Health Needs and Permanent Supportive Housing

Do all chronically homeless people have health issues requiring permanent supportive housing? No. But the design and delivery of PSH needs to heed the health needs of chronically homeless people, while avoiding the pitfalls of a solely medical model in service delivery.

Homeless individuals have poorer health than the general population[1]. However, these individuals with poor physical and mental health and substance use issues can achieve stable housing[2]. Research from Toronto indicates that 72% of people in a Housing First program report improved physical health once moved into housing; however, while people with longer-term homelessness were likely to report improvements in mental health after moving into scattered-site housing with supports, they were less likely to report improvements in physical health[3].

There are statistically significant differences in self-reported physical health and self-reported mental health amongst homeless people, with homeless people fairing worse than the general population[4]. Length of homelessness has a direct link to the severity of the health issues, with people experiencing homelessness 5 or more years much more likely to have chronic health issues, and multiple chronic health issues much more prevalent amongst those homeless for a long time[5]. This would seem to suggest that PSH should first focus on those that have been homeless for longer periods of time with co-occurring health issues rather than focusing solely on health issues in the assessment.

The various types of specific health issues confronted by homeless people are numerous. For example, cardiovascular disease is more frequent than the general population[6], and can be compounded by the high propensity of cigarette smokers (almost 9 out of 10 according to self-reports) within the homeless population. Serious health conditions found to be statistically significant in difference from the general population include: Heart Disease (5 times greater than the general population), Diabetes (2 times greater than the general population), Arthritis or Rheumatism (3 times greater than the general population), Epilepsy (20 times more likely than the general population), Liver Disease, Hepatitis C (30 times greater than the general population), Hepatitis B, Cancer (4 times greater than the general population), Stomach or Intestinal Ulcers, Allergies (other than food allergies), and Migraines[7].

Tolomiczenko and Goering almost 25 years ago demonstrated that mental illness does not usually cause homelessness[8]. While not a precipitating factor, it can be exacerbated by the experience of homelessness. Stereotypes of the homeless population infiltrated with high rates of psychosis like schizophrenia are unfounded. While there will always be a smaller percentage of homeless people that experience schizophrenia – 6% lifetime prevalence amongst the homeless population in Canada and 10-13% found amongst rigorous US studies[9], the truth is that depression and anxiety disorders with alarming rates of suicidal ideation and suicide attempts are more common[10].

The costs and service use impacts of mental illness on emergency rooms amongst homeless persons, however, warrants attention. According to CIHI more than 50% of emergency room visits and hospitalizations amongst homeless people in any given year are a result of mental illness[11]. Given reported improvements in mental health and wellness after a housing intervention in Housing First[12], emphasis on housing is warranted to decrease these expensive health utilization costs to address compromised mental wellness experienced while homeless.

There is a high rate of brain injury amongst homeless people[13], but interestingly this often happens younger in life and predates their homelessness – as high as 58% amongst homeless men and 42% amongst homeless women[14]. Recent research on youth homelessness has also demonstrated that more than 50% of youth that experience homelessness have experienced a brain injury[15]. Given cognitive limitations and issues with impulse control that happen amongst people with brain injuries, different housing models can be necessary within PSH to provide a supportive environment that is attuned to the behaviours that these conditions may present.

Frequency of alcohol use and abstinence rates are not particularly dissimilar between the homeless and non-homeless populations[16]. However, instances of heavy drinking (5 or more drinks on one occasion) and rates of substance addiction are higher amongst the homeless population, as is the consumption of non-beverage alcohol where almost 10% of the homeless population uses daily[17]. Problems with alcohol use disorders are between 6-7 times more prevalent amongst the homeless population, and especially prevalent amongst homeless men where upwards of 60% will have an alcohol use disorder[18]. Use of tobacco is prevalent in almost 90% of the homeless population compared to 18% of the general population[19], which also needs to be taken into account when designing housing and service options – a rate that is most likely going to remain high even with the availability of cessation programs. While it is difficult to accurately and comprehensively quantify the depth and breadth of the use of other drugs amongst the homeless population (illicit drugs), US research from a couple of decades ago found the median prevalence of drug use disorders to be 30%[20]. The “drug of choice” within the homeless population is usually influenced by geography and ebbs and flows in popularity relative to availability and price. It would seem, however, that for several decades alcohol (including non-palatable alcohol), crack cocaine, marijuana, oxy and methamphetamine have been popular. Given the propensity for mental illness and substance use disorders to happen concurrently, it is important for PSH to take this into consideration. Moreover, given the rate of substance use there is a compelling case for PSH to embrace a harm reduction framework relative to substance use – neither condoning nor supporting, but accepting the rate of use as fact and commonplace.

Overall, mortality rates are much higher amongst homeless people than the general population. For example, a study from the late 1990s showed homeless youth in Montreal have a mortality rate 9 times higher for males and 31 times higher for women than other youth in Quebec[21]. A frequently cited study by Dr. Stephen Hwang[22], demonstrates that amongst the shelter using population in Toronto that mortality rates are 8.3 times higher than the mean for 18-24 year olds; 3.7 times higher than the mean for 25-44 year olds; and, 2.3 times higher than the mean for 45-64 year olds.  Higher mortality rates and advanced ageing can be improved upon through PSH that offers safety and security to its residents with access to care that people may have been unable to access while homeless…or at least not sustainably or proactively or intensely access while homeless.

