Harm Reduction Housing: Fidelity to a Model - PowerPoint Presentation

1. Harm Reduction Housing:Fidelity to a ModelDennis Watson, Ph.D. and Valery Shuman, ATR-BC, LCPCSeptember 13, 2013www.pbhealth.iupui.edu

2. Dennis P. Watson, PhDAssistant ProfessorIndiana University Richard M. Fairbanks School of Public Health, Indianapolis317.274.3245dpwatson@iupui.edu

3. Valery M. Shuman, MAAT, ATR-BC, LCPCAssociate DirectorMidwest Harm Reduction Institute773.334.7117 x.1021vshuman@heartlandalliance.org

4. Funding for this study provided by the National Institute on Drug Abuse (NIDA; Award No. R36DA027770)

5. What is the Housing First Model (HFM)?

6. Pathways to HousingConsumer Preference Supportive Housing Model developed in the early 1990s (Tsemberis and Asmussen, 1999)Serves chronically homeless with co-occurring disorders (CODs)Reaction to “treatment first”/continuum of care (CoC) housingLow-threshold admissionsRICH with Low-demand services (ACT teams: 24-hours/day; multi-disciplinary, nurse on team, vocational specialist on team)Harm reduction philosophy in services

7. Midwest Harm Reduction Institute

8. Key Outcomes Demonstrating EffectivenessHigh housing retention rates (Mares & Rosenheck, 2007; Perlman & Parvensky, 2006)Fewer hospitalizations (Sadowski et al., 2009)Higher perceived choice in services (Greenwood et al., 2005; Tsemberis, Gulcur, & Nakae, 2004)Reduced substance use and abuse (Padgett et al., 2010)Reduced involvement in criminal activity (DeSilva, Manworren, & Targonski, 2011)

9. 225 homeless individuals with co-occurring disorders Randomly assigned to either:housing contingent on treatment participation (control)housing without treatment prerequisites (experimental)Interviews conducted every six months for 24 months(Tsemberis, 2004)

10. Experimental group:obtained housing earlierremained stably housedreported higher perceived self-determinationUtilization of substance use treatment was significantly higher for the control groupBUT no difference was found in substance use or psychiatric symptoms(Tsemberis, 2004)

11. Midwest Harm Reduction InstituteDenver’s Housing First Collaborative -Perlman & Parvensky, 2006 Emergency Room Services by 34%Inpatient Hospitalization by 80%Outpatient Care by 50%Net result to health costs by 45 %

12. Massachusetts Home & Healthy for Good Project

13. Nationwide DiffusionTen-Year Plans to End HomelessnessA Plan, Not a Dream: How to End Homelessness in 10 Years (National Alliance to End Homelessness 2000)Over 234 communities as of September 2009More than 10% drop in chronic homelessness since 2007 (HUD, 2011)

14. Problems with Diffusion and AdoptionLack of replication guidelinesStrength of abstinence-based philosophy in service provisionLack of clear understanding of:Harm reductionLow demand servicesProgram-level barriers

15. Fidelity

16. What does Housing First look like where you work?We are providing the HFM with 100% fidelityWe are providing the HFM with 85% or greater fidelityWe are providing the HFM with around 50% fidelityWe are lost in the dark with our provision of HFM

17. Study: Design & Testing of the HFM Fidelity IndexThe indexDeveloped in two phases29 components along 5 dimensionsHuman resources-structure and compositionProgram boundariesFlexible policiesNature of social servicesNature of housing and housing servicesNational (randomized quota) sample of programs12 self-designate “abstinence-based”39 self-designate as “Housing First”

18. Two Types of HFM Programs Some of the “Housing First” programs had abstinence-based policies18 had abstinence-based policies and proceduresConflicted with with basic philosophy of HFMSplit HFM programs into two groupsHousing First without abstinence-based policies and practices (21)Housing First with abstinence-based policies and practices (18)

19. Results: Fidelity Scores by Group TypeFidelity differed significantly by program type“Flexible policies” was the most reliable dimension

