Normalisation of Housing and Living Conditions in the Field of Homeless Services:

Some Financial Arguments

Dr. Volker Busch-Geertsema, Association for Innovative Social Research and Social Planning (GISS) e.V., Bremen, Coordinator of the European Observatory on Homelessness

7th European seminar on local homeless strategies

Funding strategies: Building the Case for Homelessness

Co-hosted by the Committee of the Regions, FEANTSA and HABITACT

Brussels, Friday 8 June 2012

Overview

Housing First as an alternative to staircase systems: Quick normalisation of housing and living circum-stances as a better way of integration

Not only better but cheaper as well? Financial arguments in favour of Housing First and a quick normalisation of housing and living conditions for homeless people

Some problems regarding usual financial arguments

Potentials of Cost-Effectiveness Studies in Europe

Ending homelessness: More than a financial question

The Critique of the Staircase Approach

In the staircase model homeless people have first to address their problems before moving to the next stage of a series of steps towards ordinary self-contained housing (often considered as without further support)

In this model homeless people have to be made “housing ready” in different stages, with decreasing intensity of support, control and supervision and increasing autonomy and privacy

Permanent housing is understood as a “reward” for showing (and maintaining) sobriety and compliance with treatment and support plans

Primary housing market

moreless

more lessindividual support, care, control, discipline

private space, autonomy, normality

Secondary housing market

reception stage

“final dwelling”,full security of tenure

time-limited, no security of tenure

shared dwellings near institution, stay time-limited and based on special conditions, shared facilities

institutional setting, hostels, shelters, etc.

regular dwelling with (time-limited) occupation agree-ment based on special conditions

regular self-contained dwelling with rent contract

shared housing, “training dwell-ings”, etc.

Staircase of Transition

© GISS Bremen

Critique of Staircase Systems in Europe

Stress and dislocation because of need to move between different "stages"

Little privacy and autonomy at lower stages, lack of service user choice and freedom – revolving doors and «frequent flyers»

Standardised support in different stages

Skills learned in structured congregate settings often not transferable to independent living situation

Final move to independent housing may take years and too many homeless clients get "lost"

Homelessness may increase rather than decrease with such systems (extending lower stages, bottleneck at upper end)

Homelessness…………………………………………………………………………….

shared housing, “training dwell-ings”, etc.

regular dwelling with (time-limited) occupation agree-ment based on special conditions

regular self- contained

dwelling with rent contract

flexible individual support in housing

Housing First

reception stage

Housing First – the Alternative

Priority for rapid access to mainstream housing; no “housing readiness” and transitional steps required

Permanent and affordable housing, self-contained with security of tenure

Harm reduction approach: No requirement of abstinence

"Housing first", not "housing only”. Provision of adequate and pro-active support (with home visits) but no obligation to accept treatment, therapy or abstinence. Originally Assertive Community Treatment (ACT) essential element, but also Intensive Case Management (ICM)

Orientation on recovery and community integration

Emphasis on NORMAL housing and living conditions

Housing First: Not Only Better But Cheaper As Well?

Homelessness may cost quite a lot of money Costs of ambulances and detentions by police, court

proceedings etc. Costs of stays in emergency wards and detox units of

hospitals, in prison, in mental hospitals etc.

Most quoted example: Article in The New Yorker about “Million-Dollar Murray. Why problems like homelessness may be easier to solve than to manage” (23 Februar 2006) Policemen collected data on hospital bills and other

charges during last ten years for long-term homeless alcoholic Murray Barr who had finally died in the street of intestinal bleeding

“It has cost us one million dollar not to do something about Murray” (…) “It would probably have been cheaper to give him a full-time nurse and his own apartment”

Housing First: Not Only Better But Cheaper As Well?

Savings on non-homelessness services often main argument “If it can be shown that homelessness programs produce

positive outcomes for clients at relatively low cost and provide significant cost savings for mainstream non-homelessness services, then the case for intervention is well and truly established. “ (Zaretzky et al 2012,p. 2)

Additional indicators:* Children placed in care* Decrease in evictions and reduced maintenance (with

increased housing stability of users of tenancy support)

Housing First: Not Only Better But Cheaper As Well?

