Housing First

Housing First is a relatively recent innovation in human service programs and social policy regarding treatment of the homeless and is an alternative to a system of emergency shelter/transitional housing progressions. Rather than moving homeless individuals through different "levels" of housing, whereby each level moves them closer to "independent housing" (for example: from the streets to a public shelter, and from a public shelter to a transitional housing program, and from there to their own apartment in the community) Housing First moves the homeless individual or household immediately from the streets or homeless shelters into their own apartments. Rapid Re-Housing is based on housing first principles and is considered a subset of the Housing First approach. "Rapid re-housing" differs primarily in the provision of short-term rent subsidies (generally 3–6 months), after which the tenant either pays rent without a subsidy or has access to a Section 8 Housing Choice voucher or the equivalent.

Housing First approaches are based on the concept that a homeless individual or household's first and primary need is to obtain stable housing, and that other issues that may affect the household can and should be addressed once housing is obtained. In contrast, many other programs operate from a model of "housing readiness" — that is, that an individual or household must address other issues that may have led to the episode of homelessness prior to entering housing.

General principles

In Los Angeles, California in 1988, the "Housing First" Program for families was launched at Beyond Shelter by Tanya Tull (www.partnering-for-change.org) in response to a sharp increase in the number of homeless families with children. In 1992 Dr. Sam Tsemberis, a faculty member of the Department of Psychiatry of the New York University School of Medicine, founded Pathways to Housing in New York City. Housing First for the chronically homeless is premised on the notion that housing is a basic human right, and so should not be denied to anyone, even if they are abusing alcohol or other substances. The Housing First model, thus, is philosophically in contrast to models that require the homeless to abjure substance-abuse and seek treatment in exchange for housing.

Housing First is an approach that offers permanent, affordable housing as quickly as possible for individuals and families experiencing homelessness, and then provides the supportive services and connections to the community-based supports people need to keep their housing and avoid returning to homelessness.

Housing First, when supported by the United States Department of Housing and Urban Development, does not only provide housing. The model, used by nonprofit agencies throughout America, also provides wraparound case management services to the tenants. This case management provides stability for homeless individuals, which increases their success. It allows for accountability and promotes self-sufficiency. The housing provided through government supported Housing First programs is permanent and "affordable," meaning that tenants pay 30% of their income towards rent. Housing First, as pioneered by Pathways to Housing, targets individuals with disabilities. This housing is supported through two HUD programs. They are the Supportive Housing Program and the Shelter Plus Care Program. Pathways' Housing First model has been recognized by the Substance Abuse and Mental Health Services Administration as an Evidence-based practice.

Principles of Housing First are: 1) Move people into housing directly from streets and shelters without preconditions of treatment acceptance or compliance; 2) The provider is obligated to bring robust support services to the housing. These services are predicated on assertive engagement, not coercion; 3) Continued tenancy is not dependent on participation in services; 4) Units targeted to most disabled and vulnerable homeless members of the community; 5) Embraces harm-reduction approach to addictions rather than mandating abstinence. At the same time, the provider must be prepared to support resident commitment to recovery; 6) Residents must have leases and tenant protections under the law; 7) Can be implemented as either a project-based or scattered site model.

Housing First is currently endorsed by the United States Interagency Council on Homelessness (USICH) as a "best practice" for governments and service-agencies to use in their fight to end chronic homelessness in America.

Housing First programs currently operate throughout the United States in cities such as New Orleans, Louisiana; Plattsburgh, New York; Anchorage, Alaska; Minneapolis, Minnesota; New York City; District of Columbia; Denver, Colorado; San Francisco, California; Atlanta, Georgia; Chicago, Illinois; Quincy, Massachusetts; Philadelphia, Pennsylvania; Salt Lake City, Utah; Seattle, Washington;Los Angeles; Austin, Texas; and Cleveland, Ohio among many others, and are intended to be crucial aspects of communities' so-called 10-Year Plans To End Chronic Homelessness also advocated by USICH.

Evidence and outcomes

In Massachusetts, the Home & Healthy for Good program reported some significant outcomes that were favorable especially in the area of cost savings.

