Proof Independent Private ‘supported housing’ approach will end Veteran Homelessness, Not Building Veterans Homes!!! – Part 2 of a Series

by Terry Richards


Mercer Story

Nicholas Pleace and Joanne Bretherton “Will Paradigm Drift Stop Housing First
from Ending Homelessness? Categorising and Critically Assessing the Housing
First Movement from a Social Policy Perspective” Paper given at Social Policy
in an Unequal World: Joint Annual Conference of the East Asian Social Policy
Research Network (EASP) and the United Kingdom Social Policy Association (SPA)
University of York, United Kingdom, July 16th-18th 2012

Writer’s Note: Surveys have revealed that 80% of Veterans do not want to live in Veterans Homes whether on or off VA or other Government Property because they don’t have their total privacy, and because they are subjected to substance abuse testing, curfews, not being able to have overnight guests, and other Rules that are part of this kind of housing. Most of these Veterans say they would rather be homeless than live in this kind of housing…

It is suggested that you read Part 1 before reading Part 2 of this story. Just click onto the link:


Housing First ends homelessness.  It’s that simple. It’s a no-brainer. This level of success was unprecedented in the USA. Nothing could match the rate at which PHF ended enduring homelessness and promoted housing stability among people with severe mental illness and problematic drug and alcohol use. The founder of the PHF service in housingfirstsamt New York, Sam Tsemberis, described the key success of PHF in very simple terms:

Housing First ends homelessness. It’s that simple. The rest of the story  of ‘Housing First’ is relatively recent history.


The Housing First approach was accepted as ‘evidence based’ policy by US Federal Government and appeared in homelessness policies and service provision in Australia, Canada, Finland, France, Ireland and  the Netherlands. ‘Housing First’ services also started to be piloted in Austria, Hungary, Japan, Portugal and the UK. ‘Housing First’ has become more and more prominent as a focus for academic and research and is appearing in local and regional strategies and in the plans of service providers as well as in national level strategies. A major evaluation of Housing First pilot projects is currently underway across the EU, echoing Federal funded evaluation of Housing First pilots conducted in the USA.

On the surface, the Housing First concept appears to be the most globally important and influential policy innovation that has yet occurred in homelessness service provision. However, when the detail of what is being done and contemplated in the name of ‘Housing First’ is looked at, differences between the PHF model and much of the ‘Housing First’ practice being developed elsewhere become apparent. As ‘Housing First’ has permeated the thinking of policymakers and service providers across the US and the wider world, the core ideas of PHF have been simplified, diluted and in many instances, subjected to change. The PHF paradigm often only has a partial relationship with the wide range of new and remodelled homelessness services that have been given the ‘Housing First’ label.

The Many Faces of Housing First As has been widely noted, differences exist between PHF and what services that are referred to as ‘Housing First’ both elsewhere in the USA and in parts of the EU 6. Projects described as ‘Housing First’ in the USA include services that use one block of accommodation with on-site staffing, and a floating support services that does not directly provide or arrange any housing. There are also ‘Housing First’ services that offer both staffed specialist communal accommodation for homeless people and scattered apartments with mobile support services.

A recent editorial discussion of ‘Housing First’ in the Journal of the American Medical Association (JAMA) referred to two studies of ‘Housing First’ published by JAMA. One study was about a ‘Housing First’ service that offered only transitional housing and the other was about a ‘Housing First’ service that used specially built communal housing unit with on-site staffing following a harm reduction approach. Another recent study looking at 11 services that had sought US Federal grant to develop ‘Housing First’ services concluded from reviewing the grant submissions that only two of the 11 showed fidelity with the PHF model. Pathways itself has reacted to the increasing diversity of ‘Housing First’ service provision in the USA by issuing a ‘fidelity scale’.

