sam tsemberis. ph.d. founder and executive director pathways to housing, inc
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Pathways’ Housing First : Ending homelessness and supporting recovery for people with psychiatric disabilities and addiction diagnoses . Sam Tsemberis. Ph.D. Founder and Executive Director Pathways to Housing, Inc. Are they the homeless mentally ill or the mentally ill homeless?. - PowerPoint PPT PresentationTRANSCRIPT
Pathways’ Housing First:Ending homelessness and supporting recovery for people with psychiatric disabilities and addiction diagnoses
Sam Tsemberis. Ph.D.Founder and Executive Director
Pathways to Housing, Inc.
Are they the homeless Are they the homeless mentally ill or the mentally ill mentally ill or the mentally ill
homeless?homeless? Do people who are homeless and
mentally have more in common because they are homeless or because they have a mental illness?
What is Housing First?What is Housing First?
Is it an intervention that serves
people who are mentally ill.The model has implications for
how we address homelessness.
Housing FirstHousing First What is housing first?Why was it developed?How does it work?Is it effective?
Annapolis & BaltimoreMD
Hartford CT
Pathways’ Housing First Programs in the USA & Canada
Worcester, MA
Oakland, CA Salt Lake City, UT
Denver, CO
Chattanooga, TN
Charlotte County, FL
Philadelphia PA
NYC
Housing First Sites that received technical assistance from Pathways to Housing, Inc
Washington DC
Housing First Sites established 2003-2007
ColumbusOH
Richmond, VA
Portland, OR
Seattle, WA
Chicago, IL
Calgary
Toronto
Los Angeles, CA
Fort Lauderdale, FL
How Housing First Relates to 10-How Housing First Relates to 10-Year Plans to End HomelessnessYear Plans to End Homelessness
The National Alliance to End Homelessness advocating for Cities and States to develop 10-year plans to END HOMELESSNESS
The US Interagency Council on the Homeless focus on Ending Chronic Homelessness ($35M Initiative)
Current SystemCurrent SystemHousing and service programs: Housing and service programs:
A series of steps A series of steps
PermanentHousing
TransitionalHousing
Drop-in,Shelter
Outreach
Eligibility criteria for supportive Eligibility criteria for supportive housing: housing:
(NYC Survey of providers in 2005)(NYC Survey of providers in 2005)
Clean time –92.5% of Providers require Methadone – 11 % exclude Insight into mental illness Compliance with treatment Criminal background
– Sex offenders – 82% exclude– History of arson – 80% exclude
Credit checks
3 Assumptions of the Housing 3 Assumptions of the Housing Readiness (or treatment first) Readiness (or treatment first)
ModelModel
Referrals between agencies work – they don’t Learning to live in congregate settings prepares
you for independent living – it doesn’t People need to be psychiatrically stable and clean
and sober before before they can mange independent apartments
Misuse of resources by people who Misuse of resources by people who remain chronically homelessremain chronically homeless
Shelters: 10% of the chronically homeless utilize 50% of the system resources
Hospitals/Detoxes: 3% of clients use 28% of all Medicaid funding for these services
Jail/Prison: High rates of incarceration and recidivism rates for people who are mentally ill and homeless
Outreach/Drop-in: e.g., Million Dollar Murray-The New Yorker
Housing First Ends Cycling Housing First Ends Cycling Through Acute Care Systems Through Acute Care Systems
Permanent Supported Housing ends homelessness for people cycling throughout the “institutional circuit”
Stopping this cycle has cost implications and possibilities for reinvestment,
e.g., what if we could write a prescription for housing covered by the national insurance plan if the person we are treating has as a psychiatric disability, acute and chronic health problems, and is homeless?
4 Essential Elements of4 Essential Elements ofHousing FirstHousing First
1. Consumer Choice2. Separation of Housing and
Services3. Recovery Orientation4. Effectiveness
1. Consumer Choice is the 1. Consumer Choice is the foundation of this programfoundation of this program
Program started with a psychiatric rehabilitation approach to street homelessness (taking psych rehab to the streets –d shern et. al)
There is is a vast disconnect between what most supportive housing providers offer and what consumers say they want
Essentially, treatment and sobriety before housing
What do consumers want?What do consumers want?Housing, Housing, first!first!
