nicholas pleace - home - housing first europe...
TRANSCRIPT
Nicholas Pleace
TABLE OF CONTENTS
Acknowledgements .....................................................................................................................................6
Foreword .............................................................................................................................................................7
Introduction .......................................................................................................................................................9
1. What is Housing First? .............................................................................................................................11
1.1. IntroducingHousingFirst ............................................................................................................................ 12
1.2. TheHistoryofHousingFirst .................................................................................................................... 13
1.3. HousingFirstinEurope ............................................................................................................................... 17
1.4. TheEvidenceforHousingFirst ............................................................................................................ 20
1.4.1. EndingHomelessnessforPeoplewithHighSupportNeeds ....................................................... 20
1.4.2. HealthandWell-Being .............................................................................................................................................. 21
1.4.3. SocialIntegration ............................................................................................................................................................. 22
2. Core principles of Housing First ........................................................................................................27
TheCorePrinciplesofHousingFirst ........................................................................................................... 28
2.1. HousingisaHumanRight .......................................................................................................................... 29
2.2. ChoiceandControlforServiceUsers ............................................................................................... 30
2.3. SeparationofHousingandTreatment ............................................................................................ 31
2.4. RecoveryOrientation ...................................................................................................................................... 32
2.5. HarmReduction ................................................................................................................................................. 34
2.6. ActiveEngagementwithoutCoercion .............................................................................................. 34
2.7. Person-CentredPlanning ........................................................................................................................... 35
2.8. FlexibleSupportforasLongasisRequired ................................................................................ 36
3. Delivering Support ....................................................................................................................................39
SupportinHousingFirst ....................................................................................................................................... 40
3.1. HousingSustainment ..................................................................................................................................... 40
3.1.1. TheSupportProvided .................................................................................................................................................. 40
3.2. HealthandWell-Being ................................................................................................................................ 42
3.2.1. OrganisingSupport ........................................................................................................................................................ 42
3.2.2. ManagingNeeds ............................................................................................................................................................ 44
3.2.3. TheTreatmentandSupportProvided ........................................................................................................... 44
3.3. SocialIntegration ............................................................................................................................................... 45
3.3.1. OrganisingSupport........................................................................................................................................................ 45
3.3.2. TheSupportProvided ................................................................................................................................................. 46
4. Delivering Housing ....................................................................................................................................51
4.1. HousingandNeighbourhoodinHousingFirst ......................................................................... 52
4.2. HousingastheStartingPoint................................................................................................................... 53
4.3. ProvidingHousing ............................................................................................................................................. 54
4.3.1. WorkingwiththePrivateRentedSector ...................................................................................................... 56
4.3.2. WorkingwiththeSocialRentedSector ....................................................................................................... 57
5. Evaluating Housing First ........................................................................................................................61
5.1. TheImportanceofEvidence .................................................................................................................. 62
5.2. ProcessandEffectivenessEvaluation .............................................................................................. 63
5.2.1. ProcessEvaluation ......................................................................................................................................................... 63
5.2.2. Fidelity ..................................................................................................................................................................................... 63
5.2.3. EffectivenessEvaluation ........................................................................................................................................... 64
5.3.WhattoMeasure ............................................................................................................................................... 65
5.3.1. UseofValidatedMeasures ..................................................................................................................................... 65
5.3.2. KeyQuestionsforEvaluation ................................................................................................................................ 65
5.3.3. HousingSustainment .................................................................................................................................................. 66
5.3.4. HealthandWell-Being .............................................................................................................................................. 67
5.3.5. SocialIntegration .......................................................................................................................................................... 68
5.3.6. Cost-Effectiveness ...................................................................................................................................................... 69
5.4.HowtoMeasure ................................................................................................................................................. 69
5.4.1. PlanninganEvaluation ................................................................................................................................................ 69
6. Housing First and Wider Strategy ....................................................................................................73
6.1. TheStrategicRolesofHousingFirst ................................................................................................ 75
6.1.1. IncorporatingHousingFirstintoStrategiestoFightHomelessness ...................................... 75
6.1.2. HousingFirstAlongsideOtherServices ...................................................................................................... 75
6.2. FutureApplicationsofHousingFirst ................................................................................................ 77
6.2.1. ThepossiblefutureusesofHousingFirstinclude: .............................................................................. 77
6.3.MakingtheCaseforHousingFirst ..................................................................................................... 79
APPENDIX: Examples of Housing First...............................................................................................81
Austria ...................................................................................................................................................................................................... 82
Belgium ................................................................................................................................................................................................... 83
Denmark ................................................................................................................................................................................................. 84
Finland ..................................................................................................................................................................................................... 86
France ...................................................................................................................................................................................................... 88
Ireland ...................................................................................................................................................................................................... 89
Italy ............................................................................................................................................................................................................. 90
TheNetherlands .............................................................................................................................................................................. 92
Norway .................................................................................................................................................................................................... 94
Portugal ................................................................................................................................................................................................... 95
Spain.......................................................................................................................................................................................................... 96
Sweden ................................................................................................................................................................................................... 97
TheUnitedKingdom .................................................................................................................................................................... 98
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AcknowledgementsThisGuidetousingHousingFirstinEuropewouldnothavebeenpossiblewithoutthehelpandsupportofmanyindividualsandagencies.FEANTSA,theEuropeanFederationofNationalOrganisationsworkingwiththeHomeless,withthesupportoftheStavrosNiarchosFoundation,tooktheleadinthecreationoftheHousingFirstinEuropeGuide.TheprocessofdevelopingandshapingtheGuidewasledbyRuthOwenandMaríaJoséAldanas(FEANTSA)andvolunteersupportwasprovidedbyanadvisoryboardchairedbyJuhaKaakinen (Y-Foundation)andcomprising:RobertoBernad (RAISFundación);TeresaDuarte(AEIPS);PascaleEstecahandy(DIHAL);MarcoIazzolino(HousingFirstItaliaandfio.PSD);BirthePovlsen (Socialstyrelsen); Vic Rayner (Sitra); Freek Spinnewijn (FEANTSA); Professor Eoin O’Sullivan(TrinityCollegeDublin);Dr.SamTsemberis(PathwaystoHousingNational)andProfessorJudithWolf(RadboudUniversityMedicalCentre).
ThanksarealsoduetoalltheindividualswhoprovidedinformationontheuseofHousingFirstintheircountriesforinclusioninthisGuide.
TheauthorwouldalsoparticularlyliketothankSamTsemberis(PathwaystoHousingNational),JoanneBretherton (UniversityofYork),VolkerBusch-Geertsema (GISS),MarcusKnutagård (LundUniversity),Judith Wolf (Radboud University Medical Centre) and both Ruth Owen and María José Aldanas(FEANTSA)fortheircommentsontheearlierdraftsoftheGuide.
Nicholas Pleace,
University of York,
February,2016
7
Foreword
AbouttheHousingFirstGuideEuropeTheHousingFirstEuropeGuideistheproductofamulti-nationalteamwithexperienceinoperatingHousingFirstacrossseveralmembernations.OurgoalwastodescribehowtoimplementandoperateHousingFirstthroughoutEurope.TheneedforthisGuidearosebecauseoftherapidincreaseinthedisseminationofHousingFirsttoaddresshomelessnessthroughouttheEU.HousingFirsthasprovenhighlyeffectiveinaddressinghomelessnessandthisGuideseekstoprovidetheinformationnecessaryto implement, staff and operate an effectiveHousing First program.Today, there areHousing FirstprogramsinmanyEuropeancountriesandthatnumberisincreasingbecauseHousingFirstisnowalsoacorecomponentofmanyEUmemberstates’homelessnesspolicies.
Wesought towriteaGuidethatwouldbeuseful to largeandsmallHousingFirstprogrammesandservices, operating in many different countries with unique political, economic, and social welfaresystems, and serving diverse homeless populations. This proved to be an interesting challenge.Fortunately,ourteamrepresentedanumberofmembernationsbutweneededtofindaframeworkthatwasbothpreciseandaccuratelydefinedtheprinciplesandpracticesofHousingFirstandatthesametime,wasbroadandflexibleenoughtobeadaptableandusefulacrossthediverseEUmemberstates.Attentionwasalsopaid toouraudience;wewanted tomake theGuideuseful to thevariousstakeholdergroupswithineachcountry,especiallyserviceproviders,researchersandpolicymakers.
It isourhopethattheGuideprovidesacleardescriptionofHousingFirstasaneffectivewaytoendhomelessness,especially for individualswithmentalhealthandaddictionchallenges.However, it isalsohopedthattheGuidemaybeofusetothebroaderservicescommunityandencouragetraditionalhomelessness,mentalhealth,andaddictiontreatmentservicestoembracetheclient-drivenprinciplesofHousing First that have proved so effective.Treatments that encourage self-determination haveproven more effective in reducing symptoms than compliance based approaches.We have alsoobservedinmanycommunitiesthatwhenHousingFirstisimplementeditdoesbegintotransformthepracticeofadjoiningservicesandsystemsofcare,expandingitfromasingularservicetoacommunitywideapproach.
AgrowingbodyofresearchevidencecontinuestoreinforcethefactthatHousingFirstservicesachievesignificantlybetteroutcomesinhousingstability,mentalhealth,addiction,andqualityoflife.Itishopedthat this Guidewill help organizations develop Housing First services that are consistent with theprinciplesandpracticesofthisevidencebasedmodelandtheywillachievesimilarresultsandoverallimprovementsinsystemschange.Partoftheresearchevidencealsoindicatesthatthereisapositiverelationshipbetweenprogrameffectivenessandprogramfidelity.Studiesconsistentlyreportthathighfidelityprogramsachievesuperiorresults.
OneoftheuniqueaspectsoftheHousingFirstmodelisthatithasasocialjusticedimension.HousingFirstprovideshousingasabasichumanright,notasarewardforattainingsobrietyorcomplyingwithpsychiatrictreatment.Individualsdonothavetoearnhousingortoprovetheyareworthyorreadyforhousing.HousingFirstoffersparticipantsimmediateaccesstohousingasamatterorright:toaddressthe injustice of poverty, to attempt even the playing field for thosewho are less fortunate, and toimmediatelyamelioratethesufferingofthosewhoarehomeless.
Asapracticalmatter theprogramusesaharm reductionapproach to reduce risks associatedwithdrug,alcohol,orpsychiatric issues. Ifaprogram isnotgoing to require treatmentandsobrietyasapreconditionforprovidinghousing,itwilldefactobeoperatingwithaharmreductionapproach.Thismaybeavalue-basedchallengeinsomeorganizationsorcommunities.
Because Housing First reverses the sequence from treatment-sobriety-then-housing to housing-then-treatmentandmaybe-sobriety,theapproachmaypresentachallengeincommunitieswithlongstandingsocialhousingprograms.Typically,peoplewhoqualifyforsocialhousingmustwaittheirturn,oftenforyears,inaqueuedesignedasafairsystemfordistributingarareandhighlyvaluedresource.CommunitieswhohavesuccessfullyimplementedHousingFirstinthiscontexthavehadtorethinkand
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redesigntheirsocialhousingallocationmethodologyinordertoprovide“immediateaccess”tohousingforthemostvulnerablewhoarehomelessandwhocannotbeplacedonawaitinglist.
Another dimension that has proven challenging to housing systems, is the engagement of privatemarket landlords toprovidehousing. In somecountries that isnotcontroversialbut inothers ishasbeencontroversialtoseekhousingintheprivatemarketfortenantswhohavetraditionallybeentheresponsibilityofsocialservicesandsocialhousing.
Finally, Housing First challenges communities to consider their beliefs, values and social normsconcerningindividualswithpsychiatricdiagnoses.Thedefinitionof‘communityintegration’foroften-marginalized populations is brought into sharp focus as Housing First program participants areseamlesslymovedintoregularflatsintegratedthroughoutthecommunity.Thisrepresentsaremarkableadvancement in mental health services and in social inclusion because the individuals served byHousingFirst,onlyafewdecadesago,mayhavespenttheirentirelivesininstitutions.Today,HousingFirstprogramparticipantsliveindependentlywithsupportservices,integratedintotheircommunitiesandenjoyingthesamefreedoms,lifestyle,andculturaleventsastheirneighbours.
Ultimately,oursharedvaluesaboutendinghomelessness,supportingrecovery,andsocialinclusionforpeoplewithmentalhealthandaddictionproblemsboundthemembersofourteamtogethertoworkonthisGuide. InourefforttodescribeHousingFirst’soperationandpractices, it isourhopethatwehavealsoconveyeditsspiritandvalues.
Sam Tsemberis, Ph.D.
CEO, Pathways Housing First Institute
May5,2016
9
Introduction
AbouttheGuideHousingFirstisaninnovativewayofreducinghomelessnessamongpeoplewithhighsupportneeds.HousingFirstwasfirstdevelopedbyDr.SamTsemberis in theUSAand isnowbeingused inmanyEuropeancountries.
ThisGuidewasdevelopedbyFEANTSA,theEuropeanFederationofNationalOrganisationsworkingwiththeHomeless,withthesupportoftheStavrosNiarchosFoundation.ThegoalistoprovideaguidethatcanbeusedtohelpdevelopHousingFirstservicesinEuropeancountries.
TheGuideisdesignedtoinformpeopleabouthowHousingFirstworksandtoactasastartingpointforthedevelopmentofHousingFirstservices.AstheGuidehasbeenwrittenspecificallyforEurope,itisdesignedtoprovidealevelofinformationthatisrelevanttoanydevelopmentofHousingFirstinanyEuropeancountry.ExamplesofHousingFirstbeingusedinseveralEuropeancountriesareprovided.
TheGuidewaswrittenbyNicholasPleace(UniversityofYork,UK)withthesupportofRuthOwenandMaríaJoséAldanas(FEANTSA)andanadvisoryboardofexpertsinHousingFirst,whovolunteeredtheirtimetohelpdeveloptheGuide:
₀ RobertoBernad,RAISFundación(Spain)
₀ TeresaDuarte,AEIPS(Portugal)
₀ PascaleEstecahandy,UnChezSoid’abordProgramme,DIHAL(France)
₀ MarcoIazzolino,HousingFirstItalia/fio.PSD(Italy)
₀ JuhaKaakinen,Y-Foundation(Finland)
₀ BirthePovlsen,Socialstyrelsen(Denmark)
₀ ProfessorEoinO’Sullivan,TrinityCollegeDublin(Ireland)
₀ VicRayner,Sitra(UK)
₀ Dr.SamTsemberis,PathwaystoHousingNational(USA)
₀ ProfessorJudithWolf,RadboudUniversityMedicalCentre(Netherlands)
TheGuidehasbeenwrittenforanyonewithaninterestinHousingFirstandthedevelopmentofHousingFirstservicesinEurope.TheGuideisintendedasanintroductiontoHousingFirstinEurope,providinganoverviewofthecoreprinciplesandgivingexamplesofhowHousingFirstworksinpractice.
AstheGuidehasbeenwrittentobebroadlyapplicabletoanyEuropeancountry,itdoesnotprovideagreatdealofdetailonhowtodevelopHousingFirstinanyparticularcountry.EuropeancountriesdifferfromoneanotherandtheintentionwastoprovideinformationthatisgenerallyusefulacrossEurope.Specificguidesareavailable,orwill soonbeavailable,withinseveralEuropeancountries.Guides toHousingFirsthavealsobeendevelopedinNorthAmerica.
TheGuideisdesignedtobeusedinconjunctionwiththeHousingFirstEuropeGuidewebsiteandisavailableasa freedownload.Onthewebsite,youcanfinddiagrams,videosandothermaterial thatprovidesinformationonhowHousingFirstworksindifferentEuropeancountries.
ThefirstchapteroftheGuidebeginswithabriefdescriptionofHousingFirst.Thechapterthenlooksat thehistoryofHousingFirst,providesanoverviewof theuseofHousingFirst inEuropeand thensummarisestheevidenceabouttheeffectivenessofHousingFirst.
ThesecondchaptersummarisesthecoreprinciplesofHousingFirst.ThethirdchapterlooksathowsupportisprovidedinHousingFirst.Thefourthchapterexploresthedifferentwaysinwhichhousing
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canbeprovidedtoHousingFirstserviceusers.Thefifthchaptercoversevaluation,centringonhowtomeasureandreporttheachievementsofHousingFirstservicesinEurope.Thefinal,sixth,chapterlooksattherolesofHousingFirstinwiderstrategies,includinghowHousingFirstcanworkalongsideotherhomelessnessservicesinanintegratedhomelessnessstrategy.AnappendixprovidesexamplesoftheuseofHousingFirstinEurope,describingnationalstrategiesandindividualservices.
OtherGuidesandInformationaboutHousingFirstTherearearangeofguidestodevelopingandimplementingHousingFirstandanumberofreportsandpapersthatdiscusstheevidenceforHousingFirst.Keyresourcesavailableatthetimeofwritinginclude:
₀ Pleace,N.(2008)Effective Services for Substance Misuse and Homelessness in Scotland: Evidence from an International Review Edinburgh: Scottish Government http://www.gov.scot/Resource/Doc/233172/0063910.pdf
₀ Tsemberis,S.J.(2010)Housing First: The Pathways Model to End Homelessness for People with Mental Illness and AddictionMinneapolis:Hazelden.
₀ Busch-Geertsema, V. (2013) Housing First Europe: Final Report - http://housingfirstguide.eu/website/wp-content/uploads/2016/03/FinalReportHousingFirstEurope.pdf
₀ Pleace,N.andBretherton,J. (2013)TheCaseforHousingFirst intheEuropeanUnion:ACriticalEvaluation of Concerns about Effectiveness European Journal of Homelessness, 7(2), 21-41 http://housingfirstguide.eu/website/wp-content/uploads/2016/03/The-case-for-Housing-First-in-the-EU-np_and_jb.pdf
₀ Goering,P.,Veldhuizen,S.,Watson,A.,Adair,C.,Kopp,B.,Latimer,E.,Nelson,G.,MacNaughton,E.,Streiner,D.andAubry,T.(2014)National at Home/Chez Soi Final ReportCalgary,AB:MentalHealthCommissionofCanada.-http://www.mentalhealthcommission.ca/English/system/files/private/document/mhcc_at_home_report_national_cross-site_eng_2.pdf
₀ Canadian Housing First Toolkit(2014)(FrenchandEnglish)http://www.housingfirsttoolkit.ca/
₀ Padgett, D.K., Heywood, B.F. and Tsemberis, S.J. (2015) Housing First: Ending Homelessness, Transforming Systems and Changing LivesOxford:OxfordUniversityPress.
₀ PathwaystoHousingNationalPathwaysHousingFirstFidelityScaleforIndividualswithPsychiatricDisabilities, 2013 - https://pathwaystohousing.org/research/pathways-housing-first-fidelity-scale-individuals-psychiatric-disabilities
₀ UnitedStatesInteragencyCouncilonHomelessnessThe Housing First Checklist: A Practical Tool for Assessing Housing First in Practice-https://www.usich.gov/resources/uploads/asset_library/Housing_First_Checklist_FINAL.pdf
₀ Stefancic,A.,Tsemberis, S.,Messeri, P., Drake, R. andGoering, P. (2013)ThePathwaysHousingFirst fidelity scale for individuals with psychiatric disabilities. American Journal of Psychiatric Rehabilitation,16(4),240-261.
₀ MacNaughton, E., Stefancic,A., Nelson, G., Caplan, R., Townley, G.,Aubry, T. andTsemberis, S.(2015)ImplementingHousingFirstAcrossSitesandOverTime:LaterFidelityandImplementationEvaluationofaPan-CanadianMulti-siteHousingFirstProgramforHomelessPeoplewithMentalIllness.American Journal of Community Psychology,55(3-4),279-291.
₀ Gilmer,T.P.,Stefancic,A.,Henwood,B.F.andEttner,S.L.(2015)FidelitytotheHousingFirstModelandVariation inHealthServiceUsewithinPermanentSupportiveHousing.Psychiatric Services,66(12),1283-1289.
₀ Greenwood, R.M., Stefancic,A. andTsemberis, S. (2013) PathwaysHousing First for homelesspersonswithpsychiatricdisabilities:Programinnovation,research,andadvocacy.Journal of Social Issues,69(4),645-66
1.What is Housing First?
CHAPTER 1.
Chapter1.WhatisHousingFirst?
12
1.1. IntroducingHousingFirstHousingFirst isprobablythesingle most important innovation in homelessness service design in thelast30years.DevelopedbyDr. Sam TsemberisinNewYork,theHousingFirstmodelhasprovenverysuccessful in ending homelessness among people with high support needs in theUSAandCanadaandinseveralEuropeancountries.
Housing First is designed for people who need significant levels of help to enable them to leave homelessness.AmongthegroupswhoHousingFirstservicescanhelparepeoplewhoarehomelesswithseverementalillnessesormentalhealthproblems,homelesspeoplewithproblematicdrugandalcoholuse,andhomelesspeoplewithpoorphysicalhealth, limiting illnessanddisabilities.HousingFirst services have also proven effectivewith peoplewho are experiencing long-term or repeatedhomelessnesswho,inadditiontoothersupportneeds,oftenlacksocialsupports,i.e.helpfromfriendsorfamilyandarenotpartofacommunity.IntheUnitedStatesandCanada,HousingFirstprogrammesarealsousedwithhomelessfamiliesandyoungpeople.
HousingFirstuseshousingasastarting pointratherthanan end goal.ProvidinghousingiswhataHousingFirstservicedoesbeforeitdoesanythingelse,whichiswhyitiscalled‘Housing First’.AHousingFirstserviceisabletofocusimmediatelyonenablingsomeonetosuccessfullyliveintheirownhomeaspartofacommunity.HousingFirstisalsofocusedonimprovingthehealth,well-beingandsocialsupportnetworksofthehomelesspeopleitworkswith.Thisisverydifferentfromhomelessnessservicesthattrymakehomelesspeoplewithhighsupportneeds‘housingready’beforetheyarerehoused.Someexistingmodelsofhomelessnessservicesrequiresomeonetoshowsobrietyand,engagementwithtreatmentandtobetrainedinlivingindependentlybeforehousingisprovidedforthem.Inthesetypesofhomelessnessservice,housinghappens‘last’.
Housing First is designed to ensure homeless people have a high degree of choice and control. HousingFirstserviceusersareactively encouragedtominimiseharmfromdrugsandalcoholandtousetreatment;theyarenot requiredtodoso.Otherhomelessnessservices,suchasstaircaseservices,oftenrequirehomelesspeopletousetreatmentandtoabstainfromdrugsandalcohol,beforetheyareallowedaccesstohousingandmayalsoremovesomeonefromhousing if theydonotcomplywithtreatmentordonotshowabstinencefromdrugsandalcohol.
IntheUSA,CanadaandinEurope,research shows that Housing First generally ends homelessness for at least eight out of every ten people1. Success has also been reportedwith diverse groupsof homeless people.Housing First hasworkedverywell for peoplewho are notwell integrated insocietyafterlong-termorrepeatedhomelessness,homelesspeoplewithseverementalillnessand/orproblematicdrugandalcoholuseandhomelesspeoplewithpoorphysicalhealth.
Housing First in Europe can be described as following eight core principles.ThesecoreprinciplesareverycloselybasedonthosedevelopedbyDr.SamTsemberis,whocreatedthefirstHousingFirstserviceinNewYorkintheearly1990s2.TheseprinciplesweredefinedinconsultationwithDr.TsemberisandtheadvisoryboardforthisGuide.
1 Basedonareviewofexistingevidence,see:Pleace,N.andBretherton,J.(2013)TheCaseforHousingFirstinthe
EuropeanUnion:ACriticalEvaluationofConcernsaboutEffectiveness.European Journal of Homelessness,7(2),21-41
http://housingfirstguide.eu/website/the-case-for-housing-first-in-the-european-union-a-critical-evaluation-of-
concerns-about-effectiveness/
ThefigurereferstoformerlyhomelesspeoplehousedforatleastoneyearbyaHousingFirstservice(seelaterinthis
chapterformoredetailsontheevidenceforHousingFirst).
2 Tsemberis,S.J.(2010)Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction
Minneapolis:Hazelden.
Chapter1.WhatisHousingFirst?
13
Housing is
a human right
Harm reduction
Choice and control for service users
Active engagement without coercion
Separation of housing and treatment
Person-centred planning
Recovery orientation
Flexible Support for as Long as is Required
Eight core principles:
Operatingwithinthesecoreprinciples,HousingFirstpursuesarangeofservicepriorities,whichincludeofferinghelpwithsustainingasuitablehomeandwithimprovinghealth,well-beingandsocialintegration.HousingFirstisdesignedtoprovideopportunitiestoaccesstreatmentandhelpwithintegrationintoacommunity.Thereisalsotheoptiontogethelpwithstrengtheningsocialsupportsandwithpursuingrewardingopportunities,suchasarts-basedactivities,education,trainingandpaidwork.
1.2. TheHistoryofHousingFirst HousingFirstwasdevelopedbyDr.SamTsemberis,atPathwaystoHousinginNewYork,intheearly1990s3. Housing First was originally developed to help people with mental health problems who were living on the streets;manyofwhomexperiencedfrequentstaysinpsychiatrichospitals.ThetargetpopulationsenteringHousingFirst latergrewto includepeoplemaking longstays inhomelessnesssheltersandthoseatriskofhomelessnesswhoweredischargedfrompsychiatrichospitals,orreleasedfromprison.Withsomemodificationtothesupportservices,HousingFirstservicesarenowalsousedwithfamiliesandyoungpeoplewhoarehomelessinNorthAmerica.
BeforeHousingFirst,permanenthousingwithsupportwasonlyofferedtohomelesspeopleinNorthAmericaaftertheyhadgraduatedfromaseriesofstepsthatbeganwithtreatmentandsobriety.Eachsteponthis‘staircase’wasdesignedtopreparesomeoneforlivingindependentlyintheirownhome.When all the stepswere complete, a formerly homeless personwithmental health problemswasmeant tobe ‘housing ready’because theyhadbeen ‘trained’ to live independently.These typesofservicesaresometimescalled‘staircase’,‘linearresidentialtreatment’or‘treatment-ledapproaches’.
These‘staircase’servicesandthe‘housingreadiness’culturehadoriginallyarisenfrompracticeinNorthAmericanpsychiatrichospitals,whereindividualswithadiagnosisofseverementalillnesswereinitiallyconsideredincapableoffunctioninginallareasoflifeandneededaround-the-clocksupervisionandsupport.Bythe1980s,NorthAmericanmentalhealthprofessionalswereraisingseriousquestionsabout
3 Tsemberis,S.J.(2010)Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction
Minneapolis:Hazelden.
Chapter1.WhatisHousingFirst?
14
theeffectivenessofservicesbasedon theseassumptionsaboutseveremental illness4.However,astaircaseapproachbecamefirmlyestablishedas themodel forhelpinghomelesspeoplewithhighneedsinNorthAmerica.
Thestaircaseapproachforhomelesspeoplehadthreegoals:
₀ Trainingpeopletoliveintheirownhomesafterbeingonthestreetsorinandoutofhospitals.
₀ Makingsuresomeonewasreceivingtreatmentandmedicationforanyongoingmentalhealthproblems.
₀ Makingsuresomeonewasnotinvolvedinbehaviourthatmightputtheirhealth,well-beingandhousingstabilityatrisk,particularlythattheywerenotmakinguseofdrugsandalcohol(sobriety).
During the 1990s, it started to become clear that staircase services for individualswith psychiatricdiagnoses, especially those with co-occurring addiction problems, were not always working veryeffectively5.Therewerethreemainproblems:
₀ Service users became ‘stuck’ in staircase services, because they could not alwaysmanage tocompleteallthetasksnecessarytomovebetweenonestepandthenext.
₀ Serviceuserswereoftenevictedfromtemporaryandpermanenthousingbecauseofstrictrules,suchasrequirementsfortotalabstinencefromdrugsandalcoholandbeingrequiredtoparticipateinpsychiatrictreatment.
₀ Therewereworriesaboutwhetherstaircaseservicesweresettingunattainablestandardsintherequirementstheyplacedonpeople,i.e.serviceuserswereexpectedtobehavemorecorrectlythanotherpeople;theywererequiredtobea‘perfect’citizen,ratherthananordinarycitizen.
NorthAmerican ‘supportedhousing’services,developedasanalternative tostaircaseservices,hada different approach. Former psychiatric patientswere immediately, or very quickly, given ordinaryhousinginordinarycommunitiesandreceivedflexiblehelpandtreatmentfrommobilesupportteams,withinaframeworkwheretheserviceuserhadalotofchoiceandcontrol.Supportwasprovidedforaslongaswasneeded.
‘Supportedhousing’servicesinNorthAmericadidnotrequireabstinencefromdrugsoralcohol,andtheydidnotexpect fullengagementwith treatmentasacondition forbeinghoused.Giving formerpsychiatricpatientsfarmorechoiceabouthowtheylivedtheirlives,whileencouragingpositivechangesandprovidinghelpwhenitwasaskedfor,wasfoundtobemoreeffectivethanastaircaseapproach.This supported housing model was the basis for Housing First6.
However,ashomelessnessbeganto increase,servicesforhomelesspeopleoftencontinuedtousethe stairwaymodel, because thatwas still consistentwith the predominantmental health servicesmodelintheUSA.Asmostofthosewhowereonthestreets-thevisiblyhomeless-werethoughttohaveveryhighratesofseverementalillness,itseemedreasonabletousethetraditionalmentalhealthservices approach that had often been used by psychiatric hospitals.Most homelessness servicestherefore followed the staircasemodel. In Europe too, homelessness services had been designedaccordingtoastaircaseapproach,whichsawhousingastheendgoalratherthanasthefirststepinendinghomelessness.
4 Ridgway,P.andZipple,A.M.(1990)Theparadigmshiftinresidentialservices:Fromthelinearcontinuumtosupported
housingapproaches.Psychosocial Rehabilitation Journal13,11-31.
5 Ridgway,P.andZipple,A.M.(1990)Theparadigmshiftinresidentialservices:Fromthelinearcontinuumtosupported
housingapproachesPsychosocial Rehabilitation Journal13,11-31;Carling,P.J.(1990)MajorMentalIllness,Housing,and
Supports:ThepromiseofcommunityintegrationAmerican Psychologist45,8,969-975.
