Are they the homeless mentally ill or the mentally ill homeless? People who are homeless with mental health and substance abuse problems

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1 Sam Tsemberis, PhD Founder and CEO Pathways to Housing Housing First published by Hazelden Part of the Dartmouth Hazelden EBP series People who are homeless with mental health and substance abuse problems Chronically homeless Psychiatric disabilities Addiction and abuse Health problems Poverty Isolation Stigma Trauma GINI (Social Disparity) Are they the homeless mentally ill or the mentally ill homeless? Why are people with psychiatric disabilities over represented among the homeless?

2 then MELESS Traditional Treatment and Sobriety then Housing programs $$$$ there Outreach Drop-in $$$$ are cost SHELTER $$$$$$$$ implications TRANSITIONAL Housing (housing readiness) Challenges: 1)Housing readiness is not needed 2)Clinical assumptions are not substantiated $$$$ PERMANENT Housing Dx is related to ability to function 3) Cost implications New or Rehab building Tenants are people with special needs Property management and Social Services are on site Psychiatric Treatment and sobriety usually required (can have harm reduction models as single site programs ) Single Site Single Site Effectiveness (cont d) About half stayed 3 years or more Only one-third of leavers went to stable alternative housing ( positive leavers ) Negative leavers had more severe levels of mental illness, greater incidence of substance abuse, higher supportive service needs (O Hara, 2007)

3 When people cannot access or keep housing Shelters: 10% of the chronically homeless utilize 50% of the system resources Hospitals/Detoxes: 3% of clients use 28% of all Medicaid funding for these services Jail/Prison: High rates of incarceration and recidivism rates: poverty and drug related charges for people who are mentally ill and homeless Scatter site apartments Immediate access Treatment 0r sobriety are not required What is Housing First? An evidence based consumer driven program Rooted in the principles of: Psychiatric rehabilitation Harm reduction Consumer movement Recovery oriented practice

4 What is Housing First? A clinical and housing intervention that provides immediate access to permanent housing and support and treatment services for people with mental health and addiction problems 4 Essential Ingredients of Pathways Housing First 1. Consumer Choice Philosophy 2. Separation of Housing and Services 3. Recovery Oriented Services 4. Community Integration 1. Client Choice is the Foundation of the Pathways Housing First Program Choice drives both housing and clinical services Clients choose among housing options: location, size, floor, neighborhood, furnishings and other household items of their apartments Clients choose among the services: type, frequency and intensity

5 Scatter Site Housing Most preferred choice in housing Independent Apartments Privacy, safety, security Normal housing (rented from community landlords and rent less than 20% of units) Tenants rights -housing is permanent, client holds lease Social services are off site but visits are required Treatment is offered not mandated Landlords as program partners Landlord, program and participant have a common goal -- All want safe, decent, well managed housing 1) Agency that ensure rent is paid on time 2) Agency and landlord communication -- responsive to landlord concerns 4)Agency responsible for tenant damages 5)Advantages of using rental market: quick start up, relocation, expansion as needs change, others. SERVICES: Clinical and support services provided by ACT or ICM Teams Matching the level of services to the person s needs Hi Need: ACT is a multidisciplinary team and provides support and services directly 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) ACT and ICM Off site and call services 7-24 All teams use a recovery orientation

6 LIMITS to consumer choice: clinical, legal, economic & practical issues There are clinical, legal and practical limits to choice: 1) Must agree to weekly apartment visit by team 2) Danger to self or others may lead to involuntary hospitalization 3) Other legal social issues (abuse, violence, illegal activity, etc.) Limits on housing choice 4) Economic constraints on housing choice 5) Must sign lease, pay 30% of income towards rent and observe responsibilities of standard lease USING ST T Housing First: No clinical prerequisites and rental of community based units $$ $$ $$ $$$$$$$$$$$$$$ PERMANENT SHELTER TRANSITIONAL Housing Housing (NO HOUSING READINESS) O Out reach that Tracks to housing >>>>>> PSH with support services matched to consumers needs The home visit

7 2. Separation of Housing and Treatment Services Use different criteria for success in housing and success in treatment services Relapse is anticipated; relapse is clinical problem not a housing problem Relapse does not mean eviction or loss of housing It means obtaining treatment and returning home Similarly, eviction from housing does not mean discharge from the program (it usually means relocation) Program commitment is to the personnot the housing Supporting Some Core Research World Health Organization studies (Whitaker) The Vermont Study (Harding) What Helps What Hinders Recovery? (Onken, Ridgway et al.) Exploration of Process & Stages of Recovery

8 Key Elements of the Paradigm Shift What helps what hinders: Change in view of those served Change in goals of the system Change in power relationships Change in focus and locus of care Change in treatment culture Recovery Focused Treatment People need self-directedapproaches e.g., housing first, supported employment, wellness self management They also need knowledge and skills to self-manage their condition An emphasis on holistic wellness and positive lifestyle is healing (address emotional, physical, social, cultural, and spiritual needs) Recovery Extends Beyond the Mental Health Field

9 Meaningful Social Roles Peer Support and Recovery Role Models Are of Primary Importance Peer Support

10 Hope-instilling Practice Positive messages about recovery Develop and reach small hopes Link to something larger than self Relationship True caring and honest concern See the individual and treat as a whole person Can do Messages Facilitative Partnership Person as the driver of his or her own life and recovery True caring and Honest Concern

11 Opportunities/Choices/Options Choices really matter! People have often been stuck in programs with few options and opportunities Benefits so low as to be life-stealing Meeting basic needs housing, income, transportation, health care Opening doors to community integration Social Inclusion 4. Community Integration Housing that is normal housing provides (least restrictive setting (Olmstead Decision) Provide opportunities for social integration Building community supports in integrated neighborhoods (self help, spiritual, cultural, personal skills and interests) Services assist participants with community integration activities orientation to building Mapping of their neighborhood and community

12 Community Integration and Graduation Services can be reduced over time or stopped altogether when the person no longer needs them makes for smooth graduation In HF model, the service providers walk away and the person stays home Graduation, services walk away and the person stays home! Studies of Program Effectiveness

13 Evaluating Housing First Highly effective program for the hard to house 85% housing retention rates across many cities and programs Access problems eliminated, retention increased Reduction in acute care services and significant cost savings (pre=post) Improves quality of life Tsemberis effectiveness (2004); HUD Pearson 6 cities (2007); VA Rosenheck 11 cities (2007); Larimer, cost (2009). Program Assignment reduction Choice Personal Mastery reduction Psychiatric Symptoms Proportion of time homeless increase Adapted from Greenwood et al, Research Evidence - Residential stability (85%) - Reductions in service utilization - Improved Mental Health status - Reduction in Drug Alcohol Consumption - Cost Effectiveness (over 35 studies)

14 SAMHSA s National Registry of Evidence Based Practices Mental Health Commission of Canada ($110 M; 5 city longitudinal rct) European Union (10 cities hf compared to tau) France (4 city implementation) Finland (4 city implementation)

15 For more information about Pathways Housing First Please visit our website at Or send to Question and Answers Thank you!