When asked, almost every person who is homeless (w or w/o mi) says they want housing first;
Will accept immediate access to permanent independent housing; a place of their own
Do not want to participate in psychiatric treatment or attain a period of sobriety as a precondition for housing
Housing FirstHousing FirstHonors Consumer ChoiceHonors Consumer Choice
Once housed, consumers continue to choose the type, sequence and intensity of services (or no services)
All must agree to weekly visit
Consumer choice as a Consumer choice as a continuous process in Housing continuous process in Housing
First programsFirst programs
Choices include the right to risk; people make mistakes and learn from that experience, dignity of failure
Continued practice in making choices leads to making the right choices and the experience of success
2. 2. Separation of Housing Separation of Housing and Clinical Servicesand Clinical Services
Housing Services: To find apartments, sign lease, and maintain all aspects of housing including facilitating relations with building staff
Treatment and support services: Offered not required; Relapse (SA or MH) is expected and does not result in housing loss and housing loss does not result in discharge from clinical services
HOUSING FIRST PROGRAMHOUSING FIRST PROGRAMMain ComponentsMain Components
1. Housing: Scatter site independent apartments rented from community landlords
2. Treatment: Treatment and support services provided using Assertive Community Treatment (ACT) Teams, CM or other off site services
Treatment and support services:Treatment and support services:ACT teams/CM TeamsACT teams/CM Teams
Multidisciplinary team (MD, MSW, CSAC, RN, etc)
Serves people with highest needs (severe mental illness; substance abuse; homeless, long periods of hospitalization, criminal justice; involuntary commitment orders, etc.)
Services are provided directly, 70-80%of the time in the community
7-24 on call
Teams use a recovery focus and assist with community integration
Case Management teams:Case Management teams:Brokerage Service ModelBrokerage Service Model
CM services – higher case load ratios
Must broker other needed services
Follow through and continuity of care among systems
7-24 on call
Consumer driven philosophy and interventions
Matching Housing and Support Matching Housing and Support and Treatment Services with and Treatment Services with
Client NeedsClient Needs Most people need the same things
in housing (mih or hmi) Their service and support needs
vary
Ensure services are unlimited Ensure they are consumer driven
and evidence based
Housing Component: Independent Housing Component: Independent apartments integrated into the apartments integrated into the
community*community* 1. Rental units available on the open market
(normal rental housing)2. Integration: Rent less than 20% of the total*
number of units in any one building 3. Permanence: Tenants have same rights and
responsibilities as any other lease holder4. Affordability: Apartments are subsidized;
tenants pay 30% of income towards rent
Landlords as program partners:Landlords as program partners:Landlord, agency, and tenant have a Landlord, agency, and tenant have a
common goal common goal
Landlord, agency, all want quality, safe, well managed apartments
Agency that ensure rent is paid on time and is responsive to landlord concerns
Agency wants landlord to contact agency the minute a problem occur
Agency responsible for damages Agency housing staff on call for landlord
LIMITS to consumer choice in LIMITS to consumer choice in housing issueshousing issues
There are limits to choice in these instances 1) Must sign lease or sublease 2) Pay portion of rent (30%) 3) Observing the terms of the lease
LIMITS to consumer choice on LIMITS to consumer choice on clinical servicesclinical services
There are limits to choice in these instances 1) Danger to self or others 2) Must agree to weekly visit by support
team 3) Others (abuse, violence, legal issues, etc.)
3. 3. Recovery oriented Recovery oriented servicesservices
We now know that people who are diagnosed with severe mental illness (and co-occurring SA) can live full and independent lives in the community (Harding study definition).
How do we support more individuals to achieve this goal?
