© 2013 Canadian Homelessness Research Network

ISBN 978-1-55014-637-0

Gaetz, Stephen; Scott, Fiona; & Gulliver, Tanya (Eds.), Housing First in Canada: Supporting Communities to End Homelessness. Toronto: Canadian Homelessness Research Network Press.

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This book is protected under a Creative Commons license that allows you to share, copy, distribute, and transmit the work for non-commercial purposes, provided you attribute it to the original source.

The editors wish to acknowledge the work of Sarah Jean Harrison and KC Santo who provided excellent copy-editing services. We would also like to thank the key informants who contributed to the development of each case study: Tim Richter, Katrina Milaney & Alina Turner (Calgary – Calgary Homeless Foundation), Kim Wirth/Katie Davies (Infinity Project), Brad Crewson (Victoria), Amanda DiFalco (Hamilton), John Sharpe & Timothy Ross (Fredericton), Amelia Ridgway (Vancouver), Wally Czech (Lethbridge) and Susan McGee & Alex Abboud (Edmonton).

The Canadian Homelessness Research Network (CHRN) acknowledges with thanks the financial support of the Government of Canada’s Homelessness Partnering Strategy (Employment and Social Development Canada) and the Social Sciences and Humanities Research Council of Canada. The analysis and interpretations contained in the chapters are those of individual contributors and do not necessarily represent the views of the financial contributors of the CHRN. The views expressed in this book are those of the Canadian Homelessness Research Network and do not necessarily reflect the views of the Government of Canada.

CONTENTS

Introduction – Housing First
Tanya Gulliver

Framework

A Framework for Housing First

Stephen Gaetz

Case Studies

Calgary Homeless Foundation: Calgary, Alberta
Stephen Gaetz & Fiona Scott

The Infinity Project: Calgary, Alberta
Fiona Scott & Sarah Jean Harrison

The Vivian: Vancouver, British Columbia
Fiona Scott

Transitions to Home: Hamilton, Ontario
Fiona Scott

City of Lethbridge & Social Housing in Action: Lethbridge, Alberta
Fiona Scott & Stephen Gaetz

Streets to Homes: Victoria, British Columbia
Fiona Scott

Community Action Group on Homelessness: Fredericton, New Brunswick
Fiona Scott

Nikihk Housing First/Homeward Trust: Edmonton, Alberta
Fiona Scott

Conclusion

Lessons Learned
Stephen Gaetz & Tanya Gulliver

Introduction

Housing First

Tanya Gulliver

In March 2013, there was a five-year renewal by the Government of Canada of the Homelessness Partnering Strategy (HPS). This renewal included a new focus on the Housing First approach as well as a financial commitment of $119 million. This means that communities across the country will need to integrate Housing First into the array of homelessness and prevention services that they provide.

We begin this report with a Framework document which:

• Defines Housing First and explains its history.

• Outlines the core principles of Housing First.

• Explores the difference between Housing First as a Program versus Housing First as a Philosophy.

• Discusses the key components of Housing First including models of housing and supports.

• Shares data and research about the success and effectiveness of Housing First.

Next, we provide eight different case studies from across the country. Each of these puts forth a different perspective and ‘take’ on Housing First to help create a broad understanding of the variety of settings and applications that Housing First may be used in. They range from programs with several years of service provision to one that is brand-new and just getting started. The case studies highlight models for specific sub-populations including women and Aboriginal People. The case studies also show the importance of ‘systems-responses’ and ‘wraparound services’. Housing First can’t just be done by the housing and homelessness sector; it requires active involvement from a variety of organizations and governmental entities.

The Calgary Homeless Foundation (CHF) Housing First model in Calgary, Alberta employs a ‘systems-response1’ method in which services are integrated. The CHF supports a number of Housing First programs and has some of the most robust data on successes due to the length of history and foresight. It is a good example of Housing First as both philosophy and program.

The Infinity Project in Calgary, Alberta is an example of a Housing First program aimed specifically at youth experiencing homelessness. It highlights the additional complexities of providing housing for a specific sub-population and the ways in which a Housing First program needs to be adapted in order to meet the distinct needs of a group. When read in conjunction with the Calgary Homeless Foundation case study it also helps increase an understanding of different models within one geographic community. The case study also highlights the way in which a service organization – the Boys and Girls Club of Calgary – which has been in existence since 1939, has evolved and changed its programming to reflect the new realities of the population it serves.

The Vivian Housing First program operated by RainCity Housing and Support Society in Vancouver, British Columbia, is a Housing First program run by women, for women. It uses a congregate housing model and embeds Housing First principles and beliefs with a transitional housing model. They employ harm reduction strategies. The program works with women leaving corrections, women working in the sex trade industry, women with severe mental health issues and women with significant substance use issues.

The Transitions to Home (T2H) program in Hamilton, Ontario, shows how Housing First works in a mid-size city. It provides an example of how to bring stakeholders on board and how to provide effective data. It profiles a unique partnership with the police service resulting in coordination with their EMS Social Navigator position providing service to individuals with high needs.

The City of Lethbridge and Social Housing in Actions’s Housing First program, in Lethbridge, Alberta, is based on the advice and examples of other programs in Canada and the U.S. The staff team has been documenting the key lessons learned in the implementation of a Housing First program and ten lessons are included in the case study. As one of the early adopters of a plan to end homelessness Lethbridge has seen a significant decrease in absolute homelessness, as well as a decrease in shelter usage.

The Streets to Homes program in Victoria, British Columbia, took the Toronto Streets to Homes program and adapted it for their community. It is a good example of the ability to adapt and replicate features of existing programs even when they are being offered in communities that are different than your own. Victoria’s program also provides options for affordable housing in an extremely tight housing market through their unique Private-Public Housing Initiative.

The Community Action Group on Homelessness in Fredericton, New Brunswick, provides a clear and fresh perspective of a program in development. It also provides an example of what planning for Housing First might look like in a smaller and more rural community.

The Nikihk Housing First, Bent Arrow Traditional Healing Society program at Homeward Trust in Edmonton, Alberta, is a model designed to address the over-representation of Aboriginal people in Edmonton’s homeless population. Through the integration of cultural awareness and programming, it provides an example of how Aboriginal and non-Aboriginal agencies can integrate culture into a Housing First Program. The inclusivity of the governance structure is an excellent model for other agencies working to address the needs of specific sub-populations.

We conclude with a Lessons Learned section that summarizes the key learnings from the eight Housing First programs. It also highlights best practices from research including international sources and the Mental Health Commission of Canada’s At Home/Chez Soi program, which was a demonstration project on Housing First in five select Canadian cities (Vancouver, Winnipeg, Toronto, Montreal and Moncton).

