Housing First is an effective housing and treatment intervention that ends and prevents homelessness for individuals with severe mental illness, co-occurring addictions, and other health problems, who have remained homeless for years (Gulcur et al. 2003; Tsemberis et al. 2004). Although this chronically homeless group constitutes only a minority of the homeless population, these individuals can account for over half of all public shelter stays (Kuhn and Culhane 1998). They also consume costly acute care services, such as emergency medical, substance use, and psychiatric care, often seeking out these services as a temporary respite from homelessness (Folsom et al. 2005; Kuno et al. 2000; McNiel and Binder 2005). By providing permanent, independent housing without prerequisites for sobriety and treatment, Housing First removes significant barriers to housing entry. By offering flexible and comprehensive consumer-driven support services that maximize housing retention, the model also prevents recurrent homelessness.
With an emphasis on funding permanent housing and support services for homeless individuals with disabling conditions, the federal Initiatives to End Chronic Homelessness, launched by the U.S. Interagency Council on Homelessness, is forging a comprehensive federal approach to end homelessness. Housing First programs are central components of these initiatives, as well as those of the more than 200 cities across the United States that have drafted ten-year plans to end chronic homelessness. This study examined the effectiveness of the Housing First approach, as implemented by two different programs in a suburban county, with regard to consumers’ housing status and housing retention rates. It also considers the programs’ divergent approaches to consumer selection and discharge, and their implications for consumer outcomes.
Traditional Housing and Treatment Services
Housing First offers a sharp contrast to existing housing programs for persons with mental illness, which typically offer permanent, independent housing only after consumers have demonstrated sobriety, psychiatric stability, and “housing readiness” by graduating through a sequence of short- and long-term treatments and transitional housing arrangements. One of the main reasons individuals remain chronically homeless is the reluctance of these traditional programs to provide housing to consumers who refuse psychiatric treatment, who are actively using alcohol or drugs, or whose histories of behavioral problems or criminal activity have led them to being labeled “not housing ready” (Meschede 2004). Because eligibility for housing is based on an individual’s willingness and ability to maintain sobriety, adhere to treatment, and adapt well to living in supervised congregate residences, many homeless persons with disabling conditions do not make an exit from homelessness. Those who do gain entry into housing programs are often evicted back into homelessness due to relapse, violations of program rules, or preference for self-determination and independent living, even if it means returning to the streets (Hopper 2006; Meschede 2004).
By operating housing services in a manner that is consistent with what consumers identify as their first priority—housing—Housing First engages persons whom traditional supportive housing providers have been unable to engage. Housing First programs offer immediate access to permanent independent housing, without requiring treatment compliance or abstinence from drugs or alcohol. The goals of Housing First are not only to end homelessness, but also to promote consumer choice, recovery, and community integration. Thus, Housing First programs offer housing in the form of scatter-site independent apartments in buildings rented from private landlords. Such residential arrangements honor the preference of consumers for apartments of their own (Goldfinger and Schutt 1996; Tanzman 1993) and afford people with psychiatric disabilities the opportunity to live in the community virtually indistinguishable from other residents, a fundamental aspect of recovery (Harding 1987a, b). To maintain this integration, the program does not lease more than 15% of the units in any one building. Units are rented from private landlords. This immediate offer of an independent apartment is a very powerful tool of engagement and consumers begin to recognize that the program is responsive to their needs and preferences. Addressing the consumer’s needs first is the guiding principle for all subsequent services that are offered and is the foundation for building trusting and supportive clinical relationships, an essential component of Housing First that maximizes housing retention.
Although limited community resources and funding may titrate the intensity and breadth of treatment and support services that Housing First programs may provide, ideally, consumers will have access to integrated and comprehensive support, usually through multi-disciplinary Assertive Community Treatment (ACT) teams, with slight modifications (Stein and Santos 1998). ACT teams are located off-site, but are on-call 24 hours a day, 7 days a week, and provide most services in a client’s natural environment (e.g., apartment, workplace, neighborhood) on a time-unlimited basis. Consumers are not discouraged, however, from visiting team members in their office. Teams are staffed with social workers, nurses, psychiatrists, and specialists in supported employment and peer counseling, and meet the national evidence-based practice standards for ACT (Phillips et al. 2001). Teams use a recovery-oriented practice philosophy that includes consumer choice as well as a harm reduction approach to substance use and mental health treatment. Teams offer consumers assistance with issues including housing, health care, medication, employment, family relations, and recreational opportunities (Tsemberis and Asmussen 1999). Service plans are not based on clinician assessments of consumers’ needs; rather individual consumers choose the type, sequence, and frequency of services and have the option of refusing formal treatment altogether without compromising their housing. Such a flexible, consumer-driven approach to clinical practice helps ensure that consumers remain engaged with the team, particularly during crisis, and facilitates open rapport.
