Key Questions

9. What is Housing First – a philosophy, a systems approach, or a program model?

Housing First is an overarching philosophy with a core set of principles that have implications for systems approaches to ending homelessness and for program models. The core principles described earlier (e.g., immediate access to permanent housing with no housing readiness requirements, consumer choice and self-determination) underlie and guide both systems approaches to ending homelessness and program models.

A Housing First systems approach focuses on cohesive community planning to develop coordinated, complementary programs and policies to end homelessness that are consistent with Housing First principles and practice. These feature a common intake system to Housing First programs, whether from the street, from emergency shelters, or people coming out of institutions who are at risk of becoming homeless.

Housing First as a program focuses on specific program models targeted at particular homeless populations (e.g., adults with mental illness and co-occurring addictions, families with children, youth) to reduce or eliminate homelessness and promote the wellbeing of these populations. The distinctions between systems and program interventions, and their alignment with the principles of Housing First, are depicted in this table.

10. How is Housing First different from supportive housing approaches?

Housing First houses participants immediately, without any preconditions. Housing and clinical services are separated. Participants are offered an array of health, mental health, and other support services after they are housed.

Most supportive housing approaches or “continuum of care” models provide housing only in places with built-in clinical support services. This means that the landlord and service-provider functions are integrated in the same agency. Additionally, supportive housing approaches often mandate clients to achieve and maintain sobriety, in addition to receiving ongoing psychiatric services.

In contrast, Housing First houses participants immediately, without any preconditions. Housing and clinical services are separated. Participants are offered an array of health, mental health, and other support services after they are housed. Participants choose housing, as well as which support services will best meet their needs and meet with a case manager or support staff person on a weekly or bi-weekly basis. In contrast to some other approaches, Housing First uses a harm reduction approach. The aim of harm reduction is to reduce both the risks and effects associated with substance use disorders and addiction, without requiring abstinence as a condition for maintaining housing.
 
The continuum, or supportive housing approach, is an important part of mental health and housing services for adults who are homeless. Housing First is an evidence-based approach that targets individuals who have not been well served by traditional approaches.

11. Why does Housing First emphasize consumer choice?

Housing First addresses the critique of advocates and researchers that traditional approaches to housing and service provision for adults with mental health and addictions issues tend to ignore the importance of choice. Additionally, consumers themselves have long advocated a desire to live in apartments in the community. If individuals with mental health issues who are homeless are to be positioned as full citizens, it is important to recognize that they are experts of their own lives who have been repeatedly failed by systems that have not worked and have often been characterized by a lack of choice. With Housing First, participant choice allows for these individuals to pursue choices that they see as meaningful and valuable. Promoting choice is an effective way to engage consumers in the recovery process.21, 22 Consumer choice over housing and services also promotes feelings of self-efficacy and self-determination in other aspects of life.
This graphic depicts various housing options.

12. How does Housing First promote recovery?

Housing First promotes recovery largely in terms of its person-centred approach to care and wellbeing. This person-centred approach reflects the idea that housing is a basic human right and that social justice is a guiding philosophy of Housing First. Consumer choice and self-direction are key components of both housing and clinical services. Clinical services are provided by either an ACT team or an ICM team. There is a strong emphasis on staffing in Housing First, where it is integral to get “the right people” who promote empowerment and view program participants through a strengths-based lens. Empowerment is an important principle of support because Housing First seeks to bolster the ability of participants to respond to life challenges. Consistent with an empowerment approach, support services are centered on a strengths-based orientation as opposed to a deficit model.23

These NFB films show empowerment is an important principle of support.

13. Where has Housing First been implemented?

Housing First has been widely implemented in North America and is starting to be implemented in Europe. In North America, it has been implemented in both Canada (British Columbia, Alberta, Manitoba, Ontario, Quebec, New Brunswick) and the United States (New York, South Carolina, Oregon, Massachusetts, Minnesota, California). In Alberta, where there is a 10-year plan to end homelessness, Housing First has been implemented province-wide. In Europe, Housing First has been implemented in Ireland, Portugal, Finland, the Netherlands, Hungary, Denmark, Scotland, and France.24, 25 While Housing First started as a strategy to address homelessness for people with mental health issues, in a number of places it is being used with the broad homeless population.

MYTH
Housing First is from the United States and only relevant within the United States.

MYTH BUSTED
Housing First has been widely implemented in Canada and throughout the world.

 

Provinces, states and countries with documentation
of Housing First implementation

14. What is the evidence base for Housing First in Canada?

At Home/Chez Soi, a randomized controlled trial (RCT) of Housing First in Canada, upon which this toolkit is based, provides evidence of the effectiveness of the Housing First model. Additionally, a total of nine RCTs of Housing First have been conducted in the United States. Results of these RCTs have consistently shown that Housing First reduces homelessness and hospitalization and increases housing stability and housing choice significantly more than treatment as usual (TAU) and supportive housing or case management services alone. Some of these studies have found that Housing First has facilitated improvements in health, substance use, and community integration as well.26 Housing First has been endorsed by the Employment and Social Development Canada’s (HRSDC) Homelessness Partnering Strategy. It has also been included in the U.S. Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-Based Programs and Practices (NREPP, 2007).27
 
In Canada specifically, there have been some positive findings about the implementation of Housing First:28

In Vancouver, At Home/Chez Soi was cited as one of the reasons for a reduction in homelessness, as calculated by a count.

Recent research in Vancouver estimates a cost savings of 30 per cent by giving people who are homeless stable housing.

Housing First in Calgary has been so successful there have been shelter bed closures.

A Canadian study found traditional institutional responses to homelessness (the prison system and psychiatric hospitals) substantively more expensive (estimated annual costs: $66 000 – $120 000) than investments in supportive housing (estimated annual costs: $13 000 – $18 000)

At Home/Chez Soi has substantively added to the evidence base for Housing First in Canada. This study found the following:29

Program Implementation
Housing First rapidly ends homelessness
Housing First is a sound investment
Having a place to live with supports can lead to other positive outcomes…
There are many ways in which Housing First can change lives.
Getting Housing First right is essential to optimizing outcomes.

15. How can the Housing First Model be adapted?

Housing First can be adapted for a number of groups experiencing homelessness. This toolkit provides information on Housing First for individuals who are chronically homeless with mental health and addiction needs, specifically. While Housing First is implemented in urban areas most frequently, it can be adapted and implemented almost anywhere. At Home/Chez Soi has been implemented in five different Canadian cities. Each city has adapted the Housing First intervention to meet the specific needs of its participants.
While Housing First is implemented in urban areas most frequently, it can be adapted and implemented almost anywhere.

See the map below to find out more about how the At Home/Chez Soi
adapted the HF intervention to meet the needs of its participants.

16. How does Housing First improve the quality of life of participants?

Housing First has been shown to promote a sense of autonomy, improve health and mental health, and to allow participants to begin orienting toward future goals and social relationships.30 Housing First may also enable participants to reclaim a valued identity.31

View these clips from the National Film Board and Pathways to Housing to see
how participants experience the Housing First intervention.