Resolving Poverty

Sources 21-26:


1. Housing First is not a “program.” 
It is a whole-system orientation and response.
I often hear Housing First referred a program or a particular model, as in, “We just started a Housing First program.” Or “We don’t have a Housing First program in our community yet, just transitional housing.” In these instances, the term ‘Housing First’ is most often used to mean a permanent supportive housing program that uses a Housing First approach.
it wasn’t long ago that Housing First was a new and radical concept in supportive housing circles—I think it’s incorrect to think of Housing First as a permanent supportive housing model, or as a program at all for that matter.

When we think of Housing First as a program, it creates the illusion that Housing First is just one among many choices for responding to homelessness. This sets up a dynamic in which individual programs are pitted against one another. The discussion ends up being about whether we should choose this program or that program, and whether one program is right and another one wrong. It leads to an absurd debate about whether permanent housing or emergency shelters are the solution to homelessness, when both play important but completely different roles. Thinking about Housing First as a program leads to divisions, factions, and conflicts—none of which are helpful in the effort to end homelessness.

Instead, Housing First is a whole-system orientation, and in some cases, a whole-system re-orientation. To borrow a phrase, it is about “changing the DNA” of how a community responds to homelessness. This change enables the community as a whole to: 
-- make occurrences of homelessness rare and brief
-- help people who experience homelessness obtain permanent housing quickly
-- help people access the care and support needed to maintain their housing and achieve a better quality of life.
-- Some of you may have heard about the Triple Aim of health reform. Consider these the “Triple Aim” of ending homelessness.

Achieving these aims is impossible for one program alone. Rather, it requires a variety of programs and services including homeless outreach, emergency shelter, permanent supportive housing, affordable housing, rapid re-housing, along with case management supports, health care, income supports, employment services, and more. But it’s also not enough for these programs to simply exist; they need to work as part of a whole system to help people achieve these aims. That means that the focus of all programs must be to help people obtain permanent housing quickly and without conditions and contingencies. Programs should empower people to overcome barriers to obtaining permanent housing, access the right kinds of supports and care to keep their housing, and improve their quality of life.

Housing First also requires that communities constantly examine their overall set of programs to determine if they have the capacity to achieve the three aims above. Again, this is not about choosing this program or that program, but looking at whether the system as a whole is effective.

Let’s imagine for a moment that we could hit a magic “Housing First reset button” and start all over in building our community responses to homelessness. Would you wind up with the same set of programs and models that you have now? Would you even create discrete program models? 

Now let’s imagine that we had enough resources to create the system we really need to achieve the three aims of ending homelessness. Let’s imagine we had a way to accurately assess housing and service needs at any point in time. What if we could provide different levels of housing assistance and different levels of services to people based on their needs? And what if we could actually adjust the level of assistance to people as their needs change in real-time without forcing people to move around?

That’s the system of response I would build.  Unfortunately, we don’t have a Housing First reset button. Rather than adjustable and flexible levels of assistance, we have distinct programs and models that are often unconnected, preventing people from receiving personalized levels of assistance. The funding systems that support our programs don’t always allow for this level of flexibility. Even in the face of these issues, I still believe we can pursue a more flexible and dynamic system of response. Getting there starts with the adoption of a Housing First system orientation. Meanwhile, USICH and HUD have been encouraging communities to ensure that their inventory of programs includes the types of assistance at different levels of intensity—permanent supportive housing, affordable housing, rapid re-housing, etc.—targeted through a coordinated assessment process.

2. Housing First is a recognition that everyone can achieve stability in (real) housing. Some people simply need services to help them do so.
There is confusion about whether Housing First means providing housing with services or housing alone. I hear comments like, “We want to do Housing First, but don’t have a way to pay for supportive services,” or “It’s not responsible to do Housing First when people have chronic health challenges.” Some people believe Housing First is always service intensive. Others believe Housing First is not service intensive enough. So who’s right?

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The short answer is both and neither. The problem goes back to thinking about Housing First as a program model. When we instead think of Housing First as an approach and a whole system orientation, it allows us to get away from “one-size-fits-all” solutions, and focus on matching the right level of housing assistance and services to people’s needs and strengths. 
There are some who might just need a bit of a financial boost and help with finding housing. 
Others may need a long-term rental assistance subsidy and support with their housing search, but not ongoing case management. 
And some people need permanent supportive housing, including long-term rental assistance or affordable housing coupled with case management supports.

It’s a basic equation where the constant is the goal of helping people obtain and maintain permanent housing. The variables are what level and duration of housing assistance and supportive services people need, to stay in housing. 

So yes, if a community doesn’t have a way to pay for supportive services, they won’t be able to provide the right help to people who need ongoing case management. They should look to efforts across the country to increase Medicaid’s role in paying for case management supports in housing. 
And it’s also true that providing permanent housing without services to people who have chronic health challenges may be irresponsible. Let’s just remember that not everyone needs ongoing case management to maintain housing stability.