6 Tsemberis,S.(2010)Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction
Minnesota:Hazelden.
Chapter1.WhatisHousingFirst?
15
Researchonstaircasehomelessnessservicesreportedsimilarproblemstothoseidentifiedinstaircasementalhealthservices7.Inparticular:
₀ Homelesspeoplebecame‘stuck’,unabletocompletethestepsthattheywereexpectedtofollowtoberehoused.
₀ Staircaseserviceswereabandonedbyhomelesspeoplewhodidnotlikeorcouldnotfollowthestrictrules.
₀ Therewereconcernsabouttheethicsofsomestaircaseservices-particularlyatendencytoviewhomelessnessastheresultofsomeone’scharacterflaws-withhomelesspeoplebeingblamedforcausingtheirownhomelessness.
₀ Staircaseservicescouldbeharshenvironmentsforhomelesspeople.
₀ Costswerehigh,buttheeffectivenessofstaircaseserviceswasoftenlimited.
Buildingonthesupportedhousingmodel,HousingFirst,asdevelopedbyDr.SamTsemberisinNewYork,wasfocusedonhomelesspeoplewithaseverementalillness8.Housingwasprovided‘first’ratherthan, as in thestaircasemodel, ‘last’. Housing First offered rapid access to a settled home in the community, combined with mobile support services that visited people in their own homes. Therewasno requirement to stop drinking or using drugs and no requirement to accept treatment in return for housing.Housingwasnotremovedfromsomeoneiftheirdrugoralcoholusedidnotstop,oriftheyrefusedtocomplywithtreatment.Ifaperson’sbehaviourorsupportneedsresultedinalossofhousing,HousingFirstwouldhelpthemfindanotherplacetoliveandthencontinuetosupportthemforaslongaswasneeded.
Rather than being required to accept treatment or complete a series of ‘steps’ to access housing,someoneinaHousingFirstserviceleapsoverthestepsandgoesstraightintohousing.MobilesupportisthenprovidedtohelpHousingFirstserviceuserstosustaintheirhousingandpromotetheirhealthandwell-beingandsocial integration,withina framework thatgives serviceusersahighdegreeofchoiceandcontrol(Figure1).
Figure1:SummarisingthedifferencesbetweenHousingFirstandStaircaseServices9
7 Sahlin,I.(2005)TheStaircaseofTransition:SurvivalthroughFailure Innovation: The European Journal of Social Science
Research,18(2),115-136.
Sahlin,I.andBusch-Geertsema,V(2005)TheRoleofHostelsandTemporaryAccommodation.http://housingfirstguide.
eu/website/wp-content/uploads/2016/03/The-role-of-Hostels-And-Temporary-Accomodation-ejh_vol1_
article3.pdf
Pleace,N.(2008)Effective Services for Substance Misuse and Homelessness in Scotland: Evidence from an International
ReviewEdinburgh:ScottishGovernment-http://www.gov.scot/Resource/Doc/233172/0063910.pdf
8 Tsemberis,S.(2010)‘HousingFirst:EndingHomelessness,PromotingRecoveryandReducingCosts’inI.GouldEllenand
B.O’Flaherty(eds)How to House the HomelessRussellSageFoundation:NewYork.
9 Tsemberis,S.andHenwood,B.(2013)HousingFirst:Homelessness,RecoveryandCommunityIntegration.InV.Vandiver
(ed.)Best Practices in Community Mental Health: A Pocket Guide,pp.132-150.NYOxfordUniversityPress
Receptionstage
Sharedhousing“training dwellings”,etc.
Regulardwellingwith(time-limited)occupationagreementbasedonspecialconditions
Homelessness
Regular self contained dwelling with rent contract
HOUSING FIRST
Flexible individual support in housing
HOUSING FIRST
Chapter1.WhatisHousingFirst?
16
Inthelate1990s,pioneeringAmericansocialresearchbyDennisP.Culhaneandcolleaguesshowedtherewasa small group of people with very high needs, who made long-term and repeated use of homelessness services, yet whose homelessness was never resolved10.Staircaseserviceswerefoundnot to beperformingwell in ending this long-term (“chronic” and “episodic”) homelessness11,whichwasbeingfoundtobeverydamagingtothehealthandwell-beingofthepeopleexperiencingit12.HousingFirst,which researchshowedhadbeensuccessful inNewYork, could, incontrast, endlong-term homelessness at a much higher rate than staircase services13. The systematic use of comparative research, demonstrating Housing First in comparison with other homelessness services, encouraged wider use of Housing First throughout the USA and attracted attention from the Federal government.
Importantly,there was also an economic case for Housing First. This case centred on the relatively high cost of frequent hospitalisation and incarceration associated with long-term homelessness, i.e.long-termhomelesspeopleoftenmadefrequentuseofemergencymedicalservices,hadhighratesofcontactwithmentalhealthservicesandcouldoftenhavecontactwiththecriminaljusticesystem.Astheydidnotresolvelong-termhomelessnessinmanycases,staircaseprogrammesstartedtobeseenasnotcost-efficient,especiallybecause thestaircaseservices themselveswerealso relativelyexpensive.
Research was showing that Housing First could potentially deliver significantly better results, for a lower level of spending, than staircase services14.Comparatively,HousingFirstcostsignificantlylessthanotherservices.FiguresfromPathwaystoHousingshowprogrammecostsof$57pernight,comparedto$77foraplaceinashelter(approximately€52compared€70,2012figures)15.InLondon,in2013,oneHousingFirstservicewasfoundtocostapproximately£9,600 (€13,500)perpersonperyear (excluding rent). Thiswas compared to between £1,000 per yearmore for a shelter, or nearly£8,000moreforaplaceinahigh-intensitystaircaseservice(excludingrent).Thisrepresentedanannualsavingapproximatelyequivalenttobetween€1,400and€11,250(2013figures)16.
It was also seen that by ending homelessness among people with very high support needs, Housing First could potentially save money for other services, such as psychiatric services, emergency medical services and the criminal justice system.Thiswasbecausehomelesspeoplewithveryhighsupportneeds, if theywerehousedwiththepropersupport,wouldnotencountertheseservicesasoften aswhen theywerehomeless and could stopusing themaltogether17. HomelesspeoplewithhighsupportneedscouldnowbeofferedHousingFirst,which,aswellasbeingverylikelytoendtheirhomelessness,couldbemorecosteffectivethanalternativehomelessnessservices18.
10 Kuhn,R.andD.P.Culhane.“ApplyingClusterAnalysistoTestaTypologyofHomelessnessbyPatternofShelterUtilization:
ResultsfromtheAnalysisofAdministrativeData”DepartmentalPapers(SPP)(1998).Availableat:http://works.bepress.
com/dennis_culhane/3
11 Pleace,N.(2008)Effective Services for Substance Misuse and Homelessness in Scotland: Evidence from an International
ReviewEdinburgh:ScottishGovernment-http://www.gov.scot/Resource/Doc/233172/0063910.pdf
12 Culhane,D.P,Metraux,S.,Byrne,T.,Stino,M.andBainbridge,J.”TheAgingofContemporaryHomelessness”Contexts,in
press(2013).Availableat:http://works.bepress.com/dennis_culhane/119
13 Tsemberis,S.(2010)‘HousingFirst:EndingHomelessness,PromotingRecoveryandReducingCosts’inI.GouldEllen
andB.O’Flaherty(eds)How to House the HomelessRussellSageFoundation:NewYork;Padgett,D.K.;Heywood,B.F.
andTsemberis,S.J.(2015)Housing First: Ending Homelessness,Transforming Systems and Changing LivesOxford:Oxford
UniversityPress.
14 http://www.york.ac.uk/media/chp/documents/2008/substancemisuse.pdf
15 Source:https://pathwaystohousing.org/housing-first-model
16 Pleace,N.andBretherton,J.(2013)Camden Housing First: A ‘Housing First’ Experiment in LondonYork:UniversityofYork
https://www.york.ac.uk/media/chp/documents/2013/Camden%20Housing%20First%20Final%20Report%20NM2.pdf
17 Culhane,D.P.(2008)TheCostofHomelessness:APerspectivefromtheUnitedStatesEuropean Journal of Homelessness
2.1,97-114-http://housingfirstguide.eu/website/wp-content/uploads/2016/03/The-cost-of-Homelessness-A-
perspective-from-the-United-States.pdf
Pleace,N.;Baptista,I..;Benjaminsen,L.andBusch-Geertsema,V..(2013)TheCostsofHomelessnessinEurope:An
AssessmentoftheCurrentEvidenceBaseBrussels:FEANTSAhttp://housingfirstguide.eu/website/wp-content/
uploads/2016/03/feantsa-studies_03_web-Cost-of-Homelessness.pdf
18 Pleace,N.andBretherton,J.(2013)TheCaseforHousingFirstintheEuropeanUnion:ACriticalEvaluationofConcerns
aboutEffectivenessEuropean Journal of Homelessness,7(2),21-41vidsupra
Chapter1.WhatisHousingFirst?
17
1.3. HousingFirstinEurope European use of Housing First has been encouraged by the North American research results. Initially, the inspirationcame from theoriginal servicedeveloped inNewYork19, then fromotherUSHousingFirst services20.More recently, somevery successful results from theCanadianAtHome/ChezSoiHousingFirstprogramme,arandomisedcontroltrial(RCT)involving2,200homelesspeoplecomparingHousingFirstwith existing homelessness services, havebecome influential in Europeandebates21(seeChapter5).
WithinEurope,theresultsoftheHousing First Europe research project,ledbyVolkerBusch-Geertsema,wereamongthefirsttoconfirmthatHousingFirstcouldbesuccessfulinEuropeancountries22.Alarge-scale randomisedcontrol trialaspartof theFrenchUnChez-Soid’abordHousingFirstprogramme,beingconductedbyDIHAL,will provide systematicdataonHousingFirst effectiveness across fourcities in France, in 201623.A number of observational studies, that look at Housing First but do notcompareitwithotherhomelessnessservices,havealsoreportedverypositiveresultsfromDenmark24,Finland25,theNetherlands26,Portugal27,Spain28andtheUK29.Collectively,thesefindingsshowthat:
₀ InEurope,HousingFirstisgenerallymoreeffectivethanstaircaseservicesinendinghomelessnessamongpeoplewith high support needs, includingpeopleexperiencing long-termor repeatedhomelessness.
₀ Housing First can be more cost-effective than staircase services because it is able to endhomelessnessmoreefficiently.HousingFirstmayalsogeneratecostoffsetsfor(reducethecostlyuseof)otherservices.Forexample,HousingFirstmayreducefrequentuseofemergencymedicalandpsychiatric services,prevent longandunproductive stays inother formsofhomelessnessserviceandlessenratesofcontactwiththecriminaljusticesystem.
₀ HousingFirstaddressestheethicalandhumanitarianconcernsraisedabouttheoperationofsomestaircaseservices30.
19 Padgett,D.K.;Heywood,B.F.andTsemberis,S.J.(2015)Housing First: Ending Homelessness, Transforming Systems and
Changing LivesOxford:OxfordUniversityPress.
20 Pearson,C.L.,Locke,G.,Montgomery,A.E.andBuron,L.(2007)The Applicability of Housing First Models to Homeless
Persons with a Severe Mental IllnessUSDepartmentofHousingandUrbanDevelopment:WashingtonDC.
https://www.huduser.gov/portal/publications/hsgfirst.pdf
21 Goering,P.,Veldhuizen,S.,Watson,A.,Adair,C.,Kopp,B.,Latimer,E.,Nelson,G.,McNaughton.E.,Streiner,D.andAubry,
T.(2014)National At Home/Chez Soi Final ReportCalgary,AB:MentalHealthCommissionofCanada.-http://www.
mentalhealthcommission.ca/English/system/files/private/document/mhcc_at_home_report_national_cross-site_eng_2.
22 Busch-Geertsema,V.(2013)Housing First Europe: Final Report-http://housingfirstguide.eu/website/wp-content/
uploads/2016/03/FinalReportHousingFirstEurope.pdf
23 Tinland,A.,Fortanier,C.,Girard,V.,Laval,C.,Videau,B.,Rhenter,P.,Greacen,T.,Falissard,B.,Apostolidis,T.,Lancon,C.,
Boyer,L.andAuquier,P.(2013)EvaluationoftheHousingFirstprograminpatientswithseverementaldisordersinFrance:
studyprotocolforarandomizedcontrolledtrialTrials,14,p.309
24 Benjaminsen,L.(2013).PolicyReviewUp-date:ResultsfromtheHousingFirst-basedDanishHomelessnessStrategy.
EuropeanJournalofHomelessness,7(2),109-131-http://housingfirstguide.eu/website/?p=4906
25 Pleace,N.,Culhane,D.P.,Granfelt,R.andKnutagård,M.(2015)The Finnish Homelessness Strategy: An International Review
Helsinki:MinistryoftheEnvironment-https://helda.helsinki.fi/handle/10138/153258
26 Wewerinke,D.,AlShamma,S.andWolf,J.(2013)Housing First Europe. Local Evaluation Report Amsterdam
http://housingfirstguide.eu/website/housing-first-europe-local-evaluation-report-amsterdam
27 Ornelas,J.,Martins,P.,Zilhão,M.T.andDuarte,T.(2014)HousingFirst:AnEcologicalApproachtoPromotingCommunity
IntegrationEuropean Journal of Homelessness(8.1),29-56-http://housingfirstguide.eu/website/housing-first-an-
ecological-approach-to-promoting-community-integration/
28 https://www.raisfundacion.org/sites/default/files/rais/noticias/infografia_habitat_DEF_A3.pdf
https://raisfundacion.org/es/informate/noticias_y_eventos/jornada-internacional-h-bitat
https://issuu.com/rais_fundacion/docs/presentaciones_habitathf_web?e=5650917/30872088
29 Bretherton,J.andPleace,N.(2015)HousingFirstinEngland:AnEvaluationofNineServices-
https://www.york.ac.uk/media/chp/documents/2015/Housing%20First%20England%20Report%20February%202015.pdf
30 Sahlin,I.andBusch-Geertsema,V(2005)TheRoleofHostelsandTemporaryAccommodation.Vidsupra
Chapter1.WhatisHousingFirst?
18
In2016,HousingFirstwasbecomingincreasinglyimportantinEurope.Insomecases,HousingFirstwasintegral tocomprehensivehomelessnessstrategies, inothers,experimentswerestillunderway.ThecountrieswhereHousingFirstwasbeingusedinclude:
₀ Austria
₀ Belgium
₀ Denmark
₀ Finland
₀ France
₀ Ireland
₀ Italy
₀ The Netherlands
₀ Norway
₀ Portugal
₀ Spain
₀ Sweden
₀ The United Kingdom
HousingFirsthasbeensuccessfullypiloted in Vienna31.NineHousingFirstprojectswere testedin Belgium in 2015,with 150homelesspeoplewith high support needs receivingHousingFirst.TheprogrammeisbeingevaluatedwithaviewtotestingwhetherHousingFirstcouldbemorewidelyused32(seeAppendix).
Thefirststageofthe DanishHomelessnessStrategyfrom2009-2013wasoneofthefirstlarge-scaleHousingFirstprogrammesinEuropeandhousedmorethan1,000people33.AsummaryoftheDanishprogrammeisincludedintheAppendix.
FinlandhasmadeextensiveuseofHousingFirstwithinitsnationalstrategytoreduceandpreventhomelessness34.Absoluteandrelativereductionsinlong-termhomelessnesshavebeenachievedbyusingamixofHousingFirstservicemodels,includingbothcongregateandscatteredhousingmodels(seeChapter 3 andChapter 4).35An example of a FinnishHousing First service is described in theAppendix. Initialresultsfromthe FrenchUnChezSoid’abordHousingFirstpilotprogrammearepositive36,withtheexistingworktocontinuethrough2017beforeuseofHousingFirstisexpandedfrom2018onwards(seeAppendix).
In Italy in2015,homelessnessserviceprovidersandacademicscooperatedtoformtheHousingFirstItalianNetwork37,aconfederationoforganisationsproviding,orwithaninterestin,HousingFirst.HousingFirstItaliahad51membersin10Italianregions,ofwhich35hadoperationalprojectsin2015.TwoItalianexamplesofHousingFirstservicesaresummarisedintheAppendix.
In201417,HousingFirstserviceswereoperatingacrossthe Netherlands.InAmsterdam,theDiscusHousingFirstprojecthadbeenoperatingsuccessfullysince200638. InPortugal,theCasasPrimeiro39
31 http://www.neunerhaus.at/fileadmin/Bibliothek/Neue_Website/Neunerhaueser/Housing_First/20150925_HousingFirst_
Report_english.pdf
32 http://www.housingfirstbelgium.be
33 Benjaminsen,L.(2013).PolicyReviewUp-date:ResultsfromtheHousingFirst-basedDanishHomelessnessStrategy.
EuropeanJournalofHomelessness,7(2),109-131.Vid supra
34 http://www.housingfirst.fi/
35 Pleace,N.;Culhane,D.P.;Granfelt,R.andKnutagård,M.(2015)The Finnish Homelessness Strategy: An International Review
Helsinki: Ministry of the Environment. - https://helda.helsinki.fi/handle/10138/153258
36 http://hf.aeips.pt/wp-content/uploads/2013/10/Pascale.pdf
37 http://www.housingfirstitalia.org/en/
38 Wewerinke,D.,AlShamma,S.andWolf,J.(2013)Housing First Europe Local Evaluation Report Amsterdam. Vid supra
39 http://www.aeips.pt
Chapter1.WhatisHousingFirst?
19
serviceinLisbonhaspioneeredtheuseofHousingFirst40.AsummaryofCasasPrimeiroispresentedintheAppendix. InSpain,thefirstHousingFirstservice,HÁBITAT,beganoperationsinMay2014,workinginMadrid,BarcelonaandMálaga41.TheHÁBITATprojectwasevaluatedthroughoutandHousingFirsthasnowbecomepartofwiderSpanishhomelessnessstrategy42(seeAppendix).
NorwegianuseofHousingFirsthasexpandedquiterapidlyfrom12HousingFirstserviceswith135serviceusers inDecember2014to16HousingFirstserviceswithatotalof237serviceusers inJuly201543.InNorway,HousingFirstisoneofarangeofservicesusedwithinanintegratedhomelessnessstrategy(seeAppendix).
In Poland, a practitioner conference on Housing First was held inWarsaw in February 201644. PromotionofHousingFirstisbeingpursuedbyanevidence-basedadvocacyproject.
In Sweden, the University of Lund has been actively promoting the idea of Housing Firstwithhomelessnessserviceprovidersandpolicymakers.In2009,theUniversityhostedanationalconferenceonHousingFirst.Twomunicipalities,StockholmandHelsingborg,begantooperateHousingFirstservicessoonafterwards,asadirectresultofthisconference.Sincethattime,another11municipalitieshavestartedupHousingFirstservices.ItseemsthatHousingFirsthasspreadevenmorewidelyinSweden,since94municipalitiesstatethattheyprovideHousingFirstservicestotheircitizens(accordingtooneofthe‘OpenComparisons’conductedbytheNationalBoardofHealthandWelfare).Theseon-goinginitiativeshavebeendevelopedatlocallevelratherthanasaresultofnationalpolicy45(seeAppendix).
Inthe UK,thefirstsuccessfulexperimentwithHousingFirstwasrunbyTurningPointinScotlandin 201046.Anobservationalevaluationconductedoverthecourseof2014-2015alsoshowedthatearlyexperimentswith Housing First in Englandwere also proving successful47, although as in Sweden,developmentwasoftenatlocallevel.InEngland,therewasnotyetanationalHousingFirstpolicyasofearly2016,buttheEnglishfederationofhomelessnessorganisations(HomelessLink)hadlaunchedaHousingFirstEnglandinitiativetopromotetheuseofHousingFirstinthecountry.Additionally,theWelshGovernment recommended the use ofHousing Firstmodels in its guidance for its recentlyrevisedhomelessnesslawsin2015(seeAppendix).
InsomecountriesinCentralandEasternEurope,HousingFirstwasstillintheprocessofbeingdevelopedin2015/16.ExperimentswithHousingFirsthavetakenplaceinthe CzechRepublicand Hungary.
40 Ornelas,J.,Martins,P.,Zilhão,M.T.andDuarte,T.(2014)HousingFirst:AnEcologicalApproachtoPromotingCommunity
IntegrationEuropean Journal of Homelessness(8.1),29-56.-http://housingfirstguide.eu/website/housing-first-an-
ecological-approach-to-promoting-community-integration/
41 https://raisfundacion.org/es/que_hacemos/habitat
42 http://www.msssi.gob.es/ssi/familiasInfancia/inclusionSocial/docs/ENIPSH.pdf
43 Source:NorwegianStateHousingBank.Notethatnotall16HousingFirstserviceswerefullyoperationalinJuly2015,
somewereyettostartsupportinghomelesspeople.
44 http://www.czynajpierwmieszkanie.pl/en/
45 Formoreinformationsee:http://www.soch.lu.se/en/research/research-groups/housing-first
46 http://www.turningpointscotland.com/what-we-do/homelessness/glasgow-housing-first/
47 Bretherton,J.andPleace,N.(2015)Housing First in England: An Evaluation of Nine Services - https://www.york.ac.uk/
media/chp/documents/2015/Housing%20First%20England%20Report%20February%202015.pdf
Chapter1.WhatisHousingFirst?
20
1.4. TheEvidenceforHousingFirst
1.4.1. EndingHomelessnessforPeoplewithHighSupportNeeds
Housing First services arevery successful at ending homelessness for homeless peoplewith highsupportneeds.Inmostcases,EuropeanHousingFirstservicesendhomelessnessforatleasteightoutofeverytenpeople48.
₀ In2013, theHousingFirstEuropeprojectreportedthat 97% ofthehigh-needhomelesspeopleusingtheDiscusHousingFirstserviceinAmsterdamwerestillintheirhousingafter12monthsintheservice.InCopenhagen,theratewas 94% overall,withasimilarlyimpressivelevelreportedbytheTurningPointHousingFirstserviceinGlasgow(92%).TheCasasPrimeiroHousingFirstserviceinLisbonreportedarateof79%49.
₀ TheFrenchUnChez-Soid’abordHousingFirstprogrammereportedinterimresultsinlate2013,showing 80%ofthe172homelesspeopleusingHousingFirstservicesinthefourcitypilotsiteshadretainedtheirhousingfor13months50.
₀ InitialresultsfromtheSpanishHÁBITATHousingFirstprogrammeindicatedextremelyhighlevelsofhousingsustainmentinlate201551.
₀ Finlandhasreportedafallintheabsolutenumbersoflong-termhomelesspeoplefollowingtheadoptionofanationalstrategycentredonusingHousingFirsttoendlong-termhomelessness.In2008,2,931peoplewerelong-termhomelessinthetenbiggestcities.Thisnumberhaddroppedto2,192inlate2013,areductionof25%. Numbersoflong-termhomelesspeoplefellfrom 45% to36%ofthetotalhomelesspopulationduringthesameperiod52.
₀ In2015,anobservationalevaluationofHousingFirstinEnglandreportedthat,acrossfiveHousingFirstservices,74% ofhomelesspeoplehadretainedtheirhousingforatleast12months53.
₀ In2015,theHousingFirstserviceinViennareportedthat,amongalltheserviceusersworkedwithoveratwo-yearperiod, 98% werestillintheirapartments54.
Success rates inEuropeparallelorexceed the results achieved inNorthAmerica.USstudieshavereportedratesofhousingsustainmentbetween80%and88%55.TherecentevaluationoftheCanadianAtHome/ChezSoiprogrammereportedthatHousingFirstserviceusersspent73%oftheirtimestablyhousedovertwoyears,comparedto32%ofthosereceivingotherhomelessnessservices56.
48 Pleace,N.andBretherton,J.(2013)TheCaseforHousingFirstintheEuropeanUnion:ACriticalEvaluationofConcerns
aboutEffectivenessEuropean Journal of Homelessness,7(2),21-41
http://housingfirstguide.eu/website/the-case-for-housing-first-in-the-european-union-a-critical-evaluation-of-
concerns-about-effectiveness/
49 Busch-Geertsema,V.(2013)Housing First Europe: Final Report-http://housingfirstguide.eu/website/wp-content/
uploads/2016/03/FinalReportHousingFirstEurope.pdf
50 http://hf.aeips.pt/wp-content/uploads/2013/10/Pascale.pdf
51 https://www.raisfundacion.org/sites/default/files/rais/noticias/infografia_habitat_DEF_A3.pdf
52 Pleace,N.,Culhane,D.P.,Granfelt,R.andKnutagård,M.(2015)The Finnish Homelessness Strategy: An International Review
Helsinki:MinistryoftheEnvironment.-https://helda.helsinki.fi/handle/10138/153258
53 Bretherton,J.andPleace,N;(2015)Housing First in England: An Evaluation of Nine Services-https://www.york.ac.uk/
media/chp/documents/2015/Housing%20First%20England%20Report%20February%202015.pdf
54 Neunerhaus(2015)Housing First Pilot Project Report-http://www.neunerhaus.at/fileadmin/Bibliothek/Neue_Website/
Neunerhaueser/Housing_First/20150925_HousingFirst_Report_english.pdf
55 Tsemberis,S.(2010)‘HousingFirst:EndingHomelessness,PromotingRecoveryandReducingCosts’inI.GouldEllenand
B.O’Flaherty(eds)How to House the HomelessRussellSageFoundation:NewYork.
56 Goering,P.,Veldhuizen,S.,Watson,A.,Adair,C.,Kopp,B.,Latimer,E.,Nelson,G.,MacNaughton,E.,Streiner,D.andAubry,
T.(2014)National At Home/Chez Soi Final ReportCalgary,AB:MentalHealthCommissionofCanada.-http://www.
mentalhealthcommission.ca/English/system/files/private/document/mhcc_at_home_report_national_cross-site_eng_2.
Chapter1.WhatisHousingFirst?
21
Aninternationalevidencereviewconductedin2008reportedthatbetween40%and60%ofhomelesspeoplewithhighsupportneedswereleavingorbeingejectedfromstaircaseservicesbeforetheywererehoused.ThiswasinsharpcontrasttoHousingFirstservicesthatweretypicallykeeping80%ormoreoftheirserviceusershousedforatleastoneyear57.
Aspreviouslystated,HousingFirstisverysuccessfulatendinghomelessnessamonghomelesspeoplewithhighsupportneeds.However,therearesomepeople,typicallybetween5-20%ofserviceusers,forwhomHousingFirstisnotabletoprovideasustainedexitfromhomelessness.
1.4.2. HealthandWell-BeingHousingFirstcanmakeapositivedifferencetothehealthandwell-beingofhomelesspeoplewithhighsupportneeds:
₀ In2013,theHousingFirstEuroperesearchprojectreportedthat70%ofHousingFirstserviceusersinAmsterdamhadreducedtheirdruguse,with89%reportingimprovementsintheirqualityoflifeand70%reporting improvements intheirmentalhealth.PositiveresultswerealsoproducedbytheTurningPointserviceinGlasgow,wheredrug/alcoholusewasreportedtohavestabilisedorreducedinmostcases.IntheCasasPrimeiroserviceinLisbon,80%reportedalowerlevelofstress.DanishHousingFirstservicesreportedamoremixedpicture,but32%reportedimprovementsinalcoholuse,25%animprovementinmentalhealthand28%inphysicalhealth58.
₀ In2015,interimresultsreportedfromtheFrenchUnChez-Soid’abordHousingFirstprogramme59 showedthat,inthesixmonthspriortoinclusioninHousingFirst,homelesspeoplehadspentanaverageof18.3nightsinhospital.WhentheyhadbeenusingHousingFirstfor12months,thetimespentinhospitalinthelastsixmonthshadfallento8.8nightsonaverage.Contactswithhospitalsandthefrequencyofstaysinhospitalhadfallensignificantly.
₀ The2015evaluationofHousingFirst inEngland found that63%of serviceusers self-reportedimprovementsinphysicalhealthand66%self-reportedgainsinmentalhealth,withsomesmallerimprovementsarounddrugandalcoholuse60.
HousingFirst,bothinEuropeandNorthAmerica,hasbeenshowntodeliverimprovementsinhealthandwell-being.Resultscanbevariable-notallHousingFirstserviceusersbenefitfrombetterhealthandwell-being-butHousingFirstisabletodeliverpositivechangesformanyofthepeopleusingit61.
57 Pleace,N.(2008)Effective Services for Substance Misuse and Homelessness in Scotland: Evidence from an International
ReviewEdinburgh:ScottishGovernment-http://www.gov.scot/Resource/Doc/233172/0063910.pdf
58 Busch-Geertsema,V.(2013)Housing First Europe: Final Report-http://housingfirstguide.eu/website/wp-content/
uploads/2016/03/FinalReportHousingFirstEurope.pdf
Somedeteriorationinhealthandwell-beingwerealsoreported.
EstecahandyP.A“HousingFirst”TrialinFrance-http://hf.aeips.pt/wp-content/uploads/2013/10/Pascale.pdf
59 Tinland,A.andPsarra,C.(2015)HousingFirst:LessonsfromFrancepresentationattheIGHHomelessness in a Global
Landscapeconference,Chicago,June2015
60 Bretherton,J.andPleace,N.(2015)Housing First in England: An Evaluation of Nine Services - https://www.york.ac.uk/
media/chp/documents/2015/Housing%20First%20England%20Report%20February%202015.pdf
61 Pleace,N.andQuilgars,D.(2013)Improving Health and Social Integration through Housing First: A Review.Brussels:DIHAL/
FEANTSAhttp://www.housingfirstguide.eu/website/wp-content/uploads/2016/03/improving_health_and_social_
integration_through_housing_first_a_review.pdf
Johnson,G.,Parkinson,S.andParsell,C.(2012)Policy shift or program drift? Implementing Housing First in AustraliaAHURI
FinalReportNo.184-
http://www.ahuri.edu.au/__data/assets/pdf_file/0012/2064/AHURI_Final_Report_No184_Policy_shift_or_program_drift_
Implementing_Housing_First_in_Australia.pdf
Chapter1.WhatisHousingFirst?
