Gregg Pieples
Greater Cincinnati Behavioral Health Services
gpieples@gcbhs.com
Andy Hutzel
Over-the-Rhine Community Housing
ahutzel@otrch.org
Fred Baxter
Greater Cincinnati Behavioral Health Services
flbaxter@gcbhs.com
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Community Mental Health Agency
Founded in 1971
350 employees
Serves approximately 6000 individuals per year
Services offered:
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Psychiatric
Care Management
Specialized Care Management (Homeless, Court)
Counseling
Vocational
Day Program
Integrated Health Care – Nursing, medical care, pharmacy services
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Projects for Assistance in Transition from Homelessness
(PATH) – Homeless Outreach
PATHS TO RECOVERY
Uses Housing First Approach
IDDT/ACT Team
Integrated Behavioral Health Counselors in Health Care for
Homeless Site
Housing First ACT Team
Uses Housing First Approach
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Mental Health
 Greater Cincinnati Behavioral
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Substance Abuse
 Alcoholism Council
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Housing
 OTRCH
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Evaluation
 SARDI -
Wright State University
Scattered Site
S+C
OTRCH
GCB
Owner / Landlord
Housing Voucher
Front Desk Staff
Care Management
Counseling
Groups
Jimmy Heath House
Front Desk
OTRCH
93 Admissions to date
75 current units of housing
25 Congregate units (JHH)
48 Scattered-site units
Chronically homeless
Chronic Public Inebriates
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Multiple arrests
Failed Treatment Hx
Non-service connected
Currently using
Currently homeless
Official Start Date: October 2009
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A consumer driven housing and support
service that offers people who are homeless
immediate access to an apartment of their
own and the services needed for recovery.
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The direct, low barrier placement into permanent housing
 No requirement to complete another program first
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Provision of intensive, readily available support services
 Although participation in these services is not required
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Sobriety is not a requirement
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Use of Evidence based practices (EBP)
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Continued services regardless of previous or continued
failures
Consumer driven
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SAMHSA / HUD priority
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Housing First is an "evidence-based practice,“
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Multiple research studies report that HF programs consistently show significant positive impact on
its target population
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Longer stays in Housing
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Reduced substance use
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Less hospitalizations and incarcerations
Impact of using a Housing First methodology at Pathways to Housing
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Showed significant housing retention rates and lower substance use rates as compared with
traditional Contiuum of Care programs.
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Autonomy & Control. Perceived choice was much higher in Housing First.
The Streets to Homes program in Toronto
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housed more than 1,500 people since inception
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87 percent have remained housed.
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Reduction in the use of …
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Substances, emergency services such as 911, emergency rooms, ambulance, fire, police detox, and jail
"Some people think when you give housing away that you’re actually
enabling people as opposed to helping them get better. Our
experience has been that the offer of housing first, and then
treatment, actually has more effective results in reducing addiction
and mental health symptoms, than trying to do it the other way. The
other way works for some people, but it hasn’t worked for the people
who are chronically homeless."
