Pathways Housing First!
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Program Philosophy and Practice
February 24, 2015
This Morning’s Agenda
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Welcome
Overview to the training
Introduction to Housing First program model
Housing operations
Support and treatment services
Treatment Philosophy
Harm Reduction/Peer Support
Research evidence: At Home/Chez Soi
Housing First as an Approach to Services
Open Forum Discussion (ongoing)
HPS Homeless-Services System
Redesign
• Transformation: Change expectations and outcomes for local
and regional systems for chronically homeless
• Redesign: Change ways of organizing and delivering services so
that they appropriate to client needs
• Collaboration: Organizations working together towards the
same goal of ending homelessness
• Tangible metrics: to determine program and system success,
and examine how funds are expended
Homeless Population
80% transitionally
homeless
10-15% episodically
homeless
5-10% chronically
homeless
10% use
50% of
system
resources
WHO IS ELIGIBLE?
Who are ‘the chronically homeless?’
• Living on the streets, shelters,
drop-in center
• Mental health problems
• Addiction and abuse
• Health problems
• Extreme Poverty
• Isolation
• Stigma
• PTSD/Trauma
• Loyalty as a value (loyal
brother and friend)
• Likes to cook, creative
• Listens to country music
• Follows sports teams
• Protective, roots for the
underdog, sociable
• Has a remarkable memory for
people and names
• Opportunities to learn about
addiction
Traditional Services Approach
Level of independence
Permanent
housing
Transitional
housing
Shelter
placement
Homeless
Treatment compliance + psychiatric stability + abstinence
Staircase Model is Based on Unrealistic
Expectations
Intersection of Mental Illness, Addiction
and Homelessness
Institutional Circuit
HOUSING FIRST
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Is a Paradigm Shift
Housing First Model
Permanent
housing
Transitional
housing
Shelter
placement
Homeless
Ongoing, flexible support
Harm Reduction
Housing First:
Key Elements of the paradigm Shift
Change in understanding of the causes and solutions for
homelessness (poverty not psychopathology)
1)
2)
Change in program philosophy (client choice)
Change in view of people served (people are capable of making
their own choices)
3)
Change in power relationships (client directs the type and
sequence of services)
4)
Change in service location and orientation (community-based not
office-based)
5)
Changes as continuous quality improvement (ongoing data
collection and program evaluation)
6)
5 Dimensions of a Pathways’
Housing First Program Fidelity
Housing: Independent Apartments in
Community Settings (Rental and Social)
• Most participants prefer own place in normal
settings
• Independent apt
• Scatter site (<20%)
• Creates sense of home
• Tenants Rights
• Affordable (30%) +rent supp
• Decent
• Support services are off site
HF is Permanent Supportive Housing
Integrated
Indistinguishable
Support services
are off site
Scatter site rural setting, Pathways VT
200 Tenants, 200 Apartments, 2 Counties, 6 Cities,
95 Landlords:
Housing Retention Rate 90.5% (12 mo)
Landlords as Program Partners
Common Goal
Landlord, agency and participant–
All want safe, decent, well-managed housing
Choice, Relocation and Limits to
Choice
• 2 Program requirements
A) 30% of Income towards rent
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B) Weekly apartment visits (change over time or
crisis)
• Negotiation about apartment relocation is different
than conversation about selecting first apartment
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• Conditions that require additional support, e.g.,
mobile crisis, involuntary commitment
Clinical and Support Services
• Consumers choose the type,
frequency and intensity of
services
•
Program requires home visit
(and there are limits to choice)
Goals of Housing First
• End Homelessness by providing immediate
access to permanent housing and supports for
people with behavioral health, addiction and
other complex problems
• Build self-determination and mastery (recovery)
by offering consumer-driven services
• Improve consumer’s quality of life and support
recovery
Housing first, what’s second?
Health &Wellness/Chronic and Acute Health Problems
job, training, education
Finances/Budgeting/Mo
ney Management
Alcohol/Drug -- Use Abuse
Mental Health Issues
Eviction
prevention
lega
l
Choice is the foundation and driving force
that directs clinical and housing services
• Choice, self-determination and building towards
graduation at the point of entry
• Practical limits of choice: real estate market,
standard lease obligation, fixed incomes, and other
real world constraints.
• Clinical issues and constraints to choice: psychiatric
emergencies, relapse, social networks, and more.