22
1.4.3. SocialIntegrationSocialintegrationhasthreemainelements:
₀ Social support, which centres on someone feeling that they are valued by others, calledesteem support; help in understanding and copingwith life, called informational support; social companionship(spendingtimewithothers)andpracticalorinstrumental support62.
₀ Community integration,whichcanbetrickytodefineprecisely,butwhichgenerallyreferstopositive,mutuallybeneficialrelationshipsbetweenHousingFirstserviceusersandtheirneighbours. Inabroadersense,communityintegrationalsoreferstoahomelesspersonnotbeingstigmatisedbythecommunity63.HousingFirstcanhelpsomeonetoadjusttonewcommunityroles,i.e.beingagoodneighbour.
₀ Economic integration,whichcanmeanpaidwork,butalsosociallyproductiveorrewardingactivities,rangingfromparticipatinginarts-basedactivitiesthroughtoinformalandformaleducation,trainingandjob-seeking.
A key goal of Housing First (see Chapter 3 and Chapter 4) is to promote social integration in thecommunity.Housingfunctionsas thebasis,or foundation, fromwhichHousingFirstseeks tohelpaserviceuserdevelop the social supports, community integrationandeconomic integration that canimprovetheirqualityoflife.Goodqualitysocialsupports,livingalifethatinvolvespositiveengagementwiththesurroundingcommunityandhavingastructured,purposefulexistence,canalldemonstrablyenhancehealthandwell-being64.
₀ TheCasasPrimeiroHousingFirst service inLisbon reported thatalmosthalf theHousingFirstserviceusershadstartedtomeetpeopleincaféstosocialise,with71%reportingtheyfelt‘athome’intheirneighbourhoodand56%reportingfeelingpartofacommunity65.
₀ ArecentevaluationofHousingFirstinEnglandfoundthatof60usersofHousingFirstservices,25%hadreportedregularcontactwiththeirfamilypriortoworkingwithHousingFirst,risingto50%oncetheywerereceivingHousingFirstsupport.PriortoworkingwithHousingFirst,78%ofpeoplewereinvolvedinnuisancebehaviour,suchasdrinkingalcoholonthestreet.Thisfellto53%aftertheybeganworkingwithHousingFirst66.
₀ ThereisqualitativeresearchfrombothEuropeandNorthAmericathatshowsthatpeopleusingHousingFirstcanhaveagreatersenseofsecurityandbelongingintheirlivesthanwasthecasebeforehomelessness.ThishasbeendescribedasHousingFirstenhancingsomeone’ssenseofsecurityintheirday-to-daylife,orontological security67.
EvidencethatHousingFirsthasthecapacitytohelphomelesspeoplewithhighsupportneedsintopaidworkisnotextensiveinEuropeorNorthAmerica,butitmustbenotedthatthepeopleusingHousingFirstoftenfacemultiplebarrierstoemployment.HousingFirstisdesignedtodeliverimprovementsinhealth,well-beingandsocialintegration.HousingFirstisnotpresented,norexpectedtobeseen,asa‘miraclecure’orpanaceathatwillrapidlyendallthenegativeconsequencesofhomelessness.HousingFirstsuccessfullyendshomelessnessandthat, in itself,createsasituationinmarkedcontrasttothemultipleriskstohealth,well-beingandsocialintegrationthatareassociatedwithhomelessness.
62 Cohen,S.andWills,T.(1985)Stress,SocialSupportandtheBufferingHypothesisPsychologicalBulletin,98,310-357.
63 Pleace,N.andQuilgars,D.(2013)Improving Health and Social Integration through Housing First: A Review
64 Ibid.
65 Ornelas,J.,Martins,P.,Zilhão,M.T.andDuarte,T.(2014)HousingFirst:AnEcologicalApproachtoPromotingCommunity
IntegrationEuropean Journal of Homelessness(8.1),29-56-http://housingfirstguide.eu/website/wp-content/
uploads/2016/03/Housing-First-An-Ecological-Approach.pdf
66 Bretherton,J.andPleace,N.(2015)Housing First in England: An Evaluation of Nine Services https://www.york.ac.uk/media/
chp/documents/2015/Housing%20First%20England%20Report%20February%202015.pdf
67 Padgett,D.K.(2007).There’snoplacelike(a)home:Ontologicalsecurityamongpersonswithseriousmentalillnessinthe
UnitedStates.Social science & medicine,64(9),1925-1936,p.1934.
CHAPTER 2.
2.Core principles of Housing First
Chapter2.CoreprinciplesofHousingFirst
28
TheCorePrinciplesofHousingFirstAllHousingFirstservicesarebasedonthePathwaysmodel,developedbyDr.SamTsemberis,inNewYorkintheearly1990s68. The core principles of Housing First in Europe are drawn directly from the Pathways model.However,therearesignificantdifferencesbetweensomeEuropeancountriesandNorthAmericaandbetweenEuropeancountriesthemselves..ThismeansthatthecoreprinciplesforHousingFirst inEuropedonotexactlymirror thoseof theoriginalPathwaysmodel.The eight core principles of Housing First in Europe, developed in consultation with the advisory board for this Guide,ofwhichDr.Tsemberiswasamember,are:
Housing is
a human right
Harm reduction
Choice and control for service users
Active engagement without coercion
Separation of housing and treatment
Person-centred planning
Recovery orientation
Flexible Support for as Long as is Required
Eight core principles:
ThischapteroftheGuidepresentsadetaileddiscussionoftheeightcoreprinciplesofHousingFirstservicesinEurope.
68 Tsemberis,S.(2010)HousingFirst:ThePathwaysModeltoEndHomelessnessforPeoplewithMentalIllnessand
AddictionMinnesota:Hazelden.
Chapter2.CoreprinciplesofHousingFirst
29
2.1. HousingisaHumanRightTheUNCommitteeonEconomic,SocialandCulturalRightsestablishedarighttohousingthatsaysthatapersonshouldbeabletoliveinsecurity,peaceanddignity69.
This includes:
₀ Legal security of tenure, centred on legal protection from forced eviction, harassment by landlords and other threats to having a settled home.
₀ Affordability, in the sense that housing costs should not be so high as to mean that food, education and access to healthcare are unaffordable.
₀ Habitability, which effectively means that housing is in a reasonable state of repair and provides adequate shelter and living space.
₀ Availability of services, which centres on the infrastructure needed to make housing habitable, i.e. sanitation, capacity to prepare and cook meals, washing facilities, storage, heating and lighting and waste disposal facilities.
₀ Accessibility, which means that housing should be available to those who require it. Where appropriate, housing should maximise the capacity for someone with a physical disability or limiting illness to live independently.
₀ Location, i.e. housing must allow access to necessary services. This includes education, health, shops and other services. Housing should also be within access of opportunities for paid work and civic participation. Housing should not be in an environment that is hazardous to health.
₀ Cultural adequacy, i.e. housing should allow people to live in ways that do not disrupt their culture. This means housing should allow for the expression of cultural identity.
TheEuropeanTypology ofHomelessness (ETHOS) defineswhat ismeant by a home in a differentway,usingtheideaofphysical,socialandlegaldomains.Thephysicaldomaincentresonhavingone’sownlivingspace,inotherwords,yourownfrontdoortoyourownhome,whichisunderyourexclusivecontrol.Thesocialdomaincoversthespaceandprivacyneededtoliveanormallifeasanindividual,acoupleorafamily.Thelegaldomainechoestheinternationaldefinitionofarighttohousing,i.e.securityofresidencethatislegallyprotected70.
Housing First emphasizes the right that homeless people have to housing.Housingisprovidedfirst,ratherthanlast,withoutanyexpectationthatahomelesspersonhastobehaveincertainways,complywithtreatment,orbeabstinentfromdrugsoralcohol,beforetheyaregivenahome.Housing First does not expect homeless people to earn their right to housing, or earn a right to remain in housing.
PeopleusingHousingFirstareexpectedtofollowtheconditionsoftheirlease,ortenancy,inthesamewayasanyotherperson rentingahomewouldbe,with supportbeingprovided toenable them todothis.HousingFirstservicesalsoexpecttheretoberegularcontactbetweensomeoneusingtheirserviceandasupportworker,forexampleataweeklymeeting,whichincludescheckingwhetherthereareanyproblemswiththeirhome(seeChapter3).
ThehousingofferedbyHousingFirstisnottemporaryaccommodation.HousingFirstoffersarealhomewithinthetermsofboththeUNandETHOSdefinitions.
69 http://www.ohchr.org/EN/Issues/Housing/toolkit/Pages/RighttoAdequateHousingToolkit.aspx
70 EuropeanTypologyofHomelessness-English:http://housingfirstguide.eu/website/wp-content/
uploads/2016/03/ETHOS-EN.pdf
Chapter2.CoreprinciplesofHousingFirst
30
2.2. ChoiceandControlfor ServiceUsers
A key principle of Housing First is that people using the service should be listened to and their opinions should be respected.SomeoneusingHousingFirst isabletoexerciserealchoicesabouthowtheylivetheirlivesandthekindsofsupportthattheyreceive.
ThiscoreprincipleofHousingFirstcentresonenablinghomelesspeopletodecidewhattheirneedsareandhowthoseneedscanbemet.Inpracticethismeans:
₀ Itshouldnotbeassumedthatallhomelesspeoplewithhighsupportneedswillsharebehavioursandothercharacteristics.Theirneedscannotbeeffectivelymetwithastandardisedpackageofserviceswhichmakesnoallowanceforindividualneeds,characteristics,behaviourorexperiences.
₀ Thebestwaytounderstandahomelessperson’sneedsistolistentothepersonandtheirviewsonthekindsofhelptheyneed.
₀ Tolistenandrespondtosomeone’sneedsandopinionseffectively,HousingFirstmustrespectthatindividualandtheirstrengths,ratherthanfocusingnegativelyontheirlimitations.AHousingFirstservicecannotbepatronising.HousingFirstcannotfunctionontheassumptionthatHousingFirststaffunderstandsomeone’sneedsbetterthantheydothemselves.
₀ Compassion,warmthandunderstandingfromHousingFirststaffareasimportantasrespect,whenenablinghomelesspeopletochoosetherightcombinationofsupportforthemselves.
₀ Housing First actively encourages engagement with the treatment someone needs, includingreducingtheharmfromdrugsandalcoholandencouragingsomeonetoseekhelpwithmentalorphysicalhealthproblems.Helpwithcommunityengagementandestablishingandre-establishingsocialsupportsarealsoonoffer.Whilecontrolrestswiththeserviceuser,HousingFirstworkersactivelywork to informsomeoneusingHousingFirstof thepossibilitiesopento themtomakepositivechangesintheirlives(see2.6).
₀ Supportmust be flexible, imaginative and able to adapt to the specifics ofwhat an individualpersonusingHousingFirst requires. It ispossible tomaintainasetofclearlydefined functionsforsupportinHousingFirst(seeChapter3)butHousingFirstmustalsobeabletorespondtothespecificneedsofeachserviceuser.
₀ HousingFirstistailoredtoindividualneeds,recognisingindividualstrengths,anddoesnotuseastandardisedorlimitedsetofresponses.HousingFirstserviceusersarenotofferedhelpthattheydonotactuallyneed.Thisrequiresrecognisingthestrengthsthateachserviceuseralreadyhas,ordevelopsovertime.
InHousingFirst,self-determinationisseenasthestartingpointofrecovery.Shareddecision-making,betweenserviceusersandserviceproviders,isanessentialpartofrecoveryintheHousingFirstmodel71. Thisissometimesdescribedas‘consumerchoice’inNorthAmericanHousingFirstservices.
InEurope,therehasbeenagrowingemphasisonserviceuserself-determinationinsocialworkandhealthservicesoverthelast25years.Self-determinationisalsousedbysomehomelessnessservices.Europeanpractice, suchas the ‘personalisationagenda’, canclosely resembleself-determination inHousingFirst.Sitradefinespersonalisationinthefollowingway72:
Personalisation means individuals having maximum choice and control over the public services they require - moving from the culture of ‘one size fits all’ to tailoring support to meet individuals’ aspirations and build on their strengths.
71 Greenwood,R.M.,Schaefer-McDaniel,N.J.,Winkel,G.andTsemberis,S.J.(2005).Decreasingpsychiatricsymptomsby
increasingchoiceinservicesforadultswithhistoriesofhomelessness.American Journal of Community Psychology,36(3-
4),223-238.
72 http://www.sitra.org/policy-good-practice/personalisation/
Chapter2.CoreprinciplesofHousingFirst
31
HousingFirstmustbalancetheneedforchoiceandcontrolwhileworkingwitheachpersontoencourageandsupportengagementwithtreatment.Ultimately,HousingFirstaimstoenhancethehealth,well-beingandlifechancesofeveryindividualwhoissupported,increasingtheirchancesofalastingexitfromhomelessness.
All Housing First serviceswork by balancing priorities. Finding a balance centres on ensuring thatserviceuserchoiceandcontrol is inplace,whileat thesame timeworkingactively topromote thewell-beingofeachserviceuser.HousingFirstensureschoice,respectsopinions,supports individualstrengthsandisintendedtobebothunderstandingandcompassionate,butitalsoactivelyencouragesserviceuserstowardsrecovery73.
2.3. SeparationofHousingand Treatment
Housing First ensures the human right to housing is not compromised by requiring service users to engage with treatment either to access housing, or to remain in housing.Housing isthereforeseparate fromtreatment.
In practice this means:
₀ Access to housing, being offered a home by a Housing First service, is not conditional on behavioural change or accepting treatment. In practice, this means housing is still offered if someone does not stop drinking, will not accept treatment for mental health problems or turns down other offers of support.
₀ Remaining in housing provided via Housing First does not require someone to change their behaviour or accept treatment. Housing First does support someone to follow the terms of a lease or tenancy in the same way as anyone else renting a home would. Housing First also requires regular meetings with Housing First staff, which includes monitoring housing sustainment. However, Housing First does not remove people from housing for not changing their behaviour, or not using treatment.
₀ If someone is evicted, it should usually only be by a landlord because of lease or tenancy violations. Housing First is designed to re-house a service user who is evicted and to offer them support during the re-housing process. The support services offered by Housing First are continuous and not connected to the housing. This allows a Housing First service to continue to provide continuity in support through residential changes or a clinical crisis (a critical turning point in a person’s physical or mental health).
Housingisseparatedfromtreatmentinanotherpositivesense.WhileHousingFirstofferssupportfor as long as may be required(see2.8),whenandifsomeone’suseofHousingFirstsupportservicesstops,theykeeptheirexistinghome.IfsomeonenolongerneedsHousingFirst,theydo notneedtomovesomewhereelse.
Unlikesomeotherhomelessnessservices,HousingFirst iscommittedtothepersonandnottotheirhousing.HousingFirstisperson-based,notplace-based.
73 Löfstrand,C.andJuhila,K.(2012)TheDiscourseofConsumerChoiceinthePathwaysHousingFirstModelEuropean
Journal of Homelessness6(2),47-68
Chapter2.CoreprinciplesofHousingFirst
32
This means that:
₀ When someone decides to move home, Housing First support and treatment services remain in contact with them and continue to support them in their new home.
₀ When someone loses a home that Housing First helped them access, either through eviction or because they abandon their home, Housing First support and treatment services remain in contact with them. If a Housing First service user has lost their home, the Housing First service seeks to find them another home as soon as possible.
₀ If someone goes into an institutional setting, Housing First support and treatment services remain in touch. For example, if someone has to go into a psychiatric hospital, Housing First will remain in contact with them and either seek to retain their existing housing or arrange new housing in time for when they leave hospital. Housing First will also remain engaged on the same basis if someone is given a short prison sentence.
One challenge for Housing First services can be when apartments are provided in a dedicatedcongregateorcommunalsetting.ThismeansthathousingisprovidedinanapartmentblockorblockofflatsthatisonlyforpeopleusingHousingFirst.Here,itisimportanttoensurethattherightssomeonehastotheirhousingarethesameasanyonerentingordinaryaccommodation.Thiscanmean,intheory,that someonecan live inanapartmentblock forHousingFirst serviceusersafter their supporthasendedbymutualconsentwiththeHousingFirstteam,oriftheyhavedecidedtostopusingHousingFirst supportand treatment.Theirhousingand theirhousing rightsareseparate from the treatmentandsupporttheycanreceive.Thismayseemanextremeexample,butthecoreprincipleofseparationofhousingandtreatmentcannotbecompromisedifaserviceisfollowingaHousingFirstmodel.ThisapproachhasbeenadoptedinsomeFinnishHousingFirstservices74(seeChapter4).
SomeHousingFirstservicessub-letorsub-leasehousingunitstoserviceusers.Thiscanbefortworeasons.First,itcanprovidereassurancewhenworkingwithlandlordsintheprivateandsocialrentedsectorsthatlegalresponsibilityfortheirhousingiswiththeHousingFirstservice,notwithanindividualusing that service. Second, if there is a problemwith someone’s housing,HousingFirst can rapidlymovesomeoneawayand,equallyrapidly,placetheminalternativehousing,becausetheyarenotthetenantorleaseholder.
Sucharrangements involvestrikingabalancebetweenensuringsomeone’shumanright tohousingwhilesimultaneouslyplacinglimitationsontheirlegalrighttothathousing.EthicalbehaviourbyHousingFirstservicesusingthesearrangementsisofverygreatimportance,ifthecoreprincipleofseparationbetween housing and treatment is to be properly maintained. Some British Housing First servicesimmediatelygiveallHousingFirstserviceusersafulltenancy,givingthemthesamehousingrightsasanyoneelserentingsocialorprivaterentedhousingwouldhave75(seeChapter4).
2.4. RecoveryOrientationA service with a recovery orientation focuses on the overall well-being of an individual. This includes their physical and mental health, their level of social support (from a partner, family or friends) and their level of social integration, i.e. being part of a community and taking an active part in society.Promotingrecoverycanincludeenablingaccesstoeducationorhelpingsomeonefindarewardingleisureactivity.Followingarecoveryorientationissomethingfarwiderandmoreambitiousthanjustregulatingdrugoralcoholuse,orsupportingengagementwithtreatment.Itisaboutdeliveringasecureandrewarding life forsomeone,creatinga life that integrates them intoacommunity, intohousingandintowidersocialandeconomiclifeinapositiveway.
74 PleaceN.,CulhaneD.,GranfeltR.,KnutagardM.TheFinnishHomelessnessStrategy:AnInternationalReview(2015)
http://works.bepress.com/dennis_culhane/145/
75 https://www.york.ac.uk/media/chp/documents/2015/Housing%20First%20England%20Report%20February%202015.pdf
Chapter2.CoreprinciplesofHousingFirst
33
The concept of recovery can be approached from different angles76 but centres on an individual gaining a sense of purpose, with the prospect of a better and more secure life. There is an emphasis on the person “recovering themselves”, choosing the direction for their future life.
IntheHousingFirstmodel,homelesspeopleareabletorecover:meaningtheyareabletoregainamoremeaningfulandhopefullife.Recoverydoesnotmeanthatserviceuserswillnolongerexperienceproblems,symptomsorstruggles.Nordoes recoverymean that theywillno longerusespecializedservices,medicationornecessarilybeabletolivecompletelyindependently.Theprocessofrecoveryisuniqueandpersonal. It isaprocessoftrialanderror, involvingsmallstepsforwardandbackward.It is a process of celebrating successful experiences, but alsoof experiencing feelingsof pain andfrustration.WithinHousingFirst,therecoveryprocessisindividualandthesupportisdesignedtoworkflexiblytoenablesomeonetochoosetheirownpathtoabetterlife77.
Serviceswitha recoveryorientationareaware that a serviceusermayhaveexperienced traumaticevents.Theyarebuiltonunderstandingsomeoneusingaservice,intermsoftheircurrentsupportneeds,but also in termsof their other characteristics and their experiences.A recovery-orientated service,like Housing First, seeks tomaximise the strengths and potential of the people receiving support,encouraging the idea thatpositivechange ispossible.Over time, theapproachmay involveserviceusersbeinggivenresponsibilities,suchaspeermentoring,actingasarepresentativeofotherHousingFirstserviceusersordevelopingtheirownsupportplans.Therewillalsobeanemphasisondevelopingpersonal relationships, helpingwherenecessarywithemotional literacy (thecapacity tounderstandandcorrectlyprocessemotion)andwithenablingserviceuserstobuildtrustingrelationships.Servicesthatadoptarecoveryorientationoftenusemotivationalinterviewingtechniques.
HousingFirstactively encouragesthefollowing:
₀ Useoftreatmentformentalhealthproblemsandotherhealthproblems
₀ Harmreductioninrelationtodrugsandalcohol
₀ Changestobehaviourinordertoreduceriskstohealthandwell-being
₀ An awareness that positive change is possible and theopportunity to have abetter life in thefutureisarealisticoptionforpeopleusingHousingFirst.
The recovery orientation in Housing First is a philosophy thatmeans that the support provided byHousing First always emphasises the fact that a service user can choose a better future as a realpossibility thatcanbeachieved.Supportand treatment is inplaceandavailable toenable this,butthisisjustoneaspectoftherecoveryorientation,whichalsoseekstoplacetheideaofrecoveryasarealisticprospectinthemindofeveryoneusingHousingFirst.
Therecoveryorientationhastobecarefullymanagedinthecontextofmaintainingaclearandequalemphasisonchoiceandcontrolandperson-centredplanningwithinHousingFirst.Itisimportantthatthepositivemessagesofarecoveryorientationarecarefullyputinplace.Inparticular:
₀ Promotingrecoverymustalwaysreflectwhatsomeonewantsforthemselves,notanyoneelse’sideasaboutwhichdirectiontheirlifeshouldtake.PeopleusingHousingFirstmustbelistenedtoandtheirchoicesrespected.TherecoveryorientationisoneaspectofHousingFirst.
₀ Followingarecoveryorientationmustberealisticandgrounded,butnopresumptionsshouldbemadeaboutwhatsortoflifeaHousingFirstserviceusercaneventuallyachieveforthemselves.
76 Wolf,J.(2016).Krachtwerk. Methodisch werken aan participatie en zelfregie.(StrengthsWork,aSystematicMethodfor
ParticipationandSelf-Direction).Bussum:Coutinho.
77 Rapp,C.andGoscha,R.(2006).Thestrengthsmodel,casemanagementwithpeoplewithpsychiatricdisabilities.Oxford
UniversityPress;Saleebey,D.(2006).The strengths perspective in social work practice, vol. 4.Boston:PearsonEducation,
Inc.
Chapter2.CoreprinciplesofHousingFirst
34
2.5. HarmReductionHarm reduction is based on the idea that ending problematic drug and alcohol use can be a complex process and that services requiring abstinence, or detoxification, do not work well for many homeless people.HarmreductionismainstreampracticeinsomeNorthernEuropeancountries,suchasFinlandortheUKandislongstandingpracticeinFrance78,butitisnotuniversallyemployedthroughoutEurope.There is extensive evidence that harm reduction is more effective with homeless people with high and complex needs than abstinence-based or detoxification services79.
Harmreductionviewsproblemdrugoralcoholuseasresultingfromothersupportneedsandalsoashavingthepotentialtocomplicateandincreaseothersupportneeds.Forexample,drugusecannotbetreatedordealtwithinisolation;ithastobeunderstoodinrelationtoaperson’sothersupportneeds,characteristicsandbehaviour.
A holistic (whole person) approach that seeks to address all the causes and consequences of drug and alcohol use is central to the harm reduction philosophy. Equally, harm reduction seeks to persuade and support people to modify drug and alcohol use that causes them harm. Harm reduction offers support, help and treatment, but does not require abstinence from drugs and alcohol.
Harmreduction ispersuasive inapproach80.Thegoal isnotnecessarily tostopalldrugandalcoholuse,buttoreducetheharmthatsomeoneexperiences,helpingthemtoreduceandmanagetheiruse.Ifsomeonewantstobeabstinent,aharmreductionapproachcanenablethistohappen,butaharmreductionapproachwillalsoengagewithanactiveuser,workingwiththemtoencouragereductionsintheirdrugandalcoholuse.
HarmreductionplaysanintegralroleinHousingFirst.HousingFirstcouldnotemphasisehousingasahumanright,promoteserviceuserchoiceoroffertheseparationofhousingandtreatment, if itdidnotuseharmreduction.Ifabstinencewererequired,housingcouldnotbeofferedto,orretainedby,anyonewhorefusedtostopdrinkingortakingdrugs.
2.6. ActiveEngagementwithout Coercion
Active engagement without coercion, which is American terminology, can be described as an assertive, though very importantly not aggressive, way of working with Housing First service users. The emphasis is on engaging with Housing First service users in a positive way that makes them believe that recovery is possible. This is the technique by which Housing First pursues a recovery orientation (see 2.4).
Within the harm reduction and recovery orientation of Housing First, the emphasis is always on positively trying to get people using Housing First to engage with the help they need.HousingFirstserviceusersarealsoaskedtolookconstructivelyatanyaspectsoftheirbehaviourthatmightthreatentheirexitfromhomelessnessortheirhealth,well-beingandqualityoflife.
78 Dr.ClaudeOlivensteinwasinfluentialinintroducingtheconceptofharmreductioninFranceinthe1970s.
79 Pleace,N.(2008)EffectiveServicesforSubstanceMisuseandHomelessnessinScotland:EvidencefromanInternational
ReviewEdinburgh:ScottishGovernmenthttp://www.gov.scot/Resource/Doc/233172/0063910.pdf
80 Pleace,N.(2008)Effective Services for Substance Misuse and Homelessness in Scotland: Evidence from an International
ReviewEdinburgh:ScottishGovernmenthttp://www.gov.scot/Resource/Doc/233172/0063910.pdf
Chapter2.CoreprinciplesofHousingFirst
35
₀ PeopleusingHousingFirstmustneverbethreatenedwithsanctionsforbehavingornotbehavingincertainways.Thereshouldbenodenialofaccesstohousing,orthreatstoexistinghousing,orremovalofsupportortreatment,ifsomeonedoesnotmodifytheirbehaviourinwaysthatHousingFirststaffmaythinkwouldbebeneficialtotheirwell-being81.
₀ Equally, Housing First, using a recovery orientation and harm reduction, works actively andcontinuallytoemphasisethatsupport,treatmentandadvicearealwaysavailableandthatpositivechangestohealth,well-being,socialintegrationandoverallqualityoflifearepossible.Discussion,advice,information,supportandpersuasionareallmechanismstoachievethis.
2.7. Person-CentredPlanning
Housing First services use person-centred planning, which essentially involves organising support and treatment around an individual and their needs82. This focus reflects the emphasis on choice and control for service users. It can be summarised as Housing First adapting to and organising itself to service users, rather than expecting someone to adjust and adapt themselves to the Housing First service.
Somehomelessnessservicesexpect someone to followasetpath,usingafixed rangeof serviceswhich alwayswork in the samewaywith everyone. Housing First encourages individuals towardsrecovery,butisdesignedtoenablethemtobuildtheirownpath,usingtheparticularmixofservicesthatsuitsthem.
EveryoneusingaHousingFirstservice isencouragedandsupportedtochoosethekindof lifetheywanttolive.Choiceandcontrolplayanimportantpartinthis,withHousingFirstserviceusersmakingrealdecisionsaboutthekindsofsupportandtreatmenttheywishtoreceive.Person-centredplanningwithinHousingFirstcentresonunderstanding:
₀ Allaspectsofthelifethatsomeonewishestolive,i.e.thingsthatareworthwhile,rewardingandwhichenhancetheirwell-beingandtheirchancesforhappiness.Thisextendsbeyondensuringthathousingissuitableandthecorrectrangeoftreatmentandsupportisinplace.
₀ TheneedssomeoneusingHousingFirstmayhavearoundsocial integration.Social integrationincludesthingssuchasgoodsocialsupports(friendsand/orfamilyand/orapartner),participationinciviclife(beingpartoftheirneighbourhoodandsociety,notisolatedfromit)andcontributingtosociety,e.g.throughvolunteering,paidwork,orotherproductiveactivity.Goodsocialintegrationcanenhancehealthandwell-beingbypositivelyenhancingself-esteem83.
₀ Therangeofsupportofferedbyperson-centredplanningmight include:helpwithrunningandmaintainingahome;practicalskillslikecookery,budgeting,shoppingandmanagingbills;debtandmoneyadviceandsupportwithdecorationandfurnishing.Intheareaofsocialsupport,aperson-centredplanmightconcernitselfwithestablishingorre-establishingfriendshipsandpositivefamilyrelationships.HousingFirstmightalso,asregardssocialintegration,encourageandsupportentryintoeducation,training,arts-basedactivities,volunteering,paidworkandcommunityparticipation.Finally,withregardtohealthandwell-being,aperson-centredplanwouldencourageandsupportHousingFirstserviceuserstoengagewithtreatment.
HousingFirst isconcernedwith thehumanrightsandhumanneedsofhomelesspeople, their righttohousingandtheirrighttoareasonablequalityof life.HousingFirst isnotdeliveringarealanswertohomelessness if itmerely ‘warehouses’homelesspeoplewithhighsupportneeds inhousingandmaintains them with support services. Flexible, personalised support is essential. Person-centredplanningshouldhaveseveralfeatures:
81 Oneexceptionisifanindividualthreatensstaffsafety,inwhichcaseengagementmayneedtocease,eithertemporarily
orpermanently.
82 InEurope,theterm‘person-centredplanning’canbeusedtorefertoasystemforhelpingsomeonemanageallaspects
oftheirlife.Thisissimilarto,butnotidenticaltowhatismeantbyperson-centredplanninginaHousingFirstservice.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/250877/5086.pdf
83 Cohen,S.andWills,T.(1985)Stress,SocialSupportandtheBufferingHypothesisPsychologicalBulletin,98,pp.310-357.
Chapter2.CoreprinciplesofHousingFirst
36
₀ EnsuringaHousingFirstserviceuserisatthecentreofanydecisionsthatmaychangetheirlife.
₀ UnderstandingwhateachpersonusingHousingFirstwantsfromlife,howtheywishtoliveandwhattheywishtodo.Thiswillinvolvewhattheywantintermsofrelationships,theirplaceinsocietyandhowtheywishtospendtheirtime.
