Home Again provides permanent housing and support services to individuals who are experiencing or at risk of chronic homelessness using a Housing First approach. Outcomes from the program documented through a research study have shown clear advantages over standard approaches to providing care to people experiencing chronic homelessness.
Problem or Challenge:
The fundamental problem that Housing First programs address is extreme housing instability. For individuals experiencing chronic homelessness, this instability takes the form of months or years in shelters or on the streets, or as is often the case, multiple episodes of homelessness interspersed with time spent in hospitals, detox, jails, or short stays with others. Adults who experience chronic homelessness often have serious and persistent health issues, including mental illness, substance addiction, and primary health conditions that are difficult to impossible to manage while homeless.
The traditional response to chronic homelessness has been emergency shelter, which has been largely ineffective in ending homelessness among this population. In Worcester, MA, the community designed a Housing First program called Home Again to specifically address the needs of individuals experiencing chronic homelessness and other very vulnerable adults at risk of chronic homelessness. Through this collaborative effort to target the most vulnerable single adults for permanent supportive housing using a Housing First approach, the number of individuals experiencing chronic homelessness in the community fell from 129 to four within three years (based on the 2008 and 2011 Point-in-Time counts).
In 2007, a collaborative group of homeless service providers approached the Health Foundation of Central Massachusetts for funding to plan and then pilot test a Housing-First type approach to addressing chronic homelessness in Worcester. The project, called Home Again, provides stable, permanent homes and support services for homeless adults throughout the City of Worcester and surrounding communities.
Using a Housing First approach
Participants in Home Again are adults experiencing chronic homelessness and “pre-chronically” homeless adults defined as an unaccompanied adult who does not meet the definition for chronic homelessness but is currently experiencing homelessness and exhibiting characteristics associated with chronic homelessness and is likely to become chronically homeless unless there is an intervention with housing and support services to help them end their homelessness. Participants need not be sober (i.e., refrain from drinking alcohol or using drugs) in order to participate in Home Again. Instead, case management and other services are provided to participants in order for them to develop a harm reduction action plan and achieve a healthy lifestyle.
Case managers work directly with each participant to achieve permanent housing early in their engagement with services. The goal is for participants to move into permanent subsidized housing within a few weeks of program engagement; the average time from engagement to entry into permanent housing is less than three months. The case manager to participant ratio is 1:10 initially; caseloads may increase as participants stabilize.
Case managers accompany participants as they search for a place to live, and in some cases are able to direct them toward housing units, some of which are owned by agencies represented on the Home Again Steering Committee. In the first year close to half of Home Again participants were housed in scattered apartments and the other half in a single room occupancy (SRO) model. Currently, the majority of participants are in scattered apartments, which vary from SRO units to one-bedroom apartments. Home Again works to relocate or re-house participants when a housing placement does not work. The program’s design specifies that participants cannot be terminated by the program back into homelessness. The program works to find alternative housing settings to prevent the person from re-entering homelessness. Home Again can also serve as a representative payee for money management if the participant chooses.
Case management services continue after the participant is housed. Services are provided by a team of case managers which develops a comprehensive treatment plan with each participant. Case managers assist with housing searches and daily living activities, provide vocational services, and offer benefits assistance. They also work to ensure timely access to healthcare services, in-home nursing if needed, and mental health and substance abuse treatment.
Tenant-based rental subsidies for Home Again participants have come primarily through funding from HUD’s Continuum of Care programs. Community Healthlink also has brought Medicaid resources for services through CSPECH(Community Support Program for People Experiencing Chronic Homelessness), a program managed by the Massachusetts Behavioral Health Partnership. (The Medicaid dollars have largely replaced the initial service funding provided by the Health Foundation). As a Health Care for the Homeless provider, Community Healthlink is able to connect Home Again participants with the services of its primary care and behavioral health teams, and closely coordinate case management and clinical staff. Its clinical street outreach team and its health services team that visits the shelters are important vehicles for identifying individuals in need of Home Again services.
Retooling the Community’ Response to Chronic Homelessness
Launched in 2007, Home Again became a key element of the Three-Year Plan to End Homelessness in Worcester developed by the City Manager’s Task Force on Homelessness later that year. The plan called for a radical restructuring of the community’s response to homelessness with the goal of replacing shelters with a system of response grounded in the principles of Housing First.
A major impetus to the Home Again program came in November 2009, when people wanting to stay at the city’s People in Peril adult shelter were required to go to a new triage center to be screened instead of automatically being admitted. In addition, the goal of the plan was to close the People in Peril shelter and replace it with a new model with fewer beds and a focus on rapid re-housing. The impending closing of the shelter created an additional urgency to house people who were experiencing chronic homelessness and an opportunity to engage and work proactively with long-term shelter users.
The Worcester Continuum of Care saw Home Again as a means to build upon and expand Housing First initiatives already under way in the community to serve this population. It created a central intake process and developed a single list of individuals experiencing chronic homelessness in the city to target for housing and supports. The Continuum prioritized HUD Continuum of Care funding to lease apartments through Home Again. Continued funding for these housing costs is provided through the Continuum of Care annual renewal process.
By February 2011, the shelter had closed and the number of chronically homeless individuals counted at a point in time had fallen to four. The Continuum, which is staffed by the Central Massachusetts Housing Alliance, regularly monitors the community’s progress toward achieving and sustaining its goal of ending long-term homelessness.
Home Again was evaluated over the course of initial pilot periods by an evaluation team from the Boston University School of Public Health. The evaluation used a rigorous, randomized-control design which compared outcomes for Home Again participants with individuals receiving the standard care in Worcester. Sixty individuals were enrolled and randomized to receive either Home Again or standard care services. Among the findings:
Home Again participants were two and a half times as likely as individuals receiving standard care to achieve and maintain housing over six months.
Participants’ use of hospital emergency services decreased by an average of 1.46 visits per three months during the evaluation period. By contrast, the standard care participants reported an increase of .62 visits per three months.
Participants were nearly twice as likely as standard care participants to have good social support.
Contact Info for Follow-up:
Home Again website: www.homeagaincentralma.org. This offers information on the program and a link to the evaluation report.
Evidence Based Practice: Permanent Supportive Housing
Evidence Based Practice: Housing First
Evidence-Based Practice: Rental Housing Assistance
Promising Practice: Coordinated Entry (centralized intake)
Model Program: Home and Healthy for Good
Model Program: Community Support Program for People Experiencing Chronic Homelessness