The Cat-Tribe
19-03-2005, 03:01
I'm a very liberal, staunch Democrat, but I'll give even the Bush Administration its due. I just read this article (http://www.motherjones.com/news/feature/2005/01/01_405.html) about Pathways to Housing. I'm impressed with an actual example of "compassionate conservatism" in action.
I won't quote that article (which is long), but I'll post these two (I can only provide a link to the cached version of the first one):
'Housing First' Becoming Standard Model for Homeless Populations (http://64.233.179.104/search?q=cache:RqneH3-_gmoJ:www.knowledgeplex.org/news/55942.html+Pathways+Bush+administration+homeless&hl=en)
Colleen Fitzpatrick
Mental Health Weekly
November 17, 2004
As a psychiatric outreach worker in New York City during the 1980s, Sam Tsemberis heard a lone, unified message from many of the chronically homeless people with mental illness whom he encountered.
"What I need is a place to live," they told him. "A place that's my own place. Where I don't have to live with a group of people. Where I don't have to live in treatment if I don't want to. Where I don't have to hide my beer under the couch when you come and visit."
The more Tsemberis heard and thought about this request, the more reasonable it sounded. Yet no such housing formally existed for chronically homeless people with mental illness, many of whom also had a substance abuse disorder.
Instead, the going model was--and largely remains--a "linear residential treatment program," which directs people through a continuum of services: outreach, then intermediary, usually congregate housing, and finally, permanent housing.
Furthermore, the rules for many supportive-housing programs often include that participants be clean and sober, and undergo psychiatric assessments, take medication if prescribed and engage in other treatment and services.
Tsemberis, who holds a doctorate in clinical community psychology, began to view that approach not only as inflexible and counter to what he was hearing in the streets, but also discriminatory.
Providers and policies were "requiring people with mental illness to cure their clinical condition before they could house them," he said. "There's something quite discriminatory about that. There is no other population for whom this is required."
Out of his experience came Pathways To Housing, Inc., which Tsemberis founded in 1992 with a $ 500,000 grant from the New York State Office of Mental Health and which is based on a "housing first" strategy.
Pathways' approach brings chronically homeless mentally ill people--90 percent of whom have a substance abuse disorder--in from the streets and immediately places them in permanent, private-market apartments and other residences scattered throughout the city. Only after housing is secured does the Pathways staff bring on the services, in the form of assertive community treatment (ACT) teams.
The idea behind "housing first" is that providing a person with stabilized housing creates a foundation for recovery to begin. It's a consumer-driven model that assumes that if people with serious and persistent mental health disorders can survive on the streets--figuring out where to eat and sleep and how to receive a check from the Social Security office and protecting their physical safety--then managing an apartment is, as Tsemberis says, "a piece of cake."
Philip F. Mangano, the Bush administration's point person on homelessness, said that the model "says that housing is the appropriate nexus point for the delivery of services."
So far, about 85 percent of Pathways' 500 tenants have remained in their homes, according to a study of the program published in the April issue of the American Journal of Public Health (Vol. 94, No. 4).
Calling the strategy "groundbreaking," Mangano credits Tsemberis and the private, non-profit Corporation for Supportive Housing with expanding the "housing first" technology from the mental health field where it originated to use with all vulnerable homeless populations.
The approach got a huge national boost in 2003, when the federal Interagency Council on Homelessness (ICH), where Mangano is executive director, announced its chronic homelessness initiative. The initiative awarded some $ 35 million to nearly a dozen localities nationwide to implement innovative approaches to addressing homelessness, including incorporating "housing first" strategies.
Communities such as Philadelphia, San Francisco, Denver, Fort Lauderdale and northern Louisiana are in various stages of adopting elements of "housing first" approaches.
Though obstacles remain to widespread implementation, many housing experts view it as the standard for sheltering people with chronic disabilities.
