Four Clarifications about Housing First

I must make a confession. When I first came to Washington to work for USICH, I was a bit skeptical about how sold the Federal government was on Housing First. I knew that Housing First was mentioned in Opening Doors, but did the Federal government truly embrace it? After all, it was not so long ago that terms like “harm reduction” were considered four-letter words by the Federal government.

So imagine my happy surprise when I discovered that I was flat-out wrong. In the first of what I learned would be many interagency meetings on chronic homelessness, Housing First adoption was  discussed as a primary strategy for accelerating progress. And one of the very first tasks I was given was to help provide a clear, operational definition of Housing First. The result of that work is USICH's Housing First Checklist , a tool that communities can use to adopt Housing First across their programs and overall community response. Not only does this Administration fully believe in Housing First, but it is working to make Housing First the underlying approach behind every community's response to homelessness.

Ironically, while Housing First is at the forefront of the Federal government’s response to homelessness, I’ve learned that many communities are still engaged in the so-called “Housing First debate.” Communities continue to examine whether Housing First is the right way to address homelessness, saying things like, “We already have a Housing First program, we don’t need any more.” Or “One size doesn’t fit all. Housing First isn’t for everyone.” Or even, “It’s immoral and harmful to put people who drink into housing.”

But does anyone really think homelessness is safer than housing?

What I take from these “debates” is that Housing First is still misunderstood.  So, as a representative of USICH I offer this attempt to provide some clarifications on Housing First.

1. Housing First is not a “program.” It is a whole-system orientation and response.

I often hear Housing First referred a program or a particular model, as in, “We just started a Housing First program.” Or “We don’t have a Housing First program in our community yet, just transitional housing.” In these instances, the term ‘Housing First’ is most often used to mean a permanent supportive housing program that uses a Housing First approach.  Although I see it as a sign of progress that permanent supportive housing and Housing First are being conflated—it wasn’t long ago that Housing First was a new and radical concept in supportive housing circles—I think it’s incorrect to think of Housing First as a permanent supportive housing model, or as a program at all for that matter.

When we think of Housing First as a program, it creates the illusion that Housing First is just one among many choices for responding to homelessness. This sets up a dynamic in which individual programs are pitted against one another. The discussion ends up being about whether we should choose this program or that program, and whether one program is right and another one wrong. It leads to an absurd debate about whether permanent housing or emergency shelters are the solution to homelessness, when both play important but completely different roles. Thinking about Housing First as a program leads to divisions, factions, and conflicts—none of which are helpful in the effort to end homelessness.

Instead, Housing First is a whole-system orientation, and in some cases, a whole-system re-orientation. To borrow a phrase, it is about “changing the DNA” of how a community responds to homelessness. This change enables the community as a whole to:

• make occurrences of homelessness rare and brief
• help people who experience homelessness obtain permanent housing quickly
• help people access the care and support needed to maintain their housing and achieve a better quality of life.

Some of you may have heard about the Triple Aim of health reform. Consider these the “Triple Aim” of ending homelessness.

Achieving these aims is impossible for one program alone. Rather, it requires a variety of programs and services including homeless outreach, emergency shelter, permanent supportive housing, affordable housing, rapid re-housing, along with case management supports, health care, income supports, employment services, and more. But it’s also not enough for these programs to simply exist; they need to work as part of a whole system to help people achieve these aims. That means that the focus of all programs must be to help people obtain permanent housing quickly and without conditions and contingencies. Programs should empower people to overcome barriers to obtaining permanent housing, access the right kinds of supports and care to keep their housing, and improve their quality of life.

Housing First also requires that communities constantly examine their overall set of programs to determine if they have the capacity to achieve the three aims above. Again, this is not about choosing this program or that program, but looking at whether the system as a whole is effective.

Consider the following thought experiment.

Let’s imagine for a moment that we could hit a magic “Housing First reset button” and start all over in building our community responses to homelessness. Would you wind up with the same set of programs and models that you have now? Would you even create discrete program models?

Now let’s imagine that we had enough resources to create the system we really need to achieve the three aims of ending homelessness. Let’s imagine we had a way to accurately assess housing and service needs at any point in time. What if we could provide different levels of housing assistance and different levels of services to people based on their needs?  And what if we could actually adjust the level of assistance to people as their needs change in real-time without forcing people to move around?

