Moving Towards Operation of MHSA Housing: Gaining Community Acceptance for Housing First, Harm Reduction and Voluntary Services MHSA Small County TA Call June 16, 2010

2 What is Supportive Housing? Supportive Housing is PERMANENT AFFORDABLE HOUSING combined with a range of SUPPORTIVE SERVICES that help PEOPLE WITH SPECIAL NEEDS live stable and INDEPENDENT lives.

3 People who:  BUT FOR HOUSING cannot access and make effective use of treatment and supportive services in the community; and  BUT FOR SUPPORTIVE SERVICES cannot access and maintain stable housing in the community. Who is Supportive Housing For?

4 What is Housing First? Housing First - The direct, or nearly direct, placement of targeted homeless people into permanent housing. While supportive services are to be offered and made readily available, the program does not require participation in these services to remain in the housing. - The use of assertive outreach to engage and offer housing to homeless people with mental illness who are reluctant to enter shelters or engage in services.

What is Housing First? (continued) - Once in housing, a low demand approach accommodates client’s alcohol and substance use, so that relapse will not result in the client losing housing. - The continued effort to provide case management and to hold housing for clients, even if they leave their program housing for short periods.

6 Principles of Housing First  Housing is a choice, not a placement  Housing is a person’s home, not a residential treatment program  People have a right to safe, affordable housing

7 Housing First  A Housing First approach rests on two central premises: – The best way to end homelessness is to help people move into permanent housing as quickly as possible – Once in housing, formerly homeless people may require some level of services to help them stabilize, link to long-term supports, and prevent a recurrence.

88 Defining “Housing First” Philosophies 8  Safe, affordable housing as a right and a prerequisite for effective services.  Provide permanent housing opportunity as soon as possible.  Do not focus on “housing readiness” or sobriety as a prerequisite.  Facilitate easy access to housing  Housing stability is primary objective  Incremental change is normal.  Quality of life and well-being measure success.

Core Elements of Housing First Crisis Intervention: Helps stabilize participants while they are acquiring permanent housing. Permanent Housing Services: Helps participants obtain permanent housing. Assist with move-in and other costs associated with becoming rehoused, including short-term rent subsidy. Case Management/Wraparound Services: Helps to stabilize participants once they are housed.

10 Housing First: What we have learned Some homeless people cannot or choose not to navigate the Continuum of Care. They do not or cannot comply with program requirements and get screened out or kicked out of shelters, day centers, transitional housing programs Homeless people/families who meet all the program requirements can get “stuck” in transitional programs because there is no exit—no affordable permanent housing options are available. People with serious psychiatric problems and/or substance use can maintain stable housing without going through stages in the Continuum of Care approach; without being “housing ready”.

11 Housing + Services Make a Difference More than 80% of supportive housing tenants are able to maintain housing for at least 12 months Most supportive housing tenants engage in services, even when participation is not a condition of tenancy Use of the most costly (and restrictive) services in homeless, health care, and criminal justice systems declines Nearly any combination of housing + services is more effective than services alone “Housing First” models with adequate support services can be effective for people who don’t meet conventional criteria for “housing readiness” Consistent Findings of Research

Start Up Challenges Accepting the Housing First approach – that the first priority is to house people not fix them. Accepting that some community resources will eventually shift from crisis/emergency services such as shelters to permanent housing Accepting that services focus on maintaining housing, not “treatment” Selecting an appropriate site or locating landlords willing to participate in the program Recruiting landlords and maintaining good relations Encouraging shelters and transitional programs to refer clients immediately to minimize time spent in emergency setting (rapid rehousing) Hiring or re-training staff to play new/different roles, including engaging tenants in voluntary services

Sustaining Housing First Biggest challenge is locating enough affordable housing to meet the tenant demand Requires at least one or probably several of the following:  Housing subsidies –e.g. tenant based Housing Choice vouchers or other forms of subsidy  Developing strong relationships with landlords and negotiating reasonable rents  Focus on increasing tenant incomes so they can afford to pay more rent  Developing new affordable housing that is financed in such a way that the rents are affordable to extremely low-income tenants

What is the hardest element of Housing First to sell to the community???

Harm Reduction in Supportive Housing Harm Reduction is a model that helps us look at and understand real change – slow change, not quick withdrawal. Slow change allows for the natural development of coping mechanisms to replace drug use. Harm Reduction is another example of changing the housing options available instead of focusing on preparing people with the greatest barriers for housing “readiness” Low demand housing models work even for those with most severe psychiatric disorders or substance use problems

16 Key Principles to Keep in Mind  The goal of all of us is to help people succeed in housing (even if they are using substances)  The quality of life of users can be improved and enhanced while they still use drugs or alcohol.  People can have substance abuse problems and still function and meet life obligations.  Tenants have both rights and responsibilities under their leases, and the lease will guide our response to their issues and behaviors  In helping people reduce the harm caused by their substance use, self-awareness is increased, and other benefits follow.