3. Housing First is about health, recovery, and well-being. Housing itself is the foundation and platform for achieving these goals.
The idea that programs within a Housing First approach sometimes require “intensive” services should not be taken to mean that the focus of services is on therapeutic or treatment goals. In fact, the Housing First approach emphasizes services that focus on housing stability, then using that housing as a platform for connecting people to the types of services and care that they seek and want. It’s based on the basic premise that if people have a stable home, they are in a better position to achieve other goals, including health, recovery and well-being than when they are homeless.

This is true for many reasons. It’s hard to comply with any kind of health care or treatment regimen when you have no certainty about where you are going to sleep. A person infected with TB will have a hard time completing a course of antibiotic treatment when they are bouncing from one shelter to another. It’s also hard to focus on recovery from addiction when you don’t have the certainty that you have a permanent place where you can stay each day, surrounded by supportive people. And for people who’ve experienced trauma, it can be impossible to shift away from a “fight-or-flight” mindset that comes with PTSD when they continue to live a rough life on the streets.

Let it be known, once and for all, that Housing First is about health and well-being. Housing First is about recovery. And connecting people to substance abuse or mental health treatment is entirely consistent with Housing First. 
Housing First recognizes that health and recovery are so much more attainable when people have a safe and stable home.  A Housing First approach recognizes that there are many paths to recovery and well-being—some of which are direct and some of which are long and indirect. But all of those (recovery) paths start with a home.

4. Housing First is about changing mainstream systems.
Housing First is, and always has been, about changing mainstream systems. The approach emerged as a reaction to traditional mental health treatment modality, which thought that the way to address the needs of people with psychiatric symptoms on the street was to get them into psychiatric treatment, typically at an inpatient facility. Housing First was about changing the mental health system’s paradigm to recognize that housing is foundational to mental health recovery.

Housing First’s role in changing mainstream systems should not stop with the mental health system. Housing is just as foundational to addiction recovery and psychical well-being as it is to mental health. The new frontiers are to engage the substance abuse treatment system and the mainstream health care system around housing.
Substance abuse treatment systems are integrating housing priorities alongside states like New York and New Jersey by adopting supportive housing as part of their own systems responses.
Meanwhile, there are enormous opportunities to engage the mainstream health care system (Medicaid, managed care, and hospital systems) around housing, given the systems transformations underway through the Affordable Care Act.

There is a hunger to achieve health reform’s Triple Aim of improved health outcomes, improved healthcare experiences, and lower costs. 
Those of us who’ve been working to end homelessness know that affordable and supportive housing are part of that solution. 
It’s going to take engagement and persistence to make the health system aware of this. Luckily, this is precisely the kind of engagement and persistence that Housing First does so well.
Back to Basics – What Exactly is Housing First & Rapid Re-Housing? (2012)

A lot of the time I find “Housing First” and “Rapid Re-Housing” to be misused terms. When asked to assist organizations or communities realign their service delivery to be more effective or to evaluate their housing programs, this is the understanding of Housing First and Rapid Re-Housing that I try to generate awareness of in the community. As this is a blog and not a two or three day training seminar, I am focusing on hitting the high points.

As a philosophy, housing first focuses on any attempt to help people who have experienced homelessness to access housing before providing assistance and support with any other life issues. In this orientation, the intervention of Housing First and Rapid Re-Housing both fit. Given housing is the only known cure to homelessness, the success comes with helping ideal candidates achieve the cure sooner rather than later.

As an intervention, HOUSING FIRST is a specific type of service delivery. Delivered through Intensive Case Management or Assertive Community Treatment, fidelity to the core aspects of the service can be measured. Housing First is specifically not a “first come, first served” intervention. Housing First intentionally seeks out chronically homeless individuals that have complex, and co-occurring issues, and serves those with the highest acuity first. The individual (family) served through Housing First is homeless and has most often been homeless for quite some time, usually as a result of these issues and the failure of the human and health service delivery spectrum to address these issues in order to solve the person’s homelessness.

Participation in Housing First is voluntary – people cannot be forced or coerced to participate in a Housing First intervention. 
Individuals who consent to receive a Housing First intervention are provided assistance with accessing housing of their choosing (subject to affordability, action-ability and appropriateness) and supports for at least 12-18 months in an ICM approach (subject to the ability to integrate clients with longer-term community supports) and longer in an ACT approach.

