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Housing First is a policy that offers unconditional, permanent housing as quickly as possible to homeless people, and other supportive services afterward. It was first discussed in the 1990s, and in the following decades became government policy in certain locations within the Western world.[1] There is a substantial base of evidence showing that Housing First is both an effective solution to homelessness and a form of cost savings, as it also reduces the use of public services like hospitals, jails, and emergency shelters.[2] Cities like Helsinki and Vienna in Europe have seen dramatic reductions in homelessness due to the adaptation of Housing First policies,[3][4] as have the North American cities Columbus, Ohio, Salt Lake City, Utah, and Medicine Hat, Alberta.[5][6][7][8][9][10]

Housing First 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 or house in the community), Housing First moves the homeless individual or household immediately from the streets or homeless shelters into their own accommodation.

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.

Housing first strategy is a unique idea, as it is a comprehensive solution incorporating support for homeless people in all aspects of their personal and social life. It does not intend to provide housing for the people in need and forget about them.[11] [12] [13] [14] The housing first philosophy is a paradigm shift, where quick provision of stable accommodations is a precondition for any other treatment to reduce homelessness. Meanwhile, this approach relies on layers of collaborative support networks that promote stability and eliminate factors that cause or prolong homelessness. The supporting system addresses issues such as healthcare, education, family and children, employment, and social welfare.[15] [16]

General principles

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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.[17]

History

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In the late 19th century, Don Bosco pioneered both the concept that would later become known as Housing First in Italy[citation needed] as well as pioneering the concept that would provide Dorothy Day the basis for her Catholic Worker Movement House of Hospitality founded in 1933. Bosco himself was inspired by and created a need society based on the teachings of St. Francis de Sales, a 16th and 17th century clergyman who was also at the forefront of early movements insisting that basic needs of the people be met first without various rules and regulations.[citation needed][improper synthesis?]

The formal Housing First Model has its origins in "Supported Housing" implemented in North America during the 1990s. For many years, the conventional action taken in regard to people experiencing homelessness was that of psychiatric hospitalization, where doctors considered individuals diagnosed with severe mental illness incapable of functioning in all areas of life and that they required around-the-clock supervision and support. This also reflected the idea prevalent at the time that all or a vast majority of people experiencing homelessness were suffering from mental illnesses. However, by the 1980s, experts began to raise questions regarding the underlying assumptions of this approach.[18]

In response, a "staircase" approach began to be utilized. The staircase approach for people experiencing homelessness had three goals: training people to live in their own homes after being on the streets or in and out of hospitals; making sure someone was receiving treatment and medication for any ongoing mental health problems; and making sure someone was not involved in behavior that might put their health, well-being, and housing stability at risk, particularly that they were not utilizing drugs or alcohol. Housing was seen as the end goal of the program.[19]

This model had several flaws. Those served by the staircase model often became "stuck" in staircase services, because they could not always manage to complete all the tasks necessary to proceed. Participants were often evicted from housing due to failure to abstain from drugs and alcohol and refusing to undergo psychiatric treatment. Programs also had high levels of standards beyond those expected from a "typical citizen" - participants were expected to be the "perfect citizen" in order to continue.[20]

Supported housing services developed as an alternative to staircase services for psychiatric patients. In contrast to the staircase approach, former psychiatric patients were very quickly provided with ordinary housing and received flexible help and treatment from mobile support teams. Support was provided for as long as was needed. Importantly, supportive housing did not require individuals to abstain from drugs or alcohol and providers did not expect full engagement with treatment as a condition for being housed.

Building on the supported housing model, but applied to people experiencing homelessness, Housing First was developed by Dr. Sam Tsemberis, a faculty member of the Department of Psychiatry of the New York University School of Medicine.[21] Housing was provided ‘first' rather than, as in the staircase model, ‘last'. Housing First offered rapid access to a settled home in the community, combined with mobile support services that visited people in their own homes. There was no requirement to stop drinking or using drugs and no requirement to accept treatment in return for housing. Housing was not removed from someone if their drug or alcohol use did not stop, or if they refused to comply with treatment. If a person's behavior or support needs resulted in a loss of housing, Housing First would help them find another place to live and then continue to support them for as long as was needed. Dr. Tsemberis founded Pathways to Housing in New York City in 1992 to implement this model.