SERVICES MATCH CLIENT NEEDS
“NO WRONG DOOR”
ACT Team
Direct services;
trans-disciplinary
practice
ICM Teams
Some direct services;
brokerage model
Spiritual
Employment/
education
Income
Entitlements/
Legal
Wellness/
Nutrition
Participants
Immediate access;
client-directed
Friends &
Family
CLIENT
RN/MD
Arts /
Creativity
Addiction
HOUSING
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PEER
SUPPORT
Mental
Health
SERVICES: Matching the level of services to the
person’s needs (rearrange existing service models)
Intensive Case-management
• Moderate Need: ICM case
management team provides
support and brokers services
• Services provided in the
participant’s home or community
(group meetings offered at offices
or other community settings)
• Off site and on-call services 7-24
• All teams use a recovery
orientation
Local Service Coordinators
Regional Specialists
● Substance Abuse Specialist
● Peer Specialist
● Supported Employment
Specialist
● Digital Literacy Specialist
● Wellness Specialist
● Nurse
● Psychiatric Support
State-wide Admin Support
State-wide On Call Services
Pathways HF Program Staff
Red Clover Properties
- 2 Housing Specialists
Franklin/Grand Isle
- 1 Service Coordinator
- .5 Substance Abuse Specialist
Chittenden
- 3.5 Service Coordinators
- .3 Substance Abuse Specialist
Regional Service Specialists
- 2 Team Leaders
- 1 Supportive Employment Specialist
- 1.5 Computer Literacy Specialist
- .5 Nurse
- .3 Psychiatrist
Statewide
- Medical Director
- Project Manager
- Intake Coordinator
- Housing Director
- Administrative Staff
= Red Clover Properties
(Housing Team)
Regional Service Specialists
- 1 Team Leader
- .5 Computer Literacy Specialist
- .5 Substance Abuse Specialist
- .5 Peer Specialist
- .3 Nurse
-. 1 Psychiatrist
Washington
- 2.5 Service Coordinators
- .5 Substance Abuse Specialist
Addison
- 1 Service Coordinator
- .5 Substance Abuse Specialist
Windsor
- 1 Service Coordinator
Red Clover Properties
- 1 Housing Specialist
Windham
- 2.5 Service Coordinators
SEPARATION OF
HOUSING
AND SERVICES
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Separated spatially,
conceptually,
and operationally
PRINCIPLE 3: HOUSING and SERVICES
ARE SEPARATE DOMAINS
Program Philosophy,
Program Values
and
Program Practice
Philosophy
• Humanitarian: Psychological, Economic and
Human Rights Integration
1) Positive view of human
nature
2) Provide fundamental
security and support
3) Person is self-motivated
(program: housing as a
human right)
Medicine Wheel
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Focus on Aboriginal homeless population
• 3rd arm included traditional healing approaches
(e.g., medicine wheel)
RECOVERY
ORIENTATION
Person Centered
Capability focus
Inter-personal (you
are an active agent
in the treatment
and outcome)
Relationship is the Foundation
Key Role for Peer Support
PATHWAYS HOUSING
FIRST PROGRAM
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What is Program Fidelity?
How do you Measure it?
Why does it matter?
Why Fidelity?
The case of Housing First… “It’s all
about Housing & Choice”
Pathways Housing First Fidelity Scale Results: Program Spectrum
“Participants can choose the housing
they want regardless of whether they are
actively using.”
“Participants can choose to be clean and
sober and they’ll get an apartment. Or
they can choose to continue using and
we’ll still give them housing in a room &
board”
Fidelity Site Visit
• Before visit: collect basic info
o What types of housing do participants live in
o How long did it take to get into housing
o What percentage of participants have been discharged
• Team meeting observation
• Individual interviews with staff
o All frontline providers; Each discipline
o Team Leader
o Program Director, Administrators
• Focus group with program participants
• Chart review (random selection)
• Optional: home visits
Key Point
PATHWAYS HOUSING FIRST
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Program Evaluation and
Research Outcomes
MENTAL HEALTH COMMISSION OF CANADA (2009):
AT HOME/CHEZ SOI -- 5 CITIES, RCT N=2,215
Homelessness and Mental Illness
 Homelessness is a significant social problem in Canada
(Estimates of 200,000 individuals per year)
 Prevalence of mental illness and substance
abuse/dependence is high and associated with poorer
outcomes
 Higher use of health, criminal and social services
At Home/Chez Soi
Demonstration Project
• 2008 federal gov’t allocated $110 million over 5
years to the Mental Health Commission of Canada
(www.mentalhealthcommission.ca)
• Action research on how to support people with
severe mental illness to exit homelessness
• 85% funding for services and 15% for research
• Largest study of its kind in the world
Who Participated in At Home/Chez Soi?
• 2148 participants
• 1158 in Housing First (HF)
• 990 in Treatment as Usual (TAU)
• Primarily middle-aged
• 32% of participants are women
• 22% of participants identified as being an Aboriginal person
• Typical total time lifetime homeless is nearly 5 years
• All have one or more serious mental health issue
• Majority have a concurrent disorder
• More than 90% had at least one chronic physical health problem
Housing: Stability – by Program
Percentage of time housed
Summary of Fidelity Rating Results
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12 programs rated on 38 fidelity items in 5 domains
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Early implementation (Year 2) and one year later (Year 3)
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Overall, strong fidelity to the Housing First model (program
ingredients rated above 3 on a 4-point scale)
71% Year 2; 78 % Year 3
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Higher fidelity in the 12 programs (5 ACT, 7 ICM) was related to:
- greater direct and indirect service time and more contacts with
- participants (corr. = .55 to .60)
- greater housing stability (% of time in housing)
- greater improvement in quality of life (d = .10) and community
functioning (d = .11)
Lessons Learned:
1. CAPABILITIES
• People are much more capable
than we imagined possible.
• We have often confused
functionality with capability
2. Need to Assume More Risk and
Responsibility
Making progress requires a change in approach
that involves taking some calculated risks for
all of us (staff, board members, landlords,
housing authority and policy makers,
participants, family members, and the public).
Housing First
(scatter-site,
off site services)
Redesigning the System:
System Transformation
Single Site HF
(on-site services)
Respite, Communitybased, Residential
Treatment
Shelters, Drop-in
Outreach
Least restrictive to more restrictive setting
3. Dissemination/Replication
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High fidelity yield consistently high results:
80%- 90%
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Need local champion
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Clear understanding of program model
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Compatible values in host agency culture
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Resources for Housing and Services
THANK YOU for your attention
Contact us: sam@pathwaysnational.org
Visit: www.Pathwaystohousing.org
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