Pathways Housing First! Program Philosophy and Practice February 24, 2015 ____________________________________________________________

This Morning’s Agenda Welcome Overview to the training Introduction to Housing First program model Housing operations Support and treatment services Treatment Philosophy Harm Reduction/Peer Support Research evidence: At Home/Chez Soi Housing First as an Approach to Services Open Forum Discussion (ongoing)

HPS Homeless-Services System Redesign Transformation: Change expectations and outcomes for local and regional systems for chronically homeless Redesign: Change ways of organizing and delivering services so that they appropriate to client needs Collaboration: Organizations working together towards the same goal of ending homelessness Tangible metrics: to determine program and system success, and examine how funds are expended

10% use 50% of system resources Homeless Population 5-10% chronically homeless 10-15% episodically homeless 80% transitionally homeless

WHO IS ELIGIBLE? Who are ‘the chronically homeless?’ Living on the streets, shelters, drop-in center Mental health problems Addiction and abuse Health problems Extreme Poverty Isolation Stigma PTSD/Trauma Loyalty as a value (loyal brother and friend) Likes to cook, creative Listens to country music Follows sports teams Protective, roots for the underdog, sociable Has a remarkable memory for people and names Opportunities to learn about addiction

Traditional Services Approach Level of independence Treatment compliance + psychiatric stability + abstinence Homeless Shelter placement Transitional housing Permanent housing

Staircase Model is Based on Unrealistic Expectations

Intersection of Mental Illness, Addiction and Homelessness Institutional Circuit

HOUSING FIRST Is a Paradigm Shift _________________________________________________________________

Homeless Shelter placement Transitional housing Permanent housing Ongoing, flexible support Harm Reduction Housing First Model

Housing First: Key Elements of the paradigm Shift 1) Change in understanding of the causes and solutions for homelessness (poverty not psychopathology) 2) Change in program philosophy (client choice) 3) Change in view of people served (people are capable of making their own choices) 4) Change in power relationships (client directs the type and sequence of services) 5) Change in service location and orientation (community-based not office-based) 6) Changes as continuous quality improvement (ongoing data collection and program evaluation)

5 Dimensions of a Pathways’ Housing First Program Fidelity

Housing: Independent Apartments in Community Settings (Rental and Social) Most participants prefer own place in normal settings Independent apt Scatter site (<20%) Creates sense of home Tenants Rights Affordable (30%) +rent supp Decent Support services are off site

HF is Permanent Supportive Housing Integrated Indistinguishable Support services are off site

Scatter site rural setting, Pathways VT 200 Tenants, 200 Apartments, 2 Counties, 6 Cities, 95 Landlords: Housing Retention Rate 90.5% (12 mo)

Landlords as Program Partners Common Goal Landlord, agency and participant– All want safe, decent, well-managed housing

Choice, Relocation and Limits to Choice 2 Program requirements A) 30% of Income towards rent B) Weekly apartment visits (change over time or crisis) Negotiation about apartment relocation is different than conversation about selecting first apartment Conditions that require additional support, e.g., mobile crisis, involuntary commitment

Clinical and Support Services Consumers choose the type, frequency and intensity of services Program requires home visit (and there are limits to choice)

Goals of Housing First End Homelessness by providing immediate access to permanent housing and supports for people with behavioral health, addiction and other complex problems Build self-determination and mastery (recovery) by offering consumer-driven services Improve consumer’s quality of life and support recovery

Housing first, what’s second? Health &Wellness/Chronic and Acute Health Problems Finances/Budgeting/Mo ney Management Alcohol/Drug -- Use AbuseMental Health Issues job, training, education Eviction prevention lega l

Choice is the foundation and driving force that directs clinical and housing services Choice, self-determination and building towards graduation at the point of entry Practical limits of choice: real estate market, standard lease obligation, fixed incomes, and other real world constraints. Clinical issues and constraints to choice: psychiatric emergencies, relapse, social networks, and more.

SERVICES MATCH CLIENT NEEDS “NO WRONG DOOR” Spiritual Wellness/ Nutrition Arts / Creativity HOUSING Addiction PEER SUPPORT Income Entitlements/ Legal Employment/ education Mental Health Friends & Family ACT Team Direct services; trans-disciplinary practice ICM Teams Some direct services; brokerage model Participants Immediate access; client-directed RN/MD CLIENT iiiii

SERVICES: Matching the level of services to the person’s needs (rearrange existing service models) Intensive Case-management Moderate Need: ICM case management team provides support and brokers services Services provided in the participant’s home or community (group meetings offered at offices or other community settings) Off site and on-call services 7-24 All teams use a recovery orientation

Regional Specialists ● Substance Abuse Specialist ● Peer Specialist ● Supported Employment Specialist ● Digital Literacy Specialist ● Wellness Specialist ● Nurse ● Psychiatric Support State-wide Admin Support State-wide On Call Services Local Service Coordinators