Example from Finland: Juha Kaakinen, programme leader of Finnish Programme to end long-term homelessness in a recent presentation (From Housing First to Ending Homelessness): “A survey carried out in a Tampere supported housing unit

shows that housing with intensified support halves the use of social and health care services compared to service-use during homelessness. This equates, to 14 000 euros of savings per resident/year. The total annual savings for 15 residents in the unit in question amounted to 220 000 euros. The greatest savings were gained from the decreased use of institutional care and special health care. This housing unit has 22 independent flats and 5 support workers.” (Kaakinen 2012)

Housing First: Not Only Better But Cheaper As Well?

Some problems Reduction of the use of non-homelessness services

through homelessness support: Real cost offsets against Housing First with ACT only for “high cost” homeless people

Not all homeless people are heavy users of non-homeless services like health and justice system

Duration of service use plays an important role. Housing First support is ongoing – potentially for years - while stays in hospital, prison or detox units are time-limited

Savings are made in sectors for which other government departments might be responsible than those financing homeless services

It might be difficult to realise the savings (some of them could only be realised by reducing places and personnel in criminal justice and health system)

Housing First: Not Only Better But Cheaper As Well?

Rosenheck 2000: Assertive Community Treatment (as in Housing First

projects) only “cheaper” for “the most resource-intensive 10% of clients.”

Poulin et al. 2010: “Supportive housing models for people with serious mental

illness who experience chronic homelessness may be associated with substantial cost offsets, because the use of acute care services diminishes in an environment of housing stability and access to ongoing support services. However, because persons with substance use issues and no recent history of mental health treatment used relatively fewer and less costly services, cost neutrality for these persons may require less service-intensive programs and smaller subsidies.”

Potentials of Cost-Effectiveness Studies in Europe

In Europe comparing one type of service for homeless people with others is an alternative strategy to show positive financial effects. Housing First is not a cheap service, but staircase systems aren’t either. Some examples from Germany:

*Clients may claim minimum benefit for their subsistence in addition

Type Costs p day Costs p month Costs p year

Caritas crisis accommodation Berlin*

115.45 € 3,511.60 € 42,139.25 €

“Stationary” hostel Munich (including pocket money and full board)

93.89 € 2,855.78 € 34,269.31 €

Halfway house in Berlin (social work and rent)*

42.89 € 1,304.57 € 15,654.85 €

Floating support in Berlin(social work and Ø-rent)*

34.29 € 1,042.99 € 12,515.85 €

Potentials of Cost-Effectiveness Studies in Europe

Important to note that Housing First can cover different types of support services: Not all homeless people with special needs will need

Assertive Community Treatment (probably the most costly type of support in housing, see also Tsemberis at al 2012)

A majority might be better served with “Housing First Light”

It should be relatively easy to prove that Housing First services are not only more effective but will also cost less if support in housing is adjusted to specific individual needs We need more studies on the costs of homelessness in

Europe There is great potential for cost-effectiveness studies

comparing costs and effects of staircase systems with Housing First approaches

Potentials of Cost-Effectiveness Studies in Europe

Cost-effectiveness studies must provide a real basis for comparisons including duration and intensity of support and the costs of subsistence

While there are some costs involved for increased mobility of support teams in “housing led” services (floating support in scattered housing) high costs for staircase systems and congregated housing originate from special requirements for concentrated accommodation (24 hours staffing, fire precautions, more potential conflicts, less use of self-help potential of clients)

Floating support in housing will only be better AND cheaper, if intensity and duration of support are closely adjusted to the needs of (formerly) homeless people

Ending Homelessness and Normalising Housing and Living Conditions of Homeless People:

More than a Financial Question!!

Even if more effective services for homeless persons might cost more than less effective provisions in some cases, “their value ultimately depends on the moral and political value society places on caring for its least well-off members” (Rosenheck 2000).

