Harm Reduction Housing: Fidelity to a Model

Transcription

1 Harm Reduction Housing: Fidelity to a Model Dennis Watson, Ph.D. and Valery Shuman, ATR-BC, LCPC September 13,

2 Dennis P. Watson, PhD Assistant Professor Indiana University Richard M. Fairbanks School of Public Health, Indianapolis

3 Valery M. Shuman, MAAT, ATR-BC, LCPC Associate Director Midwest Harm Reduction Institute x.1021

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 Housing Consumer 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) housing Low-threshold admissions RICH 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 Effectiveness High 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 earlier remained stably housed reported higher perceived self-determination Utilization of substance use treatment was significantly higher for the control group BUT no difference was found in substance use or psychiatric symptoms (Tsemberis, 2004)

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

12 Massachusetts Home & Healthy for Good Project

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

14 Problems with Diffusion and Adoption Lack of replication guidelines Strength of abstinence-based philosophy in service provision Lack of clear understanding of: Harm reduction Low demand services Program-level barriers

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

17 Study: Design & Testing of the HFM Fidelity Index The index Developed in two phases 29 components along 5 dimensions 1. Human resources-structure and composition 2. Program boundaries 3. Flexible policies 4. Nature of social services 5. Nature of housing and housing services National (randomized quota) sample of programs 12 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 policies 18 had abstinence-based policies and procedures Conflicted with with basic philosophy of HFM Split HFM programs into two groups Housing First without abstinence-based policies and practices (21) Housing First with abstinence-based policies and practices (18)

19 Results: Fidelity Scores by Group Type Fidelity 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 selfdesignated as Housing First?

22 6 Essential Elements 1. Low threshold admissions policy 2. Harm reduction-based policies & practices 3. Separation of housing and services 4. Reduced service requirements 5. Eviction prevention 6. Consumer education Six slides that follow provide examples of ingredients necessary for these components. Ingredients represented are not: Mutually exclusive to one element Exhaustive of all ingredients of a good Housing First program

23 Low Threshold Admissions Policy Program 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 procedures Program 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 services Housing 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 requirements Consumers 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 Prevention Program 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 Education Ongoing consumer education in Housing First and Harm Reduction!!!! *Involvement of consumers in program design and implementation

29 Program-Level Barriers Funding Designates who program can and cannot serve *Under-resourced supportive services Property management Decides who they will or will not house Often has stricter rules than program Structure of housing *Project-based housing affects the role of case management Organizational culture Staff attitudes

30 Two Dimensions of Housing First 1. Program flexibility Encapsulated by: Low-threshold admissions policy Harm reduction Separation of housing and services Reduced service requirements Eviction prevention 2. Consumer education A 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 Barriers 1. Housing case management as minimum service requirement 2. Strategize ways to be flexible within limits of outside rules Can consumers use away from property? Develop individualized risk management plans If funding requires treatment: Do not force consumers to engage in more than minimum Offer a wide range of service choices Are you able to maneuver consumers between properties? 3. Advocates should not be rule enforcers Have separate staff in charge of property and case management services 4. Do not protect consumers from natural consequences

34 Conclusion The HFM is complex There is confusion HFM implementation Not all HFM programs look the same Barriers to full implementation are okay, but: It is important that they are recognized Strategies should be developed to work within limitations

35 Consumer Quote It [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 Readings DeSilva, 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), 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), Gladwell, M. (2006, February 13). Million-dollar Murray: Why problems like homelessness may be easier to solve than to manage. The New Yorker, 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),

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 mes.pdf National 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, 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

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), Tsemberis, S., & Asmussen, S. (1999). From streets to homes -- The Pathways to Housing Consumer Preference Supported Housing Model. Alcoholism Treatment Quarterly, 17(1), 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), 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),

39 References and Recommended Readings (cont.) 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: 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: 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, 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