Separation of Housing and Services
A disproportionate number of the chronically homeless are people with mental illness and substance use disorders. Sam Tsemberis, founder of Pathways to Housing First, argues that it doesn't need to be this way. His program's remarkable success rate--an estimated 85 percent of participants find homes and remain there--makes his case. In the following excerpt from Tsemberis's book Housing First, the author outlines key tenets of his program and how it works.
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Some people think when you offer housing right away that you're actually enabling people as opposed to helping them get better. Our experience has been that providing housing first, and then treatment, actually has more effective results in reducing addiction and mental health symptoms, than trying to do it the other way. The other way works for some people, but it hasn't worked for the people who are chronically homeless.
- Sam Tsemberis
Founder and CEO of Pathways to Housing, Inc.
All PHF clients have ready, reliable access to treatment and comprehensive support services, usually through a multidisciplinary team approach such as an assertive community treatment (ACT) or intensive case management (ICM) program.... These teams are located off-site, but they are available on-call 24/7. They provide most services in a client's natural environment- usually in the apartment, neighborhood, or workplace. The service is time-unlimited; it is offered as long as a client needs the given level of support.
The aim of the support and treatment is to help clients address their needs: physical health, mental health, employment, family reconnection, recovery goals and/or addiction problems. These clinical issues are regarded as separate and distinct from clients' housing issues - matters such as apartment maintenance, problems with paying rent, lease renewals, and so on. The criteria that determine a client's success as a tenant or a client of an ACT team are very different. For example, if a client has a psychotic episode and needs in-patient hospital treatment, she would receive help getting to the hospital and help returning to her apartment after discharge. In this example, the housing domain and clinical domain are separate; in other words, she does not risk losing her apartment because she had a clinical crisis. She would risk of losing her apartment only for the same reasons any other leaseholder in the building would: nonpayment of rent, too many visitors, illegal activity in the apartment, noise or disruption, or any other behavior that constitutes a lease violation. Even if she was evicted for one of these reasons, she would lose her apartment but, because the PHF team is off-site, she would still have the support of the team while relocating to another unit.
By separating the criteria for getting and keeping housing from a client's treatment status- while at the same time maintaining a close ongoing relationship between these two components- PHF programs help prevent the recurrence of homelessness when clients relapse into substance abuse or have a psychiatric crisis. When necessary, team members provide intensive treatment or facilitate admission to a detox center or hospital to address a clinical crisis. However, there is no need to add eviction or fear of eviction into a clinical crisis. When the crisis passes, (e.g., after the client completes inpatient treatment), the client simply does what any other human being would want to do: he or she goes home.
Similarly, in the event of an eviction for a lease violation, PHF's housing staff will facilitate a move directly into another apartment if one is available. If not, housing staff will help move the client into short-term housing until another apartment can be found. This continuity of care is possible because the clinical team is off site, separate from any housing component. Thus, the same team members can help the client move from one location to another. In this manner, the PHF model provides continuity of clinical care during a housing crisis and continuity of housing stability during a clinical crisis.
There is another advantage to separating housing and clinical services. As clients continue to attain self-care skills and begin to develop supports and connections within their new communities, they will need fewer or less frequent clinical services. As a client's situation stabilizes, the team will visit their apartment less and less often. Clients can easily be transferred from ACT services to ICM services with no disruption in housing. This separation of clinical from housing services allows for flexible adjustments in frequency of services and an easy way to continue matching the client's needs to the support team's services while keeping housing constant.
When the client is self-sufficient, there can be a complete separation of housing and services. The client continues to live in the apartment and pay rent, with no need for program services. A client does not need to move out of an apartment or transition elsewhere in order to graduate from the PHF program. Graduation simply means that PHF services are discontinued or the client receives less-intensive services through a community-based program and continues to live at home.