Suzanne Wagner
Andrea White
Housing Innovations
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Introductions
Background on Best Practices and Federal
Priorities
Housing Stabilization Services
◦ Overview of HSS
◦ Using the Lease to Structure the Work
◦ Coordination of Support Services with
Landlords/Property Management Services
◦ Connections with Mainstream Resources
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CTI Overview
Case Examples
Wrap up
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New federal directions (HEARTH and Federal
Strategic Plan (FSP) and
Evidence Based Practices (EBPs)
◦ Reduce length of time people spend in the crisis of
homelessness
◦ Rapidly exit them from homelessness and access
permanent housing
◦ Provide services in the home to achieve housing stability
and prevent returns to homelessness
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Principles and practices of Housing First have
been expanded to other homeless populations
besides chronically homeless with success
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New CoC Performance Standards- HEARTH–
“Homeless Emergency Assistance and Rapid
Transition to Housing”
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Reduce Length of Time Homeless
Reduce Newly homeless
Reduce Returns to Homelessness
Increase Permanent Housing Exits
Increase/Maintain Income
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Federal Strategic Plan (FSP) – “Opening Doors”
◦ Retool the Homeless Crisis Response System
◦ More Permanent Housing Options
 Rapid Rehousing
 PSH
 Service Enriched Housing
◦ Focus on Employment and Income
◦ Use Mainstream Resources – income and services
◦ Get Kids in School
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Working toward Family self-sufficiency
◦ Increase income;
◦ Enhance household budgeting and bank
relationships;
◦ Invest in basic educational attainment;
◦ Advance school enrollment for all children; and
◦ Promote good tenancies through lease compliance.
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Principles and Practices with Applicability to Other
Homeless Populations
 Immediate access to housing
 Low or no threshold for entry
 Single site or scatter site housing
 Harm reduction approach to substance use and
other life issues
 Limited program requirements and case
management service model
 Separation of housing and treatment/support
services. Focus on housing stability
 Not “Housing Only”, must have services
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Emerging practice
Do basic and simple screening for housing
barriers
Provide a minimal amount of assistance to
all people
Provide additional assistance as needed by
the household
Based on research (or lack thereof) that we
cannot predict who will become homeless
and instruments to determine need for
services have not been validated.
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Critical Time Intervention (CTI) TI has been
recognized an Evidence-Based Practice by the
federal Substance Abuse and Mental Heath
Services Administration (SAMHSA) and the
President’s New Freedom Commission on Mental
Health
CTI is based on the research of Columbia
University’s (Columbia Center for Homelessness
Prevention Studies) work with the homeless
individuals
Point at which person moves into new housing
provides a critical opportunity to make changes
www.criticaltime.org
End family’s homelessness permanently
Assist families to stabilize in housing
Assist people to secure/maintain stable income
Assist families to reintegrate into the community
Assist families to access and use mainstream
resources
Assist families to establish long term goals as a
motivator for change
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Housing is the goal, the lease and family’s
self-defined long term goals focus the work
Best predictor of the future is the past, get
housing history
Treatment/services are often resources to
achieve the goal, not the goal itself
Not always a linear process
“Assertive” landlord/property mgmt is
necessary
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Provide services in the home and the
community
Ongoing assessments of housing barriers to
prevent housing loss
Connect with other mainstream and
community-based services – benefits and
services
Connect with natural supports including
spiritual
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Landlords and property managers to establish
tenancy obligations and enforce them
Focus on eviction prevention and use the
structure of the lease to guide your
interventions
Coordinate Property Management and Social
Services interventions
Use Evidence-Based Practices EBP’s
◦ Critical Time Intervention
◦ Motivational Interviewing
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Maintaining housing
Increase/stabilization of income (earned
and benefits)
Connections with services and supports to
prevent becoming homeless again
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Assessment
◦ Goals
◦ Understanding Barriers to Housing
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Engagement on Common Goals
Education
◦ Expectations of Tenancy, Lease and Housing Options
◦ Available Resources for Support
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Housing Stabilization Plans (aka “Service Plans”) and Services:
◦ Using treatment as a link to self-defined goals
◦ Using CTI as a tool
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Linkages and Coordination
◦ Landlords/Property Managers, Community, Services, Treatment
Resources
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Evaluate progress
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Paying Rent
• Income and financial management
• Subsidy Compliance if applicable
• Logistics: check or money order, timeliness
Maintaining Apartment
• Understanding and meeting cleanliness standards
• Inspections
• Safety and managing repairs
Quiet Enjoyment
• Getting along with neighbors
• Visitors
• Following building/unit rules and norms
Occupancy
• Only people on the lease live there
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Don’t pay rent
Violate rules e.g., noise
Hoard or otherwise create health and safety
hazard
People move in who are not on the lease
Engage in criminal activity
Others??
Need to monitor and assist in meeting
tenancy obligations
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Limit the areas of
intervention based
on housing barriers
assessment
Focus on the most
pressing needs that
impact housing
Be aware this may
not be a linear
process
Relate all
interventions to
keeping housing +
long term goals
Be mindful about
moving from crisis
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Housing Stabilization and Lease Compliance
Income and Financial Management
Family & Other Relationships
Mental Health and Medical
Substance Use and Misuse
Life Skills
Strengths and Potential for Change – how has
person managed in the past?
