Understanding the “Support” in Supportive Housing Richard Cho 100,000 Homes Campaign “All Hands on Deck” Call September 14, 2011
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Understanding the “Support” in Supportive
Housing
Richard Cho
100,000 Homes Campaign
“All Hands on Deck” Call
September 14, 2011
2
Corporation for Supportive Housing
CSH is a national non-profit organization that helps communities create permanent housing with services to
prevent and end homelessness.
CSH advances its mission through advocacy, expertise, innovation, lending, and grant-making.
Key Questions
What is supportive housing?
What are the services in supportive housing?
How can we pay for the services in supportive housing?
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What is Supportive Housing?
Supportive housing is permanent, affordable
housingcombined with
a range of supportive services
that help people with special
needslive stable and independent lives.
5
People who:
But for housing cannot access and make effective use of treatment and supportive services in the community;
and
But for supportive services cannot access and maintain stable housing in the community.
Who is Supportive Housing For?
6
Supportive Housing Comes in Many Forms
Apartment buildings exclusively housing formerly homeless individuals and/or families.
Rent subsidized apartments leased in open market.
Apartment buildings with mixed income households, including the formerly homeless.
Long-term set aside of units within privately owned buildings.
Services integrated within existing affordable housing developments.
Single family homes, including shared housing environments.
More than Housing + Services
Simply pairing rent subsidies or affordable housing units with services does not make supportive housing
In supportive housing, housing and services linked such that whole is greater than sum of parts (synergistic effect):– Services informs housing/property management– Housing’s function viewed as platform for
improving outcomes for most vulnerable Not just any services – Supportive housing
entails specific approach to services
What is the Services Model in Supportive Housing?
Ironically, the “support” in supportive housing is most difficult aspect of the model to describe
Usual approaches fall short:– The “laundry list”– Titles like “case manager,” “services coordinator”– Staffing ratios (e.g. “1:20” or “1:15”)– Terms and phrases like “flexible,”
“comprehensive,” “voluntary vs. mandatory” Need better deconstruction of services in
supportive housing
What Do We Know About the People Supportive Housing Tries to Reach?
Chronic behavioral health challenges (mental illness, substance use, often co-occurring)
Physical health/medical challenges Long histories of homelessness (lack of recent
experience living in housing) and instability Likely to engage in “risky” behaviors Often involved in multiple public service settings May be “resistant” to services and change
Mismatch of Various Service Modalities
Services Modality
What It Is Reaction
Treatment/ therapeutic emphasis
Services are clinical and focus on treatment of mental illness or substance use
Housing refusal, early attrition or termination, return to homelessness
Brokered case management
Services as “yellow pages”; referrals out to various community-based or mainstream services
Low trust of case manager, low engagement from services, lease violations
“Self-help” or behavioral modification
Services emphasize self-awareness and behavioral change
High failure rate, low engagement in services
Why Do These Approaches Fail?
Presume same “needs hierarchy” between services provider and tenant
Fail to recognize tenant’s past negative experiences with services
Assume that tenant’s own behaviors, patterns, actions are the main source of pathology
Expectation of change in short-term despite long history and pattern of instability
Competing Need Hierarchies?
Behavioral Health
Physical Health
Housing
IncomeFamily/
Relationships
Independence
Independence
IncomeFamily/
Relationships
Housing
Physical Health
Behavioral Health
Provider’s Assumed Hierarchy of Tenant’s Needs
Tenant’s Actual Hierarchy of Own Needs
Implications for Services
Having pre-determined and proscribed set of service goals will lead to disappointment
Requiring services participation as condition of tenancy does not work if tenant values independence greater than housing– Given long history of having no housing, individuals may not
feel the “value” of housing immediately Judgmental attitude towards behaviors will
encourage tenants to lie or disengage Services must overcome perception of negativity Recognize that change will take a long time, will be
incremental, and non-linear
Key Considerations for Effective Services in Supportive Housing
Emphasis on engagement, rapport building Goal of services should be to help individuals remain
housed through problem-solving– Help them retain housing at least long enough to help them
rebuild attachment and develop healthy fear of losing housing again
Place tenant in driver seat of goal setting Non-judgmental attitude increases open
communication and ability to anticipate problems Allow for incremental change Cultivate sense of self-care and wellness through
compassion not condescension or coercion
A Simple Theory of Change for Supportive Housing
Tenants are chronically homeless, have complex health conditions, and are
resistant to change
Prioritization and Placement in
Housing
Troubleshooting of Housing Problems /
Lease Violations
Housing Stability
Engagement and Rapport
Building
Motivational Enhancement
and Empowerment
Services Goal
Setting
Connection to and Coordination of
Needed Services (Health, Behavioral
Health, Employment)
Improved Health and Social Outcomes (Recovery)
Three Functions of Services
Tenants are chronically homeless, have complex health conditions, and are
resistant to change
Prioritization and Placement in
Housing
Troubleshooting of Housing Problems /
Lease Violations
Housing Stability
Engagement and Rapport
Building
Motivational Enhancement
and Empowerment
Services Goal
Setting
Connection to and Coordination of
Needed Services (Health, Behavioral
Health, Employment)
Improved Health and Social Outcomes (Recovery)
Revisioning the Services in Supportive Housing as Three “Stool Legs”
Housing Stability Supports
•Focused on ensuring housing stability•Troubleshooting housing-related issues•Preventing lease violations and eviction
Care Management•Focused on improving health care access and coordination and shifting service use from inpatient/crisis to outpatient/preventive•Health care assessment, planning, coordination of services•Can incorporate Wellness Self-Management
Rehabilitative/ Recovery Services
•Focused on skill-building around activities of daily living•Education about behavioral health, medications•Peer supports•Recovery readiness services•Relapse prevention
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Enables Understanding of Link to New Payment Systems Under Medicaid
Housing Stability Supports
•Not Medicaid eligible
Care Management
•Consistent with services model under Health Homes State plan option
Rehabilitative/ Recovery Services
•Eligible under Home and Community Based Services (1915c or 1915i)
Most Services in SH Match Medicaid Eligible Services
Analysis “crosswalking” services in supportive housing with 1915c Home and Community Based Services found that:
– 61% of services matched HCBS by category/type
– 85% of service hours delivered were of those types that matched HCBS
The Future
In the future, will supportive housing’s services model be assembled in a modular fashion and through new organizational?– Linkage to Health Homes (e.g. FQHCs) to pay for
care management?– Home and Community Based Services to
reimburse rehabilitative services?– State grant or federal MH or SA block grant funds
to pay for housing stability supports?
Shift in Emphasis and Capacity of Supportive Housing Services?C
are Management
Rehabilitative Supports
Housing Stability Supports
Care management
Rehabilitative Services
Housing Stability Supports
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