There is no expectation of sobriety, treatment, compliance or mandated service pathways. Service participants do not need to participate in psychiatric services if they do not want to; they do not need to participate in things like anger management classes if they don’t want to; they do not need to attend life skills classes if they do not want to; they do not need to attend parenting classes if they do not want to; they do not need to address their physical health issues if they do not want to – and I could go on. 
The only real expectations of Housing First, which the individual agrees to prior to starting with the program, is to agree to have their support workers visit them in their home – usually multiple times per week in the early days of program participation, to pay their rent on time and in full (or agree to third party payment of their rent), and to work hard to avoid disrupting the reasonable enjoyment of other tenants in the same building that would cause their eviction.

There are many “tricks of the trade” that help folks in achieving residential stability in Housing First. For one, caseloads are kept at a reasonable size, with an emphasis on Housing First as a quality intervention, not a quantity intervention. In ICM service delivery, one case manager works with 15-20 clients depending on where the clients are at in their journey to stability and level of complexity. Another “trick of the trade” is working with the client to develop a personal guest policy, where the client themselves determine when they think it is a good idea to have guests over, how many guests they think it is reasonable to have over at any one time, the types of activities they think are appropriate to engage in within their apartment, and what they think is appropriate should they find their actions in conflict with their guest policy. Yet another “trick of the trade” is to infuse the “responsible tenant” discussion into conversation with the client at least three times in the early stages of the program whereby the client themselves articulates what they think it means to be a responsible tenant.

Services in HOUSING FIRST are offered through a harm reduction philosophy, in a non-judgmental manner and from a client-centered position. Supports are provided in vivo, and there is an expectation that individuals served through the intervention will access a broader range of community resources, have meaningful daily activities, and work towards greater independence and improved life satisfaction. The support worker in Housing First can expect to model and teach skills and behavior in the client’s apartment and in the community. It is not uncommon for the support worker to have one-on-one time with the client to teach things like cooking, cleaning, laundry, grocery shopping, and the like. It is not uncommon for the support worker to accompany the client to appointments in the community like working with welfare, shopping, doctor appointments, etc.

There is intentional case planning that occurs in Housing First. The first focus of the case planning is on housing stability…primarily paying attention to meeting basic needs, understanding how relationships can impact tenancy, ensuring that the individual feels safe in their apartment, and understanding the supports available to help them maintain housing. Momentum gained in these areas translates into the development of an Individualized Service Plan where specific goals are identified and an action plan is put in place for each of them. Through this service plan, the emphasis is on greater life stability overall.

Housing First is not a “first come, first served” approach to service delivery. Regardless of whether the Housing First supports are provided through Intensive Case Management or Assertive Community Treatment, access should be coordinated on a system-wide basis. With Housing First, supports are de-linked from staying housed, and as such if an individual loses their housing they do not lose their supports and will be re-housed as many times as necessary until the person achieves housing stability. There are no limits on the number of times that a person can be re-housed. Re-housing is not seen as a failure. It is seen as an opportunity to learn, adapt, grow and try again.

Service participants supported through Housing First often have a history of considerable interaction with health, mental health, addiction, police, criminal justice, ambulances – and other types of emergency services and institutions. Through the housing and support work, most often one will see a decrease in this degree of interaction with emergency services, and a more deliberate and strategic engagement with more appropriate services. It is still possible that Housing First program participants end up in hospital or accessing treatment services, but the supports remain active during these periods of time, with assistance provided in discharge planning as much as possible, and active support in the implementation of treatment protocols as much as possible.

Housing First relies on a number of proven practices and evidence-informed service delivery. Examples of the types of professional skills a Housing First practitioner is likely going to have mastery of include: Motivational Interviewing; Assertive Engagement; Wellness Recovery Action Plans; Illness Management Recovery; Integrated Dual Disorder Treatment; Trauma Informed Service Delivery; Harm Reduction Practices; Crisis Planning; Supported Employment; etc.

While Housing First is most frequently delivered through scattered site housing units integrated within “regular” apartment buildings throughout a city, it is possible to have congregate Permanent Supportive Housing that practices Housing First. But, there really is no such thing as “Housing First Housing”. When I hear that, and break it down with people, most often what they really are trying to say is a low-barrier congregate PSH environment that practices all the aspects of a Housing First intervention.

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The place a participant lives in Housing First must be permanent housing, where “permanent” means that if they follow the lease, pay rent and don’t disrupt the reasonable enjoyment of others they have the same security of tenure as any other renter. The lease is “standard” – meaning it contains no language or stipulations different than any other renter. This does not preclude the use of Master Leasing or Head Leasing where an organization leases the apartment unit and legally sub-leases to a program participant, with an understanding that there can be no impediments to the program participant taking on the lease in full in the future.

When asked to set up an evaluation framework for Housing First, it is my contention that 80% or more of the individuals served should remain housed long term. I also tend to look at reductions in use of emergency services and engagement with the criminal justice system. Then, I focus my attention on how the acuity of the individual decreases overtime, as well as changes in quality of life as a result of the intervention.

