Housing First

Housing First is a recovery-oriented approach to ending homelessness that centres on quickly moving people experiencing homelessness into independent and permanent housing and then providing additional supports and services as needed. It is an approach first popularized by Sam Tsemberis and Pathways to Housing in New York in the 1990s, though there were Housing First-like programs emerging elsewhere, including Canada, prior to this time.

The basic underlying principle of Housing First is that people are better able to move forward with their lives if they are first housed. This is as true for people experiencing homelessness and those with mental health and addictions issues as it is for anyone. Housing is provided first and then supports are offered, including physical and mental health, education, employment, substance abuse, and community connections.

In the book Housing First in Canada: Supporting Communities to End Homelessness, it says, “Housing is not contingent upon readiness, or on ‘compliance’ (for instance, sobriety). Rather, it is a rights-based intervention rooted in the philosophy that all people deserve housing, and that adequate housing is a precondition for recovery.”

Core Principles

There are five core principles of Housing First:

1. Immediate access to permanent housing with no housing readiness requirements. Housing First involves providing clients with assistance in finding and obtaining safe, secure and permanent housing as quickly as possible. Key to the Housing First philosophy is that individuals and families are not required to first demonstrate that they are “ready” for housing. Housing is not conditional on sobriety or abstinence. Program participation is also voluntary. This approach runs counter to what has been the orthodoxy of “treatment first” approaches, in which people experiencing homelessness are placed in emergency services and must address certain personal issues (addictions, mental health) prior to being deemed “ready” for housing.
2. Consumer choice and self-determination. Housing First is a rights-based, client-centred approach that emphasizes client choice in terms of housing and supports.

• Housing: Clients are able to exercise some choice regarding the location and type of housing they receive (e.g., neighbourhood, congregate setting, scattered site, etc.). Choice may be constrained by local availability and affordability.
• Supports: Clients have choices in terms of what services they receive and when to start using services.

3. Recovery orientation. Housing First is not simply focused on meeting basic client needs, but on supporting recovery. A recovery orientation focuses on individual well-being and ensures that clients have access to a range of supports that enable them to nurture and maintain social, recreational, educational, occupational, and vocational activities.For those with addictions challenges, a recovery orientation also means access to a harm reduction environment. Harm reduction aims to reduce the risks and harmful effects associated with substance use and addictive behaviours for the individual, the community, and society as a whole, without requiring abstinence. However, as part of the spectrum of choices that underlies both Housing First and harm reduction, people may desire and choose abstinence-based housing.

4. Individualized and client-driven supports. A client-driven approach recognizes that individuals are unique and so are their needs. Once housed, some people will need minimum supports while other people will need supports for the rest of their lives (this could range from case management to assertive community treatment). Individuals should be provided with “a range of treatment and support services that are voluntary, individualized, culturally appropriate, and portable” (Goering et al., 2012:12). Supports may address housing stability, health and mental health needs, and life skills. Income supports and rent supplements are often an important part of providing client-driven supports. If clients do not have the necessary income to support their housing, their tenancy, health, and well-being may be at risk. Rent supplements should ensure that individuals do not spend more than 30% of their income on rent.It is important to remember that a central philosophy of Housing First is that people have access to the supports they need and want. Access to housing is not conditional upon accepting a particular kind of service.

5. Social and community integration. Part of the Housing First strategy is to help people integrate into their community, and this requires socially supportive engagement and the opportunity to participate in meaningful activities. If people are housed but become or remain socially isolated, the stability of their housing may be compromised. Key features of social and community integration include:

• Separation of housing and supports (except in the case of supportive housing)
• Housing models that do not stigmatize or isolate clients. This is one reason why scattered site approaches are preferred.
• Opportunities for social and cultural engagement supported through employment and vocational and recreational activities.

While all Housing First programs ideally share these critical elements, the model's application is considerably varied based on the population served, resource availability, and other factors related to the local context. There is no “one size fits all” approach to Housing First.

The Application of Housing First

It is important to consider different models to fully understand how Housing First is applied in different contexts. While there are core principles that guide its application, it is worth distinguishing Housing First as a philosophy, a systems approach, a program model, and a team intervention.

As a philosophy, Housing First can be a guiding principle for an organization or community that prioritizes getting people into permanent housing with supports to follow.

Housing First can be considered embedded within a systems approach when the foundational philosophy and core principles of Housing First are applied across an integrated systems model of service delivery.

Housing First can be considered more specifically as a program when it is operationalized as a service delivery model or set of activities provided by an agency or government body. Finally, one needs to consider Housing First teams, which are designed to meet the needs of specific target populations, defined in terms of either the characteristics of the sub-population (age or ethno-cultural identity, for instance), or in terms of the acuity of physical, mental and social challenges that individuals face. Housing First teams can include ACT teams and ICM teams.