Research conducted in the late 1990s by pioneering American social researcher Dennis P. Culhane and others demonstrated that the housing first model was more effective at ending long-term homelessness than previous models of care.[22] The systemic use of comparative research demonstrated the model's effectiveness.[23]

Definition

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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.[24]

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.[25] This housing is supported through two HUD programs. They are the Supportive Housing Program and the Shelter Plus Care Program.[26]

Execution

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The Housing First Model is executed through either a scattered-site or project-based implementation. A scattered-site Housing First program is a model in which residents are offered the opportunity of being housed in individual housing units throughout a community.[27][28] This model integrates participants in a community as opposed to assembling multiple or all participants in one project or location.[29] In a project-based Housing First implementation, residents are offered units within a single housing project or site. This model congregates multiple or all participants in one locality.[30] In both the scattered-site and project-based Housing First programs, residents are given access to a wide variety of supportive health and rehabilitation services which they have the option, although not mandatory, to participate in and receive treatment.[25]

Weekly staff visits as well as a normal lease agreement are also a part of the program. Consumers have to pay 30 percent of their income every month as rent.[31] Rather than have a homeless person remain in an emergency homeless shelter, it was thought to be better to quickly get the person permanent housing of some sort and the necessary support services to sustain a new home. But there are many complications that must be dealt with to make such an initiative work successfully in the middle to long term.[32][33]

Endorsement

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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.[34]

Locations in The United States

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Housing First programs currently operate throughout the United States in cities such as New Orleans, Louisiana;[35] Plattsburgh, New York; San Diego, California;[36] Anchorage, Alaska; Salisbury, Maryland;[37] Minneapolis, Minnesota; New York City; District of Columbia; Denver, Colorado; San Francisco, California; Atlanta, Georgia; Chicago, Illinois; Portland, Maine;[38] Quincy, Massachusetts; Philadelphia, Pennsylvania; Salt Lake City, Utah;[39] Seattle, Washington; Los Angeles; Austin, Texas;[40] San Antonio, Texas;[41] and Cleveland, Ohio[42]

Evidence and outcome

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Research in Seattle, Washington, 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.[24][43][non-primary source needed] Results of which appeared in the Journal of the American Medical Association April, 2009.[24] 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 [in chronic homelessness] overall since enacting the plan in 2005" according to the Utah Division of Housing and Community Development.[44] There has been some success with Utah's housing first plan, reducing chronic homelessness by 91 percent over the first ten years.[45]

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.[46]

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.[47] 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.[48][49]

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. 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.[50]

The implementation of Housing First philosophy when working with homeless families and young adults has been shown to increase clients' enrollment in public assistance benefits, decrease involvement in the child welfare system, and have very few returning to homelessness.[51]

When comparing the effects of Housing First on older and younger homeless adults, older homeless adults have shown significantly higher rates of improvement in areas like mental component summary scores, condition specific quality of life, mental health symptom severity, and percentage of days stably housed.[52]

When comparing the effects of Housing First on homeless adults with lower or borderline intellectual functioning to homeless adults with normal intellectual functioning it has been shown that there is no significant difference.[53]


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Critics of the Housing First approach have argued that some of the most severely mentally ill or drug addicted cannot be served effectively by the approach. In San Francisco, home to over 4,000 people experiencing homelessness and mental illness or drug addiction[54], a recent study found that 91% of those approached by the San Francisco homeless outreach team during sweeps refused the shelter offered to them[55], often due to underlying drug addiction or mental illness. Even when such individuals do accept housing, there are serious issues: 16% of all overdoses in San Francisco occur in government provided SROs[56] where there is insufficient infrastructure to prevent overdoses. Recent studies have suggested that institutionalization and compulsory drug rehab are ineffective in many cases[57], which has led to a broader adoption of Housing First solutions, but in practice support for these individuals in need often ends the moment they are housed. As a result, many struggle to move on to more sustainable self sufficient living; residents of San Francisco's SROs are more than twice as likely to overdose or return to homelessness than they are to move into permanent housing.[58] 

