normalisation of housing and living conditions in the field of homeless services: some financial...
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Presentation given by Dr. Volker Busch-Geertsema, Association for Innovative Social Research and Social Planning (GISS) e.V., Bremen, Coordinator of the European Observatory on Homelessness, at a FEANTSA seminar on "Funding strategies: Building the case for homelessness", hosted by the Committee of the Regions, June 2012TRANSCRIPT
Normalisation of Housing and Living Conditions in the Field of Homeless Services:
Some Financial Arguments
Dr. Volker Busch-Geertsema, Association for Innovative Social Research and Social Planning (GISS) e.V., Bremen, Coordinator of the European Observatory on Homelessness
7th European seminar on local homeless strategies
Funding strategies: Building the Case for Homelessness
Co-hosted by the Committee of the Regions, FEANTSA and HABITACT
Brussels, Friday 8 June 2012
Overview
Housing First as an alternative to staircase systems: Quick normalisation of housing and living circum-stances as a better way of integration
Not only better but cheaper as well? Financial arguments in favour of Housing First and a quick normalisation of housing and living conditions for homeless people
Some problems regarding usual financial arguments
Potentials of Cost-Effectiveness Studies in Europe
Ending homelessness: More than a financial question
The Critique of the Staircase Approach
In the staircase model homeless people have first to address their problems before moving to the next stage of a series of steps towards ordinary self-contained housing (often considered as without further support)
In this model homeless people have to be made “housing ready” in different stages, with decreasing intensity of support, control and supervision and increasing autonomy and privacy
Permanent housing is understood as a “reward” for showing (and maintaining) sobriety and compliance with treatment and support plans
Primary housing market
moreless
more lessindividual support, care, control, discipline
private space, autonomy, normality
Secondary housing market
reception stage
“final dwelling”,full security of tenure
time-limited, no security of tenure
shared dwellings near institution, stay time-limited and based on special conditions, shared facilities
institutional setting, hostels, shelters, etc.
regular dwelling with (time-limited) occupation agree-ment based on special conditions
regular self-contained dwelling with rent contract
shared housing, “training dwell-ings”, etc.
Staircase of Transition
© GISS Bremen
Critique of Staircase Systems in Europe
Stress and dislocation because of need to move between different "stages"
Little privacy and autonomy at lower stages, lack of service user choice and freedom – revolving doors and «frequent flyers»
Standardised support in different stages
Skills learned in structured congregate settings often not transferable to independent living situation
Final move to independent housing may take years and too many homeless clients get "lost"
Homelessness may increase rather than decrease with such systems (extending lower stages, bottleneck at upper end)
Homelessness…………………………………………………………………………….
shared housing, “training dwell-ings”, etc.
regular dwelling with (time-limited) occupation agree-ment based on special conditions
regular self- contained
dwelling with rent contract
flexible individual support in housing
Housing First
reception stage
Housing First – the Alternative
Priority for rapid access to mainstream housing; no “housing readiness” and transitional steps required
Permanent and affordable housing, self-contained with security of tenure
Harm reduction approach: No requirement of abstinence
"Housing first", not "housing only”. Provision of adequate and pro-active support (with home visits) but no obligation to accept treatment, therapy or abstinence. Originally Assertive Community Treatment (ACT) essential element, but also Intensive Case Management (ICM)
Orientation on recovery and community integration
Emphasis on NORMAL housing and living conditions
Housing First: Not Only Better But Cheaper As Well?
Homelessness may cost quite a lot of money Costs of ambulances and detentions by police, court
proceedings etc. Costs of stays in emergency wards and detox units of
hospitals, in prison, in mental hospitals etc.
Most quoted example: Article in The New Yorker about “Million-Dollar Murray. Why problems like homelessness may be easier to solve than to manage” (23 Februar 2006) Policemen collected data on hospital bills and other
charges during last ten years for long-term homeless alcoholic Murray Barr who had finally died in the street of intestinal bleeding
“It has cost us one million dollar not to do something about Murray” (…) “It would probably have been cheaper to give him a full-time nurse and his own apartment”
Housing First: Not Only Better But Cheaper As Well?