Regional Service Specialists - 2 Team Leaders - 1 Supportive Employment Specialist Computer Literacy Specialist -.5 Nurse -.3 Psychiatrist Franklin/Grand Isle - 1 Service Coordinator -.5 Substance Abuse Specialist Chittenden Service Coordinators -.3 Substance Abuse Specialist Washington Service Coordinators -.5 Substance Abuse Specialist Windham Service Coordinators Statewide - Medical Director - Project Manager - Intake Coordinator - Housing Director - Administrativ e Staff Red Clover Properties - 2 Housing Specialists = Red Clover Properties (Housing Team) Red Clover Properties - 1 Housing Specialist Windsor - 1 Service Coordinator Addison - 1 Service Coordinator -.5 Substance Abuse Specialist Regional Service Specialists - 1 Team Leader -.5 Computer Literacy Specialist -.5 Substance Abuse Specialist -.5 Peer Specialist -.3 Nurse -. 1 Psychiatrist Pathways HF Program Staff

SEPARATION OF HOUSING AND SERVICES __________________________________________________________________________________________________ ___________ Separated spatially, conceptually, and operationally

PRINCIPLE 3: HOUSING and SERVICES ARE SEPARATE DOMAINS

Program Philosophy, Program Values and Program Practice

Philosophy Humanitarian: Psychological, Economic and Human Rights Integration 1) Positive view of human nature 2) Provide fundamental security and support 3) Person is self-motivated (program: housing as a human right)

Medicine Wheel Focus on Aboriginal homeless population 3 rd arm included traditional healing approaches (e.g., medicine wheel)

Person Centered Capability focus Inter-personal (you are an active agent in the treatment and outcome) RECOVERY ORIENTATION

Relationship is the Foundation Key Role for Peer Support

PATHWAYS HOUSING FIRST PROGRAM What is Program Fidelity? How do you Measure it? Why does it matter? ____________________________________________________________________

Why Fidelity?

The case of Housing First… “It’s all about Housing & Choice” Pathways Housing First Fidelity Scale Results: Program Spectrum “Participants can choose the housing they want regardless of whether they are actively using.” “ Participants can choose to be clean and sober and they’ll get an apartment. Or they can choose to continue using and we’ll still give them housing in a room & board”

Fidelity Site Visit Before visit: collect basic info o What types of housing do participants live in o How long did it take to get into housing o What percentage of participants have been discharged Team meeting observation Individual interviews with staff o All frontline providers; Each discipline o Team Leader o Program Director, Administrators Focus group with program participants Chart review (random selection) Optional: home visits

Key Point

PATHWAYS HOUSING FIRST Program Evaluation and Research Outcomes __________________________________________________________________

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

Homelessness and Mental Illness  Homelessness is a significant social problem in Canada (Estimates of 200,000 individuals per year)  Prevalence of mental illness and substance abuse/dependence is high and associated with poorer outcomes  Higher use of health, criminal and social services

At Home/Chez Soi Demonstration Project 2008 federal gov’t allocated $110 million over 5 years to the Mental Health Commission of Canada ( Action research on how to support people with severe mental illness to exit homelessness 85% funding for services and 15% for research Largest study of its kind in the world

Who Participated in At Home/Chez Soi? 2148 participants 1158 in Housing First (HF) 990 in Treatment as Usual (TAU) Primarily middle-aged 32% of participants are women 22% of participants identified as being an Aboriginal person Typical total time lifetime homeless is nearly 5 years All have one or more serious mental health issue Majority have a concurrent disorder More than 90% had at least one chronic physical health problem

Housing: Stability – by Program Percentage of time housed

Summary of Fidelity Rating Results 12 programs rated on 38 fidelity items in 5 domains Early implementation (Year 2) and one year later (Year 3) Overall, strong fidelity to the Housing First model (program ingredients rated above 3 on a 4-point scale) 71% Year 2; 78 % Year 3 Higher fidelity in the 12 programs (5 ACT, 7 ICM) was related to: - greater direct and indirect service time and more contacts with - participants (corr. =.55 to.60) - greater housing stability (% of time in housing) - greater improvement in quality of life (d =.10) and community functioning (d =.11)

Lessons Learned: 1. CAPABILITIES People are much more capable than we imagined possible. We have often confused functionality with capability

2. Need to Assume More Risk and Responsibility Making progress requires a change in approach that involves taking some calculated risks for all of us (staff, board members, landlords, housing authority and policy makers, participants, family members, and the public).

Respite, Community- based, Residential Treatment Single Site HF (on-site services) Housing First (scatter-site, off site services) Redesigning the System: System Transformation Shelters, Drop-in Outreach Least restrictive to more restrictive setting

3. Dissemination/Replication High fidelity yield consistently high results: 80%- 90% Need local champion Clear understanding of program model Compatible values in host agency culture Resources for Housing and Services

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