Rapid Re-Housing is a support intervention intended to serve longer-term episodically homeless people with mid-range acuity; these clients typically have co-occurring issues that are at the core of their frequent returns to homelessness and/or long-standing patterns of precarious housing. The individual or family is homeless and usually has two or three life areas where assistance in accessing community-based resources should improve their life and housing stability on a go-forward basis. Usually recipients of Rapid Re-Housing are aware of a range of community supports; they simply have not been meaningfully and sustainably connected with those resources.

One of the first mistakes in how people talk about Rapid Re-Housing is that they refer to it as “Housing First Light”. It is not. It is a different type of intervention that happens to have a lot of similarities to Housing First. Secondly, some organizations and communities erroneously lump any program that assists with rapid access to housing as being Rapid Re-Housing. This, as well, is false. There can be some awesome approaches to helping people access housing quickly, which are not Rapid Re-Housing.

With mid-range acuity at time of program entry, Rapid Re-Housing recipients usually receive supports for a minimum of six months, with possibility of renewal of service in three month increments based upon traction in sustainably meeting needs that will enhance housing and life stability (and should there be persistent barriers to improved stability, the client may be more accurately considered a Housing First client).

The supports delivered in Rapid Re-Housing are typically case management supports, but are neither Intensive Case Management nor Assertive Community Treatment – though there are typically time periods of support that are more intensive than others. Supports are delivered in community. There is an expectation that the individual (family) will be supported in accessing community resources, have meaningful daily activities, and work towards greater independence and improved life satisfaction. There will be teaching and modeling in Rapid Re-Housing, like Housing First, but the intensity of this and the duration of it is quite often (though not always) less than what one would experience in Housing First.

Importantly, Rapid Re-Housing is more than a financial assistance program; it comes with the expectation that the client will engage with support services. However, the support services have no expectation of engagement in treatment, compliance or mandated service pathways. Like Housing First, Rapid Re-Housing is offered through a harm reduction philosophy, in a non-judgmental fashion and from a client-centered position.

Rapid Re-Housing is almost exclusively delivered through scattered site apartments. Participants sign a standard tenancy agreement. Nowhere in the lease does it stipulate that an individual has to participate in programming or will be evicted. For all intents and purposes, the housing is permanent. So long as the individual follows the lease and pays their rent they have the same security of tenure as any other renter.

Rapid Re-Housing also features structured case planning with goal identification and an action plan put into place to assist with reaching these goals. Compared to Housing First, Rapid Re-Housing clients are usually more able to engage in the process of goal identification and attainment quicker given their acuity is not as high and their time spent homeless has not been chronic.

It is best if people gain access to Rapid Re-Housing through a coordinated access function within a community. This will ensure the best fit of mid-range acuity clients to the appropriate intervention. It should weed out those clients that would be better served through a more intensive and longer-term intervention like Housing First. It should also week out those individuals and families that ultimately can resolve their own homelessness without case management supports of any kind (which make up the majority of people in any community).

When I set up evaluation frameworks for Rapid Re-Housing, I tend to look for a housing stability rate in the 90% range. Like Housing First, I also want to focus some attention on decreasing acuity over time and improved quality of life as a result of the intervention.

There are certain things that Housing First and Rapid Re-Housing both are not. First of all, Housing First is NOT “housing only”. I would posit that in most instances getting people housed is relatively easy compared to the hard work of supporting them to stay housed. 
Neither Housing First nor Rapid Re-Housing are a fad. They each are proven to be successful when practiced in a certain manner with a specific client group. 
There is no such thing as a “sober” or “dry” Housing First or Rapid Re-Housing program. Participants may choose to abstain, but abstinence cannot be a pre-requisite for program participation. 
There is no such thing as a transitional housing program that is Housing First or Rapid Re-Housing because one of the core elements of both interventions is that the housing that people secure is permanent. 
Neither Housing First nor Rapid Re-Housing are the only forms of effective housing interventions. There are plenty of good approaches to helping homeless individuals and families access housing that I have seen in my travels that seem to demonstrate positive outputs. Organizations and communities should feel compelled to call these programs something that they are not. 
Neither Housing First nor Rapid Re-Housing “fix” or “heal” people. The job in Housing First and Rapid Re-Housing is to support the individual access and maintain housing regardless of their history or life issues. Both acknowledge that people may still have active addictions, compromised mental wellness, difficulties budgeting, issues with impulse control, problematic social behaviors, physical ailments, etc. – yet people with these or any other life issues can have the issues and have a life without any future homelessness.
Housing First Impact on Costs and Associated Cost Offsets: A Review of the Literature (November 2015)

Housing First (HF) programs for people who are chronically or episodically homeless, combining rapid access to permanent housing with community-based, integrated treatment, rehabilitation and support services, are rapidly expanding in North America and Europe. Overall costs of services use by homeless people can be considerable, suggesting the potential for significant cost offsets with HF programs. Our purpose was to provide an updated literature review, from 2007 to the present, focusing specifically on the cost offsets of HF programs.