Savings on non-homelessness services often main argument “If it can be shown that homelessness programs produce
positive outcomes for clients at relatively low cost and provide significant cost savings for mainstream non-homelessness services, then the case for intervention is well and truly established. “ (Zaretzky et al 2012,p. 2)
Additional indicators:* Children placed in care* Decrease in evictions and reduced maintenance (with
increased housing stability of users of tenancy support)
Housing First: Not Only Better But Cheaper As Well?
Example from Finland: Juha Kaakinen, programme leader of Finnish Programme to end long-term homelessness in a recent presentation (From Housing First to Ending Homelessness): “A survey carried out in a Tampere supported housing unit
shows that housing with intensified support halves the use of social and health care services compared to service-use during homelessness. This equates, to 14 000 euros of savings per resident/year. The total annual savings for 15 residents in the unit in question amounted to 220 000 euros. The greatest savings were gained from the decreased use of institutional care and special health care. This housing unit has 22 independent flats and 5 support workers.” (Kaakinen 2012)
Housing First: Not Only Better But Cheaper As Well?
Some problems Reduction of the use of non-homelessness services
through homelessness support: Real cost offsets against Housing First with ACT only for “high cost” homeless people
Not all homeless people are heavy users of non-homeless services like health and justice system
Duration of service use plays an important role. Housing First support is ongoing – potentially for years - while stays in hospital, prison or detox units are time-limited
Savings are made in sectors for which other government departments might be responsible than those financing homeless services
It might be difficult to realise the savings (some of them could only be realised by reducing places and personnel in criminal justice and health system)
Housing First: Not Only Better But Cheaper As Well?
Rosenheck 2000: Assertive Community Treatment (as in Housing First
projects) only “cheaper” for “the most resource-intensive 10% of clients.”
Poulin et al. 2010: “Supportive housing models for people with serious mental
illness who experience chronic homelessness may be associated with substantial cost offsets, because the use of acute care services diminishes in an environment of housing stability and access to ongoing support services. However, because persons with substance use issues and no recent history of mental health treatment used relatively fewer and less costly services, cost neutrality for these persons may require less service-intensive programs and smaller subsidies.”
Potentials of Cost-Effectiveness Studies in Europe
In Europe comparing one type of service for homeless people with others is an alternative strategy to show positive financial effects. Housing First is not a cheap service, but staircase systems aren’t either. Some examples from Germany:
*Clients may claim minimum benefit for their subsistence in addition
Type Costs p day Costs p month Costs p year
Caritas crisis accommodation Berlin*
115.45 € 3,511.60 € 42,139.25 €
“Stationary” hostel Munich (including pocket money and full board)
93.89 € 2,855.78 € 34,269.31 €
Halfway house in Berlin (social work and rent)*
42.89 € 1,304.57 € 15,654.85 €
Floating support in Berlin(social work and Ø-rent)*
34.29 € 1,042.99 € 12,515.85 €
Potentials of Cost-Effectiveness Studies in Europe
Important to note that Housing First can cover different types of support services: Not all homeless people with special needs will need
Assertive Community Treatment (probably the most costly type of support in housing, see also Tsemberis at al 2012)
A majority might be better served with “Housing First Light”
It should be relatively easy to prove that Housing First services are not only more effective but will also cost less if support in housing is adjusted to specific individual needs We need more studies on the costs of homelessness in
Europe There is great potential for cost-effectiveness studies
comparing costs and effects of staircase systems with Housing First approaches
Potentials of Cost-Effectiveness Studies in Europe
Cost-effectiveness studies must provide a real basis for comparisons including duration and intensity of support and the costs of subsistence
While there are some costs involved for increased mobility of support teams in “housing led” services (floating support in scattered housing) high costs for staircase systems and congregated housing originate from special requirements for concentrated accommodation (24 hours staffing, fire precautions, more potential conflicts, less use of self-help potential of clients)
Floating support in housing will only be better AND cheaper, if intensity and duration of support are closely adjusted to the needs of (formerly) homeless people
Ending Homelessness and Normalising Housing and Living Conditions of Homeless People:
More than a Financial Question!!