ENDNOTES

1. http://calgaryhomeless.com/assets/SystemPlanning/CHSS-System-Planning-Framework-online-jan2012.pdf

A Framework

for Housing First

Stephen Gaetz

In recent years, Housing First has emerged as a key response to homelessness in many parts of the world including the United States, Europe and across Canada. It is considered to be a highly significant policy and practice innovation that has had a dramatic impact on how homelessness is addressed. As the popularity of Housing First grows and takes deeper root across Canada, there is a growing interest in understanding how it works, and how it can be adapted to different community contexts.

As more and more communities move to embrace Housing First, there is a need to understand what works and for whom, and the contextual factors that shape success in facilitating community buy-in, and in the planning and implementation of the model. Housing First does not promise to be the only response to homelessness in a given community – ideally it plays an important role alongside other interventions, including prevention, emergency services, and other models of accommodation and support (including effective transitional and supportive housing models that lead to permanent and adequate housing). However, as a key strategy in reducing homelessness, the evidence for the effectiveness of Housing First cannot be disputed. Considerable research in Canada, the United States and other countries attests to the effectiveness of this model in providing permanent housing and supports to individuals and families we might otherwise deem ‘hard to house’, including the chronically homeless and those with complex mental health and addictions challenges.

The planning and implementation of Housing First is sometimes a challenge in communities where there is a lack of clarity about exactly what it means and how it works in different community contexts. There is often skepticism about whether local circumstances and conditions will allow for its effective application (Can it work in small towns or rural areas? What if there is very little affordable housing?). There is sometimes resistance from traditional service providers because the underlying philosophy of Housing First may clash with established values (the focus on Harm Reduction, for instance) or be seen as a threat to the status quo. Finally, there are questions about its effectiveness and applicability for specific sub-populations, be they youth, Aboriginal persons, or those with addictions or mental health challenges.

The framework presented here is intended to provide an overview of Housing First, its history and the core principles that underlie its application, drawing on the extensive research and evidence that now exists. The framework also outlines the ‘philosophy’ of Housing First and different program models and articulates some key issues that can have an impact on successful implementation. A common framework for Housing First provides researchers, planners and communities with clarity and guidance in developing effective strategies for implementation.

WHAT IS HOUSING FIRST?

Housing First is a recovery-oriented approach to homelessness that involves moving people who experience homelessness into independent and permanent housing as quickly as possible, with no preconditions, and then providing them with additional services and supports as needed. The underlying principle of Housing First is that people are more successful in moving forward with their lives if they are first housed. This is as true for homeless people and those with mental health and addiction issues as it is for anyone. Housing is not contingent upon readiness, or on ‘compliance’ (for instance, sobriety). Rather, it is a rights-based intervention rooted in the philosophy that all people deserve housing, and that adequate housing is a precondition for recovery. According to Pathways to Housing, an early adopter of Housing First programs in the U.S., “The Housing First model is simple: provide housing first, and then combine that housing with supportive treatment services in the areas of mental and physical health, substance abuse, education, and employment” (Pathways to Housing website).

Housing First is often held up as a way of doing things differently. As an approach, it can be contrasted with what has often been the standard approach to working with homeless people, where there is an expectation that individuals and families first ready themselves for housing by addressing their mental health or addictions problems, or minimally, that individuals and families move out of homelessness of their own ‘free will’, with little active intervention (Waegemakers-Schiff & Rook, 2012). This has been characterized as a ‘treatment first’ or ‘treatment as usual’ approach: people who are homeless are placed in emergency services and then other kinds of supported living environments (such as transitional housing) until they are deemed ‘ready’ for independent living (having received access to health care or treatment) or until housing is available. This service model is often highly regulated and involves expectations of compliance with treatment and abstinence from drugs and alcohol.

The Housing First approach differs substantially from the treatment first model, and is typically operationalized in the following way. First, through outreach or a targeted approach, people who are homeless are presented with the option of housing, without it being conditional on any lifestyle, behavioural or treatment expectations (such as abstinence). Second, people have some say in terms of the type and location of housing, taking into account the availability of affordable housing in a given community. There is an expectation that housing be of reasonable quality. Third, people are rehoused as rapidly as possible, minimizing time spent absolutely homeless or in emergency services. Finally, ongoing services and supports are offered and made available to those who want them and need them. These can include rent supplements, case management, help developing connections within the community, etc. For those with addiction issues, housing is not conditional on sobriety. Others may want abstinence-only housing. Matching supports to client needs and to the acuity of mental health and addictions issues is a challenge for effective programming. While providing shelter and supports is central to Housing First, the approach works best when it helps people nurture supportive relationships and become meaningfully engaged in their communities.

In most communities struggling to deal with homelessness, resources are generally scarce and priority is often given to high-needs clients who may have more trouble obtaining and maintaining housing on their own. This includes families, chronically homeless individuals and those with mental health and addiction challenges.

A HISTORY OF HOUSING FIRST

The roots of Housing First in Canada go back to the 1970s. At that time, Houselink, in Toronto, developed an approach to working with people with mental health and/or addictions issues where the provision of housing was considered a priority. The term ‘Housing First’ came into popular usage because of the development of programs in New York (Pathways to Housing) and Los Angeles (Beyond Shelter) (Waegemakers-Schiff & Rook, 2012). Though the name originated with the latter example, the concept was popularized by Sam Tsemberis through his work with Pathways to Housing (New York), which was established in 1992 (Padgett, 2007).

It is worth providing a short description of Pathways to Housing (Pathways), as this model has informed many future developments in Housing First. Pathways targets homeless people with more serious mental health and addictions issues (McCarroll, 2002). It began with a realization that for people struggling with these issues, prolonged experiences of homelessness often worsened their mental health or addictions issues.

According to the Pathways model, clients are identified through two intake streams; either through street outreach or discharge planning from hospitals. Once contact is made, clients discuss and choose the type of housing they want (and where) and the type of supports they will need. Working with private landlords and using a scattered site model, clients are offered accommodation. The definition and importance of scattered-site housing is emphasized in this quote by Sam Tsemberis:

“It is not specialized housing, it is ordinary housing. What makes it different and what makes it effective is that people are also provided with lots of good services […] For people who have spent years excluded, in group homes, hospitals, jails, shelters, and other large public service settings, having a place of their own, their own home, has a huge appeal” (Tsemberis, as quoted in Evans, 2012).

Clients are provided with rental supplements, with the goal that they pay no more than 30% of their income on rent. Basic furnishing and supplies are provided, in order to help the person get set up in their new home. The only conditions of participating in the Pathways program are that people be willing to participate in a money management program whereby their rent is paid directly to a landlord, and that they agree to at least two staff visits per month (Greenwood et al., 2005).