"This works for the most chronically disabled people," says Ann O'Hara, associate director of the Technical Assistance Collaborative in Boston. "It gets them affordable, decent housing, and helps them engage with the mental health system in ways that meet their felt needs first. This helps them build the trust that will help them get the other services."
In New York City, with its homeless population of about 38,000, most people who become Pathways tenants are identified through staff outreach efforts. Some tenants are referred by city outreach teams, shelters and drop-in centers. Data from 1999 show that 65 percent had last lived on the streets, 18 percent in shelters and 7 percent in treatment facilities.
Participants must pay 30 percent of their income toward rent. This amounts to about $ 200 a month after tenants begin receiving monthly disability checks of $ 500 to $ 800. About 80 of the 500 tenants have Section 8 federal housing vouchers. For the rest, Pathways pays the difference, using subsidies from the U.S. Department of Housing and Urban Development's Shelter Plus Care program and from New York's state mental health office. A unit costs $ 20,000 on average.
Not surprisingly, the biggest challenge is helping members find apartments at fair market rent, though Tsemberis says that landlords like working with Pathways tenants because rental payments are guaranteed. Housing is scattered among buildings mainly throughout the city's lower-middle-class sections; Pathways has a network of 115 landlords.
Once a member is housed, Pathways staff converges in the residence with offers of treatment, support and other services. Each tenant is assigned an ACT team, a community-based, multidisciplinary team of mental health professionals that is available 'round-the-clock' to provide or link the tenant with services.
Beyond their financial obligations, tenants must fulfill only one requirement: to meet with a service coordinator at least twice a month during their first year of tenancy. Though the intensive and wide-ranging psychiatric, supportive and substance abuse treatment services are available, tenants do not have to use them. Many, however, do, Tsemberis says.
Though the "housing first" strategy emerged from the mental health field, it nonetheless nonetheless does not sit well with all behavioral health professionals.
It embraces a harm-reduction rather than abstinence model of addiction treatment, which flies in the face of the philosophy espoused by many addiction treatment programs and the people who run them.
Another reason that some behavioral health professionals are skeptical is that the strategy removes control from professionals and gives it to consumers.
"It's a challenge to take people at their word, and give them an apartment to go into, a place of their own," Tsemberis says. He recalls his own training as a psychologist, and being taught that mental illness is incapacitating, and that people with mental disorders couldn't possibly make it on their own.
They can, of course, Tsemberis says, adding that "the most anxious part of the decision-making is to turn the control for the decision over to the consumer ... A lot of providers are uncomfortable doing that."
O'Hara weighs in on this point, as well. "Housing first" strategies recognize that "people need to be housed, and the fact that they may not be engaged in the types of services that some mental health clinicians say they should be is really not relevant.
"What's relevant is what kind of housing do people need to be stabilized so they can receive services," said O'Hara. "To a housing professional, it's completely common sense. It's very logical: you address the issue of housing and that in and of itself is a measurable outcome."
She identifies some obstacles to the strategy's widespread implementation: a limit to the number of HUD's Section 8 vouchers. "We haven't seen any new Section 8 vouchers since 2001. The numbers of subsidies coming out of the homeless program are just not enough to deal with the demand. It's a huge barrier," O'Hara says.
The numbers underscore that difficulty. People getting Supplemental Security Income (SSI) payments take home just 18 percent of the median income, on average. There are some 4.9 million SSI recipients; perhaps one-third of them are people with serious mental illness. An estimated 440,000 people with disabilities have Section 8 vouchers; it's unclear how many of those are people with mental health problems.
Another obstacle, O'Hara says, is finding ways to pay for the behavioral health and other services that accompany the model. "Some states are better positioned than others to bill Medicaid for the ACT services to go along with this," she says. For example, some states are rewriting their Medicaid waivers to allow for reimbursement of services under the rehabilitation option.