• ACT teams (assertive community treatment) are designed to provide comprehensive community-based supports for clients with challenging mental health and addictions issues and may support individuals in accessing psychiatric treatment and rehabilitation. These teams may consist of physicians and other health care providers, social workers, and peer support workers.
• ICM teams (intensive case management) are designed to support individuals with less acute mental health and addictions issues through an individualized case management approach. The goal of case management is to help clients maintain their housing and achieve an optimum quality of life by developing plans, enhancing life skills, addressing physical and mental health needs, engaging in meaningful activities, and building social and community relations.

What Kind of Housing?

A core principle of Housing First is individual choice and self-determination. In essence, individuals should have the freedom to choose the type and location of their housing.

The Pathways model prioritizes the use of scattered-site housing which involves renting independent units in the private rental market. One benefit of this approach is that it gives clients more choice and may be less stigmatizing (Barnes, 2012). It is in keeping with consumer preferences to live in integrated community settings. From a financial perspective, there is a benefit to having the capital costs of housing absorbed by the private sector.

In other cases, the use of congregate models of housing may be beneficial. In such a model, in which there are many units in a single building, the benefits may include on-call supports and a stronger sense of community. In some national contexts (Australia, many European nations), social housing is more readily used to provide housing for individuals in Housing First programs. In such contexts, there is a more readily available supply of social housing, and living in buildings dedicated to low income tenants may not be stigmatized.

Finally, some Housing First clients whose physical and mental health needs are acute and chronic may require permanent supportive housing, a more integrated model of housing and services for individuals with complex and co-occurring issues where the clinical services and landlord role are performed by the same organization.

What Kinds of Support Are Provided?

Housing First typically involves three kinds of supports:

1. Housing supports: Housing First's initial intervention is to help people obtain and maintain their housing in a way that takes into account client preferences and needs and addresses housing suitability. Key housing supports include finding appropriate housing, supporting relations with landlords, applying for and managing rent subsidies, and providing assistance in setting up a living space.
2. Clinical supports: These include a range of supports designed to enhance the client’s physical and mental health and well-being. Housing First teams often speak of a recovery-oriented approach to clinical supports that is designed to enhance well-being, mitigate the effects of mental health and addictions challenges, improve quality of life, and foster self-sufficiency.
3. Complementary supports: These are intended to help individuals and families improve their quality of life, integrate into the community, and potentially achieve self-sufficiency. They may include life skills training, engagement in meaningful activities, income supports, assistance with employment, training, and education, and community engagement.

Does Housing First Work?

It took just a few short years to resolve the debate about whether Housing First works. The body of research from the United States, Europe, and Canada attests to the success of the program, and it can now truly be described as a “best practice.”

The At Home/Chez Soi project, funded by the Mental Health Commission of Canada, is the world’s most extensive examination of Housing First. They conducted a randomized control trial where 1,000 people participated in Housing First and 1,000 received “treatment as usual.”

The results are striking: you can take a person experiencing the most chronic forms of homelessness and who has complex mental health and addictions issues and put them in housing with supports and find that they stay housed.

Over 80% of those who received Housing First remained housed after the first year. For many, their use of health services declined as their health improved, and their involvement with the legal system declined as well. An important focus of Housing First's recovery orientation is social and community engagement; many people were helped to make new linkages and to develop a stronger sense of self.

The Housing First in Canada book highlights eight Canadian case studies that attest to Housing First’s general effectiveness, especially compared to treatment-first approaches.

There are key questions that remain in developing Housing First practices, philosophies, programs, and policies across the country.

• How effectively do Housing First programs demonstrate fidelity to the model's principles? There is increasing pressure for communities to adopt a Housing First model. Examining issues of fidelity to the core principles noted above is important to ensure that communities are doing Housing First properly.
• What is the relationship between Housing First and the affordable housing supply? While the case studies in Housing First in Canada have shown that it is possible to develop a successful Housing First program even in a tight rental housing market, they were primarily successful through the use of rent supplements to increase affordability. Partnerships with existing private landlords were also shown to be very important. At the core, though, there is a housing shortage in Canada—especially in safe, secure, and affordable housing. A concurrent investment in affordable housing is necessary to ensure an end to homelessness.
• How are the needs of sub-populations met through Housing First? It is clear from existing research that one size does not fit all. However, Housing First can be adapted to suit most communities and sub-populations. Unique needs require unique answers. What will work in Victoria may not work in Montreal. What works for single adults may not work for youth. Adapting the program to meet the needs of a particular sub-population is key to ensuring success. A period of transition may be required to help certain sub-populations make the adjustment from the street or shelters to housing.
• What is the duration and extent of supports, and who is responsible for funding them? In some cases, Housing First programs provide a time-limited investment in supports, ranging from one to three years. For those who need ongoing supports, effective models for continued engagement with mainstream services need to be explored.
• Once housed, do people have adequate income to meet their basic needs on an ongoing basis? A goal for most communities is that people who are housed should pay no more than 30% of their income on rent. Rent supplements are key to ensuring that people are able to survive and thrive in housing. In many cases, people are able to “graduate” from a Housing First program, meaning they no longer require active support while still needing ongoing financial assistance.