₀ Housing First staffworkingwith people using Housing First services to ensure thatwhat theywantfromlife,theirquality of life,managingriskstotheirhealth,protectingtheirwell-beingandsustainingtheirexitfromhomelessness,isatthecentreofwhatHousingFirstdoes.
₀ Person-centred planning can mean that someone using Housing First pursues priorities thatarenot thosewhich aHousingFirst serviceprovidermight think are thebest option for them.Ultimately,HousingFirstcanencourageandsupporthomelesspeopletowardsrecovery,but itcannotinsistthattheytakeaspecificdirection(see2.6).
2.8. FlexibleSupportforasLong asisRequired
Housing First emphasises the right to housing in another sense, which is remaining in contact with a person using Housing First when they are evicted. If a Housing First service user is evicted, because of rent arrears, nuisance that causes disruption to neighbours or causing damage, Housing First remains in contact with that person and seeks to house them again. Equally, if someone using Housing First finds themselves unable to cope with living in their own home and abandons it, Housing First continues to work with them.
Ifsomeonelosestheirhome,theyarenotlefttocopeontheirownbyaHousingFirstservice.HousingFirstservicesremainengagedandcontinuetotrytoensuretheperson’srighttohousing.
Housing First offers support designed tomeet individual needs. The focus on choice and control,person-centred planning, a recovery orientation and harm reduction all underpin this fundamentalcharacteristicof aHousingFirst service.Support is adaptable, flexibleandcanalsobe imaginative,respondingtoeachuniquesetofneedsasrequired,atleastwithinthe(financial)resourcesaHousingFirstservicehasaccessto.Support intensity can rise and fall with individual need, so that Housing First can respond positively when someone needs more, or less, help on a day-to-day basis.
Asmentionedabove,supportfollowstheindividual,ratherthanbeingattachedtoaplace.ThisallowsHousingFirsttomaintaincontactifsomeonelosestheirexistinghousing,orhas,forexample,toenterhospitalorprisononashort-termbasis.
Thefinal,crucial,elementofflexibleservicedeliveryisproviding support for as long as necessary. ForpeopleusingHousingFirst,livingintheirownhomemaynotbetheirnormalexperience.Theymayhavespentyears,insomecasesdecades,inhomelessnessservices,hostelsandemergencyshelters,squattingor livingonthestreet.The support needed for adjustment to living independently may need to extend beyond a few months, and the process of ensuring that the health, well-being and social integration of a Housing First service user are as positive as possible may also take some time.
This does not mean support needs will be constantly high. Needs do change over time. Nor does support necessarily need to be permanent,asHousingFirstserviceuserscanreachapointwherethey no longer needHousing First and can eithermanagewith lower intensity support or can liveentirelyindependently.
Chapter2.CoreprinciplesofHousingFirst
37
SHARED OBJECTIVES
Alongsidethecoreprinciples,eachHousingFirstservicehasasetofsharedobjectives,whichcanbesummarisedas:
₀ Deliveringhousingsustainment.
₀ Promotinghealthandwell-being.
₀ Promotingsocialintegration,including:
• Communityintegration
• Enhancingsocialsupport
• Accesstomeaningfulandproductiveactivity
CHAPTER 3.
3.Delivering Support
Chapter3.DeliveringSupport
40
SupportinHousingFirst SupportinHousingFirstcentresondeliveringhousing sustainment, the promotion and support of good health and well-being, developing social supports and community integration and extending participation in meaningful activity. Housing First delivers these services usingmultidisciplinary teamsand/orvariousformsofhigh intensity case-managementservices.Mobile teamsofworkersprovidetheseservicestothepeopleusingHousingFirstservicesbyvisitingthemat home,orsometimesatanother mutually agreed location,suchasacafé.
3.1. HousingSustainmentThefirstgoalofHousingFirstistosecurehousing.Housingisthefirst,ratherthanthelast,issuethataHousingFirstservicedealswith.BeginningwithhousingisakeydifferencebetweenHousingFirstandsomeothermodelsofhomelessnessservice, suchasstaircaseservices, that try tomakesomeone‘housingready’beforeofferingthemahome.UsinghousingasthestartingpointmeansthatHousingFirstservicescanconcentratetheirsupportonenablingsomeonetoliveasindependentlyaspossible,supportingtheirhealthandwell-beingandofferinghelpwithcommunityandwidersocialintegration(seeChapter2).
HousingFirstisnothousingonly84. Housing is essential and is the starting point for Housing First but it must be combined with support.Ifsomeoneishoused,buttreatmentisnotbeingoffered,thereisnopracticalhelpwithday-to-dayliving,theyaresocially isolated,notpartofacommunityandhavenothingmeaningfultooccupythem,muchofwhatispotentiallydamagingabouthomelessnessisstill happening to them85.Atbest,ahomelesspersonwithhighneedswho ishousedwithoutsupport isbeing‘warehoused’withouttheoptiontomovetowardsrecovery.Atworst,homelessnesswillbecomerepeated,asunmetneedscausehousingloss86.
Support is essential to the success of Housing First. Ending homelessness at a high rate is achieved by providing high quality support services after a service user has been housed.
TherearespecificaspectsofsupportthatplayadirectroleinhelpingthepeopleusingHousingFirstsustain theirhousing.Central to theseformsofsupport isregular contactwithaHousingFirststaffmember.Alongsidecheckingthewell-beingoftheHousingFirstserviceuser,astaffmemberreviewstheir housing situationandensures therearenocurrent, orpotential, problems.MostHousingFirstserviceshavearegularmeeting,usually once a week,face-to-face,inaHousingFirstserviceuser’shome.SomeHousingFirst services require a set formof regularmeeting; others aremoreflexibleabouthowoftenthemeetinghappensandmightalsoallowittotakeplacebytelephoneoronsocialmedia.The frequency and type of contact is determined by the expressed needs of the service user.
3.1.1. TheSupportProvidedThe roleofHousingFirst staff indirectly supportinghousing sustainment can involve the followingactivities:
₀ Regular monitoring of each Housing First service user’s housing situation,checkingforcurrentandpotentialproblemswithhousingsustainment.
84 http://www.housingfirsttoolkit.ca/
85 Jones,A.andPleace,N.(2005)Daytime Homelessness London: Crisis
86 Pleace,N.(1997)RehousingSingleHomelessPeople,inBurrows,R.,Pleace,N.andQuilgars,D.(Eds)Homelessness and
Social PolicyLondon:Routledge,151-179.
Chapter3.DeliveringSupport
41
₀ Ensuring relationships with neighbours are as good as possible.ThiscanbeacrucialpartofthesupportaHousingFirstserviceprovides.Housingsustainmentcanbecloselylinkedtocommunityintegration,workerswillneedtoensure, insofaraspossible, thataHousingFirstserviceuser ishappywiththeirneighboursandthattheirneighboursarehappyto livenextdoortoaHousingFirstserviceuser.
₀ Practical advice and assistance in ensuring that a home is suitable.Thiskindofhelpmaybeprovidedwhen someone ismoving into their newhome and requires helpwith furniture,withensuringthekitchenisproperlyequippedandpowerandwaterareconnectedandworking,orifsomethinggoeswrongwiththeapartmentandhelpisneededtogetitrepaired.
₀ Help with budgeting.SomeHousingFirstserviceshavepartialcontrolofbudgetingforHousingFirst serviceusers, toensure that rent, or their contribution to rent, ispaid.Others simplyofferadvicewithmanagingmoney.Supportwithwelfarerights,i.e.claimingallwelfarebenefitpaymentstowhichtheyareentitled,mayalsobeprovidedtoHousingFirstserviceusers.
₀ Advice and support for independent living.SomeHousingFirstserviceusersmayinitiallyneedhelpwith cooking healthymeals andwith cleaning andmaintaining or decorating their homebecausethesearethingstheyhavenotdonebeforeornotdoneforalongtime.
₀ Housing First may effectively provide full, or partial, housing management services for private or social rented landlords.Here,inreturnforhavingaccesstohousing,HousingFirstservicesmayoffertomanagethehousingforthelandlord,sothatthelandlordeffectivelyhastodonothingbutreceiverentpayments.SomeHousingFirstservicesmayalsoguaranteerent.Here,theHousingFirstserviceprovidessupporttotheHousingFirstserviceuser,butalsomanagesthehousingtoreflecttheconcernsofthelandlord(seeChapter4).
₀ All other types of support should be provided as needed: it is important for Housing Firstservicestobeveryflexible,accepting,non-judgementalandhaveanethosofdoingwhateverittakes.Theymaybecalledupontohelpunclogasinkortoilet,toteachsomeoneabouttheirnewcookerorhowtoworktheremotecontrolfortheTV,tohelpthemadjusttotheirneighbourhood,usethewashingmachine,practiceavoidingadrugdealer,andoftenjusttolisten,notasaserviceproviderbutasonehumanbeingtoanother.
Monitoring of Housing situation
Ensuring good relationships with
neighbours
Practical advice and assistance
with the apartment
Advice and support for
independent living
Other flexible support when
needed
The Support Provided
Help with budgeting
Housing management
Chapter3.DeliveringSupport
42
3.2. HealthandWell-Being
3.2.1. OrganisingSupportThehealthandwell-beingofHousingFirstserviceuserstendstobemanagedusingoneoftwomainapproaches.HousingFirstservicesmayofferboththeseformsofsupport,ormayonlyprovideoneofthetwo:
₀ Intensive case management (ICM)orasimilarformofhigh-intensitycasemanagement,whichprovides some support and creates connections between service users and treatment andsupportprovidedbyotherhealth,supportandsocialworkservices.
₀ An assertive community treatment (ACT) team,oranothermultidisciplinaryteamthatdirectly provides treatmentformanyneeds, includingmentalhealthproblems,drug/alcoholproblemsandpoorphysicalhealth,andprovidesthecasemanagementneededtohelpthepersonaccesstreatmentfromotherservicesasrequired.Thisapproachtendstobeusedforhomelesspeoplewithveryhighsupportneeds.
₀ AHousingFirstserviceofferingbothICMandaninterdisciplinaryteam,whichisthebasisoftheoriginalmodel ofHousingFirst, has the flexibility to allow serviceusers tomove fromACT (orequivalent)levelsofsupporttoICM(orequivalent)andviceversa87.
There is no completely set way of providing support in Housing First.Where Housing First is an intensive case management-led service,supportwithtreatmentwillcentreonasingleworker,whomayormaynotbetrainedinsocialwork,whowillprovidesomedirectsupportandarrangeaccesstorequestedhealth,welfareandothersupportservicesonbehalfofaHousingFirstserviceuser.HousingFirst servicesmayhave specialists in addiction,peer supportworkers, healthprofessionalsorotherspecialistsinthiscase-managementrole.TheHousingFirstworkerwillalsoprovidetheserviceuserwithhousingrelatedsupporttosustaintheirhousing(1.HousingSustainment)andalsohelpthemmovetowardssocialintegration(3.SocialIntegration).
WhenaHousingFirstservice isusinga multidisciplinary team, itcanemployapsychiatrist,adrugandalcoholworker,adoctor,anurse,atrainedpeer-supportworkerwhopromotesrecovery(basedonhavingbeenthroughsimilarlifeexperiences)andspecialistsinemploymentandreconnectionwithfamily. Sometimes, all of this treatment and supportmightbeprovideddirectly, butwhere suitableexternalservicesexistandareaccessible,casemanagementcanbeused.
Housing First can, potentially, function as an entire welfare state in miniature, providing all required treatment and support by itself.HousingFirstcanalsoofferamixtureofdirectly-providedtreatmentandcasemanagement,orHousingFirstcanmainlyorentirelyarrangeaccesstoexternaltreatmentviaintensivecasemanagement.Sometimes,asingleHousingFirstserviceisabletooperateatdifferentlevelsandindifferentwaysdependingonwhattheuser’sneedsare,whichcloselyreflectstheoriginaldesignofHousingFirst.
87 Tsemberis,S.(2010)Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction
Minnesota:Hazelden.
Serviceuser/Multi-professional
intervention
ACT (Assertive Community
treatment)
ICM (Intensive case management)
Serviceuser/Professional
Mentalhealthproblemswithorwithoutaddictions
Managementandcoordinationtocreateconnectionswith
communityresources
Seriousmentalillnesswithorwithout
addictions
Type of intervention Profile Support
Directlyprovidesservices
Chapter3.DeliveringSupport
43
Thepeopleworking foraHousingFirstservicecanhaveawide rangeof trainingandcompetency.Theexactcompositionof the teamwillvary,but itcan includepeoplewhoaresocial-work trained,qualifiedandexperienced in theprovisionofhomelessnesssupport servicesand,whereanACTorsimilarmultidisciplinaryteamisused,amixofhealth,mentalhealthanddrugandalcoholprofessionals.HousingFirstmayalsoprovidespecialistsinemploymentandinpeersupport,includingtrainedsupportworkerswhohavehadlifeexperienceofhomelessnesspriortoworkingforHousingFirst.
In 2015, most of the Housing First services working in Europe, though not all, used an intensive case-management only model.ThisisbecauseHousingFirsthassofartendedtobedevelopedbyEuropeancountrieswherethestateprovidesalotofservices,withextensive,freelyavailable,health,mentalhealthanddrugandalcoholservicesthatcanbeeasilyorrelativelyeasilyaccessedviacasemanagement.However, therearesomeEuropeancountrieswherepublichealthsystemsaremuchlesswelldevelopedand,asHousingFirstbecomesmorewidespread,someEuropeanHousingFirstservicesmayfindthattheyneedtoprovidetreatmentdirectly,ratherthanbeingabletorelyoncasemanagement.
ItisworthnotingthateveninsomehighlydevelopedsocialwelfarestateslikeDenmark,France,SwedenandNorway,ACTteamsareusedinsomeHousingFirstservices88.Inpart,thisisbecausetheserviceuserhasnotrequestedtreatment–onlyhousing–eventhoughthepersonmaywellneedtreatment.Itmaybeeasiertoengageapersonintreatmentoncetheyarecomfortableandknowthetreatmentprovider.Intheseinstances,itcanbeveryuseful,forexample,tohaveapsychiatristmakeahousecallorsitinaparkandhaveacoffeewiththeserviceuser,buildingtrustbeforetreatmentisdiscussed.
A multidisciplinary team may be necessary when Housing First is working with homeless people with very high and complex needs.Mainstreamservicesmaybeunabletoeffectivelymeettheverycomplex and/or challenging needs of Housing First service users, for example because they areoffice-basedandwillnotvisitpeopleathome.Somemainstreamservicesalsostillworkin‘silos’(areoperationallyseparatefromeachother).Agoodexampleofthis iswhenHousingFirstserviceusersneedacombinationofhealth,drug/alcoholandmentalhealthservices.Mainstreamservicescanbeprovidedseparatelyanditcanbechallengingtocoordinatethem,whereasamultidisciplinaryHousingFirstteamisdesignedtoprovideamixofsupportandtreatment.
InsomeEuropeancountries,allthehealthservicesaHousingFirstserviceuserneedsshouldbefreelyavailabletothemasacitizen.However,therecanbebarrierstopublicly-fundedhealthservicesthatincludenegativepopularattitudestohomelesspeople,orrelativelycomplexbureaucracy.Homelesspeoplemay also avoid publicly-funded health services as they feel stigmatised and expect to berefusedtreatment,evenifinpracticetheywouldalmostcertainlybetreated89.HousingFirstcanworkwell in thesesituations,because itcanadvocate forandarrangeaccess toall thehealthservicesaHousing First service userwishes to use, via casemanagement.As noted, EuropeanHousing Firstservicesquiteoftenjustprovidecasemanagement,onthebasisthatallthehealthservicesneededarealreadyfreelyavailable.Then,thekeyroleofHousingFirstistoensureaccessisproperlyorganised.
Whenusingamultidisciplinaryteam,HousingFirstexercisesmoredirectcontroloverthepackageoftreatmentandsupportbeingdeliveredtoaserviceuserthanwhenusingICM.ThisisbecauseallofthemembersoftheinterdisciplinaryteamareemployeesoftheHousingFirstservice.WhenfollowinganICMapproach,thereisnotthesamelevelofcontrol,asthepeopleintheteammainlyworkforotherservices.
Cooperation with other services may require careful management and may present some challenges for Housing First services.TheeffectivenessofHousingFirstservices indelivering therequiredtreatmentandsupportisdependentinpartonexternalorganisationsoverwhichaHousingFirstservicemaynotexerciseanycontrol.IftheseexternalservicesrefusetocooperatewithaHousingFirst serviceor face fundingcuts, theHousingFirst servicemayfind itselfencounteringoperationaldifficulties.ThisriskislowerwhenHousingFirstservicesarepartofastrategicplanorpolicytoreducehomelessnessandthereisanexpectationonservicestocooperatewithoneanother(seeChapter6).
88 AmajorityofHousingFirstservicesareICMorhigh-intensitycasemanagement-based.
89 Quilgars,D.andPleace,N.(2003)Delivering Health Care to Homeless People: An Effectiveness ReviewEdinburgh:NHS
Scotland.http://www.healthscotland.com/uploads/documents/425-RE04120022003Final.pdf
Chapter3.DeliveringSupport
44
3.2.2. ManagingNeedsThere will be some individuals whose needs are too high for Housing First.Where this is thecase,proceduresneedtobeinplacetoensuretheyareabletomoveontomoresuitableservices.ApproximatelyeightoutoftenhomelesspeoplewithhighsupportneedsaresuccessfullyhousedbyHousingFirstservices,basedoncurrent(2015)EuropeanandNorthAmericanevidence(seeChapter1).
The reasons why it may not be possible to support someone through Housing First include riskmanagement.Forexample,someonelivinginordinaryhousingmayneedaveryhighlevelofmonitoringtosafeguardtheirwell-being,forexamplebecausetheyareathighriskofsuicideoroverdose.ThismaybebeyondaHousingFirstservice’scapacitytoprovide,asamemberofstaffmightneedtobeconstantlywithanindividualforalongperiodoftime.
3.2.3. TheTreatmentandSupportProvidedTreatmentandsupport,eitherprovideddirectlybyaHousingFirstmultidisciplinaryteam,orarrangedincooperationwithexternalservicesthroughcasemanagement,caninclude:
₀ Psychiatric and mental health services. Thesewill be needed as there is clear evidence thathomelesspeoplewithhighsupportneeds–throughoutEurope–havehighratesofmentalhealthproblems90.The treatmentavailable toahomelesspersonmayvary significantly inqualityandsomewill not have been able to access treatment at all prior to starting to useHousing First.Thetypeofsupportprovidedwilldependontheindividual’sneedsandthepreferencesofeachserviceuser,butHousingFirstshouldbeabletoaccessapsychiatrist,psychologist,mentalhealthnursesandspecialistmentalhealthsocialworksupportasrequired.
₀ Drug and alcohol services. These will be needed as there is pan-European evidence thathomelessnessamongpeoplewithhighsupportneedscanbeassociatedwithproblematicdrugandalcoholuse91.Again,theexacttypeofsupportprovidedwilldependonwhataserviceuserchooses,butwillusuallyinvolveadrugandalcoholspecialistwhowillworkwithinaharm-reductionframework(seeChapter2).Harmreductionseekstominimisethedamagecausedbydrugandalcoholusethroughsupportandencouragement,ratherthanusingdetoxificationandabstinenceinanattempttobringuseundercontrol.HousingFirstisaservicethatusesharmreduction,butit is alsoa service thatpromoteschoiceandusesperson-centredplanning.Thismeans that ifsomeoneusingHousingFirst decides for themselves that theywantdetoxificationor to try anabstinence-basedapproach,HousingFirstshouldarrangethatserviceforthem.
₀ Clinical services.AHousingFirstserviceusermayneedaccesstoanursewhocanmonitortheirhealth,helpthemadministertheirmedicationandfollowtreatment.AHousingFirstserviceuserwillalsorequireaccesstoafamilydoctor/generalpractitionerformedicalservices.Supportmaybeneededwhenattendingoutpatient treatmentsatahospital,whichmight includeaHousingFirststaffmemberattendinganappointmentwithaserviceuser.HousingFirstmayalsoneedtoadvocateonsomeone’sbehalftoensurethattheyhaveaccesstothepropertreatments.WhensomeoneusingHousingFirstisadmittedtohospitalfortreatment,HousingFirstandthehospitalshouldworktogethertoensurethat theirneedsarebeingmetwhentheyaredischargedfrom(leave)hospital.
₀ Personal care servicesthatprovidephysicalassistancesomeonewithalimitingillnessordisability.SomeHousingFirstserviceusersmayneedhelpwithdressing,washingandpreparationofmeals.
₀ Occupational Therapy.Thisprovidesequipmentandphysicaladaptationstohousingtoenablepeoplewithlimitingillnessanddisabilitytolivemoreindependently.AHousingFirstserviceusermayneedmodificationstotheirkitchenorbathroomorchangesthatenablethemtoenterandexittheirhomemoreeasily,oraccesstoequipmentthatmakestheirhomemoreuseable.
90 Busch-Geertsema,V.,Edgar,W.,O’Sullivan,E.andPleace,N.(2010)HomelessnessandHomelessPoliciesinEurope:
LessonsfromResearch,Brussels,Directorate-GeneralforEmployment,SocialAffairsandEqualOpportunities.
http://ec.europa.eu/social/BlobServlet?docId=6442&langId=en
91 Ibidem
Chapter3.DeliveringSupport
45
₀ Twenty-four-hour coverage.ThisshouldbeavailabletosomeonewithhighsupportneedsusingHousingFirst.Thismeans there areHousingFirst services availableduringworkinghours andsomeonewillanswerthephoneoutsideworkinghoursandrespondtoanemergency.
₀ Advice and informationonhealth,whichwillbeprovidedbyHousingFirststaff,possiblyincludingapeersupportworker.Apeersupportworkerissomeonewithdirectexperienceofhomelessnessinvolvinghighsupportneeds,whoisatrainedHousingFirststaffmember.EuropeanHousingFirstservicesmaysometimesemployformerserviceusers,orpeoplewithsimilarhistoriesaspartofanACTteamorsimilararrangementortoprovidecase-management/ICMservices.
3.3. SocialIntegrationHousing First approaches social integration by enabling homeless people with high support needs to live as independently as possible in normal housing in a normal neighbourhood.IntheHousingFirstapproach,socialintegrationisexpectedtoresultfromnormalisationofhousingandnormalisationoflivingsituation.Bygivingformerlyhomelesspeopletheoptiontoliveinthesamewayaseveryoneelse;withthesamechoicesandopportunitiesforneighbourhood-basedsocialinteractionaseveryoneelse,HousingFirstseekstopromotesocialintegration92.
Social integration centres on emotional and practical support that enables someone to be a part of a society in several senses.Tolivearewardinglife,someoneideallyneedstohaveapartner,and/orfamilyandfriendshipsthatprovidethemwithself-esteem,asensetheyarevalued,companionshipandinformalsupport.Someonealsohastofeelliketheyareapartofsociety,acceptedbytheircommunityand livingaspartof thatcommunity,not stigmatisedby theirneighboursorby their fellowcitizens.Inaddition, it is important foran individual tohaveasenseofpurpose throughastructuredactivityinwhichtheyfindmeaning,becausethistooisimportantingivingasenseofesteem,belongingandbeingpartofsociety.
Homelessness,particularlywhen it is repeatedorgoeson for a long time,often fractures the linksbetween a person and all dimensions of social life. Someonewho is homelessmay livewithout apartner,withoutcontactwithfamilyandeffectivelywithoutfriends,maybestigmatisedandrejectedbythepeoplearoundthemandfeelisolatedfromotherpeopleandfromsocietyasawhole.HousingFirstisbuiltaroundarecognitionthatalackofemotionalsupport,love,acceptancebysocietyandaplaceinsociety,aswellasalackofpurposestemmingfromsomesortofstructuredactivity,isasdamagingtoahomelesspersonasuntreatedhealthproblemsare.
Socialintegrationandhealtharealsocloselyinterrelated.Lowself-esteem,isolationandexperiencingstigmatisationhavelongbeenrecognisedasdetrimentaltophysicalandmentalhealth93.
3.3.1. OrganisingSupportThe organisation of support towards social integration by Housing First services can include thefollowingelements:
₀ Peer support, whichcanbefromanotherHousingFirstserviceuser,fromaspecialistpeerworkeror from Housing First staffwho are ‘experts by experience’ because they have lived throughsimilarexperiences.Apeer-supportworkershouldideallybeemployedasanequalmemberoftheHousingFirstteamandnotregardedasjuniortootherstaff.Peersupportworkerscanhave
92 Tsemberis,S.(2010)Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction
Minnesota:Hazelden;Johnson,G.,Parkinson,S.andParsell,C.(2012)Policyshiftorprogramdrift?ImplementingHousing
FirstinAustraliaAHURIFinalReportNo.184http://www.ahuri.edu.au/research/final-reports/184
Pleace,N.andQuilgars,D.(2013)Improving Health and Social Integration through Housing First: A ReviewBrussels:DIHAL/
FEANTSAhttp://housingfirstguide.eu/website/wp-content/uploads/2016/03/improving_health_and_social_
integration_through_housing_first_a_review.pdf
93 Pleace,N.andQuilgars,D,(2013)Improving Health and Social Integration through Housing First: A ReviewBrussels:DIHAL/
FEANTSA.Vidsupra
Chapter3.DeliveringSupport
46
uniqueinsightsbecausetheyhaveexperiencesmirroringthoseofserviceusersandcanactaspositiveexamplestoserviceusers.
₀ Advice, information, practical support and emotional supportfromHousingFirststaff–centredonweeklyvisits-whichcaninclude:
• Help with accessing education, training, volunteering, paid work and other structured,productiveactivities,suchasarts-basedorcommunity-supportingactivities.
• Helpwith creating or re-establishing social support, for example supporting attendance atsocialeventsorprovidingpracticalsupporttoallowmeetingstotakeplacewithfamily(suchaspayingtransportcosts).
• Providing information,adviceandemotional support toHousingFirst serviceusers.Weeklyvisitsthatgiveserviceusersanopportunitytotalkthroughanythingthatisbotheringthem.
3.3.2. TheSupportProvidedSocial integration is not a fixed concept, but a set of interrelated issues that can require differing levels and forms of support. Along-termorrepeatedlyhomelesspersonmaybetotallycutofffromfamily, for example, but another person in the same positionmay havemaintained positive familyrelationships,despite theircircumstances.There isnosingle typeofexperienceorneeds regardingsocialintegrationandHousingFirstmustprovidearangeofflexibleservices.Thesecaninclude:
₀ Emotional support.ThiscanbeprovidedbyaHousingFirstworker throughaweeklymeeting,takingan interest, listeningtoconcernsandprovidingpracticalassistance.This isarelationshipthatneedstobecarefullymanaged,butcanbehighlyvaluedbyHousingFirstserviceusers.
₀ Participation in community life.ThisisintegraltoHousingFirstasaservicebecausetheemphasisisverymuchonprovidinghousingthatenablessomeonetolivewithinandaspartofacommunity.Participationincommunityeventsorsmaller-scaleactions,suchasbuyingthingsfromlocalshopsand talking to neighbours, are all forms of social integration that Housing First is designed topromote.Toanextent,HousingFirstserviceusersmayspontaneouslystarttoshowthiskindofparticipationoncetheyarehousedinacommunity,butaHousingFirstworkermayalsoaccompanythemandencouragethemtodothis.Thiscanhappenatmultiplelevels:takingthemtoalocalshop,goingwiththemtoacommunityevent,beingwiththemwhentheymeettheirneighboursandsoforth.
₀ Social support from a partner, friends and family.This can be facilitated byHousing First inmultipleways.OnewaythatHousingFirstcanpromotesocialsupportistocreateopportunities,whichmaybeassimpleasbuyingsomeoneatraintickettogoandseetheirfamily,butmightbemorecomplex, forexampleaHousingFirstworkeraccompanyingsomeone tomeet familywithwhomtheyhave lostcontact.HousingFirstmayalsoprovideor facilitateaccess to familymediation,providingpsychologicalandcounsellingsupportwhenaHousingFirstserviceuser’sfamilyrelationshiphasbrokendownandneedstoberepaired.HousingFirstmightalsofacilitateandencourageopportunitiesforsocialisation,providingemotionalsupporttosomeonewhentheyareseekingfriendsoranewpartnerandarranging,orsometimesaccompanyingthemto,socialevents.
₀ Managing negative relationships.ThiscanbeanissuewhereHousingFirstserviceusersneedsupport. ‘Doorcontrol’whensomeonehasbeen in thehomelessnessservicesystemoronthestreets foraconsiderable timecanbean issue,withguestswhoarenot reallywanted turningup and staying in the home of a Housing First service user.Vulnerable individualsmight alsobeexploitedbyotherhomelesspeoplewhentheyarehousedbyaHousingFirstservice.Here,HousingFirstcanofferpracticalandemotionalsupporttoensurethataHousingFirstserviceuserretainscontrolovertheirownhomeandisnothostingunwantedparties,orunwillinglyprovidingavenuefornuisanceorcriminalbehaviour.
₀ Challenging, nuisance and criminal behaviour. Thesewillbecharacteristicsofsomeindividualsusing Housing First services. Part of the management of these issues centres on access totreatment, for example noise and nuisance that upsets neighboursmay be linked to problemdrug/alcoholuse that is in turnassociatedwithmentalhealthproblemsthat require treatment.HousingFirst staffmayalsoprovide ‘coaching’ or access to services andactivities that enableHousingFirstserviceuserstobecomebetterathandling interpersonalcommunicationthrough
Chapter3.DeliveringSupport
47
increasedemotionalliteracyandangermanagement.Here,anarrayofsupport,fromcounsellingthrough to arts-based activities, alongside talking about problemswith Housing First supportworkers,canbebeneficial.
