Housing First: Defining and Analyzing a New Treatment Paradigm for Homelessness in the United States Introduction: Background Information

Housing First: Defining and Analyzing a New Treatment Paradigm for Homelessness in the United States A Dissertation Presented by Caitlin A. Carey Department of Public Policy & Public Affairs McCormack Graduate School of Policy & Global Studies University of Massachusetts Boston June 9, 2020 Committee: Michael P. Johnson, PhD (Chair) Susan R. Crandall, PhD Russell K. Schutt, PhD Introduction: Background Information ▸ 567,715 people counted as experiencing homelessness in January 2019 (U.S. Department of Housing and Urban Development, 2019) ▸ Some estimates suggest that as many as 10 million people annually spend at least one night in shelter, on the streets, or doubled up (National Law Center on Homelessness and Poverty, 2015) Introduction: History of Homelessness in the U.S. Point In Time (PIT) Count Estimates for Homeless Subpopulations Over Time 800000 Total Number of People Experiencing Homelessness 700000 600000 Number of Individuals Experiencing Chronic Homelessness 500000 Number of Individuals Experiencing Homelessness 400000 Number of People in Families Experiencing Homelessness 300000 Number of Veterans Experiencing Homelessness 200000 Number of Unaccompanied Youth Experiencing Homelessness 100000 0 2005 2010 2015 Source: created from data in the Annual Homelessness Assessment Reports to Congress, years 2005-2019 Introduction: Models of Homeless Service Provision Treatment First (Linear) Model Substance Abuse Treatment Mental Health Treatment Job Training Transitional Housing Housing First Model Substance Abuse Treatment Mental Health Treatment Job Training Source: author’s own Introduction: Theoretical Grounding for Housing First Maslow’s Hierarchy of Needs Self-Actualization (achieving one's full potential, creativity) Esteem Needs (pride, sense of accomplishment) Belonging Needs (friendships, intimate relationships) Safety Needs (personal security, financial security, health) Physiological Needs (food, water, shelter, sleep) Source: Maslow, 1947 Introduction: Prior Literature ▸ As Housing First has proliferated in the U.S., new understandings of the model have emerged and organizations have implemented the model in different ways; variation in implementation of the model is thought to be associated with variation in outcomes ▸ Pathways to Housing developed the Pathways Housing First Fidelity Scale (Stefancic et al., 2013) ▸ U.S. Department of Veterans Affairs measured fidelity in the VA’s HUD-VASH program (Kertesz, 2017) ▸ Qualitative attempts to measure fidelity (Greenwood et al., 2013) ▸ Evaluations of Housing First programs have typically focused on sobriety and improved mental health among program participants, in addition to housing retention (see Greewood et al., 2005; Kertesz et al., 2009; Padgett et al., 2011; Stergiopoulos et al., 2015; Montgomery et al., 2013; O’Connell et al., 2009; Tsai et al., 2010) Introduction: Research Questions 1. How do different groups of stakeholders define, understand, and experience Housing First? 2. What is the variation in the implementation of Housing First across the United States? 3. How does Housing First in practice compare with Housing First in theory? 4. What are the most important outcomes from Housing First according to different groups of stakeholders and how could those outcomes be measured? a) What data are currently being collected that could help to measure Housing First success at achieving the identified outcomes? b) What data should be collected to enable best evaluation of Housing First’s effectiveness? Methodology: Research Design Exploratory Sequential Mixed Methods 1. Qualitative case study of Housing First in Greater Boston 2. Develop survey based on qualitative findings 3. National survey of Housing First providers Qualitative Data Collection and Analysis Results connected to and build to Source: Creswell & Clark, 2018 Quantitative Measure, Instrument, Intervention, App, or Website Tested or applied by Quantitative Data Collection and Analysis Interpretation Methodology: Qualitative Case Study of Greater Boston Focus groups utilize value-focused thinking (VFT) to better understand how Housing First functions and identify the desired outcomes HF Program 1: Grace Mission* Expert Interviews (n=4) HF Program 2: A Pathway Home HF Program 3: Homes Now Interview with Program Leadership (n=2) Interview with Program Leadership (n=5) Interview with Program Leadership (n=2) Focus Group with Direct Service Staff (n=10) Focus Group with Program Participants (n=12) Focus Group with Direct Service Staff (n=5) Focus Group with Program Participants (n=7) Focus Group with Direct Service Staff (n=3) Focus Group with Program Participants (n=4) * The names of all participating programs and people have been changed to protect their identities. Methodology: National Survey of