Homeless Outreach & Housing First: Lessons Learned

Homeless Outreach & Housing First: Lessons Learned

by Jay S. Levy


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Product Details

ISBN-13: 9781615991365
Publisher: Loving Healing Press
Publication date: 10/28/2011
Pages: 44
Product dimensions: 7.44(w) x 9.69(h) x 0.09(d)

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The Case for Housing First: Moral, Fiscal, and Quality of Life Reasons for Ending Chronic Homelessness

There is a heavy price tag for long-term homelessness. It is not only a societal ill, but also has a negative impact on the health and welfare of the many individuals experiencing chronic homelessness. Wasserman and Clair (2010) state, "... addressing homelessness is literally a matter of life and death, as it is associated with all sorts of health outcomes such as addiction, mental illness, chronic and acute disease, malnutrition and violence." For many years, while providing outreach-counseling services, I witnessed this on the streets and in the shelters of New York City, Boston, and Western MA. Unfortunately, it was not unusual to meet people living on the fringes of our society without any sense of hope or expectation for the comforts of a better life. Throughout the 1980s, 90s and much of the new millennium, the response to homelessness has been primarily geared toward helping people who are most ready to accept services and programming, as well as providing temporary shelter for those who could soon return to work. In the meantime, long-term homelessness has become an all too common and accepted reality. In fact, research has shown that on a yearly basis 2.3 – 3.5 million people are homeless (Burt and Aron, 2000). Further, as much as 20 percent of the homeless population (Kuhn and Culhane, 1998) are either among the long-term homeless, or have had multiple episodes of homelessness.

This is at the core of the Department of Housing and Urban Development's (HUD) definition, which defines chronic homelessness (McKinney-Vento, 2002) as an individual with disability (addiction, mental or medical illness) who has been homeless for at least 12 consecutive months or has had at least 4 distinct episodes of homelessness within a three-year period. While economic realities that include unemployment, underemployment, and lack of affordable housing are amid the initial causes that can lead to chronic homelessness, other significant variables consist of major mental illness and/or addiction and other medical issues that compromise social and vocational functioning. In fact, many shelters that have prided themselves in becoming safe havens for the poor and less fortunate have also become default institutions for long-term homeless persons with acute and chronic health issues. Meanwhile, among the many myths is that people who experience chronic homelessness are unworkable or disinterested in getting help, or simply prefer their homeless life style. Unfortunately, the costs of writing off a significant proportion of the homeless population has been staggering. Misguided homelessness policies have led to both moral and fiscal concerns, while the quality of life slowly deteriorates among the homeless themselves, as well as throughout our cities and towns.

Mortality, Health, and Moral Considerations

Somehow we have convinced ourselves that people who are long-term homeless with mental illness, addiction, and/or major medical conditions need to seek treatment prior to getting housed. In many instances we have turned this into a litmus test by declaring treatment as a prerequisite for residential placement. While this has motivated some people to begin needed treatment, others have refused treatment and have thus suffered dire consequences. The stark reality is that our attempts to avoid "enabling" have led to far too many deaths. While we wait for chronically homeless persons to hit bottom and request treatment, higher numbers continue to die. Dr. Hwang, Dr. O'Connell and colleagues (1998) studied the vulnerability of particular homeless subgroups and found that people who were unsheltered or living outside for at least 6 months were at high risk of death if they fell into any of the following categories:

• Triple diagnosis of mental illness, substance abuse, medical condition

• 60 years of age or older

• History of Frostbite, hypothermia, or trench foot

• At least 3 emergency room visits over the prior 3 months

• Diagnosis of HIV/AIDS, liver or renal disease

Over a five year period, 40% of the people who were among these categories died and the average age of death was 47 (O'Connell, 2005). It is equally clear that a high proportion (at least 46%) of homeless individuals sheltered and unsheltered suffer from chronic medical conditions ranging from arthritis, hernias and foot ulcers to liver, renal, and heart disease (Burt, et al., 1999). These health issues, as well as chronic mental illness and addiction, are only exacerbated by unsafe, substandard living conditions that lack basic access to food, clean clothes, sanitary bathroom facilities and a secure place to sleep. When one considers the impact of unstable and chaotic environments on health issues, it's hard to fathom why health care professionals and residential programs serving at risk homeless individuals have often prioritized compliance with treatment above housing placement (Levy, 2010, p. 15). It is a given that successful treatment is often dependent upon living conditions that promote, rather than diminish, health and safety.

