Housing First Model Research Articles

A Qualitative Exploration of People Who Have Left Housing First and Returned to Homelessness

This article offers a thick, rich, multidimensional, and situational look into a Housing First (HF) program in Charlotte, North Carolina, called HousingWorks. This study focuses on individuals who have experienced chronic homelessness and who exited permanent supportive housing (PSH) programs that employ a HF model and return to homelessness. In January 2022, there were 582,500 people experiencing homelessness in the United States (The U.S Department of Housing and Urban Development [HUD], 2023). One-third of these individuals had patterns of chronic homelessness, which has doubled since 2016 (HUD, 2023). Additionally, one-third of unsheltered individuals are at a high risk of being unsheltered again. To address issues of chronic homelessness, emphasis has been placed on increasing supportive housing, which combines permanent affordable housing with supportive services (permanent supportive housing), commonly called a housing first, or the rapid rehousing approach. Participants exited HousingWorks for multiple individual and programmatic reasons. All exits in this study were tied to relationships individuals had with friends, family (of choice and biological), romantic partners, case managers, and neighbors. Consumers, providers, and former residents describe their experiences and offer insights for improving housing retention in PSH programs. Implications for implementation and housing first fidelity criteria are also discussed.

Europeans’ willingness to pay for ending homelessness: A contingent valuation study

The purpose of this study is to assess the utility value European citizens put on an innovative social program aimed at reducing homelessness. The Housing First (HF) model involves access to regular, scattered, independent and integrated housing in the community with the support of a multidisciplinary team. Currently, HF is not implemented by most European countries or funded by healthcare or social plans, but randomised controlled trials have stressed significant results for improved housing stability, recovery and healthcare services use. The broader implementation of HF across Europe would benefit from a better understanding of citizens' preferences and “willingness to pay” (WTP) for medico-social interventions like HF. We conducted a representative telephone survey between March and December 2017 in eight European countries (France, Ireland, Italy, the Netherlands, Poland, Portugal, Spain, and Sweden). Respondent's WTP for HF (N = 5631) was assessed through a contingent valuation method with a bidding algorithm. 42.3% of respondents were willing to pay more taxes to reduce homelessness through the HF model, and significant differences were found between countries (p < 0.001); 30.4% of respondents who did not value the HF model were protest zeros (either contested the payment vehicle-taxes- or the survey instrument). Respondents were willing to pay €28.2 (±11) through annual taxation for the HF model. Respondents with higher educational attainment, who paid national taxes, reported positive attitudes about homelessness, or reported practices to reduce homelessness (donations, volunteering) were more likely to value the HF model, with some countries' differences also related to factors at the environmental level. These findings inform key stakeholders that European citizens are aware of the issue of homelessness in their countries and that scaling up the HF model across Europe is both feasible and likely to have public support.

Europeans’ willingness to pay for ending homelessness: a contingent valuation study

Abstract Objective In Europe, 4 million people were homeless in 2009. The Staircase model of care targeted mental health, drug rehabilitation and housing readiness yields poor long-term housing results. Western countries are investing in a new model, Housing First (HF), which yields better clinical and social results. We aim to explore how much the European citizens are willing to pay for the HF model and what are the determinants of this valuation. Methods A nationally representative telephone survey conducted in 2017, targeted European adult citizens from France, Ireland, Italy, Netherlands, Portugal, Spain, Poland and Sweden. Respondent’s willingness-to-pay (WTP) (n = 5,631) for HF model was assessed through a contingent valuation method with bidding algorithm. Multivariate analyses using two-part models with a cluster and weighted design were conducted to predict: 1/ respondents’ refusal or incapacity to pay for the HF model; 2/ willingness-to-pay (continuum) for the HF model. Results 42.3% of respondents were willing to pay more taxes to reduce homelessness through HF model; 30.3% were protest zero (don’t want to pay taxes (either contested the payment vehicle-taxes- or the survey instrument); huge differences being observed between countries (P&amp;lt;.001). Respondents were willing to pay €57 (+/- 9) through annual taxes for the HF model. Respondents with higher educational attainment, paying taxes on income, reporting positive attitudes about homelessness or practices to reduce homelessness (donations, volunteering), and those residing in a country with higher share of social protection expenditures on family benefits or higher at-risk-of-poverty rate were more likely to value the HF model. Perspective These results provide key stakeholders with an understanding of the level of support from the general population for the Housing First model; especially since the determinants of this valuation were studied according to the social and environmental context of each country. Key messages More than 42% of European citizens reported to be willing to pay for reversing homelessness. More than a three quarter of European citizens thought that Government spending on Homelessness is too little.