Sam Tsemberis
Founder & CEO
Pathways to Housing
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Variations occur in…
 service type & intensity
 housing type
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Outcomes show consistency in Housing
retention but vary in other areas
Seattle vs. New York Models
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Separation of Housing & Treatment
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Client Choice of Housing & Services
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Intensive Treatment Services
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A Recovery Philosophy
Requires a change in Thinking
Housing Services
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Apply for housing subsidy
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Find apartment
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Sign lease
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Maintain housing (abide by
a lease)
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Supportive housing contact
weekly
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Treatment and Support
services
◦ Using ACT or other
Intensive Case Management
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Relapse (either MH or
SA) is expected
◦ Does not result in housing
loss
Treatment Services
Traditional Perspective
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Need to learn pro housing behavior
(transitional housing required)
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Acceptable ADL’s, sober, motivated to
work a “plan”
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Take medication
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Until proven housing ready still
homeless
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Client oriented
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Everyone has a right to housing
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Client can choose housing
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Immediately placed into
housing
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Housing not contingent on
treatment compliance
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Expectation that client will sign
lease and abide by it
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Supportive Housing Visit
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Treatment is offered not
required
If didn’t cooperate terminated due to
non compliance
Judging people to be incapable of
having an apartment
Case Manager views self as expert and
determines what is best for client
Housing First Perspective
ACT or Intensive Case Management Service
Traditional Perspective of
SA Treatment
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Integration of SA and MH treatments
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Flexibility of staff
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Demands treatment prior to move in
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Assertive outreach
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Any exception viewed as enabling
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Recognition of client preference
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Expected that clients will keep
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Close monitoring
appointments, no outreach
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Comprehensive services
If client doesn’t keep appointments
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Stage-wise treatment(i.e pre-
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contemplation)
CM will terminate services due to poor
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follow up
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Recognizes accomplishments
Case managers repeatedly point out
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Conveys optimism
bad consequences of using and
traditional substance abuse treatment
is only viable option
IDDT Perspective of SA
Treatment
Choice is the foundation of Housing First
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Dignity of Choices
 Right to risk
 People make mistakes and learn from the experience
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Learn to ask what clients want
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Offer what housing options you have
 Client makes choice
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Clients typically want their own apartment
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Treatment Services are offered; not required
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Landlord, Agency and Tenant have common goal
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Agency makes sure rent is on time
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Agency is responsive to landlord concerns
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Tenant Rights and Responsibilities-there are limits
to choice
◦ Must sign lease
◦ Pay portion of Rent
◦ Abide by Lease
Traditional Perspective
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Clients with many needs
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into community
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require group settings
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Group settings often
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◦ case manager knows what
is in the clients best
interest
Feels part of society and
has increased sense of
self worth
Client has no choice in
housing option
Can be indistinguishable
from everyone else
have supervision 24/7
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Clients can fully integrate
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Can feel they truly have
own home
Housing First Perspective
Traditional Perspective
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Case manager views self as the expert
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determines what is best for client
Manipulating client through coercion
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no real choice
Must take meds to get into housing
Cant transport if smells like alcohol
Clients do not see consequences as
their responsibility if they don’t see
their choice
Client may reject any services
◦ except supportive housing visit
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Can’t work on any treatment goals
unless sober
Must express they want treatment
before moving into housing
Client chooses treatment goals &
services
Client determines frequency of
service & sequence of service
Focus on establishing trust by
meeting needs as presented by
client
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No strings attached
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Teaches responsibility
◦ use consequence of behavior as
opportunity to learn
Housing First Perspective
Recovery is possible
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Convey Hope
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Offer choice after Choice
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Are respectful, patient, nurturing, compassionate
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Are strength based and client centered
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Move client toward independence
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Allows SA clients to determine what recovery is to
them
Importance of Evidenced Best Practices
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Housing First
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Integrated Dual Diagnosis Treatment
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Motivational Interviewing
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Trauma Informed Care
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Strengths Based Case Management
Goes hand in hand with the Housing First
Model
A collaborative,
person-centered
form of guiding
to elicit and strengthen
motivation for change
February 2009 Revised definition
Center for Evidence Based Practices
Ohio SAMI CCOE
What is Motivational Interviewing…?