A similar inconsistency in how ‘Housing First’ is being interpreted is present across Europe. ‘Housing First’ in Finland is not the same as what is meant by ‘Housing First’ in France. In 2011, the Jury of the EU Consensus Conference, looking towards the development of an EU homelessness strategy, drew a distinction between a ‘housing-led’ response to homelessness and a ‘Housing First’ response: Given the history and specificity of the term ‘Housing First’, the jury follows the Preparatory Committee in using ‘housing-led’ as a broader, differentiated concept encompassing approaches that aim to provide housing, with support as required, as the initial step in addressing all forms of homelessness. ‘Housing-led’ thus encompasses the ‘Housing First’ model as part of a broader group of policy approaches…

The distinction summarises one of the reasons why an ambiguity has appeared around the term ‘Housing First’. The term ‘Housing First’ is being used to describe not only services following the PHF model, but also a wider range of ‘Housing-Led’ homelessness services.

In addition, ‘Housing First’ is also being used as a term to describe the adaptation of core aspects of the PHF philosophy to communal, fixed site homelessness services, i.e. blocks of apartments with on-site staffing that are only lived in by service users.

The Risks of Ambiguity There are three main risks associated with the ambiguity that now surrounds the term ‘Housing First’. The first risk is that a range of services calling themselves ‘Housing First’ are being deployed, these are services that have not been precisely defined. This is partially a question of assessing outcomes and partially a question of assessing service cost effectiveness, but it is also a question of understanding what homeless people want and need from services. What is very important is that the gains made by PHF – sustainably ending sustained homelessness for most of the homeless people with severe mental illness it works with – do not become associated with any relative failure by ‘Housing First’ services that do not closely reflect the PHF model. This risk might be summarised as a risk of damage by false association.

The second risk is that the core message about PHF – the capacity to end homelessness for most people with severe mental illness – may become ‘lost’ within an amorphous mass of ill-defined ‘Housing First’ services, a loss of key message risk. This can be illustrated by some of the responses to PHF in the UK. The UK has seen mobile resettlement services that were used to close down traditional homeless hostels in the 1980s develop into widely used ‘tenancy sustainment service’ model that uses ordinary, scattered, housing and mobile workers providing case management to both prevent homelessness and resettle vulnerable homeless people within a harm reduction framework (Pleace, 1997; Franklin, 1999; Pleace and Quilgars, 2003). Tenancy sustainment services have both a superficial resemblance to and, to varying extents, a common set of operational approaches with PHF. In this context, an often imprecise presentation of ‘Housing First’ has made PHF appear to be ‘just another’ floating support service. In the UK, this has led some policymakers and service providers react to ‘Housing First’ as if it were offering no significant innovation.

The third risk is essentially the danger that debate around Housing First may descend into argument about what is and what is not Housing First. This is potentially unproductive, as energy would be better directed at trying to understand and explore the reality of varied ‘Housing First’ services that have come into being. This might be termed definitional dispute risk.

In a situation where more precision is needed about what Housing First is, to assess and then to replicate those variants of Housing First that are successful, the question arises as to how to think clearly about Housing First. This is a process that must begin by defining what the reality of ‘Housing First’ now is.

Categorizing Housing First ‘Housing First’ services can be categorized into one of three broad groups. The first group is made up of PHF services, which adhere to the Pathways model, the second group is made up of Communal Housing First services and the third group is made up of Housing First ‘Light’ services. This broad taxonomy is a description of ‘Housing First’ services as they exist, it is not a prescription of what ‘Housing First’ is, instead the intention is to classify those services that draw heavily upon, or closely reflect, the PHF ethos.

Communal Housing First services (CHF) are focused on chronically homeless people. These services are delivered in communal accommodation that is only lived in by people using the CHF service. Accommodation takes the form of individual self-contained flats or apartments in a block or blocks. The accommodation has often been modified, or specifically designed, to provide a service for chronically homeless people. There is often an emphasis on targeting chronically homeless people with the highest needs, i.e. the most acutely problematic use of drug and alcohol, severe mental illness and poor physical health. Support and medical services are situated in the same building or are very nearby.

The Housing First elements in CHF services, which are sometimes referred to as ‘project based’ Housing First are threefold. First, accommodationwith security of tenure is provided immediately. Second, the provision of this accommodation and support are administratively separate, reflecting the separation of housing and support which is a key principle of the PHF approach. Service users do not have to engage with treatment or show abstinence from drugs and alcohol in order to access and retain their accommodation. CHF services also follow a harm reduction approach with a recovery orientation and emphasise consumer choice and control. Psychiatric, drug and alcohol services are directly provided and a CHF service may also use case management to connect service users with external services. However, a CHF services may not necessarily use the combination of ACT and ICM teams used by PHF.