17 Abstinence and Substance Use  Abstinence can be great if it works  How are we going to serve those who are very committed to their drug use?  How are we going to serve those who keep experiencing relapse?  How are we going to serve those for whom abstinence hasn’t worked?

18 Harm Reduction: Definition Harm reduction is a set of practical clinical strategies that reduce negative consequences of drug use or other activities, incorporating a spectrum of strategies from safer use, to managed use, to abstinence.

19  People have the right to make decisions about their lives and actions. Harm Reduction is about educating them to make the best decisions for themselves.  The user takes responsibility for his/her choices and behavior.  The individual sets his/her own goals in collaboration with the service provider.  There are no punitive sanctions for what someone chooses to put/not put in his/her body.  When we create punitive sanctions, people will lie.  Incremental change is normal.  Quality of life and well-being measure success. Harm Reduction Principles

20 Use vs. Symptoms vs. Behavior Symptoms Substance Use Mental Illness Behaviors As housing providers, where do we focus?

21 Symptoms, Behaviors, Housing Issues  Illegal Activity leads to Lease Violations  House Rules Violations lead to Complaints and Nuisance Issues  Poor Money Management leads to Rent Non-Payment  Poor Hygiene or Hoarding lead to Failed Inspections  Property Damage leads to Failed Inspections  Unauthorized Subtenants lead to Lease Violations  HOUSING FIRST IS NOT “ANYTHING GOES”

How do we talk to community members about these issues??

23 Talking Points: Reaching the Hard-to-Serve MHSA Housing is targeted at individuals and families who face great difficulties in finding and maintaining housing. –It is reasonable to expect that applicants for MHSA Housing will have poor credit, a difficult history with landlords, and a lack of steady income. –Housing First means that we bring people into stable housing in spite of these issues, in order to support their recovery. –Rather than identifying issues to “screen out” tenants, Housing First identifies tenant issues to create an individualized service plan.

24 Housing First is a Proven Best Practice Housing First has passed the rigorous evaluation required for inclusion in the National Registry of Evidence-based Programs and Practices (NREPP), a service of the Substance Abuse and Mental Health Services Administration (SAMHSA).

25 Housing First is a Proven Best Practice Four major outcomes were reported for Housing First: –Outcome 1: Residential stability From baseline to 2-year follow-up, Housing First participants spent approximately 80% of their time stably housed, versus 30% for participants in the comparison group, who were assigned to traditional programs that made treatment and sobriety prerequisites for housing. Similarly, from baseline to 3-year follow-up, Housing First participants spent significantly less time homeless than the comparison group.

26 Housing First is a Proven Best Practice Four major outcomes were reported for Housing First: –Outcome 2: Perceived consumer choice in housing and other services At 2-year follow-up, participants assigned to Housing First reported significantly more choice with respect to their housing, treatment, and daily living than participants in the comparison group, who were assigned to traditional programs that made treatment and sobriety prerequisites for housing. This effect was maintained at 3-year follow-up.

27 Housing First is a Proven Best Practice Four major outcomes were reported for Housing First: –Outcome 3: Cost of supportive housing and services From baseline to 2-year follow-up, participants assigned to Housing First accrued significantly lower supportive housing and services costs than participants in the comparison group, who were assigned to traditional programs that made treatment and sobriety prerequisites for housing.

28 Housing First is a Proven Best Practice Four major outcomes were reported for Housing First: –Outcome 4: Use of support services From baseline to 2-year follow-up, participants in the comparison group (who were assigned to traditional programs that made treatment and sobriety prerequisites for housing) reported significantly higher use of substance abuse treatment programs and a significantly larger proportion of time in psychiatric institutions than participants assigned to the Housing First group.

 “Standard care” emergency responses to homelessness and mental illness are very costly  Investments in supportive housing will significantly reduce services use and public costs in some systems of care  The net cost of achieving much better outcomes is relatively small – if savings can be re-invested Talking Points: Benefits to Community

Supportive Housing: It Works summary of key findings from a range of studies  ER visits down 57%  Emergency detox services down 85%  Incarceration rate down 50%  50% increase in earned income  40% rise in rate of employment when employment services are provided  More than 80% stay housed for at least one year

Additional Evidence and Resources Go to CSH web site for current research: –FAQ’s on Housing First, Voluntary Services, Cost Effectiveness, Effectiveness in Addressing Rural Homelessness –Studies demonstrating cost effectiveness of supportive housing –Study showing that supportive housing increases property values in neighborhoods

“I’m much less of a burden on society now than when I was homeless.” Gene Pittman Supportive Housing Tenant