Motivational Interviewing
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Listening with empathic
understanding
Evoking client’s own
concerns/motivations
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Reducing resistance
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Nurturing hope & optimism
Guiding Principles
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Express Empathy
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Develop Discrepancy
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Roll with Resistance
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Support Self-Efficacy
It’s about connecting to individuals that have
made a habit out of not connecting
 Precontemplation
 Contemplation
 Preparation
 Action
 Maintenance/Relapse
Prevention
Prochaska and DeClementi, Miller and Rollnick 1991
Ohio SAMI CCOE Regional Training
PreContemplation
Relapse
Contemplation
Maintenance
Preparation
Action
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Pre-contemplation  Engagement
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Contemplation & Preparation  Persuasion
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Action  Active treatment
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Maintenance  Relapse Prevention
Ohio SAMI CCOE Regional Training
NOT CHANGING CHANGING
Using drugs, not taking
meds, skipping group tx
Getting sober, taking
meds, attending groups
Benefits
“Pros”
Costs
“Cons”
Ohio SAMI CCOE Regional Training
Fred Baxter
MSW, LSW
Clinical Counselor
Team
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5 FTE’s
Program Manager
Counselor
Two Care Managers
Peer Specialist
Data person
Services
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Housing Support
Care Management
Counseling
Crisis Intervention
Groups
Peer Mentoring
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Basic Needs
Housing Support
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Cleanliness
Safety
Communication with Landlord
Lease obligations
Benefits
Food
Clothing
Medical care
Vocational
Social Supports
Non-Traditional
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Setting
◦ Often not in office
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Style
◦ Rarely a sit-down
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Length
◦ Very short sessions
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Dialogue & Topic
commonality
Rapport Building
Trust through
demonstration
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Assessment
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Groups
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Treatment Referrals
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Individual
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Engagement by Nature
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Support and Education
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Coordination of Services
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Respect Others
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Able to participate
◦ Intoxicated members
◦ Highly symptomatic members
Structure
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Welcome
Topics
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Open
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Flexible
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Examples
 Connection
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Announcements
 Coordination
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News
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Educational Segment
 What is hope?
 Cultural Diversity
 Community Safety
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Group is voluntary
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Relational
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Staff and client connected
Group patterns and counseling must consider
the members interest, motivation and
cognitive ability
A review of the population
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Chronic homelessness
Chronic alcoholism
Multiple arrests
Failed Treatment Hx
Non-service connected
Currently using
Currently homeless
Selection Committee
Committee Members
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Monthly Meeting
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DIC
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All potential Clients
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HIP Team
 Reviewed
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Cincinnati Police
 Prioritized
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DCI (Chico / Valerie)
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OTRCH
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PATH
2004
2007
Project History
2007
•Community Task Force
•InterAct for Health
•HUD SSH Funds
Awarded
2006
•Housing & Developers
•3CDC
•OTRCH
•Congregate site located
•Site Financing
•HUD SHP
•Federal Home Loan
Bank
•City HOME funds,
•Local foundations
2008
•SAMHSA Grant
•Services Agencies
•Design & Implementation
2009
2010
•First Client Housed
•Local foundations
•Jimmy Heath House
Opened Dec 2010
Today
◦ 91.2% male
◦ 52.7% African American / 45.1% Caucasian
◦ Average age = 50.11 years
◦ 11.0% Veterans
◦ 60.4% completed 12th grade
◦ 97.8% unemployed
34.1%
65.9%
Shelter
Street/Outdoors
39.6%
Scattered site apartment
60.4%
Jimmy Heath House
98.8%
97.3%
97.0%
96.9%
96.4%
92.4%
All Clients
90.3%
88.6%
Retention Excluding
Clients with a
'Deceased' Program
Discharge (N=10)
6-Month
12-Month
18-Month
24-Month
Retention
Retention
Retention
Retention
30
25
20
25.05
16.48 16.12
15
Baseline
6-Month Follow-up
10
5
12-Month Follow-up
0
Average Past 30 Day
Alcohol Use
20
15.62
15
10
Baseline
8.62
5.61
5
6-Month Follow-up
12-Month Follow-up
0
Average Past 30 Day
Alcohol Use to Intoxication
10
9.57
9.64
8
6
5.42
Baseline
6-Month Follow-up
4
12-Month Follow-up
2
0
Average # of Days Experienced
Serious Depression in Past 30 Days
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Arrest and confinement data
