Key Questions

1. What is Housing First?

Housing First is a consumer-driven approach that provides immediate access to permanent housing for people experiencing homelessness, without requiring psychiatric treatment or sobriety as determinants of “housing readiness”1,2,3. Additionally, the Housing First approach is guided by the idea that housing is a basic human right4.
Consumer choice is central to the Housing First model and guides both housing and service delivery.

Consumer choice is central to the Housing First model and guides both housing and service delivery. Housing First is a specific program approach, but it can also be looked at as a philosophy of service, and as a systems approach for addressing homelessness.

Within the Housing First model, clinical and support services are separated. Housing First participants receive housing allowances that enable them to secure typical housing in the community, and an off-site clinical team provides the support. Participants contribute no more than 30 per cent of their income for rent, sometimes from disability benefits. Participants typically live independently in scattered site apartments in the community, although they can choose to live in other housing arrangements (i.e., congregate housing). Along with housing, participants are offered an array of clinical and support services, which are individualized, flexible, and community-based. Services typically entail Assertive Community Treatment (ACT)  Assertive Community Treatment (ACT) is an approach designed for participants with high needs, including psychotic disorders. A multidisciplinary team, including a psychiatrist and a nurse, provides services and supports. At least one peer specialist is on staff. The client/staff ratio is 10:1 or less. Services and supports are provided seven days/week with 24-hour crisis coverage, and the team typically meets daily. for participants with higher needs, or Intensive Case Management (ICM)  Intensive Case Management (ICM) is an approach designed for participants with moderate needs. Efforts are integrated across multiple staff members and agencies. Staff members accompany clients to appointments and coordinate services. Services and supports are provided seven days/week, 12 hours per day. The team typically convenes monthly case conferences. for individuals with moderate needs. ACT and ICM teams both provide community-based clinical care to individuals with mental health issues. ACT services are delivered in a multidisciplinary team, whereas ICM services are coordinated or “brokered” by a case manager.

2. What is the goal of Housing First?

The goal of Housing First for individuals with mental health and addiction challenges who have experienced chronic homelessness  This term refers to individuals, often with disabling conditions (e.g. chronic physical or mental illness, substance abuse problems), who are currently homeless and have been homeless for six months or more in the past year (i.e. have spent more than 180 nights in a shelter or place not fit for human habitation). **To the extent possible, communities should prioritize those people who have been homeless the longest.  is to promote recovery. This is accomplished first by ending their homelessness and then by collaborating with them to address health, mental health, addiction, employment, social, familial, spiritual, and other needs.

View a TED talk from Dr. Sam Tsemberis about the goal and origins of Housing First/Pathways to Housing.

3. What is the problem that Housing First seeks to address?

Housing First was developed to address the problem of chronic homelessness. Individuals who have experienced chronic homelessness have been found to represent only 11 per cent of the population of shelter users but account for 50 per cent of shelter stays.5,6
 
This group, which includes a disproportionately high number of people with serious mental illness (and often addictions), represents a subset of the homeless population who tend to stay homeless for long periods of time and who are considered “difficult to house.” People who are chronically homeless tend to cyclically use emergency health services, hospitals, and the justice system, resulting in substantial costs. Housing First addresses the social circumstances of adults who are chronically homeless and living with mental health and addiction issues by first ending homelessness and then supporting participants in their process of recovery. While the model was originally developed to address chronic homelessness, its principles can and have been applied to address other forms of homelessness.

4. WHAT IS THE COST OF HOMELESSNESS IN CANADA?

It is estimated that 200,000 Canadians will be homeless over the course of a year.7 The prevalence of mental health issues is significantly higher for Canadians who are homeless, compared with the general population. The Mental Health Commission of Canada estimates that there are approximately half a million people diagnosed with a mental illness in Canada who are inadequately housed, with more than 100,000 of those individuals being homeless.8 Studies suggest that between one-quarter and one-third of Canadians who are homeless experience serious mental illness.9

In Canada, the annual estimated cost of homelessness is $7 billion.10 Individuals who are homeless are often heavy users of criminal, health, and social services, and the costs associated with this use is higher for people who are homeless than for individuals with housing.11 By targeting people who are chronically homeless using the Housing First approach, resources can be better directed to strategies that have been shown to work for this population.

