1. Homelessness: meeting individual and community needs
Noah Fay
DESC
Seattle

2. DESC components Shelter – low-barrier survival services, 450 beds
Behavioral health treatment: crisis services, outreach, outpatient treatment and ongoing care
Permanent supportive housing – 1350 units (1000 single site, 350 scattered site) – all Housing First for people with highest needs

3. Correlation between Rents and Homelessness
In Seattle, the rent for a one- bedroom apartment is about $1,884, according to the real estate site Rent Cafe. A person earning the Seattle median income, $75,000, is already at the 31 percent threshold
This Photo by Unknown Author is licensed under CC BY-SA
desc.org

4. Visible homelessness in the community
Common situations
Helpful options
Sleeping outside
Reluctance to use shelter
Disruptive/scary behavior
Frequent use of emergency medical services
Outreach
Lower barriers in shelter
Crisis outreach and diversion
More community-based and/or mobile medical services, including medical respite
As street homelessness increases in a community, a variety of situations are likely to become more noticeable. In turn, responses to these situations are desired. Some of the more common situations and the kinds of responses that are made are here. To address more visible outdoor sleeping, outreach efforts are increased to make sure that people outside know about other resources and options, and to convince them to come inside. Reports of people refusing to accept shelter or other services sometimes result in lowering of barriers to shelter entry, such as eliminating sobriety requirements, allowing pets, and other things. Disruptive or scary or perceived dangerous behavior may lead to specialized mobile crisis outreach and diversion programs so first responders have options other than jail or other enforcement actions. And for people who are on the street and heavily using crisis services, especially emergency medical services delivered by fire departments and hospitals, programs may emerge to deliver medical services in the community using mobile services or in community program settings, and sometimes via medical respite programs that give people a place to go from the hospital and get care for a limited period of time. All of these are helpful and can ameliorate the lives of the people on the street and the communities in which they reside. But in all of these cases, there is actually a better option.

5. Best option
All of the visible effects of homelessness are best addressed by housing people. We need things like outreach and crisis services, but we need to tie those to housing to make them more effective and less needed to be repeated

6. Housing First Housing First Model Conventional Model
House the most vulnerable - surround them with support they need to succeed
Resolve challenges, then move into housing
For people with the highest needs, which generally means people who are homeless the longest, have the most visible challenges, and are often the heaviest users of crisis services, the Housing First implementation of permanent supportive housing is the most effective solution. Not only does it get people off the street, but it stabilizes their lives and results in decreased behavioral and medical problems. People who were high users of crisis services end up using way less of them once housed. Housing first does this by getting past the convention notion that people need to have their underlying problems fixed before they can be housed, and instead says that people should be brought into permanent housing in whatever condition they are in, and once their provided with services and care that are much more likely to have more durable effects. 6 6

7. Dodge
This is Dodge. I want you to consider his situation as a homeless person in a wheelchair on the streets
Imagine:
Can’t be housed because all the housing has stairs
We’re going to work with you on the streets to learn how to walk and climb stairs
Meanwhile we don’t want you outside.
You can use shelter if you can leave wheelchair outside because it’s too crowded inside for your chair
C’mon just try to let us help you

8. Concept of Accommodations
We would never say that about a person in a wheelchair because we can easily imagine how to accommodate their needs with things like ramps and grab bars. Many homeless people on the street have other types of disabilities, especially behavioral health conditions like serious mental illness and substance addiction, but accommodations can be made for those as well, without assuming we need to change the person first. Services in supportive housing are the equivalent of ramps and guardrails for chronically homeless people with BH disorders 8

9. It’s a square peg in a round hole situation
It’s a square peg in a round hole situation. We can work and work to change the peg. Trying to change the person to fit the services is an exercise in frustration.
It’s not that hard to create services that fit the person. We can more readily create a square hole for the person.

10. We are often told that people on the street with these kinds of problems need “treatment.”
We have been led to believe that there is some kind of magic treatment car wash we can run people through and have them come out the other end all better.
The truth is that most who have that need likely already have received treatment for mental illness, addiction, or other conditions. We documented 16 attempts on average.
Clearly these folks were seeking change in their lives, but it wasn’t taking. Behavioral health treatment can take a long time and many episodes to reach the level of effectiveness desired. And when we provide treatment to people without first resolving their homelessness, the prognosis for adequate healing and recovery is poor.