The Denver Housing First Collaborative, operated by the Colorado Coalition for the Homeless, provides housing through a Housing First approach to more than 200 chronically homeless individuals. A 2006 cost study documented a significant reduction in the use and cost of emergency services by program participants as well as increased health status. Emergency room visits and costs were reduced by an average of 34.3 percent. Hospital inpatient costs were reduced by 66 percent. Detox visits were reduced by 82 percent. Incarceration days and costs were reduced by 76 percent. 77 percent of those entering the program continued to be housed in the program after two years.

Researchers in Seattle, Washington, partnering with the Downtown Emergency Service Center, found that providing housing and support services for homeless alcoholics costs taxpayers less than leaving them on the street, where taxpayer money goes towards police and emergency health care. Results of the study funded by the Substance Abuse Policy Research Program (SAPRP) of the Robert Wood Johnson Foundation appeared in the Journal of the American Medical Association April, 2009. This first US controlled assessment of the effectiveness of Housing First specifically targeting chronically homeless alcoholics showed that the program saved taxpayers more than $4 million over the first year of operation. During the first six months, even after considering the cost of administering the housing, 95 residents in a Housing First program in downtown Seattle, the study reported an average cost-savings of 53 percent—nearly US $2,500 per month per person in health and social services, compared to the per month costs of a wait-list control group of 39 homeless people. Further, stable housing also results in reduced drinking among homeless alcoholics.

In Utah, there has been "a 72 percent decrease overall since enacting the plan in 2005" according to the Utah Division of Housing and Community Development.

In August 2007, the US Department of Housing and Urban Development reported that the number of chronically homeless individuals living on the streets or in shelters dropped by an unprecedented 30 percent, from 175,914 people in 2005 to 123,833 in 2007. This was credited in part to the "housing first" approach; Congress in 1999 directed that HUD spend 30% of its funding on the method.

In September 2010, it was reported that the Housing First Initiative had significantly reduced the chronic homeless single person population in Boston, Massachusetts, although homeless families were still increasing in number. Some shelters were reducing the number of beds due to lowered numbers of homeless, and some emergency shelter facilities were closing, especially the emergency Boston Night Center. By 2015, Boston Mayor Marty Walsh had announced a 3-year plan to end chronic homelessness, focusing on coordinating efforts among public agencies and nonprofit organizations providing services to homeless men and women.

In 2013, the estimated national public cost of chronic homelessness was between $3.7 and $4.7 billion according to the United States Interagency Council on Homelessness (USICH). Through Housing First programs, chronically homeless individuals are using fewer hospital resources, spending less time in costly incarceration and requiring fewer emergency room visits. For example, a review of the impact of permanent supportive housing and case management on the health of the chronically homeless found evidence that these services have a positive impact on health outcomes such as self-reported mental health status and substance use, a large impact on health care utilization, and a reduction in Medicaid health care costs. Studies in New York City and in Utah have shown that every homeless person housed in programs such as Housing First saves taxpayers $10,000 and $8,000 a year, respectively. A research study at University of Northern Carolina also reported that a housing project for the chronically homeless called Moore Place had saved the county $2.4 million.

Recent US policy and legislation

The United States Congress appropriated $25 million in the McKinney-Vento Homeless Assistance Grants for 2008 to show the effectiveness of Rapid Re-housing programs in reducing family homelessness.

In February 2009, President Obama signed the American Recovery and Reinvestment Act of 2009 part of which addressed homelessness prevention, allocating $1.5 billion for a Homeless Prevention Fund. The funding for it was called the "Homelessness Prevention and Rapid Re-Housing Program" (HPRP), and was distributed using the formula for the Emergency Shelter Grants (ESG) program.

On May 20, 2009, President Obama signed the Homeless Emergency Assistance and Rapid Transition to Housing (HEARTH) Act into Public Law (Public Law 111-22 or "PL 111-22"), reauthorizing HUD's Homeless Assistance programs. It was part of the Helping Families Save Their Homes Act of 2009. The HEARTH act allows for the prevention of homelessness, rapid re-housing, consolidation of housing programs, and new homeless categories. In the eighteen months after the bill's signing, HUD must make regulations implementing this new McKinney program.

In late 2009, some homeless advocacy organizations, such as the National Coalition for the Homeless, reported and published perceived problems with the HEARTH Act of 2009 as a HUD McKinney-Vento Reauthorization bill, especially with regard to privacy, definitional ineligibility, community roles, and restrictions on eligibile activities.