₀ Handling Stigmatisation.Thiscanbeachallengeforhomelesspeoplewithhighsupportneeds,both inthesensethattheymayexperienceprejudiceduetotheirexperienceofhomelessnessitself, and because they may have other characteristics (e.g. be experiencing severe mentalillness,havingbeeninprison)thatproducefearornegativeresponsesinotherpeople.Partoftheprocessofmanagingstigmatisationispassing,i.e.appearingtobethesameaseveryoneelse.Inemphasisingtheimportanceoflivinganordinarylifeinanordinarycommunity,akeygoaloftheoriginalHousingFirstservicedevelopedbyDr.SamTsemberiswasto‘jumpover’thebarriersthatcanexistbetweenhomelesspeople,societyandsocialintegration.Bothbyappearingtobethesameaseveryoneelseandinlivingthesamewayaseveryoneelse,thesocialbarriersthatexistbetweenahousedcitizenandahomelesspersonon the streetor in ahomelessness service,arepotentiallyreduced.Equally,whenaHousingFirstserviceuseroptstousetreatmentandtoorientatethemselvestowardsrecovery, themarkers–orsetsofcharacteristicsandbehaviours– that can create stigmatisation can also be reduced. Livingwithin and beingvisibly part of acommunityisseenbytheHousingFirstapproachascreatingscopeforovercomingstigmatisation.
₀ Structured and meaningful activity. This can be particularly important in giving someone asenseofpurposeandpromotingtheirsenseofself-esteem.Thiscanbedirected,inthesenseofprogressingsomeonetowardsthepointwherevolunteeringorpaidwork(seebelow)maybecomepossibleforthem.IntheUKandFinland,aswellaselsewhereinEuropeandNorthAmerica,arts-basedactivitiesareusedasameansofhelpinghomelesspeopleengagewithstructuredactivityandworkingwithothers,thatpromotestheirself-esteemandemotionalliteracy.Thiscanbeanend in itself, or itmaybeusedaspartof aprocess that isdesigned topersuadeandsupporthomelesspeopletoengagewith(basic)adulteducationandfurthereducationortraining.HousingFirstservicesmightprovidesomeoftheseservicesdirectly,oruseamixofcasemanagementanddirectpracticalandemotionalsupporttoencouragehomelesspeopletoengagewithlocalservices.
₀ Paid work. This is possible for some Housing First service users, although they may needconsiderabletimeandsupportbeforetheyreachthepointwhereitbecomesarealisticprospect.SupportingpeopleintopaidworkisafeatureoftheFrenchHousingFirstprogramme94.Movementtowards formaleconomicactivitymight involveapathway thatstartswitharts-basedactivities,movesintobasiceducationandeventuallyvolunteering,andthenreachesthepointofapplyingfor work. Employer attitudes and underlying economic conditions are important factors inkeepingpeopleoutofwork,anditmaybethatHousingFirsthastoworkwithemployersdirectly,encouraging and supporting them to consider offeringwork to Housing First service users (inmuchthesamewayasitmayworkwithprivaterentedsectorlandlords,seeChapter4).
₀ Ontological security. Thisreferstowhatmightbecalledasenseofsafetyandpredictabilityinlifeand,inHousingFirst,centresontheroleofprovidingsomeonewithasettledhome.Disconnectionfrom other people, from society and from local community occurs in homelessness becausesomeonehasnoplaceinsociety,mostimmediatelybecausetheylackahome,butalsobecausethat lackofsettledhomeunderminesorremovestheirchancetohaveaplace inacommunityoraplaceinwidersocialandeconomiclife.Ingivingsomeonetheirownhomeasstartingpoint,HousingFirst isdesigned togivehomelesspeoplewithhighsupportneedsaplace insociety.HousingFirstisintendedtointegratehomelesspeopleintosocietyatthisfundamentallevel,usinghousingtogiveasenseofsecurity,certaintyandpredictabilitythatcomesfromknowingwhereonelivesandbelongs95.
94 The“Unchezsoid’abord”HousingFirstprogrammeinFrancehasdevelopedapartnershipfollowingtheIndividual
PlacementandSupport(IPS)model(DouglasInstitute,Montreal).The“workingfirst”programmeinMarseilleisdesigned
toenableaccesstoworkandtosupportworkamongpeopleusingHousingFirst.
95 Padgett,D.K.(2007).There’snoplacelike(a)home:Ontologicalsecurityamongpersonswithseriousmentalillnessinthe
UnitedStates.Social science & medicine,64(9),1925-1936,p.1934.
Chapter3.DeliveringSupport
48
Emotional support
Social support
Managing negative
relationships
Challenging, nuisance
and criminal behaviour
Handling Stigmatisation
Structured and
meaningful activity
Paid work
Ontological security
Participation in community
life
The Support Provided
Inemphasisingsupportwithsocial integration,HousingFirst isaddressingasetofneedsthatareassignificanttorecoveryasaccesstosettledhousingandtreatmentis.However, it isalwaysimportantnottolosesightofthecorevaluesofchoice and controlintheHousingFirstmodel96.HousingFirstisintendedtocreateopportunitiesforsocialintegration,withinaframeworkthatemphasisesrecoverybutalsochoice.UsingHousingFirstshouldnotmeansomeoneisexpectedtobehaveinonesetway.Forexample,no-oneshouldhavetotalktoaneighbourorattendacourseoracommunityeventiftheydonotwantto,becauseanotherordinarycitizen,inanotherordinaryhome,wouldbeabletoexercisechoiceinthematter.
96 HansenLöfstrand,C.andJuhila,K.(2012)TheDiscourseofConsumerChoiceinthePathwaysHousingFirstModel
European Journal of Homelessness6(2),47-68 http://housingfirstguide.eu/website/the-discourse-of-consumer-
choice-in-the-pathways-housing-first-model/
CHAPTER 4.
4.Delivering Housing
Chapter4.DeliveringHousing
52
4.1. HousingandNeighbourhoodinHousingFirst
Thereisanimportantdistinctionbetweenbeingprovidedwithaccommodationandhavingarealhome.Tobeahome,housingmustoffer:
₀ Legally enforceable security of tenure, i.e. someone using Housing First should not be in apositionwheretheyhavenohousingrightsandcanbeevictedimmediatelywithoutanywarningand/orwiththeuseofforce.
₀ Privacy. Housing must be a private space where someone can choose to be alone withoutinterferenceandcanconductpersonalrelationshipswithfamily,friendsand/ortheirpartner.
₀ Aspacethatthepersonlivingwithinithascontrolover,intermsofwhocanentertheirhomeandwhentheycandosoandalsointermsofbeingabletoliveinthewaytheywish,withintheusualconstraintsofastandardtenancyorleaseagreement.
₀ Aplaceinwhichsomeonefeelsphysicallysafe and secure.
₀ Affordability,inthatrentpaymentsarenotsohighastounderminetheperson’sabilitytomeetotherlivingcosts,suchasfoodandutilitybills.
₀ All the amenities that an ordinary homepossesses, sufficient furniture, aworking kitchen andbathroomandworkinglighting,heatingandplumbing.
₀ A fit standardforoccupation,i.e.notovercrowdedorinpoorrepair.
₀ Their own placethattheycandecorateandfurnishastheywishandwheretheycanlivetheirlifeinthewaytheychoose.Housingmustnotbesubjecttothekindofrulesandregulationsthatcanexistinaninstitution,determininghowaspaceisdecorated,furnishedandlivedin.
The European typology of homelessness (ETHOS) identifies physical, social and legal domains indefiningwhatismeantbyahome.Thephysicaldomaincentresonhavingone’sownlivingspace,i.e.someonehastheirownfrontdoortotheirownhome,undertheirexclusivecontrol.Thesocialdomainmeanshaving thespaceand theprivacy tobe ‘athome’.The legaldomainechoes the internationaldefinitionofarighttohousing,i.e.securityofresidencewithlegalprotections(seeChapter2)97.
The locationofhousing is important.However,HousingFirstserviceswillnothavetheresourcestosimplypickanywhereinacityormunicipality.Insomelocations,suchasmajorEuropeancities,therewillveryoftenbeaneedforcompromisebetweenwhatisaffordableforHousingFirstserviceusersandwhatwouldbean‘ideal’home.
Wherepossible, it is importanttoavoidareascharacterisedbyhighcrimerates,nuisancebehaviourandlowsocialcohesion/weaksocialcapital,wherethereislittleorno‘community’inapositivesenseandaHousingFirstserviceusermightbesubjecttobullyingorpersecutionorbeatcontinualriskofbeingavictimofcrime.ThereisclearevidencethatthewronglocationcaninhibitorunderminetherecoverythatHousingFirstservicesseektopromote98.Moregenerally,itisdesirabletoavoidphysicallyunpleasantlocationsandthosewithoutaccesstonecessaryanddesirableamenities,e.g.anaffordablelocalshop,publictransportlinksandpleasantgreenspace.Therightkindofneighbourhoodcanbeadeterminantofhealth,well-beingandsocialintegration99,positivelyinfluencingoutcomesforHousingFirstserviceusers.
97 EuropeanTypologyofHomelessnessandhousingexclusionhttp://housingfirstguide.eu/website/ethos-european-
typology-of-homelessness-and-housing-exclusion/
98 Pleace,N.withWallace,A.(2011) Demonstrating the Effectiveness of Housing Support Services for People with Mental Health
Problems: A ReviewLondon:NationalHousingFederation.
99 Bevan,M.andCroucher,K.(2011)Lifetime Neighbourhoods,London:DCLGhttps://www.york.ac.uk/media/chp/
documents/2011/lifetimeneighbourhoods.pdf
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SomeHousingFirstserviceusersmaywishtomoveawayfromthelocationsinwhichtheyexperiencedhomelessness.Thereasons for thismay includewanting toavoidnegativepeerpressure fromtheirformer life.For someHousingFirst serviceusers, includingwomenwhohaveexperiencedgender-based/domesticviolence,theremaybeaneedtoavoidlivingincertainareasforreasonsofpersonalsafetyandtoimprovetheirhealthandwell-being.Ideally,housingshouldnotbelocatedinanareathataHousingFirstserviceuserwishestoavoid.
Adequatehomesmustbe located in anadequateneighbourhood.Avoidingareascharacterisedbysocialproblemsandpoorfacilitieswillhelpincreasethechancesthathousingcanbesustained.
4.2. HousingastheStartingPointHousing is thestarting point rather thananend goal forHousingFirstservices.HousingFirst isverydifferent fromsomeotherhomelessnessservices that trymakehomelesspeoplewithhighsupportneeds‘housingready’beforetheyarerehoused,i.e.staircaseserviceswherehousinghappenslast. In HousingFirst,beingprovidedwithhousingiswhathappensfirst.
Theroleofahome inHousingFirsthasbeendescribedasprovidingontologicalsecurity.This isanacademic idea, but it can be summarised as someone feeling that their life is secure, predictableandsafe- theoppositeofwhat isexperienced inhomelessness,wherenothing issecureandbothimmediateandlonger-termrisksareeverywhere100.ForHousingFirstserviceusers,havingtheirownhomeisdesignedtohelpthemreturnto,orbegin,anormallife.OneAmericanacademichasdescribedtheroleofhavingahomeinHousingFirstinthefollowingway:
Having a ‘home’ may not guarantee recovery in the future, but it does afford a stable platform for re-creating a less stigmatised, normalised life in the present101.
Alongsidebeingdesignedtodeliverapermanentexitfromhomelessness,ahomehasthe following roles in Housing First:
₀ A home is the starting point of social integration.Havingahomereturns,orintroduces,HousingFirstserviceuserstoacentralpartofhavinganormallife:havingtheirownhome.HousingFirstemphasises the role of housing in beginning a process inwhich a homeless personwith highsupportneedsliveswithinacommunityandsocietyandisnolongerexcludedfromitbylackingahomeoftheirown(seeChapter3).
₀ Beingon the street, or in another insecureplace, heightensboth theperceptionand realityofbeingatphysical risk.Emergencyandcommunalhomelessnessservicesmayalsofeelandbeunsafe.The right home provides both security and predictability.SomeoneusingHousingFirstknowstheyhavesomewheretosleepanditwillbesafe.
₀ A home provides a safe and stable environment that improves the effectiveness of treatment thatHousingFirstserviceusersmayopttouse.Sustainedexperienceoftryingtoprovideeffectivetreatmentformentalandphysicalhealthproblems,orhelpwithdrugandalcoholusehasshownthat when someone is living on the street or in homelessness services, the effectiveness oftreatmentisundermined.Ifhealthservicesaretobeeffectiveforhomelesspeople,thefirststepistoensuretheyhavesomewheretoliveinwhichtheyarewarm,dry,haveregularmealsandarenotsubjecttotheextremesofstressthatcanaccompanyhomelessness102.
₀ A home brings control over life.Havingahomeallowssomeonetoexerciseprivacy,tosocialiseand to have a space inwhich to develop andmaintain a partnership.Having a homeenablessomeone to live in theway theywant to, something that is not possiblewhen in a communal
100 Pleace,N.andQuilgars.D.(2013)Improving Health and Social Integration through Housing First: A Review Brussels:DIHAL/
FEANTSA.Vidnote94.
101 Padgett,D.K.(2007).There’snoplacelike(a)home:Ontologicalsecurityamongpersonswithseriousmentalillnessinthe
UnitedStates.Social Science & Medicine,64(9),1925-1936,p.1934.
102 Quilgars,D.andPleace,N.(2003)Delivering Health Care to Homeless People: An Effectiveness ReviewEdinburgh:NHS
Scotland.http://www.healthscotland.com/uploads/documents/425-RE04120022003Final.pdf
Chapter4.DeliveringHousing
54
homelessness serviceor emergency accommodation - inwhich all living space is shared - orwhenonthestreet.
₀ Whenhousingneedsaremet, itbecomespossibletoprioritise other aspects of life.HousingFirstshowsthatlifecangetbetterbydeliveringasettledhomeandactivelyengagesHousingFirstserviceuserswiththe ideathattheirhealth,well-beingandsocial integrationcanalso improve.Thisinturnencouragesthemtoengagewithtreatmentandsupportservices.
AservicethatdoesnotofferwhatcanbeclearlyrecognisedasahomecannotberegardedasHousingFirst.Emergencyorhostelaccommodationwithsharedsleepingspace,orthatoffersonlyapartiallyprivatelivingspace,thatisnotself-contained,isnotHousingFirst.Equally,aservicethatallowsstafftosimplywalkintothehomeofaHousingFirstserviceuser,orwhichgivesthemakeytothedoorofthatperson’shome,whichtheycanusewithoutpermission,isnotHousingFirst.
Chapter3describestherange,extentandorganisationofthehousingsupportprovidedbyHousingFirstservices.
4.3. ProvidingHousingHousingFirstserviceusersareabletoexercisechoiceinusingtreatment(seeChapter2andChapter3)andshouldalsobeabletoexercisechoiceaboutwhereandhowtheywilllive.Obviously,housingoptionswillbesubjecttowhatisavailableandwhatcanbeaffordedbyHousingFirstserviceusers103,butgenerallyspeaking,
103 Insomecases,HousingFirstserviceswillpayrentsforserviceusers,inothers,rentalsubsidiesareprovidedviawelfare
systems.
Chapter4.DeliveringHousing
55
Housing First service users should expect:
₀ To be able to see housing before they agree to move into it.
₀ To be offered more than once choice of housing, i.e. they should be able to refuse offered housing if they wish without there being any negative consequence for them. In practice, a Housing First service may face challenges in finding ideal housing. This will need to be made clear to each Housing First service user, but there should be no expectation that being offered only one or two choices is sufficient. Housing First should never withdraw an offer of housing and support on the basis that someone has refused one or more offers of housing.
₀ To have the financial consequences of having their own home clearly explained to them and to have the opportunity to discuss this. Before moving into their home, Housing First service users should understand what their financial obligations will be and how much money they will have. In some European countries, which pay a basic income to anyone who is unemployed, someone may have less disposable income when housed than when living in emergency or temporary accommodation for homeless people (because they have additional living costs).
₀ To have some choice with respect to the location of the housing that they are offered.
₀ To be offered some flexibility around how they choose to live, i.e. someone may wish to live with a partner, friends or with other people, rather than on their own in an apartment. Some Italian Housing First services, for example, will support families and some English services will support couples (see Appendix).
TherearethreemainmechanismsbywhichaHousingFirstservicecandeliverhousing:
₀ Useoftheprivaterentedsector
₀ Useofthesocialrentedsector(wheresocialrentedhousingexists)
₀ Directprovisionofhousing,bybuyinghousing,developingnewhousingorusingexistinghousingstock.
The challengesfacedbyaHousingFirstservicemayinclude:
₀ Finding enough affordable, adequate housing inacceptablelocationsinhigh-pressurehousingmarkets(wherehousingdemandisveryhigh).Anyareawithhigheconomicgrowthislikelytobeachallengingplacetofindsufficienthousingoftherightsort.Thetypeofhousingavailableinsomeruralareas(arelativeabsenceofsmallerapartments)mayalsopresentachallenge.
₀ Wheresocial housing isavailable, itmaybe targeted on groups other than people who are homeless,oritmaybesubjecttohighdemand.
₀ Theremaybeproblemswiththeavailability, affordability and quality of housing in the private rented sector.
₀ Bothsocialandprivatesectorlandlords may be reluctant to house formerly homeless people withhighsupportneeds.Thereareconcernsthatpeoplewhohavebeenhomelesswillpresentmanagementproblems,suchasgettingintodisputeswithneighbours,orfailingtopaytheirrent.
₀ Housing First service users sometimes cannot access sufficient welfare benefits to pay the rent.This ismoreof an issue inEuropeancountries that have limitedwelfare systems than inthosewithextensivewelfaresystems,wherevariousformsofhousingbenefitorminimumincomebenefitpayallormostoftherentforverylowincome/vulnerablegroups.Incountrieswithmorelimitedwelfaresystems,HousingFirstservicesmayneedtofindincomestreamstohelppaytherentfortheirserviceusers.
₀ ItispossibletocreatenewhousingspecificallyforHousingFirstbutthe costs of development (building new housing) or renovating/converting existing housing are considerable. Buyinghousing isalsoanoption,butwhilethismaybecheaperthanbuildingorrenovating,again, thecostsmaybetoohighforthistobearealisticoption.
₀ NIMBY (not in my back yard) attitudeslinkedtothestigmatisationofhomelesspeoplewhichmayleadneighbourhoodstotrytostopHousingFirstservicesfromoperating in theirarea.Housing
Chapter4.DeliveringHousing
56
Firstservicesmayneedtoworkwithneighbouringhouseholds,providinginformation,reassuranceandifnecessaryinterveningifaHousingFirstserviceuserhascausedaproblem(alsointerveningifaneighbourisbehavingunreasonablytowardsaHousingFirstserviceuser).
₀ Housing First canwork flexibly and imaginatively, but itcannot fix underlying problems with affordable and adequate housing supply and may encounter operational difficulties in anycontextwherethereisjustnotenoughaffordableoradequatehousingfortheentirepopulation.
Housing First ismeant for homeless peoplewith high support needs.The need that Housing Firstservices have in terms of numbers of housing unitswill often be relatively small.Althoughdata onEuropeanhomelessnessareincomplete, itappearsthat,eveninamajorcity,aHousingFirstservicewouldprobablynotrequirehundredsofhomes104.
4.3.1. WorkingwiththePrivateRentedSectorTherearevariousways inwhichHousingFirstcanemploy theprivate rentedsectorasa sourceofhomes.Asuccessfuluseoftheprivaterentedsectorincludes:
₀ Careful inspection and checking of apartments/flatstoensurethatthestandardsandlocationaresuitable.
₀ Checkingthattenancy arrangements are correctandthataHousingFirstserviceuserhasthefullprotectionofthelawsthatcoversecurityoftenure.Insomecountries,tenanciesintheprivaterentedsectorwillbelongerandmoresecurethaninothers.
₀ Affordability checks,centringoncurrentandlikelyfuturerentlevelsbeingatalevelthatwillallowotheressentialcoststobemet.WhereaHousingFirstservicerequiresafinancialcontributionfromaserviceuser,theaffordabilityofthiscontributionmustbesubjecttoregularreview.Anyexpectedfinancialcontributionsalsoneed tobeclearlyexplained toaserviceuserbefore theyagree toacceptahome.SomeHousingFirstservicesrequirea30%contributionofincometowardsrent.Insomecountries,thisisnotpractical,astheHousingFirstserviceusermayhaveaverylowincomeandtheHousingFirstserviceitselfwillneedtopayorsubsidisetherent. Inothercountries,thewelfaresystemwillpayall,ormostof,therentforaHousingFirstserviceuser,meaningthattheHousingFirstserviceeitheronlyhastomakeasmallcontributiontohousingcosts,orhasnodirecthousingcostsatall.
₀ Negotiation and discussion with and education of private rented sector landlords and/oragentsrepresentingoneormoreprivatesectorlandlords. Itshouldnotbepresumedthatallormostprivaterentedsector landlordswillbeunsympatheticorunwillingtoworkwithaHousingFirstservice.ExperiencefromsomeHousingFirstservicesshowsthatatleastsomeprivatesectorlandlordswillbepreparedtoworkwithHousingFirstservicesoutofasenseofcivicresponsibility105.
₀ Offering a housing management servicetoprivatelandlords.Thiscanbeapowerfulincentive.AHousingFirstservicecanoffertoguaranteethatrentwillbepaidandthatanymanagementissues,suchasneighbourdisputes,willbedealtwithandperhapsalsotoundertakethemaintenance,repairorrenovationofhousing.Ifaprivatelandlordeffectivelyhastodonomorethancollectaguaranteedrent,potentialworriesaboutmakingtheirhousingavailabletohomelesspeoplecanoftenbeovercome.SomeHousingFirstservicesoffer tobedirectly responsible fora tenancy,sublettingtoaHousingFirstserviceuser,sotheservice,ratherthantheHousingFirstserviceuser,islegallyresponsibleforanyproblemswiththetenancy.
₀ Offering a financial incentive toprivaterentedsectorlandlords.This isapossiblestrategy,butexperience in somecountries, for exampleFinland and theUK, has shown that private rentedmarketstendtoreacttofinancialincentivesforhousinghomelesspeoplebyincreasingrents106.
104 Busch-Geertsema,V.,Benjaminsen,L.,FilipovičHrast,M.andPleace,N.EuropeanObservatoryofHomelessness.
FEANTSABrussels(2014)http://housingfirstguide.eu/website/extent-and-profile-of-homelessness-in-european-
member-states-a-statistical-update/
105 http://www.shp.org.uk/story/housing-first-provides-stability-chronically-homeless-people
106 Wilson,W.(2015)Households in Temporary Accommodation (England)HouseofCommonsBriefingPaperNumber02110
www.parliament.uk/briefing-papers/sn02110.pdf
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InPortugal,useoftheprivaterentedsectorbyCasasPrimeiroinLisbonhasbeenreportedasdeliveringverygoodresults,withalmosteveryHousingFirstserviceuserreporting107:
₀ A sense of controlovertheirlivingspace.
₀ Thattheyhadprivacyintheirhome.
₀ Thattheirhomewasatranquil place,somewheretheycouldfindpeaceandquiet.
₀ Thattheirhomehadall the facilitiestheyneeded.
CasasPrimeiroalsoreportsthatmany,thoughnotall,HousingFirstserviceuserslivinginprivaterentedapartmentsalsofeltathomeintheirneighbourhood.
InLondonandelsewhereintheUK,experienceofusingtheprivaterentedsectorforHousingFirstismuchmoremixed,forthefollowingreasons:
₀ Insecurity of tenure.Mostprivaterentedhousingisletonshort-term(sixor12month)tenancies.These tenancies provide some protection from eviction, but once the period covered by thetenancyends,thereisnolegalprotection.Thismeansthatsomeonewitha12-monthtenancyintheprivaterentedsectorhasnolegalprotectioniftheyareaskedtoleaveafter12months.
₀ High rents in someplaces in theUK,whichmakeallbut thecheapestprivate rentedhousinginaccessible to someone claimingwelfare benefits. Better standard housing inmore attractivelocationswasunaffordableforHousingFirstserviceusers.
4.3.2. WorkingwiththeSocialRentedSectorSocialhousingdoesnotexistinonesingleforminEuropeandisnotuniversallyavailable108.InthisGuidetoHousingFirst,socialhousingisdefinedashousingwhichisbuiltwithasubsidy,fromgovernmentand/orfromcharities/NGOs,thatofferssecurityoftenureandadequatehousingatanaffordablerent.
TherearevariouswaysinwhichHousingFirstcanemploythesocialrentedsectorasasourceofhomes:
₀ Realisingthatwhilethesocialrentedsectorcanplayanimportantroleinhousinghomelesspeople,this is not necessarily the only concern of social landlords109. Social housing can have awiderremit thanendinghomelessness, includingregenerationandstrategicmanagementofhousingmarkets.ItmaybenecessaryforHousingFirstservicestocarryoutnegotiationandadvocacy,andthecasemanagementofanapplicationtoasociallandlord.
₀ Acceptingthatsociallandlordsmayhavethesamereluctancetohouseformerlyhomelesspeoplewithhighsupportneedsthatexistsamongsomeprivatesectorlandlords.SociallandlordsmaybeworriedthathousingmanagementproblemsmayarisefromHousingFirstserviceusers,rangingfromneighbourdisputesthroughtorentnotbeingpaid.
₀ Beingpreparedtoofferhousingmanagementservicestosociallandlords,e.g.guaranteesthatrentwillbepaidandthatanyissuessuchasneighbourdisputeswillbehandledbytheHousingFirstservice.Thismightbeparticularly importantwhensomeoneusingHousingFirsthaspreviouslybeenevictedbyasociallandlord.
₀ Engagingwith allocation systems coveringmultiple social landlords,where these exist.All thesocial landlords inacityorregionmaybepartofasharedsystemwhereeligiblepeoplemakeasingleapplicationforhousingwhich issimultaneouslyreceivedbyall landlords.HousingFirstserviceusersmayneedsupportinusingthesekindsofsystems,whichmaybeonline.
107 Ornelas,J.,Martins,P.,Zilhão,M.T.andDuarte,T.(2014)HousingFirst:AnEcologicalApproachtoPromotingCommunity
IntegrationEuropean Journal of Homelessness(8.1),29-56-http://housingfirstguide.eu/website/wp-content/
uploads/2016/03/Housing-First-An-Ecological-Approach.pdf
108 Whitehead,C.andScanlon,K.(eds)Social Housing in Europe London: LSE.-http://www.lse.ac.uk/
geographyAndEnvironment/research/London/pdf/SocialHousingInEurope.pdf
109 Pleace,N.,Teller,N.andQuilgars,D.(2011)Social Housing Allocation and Homelessness Brussels:FEANTSA-
http://housingfirstguide.eu/website/wp-content/uploads/2016/04/feantsa_eoh-studies_v1_12-2011.pdf
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₀ Establishingaworkingprotocol,oragreement,thatmakesaminimumnumberofsuitablehomesavailableeachyear.Forexample,asocial landlordmightagreetosupply5%ofallvacanciestoHousingFirstserviceusersovera three-yearperiod.With largesocial landlords, forexampleamunicipalityorNGOprovidingallormostofthesocialhousinginacity,thepercentagerequiredmightbelower.
₀ ReachingaformalagreementthatHousingFirstserviceusersgetadditionalpointsorweightinginsocialhousingallocationsystems.Thiscouldbetheallocationsystemforasinglesociallandlordoritcouldbeadditionalpointsinachoice-basedlettingssystemcoveringmultiplesociallandlords.
CHAPTER 5.
5.Evaluating Housing First
Chapter5.EvaluatingHousingFirst
62
5.1. TheImportanceofEvidenceEvidencehasbeencentral to thedevelopmentofHousingFirst. It is throughthecollectionofgoodqualityevidencethatHousingFirstbecameinfluentialinhomelessnesspolicydebatesinNorthAmericaandwasabletoattractandthensustainfunding.InEurope,theemergingevidencebaseforHousingFirsthasshownthat it can work in a diverse range of countries,whichhavesignificantdifferencesintheirwelfaresystems,housingsystems,cultureandlevelsofeconomicprosperity.As isshown intheAppendix,HousingFirstevaluationsarereportingsuccessesincountriesasdiverseasDenmark,England,France,theNetherlands,Portugal,ScotlandandSpain.
ThereareseveralbenefitstoevaluatingHousingFirstservices:
₀ Strong evidence has been fundamentally important in persuading governments, charities and homelessness service providers to consider using Housing First. Federal governmentin theUSA regardsHousingFirst asa servicemodelofproveneffectiveness110 andsystematicevaluationshaveledtoHousingFirstbecomingcentraltotheCanadianandFrenchhomelessnessstrategies.EvaluationhasbeencrucialtopromotingtheideaofHousingFirst,indemonstratingthatHousingFirstworksandinshowingthatHousingFirstcanbecost-effective.However,evaluationsofHousingFirstmustbeofgoodqualityandshouldideallycontrasttheHousingFirstapproachwithexistingservices,iftheevidenceistobepersuasive.
₀ Measuring outcomes systematically and carefully allows a Housing First service to assess how well it is performing. GoodqualityevaluationallowsHousingFirstservicestolearnaboutanylimitationsintheirsupportorhousingprovision,enablingimprovementstobemade.
₀ Evaluation showing good performance can help Housing First services ensure they have funding in place andhelpmakethecaseforHousingFirstservicestobeexpanded.
₀ EvaluatingHousingFirstisthemainmeansbywhichgoodpracticeandimportantlessonsaboutprovidingHousingFirstcanbelearned.ConductingandsharingevaluationscanbeveryusefulforeveryoneinvolvedindevelopingandprovidingHousingFirstservices.
Evaluation presents risks as well as opportunities. Attention must be paid to how information onperformance is collected, because an evaluation that is not well designed or properly conductedcanunderminethecaseforan individualHousingFirstserviceandHousingFirst ingeneral.Anyoneundertaking an evaluation of Housing First needs to be clear that the evaluation, if it is properlyconducted,willnot report that aHousingFirst service isperfect.Therewill beat least someminorissuesthatneedaddressingand,whiletheratesatwhichHousingFirstwillendhomelessnessare,oncurrentevidence,usuallyveryhighcomparedtomostotherhomelessnessservices,HousingFirstwillnotworkwellforabsolutelyeveryoneinallcircumstances.