5. What are the origins of Housing First?

Following the widespread closure of psychiatric hospitals that occurred between the 1960’s and 1980’s (a period termed “deinstitutionalization”), there was a movement towards community-based mental health treatment. The early housing models that followed deinstitutionalization combined psychiatric and addiction treatment, and mandated treatment compliance and sobriety as prerequisites and conditions for obtaining and keeping housing. This model — often termed the “continuum” or “staircase” model — came under critique in the 1980s on the grounds that: (a) there is a lack of consumer choice about housing and neighbourhoods; (b) community integration is hindered by confinement to specific neighbourhoods and buildings; (c) social relationships are disrupted by movements along the continuum of housing that was offered under the previous model of supportive housing: and(d) the most vulnerable individuals tend to become caught cycling between inpatient psychiatric care and involvement with the justice system.12
Housing First emerged in response to these critiques of the continuum model in the late 1980’s. Supported by consumer advocates, Ridgeway and Zipple,13 Dr. Paul Carling espoused an approach that he called “supported housing,” which gave consumers choice in immediate permanent housing located in “normal” rental units. This model was taken up and brought to mainstream attention in the early 1990’s by Dr. Sam Tsemberis and the organization Pathways to Housing in New York City. A particular innovation of the Pathways model was to bring supported housing together with (off-site) support provided by a recovery-oriented ACT team for the benefit of people who had experienced both homelessness and mental illness. By itself, ACT had proven to be ineffective in a homelessness context. Brought together, these two models (supported housing and ACT) became a powerful combination. Over the next decade, the Pathways Housing First model emerged as probably the most well-developed and researched Housing First program.

6. How does housing first work?

Housing First seeks to end homelessness by providing immediate access to permanent housing in the community. When participants enter the program, they are provided immediate access to housing through a team that is responsible for helping participants find and get housing. A care plan is then prepared by the participant in collaboration with an ACT team or case manager, including immediate attention to helping the participant apply for disability benefits, which is important for lease eligibility. The participant forms a working alliance with her or his clinical service team or worker and identifies unique treatment goals. Clinical service teams help participants to access community health services for acute and chronic health issues. Participants are then offered assistance in pursuing their treatment goals. These goals might include vocational training and support in establishing and re-establishing social, familial, and spiritual connections. These interventions are intended to produce housing stability, participation in treatment services, and decreases in emergency service utilizations. Additionally, these interventions are intended to promote community integration14. Click here to view more Canadian examples of Housing First models.
Housing First seeks to end homelessness by providing immediate access to permanent housing in the community.

7. What are the core principles of Housing First?

Immediate access to permanent housing with no housing readiness requirements
Consumer choice and self-determination
Individualized, recovery-oriented, and client-driven supports
Harm reduction
Social and community integration

8. What are the key components of Housing First?

HOUSING

Housing should be guided by the principle of consumer choice and self-determination. Participants should be able to have some choice about unit type (scattered site, congregate) and neighbourhood preference, although choices will, in many cases, be contingent on the conditions of the local housing market. Additionally, participants should not make up more than 20 per cent of renters in a specific unit and should not pay more than 30 per cent of their income towards rent.

HOUSING SUPPORTS

A Housing Team assists participants in selecting housing of their choice. Responsibilities of the Housing Team include:

  • Helping participant search for and identify appropriate housing
  • Building and maintaining relationships with landlords, including mediating during times of conflict
  • Applying for and managing housing allowances
  • Assistance in setting up apartment
  • Independent living skills development

CLINICAL SUPPORTS

A Clinical Team provides a range of recovery-oriented, client-driven supports. Supports range from ICM, where support is coordinated by a case manager, to ACT, where support is coordinated by a multidisciplinary team. These supports address health, mental health, social care, and other needs. Effective assessments at enrolment are important for matching the right participants with the right supports. These supports are aimed at promoting community integration and improving quality of life and independent living. These supports may include:

  • Life skills for maintaining housing, establishing and maintaining relationships and engaging in meaningful activities.
  • Income support
  • Vocational assistance, such as enrolling in school, finding employment, or volunteering
  • Managing addictions
  • Community engagement

Upon learning about Housing First, many service providers will say that they have already been doing Housing First. While many housing and support programs for people who are homeless operate from a basis of recovery, individualized and consumer-directed services, and a focus on community integration, supportive housing programs are less likely to adhere to two important components of Housing First: housing choice and structure and the separation of housing and support services. In this table, we clearly delineate the key elements of these two components to show where potential differences may lie across programs and initiatives. The second column provides items from a Housing First fidelity scale based on the Pathways to Housing program;15 the third column is based on a literature review on supported Housing First;16 the fourth column is from a recent, widely distributed book on Housing First in Canada;17 and the last column contains key elements from the federal Homelessness Partnering Strategy’s (HPS) position on Housing First.18

Click here for more information on HPS and Housing First.

From this table, we can see that the recent book on Housing First in Canada and the HPS position on Housing First overlap to a large extent with the Pathways to Housing program and the literature. However, there are some divergences as well. Scattered site housing with housing subsidies and standard landlord-tenant leases are emphasized, but they are seen as not necessary for Housing First. As well, the two Canadian sources are silent on whether support services must be provided outside of the housing site and whether separate agencies must operate housing and support. To be clear, in this toolkit, we are emphasizing adherence to the original Pathways to Housing model, on which numerous applications in the U.S.19 and in Canada and Europe20 are based.