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A safe place to live
Work
Enough money to live on
Friends
Valued status and a role in the community –
purpose and structure
Move from crisis
Community
A chance for their children
“Dignity of Risk”
5 Years from now?
Explore what each family’s choice means
 History (i.e. housing, employment, safety)
 How this family became homeless: what
worked what didn’t
 How each family has managed in the past
 Preferences: what does the parent/family
want
 Financial Issues
 Implications of disabilities or service needs
and how this relates to goal
 Long term goals: how do they see their
future?
Goals set as a team of clients and worker
Focus on the issues that affect housing
retention – base on what caused the current
crisis and previous episodes of housing
instability
Immediate and longer term goals clear
 The Plan determines your interventions
Steps to reach goal clearly defined and measurable
Longer term needs require connections to other
resources.
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Tenant and Staff Roles
•Reflects areas of the assessment
•Prioritizes areas for work
•Sets time frames for work to be
accomplished
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Mainstream Resource Identification
• Clearly defines resources needed to access and/or
maintain housing including: income, benefits,
credit repair, legal services, employment
assistance, financial planning and management,
access to medical services and child care,
educational support, access to community based
services such a schools, mental health, substance
abuse, etc.
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Measure Success
• Uses documented steps to reach goal
and benchmarks set
• Uses phases to gauge expectations and
progress
• Identifies need to renegotiate goals and
resources
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One of the goals is for families to be stably housed and
in order to do so, they need to learn how to manage
their tenancy obligations.
One of the keys to achieving this goal is the active
coordination between property management and
support services staff, while maintaining the functional
separation of these two staffs.
Having separation of functions helps tenants learn by
being treated no differently from any other tenant by
the property management. (Don’t want to create
alternate reality)
Problems that threaten tenancy may motivate tenants to
use services in order to keep their housing.
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Betty is always happy to see the case
manager. They talk a couple of times a week.
The worker helped her with the children’s
school, gives her rides, and food pantry
referrals. It is always something. Betty has no
one else to help her. She has four children on
her own. She lives from crisis to crisis. The
worker feels they are making progress but
Betty just has too much to deal with.
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Landlord has a key role in helping people
understand their obligations and comply
with them. (Assertive approach)
◦ Establish the expectations for the tenant
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The social services staff provide and
arrange for services needed to maintain
housing and also function as advocates for
the tenant.
◦ Assist the tenant to meet the expectations of
tenancy
Provide written program information
Explain role of CM as resource
• Provide contact information
• Means to resolve issue so that tenant can remain in housing
Engage in proactive coordination/communication
• Check in on some regular basis, preferably meet regularly
There is some “natural” tension in the work
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Hold tenant to the obligations of the lease
Respond to problems in a timely way
Contact case manager early on when
problems first arise
Provide written notices to tenants of rule,
lease violations or late rent payment
◦ Ideally, cc the case manger
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Work with Case Manager to resolve barriers to
maintaining unit.
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Landlord/tenant mediation services
◦ Funded as homelessness prevention
◦ Education for case managers as to legal
requirements/process
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Use of the courts
◦ Stipulation process
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Planning for emergency resources
◦ Rent and Utility payment
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Housing plan to maintain tenancy
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Agreement on project goals: Assisting
Tenants to Maintain Housing
Acknowledge that the services are
transitional but also will identify on-going
supports
Each is oriented to each other’s roles
At least monthly communications focused
on tenants compliance with lease
Input and feedback from property
management staff is sought and valued
Support and acknowledge the
landlord/property management role
There is often a great deal of confusion and frustration
around what information can be shared and what information
is confidential
EXAMPLES
Public display of intoxicated behavior: Public Information
Tenant disclosing a mental health diagnosis or medical
information: Confidential
Other CONFIDENTIAL information: Any information that is
obtained in the context of professional services is deemed
privileged information
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Develop a family focused resource list
Identify Resources by Focus Areas and Tasks
Review Resources in Current Use
Add resources developed through work with
tenants
Identify Needed Connections
Income, benefits AND services
Using Client resource directories in each
region
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Benefits and Entitlements including
Emergency Assistance
Financial literacy and credit repair services
Employment Programs
Education and Job Training Programs
Legal Services
Food and Nutrition Programs
Children’s Services
Clothing and Furniture Banks
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Health Clinics
Dental Services
Mental Health Services
Substance Use Treatment Programs
Counseling Services – Family, DV, Trauma
Lists of AA and NA meetings
Emergency Services – DV Hotline, Child Abuse
and Neglect Reporting, Mobile Mental Health
Services
Social, Spiritual and Recreational
Opportunities
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Public transportation
Community centers
Camps and employment programs for adolescents
Libraries
Civic associations
Settlement houses
Parks, recreational and sports facilities
Places of worship
Adult education, classes and workshops
Tutoring and mentoring programs for children
Arts organizations
Clubs and hobby groups
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Ensure knowledge of them – directory, visits to
programs, ask clients, goals and what they
provide
Introduce yourself and your agency, especially if
there will be a lot of referrals
Explain your role and what they can expect
Attempt joint or coordinated service planning
Gather and share history (with client’s consent)
Accompany person to assist with engagement
with new service
Maintain regular contact and keep your promises
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Be Persistent, Patient And Reachable
Provide information about the person that helps them to
do their job
Recognize Each Program Has Their Personal Service &
Outcome Goals
Ask About And Understand Expectations For Participants
Be On Time For Appointments And Follow Up With Any
Information They Require For Admission
Understand How The Program Interacts With Your
Client’s Health Insurance, Entitlements, Patients Rights
To Services, & Other Collaterals
Assure The Provider Of Your Involvement
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Educating on the process
Helping tenants to negotiate for services and
enlisting the services help
Establishing regular check ins
Recognizing strong partners
Renegotiating the relationship as necessary
Assists individuals and families to stabilize in housing by:
◦ strengthening people’s ties to community services, family, and
friends
◦ the provision of a focused case management approach that is
◦ connected to each participant’s life goals.