Managed alcohol programs in the context of Housing First

Purpose Recently, Managed Alcohol Programs (MAPs have emerged as an alcohol harm reduction model for those living with severe alcohol use disorder (AUD) and experiencing homelessness. There is still a lack of clarity about the role of these programs in relation to Housing First (HF) discourse. The authors examine the role of MAPs within a policy environment that has become dominated by a focus on HF approaches to addressing homelessness. This examination includes a focus on Canadian policy contexts where MAPs originated and are still predominately located. The purpose of this paper is to trace the development of MAPs as a novel response to homelessness among people experiencing severe AUD and to describe the place of MAPs within a HF context. Design/methodology/approach This conceptual paper outlines the development of discourses related to persons experiencing severe AUD and homelessness, with a focus on HF and MAPs as responses to these challenges. The authors compare the key characteristics of MAPs with “core principles” and values as outlined in various definitions of HF. Findings MAPs incorporate many of the core values or principles of HF as outlined in some definitions, although not all. MAPs (and other housing/treatment models) provide critical housing and support services for populations who might not fit well with or who might not prefer HF models. Originality/value The “silver bullet” discourse surrounding HF (and harm reduction) can obscure the importance of programs (such as MAPs) that do not fully align with all HF principles and program models. This is despite the fact that MAPs (and other models) provide critical housing and support services for populations who might fall between the cracks of HF models. There is the potential for MAPs to help fill a gap in the application of harm reduction in HF programs. The authors also suggest a need to move beyond HF discourse, to embrace complexity and move toward examining what mixture of different housing and harm reduction supports are needed to provide a complete or comprehensive array of services and supports for people who use substances and are experiencing homelessness.

Understanding Innovation in Homeless Service Provision: A Study of Frontline Providers' Values-Readiness for Change.

Service innovation for adults experiencing mental illness and homelessness typically involves shifting from treatment-led, staircase models toward recovery-oriented, Housing-First models. Aligning frontline service providers' values to those embedded within newer models is an important, but under-investigated, influence on the innovation process. To assess values alignment in this context, we conducted semi-structured qualitative interviews with frontline providers in staircase services in Ireland (n = 50). Data showed that, while their values mostly aligned to the treatment-led model, there was meaningful evidence of more recovery-oriented values, too. Strategies to enhance innovation through values-alignment are discussed.

Knowledge, attitudes, and practices about homelessness and willingness-to-pay for housing-first across 8 European countries: a survey protocol

