Expansion of Housing First HUD-VASH & Homeless Veterans Solution-Focused Mark A. Engelhardt, MS, ACSW July 12, 2011 July 12, 2011 USF Dept. of Mental Health,

Expansion of Housing FirstExpansion of Housing First HUD-VASH & Homeless HUD-VASH & Homeless

VeteransVeteransSolution-FocusedSolution-Focused

Mark A. Engelhardt, MS, Mark A. Engelhardt, MS, ACSWACSW

July 12, 2011July 12, 2011USF Dept. of Mental Health, Law USF Dept. of Mental Health, Law

& Policy& Policy

VA Housing First InitiativeVA Housing First Initiative

National Center on Homeless National Center on Homeless Veterans – USF-FMHI & Pathways to Veterans – USF-FMHI & Pathways to Housing (Sam Tsemberis & Juliana Housing (Sam Tsemberis & Juliana Walker) – Training & Technical Walker) – Training & Technical AssistanceAssistance

13 VA HUD-VASH Programs identified 13 VA HUD-VASH Programs identified to implement a Housing First Modelto implement a Housing First Model

VAMC’s & Community PartnersVAMC’s & Community Partners

22

What is Housing First?What is Housing First?Sam Tsemberis Ph.DSam Tsemberis Ph.D

A person-centered approach designed to A person-centered approach designed to end homelessness and support recovery end homelessness and support recovery for people with mental illnessesfor people with mental illnesses

Housing First provides immediate access Housing First provides immediate access to permanent housing and support to permanent housing and support services and consumers are not required services and consumers are not required to participate in psychiatric treatment or to participate in psychiatric treatment or attain a period of sobriety in order to attain a period of sobriety in order to obtain housing. obtain housing.

33

Why Was Housing First Why Was Housing First Developed? 1992Developed? 1992

To help people with mental illnesses To help people with mental illnesses who remained homeless over timewho remained homeless over time

““Are people homeless because they Are people homeless because they have a mental illness or for the same have a mental illness or for the same reasons as everyone else”? reasons as everyone else”?

Million Dollar Murray – Million Dollar Murray – Malcolm GladwellMalcolm Gladwell Pathways to Housing, NYCPathways to Housing, NYC www.pathwaystohousing.org www.pathwaystohousing.org

44

Housing First EvidenceHousing First Evidence SAMHSA’s National Registry of Evidenced-SAMHSA’s National Registry of Evidenced-

based Programs & Practices (NREPP)based Programs & Practices (NREPP) www.pathwaystohousing.org Publicationswww.pathwaystohousing.org Publications Housing Retention at 85%Housing Retention at 85% Reduction in service utilization, ER’s JailsReduction in service utilization, ER’s Jails Improved Mental HealthImproved Mental Health Reduction in Alcohol & Drug UseReduction in Alcohol & Drug Use Cost Effectiveness Cost Effectiveness

55

National VisionNational Vision

U.S. Interagency Council on HomelessnessU.S. Interagency Council on Homelessness ““Opening Doors” – Federal Strategic Plan to Opening Doors” – Federal Strategic Plan to

Prevent and End HomelessnessPrevent and End Homelessness 5 Year Plan to End Veterans Homelessness5 Year Plan to End Veterans Homelessness SAMHSA – Evidence-Based Practices KIT SAMHSA – Evidence-Based Practices KIT

(Knowledge Informing Transformation) on (Knowledge Informing Transformation) on Permanent Supportive HousingPermanent Supportive Housing

66

National MovementNational Movement HUD has moved towards models that HUD has moved towards models that

result in Permanent Housing and has result in Permanent Housing and has conducted studies on Housing Firstconducted studies on Housing First

Hundreds of Communities across the Hundreds of Communities across the U.S. have adopted Housing First as a U.S. have adopted Housing First as a primary strategy in their “10 Year primary strategy in their “10 Year Plans to End Chronic Homelessness”Plans to End Chronic Homelessness”

Housing First Movement (since 1992)Housing First Movement (since 1992)

77

Florida LegislatureFlorida Legislature

Florida Legislation – SB 1054 (2009) Florida Legislation – SB 1054 (2009) ““The Legislature further finds that The Legislature further finds that

