Housing First


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 provides a foundation from which a person or family can access the services and supports they need to achieve stability, begin the recovery process, and pursue personal goals. While Housing First can be used in both short- and long-term interventions, the approach is closely tied to permanent supportive housing and therefore discussed in this context here. The Housing First approach can be applied to rapid re-housing as well.

Problem or Challenge:

Traditionally, many housing providers have required people experiencing homelessness to demonstrate “housing readiness” either by achieving sobriety or entering treatment before offering permanent housing. The housing readiness approach can lead to people with relatively fewer needs accessing service-intensive housing, while people with more complex problems remain in shelters or on the streets. Housing First permanent supportive housing was created when a new approach was sought to help people with long histories of homelessness secure housing.

Solution:

Housing First is an approach that offers permanent housing as quickly as possible for people experiencing homelessness, especially for people with long histories of homelessness and co-occurring health challenges, while providing the supportive services people need to keep their housing and avoid returning to homelessness.

The approach begins with an immediate focus on helping individuals and families get housing. Income, sobriety and/or participation in treatment or other services are not required as a condition for getting housing. All services are voluntary and are not a condition for retaining housing. Housing provides people with a foundation from which they can pursue other goals. Tenants are assisted in developing or improving skills for independent living while they live in permanent housing instead of requiring them to complete a transitional residential program first.

Housing is permanent, that is, it is not time limited. Housing may be provided in single-site permanent supportive housing, as set asides within apartment communities, or in scattered sites, often using some form of rent subsidies that makes the unit affordable. An apartment is usually not shared with other households. Tenants hold a lease for their housing, and have the normal rights and responsibilities of tenants. In some cases, a Housing First program may use a “master lease,” which allows the program to hold the lease and establish a sub-lease or rental agreement with the tenant. This sort of arrangement can be used when landlords might be reluctant to rent directly to a tenant because of past evictions or poor credit and the lease can often be transferred to the tenant after a period of successful occupancy.

Housing First permanent supportive housing programs often work to minimize barriers to housing access by simplifying the application process for housing or subsidies. Housing First programs work to “screen in” people with significant challenges who might be screened out of housing because of poor credit or prior evictions. If the program uses tenant-based rent subsidies, assistance is provided to help people locate a rental unit and negotiate lease agreements with landlords.

Supportive services are delivered from initial engagement through the housing search and continue after housing placement. Services focus on promoting housing stability and achieving other personal goals related to well-being and recovery. The intensity and duration of supportive services varies, depending on the population served by the program. Services in Housing First programs are often provided by multidisciplinary teams using Assertive Community Treatment or similar models, and team members make frequent visits to see clients in their homes or other community settings, instead of waiting for clients to come to an office appointment.

For people who have experienced chronic homelessness, and other people with serious mental illness or other complex and disabling challenges, services will be more intensive and designed to provide ongoing, long-term support including treatment for mental health or substance use disorders, and other health care and case management services.

Participation in services is actively encouraged but not required as a condition of tenancy. Services are flexible and individualized, and service providers do “whatever it takes” to help the person or family achieve goals related to housing stability. Service providers may offer help with practical needs (including food, clothing, household supplies) and work to establish a trusting relationship before expecting that a person will engage in treatment or more intensive case management services. Peer-based recovery services are often offered and may emphasize consumer empowerment and self-direction.

Implementation Steps/Tips:

Partnerships with landlords and housing providers: Good relationships with local landlords are often an essential component of a successful scattered site Housing First program. Housing First permanent supportive housing programs should reach out to landlord organizations and property management companies, as well as civic groups, churches, and other faith-based organizations to mitigate their concerns. Programs should maintain regular communication with landlords to ensure that participants are paying rent and being responsible tenants, and to trouble-shoot problems or resolve conflicts before they escalate. Sometimes programs offer an additional rental security deposit, or the program may place some funds into a reserve account that is available if needed to pay for damages or lost rent. Often programs will help participants move out and relocate rather than get evicted if problems cannot be resolved. When programs are successful, landlords and property managers are often willing to rent to other individuals or families served by the same program.

In single-site permanent supportive housing that uses a Housing First model, housing management and supportive services roles are usually clearly separate and performed by different staff or partner organizations who share a mission and goals related to housing people who have experienced homelessness. Effective policies and procedures are in place to facilitate ongoing communication and problem-solving. Supportive services staff usually work on-site at the building during the day and some evenings and/or weekend hours. The housing site may also provide staffing for security or “front desk” services, which may include a focus on limiting uninvited visitors and enforcing rules around tenancy that are designed to protect the safety, peacefulness, and quality of the housing for tenants and neighbors.