Twelve published studies (4 randomized studies and 8 quasi-experimental) and 22 unpublished studies were retained. Shelter and emergency department costs decreased with HF, while impacts on hospitalization and justice costs are more ambiguous. Studies using a pre–post design reported a net decrease in overall costs with HF. In contrast, experimental studies reported a net increase in overall costs with HF.

While our review casts doubt on whether HF programs can be expected to pay for themselves, the certainty of significant cost offsets, combined with their benefits for participants, means that they represent a more efficient allocation of resources than traditional services.

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HF programs offer an alternative to traditional continuum of care models, in which a select few people graduate through a series of steps to eventually integrate permanent housing. Many variants of HF programs exist, with the most basic distinction being between whether they provide supported housing (scattered-site or congregate, independent housing with external supports, such as from an ACT team), or supportive housing (congregate housing with on-site supports). Studies have shown that HF programs significantly increase the time that people are stably housed. A description of the Pathways HF supported housing model, which has been most widely implemented and evaluated, is found in the companion In Review article.

Cost-of-homelessness reports have indicated that the service use of homeless people is significant. Service providers have observed that while chronically homeless people represent only 20% of shelter users, they consume the largest share of health, social, and justice services. Malcom Gladwell’s “Million-Dollar Murray” eloquently illustrates how a combination of homelessness, mental illness, and substance abuse can lead to repeated and costly interactions with multiple service systems. Available estimates of the economic costs that homeless people in Canada generate vary widely. In one study, combining administrative data from several systems for about 5000 homeless people with SMI in New York City, average annual service use costs were US$40,500 per person. Thus the overall costs of services can be considerable, suggesting the potential for significant cost offsets, at least among the highest-cost users.
What is Housing First? (April 2016)
Housing First is a homeless assistance approach that prioritizes providing permanent housing to people experiencing homelessness, thus ending their homelessness and serving as a platform from which they can pursue personal goals and improve their quality of life. This approach is guided by the belief that people need basic necessities like food and a place to live before attending to anything less critical, such as getting a job, budgeting properly, or attending to substance use issues. Additionally, Housing First is based on the theory that client choice is valuable in housing selection and supportive service participation, and that exercising that choice is likely to make a client more successful in remaining housed and improving their life.

How is Housing First different from other approaches?
Housing First does not require people experiencing homelessness to address all of their problems including behavioral health problems, or to graduate through a series of services programs before they can access housing. Housing First does not mandate participation in services either before obtaining housing or in order to retain housing. The Housing First approach views housing as the foundation for life improvement and enables access to permanent housing without prerequisites or conditions beyond those of a typical renter. Supportive services are offered to support people with housing stability and individual well-being, but participation is not required as services have been found to be more effective when a person chooses to engage. Other approaches do make such requirements in order for a person to obtain and retain housing.

Who can be helped by Housing First?
A Housing First approach can benefit both homeless families and individuals with any degree of service needs. The flexible and responsive nature of a Housing First approach allows it to be tailored to help anyone. As such, a Housing First approach can be applied to help end homelessness for a household who became homeless due to a temporary personal or financial crisis and has limited service needs, only needing help accessing and securing permanent housing. At the same time, Housing First has been found to be a particularly effective approach to end homelessness for high need populations, such as chronically homeless individuals.

What are the elements of a housing first program? Housing First programs often provide rental assistance that varies in duration depending on the household’s needs. Consumers sign a standard lease and are able to access support as necessary to help them do so. A variety of voluntary services may be used to promote housing stability and well-being during and following housing placement.

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Two common program models follow the Housing First approach but differ in implementation. Permanent supportive housing (PSH) is targeted to individuals and families with chronic illnesses, disabilities, mental health issues, or substance use disorders who have experienced long-term or repeated homelessness. It provides long-term rental assistance and supportive services.

A second program model, rapid re-housing, is employed for a wide variety of individuals and families. It provides short-term rental assistance and services. The goals are to help people obtain housing quickly, increase self-sufficiency, and remain housed. The Core Components of rapid re-housing—housing identification, rent and move-in assistance, and case management and services—operationalize Housing First principals.

Does Housing First work?
There is a large and growing evidence base demonstrating that Housing First is an effective solution to homelessness. Consumers in a Housing First model access housing faster and are more likely to remain stably housed. This is true for both PSH and rapid re-housing programs. PSH has a long-term housing retention rate of up to 98%. Studies have shown that rapid re-housing helps people exit homelessness quickly—in one study, an average of two months—and remain housed. A variety of studies have shown that between 75 percent and 91 percent of households remain housed a year after being rapidly re-housed.