BackgroundMost European countries report rising numbers of people experiencing homelessness. For those with mental disorders, interventions are centered on achieving mental health and drug rehabilitation alongside housing readiness, often to the detriment of access to housing. Notwithstanding, more European countries are investing in a new model, Housing First (HF), which postulates immediate access to permanent housing with no initial requirements for treatment. While results of the European HF programs are published on individual-level data, little is known about the opinions of the general population about homelessness and the societal value of the HF model, which can represent barriers to the model’s dissemination. Therefore, we present the protocol of a study designed for the following objectives: 1) to explore the knowledge, attitudes, and practices (KAP) about homelessness within the general population of 8 European countries, 2) to assess the valuation of the HF model by European citizens, and 3) to estimate the lifetime prevalence of homelessness in the targeted countries.MethodsA telephone survey was conducted from March to December 2017 among adults selected from opt-in panels from France, Ireland, Italy, the Netherlands, Portugal, Spain, Poland, and Sweden. A total sample of 5600 interviews was expected, with 700 per country. The interviews included three sections: first, the KAP about homelessness; second, the valuation of the HF model by measuring a respondent’s willingness-to-pay (WTP) through the contingent valuation method; and third, an assessment of the lifetime prevalence of homelessness among the general population. Descriptive analyses and comparisons between countries will be conducted. KAP indicators will be created and their psychometric properties assessed. Determinants of WTP will be assessed through regression models.DiscussionThis survey will highlight Europeans’ views of homelessness, especially their level of tolerance towards homelessness, potential misconceptions and the most important barriers for the implementation of the HF model. Additionally, the results on the valuation of the HF model by citizens could be instrumental for key stakeholders in understanding the level of support from the general population. Ethics approval has been obtained from the Aix-Marseille University Ethics Committee (n° 2016-01-02-01) for this study, which is part of HOME_EU: Reversing Homelessness in Europe H2O20-SC6-REVINEQUAL-2016/GA726997.

Navigating Complex Implementation Contexts: Overcoming Barriers and Achieving Outcomes in a National Initiative to Scale Out Housing First in Canada

The scaling out of Housing First (HF) programs was examined in six Canadian communities, in which a multi-component HF training and technical assistance (TTA) was provided. Three research questions were addressed: (a) What were the outcomes of the TTA in terms of the development of new, sustained, or enhanced programs, and fidelity to the HF model? (b) How did the TTA contribute to implementation and fidelity? and (c) What contextual factors facilitated or challenged implementation and fidelity? A total of 14 new HF programs were created, and nine HF programs were sustained or enhanced. Fidelity assessments for 10 HF programs revealed an average score of 3.3/4, which compares favorably with other HF programs during early implementation. The TTA influenced fidelity by addressing misconceptions about the model, encouraging team-based practice, and facilitating case-based dialogue on site specific implementation challenges. The findings were discussed in terms of the importance of TTA for enhancing the capacities of the HF service delivery system-practitioners, teams, and communities-while respecting complex community contexts, including differences in policy climate across sites. Policy climate surrounding accessibility of housing subsidies, and use of Assertive Community Treatment teams (vs. Intensive Case Management) were two key implementation issues.

Changing the method of working with homeless people: a photovoice project in Italy

ABSTRACTIn Italy, many organizations are experimenting with the Housing First (HF) model to promote a change in how they work with homeless people. This change creates some difficulties, especially in promoting freedom of choice in people involved in the HF programs. This study explored the definition of “home” in homeless people’s points of view. The study participants were 5 homeless men involved in a HF program called “The Road Home” implemented in the city of Padua. Data were collected using Photovoice, a photographic method based on participatory action research. During the project, the participants took photographs to illustrate their definitions of “home” and then engaged in a critical dialogue about the images represented in the photographs. The results of the study showed that occupants identified the home as being related to family, friendship, cohabitation, and hope for the future. The Photovoice project provided an opportunity to promote discussions that revealed the true needs of the people involved, and in the meantime, it brought a change to the program and to the community, in addition to promoting the HF model in the community.

The experiences of front-line service providers of Housing First programme delivery in three communities in Ontario, Canada

In many OECD countries, the Housing First (HF) approach has emerged as a leading social policy for addressing the needs of populations experiencing chronic homelessness combined with a dual diagnosis of substance abuse issues and mental health illnesses. The HF model is an evidence-based practice for housing the long-term homeless population; as such, much of the current scholarship has focused on evaluating the outcomes for participants. This paper adds to the empirical understanding of the HF model from the perspective of service providers. The paper is based on an analysis of interviews with service providers from HF programmes in three communities in Ontario, Canada. The service providers considered the HF model to be the most effective approach to housing chronically homeless people. However, the analysis underscored challenges with implementation: lack of housing stock, lack of housing options, unwillingness of landlords to participate in the programmes, and the need for rent supplement. The analysis addresses the need to capture the perspectives of practitioners tasked with implementing the HF model. Empirical findings and recommendations may provide useful lessons for local communities and housing organisations in countries implementing the model, as well as those considering implementation.