20. Results: Housing Retention

21. Why were there such stark differences in implementation between programs that “self-designated as “Housing First”?

22. 6 Essential ElementsLow threshold admissions policyHarm reduction-based policies & practicesSeparation of housing and servicesReduced service requirementsEviction preventionConsumer educationSix slides that follow provide examples of “ingredients” necessary for these components. Ingredients represented are not:Mutually exclusive to one elementExhaustive of all ingredients of a good Housing First program

23. Low Threshold Admissions PolicyProgram serves only chronically homeless and dually-diagnosed individuals, and allows current substance users.Program has formal protocol for admitting consumers with the greatest need/vulnerability.Program places consumers into housing in one week or less.Possession of or eligibility for income benefits is not a prerequisite for housing.

24. Harm reduction-based policies and proceduresProgram uses a Harm Reduction approach and staff has a strong conceptual understanding.Program only terminates consumers who demonstrate violence, threats of violence, or excessive non-payment of rent.Program provides or requires ongoing training in harm reduction and crisis intervention for staff.Program allows alcohol use and housing allows alcohol in units.Program allows illicit drug use and housing allows illicit drugs in units.Program is flexible with missed rent payments, but holds consumer accountable.

25. Separation of housing and servicesHousing is scattered-site in building operated by private landlords.Program holds housing for hospitalization and incarceration for more than 30 days and program continues to offer case management services while unit is unoccupied.Designated staff member is responsible for outreach.Program works with consumers to find desirable housing.Program always attempts to relocate consumers when they are dissatisfied with current housing.Program has formal policy and protocol to work with consumers to prevent eviction, and has a staff member dedicated to eviction prevention.

26. Reduced service requirementsConsumers are not required to engage in any services except for case management to receive/continue receiving housing.Frequent case management visits in the first 1-6 months of placement that gradually decline over time.Enhanced participation in flexible services that meet real-time need*Adequately resourced, flexible, relational services**these items were not included in the index, but have been deemed essential through our experiences in housing work

27. Eviction PreventionProgram only terminates consumers who demonstrate violence, threats of violence, or excessive non-payment of rent.Program is flexible with missed rent payments, but holds consumer accountable.Program has formal policy and protocol to work with consumers to prevent eviction, and has a staff member dedicated to eviction prevention.

28. Consumer EducationOngoing consumer education in Housing First and Harm Reduction!!!!*Involvement of consumers in program design and implementation

29. Program-Level BarriersFundingDesignates who program can and cannot serve*Under-resourced supportive services Property managementDecides who they will or will not houseOften has stricter rules than programStructure of housing*Project-based housing affects the role of case managementOrganizational cultureStaff attitudes

30. Two Dimensions of Housing FirstProgram flexibilityEncapsulated by:Low-threshold admissions policyHarm reductionSeparation of housing and servicesReduced service requirementsEviction preventionConsumer educationA dimension of its own

31. 4 Types of HFM Programs Based on Variations in Flexibility and Education

32. 4 Types of HFM Programs Based on Variations in Flexibility and Education

33. Strategies to Overcome BarriersHousing case management as minimum service requirementStrategize ways to be flexible within limits of outside rulesCan consumers use away from property?Develop individualized risk management plansIf funding requires treatment:Do not force consumers to engage in more than minimumOffer a wide range of service choicesAre you able to maneuver consumers between properties?Advocates should not be rule enforcersHave separate staff in charge of property and case management servicesDo not protect consumers from natural consequences

34. ConclusionThe HFM is complexThere is confusion HFM implementationNot all HFM programs look the sameBarriers to full implementation are okay, but:It is important that they are recognizedStrategies should be developed to work within limitations

