Permanent Supportive Housing
Permanent supportive housing is decent, safe, affordable, community-based housing that provides tenants with the rights of tenancy and links to voluntary and flexible supports and services for people with disabilities who are experiencing homelessness. Permanent supportive housing is a proven, effective means of reintegrating chronically homeless and other highly vulnerable homeless families and individuals with psychiatric disabilities or chronic health challenges into the community by addressing their basic needs for housing and providing ongoing support.
Problem or Challenge:
Permanent Supportive Housing (PSH or “supportive housing”) is for people who need long-term housing assistance with supportive services in order to stay housed. Individuals and families living in supportive housing often have long histories of homelessness and face persistent obstacles to maintaining housing, such as a serious mental illness, a substance use disorder, or a chronic medical problem. Many supportive housing tenants face more than one of these serious conditions.
Supportive housing links decent, safe, affordable, community-based housing with flexible, voluntary support services designed to help the individual or family stay housed and live a more productive life in the community. It looks and functions much like any other brand of housing. People living in supportive housing have a private and secure place to make their home, just like other members of the community, with the same rights and responsibilities. The difference is that they can access, at their option, services designed to address their individual needs and preferences. These services may include the help of a case manager or counselor, help in building independent living and tenancy skills, assistance with integrating into the community, and connections to community-based health care, treatment, and employment services.
Permanent supportive housing programs allow people with one or more serious disabling conditions to stabilize their housing and address underlying conditions that often have gone untreated for many years. The combination of housing and supportive services creates a synergy that allows tenants to take steps toward recovery and independence.
The “permanent” in “permanent supportive housing” means the length of stay is up to the individual or family. There is no time limitation, and tenants may live in their homes as long as they meet the basic obligations of tenancy. While participation in services is encouraged, it is not a condition of living in the housing. Housing affordability is ensured either through a rent subsidy or by setting rents at affordable levels.
There is no single model for supportive housing’s design. The provision of supportive housing may involve the renovation or construction of new housing, set-asides of apartments within privately-owned buildings, or leasing of individual apartments dispersed throughout an area. There are three primary forms of supportive housing:
Single-site housing, in which the tenants receiving support services live in units in the same building or a group of buildings, with the support services provided either on site or off site.
Scattered-site housing, in which tenants live in independent apart¬ments throughout the community, in either private or agency-owned housing; depending on the program, staff can deliver some support services through home visits, or all services may be provided at other locations in the community.
Mixed housing, in which tenants live in developments that contain a mixture of supportive housing tenants and other tenants not part of the supportive housing program.
Implementation Steps and Tips:
Supportive housing emerged as an intervention to prevent and end homelessness in the 1980s. Since that time, use of the model has expanded nationwide. As its use has grown, national organizations and the Substance Abuse and Mental Health Services Administration (SAMHSA) have drawn from practice and research to identify several core elements of permanent supportive housing:
Tenant choice. Supportive housing staff helps tenants or potential tenants define their housing needs and preferences. Tenants choose whether or not to participate in services and cannot be evicted from their housing for rejecting them. In scattered-site supportive housing, tenants choose where they want to live, and receive help finding an apartment that best meets their needs.
Access. The housing is available to people who are experiencing homelessness or are precariously housed and who have multiple barriers to housing stability and employment. These barriers may include little or no income, poor or no credit histories, prior evictions, disabilities, histories of criminal justice involvement, and past or current substance abuse. In scattered-site housing, staff may facilitate access by proactively developing positive relationships with landlords, advocating on behalf of prospective tenants, and offering landlord incentives such as reimbursement for excessive damages or court costs should the tenancy be unsuccessful.
Quality. The housing is similar to what is available to other households at fair-market rents in the community. It has a home-like, residential appearance (on both the interior and exterior), and its scale, appearance, design, and quality are consistent with (or exceed) neighborhood and community standards. The housing units provide adequate living space for essential daily activities such as cooking, eating, sleeping, and studying. Ideally each unit has a private bathroom and kitchen. The housing includes appropriate safety features and meets standards for quality established by applicable codes and regulations.
Integration. Adults with disabilities have a right to receive housing and supportive services in the most integrated settings that are available. There are several ways that integration can be achieved, including scattered-site or mixed-housing models in which supportive housing tenants live in buildings that include neighbors who do not have disabilities, as well as site-based supportive housing that is located in neighborhoods that provide access to an array of community services and resources used by people with and without disabilities. Integration reduces stigma and offers tenants opportunities to interact with a broad spectrum of neighbors, as in other housing.
Rights of tenancy. Supportive housing tenants have a lease in their name and control over their living space, meaning that each tenant has a key to his or her own apartment or room and the tenant can come and go at any time and control who can visit. In some cases, a service agency may hold a lease with tenants holding a sublease, and in other cases the agency itself might own the property. Regardless of the arrangement, tenant leases or subleases confer full rights of tenancy, including limitations on landlords’ entry into the property and the right to challenge eviction in landlord-tenant court. Tenants can remain in their homes as long as the basic requirements of tenancy are met—paying the rent, not interfering with other tenants’ use of their homes, not causing property damage, etc. House rules, if any, are similar to those found in other housing.
