Housing First!And Systems Change for Housing & Mental Health Services

Sam Tsemberis

Housing First!

And Systems Change

for Housing & Mental Health

Services

Sam Tsemberis, PhD

INTERNATIONAL CONFERENCE

AEIPS LISBON, PORTUGAL

9 December, 2013

Outline

1. Existing systems and their

underlying assumptions

2. Housing First: Housing and

Services

3. Research outcomes4. System Transformations

Who is served by Housing First?

• Homeless

• Mental health problems

Addiction and abuse

• Health problems

• Poverty

• Isolation

• Stigma

• PTSD/Trauma

Housing First is also an economic intervention

The Culture of Poverty

and Public Policy

• “Culture of poverty” has become a cornerstone of a certain conservative ideology

• Poverty is not seen as caused by low wages or lack of jobs, but by bad attitudes and faulty lifestyles “sin, sick or social change” O’Sullivan)

• So in the spirit of righteousness and even compassion many programs are configured as social service programs to cure, not poverty, but the “culture of poverty”

• This is part of the unspoken ethos underlying the assumptions in todays homeless services system

Common misunderstandings about

mental illness and housing readiness

• Mental Illness as a life long course needing treatment and support

• People who are homeless and have a mental

illness (and co-occurring addiction) must first

be stable in order to be “housing ready”

• People with severe mental illness need to live where

they can be supervised

Traditional Housing

Readiness system

Homeless

Shelter placement

Transitional housing

Permanent housing

Level of

ind

ep

en

den

ce

Treatment compliance + psychiatric stability + abstinence

Key to Inpatient Ward

Bellevue Psychiatric Hospital

A short history

of services for people

with mental illness

Why do so many

Avoid mental health services?

Labelling, stigma,

isolation, cultural beliefs, etc.

Intersection of

Mental Illness, Addiction and Homelessness

Institutional Circuit

“Frequent users”

Breaking the cycle begins by taking

a consumer driven approach

9 December, 2013

Core beliefs and practices of

Pathways Housing First Program

• Social justice – housing as a basic human right

• People with mental illness and/or addiction do not have to prove they are ready for or deserve housing

• Outreach and engagement – responsibility is on the provider

• Program is based on principles and philosophy of:

▫ 1. Psychiatric rehabilitation

▫ 2. Harm reduction

▫ 3. Consumer movement

▫ 4. Recovery oriented practice

Housing First: System re-designImmediate access to housing no requirement for treatment or sobriety

Homeless

Shelter placement

Transitional housing

Permanent housing

Level of

ind

ep

en

den

ce

Treatment compliance + psychiatric stability + abstinence

Homeless

Shelter

placement

Transitional

housing

Permanent

housing

Ongoing, flexible support

Person Centered

Harm Reduction

Housing First Model

Target Population for Housing and

Services

• The program reaches out to engage people with

complex needs

• Complexity is the expectation not the

exception

• People with complex needs are welcome!

• Program practices and procedures designed to

facilitate speedy admission and provision of all

desired service (especially housing)

Housing First:

System change and system integration

• Direct access – housing right away• No assessment to determine housing readiness or optimal housing type for a consumer

• No treatment or sobriety requirements beyond standard lease

• Every consumer is given opportunity to make their own choice about where to live and who to live with

• Most want a place of their own but HF provides necessary referrals for other choices

Housing and Services

Social Inclusion and

Community Integration

“If the goal is successful community

integration then housing for people with

psychiatric disabilities should look like

where you and I live.” (ref: Olmstead

decision)

5 Essential Components of

Pathways’ Housing First

1. Consumer choice of services2. Separation of Housing and Services

(conceptually and physically separate) 3. Service Philosophy: recovery oriented4. Service array: services and support

match consumer needs (include a wide array of services)

5. Program structure: housing and services

1. Housing Choice: Independent apartments in

community settings (Scatter Site Housing Model)

�Assessment is consumers preference

�Most want own place in normal settings

� Independent apt creates sense of home

� Integrated housing (<20%)

�Services are off site

60 Tenants, 60 Apartments, 2 Counties, 6 Cities,

31 Landlords: Housing Retention Rate 90.5%

Pathways VT: Housing First In Rural Areas

Single Site Approach to Housing

First

• Some programs concentrate special needs

populations and have services on site (time

consuming, too few units, creaming, and not

socially integrated)

Son returns from tour in Afghanistan and stays

with (formerly homeless) dad in his apartment.

