Housing First in Permanent Supportive Housing Brief

HOUSING FIRST IN PERMANENT SUPPORTIVE HOUSING

What is Housing First?

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.

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 jails.

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.

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.