Mental Health America (MHA) supports Housing First policies that expedite access to permanent supportive housing for people with mental health and substance use conditions and integrate mental health and substance use treatment with an effective safety net that includes safe and affordable housing, without requiring treatment as a precondition unless the person meets the standards for civil commitment.
Many people with mental health and substance use conditions lose access to housing because of poverty and disruption of personal relationships related to their disability, and between 20 and 33% of homeless people have serious mental illnesses.[i] In addition, according to the Office of National Drug Control Policy, approximately 67% of people experiencing chronic homelessness have a primary substance use disorder or other chronic health condition.[ii] Housing First is a proven approach in which people experiencing homelessness are offered permanent housing with few treatment preconditions, behavioral contingencies, or other barriers.[iii] Although it is sometimes difficult to deal with the behavioral issues presented by people who are under the influence of drugs and experiencing mental health crises, appropriate staffing and safeguards have proven adequate to protect other residents without making sobriety and treatment preconditions to providing shelter. The training and commitment required are the same as those required to eliminate the use of seclusion and restraints in mental health treatment facilities, as advocated in MHA Position Statement 24,[iv] and more relaxed eligibility standards have proven effective in getting and keeping people off of the streets.
Research
Thus, a respected 2004 study found that:
“The Housing First program sustained an approximately 80% housing retention rate, a rate that presents a profound challenge to clinical assumptions held by many Continuum of Care supportive housing providers who regard the chronically homeless as ‘not housing ready.’ More important, the residential stability achieved by the experimental group challenges long-held (but previously untested) clinical assumptions regarding the correlation between mental illness and the ability to maintain an apartment of one’s own. Given that all study participants had been diagnosed with a serious mental illness, the residential stability demonstrated by residents in the Housing First program—which has one of the highest independent housing rates for any formerly homeless population—indicates that a person’s psychiatric diagnosis is not related to his or her ability to obtain or to maintain independent housing. Thus, there is no empirical support for the practice of requiring individuals to participate in psychiatric treatment or attain sobriety before being housed.”[v]
An even more impressive result was achieved in a seminal study published in 2000, in which Tsemberis and Eisenberg reported the effectiveness of a five-year Housing First program on people with severe psychiatric disabilities and addictions in New York City. During that time, the program provided "immediate access to independent scatter-site apartments for individuals with psychiatric disabilities who were homeless and living on the street." With an 88 percent housing retention rate, the program achieved substantially better housing tenure than did the comparison group.[vi]
Supportive housing, specifically including but not limited to Housing First programs, is supported by a significant body of evidence, summarized by Rog, D.J. et al. in a 2014 review: “Permanent Supportive Housing: Assessing the Evidence.”[ix] The review found that: “The level of evidence for permanent supportive housing was graded as moderate. Substantial literature, including seven randomized controlled trials, demonstrated that components of the model reduced homelessness, increased housing tenure, and decreased emergency room visits and hospitalization. Consumers consistently rated this model more positively than other housing models.”
According to the U. S. Interagency Council on Homelessness (ICH), “Housing First yields higher housing retention rates, reduces the use of crisis services and institutions, and improves people's health and social outcomes.”[x]
Components of the Model
The ICH model includes the following elements:
Permanent supportive housing programs differ from other living arrangements by providing a combination of flexible, voluntary supports for maintaining housing and access to individualized evidence-based support services, such as assertive community treatment (ACT). ACT is an interdisciplinary team approach that supports people in recovery in the community with intensive services. ACT teams include social workers, nurses, psychiatrists, and vocational and substance abuse counselors who are available to assist 7 days a week 24 hours a day.[xii] But variants on the ACT model are essential to success in practice. The team must have sensitivity to and knowledge of housing issues and available funding. Just having an ACT team is not enough. It takes a lot of “behind the scenes” work to keep people housed.
The Call to Action lists the required case management services, but it is worth stressing assistance with personal care, housekeeping and cleaning, and pest control, which are essential to avoid eviction, and individual counseling and de-escalation when eviction is threatened. These are the interventions stressed by the practitioners interviewed for the preparation of this position statement. The aim is to maintain permanent housing by interventions that go beyond treatment of the underlying general and mental health and substance use issues to deal with behavioral issues that threaten tenancy.
As noted by the Corporation for Supportive Housing:
“Supportive housing is not affordable housing with resident services. It is a specific intervention for people who, but for the availability of services, do not succeed in housing and who, but for housing, do not succeed in services. The housing in supportive housing is affordable, permanent, and independent. The services are intensive, flexible, tenant-driven, voluntary, and housing-based. The services in supportive housing are tenancy supports that help people access and remain in housing. Supportive housing is also a platform from which health care services can be delivered and received.”[xiii]
The 2014 review, which specifically focused on housing for people with mental health conditions, used a slightly more refined definition of permanent supportive housing:
Outcomes
The moderate level of success found by the 2014 review researchers was based on:
The Corporation for Supportive Housing summarizes the three benefits of supportive housing demonstrated by the research:
Shelters are rarely equipped to provide adequate supports to qualify as supportive housing and are transitional responses to get people off the streets. Group living facilities and psychiatric hospitals are needed by some people experiencing mental health crises, but are also transitional, since most people cannot tolerate indefinitely the degree of supervision inherent in such residences. Thus, shelters, group homes, and clinical facilities, while necessary, should be deemphasized as much as possible in favor of development of scattered-site supportive housing that is fully integrated into the community and permanently available to its residents, so that the people living there can identify it as their home.