After considering the serious ramifications of a treatment first, rather than a housing first approach, one may conclude that it is a moral imperative to house vulnerable chronically homeless persons as quickly as possible, while continuing outreach and support services. It is important to keep in mind that housing is not an end in itself, but rather an opportunity to continue our efforts to build pathways to needed treatment services and community resources.

Financial Considerations

The cost of long-term homelessness impacts us on many fronts. Just consider that every day someone resides in a homeless shelter there is a cost for the bed and the staff needed to assure their safety. Surprisingly, the cost for a shelter bed in NYC can run as high as $19,800 per year (Culhane and Metraux, 2008). In addition, the longer someone is homeless, the more likely a person will experience untreated medical, mental health and addiction issues. This not only leads to periodic crises for police, EMTs and emergency room staff, but also results in multiple hospitalizations. In other words, long-term homelessness leads to acute medical, psychiatric and addiction issues being managed and treated via shelters, emergency rooms and inpatient facilities at an extremely high cost (Kuhn and Culhane, 1998). Malcolm Gladwell (2006) wrote a compelling article in the New Yorker that tells the story of Million Dollar Murray. Murray consumed large amounts of alcohol, while living on the streets of Reno, Nevada. From time to time Murray would get sober, clean himself up and resume employment. However, without needed support services, he would relapse and end up back on the streets. Inevitably, Murray suffered a number of chronic and acute medical issues leading to multiple hospitalizations. The cost over a ten-year period added up to more than a million dollars! This price tag did not even factor in police, EMT, and other emergency services that were separate from the local hospital bill. The problem is that there is more than one Murray! There are actually a high number of unsheltered individuals going in and out of emergency rooms, detoxification facilities, and hospitals throughout our cities and towns. A five-year study of chronically homeless persons (O'Connell, et al., 2005) found that 119 street dwellers accounted for 18,384 emergency room visits and 871 medical hospitalizations. The average annual health care cost for individuals living on the street was $28,436 compared to $6,056 for individuals who were successfully placed in housing.

Fortunately, housing first options comprised of affordable housing with support staff costs considerably less than the status quo. The expenditure for subsidized housing and support services ranges from $12,000 – $20,000 per year, as compared to our significantly higher price tag for inaction. While housing first programs are no guarantee against relapse, there is a proven track record of significantly reducing medical costs and maintaining people in permanent housing (Home and Healthy for Good Report, 2010; Stefancic and Tsemberis, 2007). The financial case for providing housing with support services to at risk or vulnerable chronically homeless individuals is clear. In addition, advocates, policy makers and providers now realize that the same argument can be made for serving long-term homeless families. Overall, the evidence shows that housing with support services not only saves lives, but is also a financially wise practice.

Quality of Life Considerations

Arguably it is basic things like good health, nutritious food, a secure home, livable income, and positive relationships that are among the ingredients toward attaining a better quality of life. Successful homeless outreach begins with the challenge of building a positive relationship and offering basic need items such as food and a warm blanket, as well as access to safe shelter and/or affordable housing. Unfortunately, chronic homelessness and the growing effects of poverty have had a negative impact on the quality of life throughout our society. In many places across our country, the poor and the rich live side by side with an ever-shrinking middle class. This is expressed quite vividly in the homeless realm. I have spent much time meeting people who are impoverished and without homes next to Boston's high end stores along Newbury St., or beside New York City's Upper West Side's cafes. The irony of such a meeting is shared by all of us. Places like NYC's Port Authority and Boston's South Station have become safe havens for the homeless, while commuters generally make efforts to avoid eye contact or any kind of human connection. Even in smaller towns throughout Western MA, business owners register complaints of homeless individuals blocking their entryways and/or frightening away customers. Further, many cities and towns have struggled with how to respond to aggressive panhandling practices. Finally, it is not unusual for families to feel uncomfortable or unsafe visiting certain parks or playgrounds because a person experiencing long-term homelessness has taken up residence there. While it is true that homelessness may not be the main cause of these problems, it is understandable why many people feel inconvenienced or even threatened by their homeless neighbors. Though it is tempting to turn this into a dichotomy of us vs. them, it is clear that we are in this together. In fact, it is this type of dualistic thinking that has led to unsuccessful homelessness policies and flawed interventions. Ignoring people who are homeless, punishing them, or worse yet, treating them as second-class citizens will not resolve this thorny issue. Obviously, people without homes directly suffer the consequences including poor health and a degraded quality of life, but this is also a societal ill that affects us all. Therefore, we must find a way to address this on both individual and societal levels.