It is important to consider that street homeless individuals (sometimes referred to as “rough sleepers”) have poorer health than their shelter-using peers[23]. It is amongst the street homeless population that there is a greater incidence of chronic homelessness. Offers of PSH must keep this in mind in some respects when considering prospective tenants. If PSH looks solely to shelter environments it will likely miss some clients that would most benefit from what is being offered. Links between PSH and street outreach can be very important and effective in service delivery.

But health isn’t the only consideration. We don’t want PSH to become parallel health care providers to the mainstream health services. Health services, however, should be integrated as part of the service delivery, not the sole focus of service delivery. A more holistic view that also encompasses the need for the likes of meaningful daily activities, social networks, self care, avoidance of high risk and exploitive situations, etc are also beneficial in a PSH environment for it to be as health as possible.

[1] See for example: Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health; Hwang, SW. “The health and housing in transition study.” International Journal of Public Health. 011 Dec;56(6):609-23. Epub 2011 Aug 20; Wilkens, R et al. “Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study.” British Medical Journal. 2009 Oct 26;339; Tolomiczenko G. et al “Multidimensional social support and the health of homeless individuals.” Journal of Urban Health. 2009 Sep;86(5):791-803; Dunn JR et al. “Housing as a socio-economic determinant of health: findings of a national needs, gaps and opportunities assessment.” Canadian Journal of Public Health. 2006 Sep-Oct; Hwang SW et al. “Interventions to improve the health of the homeless: a systematic review.” American Journal of Preventive Medicine. 2005 Nov;29(4):311-9.

[2] Hwang, SW et al. “Health status, quality of life, residential stability, substance use, and health care utilization among adults applying to a supportive housing program”. Journal of Urban Health. 2011 Dec; 88(6):1076-90; Raine L and T Marcellin. “What Housing First Means” City of Toronto, 2007.

[3] Raine L and T Marcellin. “What Housing First Means” City of Toronto, 2007.

[4] Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health.

[5] Ibid.

[6] Marmot M. and Wilkinson R. Eds. 2003. Social Determinants of health: the solid facts. 2nd edition. Copenhagen: World Health Organization (WHO); Frankish CJ, et al 2005. Homelessness and health in Canada: research lessons and priorities. Canadian Journal of Public Health. 96(Supplement 2):S23-S29.

[7] Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health.

[8] Tolomiczenko G, Goering P. 1998. Pathways into homelessness: Broadening the perspective. Psychiatry Rounds. 2(8). Toronto: Centre for Addiction and Mental Health.

[9] Mental Health Policy Research Group. Mental illness and pathways into homelessness: proceedings and recommendations. Toronto: Canadian Mental Health Association; 1998; Fischer PJ WR Breakey. The epidemiology of alcohol, drug, and mental disorders among homeless persons. American Psychology 1991;46:1115-28.

[10] Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health.

[11] Canadian Institute for Health and Information. (August, 2007). Improving the Health of Canadians: Mental Health and Homelessness.

[12] Raine, L and T Marcellin. What Housing First Means. City of Toronto, 2007.

[13] Highley, JL. Traumatic Brain Injury Amongst Homeless Persons. National Health Care for the Homeless Council. 2008.

[14] Hwang SW et al. “The effect of traumatic brain injury on the health of homeless people.” Canadian Medical Association Journal, 2008; 179: 779-784.

[15] Forchuk, C et al. Service Preferences of Homeless Youth with Mental Illness. University of Western Ontario, 2012.

[16] Health Canada. Canada Alcohol and Drug Use Monitoring Survey. Ottawa, 2011. Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health.

[17] Raine, L and T Marcellin. What Housing First Means. City of Toronto, 2007; Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health.

[18] Fischer PJ WR Breakey. The epidemiology of alcohol, drug, and mental disorders among homeless persons. American Psychology 1991;46:1115-28.

[19] Khandor E and K Mason. Street Health Report 2007. Toronto: Street Health.

[20] Lehman AF and DS Cordray. Prevalence of alcohol, drug, and mental disorders among the homeless. Contemporary Drug Problems 1993;20:355-83.

[21] Roy E, et al. Mortality among street youth. Lancet 1998;352:32.

[22] Hwang SW. Mortality among men using homeless shelters in Toronto, Ontario. Journal of the American Medical Association 2000:283:2152-7

[23] Gelberg L and LS Linn. Assessing the physical health of homeless adults. Journal of the American Medical Association 1989;262:1973-9.

The Difference Between That Which We Think and That Which We Know Is One of the Most Important Distinctions To Be Made

Kathryn Schulz is a “wrongologist”, with a stellar ability to explain why we shouldn’t regret regret and provides some very credible and compelling thoughts on being wrong. I am a fan. Her bookBeing Wrong: Adventures in the Margin of Error is a terrific read and if you have never seen her TED talks, I recommend both. One of her quotes which I have used over and over again because of the brilliance of it is, “The miracle of your mind isn’t that you can see the world as it is. It’s that you can see the world as it isn’t.”

People make mistakes. They should. Theories need to be tested and will frequently be wrong or prove something unintended. Being wrong doesn’t make someone a bad person. Being wrong, however, can hinder our ability to be better at our jobs and in our lives when we fail to make distinctions between what we think – sometimes are beliefs not backed up by facts – and what weknow – things that can be proven.