Housing First Providers ▸ Survey development was informed by qualitative data to test generalizability of findings ▸ Sampling approach: ▸ Randomly select 390 cities (50%) from U.S. Census Bureau’s Annual Estimates of the Resident Population for Incorporated Places of 50,000 or More (United States Census Bureau, 2018) ▸ Manually search for all homeless service providers within sample cities that potentially use a Housing First approach (n=1,247) ▸ Online survey distributed via email ▸ 39 questions Housing First in Greater Boston: A Qualitative Case Study Expert Interviews ▸ Experts agree: ▸ Housing First is associated with being low-barrier or lowthreshold ▸ Housing First programs serve people experiencing long-term homelessness ▸ Experts disagree: ▸ About what type(s) of programs can be Housing First ▸ No consensus on emergency shelters ▸ Disagreement about whether rapid re-housing is Housing First Housing First in Greater Boston: A Qualitative Case Study Grace Mission ▸ Provides emergency shelter and permanent supportive housing (scattered-site and single-site) to individual adults and families ▸ Emergency shelter is low-barrier, but Housing First only applies to housing programs Leadership Direct service staff Program participant “A big part of our philosophy is that we don't want to evict, like ever.” “I have a lot of clients that have different addictive behaviors, and it’s not my place to put my version of appropriateness onto them. And it really comes down to them figuring out the quality of life that they want. And really working with them around keeping themselves safe is the biggest thing.” “When they own it, you can’t have guests after a certain time. It’s like a control thing. It’s not independent living. You’re living with their rules...” Housing First in Greater Boston: A Qualitative Case Study A Pathway Home ▸ Began as an addiction rehabilitation agency ▸ Transitioned to Housing First in 2016 because of HUD mandate ▸ Tried to make minimal adjustments to past practices to fit Housing First ▸ Provides emergency shelter and permanent supportive housing (scattered-site and single-site) to individual adults and families ▸ Low-barrier and Housing First are essentially synonymous; emergency shelter AND housing programs are Housing First Leadership Direct service staff Program participant Housing First is just a ”revolving door” to homelessness. The Housing First model gives housing to “those that are not well.” “I can remember being inside the prison and just thinking ‘if I just had a place to stay…I’d be able to get some things accomplished’” Housing First in Greater Boston: A Qualitative Case Study Homes Now ▸ Extremely well-funded program ▸ Provides emergency shelter to individual adults as well as permanent supportive housing (primarily scattered-site) to individual adults and families ▸ Emergency shelter is low-barrier, but Housing First only applies to housing programs Leadership Direct service staff “We know that “...put them in a home. And Program participant “I was hungry one there’s folks that then they work on whatever night at 11 o’clock. I are going to use they feel as though their got up and made a or that are going needs are at the moment. grilled cheese to drink and trying And with some motivational sandwich. I hadn't to provide as safe interviewing…maybe helps done that in five years. a place as them see some other It was a miracle to possible as we needs which they may or me.” can is a big part of may not choose to address. our role.” Housing First in Greater Boston: A Qualitative Case Study Value-Focused Thinking Housing First Means-Ends Objectives Network by the Program Participants of Homes Now Housing First in Greater Boston: A Qualitative Case Study Findings ▸ Factors influencing the implementation of Housing First: ▸ ▸ ▸ ▸ The history of the organization Motivation for utilizing Housing First Staff enthusiasm for Housing First Organization’s budget ▸ Scattered-site permanent supportive housing is preferable over single-site permanent supportive housing ▸ More client choice ▸ Better integration into the community ▸ Easier to attain/maintain sobriety (when that is a program participant’s goal for themselves) ▸ When an organization transitions to Housing First, direct service staff’s job descriptions can change drastically; there is a need for more support during transition Housing First in Greater Boston: A Qualitative Case Study Findings ▸ Outcomes of interest: ▸ Percent of program participants exiting to homelessness ▸ Percent of program participants evicted or involuntarily terminated ▸ Increased life satisfaction among program participants ▸ Increased ability to perform activities of daily living among program participants ▸ Program participant progress toward achieving goals beyond attaining and maintaining housing National Survey of Housing First Providers: Results ▸ 283 organizations operating Housing First programs participated in