There are fairly strict definitions around what qualifies as “chronic” or not, but in simple terms, chronically homeless persons are individuals experiencing ongoing episodic or continuous homelessness, with a co-occurring disability, including mental health substance misuse issues. This is a population that has very high needs. These individuals are often medically vulnerable, at risk of failing out of a more traditional housing placement, and at times highly service resistant, largely because of mental health issues. With the variety of concerns this population is facing, it can be difficult to know where to start.
That’s where housing first (HF) comes in. It’s a relatively recent approach to homelessness that connects people experiencing homelessness to housing without preconditions. In more traditional placements, people aren’t allowed into housing if they haven’t met certain requirements first. Someone must already be in transitional housing, been looking for employment, and maintaining sobriety, among other things. In contrast, housing first is based on the idea that housing is a right. Christian Sarver is the lead senior research analyst in the University of Utah’s Utah Criminal Justice Center (UCJC) and one of the lead researchers evaluating a Substance Abuse and Mental Health Services Administration (SAMHSA) grant awarded to The Road Home for their housing first program.
This program is an expansion of a previous housing first program that relied on an Assertive Community Treatment (ACT) team to provide housing and support services to individuals who had been identified by a multi-agency community partnership as being the most vulnerable homeless persons in Salt Lake City. She explained, “The idea is to house people without regard to these other challenging issues. If they want to work on these things, they’re in a better place to do so if they have a home instead of a temporary placement.”
The Housing Support and Stability Project (HSSP) expanded the original HF/ACT program by adding additional services for those clients with relatively greater needs and less access to services, specifically around substance misuse issues. Because this group has greater needs—with higher rates of mental health and substance use disorder diagnoses than the rest of the chronically homeless population—the grant included funding for more supports.
The Road Home put together an interdisciplinary team that included licensed clinicians, peer support specialists, and a part-time nurse practitioner (APRN), who could write prescriptions. Clients were staffed by the entire team, to ensure interdisciplinary services were available to meet complex needs. This support was in addition to the housing and case management support clients were already receiving through the housing first program. In an effort to make services as easily accessible as possible, the HSSP team provided mobile services.
The work meant different things for different clients, but a common theme was the creativity involved in engaging clients. Sometimes it meant providing therapy in the car on the way to an appointment or in a restaurant over a meal. Sometimes it was bringing prescriptions to their home or helping a client purchase furniture. The team hoped to help people with substance abuse issues, but a range of services were provided, even for clients who did not want to engage with substance abuse treatment. The team also continued to engage with clients who were evicted, in order to continue services and re-house them. “The goal of the intervention was first and foremost to increase the person’s safety,” said Ms. Sarver.
Now, at the end of the grant’s four-year evaluation period, some patterns have clearly emerged. First, housing outcomes. The time participants spent in shelter before enrollment in the Housing First program was 26 percent prior to enrollment and seven percent after enrollment. People continued to fail out of housing, but the amount of time they were housed increased—up to 72 percent of time spent housed, with 33 percent of clients having a negative exit from housing before enrollment and 21 percent after. “From a Housing First perspective, this is a success,” said Ms. Sarver. “This is a difficult population to place and maintain in housing, for a variety of reasons. These results show that even if people continue to engage in activities associated with housing instability, you can drastically improve housing stability with the right team.”
There was also extensive analysis of the criminal justice interactions of this group. Fifty-eight percent of participants had at least one jail booking in the two years prior to enrollment, with 47 clients accounting for over 4,000 nights in jail. Most of these offenses were low-level misdemeanors related to living in public: loitering, camping, substance use in public, open containers, etc. After enrollment, significantly fewer clients had any contact with the criminal justice system, with jail bookings down to 42 percent, accounting for less than 2,000 nights in jail. Ms. Sarver emphasized that it’s often not criminality that is driving this engagement. It’s something else.
“This criminal justice contact is generally coming from other untreated things that are going on: poverty, homelessness, mental health issues, substance use disorder. For many of the people experiencing homelessness, their contact with criminal justice has nothing to do with criminality and you can largely eliminate it by housing them.” Knowing the harmful impacts of incarceration, she wonders, “What’s driving that contact? And how can we do something about it?”
As much as was gleaned from this analysis, a variety of questions still remain. Many of the clients enrolled in the program didn’t engage in clinical services to address substance use—they would conflate clinicians with case managers and request assistance with a range of problems and not necessarily substance abuse treatment. Was it the additional support that helped? Or was it clinical help? Would enhanced case management provide the same benefit at a lower cost? Overall, the interventions in the program did help to reduce shelter use and criminal justice contacts. But which part helped? Offering a therapeutic intervention? Having additional support? The presence of medical personnel on the team? Because homelessness and criminal justice tend to be studied separately, Ms. Sarver believes this offers an interesting space for further research.
Though this evaluation for the Housing First project is over, Ms. Sarver and the UCJC team will continue their work on issues related to homelessness. The next project will be similar to Housing First in that its purpose is to help people experiencing homelessness find permanent housing. It will differ in both the nature of the intervention—this project is a modified rapid rehousing placement—and the population being helped—this project will focus specifically on families.
Butters, R. (PI). Evaluation of the Housing Support and Stability Project (HSSP). Substance Abuse and Mental Health Services Administration (SAMHSA). Award number: TI025650. Total funds: $250,532.14. September 2014 – March 2018.