December/January 2008
In this Issue
Three Decades of Housing Data
Mixed-Financing Underwrites Affordable Housing in Southwest Virginia
A Lean Makeover for Factory-Built Housing Production
Housing First for the Chronically Homeless Mentally Ill
In the next issue of ResearchWorks
Housing First for the Chronically Homeless Mentally Ill
The relevant federal agencies define a chronically homeless person as an unaccompanied individual who is disabled and continuously homeless for at least one year, or who has had four homeless episodes within the past three years. The Substance Abuse and Mental Health Services Administration estimates that 39 percent of the chronically homeless suffer from mental illness, a disability often aggravated by substance abuse and HIV or AIDS. 1
Evidence suggests that an approach called Housing First can make a positive difference in this hard-to-serve population, as can other forms of permanent supportive housing. Although some chronically homeless people with mental illness and co-occurring substance-related disorders are willing and able to commit to treatment, they may either be unable to keep such a commitment or may simply reject a conditional offer of housing. The theory behind Housing First is that street life is so demanding that people are unable to concentrate on recovery. Once the hardships of street life are left behind and they have condition-free stable housing, chronically homeless mentally ill persons are better equipped to address their illnesses.
Pathways to Housing
Perhaps the most well-known application of this model is Pathways to Housing in New York City. Established in 1993, this program finds affordable apartments for homeless individuals with psychiatric or substance-related disorders. Pathways to Housing relies on a network of landlords, brokers, and property managers who identify privately owned housing units in low-income neighborhoods in Queens, Harlem, Brooklyn, and Westchester County. Clients and Pathways personnel work together to find an acceptable apartment, and clients may select from up to three choices. The agency holds the lease and sublets the apartment to the client, who pays 30 percent of his or her income (usually from Supplemental Security Income) for rent. Pathways to Housing provides the furnishings and equipment necessary for setting up housekeeping.
Neither psychiatric treatment nor sobriety is required, but clients must participate in two case manager visits each month. Once the participant has moved into an apartment, an interdisciplinary Assertive Community Treatment (ACT) team is available around the clock to provide needed clinical, rehabilitative, and support services. Pathways’ ACT teams are composed of a nurse practitioner; part-time psychiatrist; social worker; administrative assistant; and specialists in substance abuse, wellness, family systems, and employment. Clients choose the support services and the sequencing they need. The program assumes that the client’s housing tenure will be permanent. If the client requires inpatient treatment, the apartment is held for 90 days; if the absence is longer, the client is guaranteed a new apartment when returning to the program.
Wider Use of Housing First
To learn how extensively the Housing First model is used and to explore its benefits, a study team canvassed the nation for programs that met the model’s criteria. The team found nine programs that shared the following essential features, although varying considerably in the ways they are combined and implemented:
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Direct and permanent placement in housing;
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Readily available, but not mandatory, supportive services;
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Assertive outreach to recruit potential clients and a low-demand approach that accommodates client alcohol and substance use; and
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Case management services and housing holds for clients, even if they leave the program for a short time.
In addition to New York City, the programs canvassed were in Seattle, Washington; San Diego, California; Columbus, Ohio (which has two programs); Long Beach, California; San Francisco, California; Philadelphia, Pennsylvania; and Los Angeles, California. The study was designed to be exploratory. There was no attempt made to compare Housing First to other models designed to promote housing stability among chronically homeless people.
Housing First Outcomes
Along with Pathways to Housing, two other programs were selected for further study and comparison: Reaching Out and Engaging to Achieve Consumer Health (REACH) in San Diego and the Downtown Emergency Service Center (DESC) in Seattle. The research team visited the three sites, interviewing program administrators and staff to derive closely observed descriptions of what Housing First looked like at each of the sites. In addition, researchers drew a sample of 80 clients from across the three programs and followed these participants for 12 months. Outcomes were modest but encouraging for clients with a history of being difficult to house.
Eighty-four percent of the sample participants were in their Housing First unit on the first and last days of the 12-month period; a very positive outcome. However, this indicator of housing stability masks other patterns of housing instability evinced by many of those participants. Forty-three percent of the sample spent the entire 12-month period in their selected apartments. Another 41 percent had at least one temporary absence during that time. Sixteen percent left the program voluntarily (3), left involuntarily (6), or died during the year (4).
Although the three Housing First programs approached the problem differently, all achieved some success in securing safe and healthy housing for chronically homeless individuals with mental illness and co- occurring substance-related disorders. No clear patterns of change in severity of illness or substance use emerged; assessments of the clients’ levels of impairment varied from month to month. Researchers concluded that achieving housing stability is, in itself, significant, and it’s reasonable to expect that a substantial improvement in impairment would require more than 12 months to accomplish.
Program and Policy Implications
The Applicability of Housing First Models to Homeless Persons with Serious Mental Illness describes the Housing First study and explores its policy and program implications. The report discusses features of Housing First that may help promote higher levels of housing stability for the target population, as well as differences between the tenets of the Housing First concept and federal priorities regarding substance abuse treatment. This investigation into the Housing First model provides a foundation for further research and informed discussion about how to serve a challenging client group.
The report can be downloaded at no cost from www.huduser.gov/publications/homeless/hsgfirst.html and is available in print for a nominal fee from HUD USER by calling 800.245.2691, option 1.
1. The Applicability of Housing First Models to Homeless Persons with Serious Mental Illness, U.S. Department of Housing and Urban Development, Office of Policy Development and Research (2007), p. 2.