Because a large number of clients have high needs, some will be provided with Intensive Case Management (ICM) to help them get established, while others with more acute needs may receive support from Assertive Community Treatment (ACT) teams on a weekly basis (Padgett, Gulcur & Tsemberis, 2006). The ACT team typically includes a nurse, psychiatrist, addictions specialist, employment counsellor and a peer.

“Involvement of the ACT team, which is available 24/7, is meant to assure that tenants do not become completely isolated, decompensate (inability to maintain defense mechanisms in response to stressors) to the point of requiring hospitalization, become destructive to the point of jeopardizing the rental housing, and are not left without resource contacts for additional supports. The ACT team is also intended to provide quiet encouragement to those who wish to enter or maintain mental health and/or substance abuse treatment” (Waegemakers-Schiff & Rook, 2012:6).

The Pathways model emphasizes a recovery-oriented approach to services. This means that housing and clinical services are supplemented by regular counselling, life and social skills training, etc. and that all services are provided in a client-centred way. Support services are considered voluntary and housing is not conditional upon accepting treatment. People receive support based on their own choices and for as long as they feel it necessary. Once conditions improve, many people choose to end supports. “People are free to stop treatment when they decide they do not need them or are not benefiting from them. They are also free to return to services if they feel they need additional support. Our overall goal is recovery and full integration into the community” (Tsemberis, as quoted in Evans, 2012).

One of the strengths of the Pathways program is that it has been extensively evaluated, thus providing an evidentiary basis for the effectiveness of the intervention. Support for Housing First grew in the United States as the National Alliance to End Homelessness (NAEH) and the United States Interagency Council on Homelessness (USICH) both promoted the philosophy and program model as essential components of 10 Year Plans to End Homelessness.

The success of the Pathways model, and its adoption and active promotion by the NAEH, and by Philip Mangano of USICH, meant that people began to think more seriously about its applicability north of the border. The first large scale application of a program using a Housing First philosophy in Canada was the Streets to Homes program developed and implemented by the City of Toronto in 2005, after a pilot program that involved successful relocation of one hundred ‘tent city’ squatters (Falvo, 2008). Targeting rough sleepers, the Streets to Homes mandate is to “serve homeless people who live outdoors, which includes individuals living in parks, ravines, under bridges, on sidewalks, laneways, alleys, stairwells, building alcoves, squats and living in vehicles” (City of Toronto, 2007:61). Over 60% of Streets to Homes clients are housed in private rental units, about 20% in social housing, and an additional 18% in alternative/supportive housing units (Falvo, 2009).

Since that time, Housing First has been taken up and applied in many communities in Canada. In Vancouver, the prospect of hosting the Winter Olympics spurred the local community to implement a Housing First program. In 2008, all ‘Seven Cities’ in Alberta implemented Housing First as part of their adoption and adaptation of 10 Year Plans to End Homelessness. Around that time, Canada’s Homelessness Partnering Strategy began advocating for Housing First as an underlying principle and practice that should be adopted by the 61 communities they fund.

The At Home/Chez Soi initiative, funded by the Mental Health Commission of Canada (MHCC) and which took place from 2009-2013, is one of the most important developments to solidify Housing First as a paradigm-shifting approach to homelessness in Canada. It is significant in several ways. First, the Government of Canada provided $110 million for the pilot project, which is a significant single investment that highlights the degree to which Housing First is emerging as a priority. Second, the projects in Moncton, Montréal, Toronto, Winnipeg and Vancouver were designed to enhance understanding of the opportunities and challenges to implementation when working with specific sub-populations, including Aboriginal people, newcomers, youth, etc. Finally, the funding prioritized research and evaluation, so that At Home/Chez Soi has emerged as the world’s largest and most in-depth evidence-based exploration of the effectiveness of Housing First. The project has been reporting results that highlight program effectiveness and also shed light on effective strategies for planning and implementation. A final report is expected by the end of 2013.

THE CORE PRINCIPLES OF HOUSING FIRST

The increasing popularity of Housing First and the variable ways in which the concept has been taken up and applied raises important implications about what Housing First is and what the underlying core principles are. On the one hand, the adaptability of the Housing First model means that communities can devise programs to meet their specific needs. Local and national contexts demand that the model be adapted. Such has been the case with the Pathways model as it has travelled around the globe. For example in many European countries and in Australia, the underlying and fundamental principles of Housing First have been applied in a variety of ways. The importance of taking into account cultural, policy and structural differences in social, health, welfare and housing supports suggests that strict adherence to the Pathways model may be neither practical nor desirable (Atherton & McNaughton Nichols 2008; Johnson et al. 2012; Pleace & Bretherton, 2010; Johnsen & Texiera, 2010).

On the other hand, in Canada, there is growing interest in the model by policy makers, funders and providers. This suggests that fidelity to the core principles of Housing First is important in order to ensure that the program being undertaken is in fact a Housing First program. That fidelity to the core principles of Housing First may not be adhered to as it becomes more popular is not an idle concern1. In a review of Housing First practices in North America and Europe, Pleace and Bretherton argue that:

“As ‘Housing First’ has permeated the thinking of policymakers and service providers across the US and the wider world, the core ideas of (Pathways to Housing) have been simplified, diluted and in many instances, subjected to change. The (Pathways to Housing) 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” (Kaakinen, 2012; Pearson et al., 2009; Pleace, 2012; Tsemberis, 2011, as quoted in Pleace & Bretherton, 2012:5).

As such, the case can be made that in the Canadian context, the philosophy and program model of Housing First must be guided by core principles. As new approaches to a complex issue become more popular, the concept can become a ‘brand’ – a name that can be applied to any program that provides accommodation and supports for people who experience homelessness. As such, it is important to define clear core principles to help articulate and clarify what is meant by Housing First, in order to guide planning and implementation. From a quality assurance perspective, such principles can become necessary to ensuring fidelity to the overarching goal of Housing First. While a number of programs and communities have attempted to articulate core principles (and these vary somewhat in emphasis2), the core principles presented here seek to identify what is common amongst these approaches.

The core principles of Housing First include:

1. Immediate access to permanent housing with no housing readiness requirements. Housing First involves providing clients with assistance in finding and obtaining safe, secure and permanent housing as quickly as possible. Key to the Housing First philosophy is that individuals and families are not required to first demonstrate that they are ‘ready’ for housing. Housing is not conditional on sobriety or abstinence. Program participation is also voluntary. This approach runs in contrast to what has been the orthodoxy of ‘treatment first’ approaches whereby people experiencing homeless are placed in emergency services and must address certain personal issues (addictions, mental health) prior to being deemed ‘ready’ for housing (having received access to health care or treatment).

2. Consumer choice and self-determination. Housing First is a rights-based, client-centred approach that emphasizes client choice in terms of housing and supports.

• Housing – Clients are able to exercise some choice regarding the location and type of housing they receive (e.g. neighbourhood, congregate setting, scattered site, etc.). Choice may be constrained by local availability and affordability.