More extensive studies have been completed on PSH finding that clients report an increase in perceived levels of autonomy, choice, and control in Housing First programs. A majority of clients are found to participate in the optional supportive services provided often resulting in greater housing stability. Clients using supportive services are more likely to participate in job training programs, attend school, discontinue substance use, have fewer instances of domestic violence, and spend fewer days hospitalized than those not participating.

Finally, permanent supportive housing has been found to be cost efficient. Providing access to housing generally results in cost savings for communities because housed people are less likely to use emergency services, including hospitals, jails, and emergency shelter, than those who are homeless. One study found an average cost savings on emergency services of $31,545 per person housed in a Housing First program over the course of two years. Another study showed that a Housing First program could cost up to $23,000 less per consumer per year than a shelter program.
Housing First (2014)
‘Housing First’ is a recovery-oriented approach to ending homelessness that centers on quickly moving people experiencing homelessness into independent and permanent housing and then providing additional supports and services as needed.
It is an approach first popularized by Sam Tsemberis and Pathways to Housing in New York in the 1990s, though there were Housing First-like programs emerging elsewhere, including Canada (HouseLink in Toronto) prior to this time. The basic underlying principle of Housing First is that people are better able to move forward with their lives if they are first housed. This is as true for people experiencing homelessness and those with mental health and addictions issues as it is for anyone.
Housing is provided first and then supports are provided including physical and mental health, education, employment, substance abuse and community connections.
Housing First in Canada: Supporting Communities to End Homelessness says, “Housing is not contingent upon readiness, or on ‘compliance’ (for instance, sobriety). Rather, it is a rights-based intervention rooted in the philosophy that all people deserve housing, and that adequate housing is a precondition for recovery.”

There are five core principles of Housing First:
1. Immediate access to permanent housing with no housing readiness requirements. Housing First involves providing clients with assistance in finding and obtaining safe, secure and permanent housing as quickly as possible. Key to the Housing First philosophy is that individuals and families are not required to first demonstrate that they are ‘ready’ for housing. Housing is not conditional on sobriety or abstinence. Program participation is also voluntary. This approach runs in contrast to what has been the orthodoxy of ‘treatment first’ approaches whereby people experiencing homeless are placed in emergency services and must address certain personal issues (addictions, mental health) prior to being deemed ‘ready’ for housing (having received access to health care or treatment).

2. Consumer choice and self-determination. Housing First is a rights-based, client-centred approach that emphasizes client choice in terms of housing and supports.
Housing - Clients are able to exercise some choice regarding the location and type of housing they receive (e.g. neighbourhood, congregate setting, scattered site, etc.). Choice may be constrained by local availability and affordability.
Supports – Clients have choices in terms of what services they receive, and when to start using services.

3. Recovery orientation. Housing First practice is not simply focused on meeting basic client needs, but on supporting recovery. A recovery orientation focuses on individual well-being, and ensures that clients have access to a range of supports that enable them to nurture and maintain social, recreational, educational, occupational and vocational activities.

For those with addictions challenges, a recovery orientation also means access to a harm reduction environment. Harm reduction aims to reduce the risks and harmful effects associated with substance use and addictive behaviors for the individual, the community and society as a whole, without requiring abstinence. However, as part of the spectrum of choices that underlies both Housing First and harm reduction, people may desire and choose ‘abstinence only’ housing.

4. Individualized and client-driven supports. A client-driven approach recognizes that individuals are unique, and so are their needs. Once housed, some people will need minimum supports while other people will need supports for the rest of their lives (this could range from case management to assertive community treatment). Individuals should be provided with “a range of treatment and support services that are voluntary, individualized, culturally-appropriate, and portable (e.g. in mental health, substance use, physical health, employment, education)”. Supports may address housing stability, health and mental health needs, and life skills.

Income supports and rent supplements are often an important part of providing client-driven supports. If clients do not have the necessary income to support their housing - their tenancy, health and well-being may be at risk. Rent supplements should ensure that individuals do not pay more than 30% of their income on rent.

It is important to remember that a central philosophy of Housing First is that people have access to the supports they need, if they choose. Access to housing is not conditional upon accepting a particular kind of service.

5. Social and community integration. Part of the Housing First strategy is to help people integrate into their community and this requires socially supportive engagement and the opportunity to participate in meaningful activities. If people are housed and become or remain socially isolated, the stability of their housing may be compromised. Key features of social and community integration include:
-- Separation of housing and supports (except in the case of supportive housing)
-- Housing models that do not stigmatize or isolate clients. This is one reason why scattered site approaches are preferred.
-- Opportunities for social and cultural engagement are supported through employment, vocational and recreational activities.