Programs elements that Programs elements that support recoverysupport recovery
Design the housing a vision of recovery in mind: people living fully integrated into the community,
Rent and/or develop housing that looks like normal housing not a program
Design the program so that the services can walk away from the person who no longer needs them (or return if necessary)
Recovery focused support Recovery focused support servicesservices
Provide services that support recovery: supported employment, education, wellness management, etc., in at least equal proportion to mental health and drug treatment services
Provide access to housing in a manner that that can change o accommodate positive family developments
Recovery focused services… Recovery focused services…
Convey hope, offer choice after choice, are respectful, patient, nurturing, compassionate, seek and discover capabilities and create new possibilities
How is program funded?How is program funded?
COST: Approx $22K for ACT (ICM $15K)
Support /Clinical Services- Medicaid/contracts
Housing- rental support- HUD-S+C; SHP; Vouchers- State or City Supported Housing funds or local
vouchers
4. Effectiveness4. Effectiveness
CQI and documentation of Program Effectiveness
Why evaluation and Why evaluation and research?research?
Want to build the new models based on empirical evidence -- not on assumptions, special interest, dramatic cases, or political obligations
Research provides scientific basis to inform policy and advocacy for system transformation
Research Evidence:Research Evidence:Building and evidence Building and evidence
based practicebased practiceNew York Housing
StudyFunded by SAMHSA, CSAT and NYSOMH
36 month longitudinal 36 month longitudinal randomized control trial randomized control trial
Study 3: Comparing Study 3: Comparing Pathways to HousingPathways to Housing
with Standard with Standard Treatment-Housing Treatment-Housing Programs in NYCPrograms in NYC
Study DesignStudy Design
- Longitudinal Random Assignment- N=225
- Experimental (Pathways) 99- Control (Other NYC programs) 126
Follow-up RatesFollow-up RatesEntire SampleEntire Sample
6-month
12-month
18-month
24-month
30-month
36-month
96% 94% 92% 90% 86% 86%
36-month follow up: 36-month follow up: Selected DomainsSelected Domains
Literal Homelessness
Choice and Psychiatric Symptoms
Residential Stability
Proportion of Time Proportion of Time Literally HomelessLiterally Homeless
Note. Significant at 6-, 12-, 18-, 24-, 30-, and 36-month.
00.20.4
0.60.8
1
Time
Prop
ortio
n
ExperimentalControl
Proportion of Time Proportion of Time Stably HousedStably Housed
Note. Significant at 6-, 12-, 18-, 24-, 30-, and 36-month.
0
0.2
0.4
0.6
0.8
1
Time
Prop
ortio
n
ExperimentalControl
Housing First Programs, Choice Housing First Programs, Choice & Psychiatric Symptoms& Psychiatric Symptoms
PsychiatricSymptoms
Adapted from Greenwood et al, 2005.
reduction
increase
reduction
ProgramAssignment
Proportionof time
homeless
Choice PersonalMastery
County Level Evaluation:County Level Evaluation:“Westchester County“Westchester County
halves number of homeless in 5 years”halves number of homeless in 5 years” Westchester County: (New York Times, Feb 26,
2006) Combining rent subsidies, eviction prevention
grants, and housing first the county has reduced homelessness by two-thirds since Jan. 1998
Cost $23K for HF compared to $28-$36K shelter with services
County is considering a top-to bottom shift to the housing-first model
Cross site studies – 10cities Cross site studies – 10cities same measures: VA evaluates same measures: VA evaluates chronic homelessness initiative chronic homelessness initiative
- VA: 11 cities funded by ICH show about 85% housing retention rates after first year
Cross site studies – 6 cities same Cross site studies – 6 cities same measures: HUD commissions measures: HUD commissions
study to evaluate Housing First study to evaluate Housing First
- HUD Housing First: found 84%
retention rate across six study sites
Intra-departmental cost Intra-departmental cost study:study:
DHS Cost by service typeDHS Cost by service type
SAMHSA NREBPPSAMHSA NREBPP
Pathways’ Housing First
OnSAMHSA web site National Registry of
Evidence Based Programs (NREPP)
System TransformationSystem Transformation
Reversing the existing and use transitional programs if for consumers can’t mange independent apartments
Develop plans to END Homelessness
Convene Interagency Council
System TransformationSystem Transformation
Agency and staff training in system transformation
Pilot Housing First program