• Supports – Clients have choices in terms of what services they receive and when to start using services.

3. Recovery orientation. Housing First practice is not simply focused on meeting basic client needs, but on supporting recovery. A recovery orientation focuses on individual well-being. It ensures that clients have access to a range of supports that enable them to nurture and maintain social, recreational, educational, occupational and vocational activities.

For those with addictions challenges, a recovery orientation also means access to a harm reduction environment. Harm reduction aims to reduce the risks and harmful effects associated with substance use and addictive behaviours for the individual, the community and society as a whole, without requiring abstinence. However, as part of the spectrum of choices that underlies both Housing First and harm reduction, people may desire and choose ‘abstinence only’ housing.

4. Individualized and client-driven supports. A client-driven approach recognizes that individuals are unique; so are their needs. Once housed, some people will need minimum supports while other people will need supports for the rest of their lives (this could range from case management to assertive community treatment). Individuals should be provided with “a range of treatment and support services that are voluntary, individualized, culturally-appropriate, and portable (e.g. in mental health, substance use, physical health, employment, education)” (Goering et al., 2012:12). Supports may address housing stability, health and mental health needs, and life skills.

Income supports and rent supplements are often an important part of providing client-driven supports. If clients do not have the necessary income to support their housing, their tenancy, health and well-being may be at risk. Rent supplements should ensure that individuals do not pay more than 30% of their income on rent.

It is important to remember that a central philosophy of Housing First is that people have access to the supports they need, if they choose. Access to housing is not conditional upon accepting a particular kind of service.

5. Social and community integration. Part of the Housing First strategy is to help people integrate into their community and this requires socially supportive engagement and the opportunity to participate in meaningful activities. If people are housed and become or remain socially isolated, the stability of their housing may be compromised. Key features of social and community integration include:

• Separation of housing and supports (except in the case of supportive housing).

• Housing models that do not stigmatize or isolate clients. This is one reason why scattered site approaches are preferred.

• Opportunities for social and cultural engagement are supported through employment, vocational and recreational activities.

While all Housing First programs ideally share these critical elements, there is considerable variation in how the model is applied, based on population served, resource availability and other factors related to the local context. There is no ‘one size fits all’ approach to Housing First.

THE APPLICATION OF HOUSING FIRST

In order to fully understand how Housing First is applied in different contexts, it is important to consider different models. While there are core principles that guide its application, it is worth distinguishing Housing First in terms of: a) a philosophy, b) a systems approach, c) program models, and d) team interventions.

Philosophy

As a philosophy, Housing First can be a guiding principle for an organization or community that prioritizes getting people into permanent housing with supports to follow. It is the belief that all people deserve housing, and that people who are homeless will do better and recover more effectively if they are first provided with housing. As a philosophy, it can underlie the work that an agency does, or that of a whole community. It can inform how outreach is conducted, or the mandate of an emergency shelter.

Systems Approach

Housing First can be considered embedded within a systems approach when the foundational philosophy and core principles of Housing First are applied across and infused throughout integrated systems models of service delivery. It is central to many coordinated approaches to ending homeless such as ‘10 Year Plans’. Within a ‘system of care’ approach, all services and program elements within the homelessness sector – including many mainstream services – are guided by the principles of the model. As such, each program and service is expected to support and operationalize Housing First, each having a specific role to play in the larger system. While the service providers in the system are not Housing First programs on their own, they form different parts of a larger system that works towards achieving the goals of a Housing First program. For instance, many communities in Alberta have adopted the Housing First philosophy with the expectation that all programs – including emergency services – work towards this goal. The Calgary Homeless Foundation case study (page 31) provides an illustration and explanation of how this works.

Program Models

Housing First can be considered more specifically as a program when it is operationalized as a service delivery model or set of activities provided by an agency or government body.

It is important to note that there is not a single program model for Housing First and that it can take many forms. As it grows in popularity it is applied in new ways and in different contexts, resulting in a broad range of program models. While some Housing First programs closely follow the Pathways model in that they are designed specifically to meet the needs of people with acute mental health or addictions problems, others focus more broadly on anyone who is homeless. The latter has been described by some as “Housing First Light” because of the lower level of supports required, or in Europe, “Housing Led” (Pleace & Bretherton, 2012:10). The Streets to Homes program in Toronto targets chronic rough sleepers, while other programs may focus on specific sub-populations such as Aboriginal people or youth, for instance. Different program models may offer different kinds of supports (for instance, not all programs provide rent supplements), and for different lengths of time.

The kind of housing offered may also differ substantially between programs. The Pathways to Housing model, for instance, rehouses people using a private-sector, scattered site model, which was also used by the At Home/Chez Soi team. This is in keeping with many studies of consumer preference regarding housing which reflect a desire to live independently in the community. In other national contexts, individuals are more likely to be provided with social housing units because there is a more robust supply; additionally, there is potentially less stigma attached to this option than might be the case in Canada (Johnson et al., 2012). Finally, in some communities individuals are housed in shared accommodation blocks, or congregate models of housing, as opposed to the scattered site approach.

Team Intervention

Finally, one needs to consider Housing First teams. Teams are designed to meet the needs of specific target populations, defined in terms of either the characteristics of the sub-population (age, ethno-cultural status, for instance), or in terms of the acuity of physical, mental and social challenges that individuals face. Teams are constituted to include members with particular skills and knowledge, and with defined caseloads so that individual needs are best met. Caseloads can vary and are determined by the complexity of the client group. One of the key challenges of delivering Housing First programs is matching the team support to the needs of clients, and the different team models are often adapted to meet local needs or based on contextual factors (for instance, in smaller centres there may be limited access to health care professionals).

Housing First is implemented through the following kinds of teams:

• Assertive Community Treatment (ACT) – ACT is an integrated team based approach designed to provide comprehensive community-based supports to help people remain stably housed. It is one of the most studied community programs in all of health care and has a very strong evidence base. Programs that follow the Pathways model typically offer intensive supports through ACT teams to address the needs of clients with mental health and addictions, and may support individuals in accessing psychiatric treatment and rehabilitation. These teams may consist of physicians and other health care providers, social workers and peer support workers. The latter are deemed to be key members of the team, for their experience of homelessness can become an essential resource for support and recovery. They help bridge the knowledge that other team members bring with knowledge of what it is to be homeless. ACT teams are designed for clients with the most acute needs and may provide support on an ongoing basis. In some cases, individuals will need to have access to supports 24 hours a day. The following are characteristics of ACT teams:

• A multi-disciplinary team of professionals that provides wrap-around service directly to the client.

• The team members are available 24/7 and provide real-time support.

• The ACT team meets regularly with the client and with each other (could be daily).