Homelessness and stakeholders' involvement in the Grand Duchy of Luxembourg: a qualitative study.

In 2013, between 150 and 200 people per night in the Grand Duchy of Luxembourg are estimated roofless. Abilities to respond to emergencies in the GDL are perceptibly decreased due to longer stays in emergency shelters. This study aimed to analyse the needs of long-term homeless (LTH) individuals and to put forward professional recommendations to improve support and care for homeless individuals. A local, cross-sectional, qualitative study carried out between February and September 2013 in the GDL. Semi-structured interviews and focus groups were conducted with homeless people living in Caritas housing facilities permanently over a period of 2years or temporarily over a period of 3years, as well as Caritas professionals and Luxembourgish psychiatrists. They mainly focused on the homeless person's life pathways, needs and expectations, and difficulties encountered. Twenty-two homeless persons, 13 professionals from Caritas and three Luxembourgish psychiatrists participated. Homeless persons' needs and expectations consist of the following: (i) seeking freedom and peacefulness, (ii) having their own space, being independent and (iii) living like everyone else. Professionals mainly complained about difficulties for supporting LTH persons and the lack of collaboration with Luxembourg stakeholders from social and psychiatric departments. This study has found that the current approach is not appropriate for the management of LTHness in the country. This study recommends changes within the Caritas facilities and outside, on the basis of three concepts: (i) a decent home as an essential need, (ii) respect of freedom of choice and (iii) a housing-first model.

Development and testing of an implementation strategy for a complex housing intervention: protocol for a mixed methods study.

BackgroundThere is currently a lack of scientifically designed and tested implementation strategies. Such strategies are particularly important for highly complex interventions that require coordination between multiple parts to be successful. This paper presents a protocol for the development and testing of an implementation strategy for a complex intervention known as the Housing First model (HFM). Housing First is an evidence-based practice for chronically homeless individuals demonstrated to significantly improve a number of outcomes.Methods/designDrawing on practices demonstrated to be useful in implementation and e-learning theory, our team is currently adapting a face-to-face implementation strategy so that it can be delivered over a distance. Research activities will be divided between Chicago and Central Indiana, two areas with significantly different barriers to HFM implementation. Ten housing providers (five from Chicago and five from Indiana) will be recruited to conduct an alpha test of each of four e-learning modules as they are developed. Providers will be requested to keep a detailed log of their experience completing the modules and participate in one of two focus groups. After refining the modules based on alpha test results, we will test the strategy among a sample of four housing organizations (two from Chicago and two from Indiana). We will collect and analyze both qualitative and quantitative data from administration and staff. Measures of interest include causal factors affecting implementation, training outcomes, and implementation outcomes.DiscussionThis project is an important first step in the development of an evidence-based implementation strategy to increase scalability and impact of the HFM. The project also has strong potential to increase limited scientific knowledge regarding implementation strategies in general.

The role and meaning of interim housing in housing first programs for people experiencing homelessness and mental illness.

The housing first (HF) model for individuals experiencing homelessness and mental illness differs by design from traditional models that require consumers to achieve "housing readiness" by meeting program or treatment prerequisites in transitional housing settings prior to permanent housing placement. Given a growing body of evidence for its favorable outcomes and cost effectiveness, HF is increasingly seen as an alternative to and argument against these traditional programs. As such, it is important that the elements and implementation challenges of the HF model be clearly understood and articulated. This qualitative study explored a largely unexamined aspect of the HF model-the need for and meaning of temporary residential settings (interim housing), a place to stay while waiting to secure permanent housing-using interviews and focus groups with service providers and consumers who experienced interim housing during implementation of HF in a large urban center. Although interim housing may not be necessary for all programs implementing the model, our study revealed numerous reasons and demands for safe, flexible interim housing options, and illustrated how they influence the effectiveness of consumer recovery, continuous service engagement, and housing stability.

