For how long?

Possible partnerships?

What is the philosophy of recovery?

What discourse on costs and care are you reproducing?

? ?

?

?

?

?

Not a fashion (but a specific policy), not cheap (requires high investments) and

not only housing (support is key).

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thanks.

Michele LancioneUniversity of Cambridge

ml710@cam.ac.uk

How to reference this document: Lancione, M. (2014), Housing First: So What? A Critical Review of the International Literature and Case Studies, presented at the Summer School of the Network Housing First Italia, Ragusa, 23-27 June 2014. Available at:

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Appel, P.W. et al., 2012. Housing First for severely mentally ill homeless methadone patients. Journal of addictive diseases, 31, pp.270–277. Available at: http://www.tandfonline.com/doi/abs/10.1080/10550887.2012.694602

Benjaminsen, L., 2013a. Housing First Europe. Local Evaluation Report Copenhagen. Rehousing Homeless Citizens with Assertive Community Treatment, SFI – The Danish National Centre of Social Research Herluf. Available at: www.socialstyrelsen.dk/housingfirsteurope.

Benjaminsen, L., 2013b. Policy Review Up-date : Results from the Housing First based Danish Homelessness Strategy. European Journal of Homelessness, 7(2), pp.109–131.

Busch-Geertsema, V., 2011. Housing First Europe : A “ social experimentation project .” European Journal of Homelessness, 5(2), pp.209–211.Busch-Geertsema, V., 2012a. Housing First Europe : Progress Report on a Social Experimentation Project. European Journal of Homelessness, 6(2),

pp.241–245.Busch-Geertsema, V., 2012b. The Potential of Housing First from a European Perspective. European Journal of Homelessness, 6(2), pp.209–216.

Available at: http://www.fiopsd.org/wp-content/uploads/2013/01/Feantsa-EJH-6-2_WEB.pdf#page=211 Bush-Geertsema, V., 2013. Housing First Europe. Final Report, Housing First Europe. Available at: www.socialstyrelsen.dk/housingfirsteurope.Bush-Geertsema, V., 2010. The Finnish National Programme to Reduce Long-Term Homelessness. Synthesis Report, Brussels: European Commission

Employment, Social Affairs and Inclusion. Available at: http://ec.europa.eu/social/main.jsp?catId=1024&langId=en&newsId=1419&moreDocuments=yes&tableName=news.

Collins, S.E. et al., 2012. Project-based Housing First for chronically homeless individuals with alcohol problems: within-subjects analyses of 2-year alcohol trajectories. American journal of public health, 102(3), pp.511–9. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3487630&tool=pmcentrez&rendertype=abstract [Accessed June 5, 2014].

Crane, M., Warnes, A.M. & Coward, S., 2012. Preparing Homeless People for Independent Living and its Influence on Resettlement Outcomes. European Journal of Homelessness, 6(2), pp.17–45.

Culhane, D.P., 2008. The Costs of Homelessness : A Perspective from the United States. European Journal of Homelessness, 2, pp.97–114.Culhane, D.P. & Byrne, T., 2010. Ending Chronic Homelessness : Cost-Effective Opportunities for Interagency Collaboration, Penn School of Social

Policy and Practice Working Paper. Available at: http://repository.upenn.edu/cgi/viewcontent.cgi?article=1151&context=spp_papers.Culhane, D.P., Metraux, S. & Hadley, T., 2002. Public service reductions associated with placement of homeless persons with severe mental illness in

supportive housing. Housing Policy Debate, 13(1), pp.107–163. Available at: http://www.tandfonline.com/doi/abs/10.1080/10511482.2002.9521437.

Downtown Emergency Service Center, 2008. 1811 Eastlake: First-Year Preliminary Findings, Seattle. Available at: www.desc.org.European Consensus Conference on Homelessness, 2010. Policy Recommendations of the Jury, Brussels: European Community Programme for

Employment and Social Solidarity.Fehér, B. & Balogi, A., 2013. Housing First Europe. Local Evaluation Report Budapest, Housing First Europe. Available at:

www.socialstyrelsen.dk/housingfirsteurope.

References/1

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Johnsen, S., 2012. Shifting the Balance of the Housing First Debate. European Journal of Homelessness, 6(2), pp.193–199. Available at: http://feantsaresearch.all2all.org/IMG/pdf/ejh6_2_resp_housingfirst4.pdf

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Johnsen, S. & Teixeira, L., 2012. “Doing it Already?”: Stakeholder Perceptions of Housing First in the UK. International Journal of Housing Policy, 12(2), pp.183–203. Available at: http://www.tandfonline.com/doi/abs/10.1080/14616718.2012.681579

References/2

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