Over the past couple of decades being engaged with various social justice initiatives I have seen evidence over and over again that what we think is often different than what we know. The difference manifests itself in a couple of problematic ways. For one, there is a tendency to ignore knowledge when it flies in the face of what we think – on a personal, community or organizational level. For example, there is still a large group of people that think addiction is a personal flaw when we know it is a disease. People don’t make a conscious choice to have an addiction. And like any disease, people will respond different to treatment options (think of how different people respond to cancer treatments), have different perspectives on wellness and may or may not be ready for the life changes required to tackle the disease (think of someone with unmanaged diabetes).

On the flipside, once we know something there is a tendency to stop thinking about it and ignore opportunities for improvement. Take an example from your own life…you know Friday is garbage day so you stop thinking “What day is garbage day?” It is routine knowledge. The bigger flaw is when you stop thinking about things like “What can I do to make garbage day less arduous on Thursday nights or rushed on Friday mornings.” Or maybe your thinking leads you to questions like, “How can I reduce the amount of garbage my family creates?” In my professional life, I know for certain because of compelling evidence that people do better in housing than while homeless, but I need to keep thinking about how to make the experience of housing better for previously homeless people.

A lot of time people who are passionately trying to make their world a better place one person or family at a time are so busy doing that they fail to take time for thinking or knowing. They are so ingrained in routine without critical thought or discourse that they miss opportunities for professional development, personal growth and the ability to work and function in a true learning culture.

One of the tasks I love performing in my job is helping to develop emerging leaders and improving management practices within organizations. High performing organizations have been proven time and again to get better outputs, improved long-term outcomes, enhanced employees satisfaction, enhanced satisfaction reported from service users and less turnover within the organization. As part of that training, I use the table below with the leaders and managers within the organization.

Behavior% of Actual Time Spent on Activity% of Time Ideally Spent on ActivityInforming Clarifying Directing Persuading Collaborating Brainstorming/Envisioning Quiet Time for Thinking Observing Disciplining Resolving Internal Conflicts Praising/ Encouraging Learning/Improving Knowledge Base

Time and again I find it interesting that many are spending 0% Thinking or Improving their Knowledge Base currently and put little importance on it in the ideal situation as well. It is my contention that “leaderfull” cultures embrace the importance of spending time both thinking and knowing. Senior managers, Board of Directors, Funders and Government Officials involved in program delivery need to value both thinking and knowing within organization and encourage people to take the time to do both. It doesn’t take away from doing. It makes the doing better.

Perhaps your experience is like mine – there are some very divergent (and dare I say misguided) thoughts about how best to address complex social issues. It is good to have hypotheses, but these have to be tested and positioned within a knowledge base to have merit in implementation and long-term impact. Remember that once upon a time people thought that things like blood letting were standard for a range of medical conditions, that mental illness was once thought to be demonic possession in some people, that the earth was flat, that the universe revolved around the earth, that drinking milk or wine would help people overcome the plague, and so on. These were all strong thoughts that translated into beliefs that existed for quite some time before weknew better.

And there are some thoughts that will remain in a state of flux because there isn’t an overwhelming knowledge base that is irrefutable and people’s beliefs can take the place of knowledge. The economy is one field in particular where this is abundantly the case…one need not look further that the various views on matters like taxation or social spending.

Knowledge requires acquaintance with facts, truths, or principles, as from study or investigation. At the core of knowledge is whether or not the information is indisputable. While one would hope that knowledge helps inform the train of thought that people have on a particular subject matter, it can be difficult for knowledge to trump personal beliefs. If ignorance is bliss, some people are downright orgasmic in avoiding facts.

In my keynote speaking, public addresses, media interviews and training there are certain pieces of knowledge that I draw upon frequently because I know it can collide with what many people in the room may think:

• Most chronically homeless people want housing. How do I know this? I have been part of three research studies that have asked chronically homeless people this question. Overwhelmingly, they report that they want housing. This flies in the face of a thought that people overwhelmingly choose to be homeless as a “lifestyle”. The small percentage of homeless people in these three studies that reported that they did not want housing? Well, for many of them it was because a service provider told them they were not “housing ready”. I think it is unlikely the same service provider asked them if they were “homeless ready”.

• Sobriety is not a precondition for housing success. How do I know this? Because the majority of the people in the Western World consume alcohol or other drugs and never experience homelessness. Sobriety isn’t a condition for housing success for people with substance abuse disorders either. How do I know this? Because most people with addictions to alcohol or other drugs will never experience homelessness either.

• People who are meant to feel poor will spend more on lottery tickets, which in turn can actually increase their economic poverty. How do I know this? I can point to work done by the Chicago Reporter that points to lottery spending by zip code which found overwhelmingly that people in economically poorer zip codes spent more on the lottery without returns that got them out of poverty. I can also point to the study published by the Journal of Risk and Uncertainty that proved that people feeling economically poor were more likely to spend more on lottery tickets.

• People who feel poor do not make more impulse purchases of big ticket items than the rest of society. How do I know this? Research shows the impulse control to buy things like a new flat screen TV or laptop or whatever is the same as the rest of society – it just has a much larger impact on their overall financial health and can place their housing at risk. But they are not worse at making choices than the rest of us. Higher income earners, however, can buffer the impact of the impulse better without putting as much risk on housing or other life necessities.