Housing is an adjustable commodity

• It’s not moving into a housing program

it’s moving into your home

• Financial and other tenant

responsibilities as a component of

recovery

• Programs provide tenancy related

support (e.g., furniture, repairs,

landlord, lease, neighbors, etc.)

Ontological Security and Economic

Responsibility and Citizenship

• Landlords are program partners

• Agency has a business relationship with

landlord – not a clinical relationship

• Tenant has a business relationship with

landlord (meet terms and conditions of

the standard lease; same rights and

responsibilities as any other tenant)

Working with Private Market Landlords

Housing First: Agency must assume

greater risk on behalf of consumers

• Scatter site model has positive impact on social

inclusion

• HF blurs the distinction between social housing and private market rentals

• HF challenges clinicians, agencies, and government to increase their willingness to

take risks and assume greater liability on behalf

of program participants – e.g., lease on behalf

of consumers

Some Operation Advantages of Scatter Site Housing

� Separate Housing and Services: Commitment is to the person

(rent stipend is portable, goes with the person)

� Meet challenges of operating harm reduction programs

especially when housing issues are involved

� Immediate start up (program can be operational within 1-3

months of funding)

� Develop relationship with a network of community landlords

(potential for employment opportunities)

� Last, but really first, most frequently chosen option)

JOB, JOB, JOB

evicti

on

Services

Provided Directly or Brokered

Spiritual

Wellness/Nutrition

Arts /Creativity

HOUSING

Addiction

PEERSUPPORT

LegalIncome

Entitlements

Employment/education

MentalHealth

Friends & Family

ant

ACT Team

Direct

services;

Trans-

disciplinary

practice.

ICM teams some direct;

brokerage

model

Participants-No wrong

Door –

Immediate

access—

-Client

directed

CLIENT

RN/MD

Program Philosophy and Practice for Clinical and Support Services Team:� Consumer choose type, frequency and intensity of services

� Team meeting - (1-5 times a week – ACT 3-5; ICM 1-2)

� All staff conduct Home Visits

� Working as a team: “We have each other’s back”, geographic coverage, cross coverage, etc. Rural variations include teleconferencing among a number of smaller teams

� Provide 7/24 on-call

Recovery Focused Mental Health Services

�Relationships are

foundational

����Peer support

����Knowledge and

skills to self-

manage

����Emphasis on

welcoming,

hopeful, inspiring

culture

Program Service Philosophy and Practice

• Program is welcoming, trauma –informed,

complexity capable

• Every staff member is welcoming, trauma

informed, complexity capable

• Build on strengths used during periods of success

Quadrant III High Severity Substance Use Disorders Low Severity Mental Illness

Quadrant IV High Severity Mental Illness High Severity Substance Use Disorder

Quadrant I Low Severity Mental Illness Low Severity Substance Use Disorder

Quadrant II High Severity Mental Illness Low Severity Substance Use Disorder

Four Quadrant clinical integration model

for co-occurring MH & SUD

Physical Health Risk / Complexity

Behavioral Health Risk / Complexity *

Quadrant 1

BH ↓↓↓↓ PH ↓↓↓↓

•Primary care provider

•Psychotropic medication

consultation

•Care management

Quadrant 3

BH ↓↓↓↓ PH ↑↑↑↑

•Primary care provider

•Psychotropic medication

consultation

•Establish linkages w/specialty care

•Care management

Quadrant 2

BH ↑↑↑↑ PH ↓↓↓↓

•Assertive Community Treatment

•Established linkages with

psychiatric hospitals

Quadrant 4

BH ↑↑↑↑ PH ↑↑↑↑

• Integrated Primary Care within

Assertive Community Treatment

•Established linkages with

medical/psychiatric hospital

(along with specialty care)

Low

High

High

The Four Quadrant Clinical Integration Model (modified with permission from the National Council for Community Behavioral Healthcare)

Parallel process of recovery for

Multiple Conditions

• Stage of change is issue specific not person-based

• Recovery involves:

▫ Addressing each condition over time

▫ Moving through stages of change for each condition

• Integrated treatment involves stage matched

treatment intervention for each condition

Adjust services to

meet client needs

Service Array:

EXPAND Service Definition and Approach

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

• Expand service location (in vivo) and intensity

• Use a harm reduction approach for addiction

and for mental health issues

• Social, cultural, employment, education, and

other meaningful activity

• Planning is person centered

Recovery support and definition

• Is there a palpable message of hope?