• The team is mobile, often meeting clients in their homes.

• The staff to client ratio is generally 1 ACT team per 10 clients.

• The program components are informed by client choice, peer support and a recovery-orientation.

• Services are offered on a time-unlimited basis, with planned transfers to lower intensity services for stable clients.

Members of an ACT team include:

• Clinical/medical staff (psychiatrist, doctor, nurse, substance abuse specialists);

• Peer support workers; and

• Generalist case managers who may have varied professional/experiential qualifications and who broker access to housing and complementary supports.

ACT teams may also include:

• Housing support/tenancy expertise (landlord support, housing support per securing housing, move-in and maintenance of housing unit, rent subsidy/income support specialist);

• Basic skills training (cooking, cleaning, numeracy per paying rent); and/or

• Education/employment specialist (dedicated to broader goals of social integration and self-sufficiency) (Adapted from the Mental Health Commission of Canada).

The ACT team model has been adapted in some contexts to address local challenges. Toronto, for instance, has established Multi-Disciplinary Outreach Teams (M-DOT)3 made up of outreach workers, case managers, a registered nurse, a housing worker and part-time psychiatrist. M-DOT teams were developed with the goal of connecting with marginalized, hard to reach clients (living on the streets or in ravines, for instance) with significant illness or disability related to a health, mental health or substance use, and who may be completely disengaged (and alienated from) support services.

• Intensive Case Management (ICM) – This can also be a team-based approach that supports individuals through a case management approach, the goal of which is to help clients maintain their housing and achieving an optimum quality of life through developing plans, enhancing life skills, addressing health and mental health needs, engaging in meaningful activities and building social and community relations. It has a moderately strong evidence base. It is designed for clients with lower acuity, but who are identified as needing intensive support for a shorter and time-delineated period. The At Home/Chez Soi project has identified that for many clients, the first three months can be most challenging, and providing appropriate levels of support may be crucial for recovery and retention of housing. The following are characteristics of ICM:

• One-on-one case manager to client relationship using a recovery-oriented approach (the team of case managers may include Housing and Complementary Support Workers).

• The case manager brokers access to mainstream services that the client identifies as needed to attain his or her goals.

• The case manager often accompanies clients to meetings and appointments in support of their goals/needs.

• Case managers are available on a regular schedule; caseloads are often shared to assure coverage of 7 days per week/12 hours a day.

• The staff to client ratio is generally 1 case manager per 20 clients.

• The duration of the service is determined by the needs of the client, with the goal of transitioning to mainstream services as soon as possible (Adapted from the Mental Health Commission of Canada).

• Rapid Rehousing – Often defined as distinct from Housing First, rapid rehousing operates on many of the same guiding principles. It is an approach that targets clients with lower acuity of mental health and addictions challenges. As such, the level of supports is much lower, and usually for a shorter period of time. Clients may be given short term rent supplements, and help in accessing services and supports.

Rapid rehousing teams are included in this framework, because the boundaries between higher and lower needs clients can be quite fluid. In Edmonton, Homeward Trust has formed LIFT teams which are modified ICM teams that focus on rapid rehousing, and the provision of short-term, interim supports (three months), financial support and access to furniture, for instance.

KEY COMPONENTS: HOUSING AND SUPPORTS

Who is Housing First for?

Housing First is an approach that can potentially be applied to a broad sector of the homeless population to help them reduce or end their homelessness. However, many programs target those who experience chronic or episodic homelessness.

A common typology of homelessness categorizes people as temporary, episodic and chronic homeless in order to identify the duration of homelessness and the level of needs of services and supports4. Individuals identified as temporarily homeless have a small number of episodes of homelessness that are usually of short duration. They typically manage to move out homelessness on their own, with little support from service providers. Individuals and families identified as episodically homeless have repeated episodes and for longer duration. Chronically homeless persons have fewer episodes, but for longer periods. A recent study of shelter users in Toronto, Ottawa and Guelph by Aubry, et al. (2013) found that approximately 88-94% of the homeless population can be considered transitionally homeless, 3-11% are episodically homeless, and the chronically homeless make up between 2-4%.

Episodically and chronically homeless persons are typically the target of Housing First strategies, because their life on the streets is more entrenched, their needs are more complex (mental health, health, addictions, disabilities), and the level of service use is much more intensive. Aubry et al. (2013:10) found, for instance that in spite of their small numbers, chronically homeless persons used over half of shelter bed stays in Toronto and Ottawa over a four year period. A convincing case can be made that targeting chronically and episodically homeless persons with Housing First cannot only improve the lives of impoverished people with high needs, but can also dramatically reduce the need for homelessness services over time.

Given the high needs of chronically or episodically homeless persons, the implementation of Housing First requires a consideration of the kind of housing that such individuals and families should be moved into, and the range of supports made available to them.

Housing

A key principle of Housing First is Consumer Choice and Self-Determination. In other words, people should have some kind of choice as to what kind of housing they receive, and where it is located. Understanding that housing availability is also an issue in many if not most communities, efforts should nevertheless be made to meet client needs, and ensure that the quality of housing they receive meets the Canada Mortgage and Housing Corporation (CMHC) standards of suitability. That is, housing should be adequate, affordable and suitable:

• Adequate housing is reported by residents as not requiring any major repairs. Housing that is inadequate may have excessive mold, inadequate heating or water supply, significant damage, etc.

• Affordable dwelling costs less than 30% of total before-tax household income. Those in extreme core housing need pay 50% or more of their income on housing. It should be noted that the lower the household income, the more onerous this expense becomes.

• Suitable housing has enough bedrooms for the size and composition of the resident household, according to National Occupancy Standard (NOS) requirements.

There are sometimes questions about the kind of housing that people should have access through Housing First. The Pathways model prioritizes the use of scattered-site housing which involves renting units in independent private rental markets. One benefit of this approach is that it gives clients more choice, and may be a less stigmatizing option (Barnes, 2012). It is in keeping with consumer preferences to live in integrated community settings. From a financial perspective, there is a benefit to having the capital costs of housing absorbed by the private sector. In other cases the use of congregate models of housing, where there are many units in a single building is seen as optimal although the effectiveness of this model has not yet been proven. Benefits of this approach include supports that are more efficiently delivered, giving individuals a less isolated space where they can be directly encouraged to develop a sense of community. This is akin to the Common Ground approach pioneered in New York, and is also utilized as part of the Housing First approach in Vancouver. In some communities in Canada and more particularly in other national contexts (Australia, many European nations), social housing is more readily used to provide housing for individuals in Housing First programs. In such contexts, there is a more readily available supply of social housing, and living in buildings dedicated to low income tenants may not be viewed in a stigmatized way. In some communities such as Toronto, social housing includes both larger scale congregate settings, as well as scattered-site housing. Finally, for some Housing First clients whose health and mental health needs are acute and chronic, people may require Permanent Supportive Housing (PSH), a more integrated model of housing and services for individuals with complex and co-occurring issues where the clinical services and landlord role are performed by the same organization. Those who may benefit from tightly linked and supportive social, health and housing supports as a means of maintaining their housing stability may be best served by this model.