Housing First permanent supportive housing programs can also be implemented by creating set-asides within affordable housing developments that receive investments of public funding or leverage private investments using Low Income Housing Tax Credits. This approach is used to create a set-aside of supportive housing units (1) within affordable rental properties that primarily assist other households without disabilities. Often set-asides are created through strong incentives and partnerships that involve state or local government agencies that finance housing development, operating subsidies (to make rent in the supportive housing units affordable to people experiencing homelessness) and the alignment of funding for supportive services to help tenants maintain housing stability, as well as systematic outreach and referral processes to ensure priority populations get housed.

When problem behaviors arise in Housing First supportive housing, responses are individualized and graduated, meaning that people are held accountable and there are consequences for behaviors that violate the terms of their lease agreements, but housing and service providers work together in an effort to avoid evictions. Service providers increase efforts to engage tenants in supportive services in order to mitigate problems or motivate change, and they often use service strategies such as Motivational Interviewing. Medical respite facilities or residential treatment programs may be available and used during acute crises or to meet short-term needs for more intensive support while the Housing First permanent supportive housing program preserves tenants’ right to return to their home or to relocate to another housing unit if needed. Evictions or other sanctions may be imposed in cases of violence or property damage, continued non-payment of rent, drug dealing or other criminal activity. Peer groups can also be a way for tenants in single-site housing to build their social networks, cultivate a sense of community, and be responsible and considerate tenants.

For more tips about implementing Housing First programs, see these “Tips for Success” available from SAMHSA’s Homelessness Resource Center and a toolkit prepared by the National Alliance to End Homelessness

Outcomes/Results:

The Pathways Housing First model, which was first implemented in New York City and later replicated in several cities around the country, has been rigorously evaluated. Pathways to Housing’s Housing First Program is listed in SAMHSA’s National Registry of Evidence-Based Practices and Programs (NREPP) and a summary of the research evidence is available on-line. 

In Seattle, the Downtown Emergency Service Center (DESC) operates a site-based permanent supportive housing program, 1811 Eastlake, using a Housing First approach for men and women with chronic alcohol addiction who are some of the highest utilizers of publicly-funded crisis services. Findings from an evaluation published in the Journal of the American Medical Association in 2009 (2) included taxpayer savings of more than $4 million over the first year of operation, reflecting significant reductions in hospital emergency room visits, inpatient hospitalizations, and stays in sobering facilities and shelters.

Results demonstrated by the Pathways Housing First, 1811 Eastlake, and other Housing First programs include high rates of housing retention and stability in housing, which have been demonstrated by programs serving people who had long histories of homelessness and instability. Other outcomes include less time homeless (living on the streets or in shelters) and more consumer choice regarding housing, treatment, and daily living. Housing First programs for adults experiencing chronic homelessness, including both the Pathways scattered-site model and single-site permanent supportive housing, have demonstrated substantial savings in public costs for hospital care (emergency room and inpatient hospitalizations), sobering centers, shelters, ambulance services, jails, and other services.

Resources:

In 2007 HUD released a report “The Applicability of Housing First Models to Homeless Persons with Serious Mental Illness.”

Information about the Pathways Housing First model, including a video and links to more information is available on their website.

The Corporation for Supportive Housing (CSH) and the National Center on Addiction and Substance Abuse at Columbia University (CASA) collaborated to evaluate the implementation of supportive housing for people with substance use problems who were experiencing chronic homelessness in New York City. The purpose of CASAHOPE (Housing Opportunities Program Evaluation) was to study the impact and implementation of programs that used, to varying degrees approaches consistent with Housing First. The CASAHOPE reports provide useful information about components of the model and some of the lessons learned about program implementation.

National Alliance to End Homelessness provides several resources describing Housing First, including:

Related Profiles:

Evidence-Based Practice: Permanent Supportive Housing

Evidence-Based Practice: Motivational Interviewing

Evidence-Based Practice: Critical Time Intervention

Evidence-Based Practice: Medical Respite

Model Program: Pathways to Housing (NY, NY)

Model Program: 1811 Eastlake (Seattle, WA)

Model Program: VASH PLUS (Washington, DC)

Model Program: Housing First Rhode Island (RI)

Model Program: Community Engagment Program (Portland, OR)

Model Program: CSPECH (MA)

Model Program: HOST (Alameda County, CA)

Model Program: CHHP (Chicago, IL)

References/Footnotes

1. For more information about using set-asides to create integrated permanent supportive housing, see this report from the Technical Assistance Collaborative

2. Larimer, Dr. Mary, et al. (2009) Health Care and Public Service Use and Costs Before and After Provision of Housing for Chronically Homeless Persons With Severe Alcohol Problems. Journal of the American Medical Association. April 2009, 301(13):1349-1357. *A summary of the findings of the research can also be found on DESC's website, here. 

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