• Economically poor people are amazing at budgeting money and getting by each month. How do I know this? While economic poverty can place people’s housing stability at risk, the truth is that most people with very low incomes never experience homelessness. Consider the millions of people that live below the Poverty Line or Low Income Cut Off in North America that scrape by month after month.

Those are just a few morsels. I’m not going to give away all my juicy tidbits in this blog. But one can hopefully see how knowledge can challenge some thoughts that may or may not be true.

He may have taken a ribbing for it in the media and late night talk shows – and the context and pretense for which the statement was made may be challenged by some –  but Former Defense Secretary Rumsfeld was making an important and true statement when he said,

“There are known knowns; there are things we know we know.

We also know there are known unknowns; that is to say we know there are some things we do not know.

But there are also unknown unknowns – there are things we do not know we don’t know.”

The “known knowns” are things we need to celebrate in our practice of Human Service delivery. And while we can prove that certain approaches work better than others – that may be based on anecdotes or a sample size of one rather than rigorous study – we should still be thinking about how to make the things we know better.

When we know there are some things that we do not know, we should spend more time thinking and analyzing the situation. We may look to other fields of knowledge. We may set up tests to engage in discovery. We should remain thirsty for knowledge about the things we do not know enough (or anything) about when it comes to improving practice.

And there will always be things that we don’t know we don’t know. Until we have the opportunity for discovery, the knowledge won’t be presented to us in a way that we can understand or use in practice. If we are truly operating in a learning environment, however, we will be better able to detect when a lesson is present for the learning.

I hope you will keep thinking about how to make your work better, using knowledge as best as possible, but not confusing what you think may be true with what is actually true when there is evidence to the contrary. I hope you will be open to learning new knowledge and applying it in your work, even if it flies in the face of what you have thought or practiced for years. And I hope you will remain committed to contributing to the field so that we have an ever expanding body of knowledge to be nourished by to make the experience of service recipients better. We can’t be afraid to be wrong – we must embrace it; but we can’t be fooled into seeing or believing something that isn’t actually supported by knowledge.

Back to Basics – What Exactly is Housing First & Rapid Re-Housing?

A lot of the time I find “Housing First” and “Rapid Re-Housing” to be misused terms. Below I briefly outline the definitions and service components to each. When asked to assist organizations or communities realign their service delivery to be more effective or to evaluate their housing programs, this is the understanding of Housing First and Rapid Re-Housing that I try to generate awareness of in the community. As this is a blog and not a two or three day training seminar, I am focusing on hitting the high points. (Maybe some day I will find a publisher that will take me on to write the more exhaustive description, program examples, etc – but I digress.)

As a philosophy housing first (intentionally a lower case “h” and lower case “f”) focuses on any attempt to help people who have experienced homelessness to access housing before providing assistance and support with any other life issues. In this orientation, the intervention of Housing First and Rapid Re-Housing both fit. Given housing is the only known cure to homelessness, the success comes with helping ideal candidates achieve the cure sooner rather than later.

As an intervention Housing First is a specific type of service delivery. Delivered through Intensive Case Management or Assertive Community Treatment, fidelity to the core aspects of the service can be measured. Housing First is specifically not a “first come, first served” intervention. It intentionally seeks out chronically homeless individuals that have complex, and most often co-occurring issues, and serves those with the highest acuity first. The individual (family) served through Housing First is homeless and has most often been homeless for quite some time, usually as a result of these issues and the failure of the human and health service delivery spectrum to address these issues in order to solve the person’s homelessness.

Participation in Housing First is voluntary – people cannot be forced or coerced to participate in a Housing First intervention. Individuals who consent to receive a Housing First intervention are provided assistance with accessing housing of their choosing (subject to affordability, action-ability and appropriateness) and supports for at least 12-18 months in an ICM approach (subject to the ability to integrate clients with longer-term community supports) and longer in an ACT approach.

There is no expectation of sobriety, treatment, compliance or mandated service pathways. Service participants do not need to participate in psychiatric services if they do not want to; they do not need to participate in things like anger management classes if they don’t want to; they do not need to attend life skills classes if they do not want to; they do not need to attend parenting classes if they do not want to; they do not need to address their physical health issues if they do not want to – and I could go on. The only real expectations of Housing First, which the individual agrees to prior to starting with the program, is to agree to have their support workers visit them in their home – usually multiple times per week in the early days of program participation, to pay their rent on time and in full (or agree to third party payment of their rent), and to work hard to avoid disrupting the reasonable enjoyment of other tenants in the same building that would cause their eviction.

There are many “tricks of the trade” that help folks in achieving residential stability in Housing First. For one, caseloads are kept at a reasonable size, with an emphasis on Housing First as a quality intervention, not a quantity intervention. In ICM service delivery – which is my primary area of specialization – one case manager works with 15-20 clients depending on where the clients are at in their journey to stability and level of complexity. Another “trick of the trade” is working with the client to develop a personal guest policy, where the client themselves determine when they think it is a good idea to have guests over, how many guests they think it is reasonable to have over at any one time, the types of activities they think are appropriate to engage in within their apartment, and what they think is appropriate should they find their actions in conflict with their guest policy. Yet another “trick of the trade” is to infuse the “responsible tenant” discussion into conversation with the client at least three times in the early stages of the program whereby the client themselves articulates what they think it means to be a responsible tenant.