Supports

Housing First is much more than the provision of housing. It typically involves three kinds of supports5:

1. Housing supports: The initial intervention of Housing First is to help people obtain housing, in a way that takes into account client preferences and needs, and addresses housing suitability. This work may be done by independent housing teams, or special outreach teams tasked with making connections with people who are not accessing services through existing agencies. Key housing supports include:

• Helping the client search for and identify appropriate housing.

• Building and maintaining relationships with landlords.

• Negotiating with the landlord or access to social housing or permanent supportive housing.

• Applying for and managing rent subsidies.

• Provide assistance in setting up apartments, including acquiring furniture and supplies.

• Landlord mediation, conflict resolution, crisis intervention.

• Develop skills for independent living.

2. Clinical supports: This includes a range of supports designed to enhance the health, mental health and social care of the client. Housing First teams often speak of a recovery-oriented approach to clinical supports designed to enhance well-being, mitigate the effects of mental health and addictions challenges, improve quality of life and foster self-sufficiency. As suggested above, the range of supports is necessarily client driven, and through a comprehensive assessment of client goals, interests and needs, appropriate services can be brought to bear. Some of these supports can be provided by the Housing First team itself (the ACT or ICM teams), and in other cases the teams will facilitate access to mainstream services.

A key challenge in providing clinical supports is matching the right supports to client interest and need. One of the things that has been learned by those who have been implementing Housing First is the need to have effective assessment measures to determine acuity. Flexibility is also important. In some cases a client may be matched with an ACT team, when it is later learned that an ICM team would be more appropriate (and vice versa). Susan McGee of Homeward Trust has remarked that it can take “several months to get the right match between client needs and appropriate supports” (McGee, 2013).

3. Complementary supports: Housing stabilization usually requires a broader range of supports beyond housing and clinical supports. Such supports are intended to help individuals and families improve their quality of life, integrate into the community and potentially achieve self-sufficiency. Complementary supports may include:

• Life skills – skills for maintaining housing, establishing and maintaining relationships (including conflict resolution), engagement in meaningful activities.

• Income supports for those entitled to them.

• Assistance with finding employment, enrolling in education, volunteer work and accessing training.

• Community engagement.

THE EVIDENCE: DOES HOUSING FIRST WORK?

There is a substantial body of research that convincingly demonstrates Housing First’s general effectiveness, when compared to ‘treatment first’ approaches, including research from Canada (Falvo, 2009; 2010; Goering et al., 2012; Waegemakers-Schiff & Rook, 2012; City of Toronto, 2007; 2009). In a recent review of the literature, Waegemakers-Schiff and Rook identified the major themes from 66 academic articles, including: “housing stability, satisfaction, choice versus coercion, changes in mental and physical health, issues of sobriety, reduced substance use and harm reduction, cost effectiveness, and quality of life” (Wagemakers-Schiff & Rook, 2012:9). They note ironically that despite Housing First’s emphasis on housing before treatment, virtually all of the articles focused on treatment and housing outcomes, such as decreased mental health symptoms and substance use. They also point out that virtually all of the studies focus on single adults, and the majority on people with serious mental illness and/or addictions challenges (ibid.:11). This is not surprising given the degree to which Pathways and similar programs have been the primary focus of evaluation.

The At Home/Chez Soi Toronto research team also conducted a review of the literature and found the following evidence of the model’s effectiveness:

Housing First has a positive impact on housing stability (Tsemberis & Eisenberg, 2000; Tsemberis et al., 2004; Culhane et al., 2002; Rosenheck et al., 2003; Mares & Rosenheck, 2007; Metraux et al., 2003; O’Connell et al., 2008; Pearson et al., 2007; Shern et al., 1997; City of Toronto, 2009). That is, people who participate in Housing First programs, even those with high needs and/or who are chronically homeless, generally tend to remain housed after a year (though they may move from one house to another). Tsemberis and Eisenberg (2000) demonstrated that 90% of the people involved in the Pathways program remained housed after five years. Gulcur et al. (2003) likewise demonstrated high levels of housing stability. In Toronto, a review of Streets to Homes showed that 87% of program participants remained housed after one year (City of Toronto, 2009).

Housing First reduces unnecessary emergency visits and hospitalizations (City of Toronto, 2007; Culhane et al., 2002; Gilmer et al., 2010; Larimer et al., 2009; Gulcur et al., 2003). Keeping people in a state of homelessness not only produces a range of worsening health outcomes (Frankish et al., 2005; 2008; Hwang, 2000), it also leads to lengthy and costly increases in hospitalization and in particular, emergency room visits (Hwang, 2010). As Goering et al. (2012:14) argue, “[t]his decrease in use of emergency and inpatient services is accompanied by increases in the use of community outpatient services that are better able to meet client needs and prevent unnecessary or lengthy hospitalizations. It also frees up necessary health care resources for others who need them.”

Housing First can lead to improved health and mental health outcomes, and the stabilization or reduction of addictions symptoms (City of Toronto, 2007; Mares & Rosenheck, 2010; Perlman & Parvensky, 2007; Larimer et al., 2009; Greenwood et al., 2005). While it is established that there are higher prevalence rates for mental illness and addictions, it is also understood that the experience of homelessness can exacerbate these conditions. Providing people with housing and supports reduces the risk of assault and trauma, and can help stabilize individuals with such problems. Housing stability reduces the need to access services in an emergency, and enhances the possibility of more effective health care case management and continuity of care.

Housing First reduces client involvement with police and the criminal justice system (City of Toronto, 2007; Culhane et al., 2002; Gilmer et al., 2010; Perlman & Parvensky, 2007). Canadian research identifies the relationship between homelessness, involvement with the police, and prison (O’Grady et al., 2011; Gaetz & O’Grady, 2006; 2009; Novac et al., 2006; 2007; Kellen et al., 2010). Housing stability may decrease criminal involvement, and most certainly reduces the likelihood of street-based interactions between people who are homeless and the police.

Housing First improves quality of life (City of Toronto, 2007; Gilmer et al., 2010; Mares & Rosenheck, 2010; Perlman & Parvensky, 2007). In addition to desired improvements in health outcomes (including enhanced food security) a key goal of Housing First is to enhance social and community engagement. The research demonstrates improvements in community integration for most individuals, though for “a meaningful minority, the adaptation to housing may also be associated with challenges that can complicate the integration process” (Yanos et al., 2004:133).