That’s the system of response I would build.  Unfortunately, we don’t have a Housing First reset button. Rather than adjustable and flexible levels of assistance, we have distinct programs and models that are often unconnected, preventing people from receiving personalized levels of assistance. The funding systems that support our programs don’t always allow for this level of flexibility. Even in the face of these issues, I still believe we can pursue a more flexible and dynamic system of response. Getting there starts with the adoption of a Housing First system orientation. Meanwhile, USICH and HUD have been encouraging communities to ensure that their inventory of programs includes the types of assistance at different levels of intensity—permanent supportive housing, affordable housing, rapid re-housing, etc.—targeted through a coordinated assessment process.

2. Housing First is a recognition that everyone can achieve stability in (real) housing. Some people simply need services to help them do so.

There is confusion about whether Housing First means providing housing with services or housing alone. I hear comments like, “We want to do Housing First, but don’t have a way to pay for supportive services,” or “It’s not responsible to do Housing First when people have chronic health challenges.” Some people believe Housing First is always service intensive. Others believe Housing First is not service intensive enough. So who’s right?

The short answer is both and neither. The problem goes back to thinking about Housing First as a program model. When we instead think of Housing First as an approach and a whole system orientation, it allows us to get away from “one-size-fits-all” solutions, and focus on matching the right level of housing assistance and services to people’s needs and strengths. There are some who might just need a bit of a financial boost and help with finding housing. Others may need a long-term rental assistance subsidy and support with their housing search, but not ongoing case management. And some people need permanent supportive housing, including long-term rental assistance or affordable housing coupled with case management supports.

It’s a basic equation where the constant is the goal of helping people obtain and maintain permanent housing. The variables are what level and duration of housing assistance and supportive services people need to stay in housing. So yes, if a community doesn’t have a way to pay for supportive services, they won’t be able to provide the right help to people who need ongoing case management. They should look to efforts across the country to increase Medicaid’s role in paying for case management supports in housing. And it’s also true that providing permanent housing without services to people who have chronic health challenges may be irresponsible. Let’s just remember that not everyone needs ongoing case management to maintain housing stability.

3. Housing First is about health, recovery, and well-being. Housing itself is the foundation and platform for achieving these goals.

The idea that programs within a Housing First approach sometimes require “intensive” services should not be taken to mean that the focus of services is on therapeutic or treatment goals. In fact, the Housing First approach emphasizes services that focus on housing stability, then using that housing as a platform for connecting people to the types of services and care that they seek and want. It’s based on the basic premise that if people have a stable home, they are in a better position to achieve other goals, including health, recovery and well-being than when they are homeless.

This is true for many reasons. It’s hard to comply with any kind of health care or treatment regimen when you have no certainty about where you are going to sleep. A person infected with TB will have a hard time completing a course of antibiotic treatment when they are bouncing from one shelter to another. It’s also hard to focus on recovery from addiction when you don’t have the certainty that you have a permanent place where you can stay each day, surrounded by supportive people. And for people who’ve experienced trauma, it can be impossible to shift away from a “fight-or-flight” mindset that comes with PTSD when they continue to live a rough life on the streets.

Let it be known, once and for all, that Housing First is about health and well-being. Housing First is about recovery. And connecting people to substance abuse or mental health treatment is entirely consistent with Housing First. The difference is that Housing First recognizes that health and recovery are so much more attainable when people have a safe and stable home.  A Housing First approach recognizes that there are many paths to recovery and well-being—some of which are direct and some of which are long and indirect. But all of those paths start with a home.

4. Housing First is about changing mainstream systems.

Housing First is, and always has been, about changing mainstream systems. The approach emerged as a reaction to traditional mental health treatment modality, which thought that the way to address the needs of people with psychiatric symptoms on the street was to get them into psychiatric treatment, typically at an inpatient facility. Housing First was about changing the mental health system’s paradigm to recognize that housing is foundational to mental health recovery.

Housing First’s role in changing mainstream systems should not stop with the mental health system. Housing is just as foundational to addiction recovery and psychical well-being as it is to mental health. The new frontiers of systems change are to engage the substance abuse treatment system and the mainstream health care system around housing. Substance abuse treatment systems are integrating housing priorities alongside states like New York and New Jersey by adopting supportive housing as part of their own systems responses. Meanwhile, there are enormous opportunities to engage the mainstream health care system (Medicaid, managed care, and hospital systems) around housing, given the systems transformations underway through the Affordable Care Act.

There is a hunger to achieve health reform’s Triple Aim of improved health outcomes, improved healthcare experiences, and lower costs. Those of us who’ve been working to end homelessness know that affordable and supportive housing are part of that solution. It’s going to take engagement and persistence to make the health system aware of this. Luckily, this is precisely the kind of engagement and persistence that Housing First does so well.