Implementations of Housing First in Europe: Successes and Challenges in Maintaining Model Fidelity

To describe and evaluate the fidelity of Housing First (HF) initiatives in six European countries to the Pathways HF (PHF) model and examine the larger social, historical, and political factors that may foster or impede model fidelity. Key stakeholders representing six European HF initiatives completed semi-structured phone interviews. Interviews were thematically analyzed according to five key fidelity domains and updated with interim results of a recent European research project (Housing First Europe). Dissatisfaction with the status quo was often cited as the catalyst driving searches for system change. PHF's evidence base, consumer-driven philosophy, recovery-oriented services, and view of housing as a basic right swayed local decisions to implement HF programs. Interviews yielded stronger evidence of fidelity on no housing readiness requirements, separation of housing and services, a harm reduction approach, consumer choice in services, and weaker evidence of fidelity on scatter-site housing, choice ...

The housing first model (HFM) fidelity index: designing and testing a tool for measuring integrity of housing programs that serve active substance users

BackgroundThe Housing First Model (HFM) is an approach to serving formerly homeless individuals with dually diagnosed mental health and substance use disorders regardless of their choice to use substances or engage in other risky behaviors. The model has been widely diffused across the United States since 2000 as a result of positive findings related to consumer outcomes. However, a lack of clear fidelity guidelines has resulted in inconsistent implementation. The research team and their community partner collaborated to develop a HFM Fidelity Index. We describe the instrument development process and present results from its initial testing.MethodsThe HFM Fidelity Index was developed in two stages: (1) a qualitative case study of four HFM organizations and (2) interviews with 14 HFM "users". Reliability and validity of the index were then tested through phone interviews with staff members of permanent housing programs. The final sample consisted of 51 programs (39 Housing First and 12 abstinence-based) across 35 states.ResultsThe results provided evidence for the overall reliability and validity of the index.ConclusionsThe results demonstrate the index’s ability to discriminate between housing programs that employ different service approaches. Regarding practice, the index offers a guide for organizations seeking to implement the HFM.

Exploring the Value of Mixed Methods Within the At Home/Chez Soi Housing First Project: A Strategy to Evaluate the Implementation of a Complex Population Health Intervention for People With Mental Illness Who Have Been Homeless

This paper is a methodological case study that describes the At Home/Chez Soi (Housing First) Initiative's mixed-methods strategy for implementation evaluation and discusses the value of these methods in evaluating the implementation of such complex population health interventions. The Housing First (HF) model is being implemented in five cities: Vancouver, Winnipeg, Toronto, Montréal and Moncton. At Home/Chez Soi is an intervention trial that aims to address the issue of homelessness in people with mental health issues. The HF model emphasizes choices, hopefulness and connecting people with resources that make a difference to their quality of life. A component of HF is supported housing, which provides a rent subsidy and rapid access to housing of choice in private apartments; a second component is support. Quantitative and qualitative methods were used to evaluate HF implementation. The findings of this case study illustrate how the critical ingredients of complex interventions, such as HF, can be adapted to different contexts while implementation fidelity is maintained at a theoretical level. The findings also illustrate how the project's mixed methods approach helped to facilitate the adaptation process. Another value of this approach is that it identifies systemic and organizational factors (e.g., housing supply, discrimination, housing procurement strategy) that affect implementation of key elements of HF. In general, the approach provides information about both whether and how key aspects of the intervention are implemented effectively across different settings. It thus provides implementation data that are rigorous, contextually relevant and practical.