Affordability. Supportive housing tenants ideally pay no more than 30 percent of their income toward rent and basic utilities and rarely pay more than 50 percent. The remainder of the rent is covered either by tenant-based rental assistance, which tenants can use in housing of their choice, or project-based rental assistance or an operating subsidy, which is linked to a specific location.
Coordination between housing and services. Property managers and support service staff stay in regular communication and coordinate their efforts to help prevent evictions and to ensure tenants facing eviction have access to necessary services and supports.
Delineated roles. The supportive housing model distinguishes between housing and services. Even if some services are provided on site, there is a functional separation, with the housing elements (rent collection, property maintenance, enforcement of responsibilities of tenancy) carried out by different staff than those providing services (case management, mental health treatment, wraparound services).
Tenant choice. Supportive housing tenants have choices in the support services that they receive. Rather than a limited menu of services for a particular location, supportive housing is intended to help tenants define their needs and preferences, and then to develop an individual plan of support that reflects those. As their needs change over time, tenants can receive more intensive or less intensive support services without losing their homes; the services come and go rather than the tenants.
Housing focus. To help tenants achieve residential stability, the service team focuses on increasing tenants’ ability to choose, obtain, and keep housing. It focuses on helping tenants meet their lease obligations, including paying rent, maintaining a safe and healthy living environment, allowing others the peaceful enjoyment of their homes, and complying with the terms and conditions of the lease.
Assertive outreach and engagement. Some tenants are reluctant to accept help, suspicious of promised benefits, and feel hopeless about their future. The service team uses a variety of outreach and engagement techniques that bring severely disenfranchised people into helping relationships. The most effective approaches include an attitude of respectful persistence, meeting the person’s real and immediate needs, and helping the person address difficulties one step at a time.
Case management. Skilled and flexible case managers most often serve as the bridge between tenants and the supports that help them achieve stability and long-term tenancy. Case managers first build trust, then help tenants select and obtain the supports that will work best for them. Ideally, caseloads are no more than 15 tenants to each case manager.
Recovery supports. The service team works with tenants to promote long-term stability, recovery, and a sense of themselves as contributing community members. The services that they provide directly or arrange for on behalf of tenants fall under three broad categories:
Mainstream supports, including income supports and entitlements from public benefits programs, health care from hospitals and clinics, and employment help from vocational agencies.
Specialized supports that help tenants succeed in accomplishing their goals, such as life skills training, budgeting, medication management, and behavioral health treatment.
Natural supports, including connections with peers, family, community, and faith communities.
A growing number of supportive housing providers recognize the importance of integrating formerly homeless people as members of their service teams. The advantages of peer support include increased empathy and understanding based on shared experiences, offering supportive housing tenants a living model of recovery, and helping organizations to be consumer-focused.
Many supportive housing providers use evidence based practices (EBPs) in the delivery of services to tenants. The most frequently used include:
Housing First, in which housing is offered with no preconditions;
Motivational Interviewing, which enables the provider to take the tenant’s readiness to change into account and to reinforce the tenant’s own incentives for change;
Integrated Treatment for Co-occurring Disorders, which provides and integrates treatment for both substance abuse and mental health issues;
Assertive Community Treatment, which uses a team approach to meet participants’ diverse needs;
Illness Management and Recovery, which enables tenants to manage their own symptoms; and
Supported Employment, which helps tenants take advantage of appropriate opportunities for mainstream employment.
Perhaps the most important aspect of the supportive housing service approach is that the service team goes the extra mile to help tenants succeed. Instead of putting the burden of success solely on the person being served, service teams adopt a partnership attitude and are willing to step outside the boundaries of conventional services.
Available data reinforce evidence that permanent supportive housing is an effective approach for meeting the needs of people with disabilities and chronic health conditions who have experienced homelessness. Research indicates that this combination of long-term housing and wraparound services leads to improved residential stability and reduction in psychiatric symptoms. Studies have also found that supportive housing is associated with significant reductions in costs for emergency room visits, hospitalizations, shelters, sobering centers, jails, and other public services used by people experiencing homelessness.
An Evidence Based Practices (EBP) KIT on Permanent Supportive Housing is available from SAMHSA to provide tools to support the implementation of Permanent Supportive Housing for people with mental Illness. The Kit contains a summary of research evidence. The KIT is available in a CD-ROM / DVD version or can be downloaded from the web.
The Corporation for Supportive Housing’s Seven Dimensions of Quality for Supportive Housing and accompanying assessment and resource tools.
SAMSHA’s 2010 Annual Report of findings from its Services in Supportive Housing program.
Evidence-Based Practice: Housing First
Evidence-Based Practice: Assertive Community Treatment
Evidence-Based Practice: Motivational Interviewing
Evidence-Based Practice: Integrated Treatment for Co-Occurring Disorders
Promising Practice: Vulnerability Index
Model Program: 1811 Eastlake, Seattle
Model Program: Pathways to Housing (NY)
Model Program: Rhode Island Housing First Program
Model Program: VASH Plus (Washington, DC)
Model Program: CSPECH (MA)
Model Program: HOST (Alameda County, CA)
Model Program: CHHP (Chicago, IL)
Model Program: FUSE