EvidencecancertainlyhelpsupportHousingFirst,indeeditcanbecrucialtoensuringthattheideaispromotedandthatHousingFirstservicesaresustainablyfunded.TheuseofgoodqualityevidencehasbeenfundamentaltosuccessfullypromotingHousingFirstinNorthAmerica.However,collectingevidencedoespresentsomerisksbecauseitcanhighlightlimitationsaswellassuccesses.It isalsoimportanttonotethatwhilephilanthropists,charitiesandgovernmentswillnotexpectHousingFirsttoreportperfectresults,theymaynotalwaysbepersuadedbyevidence,evenifaHousingFirstserviceisverysuccessful.
110 Tsemberis,S.(2010)Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction
Minnesota:Hazelden.
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5.2. ProcessandEffectivenessEvaluation
5.2.1. ProcessEvaluationProcess evaluation refers to exploring how a service works.ThismeansunderstandingthephilosophyofHousingFirst.EnsuringthedesignofaHousingFirstserviceisfullyunderstood,i.e.howtheHousingFirstserviceissupposedtoworkisaveryimportantfirststepinevaluation.Akeymeasurehereistheleveloffidelity (similarity) to theoriginalHousingFirstmodel.Fidelity refers to thecoreprinciplesofHousingFirstandtheoperationaldetailofthesuccessfuloriginalmodelofHousingFirst.
5.2.2. FidelityAssessingfidelityisthestartingpointofanevaluationofHousingFirst.Fidelity refers to how closely a service follows the core principles of Housing First (seeChapter2).Ifaservicedoesnotfollowthecoreprinciples,itshouldnotberegardedasHousingFirstandshouldnotbeevaluatedasanexampleofHousingFirst.
Fidelitymeasurementcanalsobedescribedastestingforparadigmormodeldrift(movingawayfromtheoriginalmodel),whichisafundamentalprincipleofanyserviceevaluation.ThismeansmakingsurethattheHousingFirstservicebeingtestedisclosetotheoriginalservicedesign,i.e.thataservicehasnotdriftedawayfrom,orwasneverreallycloseto,thecoreprinciplesofHousingFirst.Inevaluation,thisisveryimportantbecauseittellstheevaluatorsandanyonehearingabouttheresultsofanevaluationwhetherornotasuccessfulHousingFirstservice,oraHousingFirstservicewithproblems,hadhighorlowfidelitywiththecoreprinciplesofHousingFirst.Thisisimportantbecausesuccessorfailuremaybothbeheavilyinfluencedbyfidelityanditiscrucialtounderstandwhether,forexample,poorresultsfromaparticularHousingFirstservicecouldbeexplainedbylowfidelity.TheevidencefromEuropesofarsuggeststhatsuccessinHousingFirstislinkedtohighfidelitywiththecoreprinciples111.HousingFirstservicesthatfollowthecoreprinciples,althoughtheyworkinEuropeancountrieswithsometimesverydifferentwelfare,health,housingandhomelessnesssystems,havealldeliveredgoodresults inendinghomelessness(seeChapter1).
FidelitytestsexistinNorthAmerica,arebeingdevelopedforuseinEuropeandarealsobeingdevelopedandusedinindividualEuropeancountries.Theoperationaldetailsmayvary,e.g.whetherornotsocialhousing is used, orwhether a service employs an integratedmultidisciplinary team, intensive casemanagementoracombinationofsupport(seeChapter3andChapter4).OperationaldetailsmayalsoneedtovarytoallowfordifferencesincontextbetweenEuropeancountries,e.g.differencesinhealth,welfareandhousingsystems.However,adherencetothecoreprinciplesofHousingFirstcannot varyifaserviceistobeviewedashighfidelity.
ExamplesofHousingFirstfidelitytestsinclude:
₀ ThePathwaystoHousingFirstfidelitymeasure112.
₀ TheCanadianAtHome/ChezSoiprogrammefidelitymeasure113.
₀ TheFullServicePartnership(FSP)fidelitymeasure114.
111 Pleace,N.andBretherton,J.(2013)TheCaseforHousingFirstintheEuropeanUnion:ACriticalEvaluationofConcerns
aboutEffectivenessEuropean Journal of Homelessness,7(2),21-41http://housingfirstguide.eu/website/the-case-for-
housing-first-in-the-european-union-a-critical-evaluation-of-concerns-about-effectiveness/
112 http://www.housingfirsttoolkit.ca/sites/default/files/Revised_HF_Self-Assessment_Survey_12-23-13.pdf
113 http://www.housingfirsttoolkit.ca/sites/default/files/AtHomeFidelityScale.pdf
114 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4097835
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5.2.3. EffectivenessEvaluationThe evaluation of effectiveness centres on what a Housing First service is achieving.Thisaspectofevaluation includes theprogress thataHousingFirstservice ismaking in termsofdelivering theoutcomesitisdesignedtodeliver.ItisalsoimportantforanevaluationtounderstandwhatthepeopleusingaHousingFirstservicethinkaboutHousingFirst.
TheevaluationofeffectivenessstartsbyexploringthewaysinwhichaHousingFirstserviceisdelivered.Alongsideunderstanding thestructureof theHousingFirstserviceandobservinghow itworks, thisalsoinvolvesmappingtherangeofpartneragenciesinvolved,howtheserviceisfundedandhowthenetworksthataHousingFirstservicereliesonarestructuredandfunction.InordertounderstandtheeffectivenessofaHousingFirstservice,itisveryimportanttounderstandhowtheHousingFirstserviceisdesignedandhowitoperates.ThisinvolvesunderstandinghowaHousingFirstserviceistargeted,whatitisdesignedtoachieveandwhattherolesoftheHousingFirststaffteamare.
After assessing fidelity, an evaluationmustexplore the outcomes that a Housing First service is designed to achieve.ThismeanstestingwhetherornotaHousingFirstserviceisachievingwhatitissupposedtoachieve,bothintermsofoutcomesandtheviewsofthepeopleusingtheHousingFirstservice.
EFFECTIVENESS EVALUATION
WHAT a Housing first
service is achieving
PROCESS EVALUATION
HOWa service
works
FIDELITY TO THE CORE PRINCIPLES
HOW closely a service follows
the core principles of Housing First
EVALUATING HOUSING
FIRST
Exploring the effectiveness of a Housing First service has several dimensions:
₀ Promoting housing sustainment and a lasting exit from homelessness. This is sometimes also called housing retention.
₀ Enhancing the health and well-being of Housing First service users,
₀ Improving the social integration of Housing First service users.
₀ The cost-effectiveness of Housing First.
Chapter5.EvaluatingHousingFirst
65
5.3. WhattoMeasure
5.3.1. UseofValidatedMeasuresValidated measures are questions that have been repeatedly tested and found to produce consistent results.Validatedmeasurescanenhancethequalityofanevaluationandmeanthattheresultsaremorelikelytoberegardedasaccurate.Validatedmeasurescaninclude:
₀ Validatedquestionsonmentalandphysicalhealth.
₀ Validatedquestionsonqualityoflife.
₀ Validatedquestionsonsocialintegrationandsocialsupport.
Some validated measures are widely used at national level,buttherearealsoexamplesofmeasuresthatareusedinternationally.Someexamplesofvalidatedmeasuresinclude(notethislistisillustrativeonly):
₀ TheSF-12115andSF-36116measuresofhealthandwell-being.
₀ Lehman’sQualityofLifeInterview117(QoLI).
₀ Quality-AdjustedLifeYears(QALYs)usedinHealthEconomics.
₀ TheSelf-SufficiencyMatrix118(SSM)developedintheUSandadaptedforuseintheNetherlands.
₀ TheSAMSHA(SubstanceAbuseandMentalHealthServicesAdministration)scale119.
5.3.2. KeyQuestionsforEvaluationHousingFirsthasthreesetsofinterrelatedgoals(seeChapter2):
₀ Promoting housing sustainment and a lasting exit fromhomelessness (also known as housingretention).
₀ Enhancingthehealthandwell-beingofHousingFirstserviceusers,including:
• Mentalhealth.
• Physicalhealth.
• Limitingillnessanddisability.
• Drugandalcoholuse(wherethishasbeenanissueforsomeoneusingHousingFirstservices).
₀ ImprovingthesocialintegrationofHousingFirstserviceusers,including:
• Gainsinsocialsupportandself-esteem.
• Engagementincommunityandciviclife.
• Structuredandproductiveactivityandeconomicintegration.
• Working on nuisance, criminal or anti-social behaviour (where this has been an issue forsomeoneusingHousingFirstservices).
115 TheSF-12healthquestionnaireisavailableat:https://www.hss.edu/physician-files/huang/SF12-RCH.pdf
116 Availableat:http://www.shcdenver.com/Portals/902/web-content/files/JamesGenuario/JG-health%20questionnaire.
117 Pleace,N.withWallace,A.(2011)DemonstratingtheEffectivenessofHousingSupportServicesforPeoplewithMental
HealthProblems:AReviewLondon:NationalHousingFederation
118 Availableat:http://www.selfsufficiencymatrix.org/zrm-int.aspx
119 Pleace,N.withWallace,A.(2011)DemonstratingtheEffectivenessofHousingSupportServicesforPeoplewithMental
HealthProblems:AReviewLondon:NationalHousingFederation.Videsupra
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₀ Thecost-effectivenessofHousingFirst,whichhastwodimensions:
• Thecost-effectivenessofHousingFirstcomparedtootherhomelessnessservices.
• The cost offsets, i.e. savings, that Housing First can potentially generate for other types ofservice,e.g.HousingFirstcanproducereductionsinexpenditureforhealthservicesbecauseitchangesthewaysinwhichlong-termhomelesspeopleusehealthservicesandtheirlevelofuseofmedicalservicesfalls.
MeasurementofoutcomesofHousingFirstcentresonthesethreesetsofgoals.Successfuloutcomesfor Housing First rest on achieving as much as possible for each individual service user. Housingsustainment is an achievement, but it is a limited achievement if someone is isolated, bored, feelsstigmatisedorisnotexperiencingimprovementsintheirhealthandwell-being.Equally,gainsinsocialsupportareanachievement,butHousingFirstisnotworkingwellifaserviceuserisnotsustainingtheirhousingaswell.
OveralleffectivenessforHousingFirstrestsonachievingsuccessesacrossarangeofoutcomes,relatedtohousing,health,well-beingandsocialintegration.Whensuccessesareachieved,it isimportanttounderstand those successes in terms of the overallwell-being and situation of eachHousing Firstserviceuser.
EvaluationsofHousingFirstmayalsoneedtoincludeanassessmentofcost-effectiveness.Thiselementofevaluation looksat the relativecost-effectivenessofHousingFirst compared toothermodelsofhomelessnessservices.EvaluatingcosteffectivenesscanalsoincludeassessingwhetherHousingFirstgenerateswidersavingsinpublicspending.
5.3.3. HousingSustainmentHousingsustainmentcanbemeasuredinthreemainways:
₀ Length of time a Housing First service user has lived in the same home.Thisapproachhassomeadvantages:
• Itisasimplemeasurethatisinstantlyunderstandable.IfaHousingFirstserviceuserhasbeenlivingintheirhomeforayear,thisisaclearindicationofhousingsustainment.
• Themeasuregivesanideaofhousingstability,i.e.ifHousingFirstserviceusersaretypicallyremaininginthefirstapartmenttheyarehousedinforayearormore,thisindicatesthathousingisbeingveryeffectivelysustained.
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₀ Time spent in an apartment compared to time spent sleeping and living in other situations. Thisapproach:
• Providesanight-by-nightmeasureofwhereHousingFirstserviceusersareandallowsrelativechangestoberecorded.Forexample,ifsomeonewerelivingrough(onthestreet)forthreenightsaweekpriortousingHousingFirstandlivingroughdropstooneortwonightsamonth,thereisacleargain.
• Canbehardtointerpretunlessverycarefullyrecorded.Itneedstobeclearwhethernightsinanapartmentarewithinthesameapartmentornot,orwhethertherewasareasonforsomeonenottobeintheirapartmentforagivennumberofnights.
₀ Individuals’ feelings about their homes.Thisapproach:
• Enables assessment of how a Housing First service user feels about their home and howsettledtheyare.
• Looksatthesuccessofhousinginawidersense,including:
› whethersomeonefeelsphysicallysafeintheirhome;
› whethertheirhomeisaffordable;
› whethertheirhomehasallthefacilitiestheyneed;
› whethertheirhomeisofanadequatestandard(damp,poorrepairorpoorspacestandards);
› viewsontheneighbourhoodwheretheirhomeislocated;
› howhappyaHousingFirstserviceuseriswiththeirhome.
5.3.4. HealthandWell-BeingTherearethreewaystomeasurehealthandwell-being:
₀ Use very basic measures based on people’s own judgement about how their health is andwhetherthereareanychangesindrug/alcoholuse(wherethisisrelevant).
• Usingbasicmeasuresofwhethersomeonefeelstheyaregettingbetterorworse,intermsoftheirphysicalhealth,mentalhealthanddrug/alcoholuse,isverysimple.
• Answerswillbesubjective,i.e.theywillbeinfluencedbyanindividual’sinterpretationoftheirhealthandwell-being,whichmaybemorepositive,ormorenegative,thantheviewamedicalprofessionalwouldtake.
• Answerscannotbecomparedsystematically,becausetheinformationbeingcollectedisnotconsistent(HousingFirstserviceuserswillnotall interprettheirhealthandwell-beinginthesamewayaseachother).
₀ Use validated measures of health and well-being.Avalidatedmeasureisonewhichhasbeenrepeatedlytestedandfoundtobeaccurateinrecordinghealthandwell-being.AnexampleistheSF-12healthquestionnaire,whichhasbeenwidelyusedinsurveysandstatisticalresearch,whichestablishesbasicinformationonphysicalandmentalhealth.Thisapproach:
• AllowsthecollectionofdatathatcanbecomparedovertimeandacrossHousingFirstserviceusers,becausequestionsand responses takeplacewithinaclearly-definedandconsistentframework.
• Collectsdatathatmaycarrymoreinfluenceintheoutsideworld,becausetheyuserecognisedstandardsofmeasurementthathavebeentested.
• Will bemore complex and expensive to administer than just askingvery simple questionsabouthealth.
₀ Employ external evaluation of health and well-being.Medicalteamsandpsychiatristscouldbeusedtotesthealthandwell-beingamongHousingFirstserviceusersovertime.Thisisfeasibleandislikelytogenerateevidencethatistakenseriouslybyexternalagencies,butmaybedifficulttofund.
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5.3.5. SocialIntegrationInsomerespects,socialintegrationisthehardestofthevariousoutcomestomeasure:
₀ Socialsupport,participationincommunityandciviclifeandthenatureandextentofstructuredactivityareverysubjective.Whentwoindividualsreceivethesamelevelsofsocialsupport,onemayreportthattheyareisolatedandbored,andtheothermayfeelsupportedandhappy.
₀ Socialintegrationcan be interpreted in different waysfordifferentgroupsofpeople.InEurope,itisquitecommontotalkaboutthelackof‘community’inpoorareasasasocialproblem,butnottoviewthelackof‘community’inrichareasasbeingasocialproblem.Itisimportantnottoimposeanidealofwhata‘citizen’shouldbeonpeopleusingHousingFirst,whenmostothercitizensdonotmatchthatsameideal.
₀ Validatedmeasuresofsocialsupportareavailable,butthisisanareawherequalitative outcome measurement, i.e. talking to Housing First service users about their lives and level of socialintegration,may be the most effective waytocollectinformation.
₀ Measurementofsocialintegrationmusttake into account the other needs, characteristics and experiencesofHousingFirst serviceusers. IfmanypeopleusingaHousingFirst servicehaveongoing,limitingillnesses,thiswillinfluencehowmuchsuccesscanbeachievedwitheconomicintegration.
Measurementsofsocialintegrationmightincludethefollowing:
₀ Social support
• Istheuserincontactwiththeirfamily?
• Istheuserincontactwithfriends?
• Dotheyhaveapartner?
• Dotheyhaveesteemsupport,asense theyarevaluedbyothers,andwhat is their levelofself-esteem?
• Dotheyhaveaccesstoinstrumental(practical)supportfromfriends,familyand/orapartner?
• Dotheyhavesufficientsocialcompanionship?
• Aretherepeopletheycanaskforadviceand/ortalkto?
₀ Community and civic participation
• DoesaHousingFirstserviceuserparticipateincommunityevents?
• Whataretheirrelationshipswiththeirneighbourslike?
• Dotheysocialisewithintheircommunity?
• Dotheyparticipateinsocialmediafocusedontheircommunity?
• Dotheyvote?
• Dotheyvolunteerintheircommunity?
₀ Structured activity and paid work
• DoesaHousingFirstserviceuserparticipateinthecreativeorperformingarts?
• Aretheyineducationorreceivingtraining?
• Aretheyvolunteering(inanycapacity)?
• Aretheyparticipatinginaworkplacement/workexperiencescheme?
• Aretheyinpaidwork?
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5.3.6. Cost-EffectivenessThe measurement of the cost-effectiveness of Housing First services is heavily reliant on access to good quality, detailed, data.Itispossibletoproduceestimationsofcost-effectiveness,butthesearelessinfluentialthandetailedinformationthatclearlyshowsHousingFirstdeliveringeffectiveservices.It is important tonote thatcost-benefit analysis isadistinctive,highlydetailedandcomplex formofeconomicevaluationwhichshouldnotbeconfusedwithevaluationofcost-effectiveness.Therearetwobasictestsofcost-effectivenesswhichcanbeusedforHousingFirstorotherhomelessnessservices120:
₀ IsHousingFirstachievingbetter results than existing homelessness services forthesamelevelofspendingand/orforalowerlevelofspending?
₀ IsHousingFirstproducingcost offsets121,i.e.reductions in expenditure,forotherpubliclyfundedservices? For example, by ending long-term and repeated homelessness, Housing First mayproducesavingsforemergencyhealthservices,mentalhealthservices,drugandalcoholservices,the criminal justice system,welfare systems and other homelessness services. It is importantto explorewhether these savings are realisable, i.e. the reductions in long-term and repeatedhomelessness delivered by Housing First really do allow publicly-funded services to reducespending.
5.4. HowtoMeasure
5.4.1. PlanninganEvaluationWhendesigninganevaluation,itisusefultolook at how other Housing First services (or programmes or strategies using Housing First) have been evaluated andalso to lookat anycriticismof thoseevaluations.The Internet isagoodsourceof informationandresourcessuchasGoogle Scholarcanprovideinformationontheevaluationsthathavebeenconducted,withaccesstosomefreeresources.MajorevaluationsofHousingFirst,whichtendtobesupportedbylarge,publicly-fundedorganisations,oftenproducereportswhicharefreelyavailableontheInternet.SomeguidanceonevaluationisalsoavailableontheCanadian Housing First Toolkit122.
Evaluation can be comparative, which can include experimental or randomised control trials, inwhichtwoexactlymatchedgroups(aminimumof100peopleineachgroupisdesirable)aremonitored.OnegroupusesHousingFirstandtheotherusesexistinghomelessnessservices.Overthecourseofayearormore,outcomesforthoseusingHousingFirstarecomparedwiththoseforhomelesspeopleusingexistinghomelessnessservices.Thesecomparisonsareexpensivetoconduct,butproducehighqualityevidenceiftheyarecarefullydesignedandprecise.Randomisedcontroltrials(RCTs)ofthissorthavebeenusedtotesttheFrenchandtheCanadianHousingFirstprogrammesandhavegenerallyreportedverypositiveresults(seeChapter1).
Housing First has also been evaluated using comparison-group, or quasi-experimental, research. Again, theseevaluations compareonegroupusingHousingFirstwith another groupusingexistinghomelessness services, but thegroupsarenotpreciselymatchedandcanbe smaller.This kindofevaluationcanstillbeinfluential,butisgenerallyviewedasbeinglessaccurate.
120 Pleace,N.,Benjaminsen,L.,Baptista,I.andBusch-Geertsema(2013)The Costs of Homelessness in Europe: An Assessment
of the Current Evidence BaseBrussels:FEANTSAhttp://housingfirstguide.eu/website/the-costs-of-homelessness-
in-europe-an-assessment-of-the-current-evidence-base
121 Ibid.
122 http://www.housingfirsttoolkit.ca/evaluate
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ManyevaluationsofHousingFirstareobservational,whichmeanslookingatthepeopleusingaHousingFirstserviceandassessinghoweffectivetheservice is inaddressingtheirhomelessness, improvingtheirhealthandwell-beingandpromotingsocial integration (e.g.beingpartofacommunity,havingsocialsupportfromfriends,familyandapartner,see5.3).Whilethisapproachtoevaluationcanproduceuseful andpersuasive evidence, the lack of a direct comparisonwith other homelessness servicescanmeantheresultsareseenaslessconvincingthanevaluationsusingRCTsorquasi-experimentalapproaches.
Itisveryimportanttoconsidertheresources and objectives of an evaluationcarefully.Thisincludesthinkingthroughwhattheevaluationistesting,whatargumentsitmaybeusedtosupport,howmuchtimeandmoneyareavailableandthepotentialcriticismsthatmightbemadeoftheresults.WhileRCTsareoftendescribedasthebestpossibleformofevaluation,theycanstillbethesubjectofcriticismandtheir resultsmayberejected,particularly if there isseen tobeaproblemwithdesignora lackofprecision.AnRCTcannotbedonecheaplyandwill involvea lotof resources if it isgoing tobetrulypersuasive.Equally,amuchcheaperwayofevaluating,anobservationalapproach,while ithaslimitations,canstillbehighlypersuasive.
Anotherconsiderationiswhowillberesponsible for an evaluation.AnevaluationislesslikelytobeinfluentialifitisproducedbytheorganisationprovidingaHousingFirstservice,thanifanevaluationusesindependent researchers.This isnottosuggestthatanin-houseevaluation(anevaluationofHousingFirstservicesby thepeopleproviding theHousingFirstservice)hasnovalue.Theevidence fromagoodqualityin-houseevaluationcanstillbeinfluential.Nevertheless,theargumentthatanin-houseevaluationwillbelesslikelytorecordorreportproblemsmaybeusedtoquestiontheresultsofanin-houseevaluation.
Evaluations should always include feedback from Housing First service users. Giving service users aclearvoiceshouldenableanydeficienciesinHousingFirstservicestobeidentifiedandcorrected.Equally,whenHousingFirst is performingwell, service userswill have adetailedunderstandingofgoodpracticethatcanbelearnedfromandshared.EnsuringthatthepeopleusingHousingFirsthaveavoiceinevaluationisusefulforthefollowingreasons:
₀ Homelesspeopleareexpertsbyexperience;theyunderstandtheirownneedsandwhatsupporttheyrequirebetterthananyoneelsedoes.TheviewsofserviceusersonhowwellaHousingFirstserviceisworkingareaveryimportantpartofanevaluation.BoththestrengthsandanylimitationsofHousingFirstarebestunderstoodbytalkingtothepeopleusingtheservice.
₀ ThedirectexperienceofhomelesspeopleusingHousingFirst,whenHousingFirstisworkingwell,isapowerfulwayofconveyingtheeffectivenessofHousingFirst.StatisticscanbeusedtomakethecaseforHousingFirst,butthatcasecanbemademorepowerfullywhenpositiveopinionfromserviceusersiscombinedwithstatisticalevidence.
Using qualitative methods, i.e. talking topeopleusingHousingFirst in anopenway,whichallowsandencouragesthemtoexpresstheiropinions,isthe best way to learn from their experience. It isalsopossibletounderstandopinionthroughstatisticalsurveys,butitisimportantthatsurveysarenotdesignedsolelybyresearcherswithoutanyconsultationwiththepeopleusingHousingFirst,whoarelikelytohaveusefulviewsonthekindsofquestionsthatshouldbeasked.
How an evaluation is done depends on what the wider goals of Housing First are. Forexample,ifHousingFirst isbeing tested for thefirst time inaparticularcountry, regionormunicipality, itwillmakesensetouseexperimental(RCT)orcomparativeapproachestoresearch.Whenithasnotbeenusedbefore,HousingFirstneedstobetestedtoseehowwellitperformswhencomparedtoexistinghomelessnessservices.Dependingontheresultsofthatevaluation,HousingFirstmaythenbeusedonalargerscale.
Iftheexistingevidenceisstrongenough,eitherbasedonalocalevaluationortheinternationalevidencebase,itmaybedecidedthatthereisnoneedtocomparativelyevaluateHousingFirstservices.Instead,evaluation can be mainly about outcome monitoring, to ensure that the Housing First service isperformingasexpectedandtolookforanyproblems.
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Evaluation also needs to be proportionate.Arelativelyexpensiveevaluation,suchasanRCTevaluation,isonlyreallypracticalwhenlookingatalargeHousingFirstserviceorHousingFirstprogramme,notfortestingasingle,smallHousingFirstservice.Thisisbecause,toberobust,anRCTshouldinvolveatleast200people(100usingHousingFirstand100usingotherservices).ItcanstillbeveryvaluabletolookatsingleHousingFirstservicescomparatively,butsmaller-scaleserviceswith,forexample,20serviceuserscanalsobeevaluatedusingquasi-experimentalorobservationalapproaches.
CHAPTER 6.
6.Housing First and Wider Strategy
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6.1. TheStrategicRolesofHousingFirst
6.1.1. IncorporatingHousingFirstintoStrategiestoFightHomelessness
Researchshowsthathomelessnessshouldnotbeseenassimplybeingtheresultofindividualactionsoruntreatedmentalillness.HomelessnessexistsinmultipleformsinEurope.Somehomelessnessdoesnotinvolvepeoplewhousedrugs,drinktoexcessorhavementalhealthproblems,butisinsteadlinkedprimarily to theireconomicposition, awider lackofcommunity integration,poor social supportanddifficultiesinaccessingservices123.Homelessnesscanalsovarybetweendifferentgroups.Forexample,women’shomelessness ismuchmorelikelytobelinkedtoescapingdomesticviolencethanmen’s.Homelesswomenmay also avoid some forms of homelessness service, often relying on informalrelationshipstotemporarilyfindaccommodation124.Womenexperiencinghomelessnesscanthereforerequire different services from those provided to single homelessmen. Somegroups of homelesspeople,suchasteenagerswithexperienceofsocialwork-basedchildprotectionsystems,peoplewhohavebeeninprisonandarmyveterans,mayalsorequirespecialisedformsofsupport.
Preventingandreducinghomelessnessinvolvesarangeofpoliciesandservices,includingenhancingaccesstohousing,enablingdevelopmentofnewaffordablehousing,providingpreventativeservicesandarangeofothersupportservices.Somehomelesspeoplewillonlyrequireadviceandperhapssome short-term support to prevent or quickly end an experience of homelessness. Others mayneedlow-intensitysupportforafewweeks,ormonths,tohelpthemfindandsustainahome.aSomemayrequiremoresupport fora longerperiodof time toeitherexitoravoidhomelessness.Dataonhomelessness inEuropeareoftenlimited,butthere isevidencethatEuropeancountrieswithhighlyintegratedhomelessnessstrategies,providingarangeofwell-coordinatedservices,suchasDenmarkandFinland,haveverylowlevelsofhomelessness125.
GuidanceonintegratedhomelessnessstrategiesisavailableontheFEANTSAwebsite126.AreviewofthesuccessfulFinnishintegratedhomelessnessstrategywaspublishedin2015127.ArangeofdiscussiononhomelessnessstrategiesinEurope,includingdescriptionsandcriticalevaluations,isavailableintheEuropean Journal of Homelessness128.
6.1.2. HousingFirstAlongsideOtherServices HousingFirst isnotdesignedtoactasasolution toall formsofhomelessness.Nor isHousingFirstintendedtoworkinisolation:itrequiressupportfromthehealthandsocialworksectorsandfromotherhomelessnessservices.Aspartofanintegratedhomelessnessstrategy,HousingFirstworkswiththosepeoplewhosehomelessnesscannotbepreventedorwhoseneedscannotbemetbyhousingalone,orbyhousingandlow-intensitysupportservices.
123 Busch-Geertsema,V.,Edgar,W.,O’Sullivan,E.andPleace,N.(2010)Homelessness and Homeless Policies in Europe:
Lessons from Research,Brussels,Directorate-GeneralforEmployment,SocialAffairsandEqualOpportunities.Vid.Note91
124 Baptista,I.(2010)’WomenandHomelessnessinEurope‘inO’Sullivan,E.,Busch-Geertsema,V.,Quilgars,D.andPleace,N.
(eds.)Homelessness Research in EuropeBrussels:FEANTSA.
125 Busch-Geertsema,V.,Benjaminsen,L.,FilipovičHrast,M.andPleace,N.(2014)Extent and Profile of Homelessness in
European Member States: A Statistical UpdateBrussels:FEANTSA-http://housingfirstguide.eu/website/wp-content/
uploads/2016/04/feantsa-studies_04-web2.pdf
126 ToolkitsonHomelessnessStrategies:www.feantsa.org
127 Pleace,N.,Culhane,D.P.,Granfelt,R.andKnutagård,M.(2015)The Finnish Homelessness Strategy: An International Review
Helsinki:MinistryoftheEnvironment-https://helda.helsinki.fi/handle/10138/153258
128 http://www.feantsaresearch.org-The European Journal of HomelessnessisalsoindexedonGoogleScholar.
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TheoriginatorofHousingFirst,Dr.SamTsemberis,hassuggesteda role forHousingFirstwithinanintegrated homelessness strategy, inwhich homeless peoplewith high support needs are initiallyofferedHousingFirstandthosewhoseneedscannotbemetbyHousingFirstarethenofferedlong-term,congregateorcommunalsupportedhousingwithon-sitesupportstafforinstitutionalcare.
Figure1:A‘ReverseStaircase’Strategy129
Anintegratedhomelessnessstrategymighthavethefollowingkindofstructure:
₀ Preventative services,offeringhousingadvice,supportandpracticalhelpwithaccessinghousingandsupportservicesforpeoplewithhigherneedswhoareatriskofhomelessness.
₀ Emergency accommodation for people who suddenly become homeless, working inclosecoordinationwithpreventativeservicestotrytoavoidanyexperienceofhomelessnessbecomingprolongedorrepeated.