Though consumers can refuse formal clinical services, such as taking psychiatric medication, seeing a psychiatrist, or working with a substance use specialist, the programs have requirements for a minimum of one visit per week by the team. The main purpose of the periodic apartment visits are to assure tenants’ safety and well-being, to assess the condition of their apartment, and most importantly to keep open the channels of communication between the consumer and members of the team. A typical visit consists of observing the consumer’s mental and physical state, following up on outstanding issues from the last visit, and offering assistance with any domain the consumer wishes to address, from apartment repairs to visiting families. The visits provide two essential forms of support: instrumental and emotional. The team often helps out with routine chores, but perhaps more importantly conveys to the consumer that he or she matters to the team. The team may just ‘sit and chat’ for a while but through it all they are empathic, compassionate, and purveyors of hope.
Consumers have their own lease or sublease and have the same rights of tenancy as other residents in their buildings. As tenants, consumers remain housed as long as they meet the obligations of a standard lease. As in most supportive housing programs, consumer have an obligation to pay 30% of their income towards rent (typically, 30% of their Supplemental Security Income). Further, by separating the criteria for housing from treatment, Housing First programs prevent reentry into homelessness for this high-risk group. The adverse consequences of relapse into substance abuse or a psychiatric crisis are mitigated because relapse is addressed by providing intensive treatment or facilitating admission to detox or hospital to address the clinical crisis—not by eviction because the consumer is using or experiencing psychotic symptoms. After completing treatment for their clinical conditions, consumers return to their apartments. Consumers in Housing First programs only risk eviction from their apartments for the same reasons as other building tenants including nonpayment of rent, creating unacceptable disturbances to neighbors, or for other violations of a standard lease. To prevent such evictions, teams work closely with consumers and landlords to address potential problems in the early stages.
Initial evaluations of Housing First in urban areas with primarily street-dwelling samples have yielded dramatically successful results. In one randomized clinical trial of housing alternatives over a four year period, individuals assigned to Housing First spent significantly less time homeless, more time in stable housing, and accrued fewer costs in terms of residential stays as compared to consumers in more traditional housing programs (Gulcur et al. 2003; Tsemberis et al. 2004). Additionally, although consumers in traditional programs reported higher rates of substance use treatment, there were no significant differences in rates of alcohol or substance use between the two groups (Padgett et al.2006). Further, consumer choice, an essential component of Housing First, has been associated with decreased psychiatric symptomatology, a relationship that is partially mediated by perceived sense of personal control or mastery (Greenwood et al. 2005). Finally, consumers rated housing satisfaction significantly higher when living in more independent supported housing settings as compared to congregate or community residences (Siegel et al. 2006). The study reported here explores whether the Housing First approach can achieve similar high levels of residential stability with a sample of chronic shelter users with psychiatric disabilities in a suburban county. Additionally, it identifies issues that may arise when the Housing First intervention is implemented by an agency that has previously practiced the traditional “housing readiness” approach to housing and treatment for the population.
In the early months of 2000, a County Department of Social Services (DSS) contracted two organizations to provide Housing First services to consumers with psychiatric disabilities, and often co-occurring substance abuse disorders, who were chronic recidivists in the county’s homeless shelter system. One provider was an agency with a long established record of operating Housing First programs but new to the county (Pathways to Housing); the other was a newly formed Consortium of treatment and housing agencies from within the county but with no prior experience operating Housing First. The study randomly assigned shelter users to one of the two Housing First programs as well as a “treatment as usual” control group. The housing status of participants in all three groups is presented at the 20-month follow-up point and housing retention rates for the two Housing First groups through just under four years. Additionally, because the goals of Housing First are to screen-in those clients considered “difficult to house,” and to accept everyone from this targeted group who meets eligibility criteria on a first-come, first-served basis, we present data on the proportion of consumers outreached/engaged versus actually housed. We also discuss how the engagement and retention data suggest that the Housing First agencies may have taken different approaches to housing placement and discharge. Finally, in order to address the cost-effectiveness of the Housing First approach, we present the contractual per/client costs that were associated with each program.