1811 Eastlake is a permanent supportive housing program operated by the Downtown Emergency Service Center (DESC) in Seattle. 1811 Eastlake provides housing and services for 75 formerly homeless men and women with chronic alcohol addiction. It is designed to address the needs of people with a high level of health vulnerability who are some of the highest utilizers of publicly-funded crisis services. It offers an example of the Housing First approach adapted to meet the needs of this population within a single housing setting, where both housing and services are delivered by the same agency.
Problem or Challenge:
Extraordinarily high public costs are associated with the utilization of emergency and hospital services, emergency transportation, detoxification services, court, jail and legal services by chronically homeless individuals who are alcohol-dependent. People with long-term and severe alcohol problems who experience chronic homelessness die on the streets far more frequently than any other subset of the homeless population. 1811 Eastlake is a supportive housing project designed to meet the needs of this population. Tenants of the project are typically over 45 years of age, have at least 15 years of chronic alcohol addiction and homelessness history, and an average of 16 failed attempts at conventional alcohol treatment.
1811 Eastlake uses a Housing First program model to provide permanent housing with wraparound services for 75 homeless men and women with chronic alcohol addiction. When it opened in 2005 it was one of the few housing programs of its kind to address the needs of people suffering from chronic homelessness and alcoholism, who are the highest utilizers of crisis services. The project’s objectives are to help tenants achieve housing stability, reduce alcohol consumption and its harmful effects, reduce tenants’ use of the community’s crisis response system, and reduce public nuisances.
Located in the Denny Triangle neighborhood of downtown Seattle, 1811 Eastlake provides 75 furnished units of permanent supportive housing. The ground floor includes a community dining room area, kitchen, lounge areas, offices for DESC staff, and private spaces for counseling, nursing, and other services. A large deck provides an outdoor area for tenants.
No sobriety or abstinence requirement is imposed as a condition of tenancy, and tenants are not required to participate in substance abuse treatment or other services as a condition of occupancy. They have leases and rent payment requirements based on individual income. Like other Housing First programs, 1811 Eastlake is premised on the philosophy that interventions and service supports are more effective after individuals are living in their own housing rather than on the streets or in shelters, and that, once in permanent housing, people can begin to regain the confidence and control over their lives they lost when they began experiencing homelessness. In addition to not requiring that individuals “clean up” in order to qualify, the program provides individualized support services that address the precise issues that tenants are facing. These services include comprehensive mental health services, chemical dependency counseling, nursing support, medication assistance, and help with independent living skills, such as money management and housekeeping. Meals are also offered on site.
While the components of the service model of 1811 Eastlake are similar to other Housing First programs, its delivery is different from the mobile Assertive Community Treatment (ACT) teams commonly used in scattered sites programs. Like ACT, DESC provides multidisciplinary, around-the-clock staffing, but support staff members are located on site, enabling them to respond immediately to issues that may arise. Site-based Residential Counselors provide around the clock crisis intervention availability and general support, while on-site Clinical Support Specialists provide individualized intensive case management and coordination with community-based services such as primary health care and behavioral health services (the latter being primarily delivered by DESC’s own licensed mental health and substance abuse treatment programs). Housing integrated with on-site services allows for the constant availability of intensive services at a lower per-person service cost than the ACT model.
DESC owns and manages the housing where its clients live and is also the primary service provider. Basic property management functions are carried out by the site-based staff who report to the same project manager as the clinical staff. This blended approach, which differs from many other permanent supportive housing program models, allows staff to provide a high level of supervision and offers greater latitude in responding to the challenges of housing individuals with active addictions. DESC learned that the key to success is good communication and a tight partnership between service and housing staff. Daily team meetings and collaborative case planning enhance coordination and consistency so that staff resources are immediately responsive to client needs.
Tenant Identification and Outreach
DESC partners with county officials to deliberately seek out the most expensive consumers of crisis services, including the community’s major public hospital, the sobering center, and the County’s detox facility and jails. Through DESC staff outreach at the sobering center, in shelters and other places, eligible individuals are contacted and offered tenancy in the project. Only four of the initial 79 people contacted turned down the offer of housing at 1811 Eastlake.
The tenant profile is predominately male, and about a third of tenants are Native American. The average resident reported being homeless 31 of 36 months prior to moving in. They are overwhelmingly disabled with chronic health conditions, many resulting from years of alcohol abuse. Over forty percent have a co-occurring severe mental illness.
The on-site service team consists of a registered nurse and five clinical social workers (“Clinical Support Specialists”), who work with tenants to develop client-centered service plans. On-site support specialists are able to formally and informally engage and interact with tenants, most of whom rarely seek help on their own. Because the use of services by tenants is voluntary, staff members use “assertive engagement” to seek out tenants and draw them into services by demonstrating how the supports can be useful from the tenant’s perspective.
There are also 2-3 Residential Counselors on duty at any one time. They carry out functions related to security, rule enforcement, crisis intervention, and counseling. Residential Counselors, in their routine contacts with tenants, see things that are critical to the support specialists’ understanding of their clients, and by sharing information they help the team to coordinate care.
The project prohibits alcohol consumption in public areas both in and outside the building, but tenants may drink in their rooms. Alcohol is not provided to tenants; they must purchase it themselves. About half of the tenants voluntarily participate in a managed alcohol distribution program through which staff members store and dispense to the tenant upon an agreed schedule the alcohol that the tenant has purchased. On-site staff continually support and encourage tenants to reduce alcohol consumption. An evaluation of the project found that the longer the tenants stay in the housing, the less they drink.
DESC partnered with the Addictive Behaviors Research Center at the University of Washington to evaluate the effectiveness of 1811 Eastlake. The three-year study, funded by the Robert Wood Johnson Foundation, focused on the first 95 tenants of the project, plus a wait-list control group of 39 people. Among the findings from the first report, published in the Journal of the American Medical Association in 2009:
The program saved taxpayers more than $4 million over the first year of operation. During the first six months, the study reported an average cost savings of nearly $2,500 per month per person in health and crisis system costs. Visits to the hospital alone decreased by 32percent.
Adjusting for deaths (6), 74 percent of tenants remained housed for at least one year.
The number of days residents consume alcohol to intoxication was reduced by nearly 50 percent.
A paper detailing changes in alcohol consumption rates and alcohol-related problems experience by residents in their first two years of residency was published in the American Journal of Public Health in 2012. Included in the results of that study are a steady decrease over time in the amount of alcohol consumed by residents, from a median of 20 to 12 drinks per typical drinking day, and a decrease in the recent experience of delirium tremens by over half, from affecting 65 percent of residents to 23 percent.
Contact Info for Follow-up:
Downtown Emergency Service Center (DESC): www.desc.org
The site includes links to the University of Washington research study as well as a HUD publication (The Applicability of Housing First Models to Homeless Persons with Serious Mental Illness) featuring DESC and its other Housing First programs.
Evidence Based Practice: Housing First
Evidence Based Practice: Permanent Supportive Housing
Model Program: Pathways to Housing (NY, NY)
Model Program: Rhode Island Housing First (RI)
Model Program: Chicago Housing for Health Partnership (Chicago, IL)