Effective Pretreatment Strategies

Homeless outreach

Over time, the world of a person experiencing long-term homelessness gets more and more defined by meeting immediate needs such as finding food and shelter, staying warm, and may even include ongoing efforts to feed addiction, rather than continually searching for work and affordable housing. Anyone who has experienced long-term unemployment understands the internal struggle of maintaining hope when the prospects of success continually appear grim. Many people who experience long-term homelessness are hesitant to trust others and have found a sense of meaning that reflects their culture, individuality, and homeless circumstance, while upholding their personal values and need for freedom and safety. These survival strategies, meaning making, and clinging to strongly held beliefs and values, form an integral part of the adaptation to the traumatic experiences of homelessness. The central challenge of outreach (See 10 Golden Rules list, p. 11) is to develop a trusting relationship that respects the autonomy of the individual, as well as speaking a language that consists of shared words, ideas, and values (Levy, 2004). This is at the heart of a pretreatment approach, which is governed by the following cardinal rule: Meet clients where they are at! The relationship is the foundation of pretreatment work, while common language development is its main tool (Levy, 2010). It is from the safety of a trusting relationship and the development of a common language that makes it possible to offer potential resources and services that resonate well in the world of the homeless person. Ironically, the outreach worker is often struggling to access the very resources and services that their clients need most; namely income and affordable housing with support services!

Housing First

It is essential that we directly connect affordable housing and support service options to outreach teams and shelter staff, so that it can be readily available to persons experiencing chronic homelessness. If we really want to resolve long-term homelessness, we need to offer accessible, affordable housing alternatives with support services. This includes a very broad-based eligibility criterion that is inclusive rather than exclusive. Housing first does not require that a person partake in mental health, addiction program or medical treatment; or that they achieve sobriety prior to being housed. The basic premise is that people should be housed as quickly as possible with support services that can develop pathways and/or bridges to community resources, services and treatment. The only thing required to enter a housing first apartment is a designation of chronic homelessness or high vulnerability and a willingness to accept an outreach support service. Throughout the Western MA area, we have developed the Regional Engagement and Assessment of Chronically Homeless Housing First Program (REACH). This program not only attaches affordable housing options directly to outreach workers, but then directly involves the outreach workers in providing ongoing support services to newly housed individuals. This is a relationship-centered model that supports transitions to needed housing, resources and services. Other important tasks for outreach staff include providing advocacy with landlords, as well as rapid response to any issue that may threaten safety and/or permanent housing. The need for rapid response falls under four basic categories:

1. Non-payment of Rent

2. Conflict with Neighbors

3. Destruction of property

4. Personal Safety of tenant

If a person were once again to experience homelessness due to eviction or prematurely leaving their apartment, the homeless outreach process can easily resume. However, now the outreach team and hopefully the person re-experiencing homelessness have a chance to get perspective on the challenges of housing stabilization. Lessons learned from previous housing first attempts serve as a catalyst to renew our efforts to rapidly re-house the person who is in dire need of a safe and secure residence with support services. Housing first efforts have been tried in many cities throughout the country including Philadelphia, Boston, New York City, Las Vegas, and Seattle. Multiple studies have confirmed successful outcomes such as better than 84% housing retention rates, as well as reducing overall health care costs (Home and Healthy for Good Report, 2010; Stefancic and Tsemberis, 2007). The same pretreatment approach used to promote successful outreach can also be used to continue the work with newly housed individuals. This means that the residential outreach support services should continue to emphasize the basic pretreatment principles of relationship building, common language development, support transitions to needed resources and services, promote safety through harm reduction and crisis intervention, as well as facilitate and support positive change (Levy, 2000). Whether or not a particular housing first program is run as a scattered site or congregate living model, it is essential that the support service component is well developed and responsive to the immediate needs of the tenant, landlord and neighbors. This also means providing the right level and intensity of support services based on the willingness and needs of the individual.


Excerpted from "Homeless Outreach & Housing First"
by .
Copyright © 2012 Jay S. Levy, MSW, LICSW.
Excerpted by permission of Loving Healing Press, Inc..
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

Table of Contents

Pretreatment Principles & Applications,
The Case for Housing First: Moral, Fiscal, and Quality of Life Reasons for Ending Chronic Homelessness,
10 Golden Rules of Outreach Counseling (Pretreatment Perspective),
Ronald's Narrative: The Original Housing First,
Stages of Engagement,
Helping the Homeless,
7 Ways of Helping,
About the Author,

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