Despite the challenges, Tsemberis is encouraged by the interest he is seeing around the country in "housing first" models. "The tide has turned, in a way, and people have seen there's a usefulness to it. And it's effective because it's sympatico with the consumer," he says. "For all of the talk, it is based on love, respect and creating possibilities for people with mental illness."
Permanent, Unconditional Housing for the Chronically Mentally Ill and Homeless (http://www.jointogether.org/sa/action/dt/news/reader/0,2812,576243,00.html)
2/18/2005
The Pathways to program, founded in New York City in 1992 and recently introduced to Washington, D.C, offers no-strings-attached housing and optional services to people who are chronically homeless due to mental illness, Mother Jones reported in its January/February 2005 issue.
There are about 600,000 people living without homes on any given day, according to the U.S. Department of Health and Human Services. The chronically homeless make up 10 percent of the homeless population, but occupy about one half of the available space in emergency shelters.
After a psychiatric evaluation determining the client's capacity for self-sufficiency, Pathways places homeless clients into new apartments within two weeks, with no requirements or conditions. Medical, psychiatric, substance abuse and job counseling services are all offered to Pathways clients, but are not mandatory.
Pathways establishes bank accounts for its clients, where the client's previously uncollected government benefits are deposited and rent is automatically deducted, and leaving living expenses to the client's discretion.
Foundations, government grants, and these unclaimed benefits provide the $22,000 it takes to house and treat each client for one year -- a feat Pathways completes for a little over half the cost for equivalent government-run support services, and at a greater success rate.
After one year, the chronically homeless in New York City's more conventional treatment system have been without housing 28 percent of the time, while those in the Pathways program are only homeless for 3 percent of the time.
"You're curing the housing problem first. You cure the person later," explains Sam Tsemberis, founder of Pathways. This reversal in the order of services is unique, controversial, and, most importantly, effective.
Pathways currently serves almost 500 New York clients, and it plans to house 75 homeless people in Washington using its recent $750,000 start-up grant from the Department of Mental Health. The Bush administration supports programs like Pathways as part of its effort to focus on long-term homelessness and permanent housing rather than emergency shelters.
Finally, here is a link to the Pathways to Housing (New York) website (http://www.pathwaystohousing.org/index.html).
I won't quote that article (which is long), but I'll post these two (I can only provide a link to the cached version of the first one):
'Housing First' Becoming Standard Model for Homeless Populations (http://64.233.179.104/search?q=cache:RqneH3-_gmoJ:www.knowledgeplex.org/news/55942.html+Pathways+Bush+administration+homeless&hl=en)
Colleen Fitzpatrick
Mental Health Weekly
November 17, 2004
As a psychiatric outreach worker in New York City during the 1980s, Sam Tsemberis heard a lone, unified message from many of the chronically homeless people with mental illness whom he encountered.
"What I need is a place to live," they told him. "A place that's my own place. Where I don't have to live with a group of people. Where I don't have to live in treatment if I don't want to. Where I don't have to hide my beer under the couch when you come and visit."
The more Tsemberis heard and thought about this request, the more reasonable it sounded. Yet no such housing formally existed for chronically homeless people with mental illness, many of whom also had a substance abuse disorder.
Instead, the going model was--and largely remains--a "linear residential treatment program," which directs people through a continuum of services: outreach, then intermediary, usually congregate housing, and finally, permanent housing.
Furthermore, the rules for many supportive-housing programs often include that participants be clean and sober, and undergo psychiatric assessments, take medication if prescribed and engage in other treatment and services.
Tsemberis, who holds a doctorate in clinical community psychology, began to view that approach not only as inflexible and counter to what he was hearing in the streets, but also discriminatory.
Providers and policies were "requiring people with mental illness to cure their clinical condition before they could house them," he said. "There's something quite discriminatory about that. There is no other population for whom this is required."
Out of his experience came Pathways To Housing, Inc., which Tsemberis founded in 1992 with a $ 500,000 grant from the New York State Office of Mental Health and which is based on a "housing first" strategy.