◦ Obtained from the Hamilton County Clerk of Courts
◦ 57 clients
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Criminal justice data
◦ Obtained for the 24-month period before and after
housing placement
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60% reduction in arrests (335) between the preand post-housing periods
Time Period
# of Arrests
% of Total Arrests
Pre-housing period
563
71.2%
Post-housing period
228
28.8%
Total
791
100%
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Statistically significant reduction in arrests
Pre-housing
period
Average # of
arrests
Post-housing
period
9.88
4.00
Level of
significance
.000
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44% reduction in jail days between the pre- and
post-housing periods
642 fewer jail days in the post-housing period
Time Period
Pre-housing period
Post-housing period
Total
# Days Confined
% of Total
Confinement
1456
64.1%
814
35.9%
2270
100%
◦ No statistically significant reduction in jail days
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Examined the relationship between
 service dosage & changes in alcohol and mental health
outcomes
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Clients with greater baseline alcohol use & more
individual counseling sessions
 had reduced alcohol consumption
 between baseline & 6-month follow-up
 (F = 15.98, p = .000)
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Strong Regression
 29.7% of the change in alcohol use explained by the model
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Excellent housing retention
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Sustained reductions in alcohol use
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Reduced criminal justice activity
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Low staff turnover
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Strong, continued partnerships
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Active participation in services
97.7%
Care
85.2%
80.7%
85.2%
Group
Individual
Housing
Management Counseling Counseling
Support
Operations
Traditional Property Mgmt
Property Mgmt in HF
Application process is first come,
first serve
Selection Committee determines
most vulnerable
Property manager makes decisions
Blended management committee
makes decisions
Eviction notices if late on rent
Housing retention and payment
plans if late on rent
3 strict compliance letters = eviction 6 or more strict compliance letters
depending on act
Substance use not tolerated
Substance use discussed openly and
attempt to address
Rules are rules
Rules can be guidelines
May or may not have supportive
services
Extensive supportive services,
engaged in all
No front desk staff
Front desk staff are eyes & ears for
all
Clear roles with service provider
Many roles overlap with services
Scattered-Site
Congregate
Many, diverse landlords
One landlord
Ability to transfer
Tough it out
No house rules or front desk
staff
House rules, 24 hr staff &
monitoring, incl video cameras
Transportation issues
Know where to find residents
Typically 4-6 unit buildings
More people and units
Less expensive
More expensive
Less services
More services, on site staff
Volunteer groups, activities
Lessons Learned
Communication and teamwork
 Measure success in years, not weeks or
months
 Housing First for the 10th time
 Difficult decisions
 Every Housing First project is a bit
different
 Be creative in addressing issues
 Chronic illness much greater than
anticipated
 Patience is critical
 Staff morale is ongoing concern
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Try to be a helper rather than a policeman.
Even when dealing with very difficult behavior, most
people are doing the best they can (at the
moment). They are up against their limitations. “When I
knew better, I did better”
Services need to be individualized and focus on the
particular needs of the client. Clients can demonstrate
the same behavior with very different etiologies.
Trauma and mental illness are often the occult cause of
negative behavior, substance abuse may take center
stage and be the most apparent issue but it may not be
the source of the issue.
It is difficult for homeless individuals to transition into
permanent housing. We frequently see men and
women who have been “housed” for years remain a
“Homeless Person” in their mind.
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Assess carefully –clients are frequently having cognitive
issues or suffering from dementia from long term
substance abuse.
Harm Reduction needs to be the center of the approach
to individuals in housing first programs
When working with actively using addicts, interventions
should first focus on the negative behavior, not the
addiction it’s self. It’s not the substance abuse in
and of it’s self , it’s the behavior.
Not all negative behavior is based on addiction. One
should look at social skills, competency, physical
limitations, cognitive abilities. Many clients do not have
basic coping skills or ability to manage a household.
Chronic means chronic issues will reoccur
And small group exercise
1.
Centers for Disease Control and Prevention.
(1999). Framework for Program Evaluation in
Public Health. Morbidity and Mortality Weekly
Report, 48(RR11), 1-40.
1.
2.
Substance Abuse and Mental Health Services
Administration. Permanent Supportive Housing:
Evaluating Your Program. HHS Pub. No. SMA10-4509, Rockville, MD: Center for Mental
Health Services, Substance Abuse and Mental
Health Services Administration, U.S.
Department of Health and Human Services,
2010.
Burt, M.A. (2004). The Do-It-Yourself Cost-
Study Guide. Assessing Public Costs Before and
After Permanent Supportive Housing: A Guide
for State and Local Jurisdictions. Corporation
for Supportive Housing.
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Most difficult to house client
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What are the barriers to successful housing?
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What are some strategies to overcome those
barriers
Would any HF principles assist in the process?