Supportive Housing Cuts Costs of Caring for the Chronically Homeless

IN THE LATE 1990S, SEATTLE LEADers recognized the city had a problem. Homeless people with severe alcoholism consumed a tremendous share of public dollars, cycling in and out of emergency departments and the criminal justice system. The city’s political, business, and hospital leaders joined forces with social service and substance abuse treatment agencies to adopt a new strategy not only to curb costs, but also to keep so many chronically homeless people from dying on the streets. One of their first calls was to the Downtown Emergency Service Center (DESC), a group that ran housing projects targeting mentally ill and other vulnerable homeless populations. The city’s leaders asked the DESC to take a “housing-first” approach by creating a new facility where chronically homeless people with severe alcohol abuse problems could find shelter without first having to stop drinking or enter treatment. Bill Hobson, executive director of the DESC, explained that most shelters or housing facilities make treatment or abstinence a condition of housing. But the population Seattle was targeting included individuals who had repeatedly failed treatment programs— some as many as 20 times, Hobson explained. “Let’s accept that these individuals can’t or won’t stop drinking, and they are hurting the greater society with their use of crisis services,” he explained. The DESC adopted a “harmreduction” strategy, which aimed to reduce the harmful effects of drinking on the individual and on society, Hobson explained. The organization identified homeless people who incurred the greatest public costs because of their alcohol use problems and offered them individual apartments in a new facility at 1811 Eastlake. The facility opened in 2005 with a 24-hour staff of social workers and other clinicians. Staff helped residents access social and medical services and worked with them to address behavioral issues that had caused them to lose previous housing. Most residents continued drinking despite discussions with staff about the harmful effects of doing so. “Harm reduction is about helping people prepare to change,” Hobson said. It was a radical experiment, with its share of critics. But it worked. The housing-first model used by the DESC at 1811 Eastlake has been emulated by communities across the country working to eliminate chronic homelessness among individuals with severe substance abuse problems, mental illness, or other chronic diseases. Between 2006 and 2010, the number of beds in such supportive housing programs in the United States increased from 176 830 to 236 798. The United States Interagency Council on Homelessness (USICH) also has embraced the housing-first approach to chronic homelessness as a pillar of its plan to end homelessness in the United States. “Chronically homeless individuals are extremely expensive for the taxpayer,” said Barbara Poppe, executive director of the USICH. “[Supportive housing] benefits the entire community because people are not languishing on the streets.”

Reconciling Alternative to Incarceration and Treatment Mandates with a Consumer Choice Housing First Model: A Qualitative Study of Individuals with Psychiatric Disabilities

This study sought to understand how individuals experienced participating in a Housing First (HF) program, which is designed to operate along principles of permanent housing, consumer choice, and harm reduction, while simultaneously participating in an alternative to incarceration (ATI) program that incorporates treatment mandates, abstinence monitoring, and court reporting which tend to be in tension with the HF model. Analysis of semi-structured qualitative interviews with 20 participants suggests that though participants recognized the constraints of the ATI program and legal mandates, they somewhat surprisingly experienced the HF program in accordance with the model's stated principles. The majority of participants remained in the HF program after four years and reported positive outcomes, which many attributed to having a home of their own. Having the ATI program serve as a mediator with the criminal justice system may have allowed the HF program to have a buffer between the participant and the legal system and helped keep the housing and consumer-driven services separate from explicit legal requirements.

Moving From Street to Home: Health Status of Entrants to a Housing First Program

Housing First (HF) is an evidence-based practice that ends chronic homelessness for individuals with serious mental illness by providing immediate access to permanent independent housing and team-based community supports. Little is known about the health status of homeless individuals entering HF programs. Through a cross-sectional analysis, this paper reports on the chronic physical disease burden of people entering a newly established HF program and examines whether these individuals recognize and request support for ongoing health-related issues. The authors' evaluation confirmed significantly higher rates of chronic disease (60%) and fair/poor self-reported health status (47%) than the general urban population of Philadelphia. The majority of clients reported they wanted to address both medical (67%) and mental health (68%) problems, but a much lower percentage reported wanting to reduce substance use (23%) or take psychiatric medications (25%). The authors conclude that formerly homeless entrants to HF programs have a high burden of chronic disease with complex health-related needs. Additionally, these individuals look to the program for health-related assistance. As the HF model is disseminated throughout the United States to end chronic homelessness, these findings support the development of flexible, integrated, person-centered health services within the HF service delivery system as a potentially effective method to address complex health needs.