Supporting People that Have Complex Challenges and Have or are About to Lose their Accommodation: When is it Okay to Say “That’s enough, we’ve done all we can?”

The OrgCode team get asked this question a lot. As communities find themselves housing and supporting more and more people with higher acuity and unique personalities and behaviors, they are facing an increasing number of challenges. Amidst those challenges, there is a desire on the part of some service providers to draw a line in the sand…a threshold that cannot or should not be passed, and if there is, comes with a consequence of retracting housing and/or support. In performing due diligence in these difficult situations, I think the following questions can provide good guidance:

Are your staff to client ratios sufficient?

Some organizations have started serving higher acute people without adjusting their staff to client ratios. They are still using old ratios of when they had a greater mix of people to support or lower acuity people to support. Maybe the reason the person/family is struggling with maintaining their housing is that there are not enough work hours in the week for you to adequately support people with higher needs. Adjust your caseload and the problem may be fixed.

Do you know whether or not the person/family still wants housing?

Choice is paramount to our work. Too often I have seen well-intentioned service providers make assumptions about a person or family wanting housing or continuing to want housing when there are difficulties. As painful as this may seem, it is still the person/family’s choice of whether or not they want to continue with accessing or maintaining housing. Don’t assume – ask. If they do still want housing, fantastic. If they don’t still want housing, don’t pressure them to accept or want something they have rejected.

Do you believe in Housing First?

Here, I am talking about Housing First as an intervention, not as a philosophy. One of the core tenets of the Housing First intervention is that a person does not lose their supports if they lose their housing, so long as they still want to be housed. As such, there are no limits on the number of times a person/family can be re-housed, so long as they still want supports. There is no “enough is enough”.

What types of cases are you prioritizing through Coordinated Entry for Permanent Supportive Housing?

Imagine a situation where the very people you are struggling to keep housed are, in fact, the same types of people you are making a top priority for Permanent Supportive Housing…why would you keep prioritizing a type of household you don’t know how to support?

What is the nature of the difficulty in sustaining the tenancy – and have appropriate measures been tried to address these issues?

Not all disruptions or issues with a tenancy are equal. And each has different strategies and techniques that can be used to address them. For example, non-payment of rent can potentially be addressed by having a payee. Relatively simple. Another example, a person who performs arson in their own unit may be okay if moved to an older unit made of cinder blocks without other flammables. Relatively hard. Then there are those situations in between. Take for example, a person who uses substances in a challenging or chaotic manner. Perhaps putting harm reduction strategies in place can modify when they use, where they use or who they use with, thereby decreasing impacts on the tenancy. Guest management is also a frequent issue named. Personal guest policies can work, but are not foolproof. Perhaps a move to a 24/7 PSH building with onsite staffing, a concierge, and or restrictions on the number of guests allowed at one time or defined hours for guests would make the difference.

Were program expectations clearly communicated in multiple formats?

There have been instances we have evaluated where the central problem is that program participants never had a conversation regarding what it means to be a responsible tenant before they moved in, didn’t understand (or even review) the lease, or if there were other expectations of participating in the support program, this was not done in advance. We recommend that time is spent discussing or role playing elements of being a tenant in advance of being a tenant. We also recommend that we try to communicate these expectations in different formats – at least in writing and verbally. We have even seen some programs use pictures to demonstrate acceptable and unacceptable ways of meeting expectations. Lastly, when it comes to the lease, we strongly recommend people do not just sign on the bottom line without understanding what they are signing. To that end, we have encouraged many programs to take standard lease clauses and have them rewritten in plain language that program participants have a greater likelihood of understanding.

Was the match to the type of unit appropriate?

Let’s say the program participant likes to party until 4am with their friends. While rare, it may be possible to find an accommodation where this is entirely okay as opposed to, say, a traditional multi-unit residential building filled with families and senior citizens. We have seen instances where the matching process was improper in the first go-round, but having the person move to a trailer in the country was fabulous; and other instances where a person was moved to a building where seemingly all of the tenants would also be up to 4am on a regular basis with their friends, and adding one more to the mix didn’t upset the apple cart.

Is transfer to a different type of support program possible?

Not ideal at a large scale, but possible with individual cases, is transferring people from one type of support program to another. This is not about pushing a “problem” ahead, this is about improving the match. Maybe Rapid Re-Housing isn’t enough and the person would benefit from Intensive Case Management or Permanent Supportive Housing. Maybe Permanent Supportive Housing isn’t enough and the person meets the criteria for an Assertive Community Treatment program or a Long-term Care Facility of Hospice Care. The more communities function as systems of care, rather than a collection of projects, the easier it is to make these sorts of housing-support transitions.

Are there variations in success across different service providers?

This is where a common assessment tool and good data can be your friend. Let’s say you have two (or more) service providers who generally serve people of comparable acuity with comparable staffing levels. If Agency A is achieving long-term housing success with most of its program participants and Agency B is not, what can Agency A teach Agency B so they have similar success?

Do you have the right training?

There are many instances we have encountered where the issue is NOT the program participants, it is that the service staff were never trained on how to adequately, and in many instances proactively, address the types of situations and behaviors that place the tenancy at risk. Every organization needs to review the core competencies required for housing support positions and ensure staff have access to the training that allows them to meet those core competencies.

What types of tools and information are you gathering to enhance supports?

Whether using the SPDAT (not just the VI-SPDAT) or other type of objective assessment tool, mine the information for direction on where best to proactively support people. Couple this with information that is gleaned through the intake process and home visits. Proactively put together a support plan or use tools in your toolbox that can decrease the likelihood of permanent disruptions to the tenancy. Consider things like a Risk Assessment, the Honest Monthly Budget, Crisis Planning, and using the SPDAT to support Stages of Change.

Is there a community table to case conference challenging cases – preferably with the program participant present?

Some of us are usually smarter than one of us. Put together a structure in your system of care where a broad range of service providers and allied professionals come together at set intervals to brainstorm ways to better support program participants that are struggling. The answers may be found in the minds of those around the table. And when the program participant is welcome at the table, they have a direct voice in expressing their current and future needs.