Using Critical Time Intervention as a Scalable Solution to Crisis Homelessness

We have made meaningful progress over the past decade in addressing chronic homelessness in the United States, as evidenced by a 35% reduction between 2007 and 2016 in the number of persons experiencing chronic homelessness on a single night. The significant expansion of permanent supportive housing (PSH) over this time period is rightly credited as driving this progress and helps illustrate what is possible if resources are directed towards evidence-based, housing-focused solutions.

Yet, PSH should not be understood as a one-size fits all solution to homelessness. With annual costs that can exceed $15,000, it is a resource-intensive intervention, and it may not be feasible or necessary to provide such an intensive intervention to all persons experiencing homelessness. Alternative solutions that are less resource intensive, but equally effective as PSH, are therefore sorely needed for the bulk of the homeless population who experience short-term or “crisis” homelessness. For these individuals (who make up about 85% of the overall sheltered homeless population), an episode of homelessness is often triggered by an event such as an eviction, dissolution of a relationship, or transition out of an institutional living arrangement, such as foster care, prison, inpatient hospitalization, or substance abuse treatment. Unfortunately, progress in addressing crisis homelessness has not kept pace with that made on chronic homelessness: after subtracting out reductions in chronic homelessness, between 2007 and 2015, there was only a 6% decline in homelessness among single adults.

Fortunately, the emergence of a new paradigm in the homelessness assistance sector focused on housing stabilization, coupled with recent Medicaid policy developments, provides a unique opening for substantial progress to be made in reducing crisis homelessness. Recognizing this opportunity, my colleague Dennis Culhane and I recently presented a proposal to leverage the evidence-based intervention Critical Time Intervention (CTI) as a means to expand the availability of rapid re-housing—a promising new strategy that focuses on providing short-term, highly flexible assistance to help homeless households quickly achieve housing stabilization—for persons experiencing crisis homelessness.

Adapting CTI into a large-scale rapid re-housing intervention would make for a sound and feasible policy response to crisis homelessness for several reasons. First, the CTI and rapid re-housing conceptual and program models align nearly perfectly, meaning that a CTI-based rapid re-housing program model would be fairly straightforward to implement. Second, CTI has a strong evidence base as an effective intervention for reducing homelessness, and an integration of rapid re-housing and CTI could therefore amplify the impact of existing rapid re-housing programs. Third, recent guidance issued by the Centers for Medicaid and Medicare Services (CMS) suggests that most of the services at the core of a CTI-based rapid re-housing program could be reimbursed by state Medicaid programs, thereby providing the necessary funding to scale-up the approach with federal resources.

Implementing a CTI-based rapid re-housing at a large scale would have benefits at multiple levels. First, at the individual level, the housing stability and connections to community-based treatment and supports afforded by CTI would lead to improved health, economic, and social outcomes. Second, from the perspective of health care systems, and Medicaid in particular, the expansion of CTI-based rapid re-housing services could lead to more efficient and effective use of health care dollars.  Third, the implementation of our proposal would have a number of potential benefits to society, the most notable of which would be a substantial reduction in overall homelessness. Society would also benefit from reduced utilization of criminal justice system resources, public assistance, and other public services, as CTI has been linked with reductions in such services.

To be sure, there are challenges that would need to be addressed in implementing this idea. These include the need to appropriately tailor CTI for those experiencing crisis homelessness; having a trained workforce in place to deliver CTI-based rapid re-housing at scale; determining the best mechanism for states to include CTI in their Medicaid benefit package; and resolving how to pay for the temporary financial assistance component of rapid re-housing.

Fortunately, there is important work already being done to address these challenges and figure out how best to integrate CTI and rapid re-housing. Most notably, in a project supported by the Melville Charitable Trust, the Center for the Advancement of Critical Time Intervention is partnering with the National Alliance to End Homelessness to develop and test an integration of CTI into rapid re-housing programs in Connecticut. Such work is crucially important and holds great promise. To make real progress in addressing crisis homelessness similar work should be actively encouraged.Byrne_photo

About the Author: Tom Byrne is an Assistant Professor of Social Welfare Policy at the Boston University School of Social Work.  He is also an Investigator at the U.S. Department of Veterans Affairs’ National Center on Homelessness Among Veterans. 

Campaign for NY/NY Housing

The National Center supports the Campaign 4 NY/NY Housing urging New York Governor Andrew Cuomo to fund 35,000 supportive housing units across New York State over the next ten years.