CHF is used in the USA and is a significant part of the Finnish National Homelessness Strategy which describes itself as following a ‘Housing First’ approach. The Finnish ‘Name on the Door’ Programme, includes extensive remodelling of existing, dormitory homeless hostels, with self contained flats and also changing the operational ethos of former hostels to reflect ‘Housing First’ principles. The goals are ambitious and centre on halving long term homelessness by 2011 and effectively ending it by 2015. The key features of the Finnish approach have been summarised as follow: The Finnish Programme also includes ‘Housing First’ services that use scattered site housing. Services must respect the basic human need for privacy. Service users must have their own rental contract/tenancy. Permanent housing is the base that allows other problems to be solved. Allowance of alcohol consumption. Separation of housing and services. Individually tailored services based on needs assessment. An emphasis on permanent not temporary solutions.  Existing shelters and dormitories are inadequate and must be replaced by supported housing units.

There has been considerable expenditure and a marked shift in homelessness service provision in Finland. The country saw a reduction from 3,665 places in homeless shelters (emergency accommodation) in 1985 to just 144 places in 2011. During the same period, provision of independent flats for homeless people increased from 65 to 2,296.

The parallels between CHF with PHF are considerable, but a key – very significant – difference centres on the provision of shared accommodation blocks with on-site staffing rather than using scattered housing. Yet CHF services in the US define themselves in relation to the PHF model and its principles and derive their own operational models from PHF. In Finland, the development and use of the CHF model initially evolved separately from PHF. As the Finns became aware of PHF, they began to define their National Strategy and their CHF services in reference to PHF and be influenced by the model. The Finns even asked the chief architect of PHF, Tsemberis, to review their services, eliciting a not uncritical assessment of their use of CHF, which Tsemberis saw as undermining the potential for community reintegration among service users. Nevertheless, the influence of PHF is very strongly evident in CHF services, even if those services are not PHF services, and this is perhaps the ultimate argument for regarding them as a form of ‘Housing First’. Housing First ‘Light’ (HFL) services are those services which follow, or which reflect, the PHF model but which offer significantly less intensive support services and are more heavily reliant on case management. HFL services can sometimes be described as reflecting the PHF paradigm because some of these services developed separately, though they share many elements of the PHF ethos and also resemble PHF in how they operate. Many of the principles of PHF are adopted, including immediate or ‘rapid as possible’ provision of adequate, secure and permanent housing that is scattered throughout a community. There is no requirement to stay in a hostel, staircase service or any other form of communal accommodation, or to be made ‘housing ready’, before being given access to housing.

HFL services give each individual service user a single key-worker, who may provide practical advice and some emotional support but whose main role is as a case manager, arranging access to the externally provided treatment and support that each homeless individual or household needs. HFL services do not directly provide medical, psychiatric or drug and alcohol services. As with PHF, housing and support are separated, there is no requirement for abstinence, no requirement for compliance with treatment and a harm reduction approach is followed. HFL services can be used for chronically homeless people, but it can also be employed for homeless people with lower support needs who need less assistance to sustain a tenancy.