Pathways' approach brings chronically homeless mentally ill people--90 percent of whom have a substance abuse disorder--in from the streets and immediately places them in permanent, private-market apartments and other residences scattered throughout the city. Only after housing is secured does the Pathways staff bring on the services, in the form of assertive community treatment (ACT) teams.
The idea behind "housing first" is that providing a person with stabilized housing creates a foundation for recovery to begin. It's a consumer-driven model that assumes that if people with serious and persistent mental health disorders can survive on the streets--figuring out where to eat and sleep and how to receive a check from the Social Security office and protecting their physical safety--then managing an apartment is, as Tsemberis says, "a piece of cake."
Philip F. Mangano, the Bush administration's point person on homelessness, said that the model "says that housing is the appropriate nexus point for the delivery of services."
So far, about 85 percent of Pathways' 500 tenants have remained in their homes, according to a study of the program published in the April issue of the American Journal of Public Health (Vol. 94, No. 4).
Calling the strategy "groundbreaking," Mangano credits Tsemberis and the private, non-profit Corporation for Supportive Housing with expanding the "housing first" technology from the mental health field where it originated to use with all vulnerable homeless populations.
The approach got a huge national boost in 2003, when the federal Interagency Council on Homelessness (ICH), where Mangano is executive director, announced its chronic homelessness initiative. The initiative awarded some $ 35 million to nearly a dozen localities nationwide to implement innovative approaches to addressing homelessness, including incorporating "housing first" strategies.
Communities such as Philadelphia, San Francisco, Denver, Fort Lauderdale and northern Louisiana are in various stages of adopting elements of "housing first" approaches.
Though obstacles remain to widespread implementation, many housing experts view it as the standard for sheltering people with chronic disabilities.
"This works for the most chronically disabled people," says Ann O'Hara, associate director of the Technical Assistance Collaborative in Boston. "It gets them affordable, decent housing, and helps them engage with the mental health system in ways that meet their felt needs first. This helps them build the trust that will help them get the other services."
In New York City, with its homeless population of about 38,000, most people who become Pathways tenants are identified through staff outreach efforts. Some tenants are referred by city outreach teams, shelters and drop-in centers. Data from 1999 show that 65 percent had last lived on the streets, 18 percent in shelters and 7 percent in treatment facilities.
Participants must pay 30 percent of their income toward rent. This amounts to about $ 200 a month after tenants begin receiving monthly disability checks of $ 500 to $ 800. About 80 of the 500 tenants have Section 8 federal housing vouchers. For the rest, Pathways pays the difference, using subsidies from the U.S. Department of Housing and Urban Development's Shelter Plus Care program and from New York's state mental health office. A unit costs $ 20,000 on average.
Not surprisingly, the biggest challenge is helping members find apartments at fair market rent, though Tsemberis says that landlords like working with Pathways tenants because rental payments are guaranteed. Housing is scattered among buildings mainly throughout the city's lower-middle-class sections; Pathways has a network of 115 landlords.
Once a member is housed, Pathways staff converges in the residence with offers of treatment, support and other services. Each tenant is assigned an ACT team, a community-based, multidisciplinary team of mental health professionals that is available 'round-the-clock' to provide or link the tenant with services.
Beyond their financial obligations, tenants must fulfill only one requirement: to meet with a service coordinator at least twice a month during their first year of tenancy. Though the intensive and wide-ranging psychiatric, supportive and substance abuse treatment services are available, tenants do not have to use them. Many, however, do, Tsemberis says.
Though the "housing first" strategy emerged from the mental health field, it nonetheless nonetheless does not sit well with all behavioral health professionals.
It embraces a harm-reduction rather than abstinence model of addiction treatment, which flies in the face of the philosophy espoused by many addiction treatment programs and the people who run them.
Another reason that some behavioral health professionals are skeptical is that the strategy removes control from professionals and gives it to consumers.