On June 22, 2010, the United States Interagency Council on Homelessness presented Opening Doors: Federal Strategic Plan to Prevent and End Homelessness to the Obama Administration and Congress. This is the nation's first comprehensive strategy as mandated by the HEARTH Act and includes Housing First as a best practice for reaching the goal of ending chronic homelessness by 2015.

On June 11, 2014 the 100,000 Homes Campaign in the United States, launched in 2010 to "help communities around the country place 100,000 chronically homeless people into permanent supportive housing" announced that it reached its four-year goal of housing 100,000 chronically homeless people nearly two months before its July 29 deadline.

New York Times journalist David Bornstein summarized key elements of the 100, 000 Homes Campaign that campaign leaders attribute to its success. This included learning individual homeless people's "name and need" by mobilizing volunteers to go very early in the morning to check on them, establishing a "vulnerability index" so they could prioritize certain homeless people and "bring housing advocates and agency representatives together to streamline the placement processes, and share ideas about how to cut through red tape."

Application to family homelessness

The Housing First methodology was initially developed in 1988 in Los Angeles, California, to address an increase in family homelessness. The basic methodology helps homeless families to relocate from shelters and transitional housing directly into permanent rental housing in the community at-large as quickly as possible, with home-based case management support for a traditional period of time. In other words, the services traditionally being provided in transitional housing were instead provided to families after they had been assisted in relocating to permanent housing at rents they could afford. This was a major innovation in the field at the time. The basic premise was that families were more responsive to interventions and support from a stable permanent housing base than while still homeless. In the 2009 HEARTH Act, the housing first approach to ending homelessness was codified into law. Housing First programs for families differ dramatically from Housing First for the chronically homeless, as children are involved! Beyond Shelter's leadership promoted this new approach across the country for the next 20 years, working collaboratively with the National Alliance to End Homelessness.

Outside the United States

Australia

In South Australia, the State Government of Premier Mike Rann (2002 to 2011) committed substantial funding to a series of initiatives designed to combat homelessness. Advised by Social Inclusion Commissioner David Cappo and the founder of New York's Common Ground program, Rosanne Haggerty, the Rann Government established Common Ground Adelaide building high quality inner city apartments (combined with intensive support) for "rough sleeping" homeless people. The government also funded the Street to Home program and a hospital liaison service designed to assist homeless people who are admitted to the emergency departments of Adelaide's major public hospitals. Rather than being released back into homelessness, patients identified as rough sleepers are found accommodation backed by professional support. Common Ground and Street to Home now operate across Australia in other states.

Canada

In its Economic Action Plan 2013, the Federal Government of Canada proposed $119 million annually from March 2014 until March 2019—with $600 million in new funding—to renew its Homelessness Partnering Strategy (HPS). In dealing with homelessness in Canada, the focus is on the Housing First model. Thus, private or public organizations across Canada are eligible to receive HPS subsidies to implement Housing First programs. In 2008, the Federal Government of Canada funded a five-year demonstration program, the At Home/Chez Soi project, aimed at providing evidence about what services and systems best help people experiencing serious mental illness and homelessness. Launched in November 2009 and ending in March 2013, the At Home/Chez Soi project was actively addressing the housing need by offering Housing First programs to people with mental illness who were experiencing homelessness in five cities: Vancouver, Winnipeg, Toronto, Montréal and Moncton. In total, At Home/Chez Soi has provided more than 1,000 Canadians with housing.

Housing First has grown in popularity in Canada and used in many Canadian ten-year plans to end homelessness, such as those in Edmonton and Calgary, Alberta. Housing First: A Canadian Perspective (TM) is spearheaded by Pathways to Housing Calgary and director Sue Fortune. Canadian adaptations to Housing First have demonstrated positive outcomes as documented on the website: www.thealex.ca (Housing Programs; Pathways to Housing). Canadian implementations of Housing First must be tailored to Canadian homelessness, resources, politics and philosophy.