11. If you break your ankle, maybe you’ll undergo an expensive surgical procedure to repair the break.
And when you are sent home, you’ll be provided with equipment to ensure the repair has the conditions needed to heal.
For people who undergo behavioral health treatment, housing is the equivalent of the orthopedic boot and crutches. Provision of behavioral health treatment is costly, especially in hospital settings. When people are homeless in the community rather than housed, they don’t have the protective equipment needed to ensure healing and lasting change from the treatment.

12. Outreach
Outreach is often a critical service to help homeless people access other needed services, but quite often it’s as though we tie our outreach workers’ hands behind their back. They can be friendly and skilled, but at some point they need to get the person to accept what they are offering. Quite often what they are able to offer is help accessing other services and housing.
And very often that involves asking the homeless person to share personal information, social security number, income verification, etc., to determine eligibility. Remember that the nature of outreach is going out to people who were not asking for your help in the first place. If that help is intrusive and the outcome is theoretical, it’s difficult to get very far.
But when they can offer housing, it’s a different story.
You may have heard about homeless people who say they choose to be homeless, to be outside. You may have talked with people yourself who have said this to you. What I have come to understand about this is that people don’t prefer to live in unpleasant and difficult circumstances, but in some cases make this choice compared to what they believe the alternative to be, like a crowded shelter or a program where they tell you all the things you need to change about yourself. But what we found when offering people with the highest needs, sometimes the people believed to be homeless by choice, permanent housing with support but without requirements to change or be in a program, people are eager to accept it.
When we did the lease up of one permanent supportive housing project for people who were selected based on being the heaviest users of crisis services, we got a rank-ordered list based on total cost and went out and found everyone we could on the list and offered them housing. We only had to talk to 79 of them to fill all 75 units in the building; The other four came in later when we had opening and more time to convince them it was for real. This is in contrast to other programs that have been reported on for the same target population. In one case, people had been picked up for law violations and offered housing in a program, but would have to agree to abstinence. If they chose not to enter the program, they would go to jail for the violation. Nearly half rejected the program and went to jail instead. They saw the program as not aligned with their needs and rejected it despite a negative consequence.

13. Reduced strain on community resources
Compared to controls, housed participants showed greater reductions in use of publicly funded services and overall costs.
Cost offsets of housing > $4m for 1st year.
More time in housing associated with greater reduction in costs.
What happens to use of community crisis services when people become housed? They use them a lot less. This shows results published in the Journal of the American Medical Association. For the group of heaviest crisis system users I mentioned, when you added up their total cost of services for healthcare, incarceration, sobering/detox, and shelter in the year prior to becoming housed, and then compared their use of those same services for the one year after being housed, we saw a reduction of $4million. The housing itself cost a little more than $1M to operate, including the provision of services.
Figure and findings from Larimer et al. (2009)

14. Improvements to the community
$4M of crisis system costs of residents were eliminated in first 12 months of operation:
56% of this in Medicaid payments
County jail bookings down 45%
Jail days down 48%
Sobering center usage down 91%
Shelter usage down 93%
And here is how that $4M in cost offsets breaks down. A majority is in savings to the healthcare system. Use of jail went way down, and primarily was comprised of people who had old warrants in place before becoming housed. Our local sobering sleep off center effectively had been serving as nightly shelter for many of these individuals. Once they became housed, the sobering center no longer had clientele who stayed there every night.

15. Housing First key evidence
Works for people who refuse or are refused from other interventions
High housing retention rates
Reduces crisis systems costs
Improves health status
Reduces substance use and related problems
Decreases criminal justice system involvement
Begins to reconnect people with the life of the community
Hand sanitizer – Clint frequent ER visits

16. Critical components for success
Remove entry barriers like criminal history criteria
Understand adjustment process
Voluntary services
Harm reduction
Engage staff
Engage tenants
Flexible approach to problem-solving
Bring health care and personal care services to housing
Persistence
Positive, hopeful outlook!
Crim hx study
Race equity
Story of Bill
Story of DA – probs with oven,
Isolating, sleeping outside, sleeping on floor
Harm reduction – seat belts and guardrails metaphor
It’s not enough to just house people, services need to be robust and tailored.
Customized adjustments