1. How can Housing First help us end homelessness?
Dr Sam
Founder of Pathways to Housing

2. How Can Housing First Help to End Homelessness?
Sam Tsemberis, Ph.D.
Pathways Housing First Institute
Department of Psychiatry,
Columbia University Medical Center
CRISIS UK, APRIL 20 , 2017

3. 1. Can you explain the problem you were trying to solve in the U.S.?
and how Housing First approached it differently?

4. Homelessness in the USA
HUD P.I.T. COUNT JAN 2015
564,708 TOTAL HOMELESS
206,286 PEOPLE IN FAMILIES
358,422 INDIVIDUALS
National Coalition for the Homeless estimates 3.5 million
(1.35 million children)

5. Early 1980’s people began to appear on the streets
Who are they and where are they coming from?
Disproportionately high numbers of individuals with mental illness
Deinstitutionalization?
‘83 on word Homeless appears
with mental illness

6. Immediate response: Red Cross/Doctors w/o Borders
Emergency outreach 1
Emergency shelter 2
Transitional housing’ 3
Food programs 4
Clothing programs 5
Faith based programs 6

7. Homeless services Staircase (Treatment First) approach
Permanent housing
Transitional housing
Level of independence
Shelter
Homeless
System built upon 1) frequently practiced but inaccurate assumptions about Mental illness, addiction and functional ability and 2) long standing attitudes about those who are poor

8. “Normals teach us rules, outliers teach us laws”
Labelling:
“treatment
resistant” or
“hard to house”

9. 10% of POPULATION USES 50% OF SYSTEM RESOURCES
Consequences of failed approach or hard to reach? The focus on the “chronically” homeless
10% of POPULATION USES 50% OF SYSTEM RESOURCES
Jails
Shelters
Hospitals/
Detox
Streets
Institutional Circuit 9

10. We
Dolbeare, C.N. (2001). Changing priorities; The federal budget and housing assistance – National Low Income Housing Coalition, Washington DC.

11. The poorest (including people on fixed income) are priced out of the real estate market

12. Gini Coefficient – income disparity and Social Services
CA 555
DE 470
US 1,079
IN 58,787
Paul Toro: there is a correlation between GINI and social services

13. Who is experiencing homelessness? How are they best served?
Prevention
Families and youth show similar patterns
80% transitionally homeless
10-15% episodically
5-10% chronically
Rapid Rehousing
Permanent Supportive
Housing
640 from
Housing
First

14. 2. Explain the Principles of Housing First
and
a) how it challenges the status quo and
c) how does it raise the prospect of ending different forms of homelessness?

15. HF Requires Significant Change in the Culture and Provision of Social services and Housing
View of people served
Change in power relationships
Change in treatment practices
Commitment to ongoing support
Commitment to social inclusion

16. Requires Program Re-Design
And New Practice

17. Pathways’ Housing First Model
“Housing is a Basic Human Right”
PARDIGM SHIFT
Permanent supportive housing
Transitional housing
Immediate Access Ongoing, flexible support
Harm Reduction
Housing as a Right
Emergency Shelter Placement
Homeless
*Immediate Access to A Place of Your Own
Support and treatment are part of the offer 17

18. Welcoming Complexity! Welcoming Program Culture
Trauma Informed and trauma competent
Culturally Informed
Evidence Based
Intent to Treat (no discharge as policy)

19. 5 Principles of Housing First
Consumer Choice
Separation of Housing and Services
Services Array to Match Needs of Consumers
Recovery Focused Practice
Community Integration

20. 2 Program Requirements Admission Criteria: 3 Conditions:
Must meet program criteria
3 Conditions:
Comply with standard lease (pay 30% of income to rent)
Agree to Home visit
(1 x week)

21. Client Directed Services - “No Wrong Door”
Family/
Friends
Legal/ Justice
Education
Spiritual
EMPLOY
MENT
CLIENT
SOCIAL
SUPPPORT
HEALTH
Discuss service choices
Arts /
Creativity
Addiction Tx
Mental
Health
HOUSING

22. The Ultimate Goal of Housing First is Recovery

23. Prospect of Ending Homelessness for different populations
ONGOING RENT SUPPORT
chronic
Service
Needs
Families
HUD.GOV/FAMILYOPTIONS
Population or Complexity of Needs

24. 3. How did you interest people (housing and non-housing) in the value of Housing First?
4. How do you address any concerns people have about removing the conditionality applied by other homeless services (e.g., people having to be clean or sober, without symptoms, etc.?

26. Housing First in 5 Cities: different sizes and composition across Canada
Mental Health Commission
Of Canada
$110M 5 YEARS
At Home/Chex Soi
HF is an
Evidence
Based
Practice*
Vancouver
Pop: 578, 000
Moncton
Pop: 107,000
Winnipeg
Pop: 633, 000
Montreal
Pop: 1,621,000
The graphs show that housing stability does not differ much across the sites. On the y axis is the % of time spent in stable housing, and on the x axis is the number of months spent in the study. The red line represents participants receiving the Housing First Intervention, the blue line represents the participants receiving treatment as usual.
Toronto
Pop: 2,503,000
Aubry, T. et al., Psych Services 2014, 2015.