Services in Housing First are offered through a harm reduction philosophy, in a non-judgmental manner and from a client-centered position. Supports are provided in vivo, and there is an expectation that individuals served through the intervention will access a broader range of community resources, have meaningful daily activities, and work towards greater independence and improved life satisfaction. The support worker in Housing First can expect to model and teach skills and behavior in the client’s apartment and in the community. It is not uncommon for the support worker to have one-on-one time with the client to teach things like cooking, cleaning, laundry, grocery shopping, and the like. It is not uncommon for the support worker to accompany the client to appointments in the community like working with welfare, shopping, doctor appointments, etc.

There is intentional case planning that occurs in Housing First. The first focus of the case planning is on housing stability…primarily paying attention to meeting basic needs, understanding how relationships can impact tenancy, ensuring that the individual feels safe in their apartment, and understanding the supports available to help them maintain housing. Momentum gained in these areas translates into the development of an Individualized Service Plan where specific goals are identified and an action plan is put in place for each of them. Through this service plan, the emphasis is on greater life stability overall.

Housing First is not a “first come, first served” approach to service delivery. Regardless of whether the Housing First supports are provided through Intensive Case Management or Assertive Community Treatment, access should be coordinated on a system-wide basis. With Housing First, supports are de-linked from staying housed, and as such if an individual loses their housing they do not lose their supports and will be re-housed as many times as necessary until the person achieves housing stability. There are no limits on the number of times that a person can be re-housed. Re-housing is not seen as a failure. It is seen as an opportunity to learn, adapt, grow and try again.

Service participants supported through Housing First often have a history of considerable interaction with health, mental health, addiction, police, criminal justice, ambulances – and other types of emergency services and institutions. Through the housing and support work, most often one will see a decrease in this degree of interaction with emergency services, and a more deliberate and strategic engagement with more appropriate services. It is still possible that Housing First program participants end up in hospital or accessing treatment services, but the supports remain active during these periods of time, with assistance provided in discharge planning as much as possible, and active support in the implementation of treatment protocols as much as possible.

Housing First relies on a number of proven practices and evidence-informed service delivery. Examples of the types of professional skills a Housing First practitioner is likely going to have mastery of include: Motivational Interviewing; Assertive Engagement; Wellness Recovery Action Plans; Illness Management Recovery; Integrated Dual Disorder Treatment; Trauma Informed Service Delivery; Harm Reduction Practices; Crisis Planning; Supported Employment; etc.

While Housing First is most frequently delivered through scattered site housing units integrated within “regular” apartment buildings throughout a city, it is possible to have congregate Permanent Supportive Housing that practices Housing First. But, there really is no such thing as “Housing First Housing”. When I hear that, and break it down with people, most often what they really are trying to say is a low-barrier congregate PSH environment that practices all the aspects of a Housing First intervention.

The place a participant lives in Housing First must be permanent housing, where “permanent” means that if they follow the lease, pay rent and don’t disrupt the reasonable enjoyment of others they have the same security of tenure as any other renter. The lease is “standard” – meaning it contains no language or stipulations different than any other renter. This does not preclude the use of Master Leasing or Head Leasing where an organization leases the apartment unit and legally sub-leases to a program participant, with an understanding that there can be no impediments to the program participant taking on the lease in full in the future.

When asked to set up an evaluation framework for Housing First, it is my contention that 80% or more of the individuals served should remain housed long term. I also tend to look at reductions in use of emergency services and engagement with the criminal justice system. Then, I focus my attention on how the acuity of the individual decreases overtime, as well as changes in quality of life as a result of the intervention.

Rapid Re-Housing is a support intervention intended to serve longer-term episodically homeless people with mid-range acuity; these clients typically have co-occurring issues that are at the core of their frequent returns to homelessness and/or long-standing patterns of precarious housing. The individual or family is homeless and usually has two or three life areas where assistance in accessing community-based resources should improve their life and housing stability on a go-forward basis. Usually recipients of Rapid Re-Housing are aware of a range of community supports; they simply have not been meaningfully and sustainably connected with those resources.

One of the first mistakes in how people talk about Rapid Re-Housing is that they refer to it as “Housing First Light”. It is not. It is a different type of intervention that happens to have a lot of similarities to Housing First. Secondly, some organizations and communities erroneously lump any program that assists with rapid access to housing as being Rapid Re-Housing. This, as well, is false. There can be some awesome approaches to helping people access housing quickly, which are not Rapid Re-Housing.

With mid-range acuity at time of program entry, Rapid Re-Housing recipients usually receive supports for a minimum of six months, with possibility of renewal of service in three month increments based upon traction in sustainably meeting needs that will enhance housing and life stability (and should there be persistent barriers to improved stability, the client may be more accurately considered a Housing First client).

The supports delivered in Rapid Re-Housing are typically case management supports, but are neither Intensive Case Management nor Assertive Community Treatment – though there are typically time periods of support that are more intensive than others. Supports are delivered in community. There is an expectation that the individual (family) will be supported in accessing community resources, have meaningful daily activities, and work towards greater independence and improved life satisfaction. There will be teaching and modeling in Rapid Re-Housing, like Housing First, but the intensity of this and the duration of it is quite often (though not always) less than what one would experience in Housing First.