In Calgary, Alberta, the Alex Pathways to Housing Calgary which opened in 2007, has 150 individuals in scatter site homes in 2013. Clients pay 30 percent of their income towards their rent: 85 percent of Pathways to Housing clients receive Assured Income for the Severely Handicapped (AISH) benefits and 15 percent receive Alberta Works. The Alex Pathways to Housing uses a Housing First model, but it also uses Assertive Community Treatment (ACT), an integrated approach to healthcare where clients access a team of "nurses, mental health specialists, justice specialists and substance abuse specialists." Director Sue Fortune is committed to the 10 Year Plan To End Homelessless in the Calgary Region. Fortune reported that the Housing First approach resulted in a 66 percent decline in days hospitalized (from one year prior to intake compared to one year in the program), a 38 percent decline in times in emergency room, a 41 percent decline in EMS events, a 79 percent decline in days in jail and a 30 percent decline in police interactions. Sue Fortune, Director of Alex Pathways to Housing in Calgary in her 2013 presentation entitled "Canadian Adaptations using Housing First: A Canadian Perspective" argued that less than 1% of existing clients return to shelters or rough sleeping; clients spend 76% fewer days in jail; clients have 35% decline in police interactions.

Pathways to Housing Canada describes the Housing First as a "client-driven strategy that provides immediate access to an apartment without requiring initial participation in psychiatric treatment or treatment for sobriety."

Finland

In 2007 the centre-right government of Matti Vanhanen began a special program of four wise men to eliminate homelessness in Finland by 2015.

The programme to reduce long-term homelessness targets just some homeless people. Assessed on the basis of social, health and financial circumstances, this is the hard core of homelessness. The programme to reduce long-term homelessness focuses on the 10 biggest urban growth centres, where also most of the homeless are to be found. The main priority, however, is the Helsinki Metropolitan Area, and especially Helsinki itself, where long-term homelessness is concentrated.

The programme is structured around the housing first principle. Solutions to social and health problems cannot be a condition for organising accommodation: on the contrary, accommodation is a requirement which also allows other problems of people who have been homeless to be solved. Having somewhere to live makes it possible to strengthen life management skills and is conducive to purposeful activity.

Because of all the reasons there are for long-term homelessness, if it is to be cut there need to be simultaneous measures at different levels, i.e. universal housing and social policy measures, the prevention of homelessness and targeted action to reduce long-term homelessness.

The programme’s objectives are:

• To halve long-term homelessness by 2011
• To eliminate homelessness entirely by 2015
• More effective measures to prevent homelessness

France

French government launched a Housing First-like program in France on 2010 in 4 majors cities : Toulouse, Marseille, Lille and Paris called "Un chez-Soi d'abord". It follows the same principles as the Canadian and US programs : it is focused on the homeless people with mental illness or addicted to drugs or alcohol. The plan is on a 3 years basis for each individual, sheltered in an apartment lend by a NGO.

They are given the needed help to reinsert and take medical care to the tenants, at home. The first houses are ready and working in 3 cities since 2011 and a hundred apartments will be available for the public in Paris starting on May 2012.

Several NGOs are involved in this experiment, they are assuring the rental management as well as the social support for the housed people.

Those NGOs are linked with scientists investigating the results of the experiment and serve as a relay for informations and status reports on the targeted public. The lead team of "Un chez-soi d'abord" is expecting results to be published around 2017.

Japan

Though homeless support group like Nonprofit organization Moyai, Bigissue, Médecins du Monde Japan have requested the Housing First, Japanese government does not have Housing First program yet. Traditionally,the government offers public housing so called Koei-jutaku for low-income people by Public housing law and it is run by local government. Rent fee is subject to change according to household income. Because applicants must be selected by lottery, low-income people can not live in the housing soon though they have an advantage.There are couple of Housing First-like programs.Non profit organization Littleones renovates discarded homes or empty homes and they rent the rooms for single mother with financial and occupational support. Tsukuroi Tokyo fund advocates a housing first and they built a shelter specially for homeless people.

Criticism of Housing First

One-size-fits-all

The United States Department of Housing and Urban Development has been underfunding or eliminating poverty fighting programs and has replaced them with the Housing First modeled programs. Ralph da Costa Nunez, the President and CEO of the Institute for Children, Poverty and Homelessness (ICPH), who is also a Professor at Columbia University, predicted this one-size-fits-all is destined to fail as statistics in New York City prove. Dr. Nunez described Housing First's one-size-fits-all approach not as "public policy" but rather as "public stupidity." Nunez advocates for a three tiered approach to addressing homelessness with Housing First as only the first component of that approach.