Housing First is an alternative approach Housing First is an alternative approach to the current system of emergency to the current system of emergency shelter or transitional housing…to shelter or transitional housing…to encourage (Fl.) homeless continuums to encourage (Fl.) homeless continuums to adopt the Housing First approach to adopt the Housing First approach to ending homelessness for individuals and ending homelessness for individuals and families”families”

88

Local Florida CommunitiesLocal Florida Communities Local Coalitions have “promoted” Housing Local Coalitions have “promoted” Housing

First in their HUD Continuum of Care First in their HUD Continuum of Care applications (New Hearth Act), yet may applications (New Hearth Act), yet may not clearly understand the core recovery not clearly understand the core recovery principles, have access to immediate principles, have access to immediate housing, staffing patterns and funding.housing, staffing patterns and funding.

Several localities have been successfulSeveral localities have been successful Others have “pushed back” the concept Others have “pushed back” the concept

99

VA Housing First SitesVA Housing First Sites

Bay Pines – St. Bay Pines – St. Petersburg, Fl.Petersburg, Fl.

New Orleans, LANew Orleans, LA Dallas, TXDallas, TX Washington, DCWashington, DC Philadelphia, PAPhiladelphia, PA New York City – New York City –

Bronx & NY HarborBronx & NY Harbor

Boston, MABoston, MA Chicago, IllChicago, Ill Detroit, MIDetroit, MI Denver, CODenver, CO Portland, ORPortland, OR San Francisco, CASan Francisco, CA Greater Los Greater Los

AngelesAngeles

1010

Veterans – Target Veterans – Target PopulationsPopulations

Long Term HomelessLong Term Homeless Living on the Streets, Shelters, ElsewhereLiving on the Streets, Shelters, Elsewhere High Risk for Criminal Justice SystemHigh Risk for Criminal Justice System High Prevalence of Co-occurring High Prevalence of Co-occurring

DisordersDisorders Complex Healthcare Problems & TraumaComplex Healthcare Problems & Trauma Veterans Strengths & Access to BenefitsVeterans Strengths & Access to Benefits Outreach, Engagement & Peers Outreach, Engagement & Peers

1111

VA Housing First Roll OutVA Housing First Roll Out

50+ Dedicated Housing First Vouchers50+ Dedicated Housing First Vouchers Reduction in Caseload Sizes Reduction in Caseload Sizes Option to Subcontract all or a Portion of Option to Subcontract all or a Portion of

the Program with Community Partnersthe Program with Community Partners Increase Substance Abuse, Housing, Increase Substance Abuse, Housing,

Peer Specialists & Engagement with Peer Specialists & Engagement with VAMC’sVAMC’s

Emphasis on Field-based & TechnologyEmphasis on Field-based & Technology

1212

Current Development Current Development ActivityActivity

Data Analysis of Available VouchersData Analysis of Available Vouchers Timetable From Outreach to Housing Timetable From Outreach to Housing

including Public Housing Authoritiesincluding Public Housing Authorities Housing Stock & Landlord DevelopmentHousing Stock & Landlord Development Start up funds and community resourcesStart up funds and community resources HUD-VASH Team Composition & HUD-VASH Team Composition &

ApproachApproach History of Referrals & Targeted ReferralsHistory of Referrals & Targeted Referrals

1313

Current DevelopmentCurrent Development

Gradual Shift to Harm Reduction for VAGradual Shift to Harm Reduction for VA Motivational Interviewing TechniquesMotivational Interviewing Techniques Access to Co-occurring Services Varies Access to Co-occurring Services Varies

among VAMC’s and Communitiesamong VAMC’s and Communities Telemedicine in Rural AreasTelemedicine in Rural Areas Technology – Smart Phones, computersTechnology – Smart Phones, computers Co-location in the communityCo-location in the community

1414

In the Context of RecoveryIn the Context of Recovery

Self-Direction Self-Direction (Housing Choices)(Housing Choices)

Individualized & Individualized & Person-DrivenPerson-Driven

Empowerment Empowerment (Affordability)(Affordability)

HolisticHolistic Non-LinearNon-Linear

Strengths-based Strengths-based (ability to Rent/Own)(ability to Rent/Own)

Peer Support (Dual Peer Support (Dual Recovery/AA, etc.)Recovery/AA, etc.)