"It's a challenge to take people at their word, and give them an apartment to go into, a place of their own," Tsemberis says. He recalls his own training as a psychologist, and being taught that mental illness is incapacitating, and that people with mental disorders couldn't possibly make it on their own.
They can, of course, Tsemberis says, adding that "the most anxious part of the decision-making is to turn the control for the decision over to the consumer ... A lot of providers are uncomfortable doing that."
O'Hara weighs in on this point, as well. "Housing first" strategies recognize that "people need to be housed, and the fact that they may not be engaged in the types of services that some mental health clinicians say they should be is really not relevant.
"What's relevant is what kind of housing do people need to be stabilized so they can receive services," said O'Hara. "To a housing professional, it's completely common sense. It's very logical: you address the issue of housing and that in and of itself is a measurable outcome."
She identifies some obstacles to the strategy's widespread implementation: a limit to the number of HUD's Section 8 vouchers. "We haven't seen any new Section 8 vouchers since 2001. The numbers of subsidies coming out of the homeless program are just not enough to deal with the demand. It's a huge barrier," O'Hara says.
The numbers underscore that difficulty. People getting Supplemental Security Income (SSI) payments take home just 18 percent of the median income, on average. There are some 4.9 million SSI recipients; perhaps one-third of them are people with serious mental illness. An estimated 440,000 people with disabilities have Section 8 vouchers; it's unclear how many of those are people with mental health problems.
Another obstacle, O'Hara says, is finding ways to pay for the behavioral health and other services that accompany the model. "Some states are better positioned than others to bill Medicaid for the ACT services to go along with this," she says. For example, some states are rewriting their Medicaid waivers to allow for reimbursement of services under the rehabilitation option.
Despite the challenges, Tsemberis is encouraged by the interest he is seeing around the country in "housing first" models. "The tide has turned, in a way, and people have seen there's a usefulness to it. And it's effective because it's sympatico with the consumer," he says. "For all of the talk, it is based on love, respect and creating possibilities for people with mental illness."
Permanent, Unconditional Housing for the Chronically Mentally Ill and Homeless (http://www.jointogether.org/sa/action/dt/news/reader/0,2812,576243,00.html)
2/18/2005
The Pathways to program, founded in New York City in 1992 and recently introduced to Washington, D.C, offers no-strings-attached housing and optional services to people who are chronically homeless due to mental illness, Mother Jones reported in its January/February 2005 issue.
There are about 600,000 people living without homes on any given day, according to the U.S. Department of Health and Human Services. The chronically homeless make up 10 percent of the homeless population, but occupy about one half of the available space in emergency shelters.
After a psychiatric evaluation determining the client's capacity for self-sufficiency, Pathways places homeless clients into new apartments within two weeks, with no requirements or conditions. Medical, psychiatric, substance abuse and job counseling services are all offered to Pathways clients, but are not mandatory.
Pathways establishes bank accounts for its clients, where the client's previously uncollected government benefits are deposited and rent is automatically deducted, and leaving living expenses to the client's discretion.
Foundations, government grants, and these unclaimed benefits provide the $22,000 it takes to house and treat each client for one year -- a feat Pathways completes for a little over half the cost for equivalent government-run support services, and at a greater success rate.
After one year, the chronically homeless in New York City's more conventional treatment system have been without housing 28 percent of the time, while those in the Pathways program are only homeless for 3 percent of the time.
"You're curing the housing problem first. You cure the person later," explains Sam Tsemberis, founder of Pathways. This reversal in the order of services is unique, controversial, and, most importantly, effective.
Pathways currently serves almost 500 New York clients, and it plans to house 75 homeless people in Washington using its recent $750,000 start-up grant from the Department of Mental Health. The Bush administration supports programs like Pathways as part of its effort to focus on long-term homelessness and permanent housing rather than emergency shelters.
Finally, here is a link to the Pathways to Housing (New York) website (http://www.pathwaystohousing.org/index.html).