Importantly, Rapid Re-Housing is more than a financial assistance program; it comes with the expectation that the client will engage with support services. However, the support services have no expectation of engagement in treatment, compliance or mandated service pathways. Like Housing First, Rapid Re-Housing is offered through a harm reduction philosophy, in a non-judgmental fashion and from a client-centered position.

Rapid Re-Housing is almost exclusively delivered through scattered site apartments. Participants sign a standard tenancy agreement. Nowhere in the lease does it stipulate that an individual has to participate in programming or will be evicted. For all intents and purposes, the housing is permanent. So long as the individual follows the lease and pays their rent they have the same security of tenure as any other renter.

Rapid Re-Housing also features structured case planning with goal identification and an action plan put into place to assist with reaching these goals. Compared to Housing First, Rapid Re-Housing clients are usually more able to engage in the process of goal identification and attainment quicker given their acuity is not as high and their time spent homeless has not been chronic.

It is best if people gain access to Rapid Re-Housing through a coordinated access function within a community. This will ensure the best fit of mid-range acuity clients to the appropriate intervention. It should weed out those clients that would be better served through a more intensive and longer-term intervention like Housing First. It should also week out those individuals and families that ultimately can resolve their own homelessness without case management supports of any kind (which make up the majority of people in any community).

When I set up evaluation frameworks for Rapid Re-Housing, I tend to look for a housing stability rate in the 90% range. Like Housing First, I also want to focus some attention on decreasing acuity over time and improved quality of life as a result of the intervention.

There are certain things that Housing First and Rapid Re-Housing both are not. First of all, Housing First is NOT “housing only”. I would posit that in most instances getting people housed is relatively easy compared to the hard work of supporting them to stay housed. Neither Housing First nor Rapid Re-Housing are a fad. They each are proven to be successful when practiced in a certain manner with a specific client group. There is no such thing as a “sober” or “dry” Housing First or Rapid Re-Housing program. Participants may choose to abstain, but abstinence cannot be a pre-requisite for program participation. There is no such thing as a transitional housing program that is Housing First or Rapid Re-Housing because one of the core elements of both interventions is that the housing that people secure is permanent. Neither Housing First nor Rapid Re-Housing are the only forms of effective housing interventions. There are plenty of good approaches to helping homeless individuals and families access housing that I have seen in my travels that seem to demonstrate positive outputs. Organizations and communities should feel compelled to call these programs something that they are not. Neither Housing First nor Rapid Re-Housing “fix” or “heal” people. The job in Housing First and Rapid Re-Housing is to support the individual access and maintain housing regardless of their history or life issues. Both acknowledge that people may still have active addictions, compromised mental wellness, difficulties budgeting, issues with impulse control, problematic social behaviours, physical ailments, etc. – yet people with these or any other life issues can have the issues and have a life without any future homelessness.

About a third of Iain’s time is spent initiating, redesigning, evaluating or training people on Housing First and Rapid Re-Housing and how to align an effective homeless and housing service delivery system to leverage the strengths of the intervention. If you want more info on what this entails, drop him a note at idejong@orgcode.com

There’s A Difference Between Wanting to End Homelessness and Committing to End Homelessness

If you work in the homeless service sector you should have a very simple career goal – to put yourself out of a job.

I have this belief that homeless and housing support services exist to end homelessness. They don’t exist to make people in human services feel good about themselves. They don’t exist to cleanse the consciousness of corporations through their philanthropy. They don’t exist to keep government bureaucracies humming along.

There is a difference between wanting to end homelessness and committing to end homelessness.

If you want to do something, you may or may not achieve it, and likely only under certain favorable conditions.

If you commit to do something you will have steadfast fixity of purpose. When the conditions are unfavorable you will be the catalyst to actively change those conditions, remaining solution-focused all the while instead of accepting barriers as immovable, intractable problems that get in the way of ending homelessness.

Am I so naïve to think we will never need homeless shelters again? Heck no. But we will have a lot less of them and they will return to their original use – short term, infrequent stays to meet emergency needs. They will no longer be de facto housing. They will no longer be places that we load in program incentives that actually make it difficult to leave. I like to think of homeless shelters in the same way that I think of fire stations – I hope I never need the fire department, but I sure am glad they are around when there is an emergency.

When I make a commitment to end homelessness, I am talking about the entire spectrum of homeless people. Statistically speaking, most people who use alcohol or other drugs are housed – including people with addictions – and therefore I see no reason for homeless people to have to be clean and sober unless that is there choice to be so. My commitment to end homelessness includes people who are actively using…like millions of other people around the world who actively use and have housing.

Statistically speaking, most people with compromised mental wellness – including people who don’t take their meds or see their psychiatrist – never experience homelessness, so I see no reason for homeless people to see psychiatrists or take their meds unless that is there choice to be so. My commitment to end homelessness includes people who are unwell and “non-compliant”…like millions of other people around the world who are in similar circumstances and have housing.

I commit to ending homelessness for people who believe in Jesus as well as those that don’t. If people want to be baptized or join a faith group and begin to worship, so be it. But Christianity – or any other religious belief – is not a requirement to be successfully housed. There are millions of other people around the world who are atheists, agnostics, infidels or skeptics and have housing.