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  2. ^ "Housing First". National Alliance to End Homelessness. Retrieved 2022-07-17.
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  8. ^ "Utah Reduced Chronic Homelessness By 91 Percent; Here's How". NPR.org. Retrieved 2022-07-17.
  9. ^ Garrott, Luke (2022-03-28). "SLC to extend moratorium on homeless shelters for another year while city council signals discontent with current strategy". Building Salt Lake. Retrieved 2022-07-17.
  10. ^ Gregersen, Leif. "How A Small Canadian City Took On Chronic Homelessness". Next City. Retrieved 24 August 2022.
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  13. ^ Quirouette, M. (2016). "Managing Multiple Disadvantages: The Regulation of Complex Needs in Emergency Shelters for the Homeless". Journal of Poverty. 20 (3): 316–339. doi:10.1080/10875549.2015.1094774. S2CID 155529754.
  14. ^ Katz, A.; Zerger, S.; Hwang, S. W. (2017). "Housing First the conversation: discourse, policy and the limits of the possible". Critical Public Health. 27 (1): 139–147. doi:10.1080/09581596.2016.1167838. hdl:1807/76596. S2CID 147118255.
  15. ^ Laird, G. (2007). "SHELTER - Homelessness in a growth economy: Canada's 21st century paradox". Sheldon Chumir Foundation for Ethics in Leadership.
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  17. ^ "Housing First | Explore the Solutions Database | The Solutions Database". usich.gov. Archived from the original on 2015-12-10. Retrieved 2015-12-10.
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  24. ^ a b c Larimer, Mary E; Malone, D. K; Garner, M. D; Atkins, D. C; Burlingham, B; Lonczak, H. S; Tanzer, K; Ginzler, J; Clifasefi, S. L; Hobson, W. G; Marlatt, G. A (2009). "Health Care and Public Service Use and Costs Before and After Provision of Housing for Chronically Homeless Persons with Severe Alcohol Problems". JAMA. 301 (13): 1349–57. doi:10.1001/jama.2009.414. PMID 19336710.
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  26. ^ "HUD Homeless Assistance Programs". HUD. December 21, 2007. Archived from the original on March 8, 2008.
  27. ^ Stanhope, Victoria; Dunn, Kerry (2011). "The curious case of Housing First: The limits of evidence based policy" (PDF). International Journal of Law and Psychiatry. 34 (4): 275–82. doi:10.1016/j.ijlp.2011.07.006. PMID 21807412.
  28. ^ Collins, S. E; Malone, D. K; Clifasefi, S. L (2013). "Housing Retention in Single-Site Housing First for Chronically Homeless Individuals with Severe Alcohol Problems". American Journal of Public Health. 103 (Suppl 2): S269–S274. doi:10.2105/AJPH.2013.301312. PMC 3969126. PMID 24148063.
  29. ^ Stergiopoulos, V; Hwang, S. W; Gozdzik, A; Nisenbaum, R; Latimer, E; Rabouin, D; Adair, C. E; Bourque, J; Connelly, J; Frankish, J; Katz, L. Y; Mason, K; Misir, V; O'Brien, K; Sareen, J; Schütz, C. G; Singer, A; Streiner, D. L; Vasiliadis, H. M; Goering, P. N (2015). "Effect of scattered-site housing using rent supplements and intensive case management on housing stability among homeless adults with mental illness: A randomized trial". JAMA. 313 (9): 905–15. doi:10.1001/jama.2015.1163. PMID 25734732.