₀ Lower-intensity support services for people who require some support to leave homelessness,butwhoseneedscanbemetbyrapidlyprovidingthemwithhousingandlow-levelcontactwithacase-managementserviceofferinglimitedsupport.
₀ Housing First services for homeless people with high support needs, rapidly providing housing and intensive support.TheevidenceisthatHousingFirstwillbeeffectiveinendinghomelessnessformostofthehomelesspeopleinthisgroup(seeChapter1).
₀ Supported housing models offering congregate or communal housing with support staff on-site,whichcanbeusedtoprovidemediumandlong-termsupporttohomelesspeoplewithhighsupportneeds,whoseneedsorpreferencesarenotmetbyHousingFirst.
ThereissomeevidencethatsomeEuropeancountrieshavealong-termhomelesspopulationwhoseneedshavenotbeenmetthroughexistinghomelessnessservices.IncountriessuchastheUK,thereisevidenceofahomelesspopulationwhomakerepeatedorlong-termuseofexistinghomelessnessservices,without their homelessnesspermanently ending as a result130. HousingFirst often has thecapacitytoendthisformoflong-termhomelessness,alongsidehelpinghigh-needhomelesspeoplewhospendverylongperiodsoftimelivingonthestreet,orinemergencyshelters,toexithomelessness.
129 Tsemberis,S.(2013)PresentationattheFinalConferenceofHousingFirstEuropeinAmsterdam,citedinPleace,N.and
Quilgars,D.(2013)Improving Health and Social Integration through Housing First: A ReviewBrussels:DIHAL/FEANTSA
130 Bretherton,J.andPleace,N.(2015)Housing First in England: An Evaluation of Nine Services https://www.york.ac.uk/media/
chp/documents/2015/Housing%20First%20England%20Report%20February%202015.pdf
Permanenthousing
(scatter-siteoff site services)
PermanentSingle Site
(on site services)
Longer termInstitutional Care
Community-based Residential
Treatment(on-site clinical
staff)
Least restrictive to more restrictive setting
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At a strategic level, the use of Housing First services can:
₀ Significantly reduce levels of long-term and repeated homelessness associated with high support needs.
₀ Potentially reduce costs of long-term and repeated homelessness for emergency health and mental health services, criminal justice systems and other homelessness services.
₀ Enable homeless people with high and complex support needs to live stably in their own homes.
6.2. FutureApplicationsofHousingFirst
HousingFirst isdesignedtohaveaspecificfunction,toendhomelessnessamongpeoplewithhighsupportneedsbyrapidlyprovidingthemwithhousingandintensivesupportservices.Thereisscopetoexpand theways inwhichHousingFirst isused,but thebasic functionand roleofHousingFirstarefixed; it isnot intended forgroupsofhomelesspeoplewith lowsupportneeds,noras thesolecomponentofaneffectivehomelessnessstrategy.
ItisimportanttonotethatwhilethereareservicesthatdrawontheideasofHousingFirst,forexampleusingordinaryhousingandlow-intensitysupportservicestohelphomelesspeoplewithouthighsupportneeds(sometimescalledhousing-ledorhousingsupportservices),thesearenotHousingFirst.Theuseofsuchservicespredatesthe introductionofHousingFirst inEurope. ItwassometimesarguedthatHousingFirstrepresentednothingnewinsomeEuropeancountries,becausetheseservicesalreadyexisted.However,therecanbeimportantdifferencesinthecoreprinciples,theintensityanddurationofsupportbetweentheselow-intensityservicesandaHousingFirstapproach.
WidespreaduseofHousingFirsthaspotentialimplicationsforsomeexistinghomelessnessservices.ItisnotthecasethatHousingFirstcanorshouldactasareplacementforallexistinghomelessnessservices,becauseHousingFirstisonlydesignedforonegroupofhigh-needhomelesspeople.However,there is clear evidence that Housing First outperforms some existing service models for endinghomelessnessamongpeoplewithhighsupportneeds(seeChapter1).Insomecases,forexampleinFinland,homelessnessserviceprovidershavechangedthewayinwhichtheyprovideservices,movingfrom staircasemodels toHousing First and have seen improvements in service effectiveness as aresult131.
6.2.1. ThepossiblefutureusesofHousingFirstinclude:
₀ Preventative use of Housing First.HousingFirstcanbeemployedasameanstoresettlepeoplewithhighsupportneedswhoareleavinginstitutionssuchaspsychiatrichospitals,prisonorlong-staysupportedhousing.SomeUSservicesworkwithpeopleleavingpsychiatrichospitalwhoareassessedasbeingathighriskofhomelessnessorhaveahistoryofhomelessness132.
131 Pleace,N.,Culhane,D.P.,Granfelt,R.andKnutagård,M.(2015) The Finnish Homelessness Strategy: An International Review
Helsinki:MinistryoftheEnvironment-https://helda.helsinki.fi/handle/10138/153258
132 Tsemberis,S.J.(2010)Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction
Minneapolis:Hazelden.
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₀ UsingspecialisedmodelsofHousingFirstforparticulargroupsofhomelesspeople.Thisisanotherareathatcanbeexploredatstrategiclevel.Forexample:
• Homeless women with high support needs.Thereisevidencethatwomenwithhighsupportneeds can often experience homelessness in differentways frommen, particularly in theiravoidance of services and their use of informal and sometimes precarious relationships tokeep themselves in accommodation133. Housing First, by providing homeless women withhighsupportneedswiththeirownhomes,shouldbemoreaccessiblethansomeotherformsof homelessness service, inwhichwomenmaynot feel safe.However, theexperiencesofwomen,whichmayincludehighratesofgender-based/domesticviolenceandotherabuse,meanthatthereisacaseforthedevelopmentofspecialistHousingFirst,staffedbywomenwithspecifictraining.InManchesterintheUK,ThresholdHousinghasdevelopedaHousingFirst service forhomelesswomenwithhigh supportneedswhohavehadcontactwith thecriminaljusticesystem134.
• Young people with high support needs at risk of homelessnessmayalsorequirespecificforms of support. Again, this is because their needs, characteristics and experiences maydifferfromthoseofothergroupsofhomelesspeople135.Forexample,younghomelesspeopleremaindisproportionatelylikelytohavehadexperienceofsocialservices,fosterandchildren’shomesandtohavehadnegativeexperiencesduringtheirchildhood.
• Families with high and complex needs can be supported by Housing First. There arespecificneedsherewhichcentreonaHousingFirstservicenotjustsupportinganindividual,butalsobeingabletounderstandandsupportpositivelyanentirefamily,includingchildren136. Theneedsofthesehouseholdsaroundmentalhealthproblems,drug/alcoholissuesandpoorhealth,maybesimilartothoseoflonehomelesspeople,butdifferentformsofsupportmaybeneededwhenanentirefamilyisbeingsupportedbyHousingFirst.
• Former offenders with high support needsmayalsorequirespecificsupportwhentheyleaveprison.This isanotherexampleofhowHousingFirstmightbetailored,oradjusted,tomeetspecificsetsofneeds.AnotherexamplemightbetheuseofaspecialisedmodelofHousingFirstforhomelesspeoplewithhighsupportneedswhohaveexperienceofmilitaryservice.
133 Mayock,P.,Sheridan,S.andParker,S.(2015)“It’sjustlikewe’regoingaroundincirclesandgoingbacktothesame
thing...”:Thedynamicsofwomen’sunresolvedhomelessnessHousing StudiesDOI:10.1080/02673037.2014.991378
134 http://www.thp.org.uk/services/housing-first
135 Quilgars,D.,Johnsen,S.andPleace,N.(2008)Review of Youth Homelessness in the UK,York:JosephRowntreeFoundation
-https://www.jrf.org.uk/report/youth-homelessness-uk
136 Jones,A.,Pleace,N.andQuilgars,D.(2002)Firm Foundations: an Evaluation of the Shelter Homeless to Home Service,
London:Shelter.-https://england.shelter.org.uk/__data/assets/pdf_file/0020/39521/Firm_Foundations.pdf
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6.3. MakingtheCaseforHousingFirst SeveralEuropeangovernments,forexampleDenmark, Finland, France and Spain,havedecidedtoadoptandtestHousingFirstasacornerstoneoftheirstrategic responses to homelessness.InotherEuropeancountries, thepolicy response toHousingFirsthasbeenmoreuneven137.AtEU level, thereport by the Jury at the 2010 European Consensus Conference on Homelessness recommendedconsiderationofHousingFirstandrelatedservices intacklinghomelessness138,apositionsharedbytheEuropeanCommission139.
The roleofevidence,particularlygoodqualityevidence thatsystematicallycomparesHousingFirstwithmoreorthodoxhomelessnessservices,hasbeenfundamentalinencouragingtheuseofHousingFirstinNorthAmerica.AgoodstandardofevidencehasenabledHousingFirsttodrawattentionfromEuropean governments and homelessness service providers and attract interest from internationalorganisationsliketheEuropeanCommissionandtheOECD.Ofcourse,notalltheevidenceforHousingFirstisuniversallyviewedasbeingofgoodqualityandtherewillbethosewhoremainunconvincedthattheevidenceshowsthatHousingFirstisamodeltopursue.Nevertheless,goodqualityresearchthatclearlyshowssuccessinendinghomelessnessforhigh-needpeopleandrelativecost-effectiveness,willremainimportantinmakingthecaseforHousingFirst.
In Sweden,LundUniversityhasbeenactivelypromotingtheideaofHousingFirstwithhomelessnessserviceprovidersandpolicymakers140. In Italy,theHousingFirstItaliagroup141,acollaborationbetweenservice providers, municipalities and academics, operating under the auspices of fio.PSD, has alsobeenpromotingHousingFirst.Thegrassroots,orground-up,advocacyanddiscussionofHousingFirstcanhelpput this important innovation that reduceshomelessnessamongpeoplewithhighsupportneeds,onthepolicyagenda.Collaborationsbetweenserviceprovidersanduniversities,likeinSwedenandItaly,combineprofessionals inservicedeliverywithprofessionals inevaluation,whichenhancescapacitytolobbyeffectivelyforHousingFirstbycollectingstrongevidence.
In England,HomelessLink,thefederationofhomelessnessserviceproviders,havedevelopedHousingFirstEngland142,aprogrammedesignedtopromoteHousingFirstatpolicylevelandasamodelofgoodpractice,startingin2016.Again,thisisacollaborativeeffort,closelyreflectingdevelopmentsinItalyandSweden.
HousingFirstissuccessfulbecauseofthe way in which support is provided butitisequally,perhapsevenmore, successfulbecauseof theemphasis on rapidly providing a home, and so removingapersonfromhomelessnessandtherisksanduncertaintiesassociatedwithhomelessness(seeChapter1andChapter3).Thereisresearchevidencethat,whilecoordinationofserviceswithinanintegratedhomelessness strategy produces a more effective policy response to homelessness, nothing canultimately overcome a shortage of affordable, adequate housing. Housing First is important as aninnovation,butitisalsoimportantbecauseitdrawsattentiontothecentralrolethathousingmustplaywithinastrategicresponsetohomelessness143.
HousingFirstisalsosignificantbecauseit fractures assumptions about the nature of homelessness and the people who experience homelessness. It shows that homelessness is not as simple as
137 FEANTSA(2012)On the Way Home? FEANTSA Monitoring Report on Homelessness and Homeless Policies in Europe.
Brussels:FEANTSA-http://housingfirstguide.eu/website/on-the-way-home-feantsa-monitoring-report-on-
homelessness-and-homeless-policies-in-europe/
FondationAbbéPierre/FEANTSA(2015)An Overview of Housing Exclusion in Europe: 2015-http://housingfirstguide.eu/
website/an-overview-of-housing-exclusion-in-europe-2015/
138 http://ec.europa.eu/social/main.jsp?catId=88&langId=en&eventsId=315&furtherEvents=yes
139 http://ec.europa.eu/social/BlobServlet?docId=9770&langId=en
140 http://www.soch.lu.se/en/research/research-groups/housing-first
141 http://www.housingfirstitalia.org/en/
142 www.homeless.org.uk/hfengland
143 Pleace,N.,Culhane,D.P.,Granfelt,R.andKnutagård,M.(2015)The Finnish Homelessness Strategy: An International Review
Helsinki:MinistryoftheEnvironment-https://helda.helsinki.fi/handle/10138/153258
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behaviours and attitudes that need to be changed; in fact, it is a successful service response thatsupports and enables recovery but does not demand behaviour change or use sanctions to forcechange. By rapidly providing housing, recognising the shared humanity of homeless people andrespectingtheirchoicesandencouragingrecovery,HousingFirstendshomelessness(seeChapter1).
APPENDIX:
Examples
of Housing First
Appendix
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AustriaNeunerhaus Housing First, Vienna
HousingFirstinAustriahasbeendevelopedaspartoftheWiener Wohnungslosenhilfe programme,centredonprovidingpsychosocialsupportforhomelesscitizensinVienna.Athree-yearHousingFirstservice pilot was developed, following debates about changing the staircase service models thatpredominated in Vienna. The Neunerhaus Housing First project follows the eight core principlesdescribedinChapter2.
By2015,NeunerhausHousingFirsthadworkedwith69 homeless households,includingloneadultsandfamilieswithdependentchildren.The69householdscontained131 people(46women,38men,47dependentchildren).ThescatteredhousingisprovidedbyhousingmanagementcompaniesandthepeopleusingNeunerhausHousingFirstallhavetheirown,independent,tenancyagreements.A mix of social housing, private rented and housing association homes are used.
Supportisdescribedasflexible,beingtailoredtoindividualneedswithanemphasisonpromotionofsocial inclusionandonwhat is termed ‘self-determination’and ‘participation’ (i.e.choiceandcontrol,person-centredplanning,flexiblesupportforaslongasisrequired,activeengagement).Socialinclusioniscentredonactivelyavoidingthekindsof institutionalisationthatcanbeexperiencedbyhomelesspeople.Ashousingisdealtwithimmediately,thereismoresocialworkertimetofocusoncommunityparticipationand,wherepossible,supportingHousingFirstserviceusersintopaidwork.
Results havebeenparticularly impressive in respect of housing sustainment.An evaluation reportsa98.3% housing sustainment rate for people using the Housing First service, alongside reportedgainsinsocialintegration.Anevaluation,coveringthefirsttwoyearsofoperation,isavailableathttp://www.neunerhaus.at/fileadmin/Bibliothek/Neue_Website/Neunerhaueser/Housing_First/20150925_HousingFirst_Report_english.pdf(English).
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BelgiumHousing First Belgium
TheHousingFirstBelgiumprogrammeisledatnationallevelandinvolvesthefive largest cities.Therewereatotalofeight Housing First servicesoperatingatthetimeofwriting(2015)whichwererunbyacombinationofmunicipalitiesandNGOs.HousingFirst is targetedat long-termhomelesspeoplewithanaverageoffiveyears’experienceofhomelessness,allofwhomhavehighsupportneeds.Theprogrammeaimstosupport150 people by June 2016.
Theeightservicesuseordinaryrentedapartments,relyingonamixtureofsocialhousingandprivaterented housing. There is some use of specialist, supported housing for aminority of Housing Firstserviceusers.
TheeightHousingFirstservicesdeliversupportindifferentways.AlleightHousingFirstservicesuse intensive case management, organisingaccess to requiredservicesasandwhennecessary.EachindividualusingaHousingFirstservicehastheirowndedicatedsupportworker,witheachHousingFirstworkerhavingacaseload(numberofpeopletheyaresupporting)ofbetweensixandeightHousingFirstserviceusers.
SomeoftheBelgianHousingFirstserviceshaveamultidisciplinaryteam;othersrelyentirelyonsocialworkersactingascasemanagers.The largest team, inoneof theeightservices,comprisesnurses,socialworkers,apsychologist,anemploymentspecialistandahousingspecialist;thesmallestteam,in anotherHousing First service, ismade up of only socialworkers. Five of the eightHousing Firstservices are described as being intensive casemanagement,without amultidisciplinary team.Thespecificarrangementsforeachoftheeightservicesareasfollows:
₀ Ateamofsocialworkersprovidingintensivecase-managementservices(Antwerp)
₀ Ahousingcoachandapsychologistprovidingcasemanagement(Ghent)
₀ Anurse,asocialworkerandadoctor(Brussels,service1)
₀ Specialist social workers with expertise in mental health and harm reduction providing casemanagement(Brussels,service2)
₀ Ahousingspecialistandasupportworkerprovidingcasemanagement(Hasselt)
₀ Nurses,socialworkers,aneducationspecialist,apsychologist,anemploymentspecialistandahousingspecialistinamultidisciplinaryteam(Charleroi)
₀ Socialworkersandahousingspecialistofferingcasemanagement(Liège)
₀ Nurses, socialworkers, an education specialist and a psychologist in a multidisciplinary team(Namur)
TheBelgianprogrammewasexperimentalin2015andwasbeingevaluatedatthetimeofwriting.TherewillbeareportontheeffectivenessofHousingFirst,which is likely to influencefuturepolicy.MoreinformationonHousingFirstBelgiumisavailableat:http://www.housingfirstbelgium.be/.
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DenmarkThe Danish Homelessness Strategy
Denmarkhasoneof the largestHousingFirstprogrammes inEurope.TheDanishNationalStrategy,whichwas adopted in 2008andranuntil2013, includedHousingFirstserviceswhichweretargetedatover 1,000 homeless people with high support needs144.As inBelgiumandFrance, theDanishstrategyisbeingevaluatedtoassesstheeffectivenessofHousingFirstandotherhomelessnessservicemodels insupportinghomelesspeoplewhohavehighsupportneeds.Thestrategyis ledbycentralgovernmentandtheHousingFirstservicesoperatinginDenmarkallfollowtheeightcoreprinciplesofHousingFirstdescribedinChapter2.
TheuseofHousingFirstinDenmarkhassimilaritieswiththeAtHome/ChezSoiprogrammeinCanadaand also with the French Un Chez-Soi d’abord programme. The national strategy focused on 17municipalitieswhichcontainedthemajorityofhomelessnessrecordedinDenmark,includingthethreelargestcities,Copenhagen,AarhusandOdense.Thespecificgoalswere to reduce levelsofpeoplelivingrough,totargetrisinglevelsofyouthhomelessnessmoreeffectively,toreducethetimehomelesspeoplespentinemergencyaccommodationandtobringdowntherateofhomelessnessassociatedwithpeopleleavinghospitalsandprisons.HousingFirstwasadoptedasakeyelementoftheDanishstrategywiththegoalofsystematicallytestinghowwellHousingFirstcouldworkinDenmark.Housingisprovidedthroughcooperationwithsociallandlords.
DenmarkexploredHousingFirstby lookingatmodelsusing intensive case management (the ICM model) and multidisciplinary teams (the assertive community treatment model, ACT).Therewasalsoanassessmentofbothscatteredhousingandsingle-sitecongregate/communalservices.Differentmodels,suchastheACTteamapproach,weretargetedatspecificgroupsofhomelesspeople.
ThebulkoftheDanishstrategicuseofHousingFirstwas ICMservices,whichsupportedover1,000homeless people with high support needs in 17 municipalities during 2009-2013. One ACT-basedservicehadworkedwith92individualsby2013145.
Inanevaluationcompleted in2013, thesuccessof theHousingFirstserviceswasreportedashigh,particularlyintheACT-basedservices.Therewasevidencethatthesingle-siteHousingFirstservicewassomewhatlesssuccessfulthantheservicesusingscatteredhousing.ThereareparallelswithFinlandintheuseofHousingFirstinDenmark.LikeFinland,theextensivesocialprotection(welfare)systemsinDenmarkcombinedwithsocialhousing,appeartostopmostformsofhomelessnessthatareassociatedwithpovertyandlowsupportneeds146.AsinFinland147,mostDanishhomelessnessisassociatedwithhighsupportneeds.ThisgivesHousingFirstinDenmarkacentralroleinthehomelessnessstrategy,becausemostof thehomelessness isamongthegroupsofpeople thatHousingFirst isspecificallydesignedtohelp.
Followingthepositiveresultsfromthefirsthomelessstrategy,theNationalBoardofSocialServicesdecided to implement theHousingFirst principle, includingACTand ICMapproaches, andexploretheuseoftherelatedCriticalTimeIntervention(CTI)model in24municipalitiesfromAugust2014toMay2016.A special programme foryoungpeople (aged 17-24years) is alsobeing introduced in 11municipalities fromSeptember 2015 to autumn2017.Theprogramme is designed topreventyouthhomelessnessandoneofthemethodsusedwillbetheICMmodel.Areviewoftheoutcomesfromboththeseprogrammeswillbepublishedintheautumnof2016.
144 Benjaminsen,L.(2013).PolicyReviewUp-date:ResultsfromtheHousingFirstbasedDanishHomelessness
Strategy.EuropeanJournalofHomelessness,7(2),109-131http://housingfirstguide.eu/website/wp-content/
uploads/2016/04/Policy-Review-Update-Results-Danish-Strategy.pdf
145 Asabove.
146 Benjaminsen,L.andAndrade,S.B.(2015).TestingaTypologyofHomelessnessacrossWelfareRegimes:ShelterUsein
DenmarkandtheUSA.HousingStudiesDOI:10.1080/02673037.2014.982517
147 Pleace,N.,Culhane,D.P.,Granfelt,R.andKnutagård,M.(2015)The Finnish Homelessness Strategy: An International Review
Helsinki:MinistryoftheEnvironmenthttps://helda.helsinki.fi/handle/10138/153258
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TheNationalBoardofSocialServiceshasalsobeengiventhetaskofimplementingtheHousingFirstPrincipleandrelatedfloatingsupportmodelsatnationallevelfromMay 2016 to December 2019. This programmewillcontainsupport for all municipalities, private service providers and NGOstolearnaboutHousingFirst.
AreviewoftheDanishhomelessnessstrategyisavailableathttp://housingfirstguide.eu/website/wp-content/uploads/2016/04/Policy-Review-Update-Results-Danish-Strategy.pdf(English).
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FinlandThe National Homelessness Strategy
Housing First is central to the national homelessness strategy in Finland. There is a nationalobjective to end long-term homelessness, which is often experienced by people with high andcomplex support needs. Using a combination of communal or congregate approaches, whichapplied Housing First principles to single-site projects and scattered housing approaches,Finland has achieved a marked reduction in levels of long-term homelessness. Moreinformation about the Finnish homelessness strategy, which employs Housing First within acomprehensive strategy that also emphasises homelessness prevention, can be found at: https://helda.helsinki.fi/handle/10138/153258(EnglishandFinnish)
Väinölä Housing First
Väinölä Housing First is run by the Salvation Army with housing provided by Y-Foundation148, anorganisation which develops new social housing for rent in Finland. The housing is in individual apartments, which are all located in a single apartment block.
Thesupportservicesprovidedarepresentonsiteona24/7basis.Thereisastaffteamof11 people,including socialworkers, health professionals, volunteer coordinators and awork coach,who helpsusersachievesocialintegrationthroughpaidwork.Theapproachusedisacase-managementmodel,drawingbothonthestaffteamwithinVäinöläHousingFirstandinvolvingexternalserviceprovidersasnecessary.
HousingFirstserviceusershavetheoption–thoughofcoursearenotrequired–toparticipateinatherapeuticcommunity.Theprinciplesofatherapeuticcommunitycentreon149:
₀ Offering a structured, psychologically-informedenvironment, i.e. a placewhere there aredailyactivitiesthataredesignedtopromotehealthandwell-being
₀ The therapeutic community itself is seen as amechanism bywhich treatment and support isdelivered,withanemphasison improving thesocialsupport forandself-esteemof individualswithinthecommunity
Alongside offering case management and support, Väinölä Housing First encourages voluntaryparticipationintherunningoftheservice.AllthecleaningandgardeningworkwithintheHousingFirstprojectisundertakenbythepeoplewholivethere.Thegoalistoencouragesocialsupportandsocialintegrationthroughtheexperienceoflow-thresholdwork.
PeoplelivinginVäinöläHousingFirstarealso involved in events designed to promote their social integration within the community.Thereareopenhouseevents,invitingneighboursintotheHousingFirstbuildingandotherworkcentredoninformingandeducatingtheneighbourhoodaboutHousingFirst.PeopleusingHousingFirstalsovolunteertokeeptheneighbourhoodtidy,whichisdesignedtopromotepositiverelationshipswiththesurroundingcommunity.
VäinöläHousingFirstdescribesitsownsupportprioritiesasfocusingon:
₀ Housingsustainment
₀ Healthandwell-being
₀ Socialintegration
Outcomedata, based on feedback fromHousing First service users is collected every sixmonths.Success has been reported in housing sustainment and in promoting social integration,particularly
148 http://www.ysaatio.fi/in-english/
149 http://www.therapeuticcommunities.org/
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inre-establishinglinkswithfamilyandfriendsandinsocialintegrationwiththelocalcommunity.Resultsarounddrugandalcoholuseandhealthhavebeenreportedasmorevariable,butthisisnotuncommoninHousingFirstservices(seeChapter1).
TherearesomedebateswithinEuropeandtheUSAabouttheuseofacongregateorcommunalmodelofHousingFirst,whichcentreontheextenttowhichsocialintegration(seeChapter3)ispossiblewhenHousingFirstserviceuserslivetogether150.FinnishHousingFirstservicesuseboththesecongregateorcommunalmodelsandapartmentsscatteredinthecommunity.
More information about Väinölä Housing First is available at: http://www.pelastusarmeija.fi/paikkakunnat/espoo/asumispalvelu(Finnish)
150 Pleace,N.,Culhane,D.P.,Granfelt,R.andKnutagård,M.(2015)The Finnish Homelessness Strategy: An International Review
Helsinki:MinistryoftheEnvironmenthttps://helda.helsinki.fi/handle/10138/153258
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FranceThe Un Chez-Soi d’abord Programme
Francehascarriedoutone of the largest trialsoftheHousingFirstmodelthathavetakenplaceinEurope(seeChapter6).TheUnChez-Soid’abordprogramme(2011-2016)pilotedHousingFirstinfourcities: Lille, Paris, Toulouse and MarseillesandisledatnationallevelbyDIHAL,theinter-ministerialbodyresponsibleforthenationalhomelessnessstrategy.Theprogrammeinvolvesthehealth,housingand social welfare departments in the French government. The Housing First services all havemanagementcommitteesat local level,whichtypically involveallparticipatingorganisations(health,socialwork,socialwelfare)andthereisalsoanationalsteeringgroup.
The Housing First services provided via the Un Chez-Soi d’abord programme all follow the coreprinciplesofHousingFirstdescribedinChapter2.
TheFrenchHousingFirstprogrammedrawsheavilyontheoriginalmodelofHousingFirstdevelopedbyDr.SamTsemberis.UnChez-Soid’abordcanalsobedirectlycomparedtotheCanadianAtHome/ChezSoinationalHousingFirstprogramme.A large-scale, highly robust, experimental(randomisedcontroltrial)evaluationofUnChez-Soid’abordisbeingconductedwith705 homeless peopleparticipating.In total,353 homeless peoplewere housedusingHousing First services,while the remaining352 receivedtheusualhomelessnessservices(treatmentasusual).TheevaluationisbeingconductedbyP.AuquierofAix-MarseilleUniversityandwillreportin2016.
Housing isprovidedby private landlords.Support isprovidedusingamultidisciplinary teamwhichincludespeersupportworkersandfollowsanACTmodel.TheHousingFirstservicesoperatewithaclientloadof10serviceusersperteammember.UnChez-Soid’abordhashighfidelitywith,i.e.closelyresembles,theoriginalHousingFirstmodeldevelopedinNewYorkandtheCanadianimplementationofHousingFirstintheAtHome/ChezSoiprogramme.
Success rates reported at 13months into theUn Chez-Soi d’abord programmewere high.80% ofHousingFirstserviceusershadsustainedtheirhousing.Therewasalsostrongevidenceofamarkedreductionintheuseofhospitals,livingrough,imprisonmentandstayinginemergencyaccommodationwhenthegroupusingHousingFirstwerecomparedto thoseusingexistinghomelessnessservices.Health,well-beingandsocialintegrationalsoimprovedamongHousingFirstserviceusers,although,asinotherHousingFirstservices,theresultswerenotalwayspositive(seeChapter1).Followingverypositive initial results, thedecisionwastakentoexpandtheHousingFirstprogramme,continuingtosupporttheexistingservicesduring2017andmovingtowardsdeploymentofHousingFirstservicesin15citiesfrom2018.
The Un Chez-Soi d’abord programme shows that there are examples of EuropeanHousing First services that closely resemble the original Pathways model from theUSA. The results from the French programme show that an implementation of the originalmodel can be successful in the European context. Such implementations of Housing Firstare sometimes referred to as having ‘high fidelity’ with the original Housing First model. SeeChapter2andChapter5.
InformationontheinitialresultsfromtheUnChez-Soid’abordprogrammeisavailableat http://housingfirstguide.eu/website/wp-content/uploads/2016/04/First-results-of-HF-experimentation-in-France-and-next.pdf(English). Furtherinformationontheprogrammeisalsoavailableviahttp://www.gouvernement.fr/sites/default/files/contenu/piece-jointe/2014/10/dihal_-_plaquette_gd_public_ucsdb_ecran.pdf(French).
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IrelandDublin Housing First
TheDublinHousingFirstprojectisoperatedbytwoNGOs,Focus IrelandandthePeter McVerry Trust,andwascommissionedbyagovernmentbody,theDublin Regional Housing Executive.TheDublinHousingFirstProjectfollowsthecoreprinciplesofHousingFirstdescribedinChapter2.
TheDublinHousingFirstprojectoperatesbothaHousingFirstserviceandwhat istermeda ‘street intake team’.Thestreetintaketeam,whichdeliversservicestopeoplelivingrough,isthesourceofreferrals toHousingFirst.People livingroughwithhighsupportneedsarereferredtoHousingFirst,while the street intake teamarranges less intensive service responses for people living roughwithlowersupportneeds.ThespecificfocusoftheHousingFirstteamis:
₀ Long-termandrepeatedlyhomelesspeople
₀ Homelesspeoplewithmentalhealthproblemsand/orproblematicuseofdrugsandalcohol
Housing ismainlyprovidedbysocial landlords,which in IrelandarebothmunicipalitiesandNGOs.Thereisalsouseoftheprivaterentedsector.