RespectRespect Responsibility Responsibility

(Leases)(Leases) Hope – Permanent Hope – Permanent

Housing & RecoveryHousing & Recovery

1515

Key Change ElementsKey Change Elements

Change from a Linear Housing ModelChange from a Linear Housing Model Change in the view of those servedChange in the view of those served Change in the goals of the systemChange in the goals of the system Change in power relationshipsChange in power relationships Change in focus and locus of careChange in focus and locus of care Change in treatment cultureChange in treatment culture Traditional Models to ContemporaryTraditional Models to Contemporary

1616

Housing ModelsHousing Models

Traditional ModelsTraditional Models Treatment FirstTreatment First Housing “Ready” (linear)Housing “Ready” (linear) Sober for a period of Sober for a period of

time 30 days to six time 30 days to six monthsmonths

Transitional – 6 months Transitional – 6 months to 24 monthsto 24 months

Staff on-site; Staff on-site; “supervised”“supervised”

Congregate livingCongregate living

Housing FirstHousing First Housing FirstHousing First Move-in with supportsMove-in with supports No sobriety required, No sobriety required,

abstinence encouragedabstinence encouraged Permanent supportive Permanent supportive

housinghousing Staff off-site, mobile, Staff off-site, mobile,

24/7 access or on call24/7 access or on call Independent livingIndependent living

1717

Housing First: Main Housing First: Main ComponentsComponents

Housing – Primarily Scattered site Housing – Primarily Scattered site independent apartments rented from independent apartments rented from community landlords community landlords

Clinical Services – Treatment and Clinical Services – Treatment and support services provided by off-site support services provided by off-site Assertive Community Treatment Assertive Community Treatment Teams or Intensive Case Management Teams or Intensive Case Management “that makes house calls” “that makes house calls”

1818

Values & PrinciplesValues & Principles

In the context of a positive relationshipIn the context of a positive relationship When consumers set their own goalsWhen consumers set their own goals Receive support and are taught skillsReceive support and are taught skills Have positive expectations for hope for Have positive expectations for hope for

the futurethe future Obtain Permanent HousingObtain Permanent Housing When people believe in their own When people believe in their own

recoveryrecovery

1919

Essential IngredientsEssential Ingredients

Consumer Choice PhilosophyConsumer Choice Philosophy Separation of Housing and ServicesSeparation of Housing and Services Recovery-oriented ServicesRecovery-oriented Services Community Integration = Community Integration =

“INCLUSION”“INCLUSION” Fidelity Scales – Structure, Philosophy, Fidelity Scales – Structure, Philosophy,

Practices: “A Matter of Degree” and Practices: “A Matter of Degree” and Quality ImprovementQuality Improvement

2020

Consumer Choice Consumer Choice PhilosophyPhilosophy

Philosophy Guides PracticePhilosophy Guides Practice Housing First provides consumers an Housing First provides consumers an

apartment of their own as a matter of apartment of their own as a matter of right or need, not as a reward for right or need, not as a reward for treatment compliancetreatment compliance

Consumer choice of housing, type, Consumer choice of housing, type, sequence (non-linear) and intensity of sequence (non-linear) and intensity of servicesservices

Harm reduction vs. strict sobriety modelHarm reduction vs. strict sobriety model

2121

Limits to Consumer ChoiceLimits to Consumer Choice

Practical and clinicalPractical and clinical Availability to affordable housingAvailability to affordable housing Local housing stock Local housing stock Weekly apartment visitWeekly apartment visit Person may be a danger to themselves Person may be a danger to themselves

or othersor others Legal Issues – Illegal activity, violence, Legal Issues – Illegal activity, violence,

etc.etc.

2222

Separation Housing & Separation Housing & ServicesServices

Housing & services are separate Housing & services are separate domainsdomains

Different expectations and Different expectations and requirements for defining successrequirements for defining success

Clinical services are a treatment Clinical services are a treatment relationshiprelationship

Housing is about responsibilities of Housing is about responsibilities of tenancy (good neighbor, tenant, etc.)tenancy (good neighbor, tenant, etc.)

