Wednesday, May 5, 2010

Formerly homeless trapped in a state of dependence by U.S. housing policy

Housing First is a homelessness intervention strategy that provides permanent supportive housing for individuals who are chronically homeless and have been diagnosed with both serious and persistent mental illness and a substance use disorder. This new model seeks to provide stable permanent housing as a first step in addressing other persistent problems—problems often caused or perpetuated by unstable living arrangements such as substance abuse, mental illness, physical illness, and unemployment. The Housing First model was first developed in 1992 by Pathways to Housing in New York. Since that time, the model has spread throughout the United States and has become the cornerstone of a paradigm shift in the homeless service system.

The logic behind this shift in strategy is that individuals who are homeless need to have their basic human needs—shelter, food, security—met before they can successfully begin to address other problems in their lives such as substance use and mental health treatment adherence. As their mental health and substance use improves, the model assumes that program participants (clients) will develop higher levels of independence, relying less and less on the supportive services offered to them. The theory that the model leads to greater independence of program participants has been supported by several studies.

However, research we are conducting in Chicago has demonstrated that there are at least three significant policy barriers, created by government regulations themselves, that can have significant negative effects on the development of greater independence among program participants. The first barrier to fostering independence is a funding mechanism offered by the United States Department of Housing and Urban Development (HUD) known as Shelter Plus Care (S+C), which requires participants to engage in supportive services (for example, case management, psychiatric care, psychotherapy, or employment services) to receive funds for housing. While not all agencies or agency programs receive funding from S+C, those that do are required to match funding for rental assistance with equal funding for supportive services, which incentivizes programs to pressure participants to engage in community services whether or not they want or are in need of them.

A second barrier exists when an agency uses Medicaid funding to support internal services for participants. Agencies are able to use this funding option when they house Medicaid eligible participants and they have staff that provide Medicaid reimbursable services (physicians, licensed social workers, and licensed therapists). These agencies fall into a trap of having to maintain participant dependence on services if the agency is to protect its funding for staffing and services. When using the Medicaid strategy, the agency does not receive money for staffing unless participants are utilizing billable services. Therefore, participant success and increased independence (less need for services) means the loss of funding.

While well-meaning policies, these regulations are creating all-or-nothing funding situations where participants cannot be gradually moved to full housing and service independence. While the spirit is toward creating housing and providing needed counseling services, the regulations have created a dependence perpetuating situation for participants and agencies alike. Both of these funding mechanisms place agencies in situations where they have to decide between building participant independence and maintaining current levels of funding. This is problematic if participant independence means less reliance on supportive services.

The third barrier is the requirement that participants be homeless at the time of intake if they are to be eligible for HUD housing services. This is particularly problematic when agencies have tailored programs that have specialized services to address the needs of participants with specified levels of functioning. For instance, an agency might have a program designed for participants with lower levels of functioning, where they are not allowed unsupervised access to kitchen equipment because of the dangers that access to a stove might impose for themselves and/or others (threat of fire). The same agency (or another agency) may have another program that is targeted for higher functioning participants whose unsupervised access to kitchen equipment is not as risky. However, when a participant is ready to move to the higher functioning program, they would not be eligible for entry because of HUD’s requirement that they be homeless to qualify for funding. This can trap the participant in the first programming, effectively blocking his or her progress toward greater self-sufficiency.

Curiously, one solution to this third barrier is to assure that participants who have improved in functioning are homeless at the time more appropriate placements become available. This might mean moving the participant from their current program to a homeless shelter while waiting for a unit to become available in a program for higher functioning participants.

This rather convoluted bureaucratic “solution,” is not always in the best interest of the individual receiving treatment. A government policy that encourages moving at-risk individuals to homeless shelters can derail an individual’s path to independence. The stigma and stress associated with moving to a shelter can negatively affect individuals who have demonstrated improvements, threatening this progress. Providing stable housing opportunities and elimination of the homeless shelter detour could go a long way to stabilizing the lives of many formerly homeless individuals and creating independent, contributing citizens in many of our nation’s communities.

-Dennis Watson
University-Community Research Coordinator