I commit to ending homelessness for people who have experienced conflict with the law, including those people that have done awful things to other human beings young and old. For one, I believe that time served is time served; that the sentence does not continue post-release. For another, and entirely pragmatically, if the evidence is clear that re-offending goes down if people have secure housing, isn’t that in my best interest? There are millions of people around the world that have been incarcerated and gone on to be successfully housed.

So you got a plan to end homelessness? Is that something you want to do or is that something you are committed to doing? The way you go about implementing the plan takes on completely different characteristics depending on which one you believe. And it usually points to particular biases in avoiding service of particular populations, whether it is explicit or not.

So your organization delivers services to people that are homeless? How about putting up on the wall somewhere for everyone to see that your ambition is to solve people’s homelessness so that your organization is no longer required? That you are working for the day where you can close the doors of your drop-in center, sell your outreach vans, give away the beds you no longer need in the shelter, etc.?

I can tell commitment when I see it, and I suspect you can too.

Commitment results in some organizations losing their money because they only wanted to serve homeless people (not end their homelessness) and reinvested in organizations that are committed to ending people’s homelessness.

Commitment results in using data to drive program change and improvements, to reflect on practice and make tough decisions, not as something that is nice to have in annual reports or collected only because some funder asked for it.

Commitment results in recruiting highly skilled people that have a passion for professional development and see their work as professional, not well-intentioned people who have neither the experience nor expertise.

Commitment results in doing your homework to see what else is working, not assuming that you are automatically doing the best work or, heaven forbid, trying to “create a best practice”.

Commitment results in having external folks – other professionals, senior managers from other agencies, funder staff – review and provide helpful commentary on how to make your work even better, not shielding away from criticism or doing nothing with information when it is provided by highly qualified people.

Commitment changes the way we talk about the issues and what we are going to do about it. No longer do we say people “aren’t housing ready” or “service resistant” or any other such phrase. No, committed folks turn that around and instead of blaming the consumer of services instead ask themselves what other types of housing or other types of services do I need to offer to be inclusive of all homeless people?

Want is an inclination. It is a desire. It can be directed to a specific need. But there is no obligation to address wants.

Commitment is a pledge. It is a promise. It means that you are going to do it. It has integrity. It is not just a dream. It is not lip service. It is putting the promise into action. Once you commit – trulycommit – you are obligated to make it happen.

Many times I have seen drafts of 10 Year Plans expurgate those sections that speak of commitment or making tough choices, thinking, I suppose, that cleaning out those sections – with the obscene suggestion that we have to do things differently – will make the document more inclusive and readily accepted. Great, so a wide-range of service providers are happy, but what about the people that are supposed to be served by those providers?

I don’t accept homelessness. I am committed to end it. I will speak truth to power in the process. I hope you will too.

Vacuum Sales and Organizational Reporting

When I lived in a Fine Arts Residence 20 or so years ago, I saw, heard and read all sorts of weird and wonderful things that I don’t think I would have ever experienced in any other setting. One of those experiences was a weekly group reading of Raymond Carver’s 1976 collection of short stories called Will You Please Be Quiet, Please? If you aren’t familiar with Carver, he is a rather gloomy, minimalist writer in the “New Realism” school. Time and location aren’t always clear in his short stories. So different than other literature I had been exposed to in high school, I really enjoyed Carver.

One of the short stories contained within Will You Please Be Quiet, Please? is called Collectors. In a nutshell there is an unemployed guy waiting at home for mail to come (as I recall), and instead a door-to-door vacuum salesman arrives. My impression from the story is that the vacuum salesman knew that a sale was unlikely/impossible, yet he enters into the home and does the full vacuum demonstration anyway. It comes across as absurd – yet depressingly realistic – as the vacuum salesperson goes through the complete sales pitch, in what seems to take hours, to someone who will never buy the product. (There is even some confusion in the story as to whether the vacuum salesman is speaking with the right person.)

A couple of paragraphs in, I suspect some of you are wondering what the heck this has to do with the usual blog content.

Well, I have been thinking quite a bit over the past few months about how and to whom organizations report to, what the process is really all about and whose interests it serves. I think if we don’t get four critical questions and answers right any type of funding and accountability goes out the window regardless of whether we are investing in education, health care, housing, homelessness, employment programs, etc. The four important questions to me are:

1. When do organizations report?

A lot of times this is an annual exercise. There are lost opportunities for internal improvements and messaging if it doesn’t happen ideally monthly, quarterly at a minimum.

2. What is the purpose of the reporting?

It should be to fulfill all aspects of Performance Management, not just Performance Measurement. Yes, there will be some backward looking accounting at outputs and expenses to date, but the real purpose of reporting should be forward looking. Reports should inform program improvements, managerial and board decisions, policy development, research and human resources. We should also use reports as a communication vehicle with the people that are served, at staff meetings, with funders and with the broader community.

3. When are those reports accepted or rejected by decision-makers?

Most often reports are passively accepted. There may be some monitoring in some communities, but it isn’t as rigorous as I think it should be. But rejecting a report? Almost unheard of, yet crucially important. I think if we want to change the culture within organizations to be evidence-informed and data-driven in their decision making then scrutiny of reports has to start internally with the organization. If an organization is willing to ask the hard questions of themselves then they are more apt to want to engage in dialogue with the tough questions externally.

