Housing First (originally Pathways to Housing as first implemented and evaluated in New York City) has become an international model for learning about evidence-based practice in social services. It has been implemented and evaluated in many countries, including USA, Canada, UK, Denmark, Netherlands, France, Portugal, Finland and the list continues to grow.
A major HF experiment implemented in five Canadian cities (www.mentalhealthcommission.ca search National Final Report. Cross-site At Home) revealed high-quality evidence consistent with those in other countries:
* Providing high-need chronically homeless people (with multiple problems like drug/alcohol abuse, mental health issues etc) with secure housing without preconditions, and supplementing that housing with either a package of (assertive community treatment (ACT) services or intensive case management (ICM) leads to good results.
* About 80% of the people are able to remain in their homes, and make less use of emergency services, shelters, police, ambulances, etc,
* …and they make progress at varying levels, toward better mental health, improved addiction behaviour, and social integration.
The housing and service packages are expensive, about $25000 per person per year in Canada for housing plus ACT, a bit less for housing plus ICM. But for the 10-30% of the homeless who fit the categories of high need, there are substantial savings or “offsets” because their use of services like emergency rooms, ambulances, police interventions, courts and jails, doctor and medical services, are reduced. For individuals with the highest needs the savings may be double the cost of intervention.
These findings are consistent with experience in other countries, as reported in an international peer review symposium on the Finnish experience (housingfirst.fi), and in a paper prepared for the European Commission on the potential for pan-European adoption of the model. ...research on Housing First is finding consistent success for Housing First services in terms of ending chronic homelessness across a range of countries, including several EU member states. (Pleace and Bretherton, The Case for Housing First in the European Union, feantsaresearch.org).
Several researchers and analysts have gone through the evaluations of Housing First, and although they comment that all evaluations are not equal in quality, they tend to feel that enough evidence has accumulated to support the kind of conclusions reached in the Canadian study. So we can with confidence conclude that Housing First (HF) is a solid approach for getting the most troubled homeless into better physical and mental space, bearing in mind that it combines secure housing with high quality support services including primary health care, mental health support, case management and others. It also appears to work well for many of the homeless with more moderate problems, although cost-benefit analysis may make it appear rather costly relative to less intensive or shorter term interventions. We should note that the intervention does not seem to have been evaluated over the longer term for those with more moderate issues, and so the possible eventual rehabilitation of the individual into employment and positive social roles has not been much documented.
HF appears to work better when clients are placed in dispersed housing units, but in some cases a communal housing complex may also be appropriate. The European paper adds that some of the support service costs might in some cases be mitigated by lower intensity or peer counselling models, although there is some controversy as to whether this might lead to less robust results.
So now that we can consider this an evidence-based service model, what happens next? Can and will this model be “scaled up”? One of the interventions at the Finnish seminar pointed out that in the USA, where the model has been federally recognized and sanctioned for five years, the HUD budget for homelessness services has remained flat. The only new money has been directed to homeless veterans. The HF approach has become well-known and has been adapted in various cities and states. However, these appear to be mostly project-based approaches, rather than being ongoing services provided to all homeless people who meet the criteria. So scaling up is a problem.
In part, scaling up is a problem because the savings identified by the research do not accrue – either to the organization sponsoring the HF intervention, nor to the agencies where the savings occur. Fewer visits to the Emergency Room do not result in reduced costs. At best they mean that wait times for the other patients may be marginally decreased. Police who are not required to pick up that homeless person that evening have other things to do. Ambulance budgets are not decreased because they carry a few less people. Doctors do not lack for other people to take up their free time.
Even if the savings could be recognized, there is no social accounting system which brings them forward to be reallocated. Social services, although they may be constitutionally in provincial or state jurisdiction, deal with problems which are amorphous, multifaceted, and not program-specific.
Homeless populations in the United States experience a mortality rate 3 to 4 times that of the general population, with the highest mortality ratios seen in the 18- to 54-year-old age group. These unacceptable disparities persist despite most chronically homeless people regularly interfacing with multiple systems including shelters, hospitals, mental health and drug and alcohol services, criminal justice, and welfare. (A Primary Care-Public Health Partnership Addressing Homelessness, Serious Mental Illness, and Health Dispartities, Weistein, L.C., LaNoue, M.D., Plumb, J.D., King, H., Stein, B., Tsemberis, S. Journal of the American Board of Family Medicine, 2013, accessed at pathwaystohousing.org)
The helping agencies might be municipal, charitable, United Way, state, federal, private for-profit, etc. Many are local NGO’s which may draw revenues from all of these sources as well as religious organizations, and volunteers.
Because social services organizations are so varied, and rely on funds from so many different sources, and jurisdictions, it is extremely difficult to develop planning models, integrated client information and case management systems, inter-agency service protocols, evaluation and systemic cost-management. Evidence-based service models are much-needed but by themselves they are not enough. They need to fit within planned, documented, and regulated systems which are adequately funded to serve and be accountable to the people and communities who rely on them. There is still much work to be done.