Housing First. What’s Second?

Housing First! What is Second?

Sam Tsemberis, PhD

20 September, 2013

Several ways to answer this question

1. Consumer/participant: what happens after housing?

2. Programs: given what we have learned from HF, what changes can programs make to be more effective?

3. Systems: What are the policy implications informed by Housing First?

4. How can we ensure that the widespread adoption of the term HF will not result in dissolution and program drift?

HF, What is second for Program Participants?

Social Networks: Friends, family, children, partners

• +Positive reconnections • +New social possibilities • - Dis/Continuity of street life

Social: Friends

• +Reconnection family and children

• +New roles and responsibilities • - Revisiting conflicts

Children & Family

After housing…

Health &Wellness/Weight Loss/Exercise

Finances/Budgeting/

Money Management

Alcohol/Drug -- Use Abuse

Mental Health Issues

JOB, JOB, JOB

eviction

HF, What is second for Services and supports? System change for housing

Services (1) service philosophy and array

• Most mental health services are primarily clinician driven, office based, specialized, and risk aversive

• Peer support is scarce

• Most effective treatment is consumer directed, community based, holistic

• What is second is surprising – prepare for a wide array • Manage new power differential effectively • Peer support must be integrated a vital component of

service/support

Services (2) service definition and approach

• Expand definition of services to include clinical, non-clinical, and other supports

• Expand definition service location and intensity (this work is up close and personal)

• Use a harm reduction approach for addiction and for mental health (and for everything other issue requiring long term strategies

• Stages of change is issue specific not person

• Planning is person centered

Services (3) Recovery support services

• Seek out (outreach) those who have been least engaged and may be most vulnerable

• Welcome , not intake (affect is important component of the service

• Is there a palpable message of hope? • We need define recovery (mental health) in participant “s

terms , i.e., improved quality of life (not the reduction of symptoms) -increased social ties, improved health and wellness, feeling of belonging, a part of the community, satisfied with living situation, etc.

HF, What is second for Housing Programs? System change possibilities for housing programs

Housing (1) The place of transitional in the age of permanent

• If we know that going directly into permanent housing with supports is the most efficient and effective way to end homelessness what is the role of transitional housing and shelter programs?

Housing (2) Introducing elements of HF into traditional programs

• Can existing programs begin to introduce elements of HF? • Change must be desired by all levels of agency • 4 key cost neutral changes to adopt:

1) target the most difficult to serve 2) do not make access or retention dependent on sobriety or treatment compliance 3) separate housing from treatment, and 4) hold units for participants who have to leave for short periods

Housing (3) Additional system changes

• Stop using diagnosis or psycho-social history or other clinical information to determine the best type housing for a consumer

• Every consumer should have the right to make their own choice about where to live and who to live with

• Give everyone a home and be prepared to support the person as needed

Housing (4) Long term – assume greater risk on behalf of consumers

• Most participants prefer scatter site and independent than single site apartments (RENT STIPENS AND MOBILE FLEXIBLE SUPPORTS)

• Most programs (esp. for poor with mental health issues) are single site group homes

• Scatter site model has positive impact on social inclusion • HF rentals have blurred the distinction between social

housing and private market (challenges the long held assumptions upon which social housing is based)

• HF challenges traditional clinicians, agencies, and government to increase their willingness to take risks and assume greater liability on behalf of program participants

HF, What is second for Policy Makers? How can we take HF to scale?

Housing First is an evidence based practice

• Numerous studies conducted by a variety of researchers across a myriad of settings with different populations all provide powerful evidence of the effectiveness and cost savings of the HF approach.

• Over time, this evidence resulted in change in government policy in the US and Canada adopting HF as the recommended approach to ending chronic homlessness (US) and homlessness (Canada).

Implementing policy change

• Having an official federal endorsement is a first step in creating system change, however funding for programs to implelement or adapt to HF, change in practice will not occur any time soon.

• Funding must be tied to policy and performance outcomes.

• Do we have enough affordable housing to implement HF? Yes. There are also implications here to inform houisng policy and how we go ahead with building much needed affordable houisng.

Continuous quality improvement, program evaluation, and research

• Eiji Toyoda applied a manufacturing culture based on continuous quality improvement and he used the Japanese concept of “kaizen,” a commitment to continuous improvements suggested by the workers themselves.

• “Workers work with their hands and their minds”

• Program participants are not passive recipients we must actively contribute to program improvements and research studies

If everything is called HF, Hey! Wait a second… Maintaining program fidelity in the face of widespread dissemination

HF Program and HF Approach • Actions must follow words, walk the talk.

• Choice

• Separation

• Social Inclusion

• -------

• Consumer choice – in a shelter

• Scatter site apartments – shared, sobriety

• No treatment admission requirements – in a single site building

Homeless

Rapid-rehousing

prevention

Low support Low needs

(families)

Moderate support & moderate needs

High support & high needs

Limits of Housing First Program Definition

We cannot afford not to end homelessness for those on the streets.

www.pathwaystohousing.org

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