the survey ▸ One of the largest-n studies of Housing First programs in the U.S. to date ▸ Responding organizations are located across 41 states and DC ▸ Primarily nonprofits (92.89%) ▸ Budgets of responding organizations range in size from $899.90 to $259,500,000.00 with an average annual budget of $9,691,130.51 Do Em er m g es tic enc y Vi ol S he e tl D n In S o r op ce S er te ns iv up K in D helt e M a y er i en Cas tch e n Ce ta e n l/B M / an Foo te r eh d av ag ior em Ba n e al k H nt ( IC ea lth M Se ) An r tiv tra He ice s S o ffic alt h br iet king ca r e y S W or P ro e rv ice gr kf or a c e m/R s De eh Re ve lo ab fe pm r Co r al P e nt r or di ogr ing am n S le Ra ate -si catt d p ee te Tr id R Ent ( C d-s an ry ei on t si t ho gr e P i u on e ea a l sing gt rma e) Ho ne Pe n us rm t Su S i an pp afe ng en o H Af av t S r tiv fo en rd upp e H ou ab or tiv s le H e H i ng ou sin ous i g (G ng El e ne de r r H al) o So be usin rH g ou si n g Ot he r National Survey of Housing First Providers: Results Programs Operated by Responding Organizations and Programs Identified as Housing First 140 120 100 80 60 40 Operate 20 0 Identify as HF National Survey of Housing First Providers: Results Self-Ratings on USICH Housing First Checklist Items and USICH Housing First Index Score Core Element of Housing First as Defined by USICH Range Average Rating Standard Deviation Access to programs is not contingent on sobriety, minimum income requirements, lack of a criminal record, completion of treatment, participation in services, or other unnecessary conditions. 0-5 4.64 0.81 Programs or projects do everything possible not to reject an individual or family on the basis of poor credit or financial history, poor or lack of rental history, minor criminal convictions, or behaviors that are interpreted as indicating a lack of “housing readiness.” 0-5 4.74 0.66 0-5 4.50 0.94 0-5 4.30 1.21 0-5 4.45 0.88 1-5 4.50 0.78 Participation in services or compliance with service plans are not conditions of tenancy, but are reviewed with tenants and regularly offered as a resource to tenants. 0-5 4.46 1.08 Services are informed by a harm-reduction philosophy that recognizes that drug and alcohol use and addiction are a part of some tenants’ lives. Tenants are engaged in nonjudgmental communication regarding drug and alcohol use and are offered education regarding how to avoid risky behaviors and engage in safer practices. 0-5 4.53 0.94 Substance use in and of itself, without other lease violations, is not considered a reason for eviction. 0-5 4.54 1.09 Tenants in supportive housing are given reasonable flexibility in paying their share of rent on time and offered special payment arrangements for rent arrears and/or assistance with financial management, including representative payee arrangements. 0-5 4.39 1.11 0-5 4.48 0.98 20 - 55 49.55 6.97 People with disabilities are offered clear opportunities to request reasonable accommodations within applications and screening processes and during tenancy, and building and apartment units include special physical features that accommodate disabilities. Programs or projects that cannot serve someone work through the coordinated entry process to ensure that those individuals or families have access to housing and services elsewhere. Housing and service goals and plans are highly tenant-driven. Supportive services emphasize engagement and problem-solving over therapeutic goals. Every effort is made to provide a tenant the opportunity to transfer from one housing situation, program, or project to another if a tenancy is in jeopardy. Whenever possible, eviction back into homelessness is avoided. USICH Housing First index score National Survey of Housing First Providers: Regression Analysis Regression Analysis for USICH Housing First Index Score Predictor Variable Budget Total staff Region1 Midwest Pacific South West Nonprofit Receives government funding Always utilized Housing First Number of years utilizing Housing First Operates scattered-site permanent supportive housing (PSH) Housing First program Housing First program(s) serve people experiencing chronic homelessness Motivated to utilize Housing First by funder requirements Level of staff enthusiasm for Housing First (0-5 rating scale) Level of staff flexibility to creatively problemsolve with program participants in order to keep them in housing (0-5 rating scale) Program participant level of involvement in decision-making (0-5 rating scale) Constant R2 n *p<0.10; **p<0.05; ***p<0.01 Standard Error Base Model 0.00 0.00 0.01** 0.01 p=0.2250 1.74 1.48 2.75 2.36 -0.61 1.68 -0.05 1.47 -1.01 4.39 6.35 4.09 1.39 1.19 0.00 0.03 Coefficient Standard Error Expanded Model 0.00 0.00 0.02* 0.01 p=0.3639 0.92 1.37 2.24 3.18 -1.38 1.57 -0.62 1.31 -1.21 3.79 7.02* 4.09 1.25 1.34 -0.01 0.02 Coefficient 4.92*** 1.13 4.27*** 1.17 -1.48 1.31 -1.51 1.25 — — 0.50 1.18 — — 0.95 0.65 — — 1.68** 0.68 — — -0.31 0.53 41.75 