• Recovery is not about the reduction of psychiatric symptoms or reducing frequency of hospitalization, it is defined in the participant’s own terms, i.e., improved quality of life; increased social ties, improved health and wellness, feeling of belonging, a part of the community, satisfied with living situation, etc.

Graduation and

Community Integration

• Services can be reduced over time or

stopped altogether

• Use of community services, resource center,

or no services

• In scatter site model, the service providers

walk away and the person stays home

Ceremonies Graduation:

Friends, family, children, partners

Summary:

Operations Lessons learned

• Match services to client need

• There’s no place like home

• The importance of hiring peers

• HF is not only a new program it is a new

way of life

HF and Systems Change: If we take HF to scale…

What Does the New System Look Like?

Housing: 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?

Community-based,

Residential Treatment

(on-site clinical staff)

Permanent Single Site

(on-site services)

Permanent

housing

(scatter-site,

off site services)

Redesigning the System:

System Transformation

Longer term

Institutional Care

Least restrictive to more restrictive setting

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 serve2) do not make access or retention dependent on

sobriety or treatment compliance3) separate conditions to be met for access and retention

of housing from treatment, and 4) hold units for participants who have to leave for

short periods

Why Change?

HF 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, Canada, Europe

adopting HF as the recommended approach to

ending chronic homlessness.

Front-LinePractice

Differing Provider Perspectives by Program Model: A Program Implementation Paradox

TF providers were consumed by the pursuit of housing

HF providers focused on clinical concerns

Housing First Model

Treatment First Model

Focus on Housing

Focus on Treatment

Stanhope, V., Henwood, B.F. & Padgett, D.K. (2009). Understanding service disengagement

from the perspective of case managers. Psychiatric Services, 60, 459-464.

MENTAL HEALTH COMMISSION OF CANADA (2009):AT HOME/CHEZ SOI -- 5 CITIES, RCT N=2,215

Dissemination and

Systems Change

Implementing policy and system

change

• Instituting official policy is a first step in creating

system change, however without funding for new

programs and training to implelement or adapt to

HF, systems change will be difficult

• Funding must be tied to policy and directly tied to

program performance outcomes.

• Is it really HF? How long from admission to house?

Are services enough, flexible, and consumer

driven? Is it housing of consumer’s choice? Etc.

SYSTEM CHANGE CASE EXAMPLES:

Stories from the field

� CASE EXAMPLE 1: INDIVIDUAL� Utah shelter director converts

� CASE EXAMPLE 2: PROGRAM� CT shelter director holds firm

CASE EXAMPLE 3:HUD–VASH system and culture change

�Why the Veterans Administration adopted HOUSING FIRST

� Issues with Outreach� Finding Housing, Section 8 applications � Security deposits, furniture�Working as a team � Harm reduction versus incident reporting� Changing priorities - meeting deadlines versus identifying the right people

Challenges In Implementation and

Program Fidelity

� Housing First is not housing only� Choice is not laissez-faire� Harm reduction is neither enabling or a road to abstinence

� Peer specialists are not junior case managers� If you give people housing they will not be motivated to get better

� The city’s vacancy rate is not a barrier

Lessons in Implementation and

Dissemination Science

• 1. Program – is the intervention well understood?• 2. Outer setting - economic, political, landlords,

partnerships with other programs and widercommunity – business, education, criminaljustice, etc.

• 3. Inner setting – org experience, staff stability, board, and org culture

• 4. Individuals - attitudes towards intervention,believe it will work or is necessary?leadership at all levels

• 5. Process - planning, engaging, executing

• People are much more capable than we imagined possible.

CapabilitiesCapabilitiesCapabilitiesCapabilities

• Moving forward Moving forward Moving forward Moving forward requires taking requires taking requires taking requires taking risks.risks.risks.risks.

Embrace risk andEmbrace risk andEmbrace risk andEmbrace risk andliability liability liability liability

• With high fidelity With high fidelity With high fidelity With high fidelity yields consistently yields consistently yields consistently yields consistently high results: 85%high results: 85%high results: 85%high results: 85%

DisseminationDisseminationDisseminationDissemination

It’s not an institution, a building or a

program -- it’s a home!

We can end chronic homelessness:

From Exclusion to Community

THANK YOU FOR YOUR

ATTENTION!

For additional information, visit:

www.pathwaystohousing.org

or email:

stsemberis@pathwaystohousing.org