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Time-limited (6-9 months)
Three 3-month phases of decreasing intensity (transition to the
community, try out, termination)-starts when moving into housing
“Manualized” Intervention with Focused services (1-3 areas from 6
assessment areas) based on threat to long-term housing stability
and access to support (mental health, housing, substance misuse,
life skills, financial, and family and other social supports)
www.criticaltime.org
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Longitudinal: adapt to family functioning over time
Individual: care is planned with the family and
addresses particular needs
Comprehensive: families can receive a variety of
services related to their many needs
Flexible: families are allowed to progress at their own
pace
Accessible: families are able to access services when
they need them and in a way which is financially and
psychologically manageable
Communication: between family and case manager
and service providers and among service providers
involved in the family’s care
Housing Planning
 Phase 1: Transition to the Community
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◦ CTI begins
Phase 2: Try-out
 Phase 3: Termination
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Phases 1-3 last approximately 1-3
months each
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Engagement
Risk Assessment: Assess for any crisis situations
Educate person about Housing Options they may be
eligible for
Provide direct services and assistance to link with
resources as needed
◦ May include income, ID, and other concrete needs to access
housing
◦ Addressing immediate needs
◦ May be linkages to needed care such as psychiatric, medical,
dental or SA
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Housing Assessment
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Assessment of new needs and resources
◦ Review assessment and revise based on current housing and
lease compliance. Identify resources needed. Focus on
community support, role and activity
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Housing Planning revision
◦ Review plan and revise based on priority area, immediate needs
and current resources.
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Assistance in making linkages: meeting with the
person and the resource if necessary
◦ Refine communication structures with landlord, services and
other supports
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Skill building for community resources
◦ Provide education about rights, responsibilities, and
expectations; model negotiation skills
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Solidifying Linkages to Community Resources
◦ This might include: legal assistance, schools for
children, religious/spiritual, community treatment and
support options
Promote independent living skills
◦ Ensure income in place, financial management, tenancy
obligations, schedule and role
Ensure communication support systems
Regular meetings monitor progress and connections
Developing longer term plan
◦ Look at non-immediate needs such as education
planning, career goals, long term housing plans
Continue to use MI techniques
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Fine Tuning Linkages
Higher Level Skills training
◦ Focus on Negotiating Skills
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Plan to address housing risks as they arise
Step down and let go- having other linkages
take primary role
◦ Ensure needs are met, develop adjust linkages if
needed
◦ Assess worker role going forward
◦ Develop formal plan with household and Linkages
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Some families may not be able to complete the
program in nine months:
◦ We have not definitively identified who that group of
families is
◦ CTI can be used as an assessment tool
◦ Identify longer term resources in the community
◦ Identify longer term rent subsidies in the community
◦ How does access to those resources get prioritized?
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Supervision:
◦ At least: weekly individual supervision, weekly team
meetings with case conferencing
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Case Conferencing:
◦ Highlight best practices, identifies themes around
barriers, highlights resources, provides clinical
consultation
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Team Meetings:
◦ Team meetings have an informational, monitoring and
support function, track where people are in the transition to
and identify common barriers, share information and
resources amongst team members, alert team to people in
distress or crisis, identify best practices
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Training
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Involve leaders
Set shared aims
Welcome everyone
Self-conscious
Non-linear
Devolve control
Manage knowledge with agility
Reflective and responsive
Sense- making
Values asking
Recognition economy
Stimulate affection among members
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The Jones family has been living in their
apartment for 6 months. The mother has had
a hard time finding a job but she is trying.
The children are doing well in school. They
seem to have a lot of people in and out. You
talked to Ms. Jones about this and she said
she has a big family. The landlord calls you.
He is ready to evict. He says that her sister
has been living there and he has warned her
three times. This is it. It is the first time you
heard about it.
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Ending homelessness takes a village
New models and strategies
New outcomes
Building on the experience of Regional
Networks to End Homelessness Pilot Projects
In order to achieve goals, must continue to
evolve services and programs
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