Housing First in Permanent Supportive Housing

Housing First is an approach to quickly and successfully connect individuals and families experiencing homelessness to permanent housing without preconditions and barriers to entry, such as sobriety, treatment or service participation requirements. Supportive services are offered to maximize housing stability and prevent returns to homelessness as opposed to addressing predetermined treatment goals prior to permanent housing entry.

Housing First emerged as an alternative to the linear approach in which people experiencing homelessness were required to first participate in and graduate from short-term residential and treatment programs before obtaining permanent housing. In the linear approach, permanent housing was offered only after a person experiencing homelessness could demonstrate that they were “ready” for housing. By contrast, Housing First is premised on the following principles:

  • Homelessness is first and foremost a housing crisis and can be addressed through the provision of safe and affordable housing.
  • All people experiencing homelessness, regardless of their housing history and duration of homelessness, can achieve housing stability in permanent housing. Some may need very little support for a brief period of time, while others may need more intensive and long-term supports.
  • Everyone is “housing ready.” Sobriety, compliance in treatment, or even criminal histories are not necessary to succeed in housing. Rather, homelessness programs and housing providers must be “consumer ready.”
  • Many people experience improvements in quality of life, in the areas of health, mental health, substance use, and employment, as a result of achieving housing.
  • People experiencing homelessness have the right to self-determination and should be treated with dignity and respect.
  • The exact configuration of housing and services depends upon the needs and preferences of the population.

While the principles of Housing First can be applied to many interventions and as an overall community approach to addressing homelessness, this document focuses primarily on Housing First in the context of permanent supportive housing models for people experiencing chronic homelessness.

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Housing First Effectiveness in Permanent Supportive Housing

Permanent supportive housing models that use a Housing First approach have been proven to be highly effective for ending homelessness, particularly for people experiencing chronic homelessness who have higher service needs. Studies such as HUD’s The Applicability of Housing First Models to Homeless Persons with Serious Mental Illness have shown that Housing First permanent supportive housing models result in long-term housing stability, improved physical and behavioral health outcomes, and reduced use of crisis services such as emergency departments, hospitals, and jail.

Core Components of Housing First

The core features of Housing First in the context of permanent supportive housing models are as follows:

  • Few to no programmatic prerequisites to permanent housing entry – People experiencing homelessness are offered permanent housing with no programmatic preconditions such as demonstration of sobriety, completion of alcohol or drug treatment, or agreeing to comply with a treatment regimen upon entry into the program. People are also not required to first enter a transitional housing program in order to enter permanent housing
  • Low barrier admission policies – Permanent supportive housing’s admissions policies are designed to “screen-in” rather than screen-out applicants with the greatest barriers to housing, such as having no or very low income, poor rental history and past evictions, or criminal histories. Housing programs may have tenant selection policies that prioritize people who have been homeless the longest or who have the highest service needs as evidenced by vulnerability assessments or the high utilization of crisis services.
  • Rapid and streamlined entry into housing – Many people experiencing chronic homelessness may experience anxiety and uncertainty during a lengthy housing application and approval process. In order to ameliorate this, Housing First permanent supportive housing models make efforts to help people experiencing homelessness move into permanent housing as quickly as possible, streamlining application and approval processes, and reducing wait times.
  • Supportive services are voluntary, but can and should be used to persistently engage tenants to ensure housing stability – Supportive services are proactively offered to help tenants achieve and maintain housing stability, but tenants are not required to participate in services as a condition of tenancy. Techniques such as harm reduction and motivational interviewing may be useful. Harm reduction techniques can confront and mitigate the harms of drug and alcohol use through non-judgmental communication while motivational interviewing may be useful in helping households acquire and utilize new skills and information.
  • Tenants have full rights, responsibilities, and legal protections – The ultimate goal of the Housing First approach is to help people experiencing homelessness achieve long-term housing stability in permanent housing. Permanent housing is defined as housing where tenants have leases that confer the full rights, responsibilities, and legal protections under Federal, state, and local housing laws. Tenants are educated about their lease terms, given access to legal assistance, and encouraged to exercise their full legal rights and responsibilities. Landlords and providers in Housing First models abide by their legally defined roles and obligations. For instance, landlords and providers do not enter tenants’ apartments without tenants’ knowledge and permission except under legally-defined emergency circumstances. Many Housing First permanent supportive housing programs also have a tenant association or council to review program policies and provide feedback, and formal processes for tenants to submit suggestions or grievances.
  • Practices and policies to prevent lease violations and evictions –Housing First supportive housing programs should incorporate practices and policies that prevent lease violations and evictions among tenants. For instance, program policies consistent with a Housing First approach do not consider alcohol or drug use in and of itself to be lease violations, unless such use results in disturbances to neighbors or is associated with illegal activity (e.g. selling illegal substances.) Housing First models may also have policies that give tenants some flexibility and recourse in the rent payment, which in many subsidized housing programs is 30% of the participant’s income. For example, rather than moving towards eviction proceedings due to missed rent payments, programs may allow tenants to enter into payment installment plans for rent arrearages, or offer money management assistance to tenants.
  • Applicable in a variety of housing models – The Housing First approach can be implemented in different types of permanent supportive housing settings, including: scattered-site models in private market apartments, where rental assistance is provided, and tenants have access mobile and site-based supportive services; single-site models in which permanent supportive housing buildings are newly constructed or rehabilitated and tenants have access to voluntary on-site services; and set-asides, where supportive services are offered to participants in designated units within affordable housing developments.