27. HF outcomes for moderate and high need participants
Percentage of time housed

28. Findings from Qualitative Interviews
Having a place of one’s provided greater overall sense of safety and improved quality of life
Served as a platform for other positive changes (reconnection, sense of belonging, feeling normal, privacy, and control to establish own routine)
Introduced new challenges; lonely, isolated, not fitting in
-Housing stability and improved quality of life was retained despite continuing to experience symptoms or struggling with addiction
-Mental health, addiction and discretionary income marginally improved

29. Cost offsets vary depending on need level
Cost Analysis: HF high need with ACT
Housing First costs $22K per person per year
Average net cost offset of $21.4K CAD (96%) per person.
$10 CAD invested in HF with ACT saved $9.60 CAD
Cost Analysis: HF moderate need with ICM
Housing First costs $14K CAD per person per year
Average net cost offset of $4.8K CAD (34%) per person.
$10 CAD invested in HF with ICM saved $3.42 CAD

30. HUD-VASH
76,329 homeless veterans
56% reduction in 3 years

31. Housing Retention
Of the 700 homeless Veterans admitted to HUD-VASH utilizing a Housing First approach, 84% (585) are still living in permanent housing, with varying lengths of stay one year after we started the pilot
Among the 115 Veterans who have left the program,
37% (43) moved to a more independent living arrangement;
20% (23) discharged to an institutional setting, including hospital, nursing home, or prison;
30% (34) relapsed into homeless or were lost to care;
13% (15) died, the majority from natural causes
(Kane, V., et al. 2014)

32. Cost Savings
Table 1. VHA Healthcare Cost (12 months pre- and post-admission), N=622
Mean Cost Pre-Admission
Mean Cost Post-Admission
Percent Change
Inpatient
Mental Health
$4,270.63
$2,407.91
Substance Abuse
$3,164.34
$1,587.38
Other (Medical)
$6,375.94
$2,311.59
Total Inpatient
$13,810.91
$6,306.88
-54.3%
Outpatient
$2,229.28
$2,037.81
$1,209.07
$1,019.00
$6,222.82
$6,677.56
Total Outpatient
$9,661.17
$9,734.37
0.8%
Total
$23,472.08
$16,041.25
-31.7%
Data source: Veterans Health Administration (VHA) Decision Support System (DSS)

33. When Housing First Doesn’t Work
The 10-20% who have repeatedly tried and failed in the scattered site model
Single site options with control of entrance and exit
Some recovery house options
Other options in managed group setting need to be explored

34. 4. How can we take Housing First to Scale
4. How can we take Housing First to Scale? What are the implications for other systems? Have you observed effective system transformation strategies?

35. Pine Street Inn, Boston
– Lydia Downey from Managing to Ending homelessness

36. Shelter utilization and capacity in a housing first approach
CAPACITY Shelter of 30 beds = 30 x 365 = 10,950 bed nights
Average stay per guest:
10 people staying 10 nights = 100 bed nights
10 people staying 180 nights = 1,800 bed nights
Annual Service Capacity
10 nights per guest = ,095 guests/year
180 nights per guest= guests/year

37. The “move-on” problem in single site supportive housing

38. Redesigning the System: System Transformation
Permanent housing (scatter-site,
off site services)
Permanent Single Site
(on-site services)
Community-based, Residential Treatment
(on-site clinical staff)
Shelter/
Emergency Housing
less investment IN EMERGENCY resources 38

39. POLITICAL WILL We know how to end homelessness Why haven’t we done it?

40. REFERENCES (partial)
Aubry, T., Tsemberis, S., Adair, C.E., Veldhuizen, S., Steiner, D., et al. (2/2015). One Year Outcomes of a Randomized Controlled Trial of Housing First in Five Canadian Cities. Psychiatric Services.
Goering, P., Veldhuizen, S., Nelson, G., Stefancic, A., Tsemberis, S., Adair, C., et al. (2015). Further Validation of the Pathways Housing First Fidelity Scale. Psychiatric Services, Psychiatric Services, 09/2015.
Padgett, D., Henwood, B., & Tsemberis, S. (2015). Housing First: Ending Homelessness, Transforming Lives, and Systems Change. New York: Oxford University Press.
Tsemberis, S. (2015). Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction. Hazelden Press, Center City, MI.
Canadian Study website:

41. Thank You! Questions? Comments?

42. Breakout sessions Definition of ending homelessness (Council chamber) Changing the culture of homelessness services (Dorchester Library) Homelessness – what next for legal reform? (Wolfson Theatre)

43. Afternoon tea
(Osler & Long Room)

44. Government plans for ending homelessness.
The RT Hon Sajid
MP Bromsgrove, Secretary of State for Communities
and Local Government

45. Jon Sparkes @jon_sparkes Chief Executive Crisis
Closing remarks
Jon
Chief Executive
Crisis

46. Drinks reception
Osler & Long Room
16.30 – 18.30