The preliminary results of the At Home/Chez Soi project are important, both because it is the largest and arguably most comprehensive study of Housing First ever conducted, but also because it was conducted in Canada. The study used a randomized trial design in which individuals were assigned at random to the Housing First option or ‘treatment as usual’ (i.e. they could receive any other homelessness-related service available). Exactly 2149 people participated in the study, 81.5% of whom were absolutely homeless at the time (the rest were precariously housed). The preliminary results after 12 months (21 and 24 month follow up studies will follow) indicate very promising improvements across all of the domains cited in the literature above. For instance, in terms of housing stability:

“Over 900 individuals from our shelters and on our streets who have not been well served by our current approach are now housed in adequate, affordable and suitable settings. Eighty six percent of participants remain in their first or second unit (as of August 2012). At 12 months those in the Housing First intervention had spent an average of 73% of their time in stable housing. In contrast, those in treatment as usual (TAU) spend only 30% of their time in stable housing” (Goering et al., 2012:6).

In addition to housing stability, the Housing First group showed a dramatic reduction in service usage, compared with the TAU group:

• 7,497 fewer nights in institutions (largely residential addiction treatment).

• 42,078 fewer nights in shelters.

• 6,904 fewer nights in transitional housing or group homes.

• 732 fewer emergency department visits.

• 460 fewer police detentions.

• 1,260 fewer outpatient visits.

• 34,178 fewer drop-in centre visits.

Because this is a comparative analysis, the At Home/Chez Soi team is also looking at the differences between the five sites, in order to understand the impact of Housing First on key sub-populations, but also in order to find out the importance of the following on success: contextual differences (the local funding, service delivery and policy contexts), city size (ranging from Moncton to Toronto), and the supply of affordable housing. In addition, the project has employed a broad range of methodologies, including qualitative interviews with key informants, process analysis, and action research with project participants, in order to understand issues related to planning and implementation and bringing landlords on board (260 different landlords). Finally, and for quality assurance purposes, research was conducted on the perspectives and experiences of clients of the program.

Does Housing First Save Money?

A key claim of Housing First is that it saves money compared to treatment as usual.

According to a recent report, The Real Cost of Homelessness (Gaetz, 2012) there are plenty of studies that demonstrate that the traditional response to homelessness is expensive, and that it may be easier and cheaper to provide people with housing and supports (Laird, 2007a; Eberle et al., 2001; Palermo et al., 2006; Shapcott, 2007; Pomeroy, 2005; 2008). For instance, in the Wellesley Institute’s Blueprint to End Homelessness (2007), it is argued that the average monthly costs of housing people while they are homeless are $1,932 for a shelter bed, $4,333 for provincial jail, or $10,900 for a hospital bed. This can be compared with the average monthly cost to the City of Toronto for rent supplements ($701) or social housing ($199.92).

The At Home/Chez Soi project has done some interesting analyses comparing the average shelter, health and justice costs of those in Housing First against those receiving TAU. The project has also conducted an analysis comparing High Service Users against the whole group. The findings are illustrative.

For instance, it was found that implementing Housing First requires an additional investment of over $4,000 per person, per year. For the full group (ranging from high to low needs) there is a return of $7 for every $10 spent on Housing First. If one focuses only on the high service user group (10% of the sample) arguably the group with the most complex mental health and addictions issues, there are even greater savings; for the high service users, an investment in Housing First saves almost $22,000 per year.

One caution is that this analysis is done on homeless individuals who have health, mental health and addictions issues. In some cases their health costs may rise, as they now have access to mainstream services that were not being utilized prior to their involvement in the program. Additionally, we do not know the cost impact of those with lower levels of need, who may require short term or ICM, but may not require more expensive ACT team supports. That is, for Housing First programs that more broadly target homeless populations not defined by mental illness, the cost recovery may be different.

Nevertheless, a key finding from this work is that targeting high needs, high service using homeless populations will actually save money. The myth that the chronically homeless have too many complicated needs, or who are too difficult and ultimately too expensive to house is undone by the results of the At Home/Chez Soi study.

CONCLUSION

There is a growing interest in Housing First as a key approach to reducing and potentially ending homelessness in Canada and around the world. In 2013, the Government of Canada signaled its support for Housing First in its five year renewal of the Homelessness Partnering Strategy. As many communities move to adopt, adapt and implement Housing First, there are many questions.

Housing First is an intervention rooted in the philosophy that all people deserve housing, that housing is a human right, and that adequate housing is a precondition for recovery. It works by moving people who are homeless into independent and permanent housing as quickly as possible, with no preconditions (readiness or sobriety). Once housed, people are provided with additional services and supports as needed and based on their choice.

This framework document is meant to outline key features of the approach, and to clarify some questions about its application. It provides a clear definition, and identifies core principles against which communities can measure the fidelity of their own efforts. The core principles of Housing First include:

1. Immediate access to permanent housing with no housing readiness requirements.

2. Consumer choice and self-determination.

3. Recovery orientation to services.

4. Individualized and client-driven supports.

5. Social and community integration.

Further, there is a clear statement of the distinction between different levels of engagement with Housing First, from adopting it as a philosophy, integrating it as a systems approach, deploying it as a program, and identifying what kinds of teams deliver the service. Housing First involves, at its most basic, providing homeless people with access to housing that is safe and affordable. Clients should have choice in the kind and location of housing, and different kinds of housing can be accessed through the model, including scattered-site rental housing, congregate housing, social housing or permanent supportive housing, for instance. But Housing First means more than simply putting a roof over one’s head. Supports of different kinds should be offered, including housing support, clinical supports and complementary supports. Given that Housing First is a client-driven model, individuals and families participating in the program should have a say in the nature and extent of supports provided.

Does Housing First work? One of the key challenges in developing effective responses to homelessness is ensuring there is a solid evidence base for interventions. Housing First exists as one of the few interventions that can be declared a Best Practice, and the weight of evidence that it is effective in providing housing stability for chronically and episodically homeless individuals is overwhelming. The At Home/Chez Soi project, funded by Health Canada to the MHCC, was a five city study that explored the process of implementing Housing First, and that evaluated the effectiveness of the program outcomes. In undertaking this evaluation, the project took into account the significance of contextual factors such as city size, rental housing market, and needs of sub-populations. This is the most extensive study of Housing First ever conducted, and it will deepen understanding of the efficacy of Housing First as a program model.

APPENDIX A

Pathways to Housing operating principles:

• Housing is a basic human right;

• There should be:

• Respect, warmth and compassion for service users;

• A commitment to working with service users for as long as they need;

• Scattered site housing using independent apartments (i.e. homeless people should not be housed within dedicated buildings but within ordinary housing);

• Separation of housing from mental health, and drug and alcohol services (i.e. housing provision is not conditional on compliance with psychiatric treatment or sobriety);

• Consumer choice and self – determination (i.e. delivering mental health and drug and alcohol services with an emphasis on service user choice and control; basing treatment plans around service users’ own goals);

• A recovery orientation (conveying a positive message that recovery is possible for service users;

• A harm reduction approach (i.e. supporting the minimization of problematic drug/alcohol use but not insisting on total abstinence).