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Adopting a Housing First Approach in Permanent Supportive Housing

Providers of permanent supportive housing that do not already use a Housing First approach can adopt this approach by reviewing existing program policies and procedures, and by learning and implementing new services and practices through training and clinical supervision. A provider that would like to move to a Housing First program model should start with the following steps:

  • Review current policies and procedures – Providers should undertake a systematic review of their current operating policies and procedures. First, providers should assess tenant selection and admission policies to ensure that they do not screen out applicants on the basis of rental, credit, or criminal histories, sobriety, income, etc. They should also evaluate the application and admission process to identify ways to streamline and shorten the process. They should review the lease terms, lease compliance, and eviction policies to ensure that they are consistent with Housing First principles and housing laws. Lease provisions that require participation in services or that deem alcohol use as lease violations or grounds for eviction should be removed. Providers should consider adding policies that help prevent eviction when a tenant falls behind on rent or experiences other lease violations.
  • Learn and adopt Housing First services approaches and practices – Providers can adopt supportive services approaches and practices that creatively engage tenants to maximize and ensure housing stability. Through training around harm reduction approaches, services staff can learn to confront and mitigate the harms of drug and alcohol use through non-judgmental communication. Staff can also receive training to develop competency around techniques like motivational interviewing, wellness self-management, and trauma-informed care. Adoption of these practices often also requires continual reinforcement through effective clinical supervision, which is key to supporting housing stability.

Useful Resources on Housing First

  • USICH’s Housing First Checklist – An easy-to-use tool for policymakers and practitioners to identify and assess whether a program or community is using a Housing First approach. This three-page tool breaks down the Housing First approach into distinguishing components at both the program and community levels.
  • Housing First in USICH’s Solutions Database – A description of Housing First along with links to examples and resources from USICH’s Solutions Database.
  • The Housing First Fidelity model index – In the April 2013 edition of Substance Abuse Treatment, Prevention, and Policy, Watson and colleagues (2013) discuss the development and testing of their Housing First Fidelity instrument. The study finds that the instrument is effective in assessing the quality of Housing First programs and for making implementation decisions.
  • Organizational Change: Adopting a Housing First Approach – The National Alliance to End Homelessness’ tool-kit on adopting Housing First as a community-wide strategy.
  • Pathways to Housing – Housing First Model – Pathways to Housing produced a step-by-step manual presents a comprehensive guide to Pathways to Housing’s Housing First approach.
  • DESC’s Seven Standards of Housing First – Seattle-based Downtown Emergency Service Center has identified seven standards essential to their Housing First approach.
  • Unlocking the Door: An Implementation Evaluation of Supportive Housing for Active Substance Users in New York City – The National Center on Addiction and Substance Abuse at Columbia University and the Corporation for Supportive Housing evaluated the implementation of nine scattered-site Housing First permanent supportive housing programs serving approximately 500 people experiencing chronic homelessness with active substance abuse disorders in New York City. The report concludes with useful lessons for what is critical to implementing a Housing First permanent supportive housing model. A full impact evaluation of these programs will be completed later in 2013. Preliminary findings indicate that the programs were successful in helping people exit homelessness, remain stably housed, and reduce their use of emergency services.

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