It is not uncommon that people start out only wanting housing and not services. Housing First accepts such people, rejected in the past, and provides the services they need to help them keep their housing, while offering to increase services as the need becomes apparent. Case managers meet people where and as they are and start building trust, which, in practice, works much better than insisting on providing services as a condition of providing housing.
The greatest ongoing difficulty encountered in Housing First programs is in maintaining enough vacant units to minimize waiting periods while guaranteeing ongoing availability of permanent housing to people already being served. This requires ongoing development of new housing, which in turn requires surmounting funding and zoning barriers. Denver, CO[xv] and Salt Lake City, UT[xvi] are examples of communities that have had greater success than others in increasing housing options for people with mental health and substance use disorders.
Funding
Supportive housing requires a substantial investment by state and local governments, which bear the burden of funding housing, with some support from the federal government, particularly through the “Section 8” program that provides rental assistance. Most rental assistance is federally funded, yet only one in four eligible low-income households receives assistance.[xvii] In addition, programs like the Low-Income Housing Tax Credit (LIHTC) should be expanded, which provide incentives for real estate developers to invest in housing that is accessible to low-income individuals.[xviii] Communities should review zoning, transportation, and related policies to ensure that low-income housing developed in inclusive and promotes economic mobility for individuals with mental health conditions.
Significantly, the federal Medicaid program, which matches state funds for mental health and substance use treatment, pays for licensed facilities but is prohibited by statute from funding other forms of housing. However, in recent years, the Center for Medicare and Medicaid Services (CMS) and SAMHSA have stressed the availability of Medicaid funding for the ancillary services required for supportive housing. For example, a 2015 CMS informational bulletin detailed how Medicaid funds could be used for “(1) Individual Housing Transition Services – services that support an individual’s ability to prepare for and transition to housing; (2) Individual Housing & Tenancy Sustaining Services - services that support the individual in being a successful tenant in his/her housing arrangement and thus able to sustain tenancy; and (3) State level Housing Related Collaborative Activities - services that support collaborative efforts across public agencies and the private sector that assist a state in identifying and securing housing options for individuals with disabilities, older adults needing LTSS, and those experiencing chronic homelessness.”[xix]
A 2014 SAMHSA-funded Corporation for Supportive Housing (CSH) white paper, “Creating a Medicaid Supportive Housing Services Benefit: A Framework for Washington and Other States,”[xx] is the best blueprint of the policy changes needed. See also, CSH’s 2015 “A Quick Guide to Improving Medicaid Coverage for Supportive Housing Services”[xxi] The Center for Budget and Policy Priorities’ 2016 white paper, “Supportive Housing Helps Vulnerable People Live and Thrive in the Community,”[xxii] and CMS’ 2015 Informational Bulletin, “Coverage of Housing-Related Activities and Services for Individuals with Disabilities.”[xxiii]
The 1915i State Plan Amendment for Home and Community-Based Services offers the opportunity to implement supportive housing services state-wide (no geographical limits are permitted), without limits on the population to be served so long as all are served who meet needs-based criteria. People being served need not be at risk of institutionalization. Thus, the 1115i waiver does not require that implementation be “cost neutral” to the federal government.[xxiv] Independent evaluations are required to demonstrate outcomes. The CSH white paper discusses the pros and cons of alternative CMS waiver strategies.
It is also critical that public benefit design and administration, such as Social Security Insurance, reinforce Housing First approaches. Benefits must be sufficient and accessible enough to support an individual in supported but independent and permanent housing. They must take into account additional costs related to any rent and upkeep of housing in that geographic market, and must be coordinated with Housing First programs to ensure that the full benefits are received when first needed. During transitions in housing or after a period of institutionalization, such as hospitalization or incarceration, public benefits should immediately consider the full costs of housing and avoid any “look back” that disadvantages Housing First. Benefits administration should be coordinated with institutions to ensure that benefits immediately consider changes in living situation when an individual returns to the community.
It is imperative that mental health and substance use treatment providers expand their reach to include permanent supportive housing, whether as part of clinical community support outreach and ACT programs, or in partnership with housing providers. To accomplish this, federal, state and local funding policy must be changed:
Benefits should not include look back periods that disadvantage transitions to housing from homelessness or institutionalization, and should be coordinated to reinforce Housing First.
The Mental Health America (MHA) Board of Directors approved this policy on September 8, 2018. It is reviewed as required by the Mental Health America (MHA) Public Policy Committee.
Expiration: December 31, 2023