“Researchers should be careful to consider (and explicitly observe) that the services utilization cost of homelessness is only one dimension of the moral issues raised by the problem. Other moral dimensions of homelessness include dehumanization, diminished capacity to actualize basic societal rights and privileges, and susceptibility to victimization, including violence” (Culhane 2008: 109.).

Thank you for your attention!

Contact

Dr. Volker Busch-Geertsema

Gesellschaft für innovative Sozialforschung und Sozialplanung e.V. (GISS, Association for Innovative Social Research and Social Planning)

Kohlhökerstraße 2228203 Bremen, GermanyFon: +49-421 – 33 47 08-2Fax: +49-421 – 339 88 35

Mail: vbg@giss-ev.de Internet: www.giss-ev.de

References Busch-Geertsema, V. (1998) Persönliche Hilfen in Normalwohnraum statt Einrichtungen für

Wohnungslose. Bessere Hilfen für weniger Geld? Ein Bremer Kostengutachten appelliert für Umsteuerung von Einrichtungen in normalen Wohnraum, in: Wohnungslos 4/1998, pp. 144-150

Gladwell, M. (2006) Million Dollar Murray. The New Yorker February 13 & 20, 2006, pp. 96-107.

Chart for Pathways Housing First copied from http://www.pathwaystohousing.org/content/our_model

Cost examples for provision in Germany (in German language): http://www.berlin.de/sen/soziales/vertraege/verguetung/Einrichtungskatalog/einrichtungnachtyp.shtml and Lehmann, R. and Ballweg, T. (2012) Der Social Return On Investment einer stationären Einrichtung der Wohnungslosenhilfe. Investitionen und sozialer Mehrwert am Beispiel des Adolf Mathes Hauses, einer Einrichtung des Katholischen M.nnerfursorgevereins Munchen e.V.. Forschungsbericht. Stand: 24.04.2012. (Munich and Eichstätt-Ingolstadt: Katholischer Männerfürsorgeverein and Kathoische Universität)

Culhane, D. (2008) The costs of homelessness: a perspective from the United States, European Journal of Homelessness, 2, pp. 97-114.

Flatau, P. and Zaretzky, K. (2008) The Economic Evaluation of Homelessness Programmes, European Journal of Homelessness, 2, pp. 305-320

Kaakinen, J. (2012) Long-term perspectives: From Housing First to Ending Homelessness, presentation at Conference on “Housing First: A Key Element of European Homelessness Strategies”, 23rd March 2012 hosted by the French Permanent Representation to the EU and FEANTSA, see http://feantsa.horus.be/code/EN/pg.asp?Page=1409

References Poulin, S.R., Maguire, M., Metraux, S., Culhane, D.P. (2011) Service Use and Costs for Persons

Experiencing Chronic Homelessness in Philadelphia: A Population-Based Study. Psychiatric Services 61, pp.1093–1098

Rosenheck, R. (2000) Cost-Effectiveness of Services for Mentally Ill Homeless People: The Application of Research to Policy and Practice. Am J Psychiatry157, pp. 1563-1570

Tsemberis, S. (2010a) Housing First: Ending Homelessness, Promoting Recovery and Reducing Costs, in: Gould Ellen, I. and O’Flaherty, B. (eds.) How to House the Homeless (New York: Russell Sage Foundation).

Tsemberis, S. (2010b) Housing First. The Pathways Model to End Homelessness for People with Mental Illness and Addiction (Center City, Minnesota: Hazelden)

Tsemberis, S., Kent, D., and Respress, C. (2012) Housing Stability and Recovery Among Chronically Homeless Persons With Co-Occuring Disorders in Washington, DC. Am J Public Health. 102,13–16

Zaretzky, K., Flatau, P., Bauskis, A., Conroy, E, Burns, L., Spicer, B. and Clear, A. (2012) Cost offsets of homelessenss assistance (paper presented at Homelessness Research Conference Melbourne 19-20 April 2012)