In recent years, "housing first" has emerged as a key response to homelessness in North America. With its growing popularity in Canada comes increasing interest in understanding how the approach works, different program models and its effectiveness for specific populations. One key factor that undoubtedly shapes the success of any housing first program is the nature and supply of affordable housing.
The basic underlying principle of housing first, pioneered by Sam Tsembaris at the Pathways to Housing project in New York in the 1990s, is that people do better moving forward with their lives if they are first housed. This is as true for homeless people and those with mental health and addiction issues as it is for anyone. According to Pathways to Housing, "The Housing First model is simple: provide housing first, and then combine that housing with supportive treatment services in the areas of mental and physical health, substance abuse, education, and employment." This approach differs from what has been (and arguably still is) the orthodoxy of our Canadian response to homelessness; in that "treatment first" approach, people who are homeless should be placed in emergency services until they are "ready" for housing (having received access to health care or treatment) or until housing is available.
Research quite convincingly demonstrates the general effectiveness of housing first over treatment first. In a 2000 study, Tsembaris and Eisenberg demonstrated that 90 per cent of people in the Pathways program remained housed five years later. A growing body of research shows that people with mental health and addiction issues do very well with a housing first approach, spend fewer days in hospital and are cheaper to support. (To see the research, visit www.homelesshub.ca/housingfirst.)
Housing first is most effective when, first, people are rehoused rapidly, minimizing time spent on emergency services. Because resources are scarce, priority should be given to high-needs clients, including families and those with mental health and addiction challenges. Second, ongoing and appropriate support must be provided for those who need them (and many don't). Those with addiction issues should have access to harm reduction-based housing, if that is what they prefer. Finally, where possible, clients should have input into the kind and location of their housing. While providing shelter and supports is central to housing first, the approach works best when it helps people nurture supportive relationships and become meaningfully engaged in their communities.
As housing first grows in popularity, it is applied in new ways and in different contexts. One challenge of implementing the approach is the ability to deliver appropriate housing support in the context of a housing shortage. I have often wondered what would have happened if the City of Toronto had attempted to implement its Streets to Homes program in the late 1990s, when rental vacancy rates were routinely below one per cent, compared to the last five years, when vacancy rates have hovered between three and four per cent.
In a tight rental market, one of the first things to go is the notion of consumer choice. One criticism of housing first is that people are often given housing in remote areas of town, far removed from services, poorly served by transit, and where people struggle to connect. Women fleeing violence may be placed in neighbourhoods that are not safe. The outcome is often isolation, continued marginalization and a compromised ability to accesses necessary services and supports. In the long run, this can undermine stability and security of tenure.
Different approaches to housing first take on the challenge of affordable housing supply in distinct ways. In Montreal, all levels of government working with the non-profit sector have sought to address the supply problem with an ongoing investment in social housing, with pathways to that housing for people who are homeless. The Streets to Homes program in Toronto relies almost exclusively on the private market, and rather than use rent subsidies, it has developed a system to fast track people so they can access other government benefits and supports. With a waiting list of more than 75,000 for social housing and with modest targets for expanding its affordable housing supply (up to 1,000 new units annually--though these targets are not being met), Toronto relies on the private rental market, making its housing first program vulnerable if the affordable housing supply shrinks.
In Calgary, the affordable housing supply has shrunk drastically over the past 10 years, while rents have skyrocketed. In rolling out its housing first model, the Calgary Homeless Foundation takes a systems approach, coupling its adaption of housing first with an investment in affordable housing (3,000 units built over the past three years) and with rent supports for people living -- or choosing to live -- in the private rental market.
The best approach to housing first, then, is to treat it not as a program or service tied to an agency, but rather, as part of a broader and more strategic response to homelessness; one that focuses on prevention by ensuring an investment in an affordable housing supply, and by requiring other sectors (mental health and corrections come to mind) to play their part in diverting people from homelessness through more effective discharge planning strategies. It is only by ensuring a sufficient supply of affordable housing that one of the central tenets of housing first -- consumer choice -- is protected.
Reprinted with permission from CAMH.