Following Panelák: a failed communist model

Sharam Kohan, a social policy expert and economist, compared the Housing First model to Panelák of the former communist countries that tried to end homelessness by providing permanent and unconditional public housing. Dr. Kohan criticized Housing First model for following Panelák's failed philosophy and approaches. Dr. Kohan points out to a growing number of reports from communities that have implemented Housing First programs which are "credited with creating slums and slumlord."

Limits of evidence based policy

On July 31, 2011, Prof. Victoria Stanhope, Ph.D., of New York University School of Social Work and Prof. Kerry Dunn, J.D., Ph.D., of University of New England School of Social Work, published “The curious case of Housing First; The limits of evidence-based policy” in the International Journal of Law and Psychiatry. Drs. Stanhope and Dunn gave an overview of evidence-based policy and presented “critiques based on its reliance on positivist methods and technical approach to policy making. Using these critiques as a framework, the paper discusse[d] the case of Housing First, a policy adopted by the Bush Administration in order to address the problem of chronic homelessness.” According to Drs. Stanhope and Dunn, the Housing First “is an example of research-driven policy making but also resulted in a progressive policy being promoted by a conservative administration. In discussing the case, the paper elaborates on the relationship between evidence and policy, arguing that evidence-based policy fails to integrate evidence and values into policy deliberations. The paper concludes with alternative models of policy decision-making and their implications for research.”

Housing First has been criticized on its failure to address broader service outcomes, namely substance abuse or that in fact, the only reason that its substance abuse outcomes were no worse was that the residents were not severely addicted. These criticisms have been rebutted on the grounds that Housing First is a program to end homelessness not to reduce substance abuse, though more recent research indicates it is more effective than traditional approaches in this regard as well. This exchange highlights the way in which the selection of outcomes sets the terms of the debate and set the parameters of “what works.” Embedded in that mantra are a priori decisions about what constitutes working and for whom; in this case it was stable housing for the chronic homeless.

According to Stanhope, Housing First “asserts a right to housing. Such a material right is an anathema to neoliberal ideology and challenges deeply held beliefs that have shaped US welfare from its inception: That no one has a right to a government benefit unless they have proved themselves to be deserving or worthy (e.g., "TANF"), or have earned it (e.g., social insurance).”

See also

• Homelessness in the United States
• McKinney-Vento Homeless Assistance Act
• At Home, a Canadian program inspired by Housing First

Bibliography

• Graves, Florence; Sayfan, Hadar, "First things first: 'Housing first,' a radical new approach to ending chronic homelessness, is gaining ground in Boston", The Boston Globe, Sunday, June 24, 2007.
• Lyons, Julia, "A Home for the Homeless", February 26, 2008, The Salt Lake Tribune
• Nashville Business Journal, "U.S homeless czar to meet with Mayor, Nashville officials Friday", Thursday, April 17, 2008.
• Greenwood, R; Schaefer-McDaniel, N; Winkel, G; Tsemberis, S (2005). "Decreasing psychiatric symptoms by increasing choice in services for adults with histories of homelessness". American J Community Psychology. 36 (3/4): 223–38. doi:10.1007/s10464-005-8617-z.
• Pathways; Housing Inc, New York (2005). "2005 APA Gold Award: Providing housing first and recovery services for homeless adults with severe mental illness". Psychiatric Services. 56: 1303–5. doi:10.1176/appi.ps.56.10.1303.
• Tsemberis, Sam; Eisenberg, Ronda R. (2000). "Pathways to Housing: Supported Housing for Street-Dwelling Homeless Individuals with Psychiatric Disabilities". Psychiatric Services. 51 (4): 487–93. doi:10.1176/appi.ps.51.4.487. PMID 10737824.
• Tsemberis S. (2004) "'Housing first' Approach" article in "Encyclopedia of Homelessness", Thousand Oaks, CA: Sage, V1, pp. 277–80.
• Tsemberis, Sam; Gulcur, Leyla; Nakae, Maria (2004). "Housing First, Consumer Choice, and Harm Reduction for Homeless Individuals with a Dual Diagnosis". American Journal of Public Health. 94 (4): 651–56. doi:10.2105/AJPH.94.4.651.
• Tsemberis, Sam; Stefancic, Ana (2007). "Housing First for Long-Term Shelter Dwellers in a Suburban County: Traditional Housing and Treatment Services". The Journal of Primary Prevention. 28 (3): 265–279. doi:10.1007/s10935-007-0093-9.