Even if more effective services for homeless persons might cost more than less effective provisions in some cases, “their value ultimately depends on the moral and political value society places on caring for its least well-off members” (Rosenheck 2000).
“Researchers should be careful to consider (and explicitly observe) that the services utilization cost of homelessness is only one dimension of the moral issues raised by the problem. Other moral dimensions of homelessness include dehumanization, diminished capacity to actualize basic societal rights and privileges, and susceptibility to victimization, including violence” (Culhane 2008: 109.).
Thank you for your attention!
Contact
Dr. Volker Busch-Geertsema
Gesellschaft für innovative Sozialforschung und Sozialplanung e.V. (GISS, Association for Innovative Social Research and Social Planning)
Kohlhökerstraße 2228203 Bremen, GermanyFon: +49-421 – 33 47 08-2Fax: +49-421 – 339 88 35
Mail: [email protected] Internet: www.giss-ev.de
References Busch-Geertsema, V. (1998) Persönliche Hilfen in Normalwohnraum statt Einrichtungen für
Wohnungslose. Bessere Hilfen für weniger Geld? Ein Bremer Kostengutachten appelliert für Umsteuerung von Einrichtungen in normalen Wohnraum, in: Wohnungslos 4/1998, pp. 144-150
Gladwell, M. (2006) Million Dollar Murray. The New Yorker February 13 & 20, 2006, pp. 96-107.
Chart for Pathways Housing First copied from http://www.pathwaystohousing.org/content/our_model
Cost examples for provision in Germany (in German language): http://www.berlin.de/sen/soziales/vertraege/verguetung/Einrichtungskatalog/einrichtungnachtyp.shtml and Lehmann, R. and Ballweg, T. (2012) Der Social Return On Investment einer stationären Einrichtung der Wohnungslosenhilfe. Investitionen und sozialer Mehrwert am Beispiel des Adolf Mathes Hauses, einer Einrichtung des Katholischen M.nnerfursorgevereins Munchen e.V.. Forschungsbericht. Stand: 24.04.2012. (Munich and Eichstätt-Ingolstadt: Katholischer Männerfürsorgeverein and Kathoische Universität)
Culhane, D. (2008) The costs of homelessness: a perspective from the United States, European Journal of Homelessness, 2, pp. 97-114.
Flatau, P. and Zaretzky, K. (2008) The Economic Evaluation of Homelessness Programmes, European Journal of Homelessness, 2, pp. 305-320
Kaakinen, J. (2012) Long-term perspectives: From Housing First to Ending Homelessness, presentation at Conference on “Housing First: A Key Element of European Homelessness Strategies”, 23rd March 2012 hosted by the French Permanent Representation to the EU and FEANTSA, see http://feantsa.horus.be/code/EN/pg.asp?Page=1409
References Poulin, S.R., Maguire, M., Metraux, S., Culhane, D.P. (2011) Service Use and Costs for Persons
Experiencing Chronic Homelessness in Philadelphia: A Population-Based Study. Psychiatric Services 61, pp.1093–1098
Rosenheck, R. (2000) Cost-Effectiveness of Services for Mentally Ill Homeless People: The Application of Research to Policy and Practice. Am J Psychiatry157, pp. 1563-1570
Tsemberis, S. (2010a) Housing First: Ending Homelessness, Promoting Recovery and Reducing Costs, in: Gould Ellen, I. and O’Flaherty, B. (eds.) How to House the Homeless (New York: Russell Sage Foundation).
Tsemberis, S. (2010b) Housing First. The Pathways Model to End Homelessness for People with Mental Illness and Addiction (Center City, Minnesota: Hazelden)
Tsemberis, S., Kent, D., and Respress, C. (2012) Housing Stability and Recovery Among Chronically Homeless Persons With Co-Occuring Disorders in Washington, DC. Am J Public Health. 102,13–16
Zaretzky, K., Flatau, P., Bauskis, A., Conroy, E, Burns, L., Spicer, B. and Clear, A. (2012) Cost offsets of homelessenss assistance (paper presented at Homelessness Research Conference Melbourne 19-20 April 2012)