2323

Clinical - HousingClinical - Housing

Clinical “crisis” does not mean eviction or loss Clinical “crisis” does not mean eviction or loss of housingof housing

Eviction from housing does not mean discharge Eviction from housing does not mean discharge from clinical services, continuing care, from clinical services, continuing care, outreach, in-reach, self-help, or other recovery-outreach, in-reach, self-help, or other recovery-oriented careoriented care

Abstinence is not “required”, but is encouraged Abstinence is not “required”, but is encouraged Housing retention is a major goalHousing retention is a major goal

2424

Landlords as PartnersLandlords as Partners Landlord, tenant and program have a Landlord, tenant and program have a

common goal = All want safe, decent common goal = All want safe, decent and well managed (quality) housingand well managed (quality) housing

Agency/consumer ensures the rent is Agency/consumer ensures the rent is paid on time; damaged paidpaid on time; damaged paid

Team is responsive to landlords needsTeam is responsive to landlords needs No rent loss for vacanciesNo rent loss for vacancies Public Housing Authorities are criticalPublic Housing Authorities are critical

2525

Advantages of Using Advantages of Using Existing Rental MarketExisting Rental Market

Quick start upQuick start up Multiple sites - scatteredMultiple sites - scattered Ability to match consumers to Ability to match consumers to

neighborhoodsneighborhoods Flexibility in relocation Flexibility in relocation Normative settings (integrated)Normative settings (integrated) Social inclusionSocial inclusion

2626

Recovery-OrientedRecovery-Oriented

Recovery from mental illnesses and Recovery from mental illnesses and substance use/abuse is possiblesubstance use/abuse is possible

People can live full and independent People can live full and independent lives in and “of the community”lives in and “of the community”

Role recovery – friend, family Role recovery – friend, family member, peer, employee, spouse, member, peer, employee, spouse, parent, sibling, church member, parent, sibling, church member, neighbor. neighbor.

2727

Implications for PracticeImplications for Practice

Instilling HOPE is crucialInstilling HOPE is crucial Relationship is foundational – eliminate Relationship is foundational – eliminate

“power’ differential and role distinction “power’ differential and role distinction between provider and consumerbetween provider and consumer

Key roles of peer support “on the team”Key roles of peer support “on the team” Meaningful social roles – beyond the Meaningful social roles – beyond the

“mental health system” = Citizenship“mental health system” = Citizenship

2828

Holistic WellnessHolistic Wellness

Wellness LifestyleWellness Lifestyle Positive daily structurePositive daily structure Meaningful activityMeaningful activity Diet, exercise, access to primary careDiet, exercise, access to primary care Healing trauma (men and women)Healing trauma (men and women) Spirituality Spirituality Connection to othersConnection to others

2929

Service DeliveryService Delivery

Assertive Field-Assertive Field-based based Interdisciplinary Interdisciplinary Team ApproachTeam Approach

Intensive Case Intensive Case Management Management

““Offer” to a range Offer” to a range of clinical servicesof clinical services

Co-occurring SAMHCo-occurring SAMH

Vocational and Vocational and Employment Employment opportunitiesopportunities

Peer SupportsPeer Supports Healthcare benefits Healthcare benefits

(Medicaid) – (Medicaid) – MedicationMedication

Housing Retention Housing Retention

3030

Targeted Websites Targeted Websites

www.hazeldon.org/bookstore www.hazeldon.org/bookstore http://www.nrepp.samhsa.gov http://www.nrepp.samhsa.gov http://www.homeless.samhsa.gov http://www.homeless.samhsa.gov http://pathprogram.samhsa.gov http://pathprogram.samhsa.gov http://www.endhomelessness.org http://www.endhomelessness.org http://www1.va.gov/HOMELESS/http://www1.va.gov/HOMELESS/

NationalCenter.asp NationalCenter.asp www.flshc.net www.flshc.net

3131

Contact Information Contact Information

Mark A. Engelhardt, MS, MSW, ACSWMark A. Engelhardt, MS, MSW, ACSW [email protected]@usf.edu 813-974-0769813-974-0769 www.mhlp.usf.eduwww.mhlp.usf.edu

3232