TheHousingFirstserviceisdeliveredusinganICM team.Aclinicalteamwhichhasspecialistsindrug/alcohol,mentalhealthandphysicalhealthandcounsellingisalsomadeavailable.TheservicesoftheclinicalteamareavailabletopeoplebeingsupportedbythelowerintensitystreetintaketeamandtheHousingFirstservice.TheHousingFirststaffhaveacaseloadofuptotenhomelesspeople.HousingFirstalsohasdedicatedstafffocusedonlocatinghousingandmanaginghousingissues.Thereisalsoa functioncentredonfindingsuitableprivate rentedsectorhousing. In2015,40 peoplewerebeingsupportedbytheHousingFirstservice.
MonitoringoftheHousingFirstserviceshowsverypositiveresultsinhousingsustainment,buttherecanbechallengesinfindingsuitablehousing(seeChapter4).Theinitialdemonstrationproject,apilotHousingFirstservicewhichwasreplacedbytheDublinHousingFirstProjectin2014,showedsuccessesin relation to improvements inhealth,mentalhealthandsocial integration;although thesewerenotuniversal,incommonwithotherHousingFirstservices(seeChapter1).
The results of the Housing First demonstration project, onwhich the Dublin Housing First projectis based, are available at: http://www.homelessdublin.ie/sites/default/files/publications/HFirst_Evaluation2015.pdf
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ItalyHousing First Italia
HousingFirstItalia isacooperativegroupcomprisingprovidersofHousingFirstservicesinItalywithacademicsupportintheformofaScientificCommitteewhichisdesigningevaluationmethodsforHousingFirstintheItaliancontext.Operatingundertheauspicesoffio.PSD(theItalianfederationofhomelessnessorganisations),HousingFirstItaliaseeksto promote the use of Housing First throughout ItalyandworktowardsgivingHousingFirstacoreroleintheItalianhomelessnessstrategy.Moreinformationisavailableat: http://www.housingfirstitalia.org/en/housing-first/(ItalianandEnglish)
Tutti a Casa Famiglie, Bologna
AmicidiPiazzaGrandeisacharityworkinginBologna,whichprovidesaHousingFirstservicetargetedathomelessfamilieswithcomplexsupportneedsincollaborationwiththecitiesinthisNorthernItalianregion.TheTuttiaCasaFamiglieHousingFirstservicefollowstheeightcoreprinciplesofHousingFirstdescribedinChapter2.
Usingscatteredapartmentsintheprivaterentedsector,theTuttiaCasaFamiglieHousingFirstserviceprovidedsupport for 42 families in 2015.The service is fundedbyamixof charitable andprivatedonationsandthesocialservicesdepartmentsinmunicipalitieshelpfamiliesmeetrentalcosts.Familiesarenotexpectedtodevotemorethan30%oftheirdisposableincomestorent.Thereisnooperationallimittothesizeoftheproject,butfundinglevelsvarybetweenmunicipalitiesinBologna,sothatthenumberssupportedaredeterminedbytotalspendingontheservice.
Amulti-disciplinary support team is used,with theTutti aCasa Famiglie service providing amix ofdirectsupportservicesandcasemanagement.ThemixofsupportofferedisnotthesameasaNorthAmericanACTteam,butcomprisesateamleaderwhoisaqualifiedsocialworker,apsychiatristwithasupervisoryroleandateamofthree‘educators’(whofocusonsupportwithsocialintegration),onesocialworker and one psychologist. Themain goal is to maximise independent living and social integration for previously homelessness families,workingwiththemforaslongasmaybenecessary.Wherepossible,thereisanemphasisonsupportingtheadultsinthefamiliesintopaidwork.
Highlevelsofhousingsustainmenthavebeenachievedsofar,withonlytwofamiliesoptingtoleavetheserviceandonemakingaplannedmoveawayfromtheBolognaregion,whichmeanttheycouldnolongerbesupported.Aninitialreviewoftheservicehasshownthattherearegoodresultsinimprovingthewell-beingoffamiliesandtheirlevelsofsocialintegration.However,theprojectwasstillworkingonenhancingperformancemeasurementduringthecourseof2015:http://www.feantsaresearch.org/IMG/pdf/ws_4_guistinietal_piazzagrande.pdf
Housing First, Ragusa
OperatedbytheDiocesanCaritasofRagusa,TettiColoratiONLUS,aSicilianHousingFirstservice,isfocusedonbothloneadultsandfamilies.TheHousingFirstserviceinRagusafollowsthecoreprinciplesdescribedinChapter2ofthisGuide.
Theserviceengageswithbothlocalhomelesspeopleandmigrantswhoarehomelessandhavesupportneeds,beingfundedbyamixoffinancialsupportfromtheDioceseofRagusa,privatedonations,centralgovernment and EU funding (EIF).Housing is provided via the private rented sector. Temporaryemergencyaccommodation isalsoprovided,whenahouseholdcannotbe immediatelyhoused,viatheDiocese of Ragusa, although in commonwith otherHousing First services, the emphasis is ongettinghomelesspeopleintotheirownindependenthomeassoonaspossible.Ateamofnineweresupporting 35 households (amix of single people and families) in 2015.A socialworker, educator,anthropologist,languageandculturalmediatorandthreevolunteersprovidedsupport,coordinatedbyateamleader.Anintensivecase-managementmodelisused,providingflexiblesupportthatistailoredtotheparticularneedsofeachserviceuser,withdecisionssuchasthefrequencyofsupportmeetingsbeingdecidedonacase-by-casebasis.
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In the absence of aminimumbasic income provided by the Italianwelfare system and barriers toemployment,HousingFirstinRagusaoftenhastopaytherentforserviceusers.Beyondfindingandsustaining housing, the service focuses on community integration, positive social support and promoting self-confidence,usingsettledhousingasafoundationfromwhichtostartworkingtowardsthesegoals.
Highlevelsofhousingsustainmentarereportedalongsidegainsinsocialintegration,healthandwell-being.Thoughtheserviceisyettobeformallyevaluated,itispartoftheHousingFirstItalianetwork,whichisworkingwithaScientificCommitteetodevelopanevidencebaseforHousingFirstinItaly.
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TheNetherlandsHVO Querido Discus, Amsterdam
HVOQueridoDiscus is aHousing First service based inAmsterdam.The service follows the eightcoreprinciplesofHousingFirstdescribed inChapter2,butplacesa loweremphasisona recoveryorientation.
TheHousingFirstserviceisrunbyanNGOandisfullyfundedbytheNetherlandsgovernment.Thefocusisonhomelesspeoplewhohavebothmentalillhealthandshowproblematicdrugandalcoholuse.Theservice isone of the oldest in Europe,havingbegunoperations in2005.Socialhousing isprovidedthroughcooperationwithahousingcorporationbasedinAmsterdam.
HVOQueridoDiscusHousingFirsthasexpandedrapidlyoverthelastdecade.In2005,therewerethreesupportofficersandoneprojectleadersupporting15HousingFirstserviceusers;by2015theservicehad45supportofficers,4teamcoordinatorsandtwoprojectleaderswithacaseloadof275 Housing First service users.In2015,HVOQueridoDiscusHousingFirsthadthecapacitytoexpandfurther.NolimitwassetonthesizeofthisHousingFirstservice.
SupportisorganisedaroundaweeklymeetingwhichcantakeplaceataHousingFirstserviceuser’shome, inapublicplaceor in theofficesofHVOQueridoDiscus. It isalsopossible forHousingFirstserviceusers to justmake telephonecontact, rather thanphysicallymeeting theHousingFirststaff.Supportisbasedaroundanintensive case-management modelandincludes:
₀ Helpwithhousingsustainmentandday-to-daylivingintheirhome
₀ Case-managingaccesstohealth,drugandalcoholandotherservices
₀ Supportwithsocialintegration,includingpracticalhelpinrebuildinglinkswithfamily
₀ Helpindealingwiththecriminaljusticesystem(whenrequired)
The caseload of each support officer is between six and nine Housing First service users. Smallercaseloads are usedwhen someone isworkingwith very high-need service users. Teammemberscanprovidecoverforeachotherwhennecessary.Support isdescribedasfluid,varyingandshiftingaccordingtotheneedsandwishesofeachHousingFirstserviceuser.
Highratesofsuccesshavebeenreported,withhigh rates of housing sustainment and improvements in mental health, drug use and social integration (thoughas inotherHousingFirstservices, thesegainsarenotuniversal,seeChapter1).HighgainsarereportedinthephysicalhealthofHousingFirstserviceusers.
Moreinformationisavailablevia:http://hvoquerido.nl(DutchandEnglish).
Housing First Utrecht
HousingFirstUtrechtintheNetherlandsfollowstheeightcoreprinciplesofHousingFirstdescribedinChapter2.
HousingFirstUtrechtisrunbyDeTussenvoorziening,anNGO.In2015,theHousingFirstservicewassupporting 80 people,oftencharacterisedbylong-termhomelessnessandseverementalillness,withproblematicdrugandalcoholuseandsometimeswithacriminalrecord.Housingisprovidedviasociallandlords.
Supportisdeliveredbyateamof14workers.EachHousingFirstserviceuserhastwoworkers.Mostof the Housing First team are qualified socialworkers and the team also includes a peer supportworker.EachindividualworkerhasprimaryresponsibilityforuptoeightHousingFirstserviceusersandsecondaryresponsibilityforuptofiveserviceusers.Thisarrangementmeansthateveryserviceuser
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hasaprimaryworkerandasecondaryworker,whocanbecalleduponiftheirprimaryworker isnotimmediatelyavailable.
TheintensityofsupportisdeterminedbyindividualneedamongHousingFirstserviceusers,theteamprovidingmore intensive support when needs are highest and reducing support when needs fall. EveryHousingFirstserviceuserhasacasemanagerwhomaintainsanoverviewoftheirneeds.Externalservicesarearrangedbycasemanagersasandwhennecessary.HousingFirstUtrechthaswhatmaybedescribedasasingle,highlyflexible teamthatcanprovidea rangeofdirectsupportatdifferinglevelsofintensityandcancase-manageexternalservicesasrequired.Theserviceoffers:
₀ Acombinedsupportteamthatrespondsflexiblytoawidespectrumofneed,varyingtheintensityandnatureofthesupportitdeliversasrequired
₀ Case-managedaccesstoexternally-providedservicesasnecessary
₀ NeitheranACTorICMmodel,butfeaturesofbothapproaches,workingwithinthecoreprinciplesofHousingFirst
In2015,HousingFirstUtrechtwasabletoreportthat85% of service usershadsustainedtheirhousingduringtheperiod2010-2015.Improvementsinmentalhealth,physicalhealthanddrug/alcoholusewerealsoreported,thoughasformanyotherHousingFirstservices,thesewerenotuniversal.Successeswerealsoreportedinsocialintegration,althoughisolationwasanissueforsomeHousingFirstserviceusers.More information onHousing FirstUtrecht is availablevia https://www.tussenvoorziening.nl/hulp-nodig/wonen/housing-first/(Dutch)
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NorwayHousing First in Norway
NorwayhaslowlevelsofhomelessnesscomparedtomanyotherEuropeancountries.Approximately150,000 people inNorway are estimated as facing disadvantage in the housingmarket and some6,200 of them are homeless151.AsinDenmarkandFinland,thissmallhomelesspopulationhashighlevelsofsupportneeds,includingseverementalillnessandproblematicdrugandalcoholuse.
NorwegianpolicycloselyreflectssomeofthecoreprinciplesofHousingFirst,focusingon‘normalisation’,whichstressestherapidprovisionofhousingwithsupportservicesbeingprovidedasrequired,ratherthanusingastaircaseapproach(servicesthataredesignedtomakesomeone‘housingready’beforeprovidinghousing).Housingisaseenasabasicrightforeverycitizen.
AsinDenmarkandFinland,HousingFirstisoneofaseriesofhomelessnessservicesprovidedwithinanintegratedstrategy.Asinseveralothercountries,theHousingFirstservicesprovidedinNorwayarebeingevaluated.
ByJuly2015,Norwayhad16 Housing First services supporting 237 people.HousingFirstmainlyusessocialhousingandthereisanemphasisonusingscatteredhousing.ManagementofeachHousingFirstserviceistheresponsibilityofamunicipality.Therehavebeenchallengesinfindingsuitable,affordablehousing in the private rented sector. Like Denmark and Finland, Norway has an extensivewelfaresystemtosupportlow-incomehouseholdswithpayingtheirrentandmeetinglivingcosts.
Each Housing First service varies in composition, none can be described as having anACT team,but all offer intensive forms of casemanagement.The first Housing First service inNorway,whichbeganoperationin2011,wasevaluatedandwasfoundtohaveachieveda93% success rateinendinghomelessness.
More information is available at: www.husbanken.no www.drammen.kommune.no www.napha.no www.fafo.noandwww.nibr.no(Norwegian).
151 2015Figures,source:HousingBank.
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PortugalCasas Primeiro, Lisbon
CasasPrimeirobeganoperationinLisbonin2009andisoperatedbyAEIPS,anNGOworkinginPortugalincollaborationwithpublicsectorbodies.TheCasasPrimeiroHousingFirstservicefollowsthecoreprinciplesofHousingFirstdescribedinChapter2.
Casas Primeiro uses private rented apartments. TheHousing First service is targeted at long-termhomelesspeoplewithsupportneeds,people living roughandhomelesspeoplewithmentalhealthproblems.Upto60 peoplearesupportedbyastaffteamof6withacaseloadofupto10 Housing First service users each.
In2015,supportwasbeingprovidedthatcentredonaweeklyhomevisit,designedtoensurehousingstabilityandhealthandwell-being.TheCasasPrimeiro teamcanconnect theHousingFirstserviceuserstootherservices,suchaseducationservicesprovidedbyAEIPS,theNGOrunningHousingFirst.CasemanagementcanalsobeusedtoconnectHousingFirstserviceuserstoexternally-provided support that they require,suchasmentalhealthservices.Supportcaninclude:
₀ Helpandcasemanagementinaccessingwelfarebenefitsandsocialservices
₀ Helpinre-establishingcontactwithfamilies
₀ Supportinaccessingeducationandemploymentservices
₀ Helpinaccessingmentalhealthandhealthservices
₀ LinkingHousingFirstserviceuserswithcommunityservices
₀ Supportwithmanagingandsustaininghousing
₀ Supportinmaintainingpositiverelationshipswithlandlordsandneighbours
₀ Personalcare
CasasPrimeirooffersaflexiblemixofdirectsupportandcasemanagement.Asingle,adaptableteamofHousingFirststafftailorsupporttosuitindividualneedsandpreferences.Aweeklygroupmeetingisusedasthemeanstodeliverpeersupport.
ResultsfromCasasPrimeirohavebeenpositive.Therehavebeenlargereductionsintheuseofemergencymedicalservicesandadmissionstopsychiatrichospitals.Resultsinhousingsustainmentaregood.Gains in health, well-being and social integrationhavealsobeendelivered,thoughaswithotherHousingFirstservicesthesearenotuniversal(seeChapter1).Reportedratesofsatisfactionamongserviceusersareveryhigh.More informationonCasasPrimeiro inbothEnglishandPortuguese isavailablefrom: http://www.aeips.pt.
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SpainHÁBITAT Housing First
HÁBITATisthefirstexampleofaHousingFirstservicetobedevelopedinSpain.DevelopedbyRAISFundación and starting operation in 2014, HÁBITAT provides a Housing First service to 38 people inMalaga,BarcelonaandMadrid.TheHÁBITATHousingFirst service follows thecoreprinciplesofHousingFirstdescribedinChapter2.
ThefocusofHÁBITATisonhomelesspeoplewithhighsupportneeds,includingpeoplewithlong-termandrepeatedexperienceofhomelessnesswithexperienceofmentalhealthproblemsandproblematicdrug/alcoholuse.Someserviceusersalsohavealimitingillnessordisability.AnevaluationofHÁBITAT,includingacontrolgroup,isongoing.HÁBITAToffersamix of private rented and social rented housing,althoughitwasreliantontheprivaterentedsectorinBarcelonain2015.
ThesupportprovidedbyHÁBITATismodelledonanICMapproach.Thereisageneralcoordinator,acoordinatorbasedineachcityandtwoHousingFirststaff,whoaresocial-worktrainedandtrainedinadulteducation, ineachcity.ThefidelityofHÁBITATtotheoriginalPathwaysmodelofHousingFirsthasbeentestedandithasbeenassessedashavinghigh fidelity with the Pathways model152 (note,however,thatHÁBITATisanICMmodel;itdoesnothaveanACTteamliketheoriginalHousingFirstserviceinNewYork,seeChapters1,2and3).
Thecomposition,intensityandnatureofsupportisdeterminedbyeachHousingFirstserviceuserandtheteamisdesignedtorespondflexibly,varyingthesupportaccordingtothespecificpreferencesandneedsofeachpersonusingHousingFirst.Thesupportcaninclude:
₀ Helpandcasemanagementinaccessingwelfarebenefits,socialandhealthservices
₀ Helpandsupportwhendealingwithpublicservices
₀ Supportinaccessingeducationandemploymentservices
₀ Supportwithmanagingandsustaininghousing
₀ Helpinre-establishingcontactwithfamilies
₀ Supportinmaintainingpositiverelationshipswithlandlordsandneighbours
₀ Supportwithpersonalcare,dailylifeandleisureactivities
TheuseofanICMmodelmeansthatHÁBITATworksinclosecooperationwithotherservices,witharelianceoncasemanagementofexternallyprovidedservicestomeettheexpressedneedsofHousingFirstserviceusers.
HÁBITATwasstillanewservice in2015,butan independentevaluationhadalreadyshownpositiveresultsforitsfirst6 months of operation.TheeconomicaspectoftheresearchshowedtheHÁBITATprogramme performingwith similar costs to those ofmore traditional services. However, HÁBITATwasdeliveringbetterresults,especiallyintheareasofhousingsustainmentandhousingsatisfaction;givingHousingFirstserviceusersasenseofsecurityandhelpingthemdeveloprelationshipswiththeirfamilies.MoreinformationabouttheinitialstagesofHÁBITATisavailableathttps://www.raisfundacion.org/en/what_we_do/habitat (English) and https://www.raisfundacion.org/es/que_hacemos/habitat (Spanish).
152 http://issuu.com/rais_fundacion/docs/presentaciones_habitathf_web?e=5650917/30872088
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SwedenHousing First in Sweden
UnlikeDenmark,FinlandandNorway,SwedenhadnotintroducedanationalprogrammewithaclearfocusonHousingFirstby2015.HousingFirstasaprogramme,philosophy,methodandservicehad,however, been introduced and incorporated in local homelessness strategies and action plans. Inaddition,HousingFirstwasalsoincorporatedintostrategicdocumentslikethenewdirectivesonthetreatmentofsubstancemisusefromtheNationalBoardofHealthandWelfare.
ThefirsttwoHousingFirstservicesinSwedenstartedin2010(StockholmandHelsingborg)andhavebeenevaluated. In 2013, theHousingFirst service inHelsingborgbecameapermanentpart of thesocialhousingprogrammeinthecity.Atthattime,the housing retention rate was 84%.TheHousingFirstpilot is nowbeingup-scaledand the resultsof thepilotwill be implementedwithin the socialhousingprogrammeinHelsingborg.
Inlate2015,14municipalitieshadHousingFirstservices.TheyallfollowthecoreprinciplesofHousingFirst,buttherearedifferencesintheiroperationaldetails.PerformanceisreportedasuniversallygoodforalltheseHousingFirstservices,bothintermsofservice-user satisfaction and housing retention rates.Thetargetgroupofall theHousingFirstservices inSwedenarehomelesspeoplefromwhatiscalled ‘Situation 1’. Situation 1 isequivalent tocategory 1and2of theFEANTSAETHOS typology(rooflessness):peopleroughsleepingandpeoplestayingatnightshelters.
EvaluationsofHousingFirstareongoingandwillproduceresultsthatcompareHousingFirstmodels.InGothenburg,theHousingFirstserviceusesoneACTteamandtwoICMteams.Inothermunicipalities,support isprovidedbysocialworkersemployedbysocial services. Inoneof themunicipalities, thewholeprogrammeisrunbyaNGO.Intwomunicipalities,sofar,thesupportservicesareprovidedundercontractfromtheCityMissionbythesocialservices.Inthiscontext,itwillbeveryusefultoidentifywhatthekeyingredientsareinthesupportgiven that make Housing First work so well in Sweden.HousingFirsthasbeenintroducedinacontextofongoing,verysignificant,reforminwelfareservicesandsocialhousingsystemsinSweden.
Aformalnetworkhasbeencreatedforall thosemunicipalities thatuseHousingFirstservices.TheymeetregularlyanddiscussdifferentaspectsofHousingFirst.Atthelastmeeting,commonalitiesanddifferencesbetweenthedifferentserviceswerediscussedandaspecialsessionfocusedonhowthedifferentservicesworkedwithdifficultcases.
Formoreinformation,see:http://www.soch.lu.se/en/research/research-groups/housing-first(English)
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TheUnitedKingdomSCOTLAND
Glasgow Housing First
TurningPoint,anNGO,begandevelopingtheUK’sfirstHousingFirstserviceinGlasgow,Scotlandin2010.GlasgowHousingFirstfollowsallthecoreprinciplesdescribedinChapter2.
TheGlasgowHousingFirstservicewasdevelopedprimarilyinresponsetoincreasing levels of drug-related deathsamongtheloneadulthomelesspopulation.Thefocuswasthereforeonproblematicdrugandalcoholuseamonghomelesspeople,notonseverementalillnessorlong-termhomelessnessas is the case for many other Housing First services, although both mental health problems andsustainedexperienceofhomelessnesswereoftenissuesforthepeopleusingGlasgowHousingFirst.Led byTurning Point, GlasgowHousing Firstwas developed in cooperationwith andwith financialsupportfromthemunicipalgovernmentofGlasgow,thePolice,theScottishGovernment,theNationalHealthServiceandsociallandlords.
In 2015, GlasgowHousing Firstwas supporting 34 people and had a capacity of up to 42 people. HousingwasprovidedthroughjointworkingwiththesociallandlordsoperatingwithinGlasgow.
Thesupportteamisledbyaservicemanagerandhasacoordinatorandtwoassistantcoordinators.DirectsupporttoHousingFirstserviceusersisprovidedprimarilythroughthreepeersupportworkers,whoin2015hadupto14 service users to support.Thepeersupportworkersareallpeoplewithdirectexperienceofhomelessnessandproblematicdrug/alcoholuse,i.e.expertsbyexperiencewhoarealsotrainedHousingFirstsupportstaff.GlasgowHousingFirstisunusualinEuropeanexamplesofHousingFirst(andalsodiffersfrommanyNorthAmericanexamplesofHousingFirst)becauseitusesexpertsby experience as frontline providers of support, rather than having separate peer supportworkers.SystemsfortrainingpeoplewithexperienceofdrugandalcoholuseasworkersandcounsellorsarerelativelywellestablishedintheUK.Supportisalsoprovidedbyotherstaffwhenrequired.
Support is designed to suit individual need and preferences andvaries accordingly. The service isdescribedasprovidingsupporttoeachGlasgowHousingFirstserviceuserthatcanvaryonaweek-by-weekbasis,dependingonwhattheywishforandwhattheirneedsare.Onaverage,serviceusersreceive two visits a week from a peer support worker.Themeetings takeplaceaccording to thepreferenceoftheserviceuser,sometimesintheirownhome,butalsoincafésorintheteam’sofficespace.Casemanagement is used to connectGlasgowHousingFirst serviceuserswithpsychiatric,medicalandotherservicesthattheHousingFirstteamdonotprovidedirectly.
The organisation of support uses a fluid, flexible approach centred on a core team that alsoencompassesanelementofcasemanagement.AswithsomeotherEuropeanHousingFirstservices,this isan individually-tailored and flexible response to expressed needs for support, rather thanstrictlyfollowinganACTorICMmodel.
In 2015, rates of housing sustainment among Glasgow Housing First service userswere very highandimprovementsinmentalandphysicalhealthandindrug/alcoholusewerereported.Progressinrelationtosocialintegrationwasmoremixed,ashasbeenreportedforotherHousingFirstservices(seeChapter1).TherewereplanstoexpanduseofHousingFirstintoneighbouringmunicipalities.
More informationaboutGlasgowHousingFirst isavailableat:http://www.turningpointscotland.com/what-we-do/homelessness/glasgow-housing-first/
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ENGLAND
Housing First England
HousingFirstEnglandisaprojectwhichaimstoraisetheprofileof,sharelearningaboutandevaluatethe use of Housing First across England.Homeless Link, the national membership body for the homelessness sector in the UK,willbedeliveringtheprojectstartingin2016.Theywillsupportstatutoryand third-sector organisations nationally and locally to further develop anddeliver the approach inEngland,andwillworkwithresearcherstobuildanevidencebaseforHousingFirstinEngland.
Moreinformationisavailablefrom:www.homeless.org.uk
Camden Housing First, London
SHP is anNGOoperating in London. SHP has developed and operated a number ofHousing Firstservices, includingservices thatusedsocialhousing.During2012-2014,apilotservicedeveloped incooperationwith themunicipal governmentwasoperated in theLondonBoroughofCamden.ThisservicefollowedthecoreprinciplesofHousingFirstdescribedinChapter2.
Thesuccessful pilot of Camden Housing First,whichwaslaterexpandedintoalargerservice,isanexampleofalow-resourceimplementationofHousingFirst.HighneedhomelesspeoplewereselectedfortheHousingFirstserviceonthebasisthattheyhadrepeated,unsuccessful,contactwiththehighly-developedhomelessnessservicesinCamden.Aminimumperiodofthreeyears’unsuccessfuluseofexistinghomelessnessserviceswasthemaincriteriaforreferral,althoughthesmallgroupsupported(upto10peopleatanyonepoint)hadoftenbeenusinghomelessnessservicesformuchlonger.
Supportwasdeliveredbyateamofthree,amanagerandtwoHousingFirstworkers,whoeachhadacaseloadofuptofivepeople.CamdenHousingFirstwasentirelyreliantonusingtheprivaterentedsector.Existingpractice intenancysustainmentorfloatingsupportservicesforvulnerablehomelesspeople in theUK isto provide a mixture of emotional support, practical advice, information and case managementusingquiteinfrequentcontacts,e.g.acoupleofhours’supportduringthecourseofatwo-weekperiod.CamdenHousingFirsttookthisexistingapproachandgreatlyintensifiedit,raisingthelevelofcontacttoseveralhoursaweek,withthecapacitytovaryaccordingtoexpressedneeds.Theorganisationofthesupportwashighlyflexible,varyingaccordingtoindividualneedandpreferencesandoftenchangingonaweeklybasis.
Alongside their role inprovidingsupport, the twoHousingFirstworkersalsohad tofindandsecureprivaterentedhousing,withoutbeingabletoofferanyincentivetoprivaterentedlandlordsinoneofthemostoverheatedhousingmarketsinEurope.Supportandcasemanagementweredeliveredwhilesimultaneouslysourcingappropriateprivaterentedhousing.
Whilehousingcouldtakeafairly longtimetosecure, thespeedatwhichthiswaspossiblewasstillgreaterthancouldbeachievedinseekingsocialhousinginLondon.Housingsustainmentwasachieved and gains in mental health, physical health and social integrationwerealsoobserved.Therewasalso someprogress in respect of drug andalcohol use, although thegroupof serviceusersbeingsupportedwassmall.
MoreinformationabouttheCamdenHousingFirstservicepilotcanbefoundat:http://www.shp.org.uk/story/housing-first-provides-stability-chronically-homeless-people
Changing Lives, Newcastle-Upon-Tyne
ChangingLivesisanEnglishNGOwhichoperatesaHousingFirstserviceinNewcastle-Upon-TyneintheNorthofEngland in cooperation with the City of Newcastle municipality.TheChangingLivesHousingFirstservicefollowsthecoreprinciplesofHousingFirstdescribedinChapter2,althoughithasanoperationaldifferencewithsomeotherEuropeanHousingFirstservices.
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TheHousingFirstserviceisfocusedonlong-termhomelesspeople.Thisgroupincludes‘entrenched’(i.e.long-term)roughsleepersandpeoplewhoarelong-termandrepeatusersofexistinghomelessnessserviceswhose homelessness has never been resolved.Themain formof housing used is privaterented sector houses and apartments, but the servicewas negotiatingwith social landlords duringthecourseof2015.In2015,theHousingFirstservicewasworkingwith38 people,withthecapacitytosupportupto60 individuals and couples.
Supportisarrangedviaacase-managementmodelwhichisbasedonanintensificationoftheexistingsupportmodelforhomelesspeoplewithsupportneeds.ThereisalongstandingpracticeintheUKofusingcase-management led, low-intensitymobile support services forhomelesspeoplehoused inordinaryhousing.ThismodelhasbeenmodifiedforHousingFirst,reducingcaseloadsandincreasingthetimespentwithserviceusersverysignificantly.Supportcanberaised,loweredandalteredasandwhenrequestedandrequiredforeachHousingFirstserviceuser.Thereislessemphasisonpursuingarecoveryorientationinsupportservicedelivery(seeChapter2andChapter3.2),withafocusonrealisticgoalsallowing for thesupportneedsandenduringphysicalandmentalhealthproblems thatmanyHousingFirstserviceusershave.
Highlevelsofhousingsustainmentarebeingachieved,alongsideimprovementsinmentalandphysicalhealthand intheuseofdrugsandalcohol.Levels of social integration are also improvingamongHousingFirstserviceusers.Again,thesepositiveachievementsarenotuniversal,asisthecaseforallHousingFirstservices(seeChapter1).
An observational evaluation of Changing Lives and other examples of the English implementationof Housing First services is available at https://www.york.ac.uk/media/chp/documents/2015/Housing%20First%20England%20Report%20February%202015.pdfMoreinformationonChangingLivesHousingFirstinNewcastleisavailablevia:http://www.changing-lives.org.uk
For more information and details, contact: [email protected]