Further reading

• AcademyHealth. (2016, July). Rapid Evidence Review: What Housing-related Services and Supports Improve Health Outcomes among Chronically Homeless Individuals?
• "Editorial: Doubled demand for housing over shelters, hotels", Spare Change News, Boston, Fri, December 2, 2011
• Bassuk, Ellen L.; Geller, Stephanie (2006). "The Role of Housing and Services in Ending Family Homelessness" (PDF). Housing Policy Debate. 17 (4): 781–806. doi:10.1080/10511482.2006.9521590.
• Benner, Tom, "Mass. Wants New Emphasis on Housing over Shelters", Spare Change News, Boston, July 15, 2011 (part 1 of 3)
• Benner, Tom, "New Homeless Policy", Spare Change News, July 29, 2011 (part 2 of 3)
• Benner, Tom, "An Exclusive Interview with Lt. Gov. Tim Murray on the State's New Housing First Policy", Spare Change News, August 12, 2011 (part 3 of 3)
• Bornstein, David, "A Plan to Make Homelessness History", The New York Times, December 20, 2010.
• Burt, Martha; et al., Helping America's homeless: emergency shelter or affordable housing?, Washington DC : Urban Institute Press, 1st edition, April 2001. ISBN 978-0-87766-701-8
• Center for the Study of Social Policy, "Affordable Housing as a Platform for Improving Family Well-Being: Federal Funding and Policy Opportunities", Financing Community Change Brief, June 2011, Washington D.C.
• Friedman, Donna Haig, et al., "Preventing Homelessness and Promoting Housing Stability: A Comparative Analysis", The Boston Foundation, June 2007.
• Karash, Robert L., "Housing Lost, Housing Regained, Housing Kept", Spare Change News, Boston, February 25, 2010.
• McCarroll, Christina, "Pathways to housing the homeless", The Christian Science Monitor, May 1, 2002
• Notkin, Susan; et al., "Families on the Move: Breaking the Cycle of Homelessness", Edna McConnell Clark Foundation, New York, NY, 1996.
• O’Flaherty, Brendan, "Making room : the economics of homelessness", Cambridge, Mass. : Harvard University Press, 1996. ISBN 0-674-54342-4
• Putnam, Kristen M., "Homelessness: Key Findings and Grantmaking Strategies", June 2002, Charles and Helen Schwab Foundation and Putnam Community Investment Consulting.
• Quigley, John M.; Raphael, Steven, "The Economics of Homelessness: The Evidence from North America", European Journal of Housing Policy 1(3), 2001, 323–336
• Roberts, Kevin, "Expert: ‘Even if shelters were better, they’re still not solving the problem'", Street News Service, Fri, December 2, 2011. Originally published in One Step Away street newspaper, Philadelphia, Pennsylvania
• Roncarati, Jill, "Homeless, housed, and homeless again", Journal of the American Academy of Physician's Assistants, June 2008.
• Tull, Tanya, "The 'Housing First' Approach for families Affected by Substance Abuse", The Source, v.13. n.1, Spring 2004, The National Abandoned Infants Assistance Resource Center

Media

• PBS, "Home at Last?, NOW series program, first aired on February 2, 2007. The topic was what will most help homeless people reenter the fabric of society and looks at the housing option.

External links

• Interagency Council on Homelessness (USA)
• Housing First - Transitional Housing for Individuals and Families
• Massachusetts Housing and Shelter Alliance
• The Partnership to End Long Term Homelessness
• Citizens' Housing and Planning Association
• National Low Income Housing Coalition
• National Alliance of HUD Tenants
• Dr. Sam Tsemberis information — Columbia University Center for Homelessness Prevention Studies (CHPS)
• Downtown Emergency Service Center, Seattle — Housing First programs
• The Philadelphia Committee to End Homelessness
• Corporation for Supportive Housing