Homelessness in New York State has doubled in the last decade, with roughly 67,000 men, women, and children staying in shelters at any given time. Countless others live on the street, in cars, or doubled-up. Supportive housing is a viable solution to this rising problem and has been proven through a large body of research to be a cost-effective and successful way to end homelessness for individuals and families, particularly for those with complex needs and disabilities. Pairing affordable housing with on-site services, supportive housing has also been shown to reduce the use of costly resources such as shelters, hospitals, psychiatric centers, and correctional institutions.

There is a significant shortage of supportive housing units in New York State, and in New York City in particular. In fact, four out of every five people eligible for supportive housing in New York City get turned away because of lack of available units.

It is time for New York State to take action and use this important opportunity to set a national example. The New York-New Jersey Regional Network of the National Homelessness Social Work Initiative sent a letter of support to Governor Andrew Cuomo advocating for the creation of the needed agreements to fund these units. We urge other individuals and organizations to join us in supporting this important and necessary step towards ending homelessness in New York State.

Learn More About the Campaign: http://www.nynycampaign.org/

Call the Governor’s Office: 1) Dial 518-474-1041; 2)  Press “1” to leave a message; 3) Leave this or a similar message: “I urge Governor Cuomo to get the housing MOU done now. He made this promise more than a year ago. Over 80,000 people are homeless across the state. Every day that passes without an MOU is another day that people live in the streets and in shelters. We need the Governor to fulfill his promise and get the MOU signed now.”

Send a Letter to the Governor’s Office:
The Honorable Andrew M. Cuomo
Governor of New York State
NYS State Capitol Building
Albany, NY 12224

 

Like this post?
Check out this one written by Kelsey Whittington, graduate assistant for the National Center for Excellence in Homeless Services.

Want more info?
Visit our website to learn more about us and our National Homelessness Social Work Initiative. And, join our mailing list to receive our newsletter.

On social media?
Follow us on Facebook and Twitter.

Moving On From PSH: Emmy Tiderington and Dan Herman Tackle The “What’s Next?” Question

Permanent Supportive Housing (PSH) is an evidence-based intervention that combines affordable housing with wrap-around support services in order to end homelessness for individuals who experience barriers to housing stability, such as serious mental illness, substance use problems, and chronic health conditions. Since the model’s inception, the number of PSH beds in the U.S. has increased substantially, up 52% just over the past ten years. Currently, the U.S. Department of Housing and Urban Development estimates that close to 320,000 PSH beds exist within the federal housing inventory. However, demand for PSH still outstrips supply, and one of the overarching questions for policymakers is how to “right-size” homeless services to individual need and maximize the use of limited resources.

While some service recipients will require the intensity of support services and housing assistance that PSH offers for a lifetime, others may not need this level of support after some time and want to transition from the PSH program into mainstream housing completely separate from supportive services. In fact, a previous study of PSH programs estimated that 5 to 25 percent of PSH residents would be able to successfully move on from these programs and live independent from services.

In recognition of this gap in the homeless service system, several recent pilot programs (commonly called Moving On initiatives) are assisting willing and able PSH residents with the transition from program-based apartments into mainstream independent units using a combination of transitional supports and affordable housing subsidies. Moving On initiatives address the PSH “supply bottleneck” by allowing homeless individuals and families with greater needs to access intensive services, while providing opportunities for those who can move on with the opportunity to achieve fully integrated, independent living in the community in the least restrictive setting possible. However, best practices for the Moving On model have yet to be developed and little is known about the outcomes of those leaving PSH through these initiatives over time.

Dr. Emmy Tiderington (Assistant Professor of Social Work at Rutgers, the State University of New Jersey), in collaboration with Dr. Dan Herman (Professor of Social Work at Hunter College), is conducting a three-year study funded by the Oak Foundation of the implementation and outcomes of New York City’s Moving On Initiative (MOI). The New York City MOI is one of the largest in the country, assisting 125 PSH recipients across five supportive housing agencies and a range of subpopulations (e.g. adults, families, and youth who have aged out of foster care) as they move from PSH into independent apartments using Housing Choice Vouchers and various transitional supports.

The aims of this mixed methods study are to: 1) Capture MOI recipient outcomes regarding quality of life, health and recovery, community integration, service utilization, and housing stability, at one year and two years post-leaving PSH; 2) Describe MOI program implementation processes and experiences within and across the five different Moving On provider agencies; and 3) Identify the individual-, program-, and system-level barriers to and facilitators of MOI recipients’ successful transition from PSH programs to independent living in the community. Findings from this study will be used to inform the development of best practices for MOI implementation and broader scale-ups of MOI across the country.