While all Housing First programs ideally share these critical elements, there is considerable variation in how the model is applied, based on population served, resource availability, and other factors related to the local context. There is no ‘one size fits all’ approach to Housing First.

The Application of Housing First
In order to fully understand how Housing First is applied in different contexts, it is important to consider different models. While there are core principles that guide its application, It is worth distinguishing Housing First in terms of: 
a) a philosophy
b) a systems approach
c) program models
d) team interventions

As a philosophy, Housing First can be a guiding principle for an organization or community that prioritizes getting people into permanent housing with supports to follow. Housing First can be considered embedded within a systems approach when the foundational philosophy and core principles of Housing First are applied across and infused throughout integrated systems models of service delivery. Housing First can be considered more specifically as a program when it is operationalized as a service delivery model or set of activities provided by an agency or government body. 

Finally, one needs to consider Housing First teams, which are designed to meet the needs of specific target populations, defined in terms of either the characteristics of the sub-population (age, ethno-cultural status, for instance), or in terms of the acuity of physical, mental and social challenges that individuals face. This can include:

ACT teams (Assertive Community Treatment) are designed to provide comprehensive community-based supports for clients with challenging mental health and addictions issues, and may support individuals in accessing psychiatric treatment and rehabilitation. These teams may consist of physicians and other health care providers, social workers and peer support workers.
ICM teams (Intensive Case Management) are designed to support individuals with less acute mental health and addictions issues through an individualized case management approach. The goal of case management is to help clients maintain their housing and achieving an optimum quality of life through developing plans, enhancing life skills, addressing health and mental health needs, engaging in meaningful activities and building social and community relations.

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What kind of housing?
A key principle of Housing First is Consumer Choice and Self-Determination. In other words, people should have some kind of choice as to what kind of housing they receive, and where it is located.

The Pathways model prioritizes the use of scattered-site housing which involves renting units in independent private rental markets. One benefit of this approach is that it gives clients more choice, and may be a less stigmatizing option. From a financial perspective, there is a benefit to having the capital costs of housing absorbed by the private sector.

In other cases the use of congregate models of housing, where there are many units in a single building, the benefits of which may include on-call supports, and for some may provide a stronger sense of community. In some national contexts (Australia, many European nations), social housing is more readily used to provide housing for individuals in Housing First programs. In such contexts, there is a more readily available supply of social housing, and living in buildings dedicated to low income tenants may not be viewed in a stigmatized way.

Finally, for some Housing First clients whose health and mental health needs are acute and chronic, people may require Permanent Supportive Housing (PSH), a more integrated model of housing and services for individuals with complex and co-occurring issues where the clinical services and landlord role are performed by the same organization.

What kinds of support?
Housing First typically involves three kinds of supports. Housing supports: The initial intervention of Housing First is to help people obtain and maintain their housing, in a way that takes into account client preferences and needs, and addresses housing suitability. Key housing supports include; finding appropriate housing; supporting relations with landlords; applying for and managing rent subsidies; assistance in setting up apartments. Clinical supports include a range of supports designed to enhance the health, mental health and social care of the client. 

Housing First teams often speak of a recovery-oriented approach to clinical supports designed to enhance well-being, mitigate the effects of mental health and addictions challenges, improve quality of life and foster self-sufficiency. Complementary supports are intended to help individuals and families improve their quality of life, integrate into the community and potentially achieve self-sufficiency. They may include: life skills; engagement in meaningful activities, income supports, assistance with employment, training and education, and community (social) engagement.

Does Housing First work?
In just a few short years the debate about whether Housing First works is over. The body of research from the United States, Europe and Canada attests to the success of the program, and it can now truly be described as a 'Best Practice'.

The At Home/Chez Soi project, funded by the Mental Health Commission of Canada is the world’s most extensive examination of Housing First. They conducted a randomized control trial where 1000 people participated in Housing First, and 1000 received 'treatment as usual'. The results are startling: you can take the most hard core, chronically homeless person with complex mental health and addictions issues, and put them in housing with supports, and you know what? They stay housed. Over 80% of those who received Housing First remained housed after the first year. For many, use of health services declined as health improved. Involvement with the law declined as well. An important focus of the recovery orientation of Housing First is social and community engagement; many people were helped to make new linkages and to develop a stronger sense of self.

The Housing First in Canada book highlights eight Canadian case studies that attest to Housing First’s general effectiveness, especially when compared to ‘treatment first’ approaches.