  30. ^ Collins, S. E; Malone, D. K; Clifasefi, S. L; Ginzler, J. A; Garner, M. D; Burlingham, B; Lonczak, H. S; Dana, E. A; Kirouac, M; Tanzer, K; Hobson, W. G; Marlatt, G. A; Larimer, M. E (2012). "Project-Based Housing First for Chronically Homeless Individuals with Alcohol Problems: Within-Subjects Analyses of 2-Year Alcohol Trajectories". American Journal of Public Health. 102 (3): 511–519. doi:10.2105/AJPH.2011.300403. PMC 3487630. PMID 22390516.
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  40. ^ "Permanent Supportive Housing | AustinTexas.gov".
  41. ^ "New Housing First Services Planned in the East Side". 16 October 2019.
  42. ^ Cleveland, Ohio
  43. ^ "CENTER FOR THE STUDY OF HEALTH AND RISK BEHAVIORS". University of Washington. Retrieved 12 February 2016.
  44. ^ Utah Housing and Community Development Comprehensive Report on Homelessness 2014
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  46. ^ "U.S. Reports Drop in Homeless Population", New York Times, July 20, 2008.
  47. ^ Brady-Myerov, Monica, "Homelessness On The Decline In Boston", WBUR Radio, Boston, September 29, 2010
  48. ^ WALSH, MARTIN J. (June 2015). "AN ACTION PLAN TO END VETERAN AND CHRONIC HOMELESSNESS IN BOSTON: 2015-2018" (PDF). City of Boston. Retrieved 12 February 2016.
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  51. ^ Collins, Cyleste C.; Bai, Rong; Crampton, David; Fischer, Robert; D'Andrea, Rebecca; Dean, Kendra; Lalich, Nina; Chan, Tsui; Cherney, Emily (January 2019). "Implementing housing first with families and young adults: challenges and progress toward self-sufficiency". Children and Youth Services Review. 96: 34–46. doi:10.1016/j.childyouth.2018.11.025. S2CID 149994756.
  52. ^ Chung, Timothy E.; Gozdzik, Agnes; Palma Lazgare, Luis I.; To, Matthew J.; Aubry, Tim; Frankish, James; Hwang, Stephen W.; Stergiopoulos, Vicky (January 2018). "Housing First for older homeless adults with mental illness: a subgroup analysis of the At Home/Chez Soi randomized controlled trial". International Journal of Geriatric Psychiatry. 33 (1): 85–95. doi:10.1002/gps.4682. PMID 28206715. S2CID 35164273.
  53. ^ Durbin, Anna; Lunsky, Yona; Wang, Ri; Nisenbaum, Rosane; Hwang, Stephen W.; O'Campo, Patricia; Stergiopoulos, Vicky (19 June 2018). "The Effect of Housing First on Housing Stability for People with Mental Illness and Low Intellectual Functioning". The Canadian Journal of Psychiatry. 63 (11): 785–789. doi:10.1177/0706743718782940. PMC 6299190. PMID 29916270.
  54. ^ Fracassa, Dominic; Thadani, Trisha (2019-09-04). "SF counts 4,000 homeless, addicted and mentally ill, but timeline for help still unclear". San Francisco Chronicle. Retrieved 2023-03-15.
  55. ^ Herring, Chris; Yarbrough, Dilara (2015-06-18). "Punishing the Poorest: How the Criminalization of Homelessness Perpetuates Poverty in San Francisco". Rochester, NY. {{cite journal}}: Cite journal requires |journal= (help)
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  57. ^ Werb, D.; Kamarulzaman, A.; Meacham, M. C.; Rafful, C.; Fischer, B.; Strathdee, S. A.; Wood, E. (2016-02-01). "The effectiveness of compulsory drug treatment: A systematic review". International Journal of Drug Policy. 28: 1–9. doi:10.1016/j.drugpo.2015.12.005. ISSN 0955-3959.
  58. ^ "SF's deadly failure on the drug crisis is unfolding inside its own housing program". The San Francisco Chronicle. Retrieved 2023-03-15.
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