OLYMPUS DIGITAL CAMERA
Dr. Emmy Tiderington

Blog Post Author: Emmy Tiderington, PhD, LMSW Assistant Professor, School of Social Work and Associate Faculty, Institute for Health, Health Care Policy and Aging Research at Rutgers, The State University of New Jersey

Dr. Tiderington’s research focuses on the implementation and effectiveness of supportive housing and other forms of homeless services as a means for ending homelessness and improving outcomes for service recipients. She is a licensed social worker with extensive direct practice experience working in supportive housing and case management services for adults with serious mental illness. In addition to leading the Moving On study, her research has explored the mechanisms and processes by which homeless adults achieve recovery from substance abuse and serious mental illness. She has also examined the individual, organizational, and macro-systemic barriers to “street-level” policy implementation of person-centered care, harm reduction, and the management of risk and recovery in supportive housing services.

Like this post?
Check out this one written by Dr. Kimberly Bender from the University of Denver.

Want more info?
Visit our website to learn more about us and our National Homelessness Social Work Initiative. And, join our mailing list to receive our newsletter.

On social media?
Follow us on Facebook and Twitter.

 

Padgett, Henwood, and Tsemberis Co-Author Upcoming Book on Housing First

A new book about Housing First by Professor Deborah Padgett at NYU’s Silver School of Social Work, co-authored with Benjamin Henwood (USC-Social Work) and Sam Tsemberis (Pathways to Housing, Inc.), will be released this fall.

Cover_HousingFirstHousing First: Ending Homelessness, Transforming Systems, and Changing Lives (Oxford University Press) is the first book to tell the story of this groundbreaking approach. In this book, Housing First (HF) is described as an unusual combination of evidence-based practice, consumer choice, and the right to housing. Authors Padgett, Henwood, and Tsemberis (the founder of Pathways to Housing) trace the history of homelessness in the United States and report on the rise of a “homeless industry” of shelters and transitional housing programs after the 1980s. The HF model challenged the standard ‘staircase’ or linear continuum by not requiring compliance with treatment, sobriety, and ‘housing readiness’ before gaining access to one’s own apartment.

Beginning with its origins in New York City in 1992 with the formation of Pathways to Housing, Inc., the HF approach has quickly spread to cities around the United States, Canada, Australia, and Western Europe. Housing First has been unprecedented in its influence on housing policies in the U.S. and abroad and is credited with ending homelessness for veterans in several U.S. cities as well as ending chronic homelessness in the state of Utah. After a five-city experimental trial, HF is now the national policy in Canada. While it has only begun to be applied to families and young adults, HF principles of immediate access to housing, support services, and harm reduction hold promise for engagement and stabilization.

The book summarizes what is known about Housing First, including qualitative findings from the New York Recovery Study led by Padgett and Henwood (funded by the National Institute of Mental Health). In addition to analyzing HF as a source of systems and organizational change, the book features first-person accounts of life after obtaining housing and services. The success of HF has shown that providing immediate access to an apartment and support services to homeless persons with ‘dual diagnoses’ is not only humane but effective.

Blog Post Author: Deborah Padgett, Professor at NYU’s Silver School of Social Work

Tiny Houses – Gaining Popularity as Temporary Housing for the Homeless

Tiny houses are one of the latest trends catching the eye of those wanting to downsize, save money, live minimally, and reduce their carbon footprint. They have become popular among people of all ages, and have triggered various business endeavors including hotels, a documentary, and a tv show. They’ve also attracted attention in the field of homeless services, as a way of providing temporary or transitional housing. This video describes these two parallel trends in tiny houses.

Several groups have created tiny housing initiatives targeting individuals experiencing homelessness, many of which emerged from original tent city encampments. For example, Quixote Village in Olympia, WA, Dignity Village in Portland, OR, and Second Wind Cottages in Newfield, NY are tiny house communities intended to provide temporary housing for formerly homeless adults. Most commonly these houses are built and maintained as part of small villages or communities for the formerly homeless, and rules and restrictions are enforced through a combination of self-governing and oversight from an agency of some kind. There are commonly community resources (e.g. laundry facilities), and some partner with social service agencies to provide support services to residents as needed. Residence is typically maintained by paying rent and/or contributing work hours to the community, and by following some set of rules and standards of living.

Initiatives like those linked above have emerged across the country. However, the trend has not received federal endorsement or scholarly attention.  Therefore, efforts are commonly funded through private donations and churches. If you are interested in learning more about the tiny house trend, many projects provide detailed information on their website about how they started and how they operate. For example, Occupy Madison, Inc. provides somewhat detailed information on how they got their program up and running.

Blog Post Author: Amanda Aykanian, Research and Project Lead at the National Center
Special thanks to Joe Hegedus of the
Marin Partnership to End Homelessness for finding some of the resources cited in this blog post.