There are key questions that remain in developing Housing First practices, philosophies, programs and policies across the country.
How effectively do Housing First programs demonstrate fidelity to the principles of the model? There is increasing pressure for communities to adopt a Housing First model. It is important to examine issues of fidelity to the core principles (as noted above) to ensure that communities are doing Housing First, as opposed to ‘housing, first”.
What is the relationship between Housing First and the Affordable Housing Supply? While the case studies in Housing First in Canada have shown that it is possible to develop a successful Housing First program even in a tight rental housing market, they were primarily successful through the use of rent supplements to increase affordability.Partnerships with existing private landlords were also show to be very important. At the core though, there is a housing shortage in Canada – especially safe, secure and affordable housing. A concurrent investment in affordable housing is necessary to ensure an end to homelessness.
How are the needs of sub-populations met through Housing First? It is clear from existing research that one size does not fit all. However, Housing First can be adapted to suit most communities and sub-populations. Unique needs require unique answers. What will work in Houston may not work in Montreal. What works for single adults may not work for youth. Adapting the program to meet the needs of a particular sub-population is key to ensuring success. A period of transition may be required to help certain sub-populations make the adjustment from the streets/shelters to housing.
What is the duration and extent of supports, and who is responsible for funding them? In some cases Housing First programs provide a time limited investment in supports, ranging from one to three years. For those who need ongoing supports, effective models for continued engagement with mainstream services need to be explored.
Once housed do people have adequate income to meet basic needs on an ongoing basis? A goal for most communities is that people who are housed should pay no more than 30% of their income on rent. The use of rent supplements is key to ensure that people are able to survive and thrive in housing. In many cases, people are able to “graduate” from a Housing First program in so far as they no longer require active supports, but they still need ongoing financial assistance.



Housing First has proven to be a realistic, humane and effective way of responding to homelessness.  

BOOK: Housing First in Canada: Supporting Communities to End Homelessness is the first book that examines how this approach has been applied in Canada. The book begins with a framework for Housing First that explains the core principles of the approach, as well as how it works in practice. The book also presents eight case studies of Housing First in Canada, exploring not just the results of its implementation, but how different communities made the shift from ‘treatment as usual’ to a new approach. Here we explore the challenges of making the case locally, the planning process, adapting the model to local contexts (urban vs. small town) or targeted populations (Aboriginal people, youth), and implementation. Much has been learned by communities that have employed Housing First and we conclude the book with a chapter that highlights key lessons learned. 
The book provides a wealth of information for those who want to understand the concept of Housing First and how to move forward with implementation. The good news is that Housing First works and can be applied in any community. 
Does Housing First Work? (2016)
Brown et al. (2016) found that participants in a Housing First program, when compared with those who received TAU, spent less time homeless, spent less time hospitalized, and had enhanced use of needed services, including substance use treatment and mental health, medical, dental, and vision care.

It appears that when providers avoid coercive relationships with participants, use of needed services improves. This finding is in sync with research on motivational interviewing; when providers follow the client's lead, instead of pushing or pulling the client, they help unleash the client's internal motivation, propelling clients towards their own goals.

Somers et al. (2017) found that participants in both congregate and scattered-site Housing First programs were better able to achieve stable housing than were participants in TAU and experienced significantly greater perceived quality of life.

A Housing First program funded by the U.S. Department of Housing and Urban Development in 2007 and 2008 showed favorable results for people who had been homeless for five years or longer and were also struggling with mental health and substance use challenges (Tsemberis, Kent, & Respress, 2012).

Studies indicate that "high fidelity" Housing First programs—those that truly honor the guiding principles and practices of the Housing First model—have better housing retention rates and are associated with fewer emergency department visits and better health, mental health, and social outcomes when compared with more traditional approaches to providing housing to people experiencing homelessness.

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The Bottom Line
It can be challenging to draw definitive conclusions from research studies about the effectiveness of Housing First programs, because different programs may have different program elements, serve populations with different complex needs, and use different outcome measures. Randomly assigning consumers to different housing programs presents practical and ethical issues as well. That said, several studies show that Housing First programs have better outcomes than other housing programs. Other studies suggest that TAU and Housing First may have similar outcomes. That leaves us with an ethical decision to make. Should we favor the more humane, client-centered, nonjudgmental approach that views safe, stable, affordable housing as a human right?

It is clear that Housing First is a preferable option that embraces a coordinated system of care at the micro, mezzo, and macro practice levels.

Developing the political will and educating potential funding sources, including state, local, and federal governments, will be key to expanding Housing First programs. Addressing the systemic causes of homelessness is crucial, including subsidies to developers to expand the supply of affordable housing, rental subsidies, income support programs, expanding the economy to eradicate income disparities and ensure that full-time workers earn living wages, providing evidence-based substance use and mental health services, and ensuring universal health insurance with parity for substance use and mental health services. Homelessness affects many Americans, including veterans, immigrants, refugees, LGBTQ people, people involved in the criminal justice system, families, and many children. Homelessness and the social costs it spawns can be eliminated.