32.41 0.26 165 0.32 161 National Survey of Housing First Providers: Regression Analysis Selected Regression Coefficients in Key Outcome Models Percent of program participants who exit directly to homelessness Budget Number of years organization has utilized Housing First Operates scattered-site permanent supportive housing (PSH) Housing First program USICH Housing First index score Motivated to utilize Housing First by funder requirements Staff enthusiasm for Housing First (0-5 rating scale) B 0.00** E High selfPercent of rating of program increased life participants who satisfaction are evicted or among involuntarily program terminated participants B E -0.02** -0.02** -0.84*** -0.55** -0.52** — -0.03* — — -0.66** — — -0.36*** — *p<0.10; **p<0.05; ***p<0.01 B E High self-rating of increased ability to perform activities of daily living (ADLs) among program participants B E High self-rating of program participant progress toward achieving their own goals beyond attaining and maintaining housing B E 1.03* 0.40** — — -0.45* — -0.25** — 1.06* — 1.09*** — — 0.30** — — Conclusion: Variation in Housing First Spectra for Areas of Variation in Defining Housing First Source: author’s own Conclusion: Housing First in Theory vs. Housing First in Practice Housing First in Theory vs. Housing First in Practice: A Conceptual Framework Source: author’s own Conclusion: Policy Recommendations ▸ Need more support for organizations transitioning to a Housing First model, especially for those that have historically operated under a very different model (e.g. sober housing) ▸ Need to implement widespread use of Housing First fidelity measure ▸ Future evaluations of Housing First programs should report the level of fidelity in order to make more meaningful crossprogram comparisons ▸ Scattered-site permanent supportive housing (PSH) is preferable to single-site PSH ▸ Need to create database of entire population of Housing First programs in the U.S. to improve future research Conclusion: Future Research ▸ Identify and validate measures for life satisfaction among program participants, ability to perform activities of daily living (ADLs) among program participants, and program participant progress toward achieving goals beyond attaining and maintaining housing ▸ Evaluate Housing First programs in the future based on their success at achieving outcomes identified by stakeholders, especially since the model is centered on client choice Thank You! Please email Caitlin.carey001@umb.edu with questions or comments Selected References ▸ ▸ ▸ ▸ ▸ ▸ ▸ ▸ ▸ ▸ ▸ ▸ Creswell, J. W., & Clark, V. L. P. (2018). Designing and conducting mixed methods research (3rd ed.). SAGE publications, Inc. Greenwood, R. M., Schaefer-McDaniel, N. J., Winkel, G., & Tsemberis, S. J. (2005). Decreasing psychiatric symptoms by increasing choice in services for adults with histories of homelessness. American journal of community psychology, 36(3-4), 223-238. Greenwood, R. M., Stefancic, A., Tsemberis, S., & Busch-Geertsema, V. (2013). Implementations of Housing First in Europe: Successes and challenges in maintaining model fidelity. American Journal of Psychiatric Rehabilitation, 16(4), 290-312. Keeney, R. (1992). Value-focused thinking: A Path to creative decision-making. Cambridge, MA: Harvard University Press. Kertesz, S. G., Austin, E. L., Holmes, S. K., DeRussy, A. J., Van Deusen Lukas, C., & Pollio, D. E. (2017). 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Direct placement versus multistage models of supported housing in a population of veterans who are homeless. Psychological Services, 6(3), 190. doi:10.1037/a0014921 Padgett, D. K., Stanhope, V., Henwood, B. F., & Stefancic, A. (2011). Substance use outcomes among homeless clients with serious mental illness: Comparing Housing First with treatment first programs. Community Mental Health Journal, 47(2), 227- 232. doi:10.1007/s10597-009-9283-7 Selected References (cont.) ▸ ▸ ▸ ▸ Stefancic, A., Tsemberis, S., Messeri, P., Drake, R., & Goering, P. (2013). The Pathways Housing First fidelity scale for individuals with psychiatric disabilities. American Journal of Psychiatric Rehabilitation, 16(4), 240-261. Stergiopoulos, V., Gozdzik, A., Misir, V., Skosireva, A., Connelly, J., Sarang, A., Whisler, A., Hwang, S. W., O’Campo, P. & McKenzie, K. (2015). Effectiveness of Housing First with intensive case management in an ethnically diverse sample of homeless adults with mental illness: A Randomized controlled trial. Plos ONE, 10(7), 1-21. doi:10.1371/journal.pone.013028 Tsai, J., Mares, A. S., & Rosenheck, R. A. (2010). A multisite comparison of supported housing for chronically homeless adults: “housing first” versus “residential treatment first”. Psychological services, 7(4), 219. U.S. Department of Housing and Urban Development. (2019). The 2019 annual homeless assessment report (AHAR) to Congress. https://files.hudexchange.info/resources/documents/2019-AHAR-Part-1.pdf