Pathways to Housing
Pathways to Housing is one of the first and the most established Housing First programs in the country, and is listed within SAMHSA’s National Registry of Evidence-Based Programs and Practices. With sites in New York, Philadelphia, Vermont, and Washington, D.C., the Pathways to Housing program is designed to end homelessness and support recovery for individuals who are homeless and have severe psychiatric disabilities and co-occurring substance use disorders. The program provides permanent supportive housing immediately, without prerequisites for psychiatric treatment or sobriety. Treatment and support services are typically provided by recovery-oriented Assertive Community Treatment (ACT) teams that incorporate harm reduction approaches.
Problem or Challenge:
Programs that require participation in treatment as a pre-requisite to housing have proven to be largely ineffective in addressing the needs of chronically homeless adults with mental illness or co-occurring disorders. Pathways to Housing has demonstrated that the offer of housing first, and then treatment, is more effective in ending homelessness, and reducing addiction and mental health symptoms.
Pathways’ Housing First program is based on the belief that housing is a basic human right: people should not have to prove that they are "housing ready" by first participating in treatment or by being clean and sober. Pathways helps people who are experiencing homelessness with psychiatric disabilities move directly from the streets into their own apartments. Once settled in a stable living situation, they can engage with the variety of services offered by the ACT team.
Pathways to Housing was founded by Dr. Sam Tsemberis in 1992, and is widely credited as being the originator of the Housing First model, beginning in the densely populated New York City housing market and later replicated in other cities and states, including Washington, D.C., Philadelphia, and Vermont. The Pathways Housing First model is simple: provide permanent housing first, and then combine that housing with supportive treatment services in the areas of mental and physical health, substance abuse, education, and employment. Under the Pathways model, housing is provided in apartments scattered throughout a community. This "scattered site" model is designed to foster a sense of home and self-determination, and help speed the reintegration of Pathways’ clients into the community.
Housing used by Pathways participants consists of privately-owned apartments that are spread throughout a community. To maximize community integration and minimize potential stigma, Pathways never rents more than 20% of a building's units nor clusters units close together in one area, to avoid creating the atmosphere of a “housing program.” Apartments are either master-leased by the program or leased directly to the client from the landlord. Client choice is a vital component of the Pathways program, so the scattered-site model helps honor participants' preferences by giving them options of where they would like to live.
Once settled in an apartment, clients pay 30% of their income toward rent, and Pathways pays the difference between the client’s rent contribution and the total rent, using a variety of funding sources to pay for rental housing assistance. Each Pathways program site has a housing department with staff who find and secure appropriate apartment units for Pathways clients. Housing department staff members also take responsibility for apartment inspections and maintenance issues, and they handle all communication with landlords about any issues that tenants may have. Pathways recognizes that relationships with landlords are key to its success, and has relationships with more than 150 landlords in New York, Philadelphia, and Washington D.C. Pathways ensures landlords that rent will always be paid in full and on time, apartment vacancies will be filled quickly, the housing department will be ready to assist with property management issues, and clinical and housing teams will be readily available whenever there is a question or concern.
Pathways develops individual, comprehensive service plans and offers services as long as tenants need them. Client-driven services tend to focus on clinical, vocational, and social supports, and health issues, and are usually provided by a multi-disciplinary team approach such as Assertive Community Treatment (ACT). The ACT team consists of social workers, nurses, psychiatrists, vocational and substance abuse counselors, peer counselors, and other professionals. While ACT is the preferred support model for persons with severe mental illness, less intensive approaches may be used for people who have more moderate needs.
Regardless of the treatment model, staff members work collaboratively with each client to articulate goals—as defined by the client—and to help move that individual toward recovery and a full, meaningful life. Teams must be community-based, providing the majority of services in a participant’s natural environment— usually their apartment, neighborhood, or workplace – and the team must be available on-call 24/7. For ACT teams, Pathways maintains a participant-to-staff ratio of 10:1.
Consistent with the principles of consumer choice, Pathways uses the harm reduction approach in its clinical services to address both substance abuse and psychiatric issues. The treatment team recognizes that participants can be at different stages of recovery and that interventions should be tailored to each tenant. Participants' tenancy in housing is not dependent on their adherence to clinical treatment, although they must meet the obligations of a standard lease. The team works with participants through housing loss, hospitalization, or incarceration and helps participants return to permanent housing after these episodes. While participants can refuse formal clinical services, the program requires them to meet with a team member on a regular basis to ensure their safety and well-being.
In addition to traditional treatment services, Pathways offers wellness groups and assists participants with nutrition, family therapy, and vocational planning, Pathways clients participate in a variety of social, recreational, and therapeutic activities, including recovery groups, and classes such as art, computers, cooking, and GED preparation. A Tenant Advisory Council provides a forum for input into the program and solicits ideas for changes to meet new needs.
A wide range of studies conducted by an array of investigators in different cities have found that Pathways to Housing programs have a significant, positive impact on its target population. Some studies were conducted by Pathways staff under federally-funded grants, others involved Pathways’ collaborations with researchers, and others were conducted by independent researchers or universities. Major findings include the following:
From baseline to two-year follow-up, Pathways Housing First participants spent approximately 80% of their time stably housed, versus 30% for participants in the comparison group, who were assigned to traditional programs that made treatment and sobriety prerequisites for housing.
At two-year follow-up, participants assigned to Pathways Housing First reported significantly more choice with respect to their housing, treatment, and daily living than participants in the comparison group.
From baseline to two-year follow-up, participants assigned to Pathways Housing First accrued significantly fewer supportive housing and services costs than participants in the comparison group.
Contact Info for Follow-up:
Pathways to Housing website: www.pathwaystohousing.org. This includes links to various research studies and program contacts in each of the four Pathways locations.
Additional information from SAMHSA
Evidence-Based Practice: Housing First
Evidence-Based Practice: Permanent Supportive Housing
Evidence-Based Practice: Assertive Community Treatment
Evidence-Based Practice: Rental Housing Assistance
Model Program: VASH Plus (Washington, DC)
Model Program: 1811 Eastlake (Seattle)
Model Program: Housing First Rhode Island
Model Program: Chicago Housing for Health Partnership (Chicago, IL)
Model Program: HOST (Alameda County)