35. Consumer QuoteIt [her current program] made me feel good about myself…[T]hey [the staff] gave me choices, you know, gave me choices where you can do this or you can do [that], it’s up to you, [the program is] just trying to provide [me] what [I] need and what [I] want, what’s best for me. That’s what made me feel good too, cause they wanted, they'd give me information where they know its gonna be good for me, its not gonna hurt me or anything. So I could take that chance and I don't have to worry cause I know they got my back…[O]ut there [when I was not in the program] I didn't have no choice you know it[’s] either “your gonna help me or you don't”. You don’t have choices out there, you just have to go with the flow if you want to get some[thing]. (HFM Consumer)

36. References and Recommended ReadingsDeSilva, M. B., Manworren, J., & Targonski, P. (2011). Impact of a Housing First program on health utilization outcomes among chronically homeless persons. Journal of Primary Care & Community Health, 2(1), 16 –20. George, C., Chernega, J. N., Stawiski, S., Figert, A., & Bendixen, A. V. (2008). Connecting fractured lives to a fragmented system: Chicago Housing for Health Partnership. Equal Opportunities International, 27(2), 161 – 180. Gladwell, M. (2006, February 13). Million-dollar Murray: Why problems like homelessness may be easier to solve than to manage. The New Yorker, 96–107.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.

37. References and Recommended Readings (cont.)Mares, A. S., & Rosenheck, R. A. (2007). Evaluation of the Collaborative Initiative to Help End Chronic Homelessness. Retrieved from http://www.hudhre.info/documents/CICH_SystemIntegrationAndClientOutcomes.pdfNational Alliance to End Homelessness. (2000). A plan, not a dream: How to end homelessness in ten years. Washington DC: National Alliance to End Homelessness.Padgett, D. K., Stanhope, V., Henwood, B. F., & Stefancic, A. (2010). Substance use outcomes among homeless clients with serious mental illness: Comparing housing First with Treatment First programs. Community Mental Health Journal, 47, 227–232.Pearson, C. L., Locke, G., & McDonald, W. R. (2007). The applicability of housing First models to homeless persons with serious mental illness. Washington, D.C.: U.S. Department of Housing and Urban Development Office of Policy Development and Research. Retrieved from http://www.huduser.org/publications/homeless/hsgfirst.html

38. References and Recommended Readings (cont.)Sadowski, L. S., Kee, R. A., VanderWeele, T. J., & Buchanan, D. (2009). Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: A randomized trial. Journal of the American Medical Association, 301(17), 1771–1778.Tsemberis, S., & Asmussen, S. (1999). From streets to homes -- The Pathways to Housing Consumer Preference Supported Housing Model. Alcoholism Treatment Quarterly, 17(1), 113–131. Tsemberis, S., Gulcur, L., & Nakae, M. (2004). Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal of Public Health, 94(4), 651–656. United States Department of Housing and Urban Development. (2011). The 2010 annual homeless assessment report to congress. Washington, D.C.: Office of Community Planning and Development, HUD.Watson, D. P. (2012). From structural chaos to a model of consumer support: Understanding the roles of structure and agency in mental health recovery for the formerly homeless. Journal of Forensic Psychology Practice, 12(4), 325–348.

39. Karus, D., Serge, L., & Goldberg, M. (2005). Homelessness, housing, and harm reduction: Stable housing for homeless people with substance use issues. Canadian Mortgage and Housing Corporation, available online at: www.cmhc.ca. Kraybill, K., Zerger, S. (2003). Providing treatment for homeless people with substance use disorders, case studies of six programs. National Healthcare for the Homeless Council, available online at: www.nhchc.org.Perlman, J., & Parvensky, J. (2006). Denver Housing First Collaborative: Cost benefit analysis and program outcomes report. Denver, CO: Colorado Coalition for the Homeless. Tsemberis, S., Gulcur, L., & Nakae, M. (2004). Housing first, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal of Public Health, Vol. 94, No. 4, 651-656.Tsemberis, S. (2010). Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction: Manual and DVD. Hazelden.Webinar Housing First: Ending Homelessness for People with Mental Illness and Addiction www.monarchhousing.org www.pathwaystohousing.orgReferences and Recommended Readings (cont.)