4. What are the consequences of having their reports accepted or rejected?

This, too, has two sides. We need to celebrate and promote those organizations and communities that take reporting seriously, do a bang up job and it informs their practice. And for those that are rejected, the starting point has to be program and reporting remediation. It is only after that has not been successful that I would advocate for pulling funding. But make no mistake about it, even with considerable political pressures at times, if a program sucks and is not defensible I am a strong advocate for decreasing or rescinding funding and reinvesting that money in programs that are proven to work. Yes some people’s jobs will be at risk. But you know what? As far as I am concerned some people’s lives are at risk if we aren’t investing in the right programs at the right times to do the right things.

Which takes me back to Carver’s Collectors. If we aren’t going to take reporting seriously, isn’t that akin to selling a vacuum to someone who will never buy it – a complete waste of time? If we don’t do anything – positively or negatively – with reports when received, isn’t that much like the unemployed guy who really can’t get a vacuum yet the demonstration is filling his time? And if recipients of reports don’t really know what to do with them, isn’t that kind of like the confusion of the vacuum salesman who may have the wrong person?

For goodness sake, don’t report for reporting sake. We are all too busy for that. Report because it makes a difference, and it will only make a difference if reporting is taken seriously internally and externally – if there are consequences to what the reports demonstrate.

5 Questions Organizations and Communities Must Ask to Improve Service and Themselves

I love the work we get to do with specific organizations and communities to help them make the change in becoming even better at their work. In the back of my mind, as I do this work, there are several questions that I try to have answered, and I encourage you to reflect on your own organization and community as you go through these questions:

1. Has the organization/community grown complacent?

I haven’t found a good measure for complacency, but there are a couple of sure-fire indicators that I pay attention to – and they happen in tandem. The first is complete satisfaction with how things are; the second is active rejection of how things might be.

The adage “grow or die” is true. That doesn’t mean to get bigger. It just means that organizations and communities have to be thirsty for information and training that enhances professional development; that they have to grow in their ability to provide efficiency or effectiveness in service delivery; and, they have to grow in such a way that ensures that what they are doing happens within a broader framework of service excellence.

I encourage people to, as appropriate, break the mold. Some people say things like “thinking outside the box”, but in some instances I think the better question is “What box?” I have never met an excellent organization/community that was happy with “good enough”.

2. What is the organization/community currently doing well?

Too often when people look at change they focus all of their energy on negatives or opportunities for improvement. In a strength-based approach I think the first step must always be to take a good look around and see what is working well. Chances are there will be some foundational pieces – people, processes, assets or technology – that can be built upon in the change process. Time and again we can build change by leveraging what is working well. And the morale of people shifts more positively when they can feel a sense of pride and ownership over pieces of work that are happening well.

3. What can the organization/community do better?

If the answer is “everything” that really means “nothing”. The purpose of this question is to focus attention on no more than 3-5 strategic or operational priorities at a time. Accomplish those change priorities well and then re-group to agree on the next 3-5. Too many times organizations/communities crash and burn because they are trying to function with too much weight of change that grinds them to a halt; or they appear rudderless and without direction because they haven’t been able to clearly and succinctly articulate those 3-5 strategic or operational priorities.

Of all five questions, determining what to do better must resonate top to bottom within the organization, and more so than the other questions, can benefit most from external expertise and analysis. Someone removed from the organization day in and day out may have an easier time zooming out and panning around before zooming back in on the most important areas to focus attention.

Organizations/communities are also more likely to need professional training, support and/or technical advice in some areas where improvements are necessary. Whenever possible, this should be included as part of the annual budget.

4. Does the organization/community listen and learn from the people that they serve?

It is frustrating to hear an organization/community talk about the needs of the people they serve when they have not first systematically and defensibly gathered information directly from those individuals. There are several important parts of this statement, so let’s break it down:

1. It has to be systematic. That is, it requires a plan and a defensible methodology. No sample sizes of one. No anecdotes used in place of hard facts.

2. It has to be defensible. This again refers to the approach used to gather the information. If people can poke holes in how the information was pulled together or analyzed they are more likely to discount the findings.

3. It has to be directly from the people served (except in those very rare cases where legally it must be another person). This avoids potential spin and factual inaccuracies. It removes potential agendas. It increases accountability.

Over all of my years of service, one of the many lessons I have seen learned time and time again is that what organizations/communities think and what they know are often two totally different concepts – and one that improves if the organization/community listens and learns from the people that they serve.

5. What seems likely to happen to the organization/community if change doesn’t happen?

I don’t have a crystal ball nor do I have a time machine that allows me to travel to the future (though I think it would be a neat premise for a movie if there was a car – like a Delorean – with a flux capacitor that, based upon a certain speed and about 1.21 jigawatts of power, allowed the people in the car to go forward or backward in time…but I digress). It seems impossible to me to absolutely predict what will happen. But I do think it is possible to monitor certain indicators and make informed opinions about the likelihood of some very specific things happening if those changes are not made. Scenario analysis can be very helpful for different people on the team to better understand how the future may unfold if changes do not happen.

All organizations/communities have a certain culture…a system of values and beliefs that holds them together; that drives actions; that informs behaviors; that influences relationships. It is never a matter of whether the culture exists. The real question is what kind do you have?

We have to evaluate on a fairly regular basis if we want to stay responsive and flexible to the needs of the people we serve. Reviewing these 5 questions is a good place to start.