There is an argument for using the term ‘Housing-Led’ to describe HFL services. However, there are two reasons for using the term ‘Housing First Light’ to describe these services. First, even though they quite often developed with reference to the PHF paradigm, HFL services do nevertheless mirror PHF in multiple respects. Second, as the terminology of ‘Housing First’ continues to spread throughout homelessness strategies and among homelessness service providers, it seems very likely that such services, even if not doing so already, will start to refer to themselves as ‘Housing First’ models. Clearly, the key difference between PHF and HFL service – the low intensity of support and heavy reliance on case management – is significant. Yet, as with CHF, there are considerable arguments in favour of regarding these services as another form of ‘Housing First’ because of the extent of the parallels in operation and shared ethos. The key differences between PHF, CHF and HFL services are summarised in Table 1. Table 1: A Taxonomy of ‘Housing First’ Services Service offered  Pathways Housing First  Communal Housing First  Housing First Light Housing with security of tenure provided immediately or as soon as possible, scattered across the community  Yes  No  Yes Uses subleasing/sub-tenancies  Yes  No  No Apartments with security of tenure provided immediately in a shared/communal block  No  Yes  No Service users have to stop using drugs  No  No  No Service users have to stop drinking alcohol  No  No  No Service users have to use mental health services  No  No  No Harm reduction approach  Yes  Yes  Yes Uses mobile teams to provide services  Yes  No  Yes Directly provides drug and alcohol services  Yes  Yes  No Directly provides psychiatric and medical services  Yes  Yes  No Uses case management/service brokerage  Yes  Yes  Yes It’s the beginning of the year, and resolutions are fresh. Exercise more. Lose weight. Spend less. Reduce stress. Gym memberships jump in January, and so do hopes that weight-loss programs and yoga classes will reshape our bodies and minds. But New Year’s resolutions don’t come cheap. According to market research corporation Marketdata Enterprises, Americans spent $62 billion in 2011 on “health club memberships, weight-loss programs, exercise tapes, diet sodas and the like,” despite the fact that many of these products don’t work. And even though Americans spend close to $19 billion a year on gym memberships alone, four out of five of those memberships are not used regularly. It’s clear that we’ve got a fairly large gap between resolutions and reality. Certainly, losing weight and getting fit are admirable goals, but there are cheaper ways to do it — and there are better ways to spend our money. So here’s an idea, one that avoids false promises and fulfills another top New Year’s resolution: to help others. Let’s take some of those dollars that we pay out on fake science and so-called miracle weight-loss products and spend them on a worthwhile alternative. Let’s tackle a big problem — say, homelessness in America. To many, homelessness is an impossible problem — too unwieldy and expensive. But ending homelessness has a price tag, just like those gizmos purporting to shed pounds and gym memberships. According to the Department of Housing and Urban Development, or HUD, it would cost $20 billion to end homelessness. That’s less than half of what we spend each year on weight loss and self-improvement. Seriously, ending homelessness is not an impossible task. One of the first steps in solving any problem is to actually believe it can be solved. The second step is to break it down into manageable tasks. Third, get started. Fourth, keep at it. The good news is that the number of people living on America’s streets has dropped by 17 percent since 2007. The number of homeless veterans has dropped by 17 percent since 2009 as well. These decreases are partly because of the outstanding work of service providers who know that not all homeless people are the same. Some are severely disabled and need long-term housing and good medical care, but many of those who become homeless lost their job in the Great Recession of 2007-2009 or got sick and fell behind on rent or house payments. What they need is help getting back on their feet. Local service agencies provide them with rapid “rehousing” so they don’t end up on the street, help with security deposits and a few months’ rent, and job assistance if needed. Such targeted aid is usually enough to bring folks back to a place where they’re self-sufficient and can take care of themselves. Much of the progress that’s been made in communities is due to federal funding — including $1.5 billion in stimulus money for homeless prevention and rapid rehousing programs. That effort, along with funding from the Department of Housing and Urban Development and the Veterans Administration, rebuts the myth that government programs do little if any good because they encourage dependency and a victim mentality in recipients. In truth, these are our fellow citizens who pay taxes and work hard but have hit a rough patch and need a temporary hand to get back on their feet. Steve Berg, vice president for programs and policy at the National Alliance to End Homelessness, suggests ways that all of us can help. “Pay your taxes and don’t complain,” he said in an interview. The money is going to programs that work. “Volunteer,” he added. “Make a donation. Talk to the influential people in your community to see if you’ve got a coordinated approach to homelessness. Find out if the numbers are going down. And don’t stop asking questions until you get good answers.” Remember, Berg says, we are the richest country in the world. Nobody should have to live on the street. Not only is it morally wrong but it ends up costing us more in the long run. Speaking of costs, I’d like to add that the $20 billion price tag for ending homelessness comes to less than half of what we spend each year on our pets. To me it’s a no-brainer. Happy New Year.

All Sources for Par 2 can be found at the bottom of the page in Part 1 of this story. Just click onto the link: