Housing ChronicallyHomeless People:

HOUSING FIRST Programs in Philadelphia

Presented by: David DunbeckHorizon House, Inc.

July 18, 2006

National Alliance To End HomelessnessEnding Homelessness: Plan, Act, Succeed

Housing First Programs“New Keys” and “Home First”

Replicated the model used by the Pathways to Housing Program

Quick access to subsidized apartments Intensive clinical support services using an

Assertive Community Treatment (ACT) Team (accept 5 individuals per month)

Recovery using a Harm Reduction Model Consumer choice is key

Representative payee; home visits

New Keys Started March, 2003 Funding:

Services – SAMHSA Treatment for Homeless grant (3 years-ended

2005) Medicaid fee-for service billing through city/state

Targeted Case Management Systems Housing –

HUD SHP grant – 25 units (3 years, renewable) HUD SPC grant – 35 units (5 years, renewable)

New Keys Target Population Chronically street homeless Dual diagnosis – serious mental illness and

drug/alcohol addiction Housing and services for up to 65 consumers Intentionally took the consumers who had not

been successful in any other treatment programs Most frequent contact with outreach Highest number of refusals of service

Home First Started January, 2004 Chronic Homeless Initiative grant:

Services – SAMHSA (3 years) VA (year-to-year) expire 2006 HRSA (3 years) Medicaid fee for services through city/state Targeted

Case Management systems (at end of grants)

Housing – HUD SHP grant – 70 units (3 years, renewable)

Home First Target Population

Chronically homeless, shelter users Serious mental illness. May have co-

occurring drug/alcohol addictions, physical disabilities

Capacity: Services for 90, housing for 75 Intentionally took the consumers who had not

been successful in any other housing or treatment programs and had high system utilization

Housing First Outcomes Currently, we have 152 consumers assigned

to New Keys and Home First: 113 are housed in their own apartments 18 are in housing process and living in shelter 9 are being engaged through outreach 7 are incarcerated (2 still have apartments) 4 are in long-term hospitalization 2 are in nursing homes 1 is living with family

Housing First Outcomes As of 2/28/06:

126 clients had lived in at least one apartment 1st apartment

70/126 were successful in their 1st apartment (56%) 2nd apartment

24/47 were successful in their 2nd apartment (51%) Cumulatively, 94/126 successful in their 2nd apt. (75%)

3rd apartment 12/14 were successful in their 3rd apartment (86%) Cumulatively, 106/126 successful by their 3rd apt. (84%)

Housing First Outcomes

Impact of Housing on Mental Health: Of those ever housed (and receiving

services): 79% showed improvement 18% stayed the same 3% deteriorated

Of those not housed (but receiving services): 20% showed improvement 70% stayed the same 10% deteriorated

Housing First Outcomes

Impact of Housing on Substance Use: Of those ever housed (and receiving

services): 57% showed improvement 34% stayed the same 4% deteriorated

Of those not housed (but receiving services): 15% showed improvement 70% stayed the same 15% deteriorated

Housing First Outcomes

Impact of Housing on Overall Life Status: Of those ever housed (and receiving

services): 84% showed improvement 12% stayed the same 4% deteriorated

Of those not housed (but receiving services): 50% showed improvement 35% stayed the same 15% deteriorated

Things We’ve learned! (Usually the hard way!)

Housing

Safety

Funding

Behavioral Health

Costs

Employment

Managing expectations/pressures

Physical Health Needs

Staffing

Maintaining the model

The forest/the trees

“Housing First + ACT”

is not the same as

“ACT”

Things We’ve Learned:

These programs are expensive and there are a lot of hidden costs:

Staffing costs Cost for furnishings Apartment damages Unpaid rents Exorbitant utilities Socialization costs Research/data analysis

Things We’ve Learned:

Housing First is still a good investment!

BUT…

Preliminary analysis shows significant (>50%) reduction in inpatient hospitalizations, detox, and rehab after engaging in services and/or getting housing.

It’s a challenge to introduce “housing first” in an agency and division that also provide “traditional” homeless and

treatment services:

Values Harm reduction Client choice

Hiring

Co-location of facilities

Things We’ve Learned:

Things We’ve Learned:

There are advantages and disadvantages to having housing services in a different agency than treatment services:

Good cop/bad cop Values

Harm reduction Client choice

Landlord issues Damages

Money Management:

Is it really therapeutic to be representative payee for your consumers?

Or would it be better to let another agency be the representative payee?

Things We’ve Learned (or are still trying to figure out):

Things We’ve Learned:

SAFETYmust be a critical consideration

when implementing ahousing-first program.

FACT: You are controlling (some of) the money of an active substance user who also has a diagnosis of serious mental illness.

Things We’ve Learned:

Address Safety concerns by:

Establishing: Boundaries, behavior expectations for consumers Policies and procedures for staff Consequences (i.e., discharge)

Training Staff

Proactively considering safety in your space planning

Things We’ve Learned:

Safety training: Understanding behavior; intervening before behavior escalates.

Lalemand Behavior Scale:* Agitated Disruptive Destructive Dangerous Threat of Lethal

* From the Non-Aggressive Psychological and Physical Intervention (NAPPI, Inc.)

Good assessments are a good investment!

Take the time to perform a thorough assessment (including physical health) at the beginning.

Don’t drop the “physical health” ball – use your nurses!

Dealing with long unmet physical health needs can be a powerful engagement tool!

Things We’ve Learned:

StaffingIt takes special people to do housing first:

Hiring good staff 120% turnover in first year

Maintaining the “revolution” Keeping good staff TRAIN, LISTEN, SUPPORT

Things We’ve Learned:

We built sustainability into our grants….but, we still weren’t prepared for the transition:

It’s always going to be a painful process, but don’t wait until you need to bill fee-for-service to begin the transition:

“Pull the bandage off” Do the necessary procedures, paperwork, etc.

fully from the beginning – it’s easier to transition with only 5, 10, or 20 consumers (and associated paperwork) than with 155 consumers!

Things We’ve Learned:

My new mantra:

“Defend the program,but don’t become

defensive”

Things We’ve Learned:

The Goal:

Housing First – Future Growth

“Welcome Home” Start-up December 2006 Services and housing for 60

Philadelphia 10-Year Plan to End Homelessness Proposes “housing first” for 360 (currently

at 150)

Contact InformationHorizon House, Inc.1201 Chestnut St., 12th floorPhiladelphia, PA 19107215-636-0606

David Dunbeck, Director of Homeless Services, david.dunbeck@hhinc.org

Carla Williams, Director of ACT, carla.williams@hhinc.org