Core principles of Housing First adopted by the Calgary Homeless Foundation and the Canadian Alliance to End Homelessness:

1. Consumer choice and self-determination;

2. Immediate access to permanent housing with the support necessary to sustain it;

3. Housing not conditional on sobriety or program participation; and

4. The ultimate goal of social inclusion, self-sufficiency, and improved quality of life and health.

REFERENCES

Aubry, T., Farrell, S., Hwang, S., & Calhoun, M. (2013). Identifying the Patterns of Emergency Shelter Stays of Single Individuals in Canadian Cities of Different Sizes. Housing Studies, (ahead-of-print), 1-18.

Barnes, S. (2012). Review of Trends, Policies, Practices and Implications of Scattered Site Housing. Toronto: Wellesley Institute

City of Toronto. (2007). What Housing First Means for People – Results of Streets to Homes 2007 Post-Occupancy Research. Toronto Shelter, Support & Housing Administration: Toronto.

Culhane, D. P., Metraux, S., Hadley, T. (2002). Public Service Reductions Associated with Placement of Homeless Persons with Severe Mental Illness in Supportive Housing. Housing Policy Debates, 13(1), 107-163. Retrieved from: http://repository.upenn.edu/spp_papers/65/

Culhane, D., Metraux, S., Min Park, J., Schretzman, M., & Valente, J. (2007). Testing a Typology of Family Homelessness Based on Patterns of Public Shelter Utilization in Four U.S. Jurisdictions: Implications for Policy and Program Planning. Departmental Papers (SPP). Retrieved from: http://works.bepress.com/dennis_culhane/1

Culhane, D., & Metraux, S. (2008). Rearranging the Deck Chairs or Reallocating the Life Boats? Homelessness assistance and its alternatives. Journal of American Planning Association, 74(1), 111-121.

Evans, W. G. (2012). Housing First: An Interview with Sam Tsemberis. Rockville, Md. SAMSA

Falvo, N. (2008). The ‘housing first’ model: Immediate access to permanent housing. Canadian Housing [Special ed.], 32-35.

Falvo, N. (2009a). Toronto’s Housing First programme and implications for leadership. Housing, Care & Support, 12(2), 16-25.

Falvo, N. (2009b). Homelessness, Program Responses, and an Assessment of Toronto’s Streets to Homes Program. CPRN Research Report. Toronto: Canadian Policy Research Networks Inc.

Frankish, C. J., Hwang, S. W., & Quantz, D. (2005). Homelessness and Health in Canada – Research Lessons and Priorities. Canadian Journal of Public Health, 96, S23-S29.

Frankish, J., Hwang, S., & Quantz, D. (2009). The Relationship Between Homelessness and Health: An Overview of Research in Canada. In J. D. Hulchanski et al. (Eds.), Finding home: Policy options for addressing homelessness in Canada (e-book), Chapter 2.1. Toronto, ON: Cities Centre, University of Toronto.

Gaetz, S. (2011). Can Housing First work if there isn’t enough affordable housing? CrossCurrents: The Journal of Addiction and Mental Health, January. Retrieved from: http://www.camhcrosscurrents.net/thelastword/2011/01/can-housing-first-work.html

Gaetz, S. (2012a). Housing First. Homeless Hub topic. Retrieved from: http://www.homelesshub.ca/Topics/Housing-First-209.aspx

Gaetz, S. (2012b). The Real Cost of Homelessness: Can We Save Money by Doing the Right Thing? Toronto: Canadian Homelessness Research Network Press.

Gilmer, T. P., Stefancic, A., Ettner, S. L., Manning, W. G., & Tsemberis, S. (2010). Effect of full-service partnerships on homelessness, use and costs of mental health services, and quality of life among adults with serious mental illness. Archives of General Psychiatry, 67(6), 645-652.

Goering, P., Velhuizen, S., Watson, A., Adair, C., Kopp, B., Latimer, E., & Ly, A. (2012). At Home/Chez Soi Interim Report. Calgary: Mental Health Commission of Canada.

Gulcur, L., Stefancic, A., Shinn, M., Tsemberis, S., Fischer, S. N. (2003). Housing, hospitalization, and cost outcomes for homeless individuals with psychiatric disabilities participating in continuum of care and Housing First programmes. Journal of Community & Applied Social Psychology, 13(2), 171-186.

Homelessness Partnering Strategy. (2013). Housing First Service Delivery Guidelines. Ottawa: Government of Canada

Hwang, S., & Henderson, M. (2010). Health Care Utilization in Homeless People: Translating Research into Policy and Practice. Agency for Healthcare Research and Quality, Working Paper No. 10002.

Kuhn, R., & Culhane, D. (1998). Applying Cluster Analysis to Test a Typology of Homelessness by Pattern of Shelter Utilization: Results from the Analysis of Administrative Data. Departmental Papers (SPP). Retrieved from: http://works.bepress.com/dennis_culhane/3

Laird, G. (2007). Shelter. Homelessness in a Growth Economy: Canada’s 21 Century Paradox. Calgary, AB: Sheldon Chumir Foundation for Ethics in Leadership.

Larimer, M. E., Malone, D. K., Garner, M. D., Atkins, D. C., Burlingham, B., Lonczak, H. S., ... & Marlatt, G. A. (2009). Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA: the journal of the American Medical Association, 301(13), 1349-1357.

Mares, A. S., & Rosenheck, R. (2007). HUD/HHS/VA Collaborative Initiative to Help End Chronic Homelessness national performance outcomes assessment preliminary client outcomes report. West Haven, CT: Northeast Program Evaluation Center.

McGee, S. (2013). Personal Communication

Metraux, S., Marcus, S. C., & Culhane, D. P. (2003). The New York-New York housing initiative and use of public shelters by persons with severe mental illness. Psychiatric services, 54(1), 67-71.

Nutley, S., Walter, I., Davies, H. (2007). Using Evidence: How Research Can Inform Public Services. Bristol, UK: Policy Press

O’Connell, M., Kasprow, W., & Rosenheck, R. (2008). Rates and risk factors for homelessness after successful housing in a sample of formerly homeless veterans. Psychiatric services, 59(3), 268-275.

Pathways to Housing NY. (2013). Retrieved from: http://pathwaystohousing.org/ny/

Pearson, C., Locke, G., Montgomery, A., Buron, L. (2007). The Applicability of Housing First Models to Homeless Persons with Serious Mental Illness. Washington, DC: US Department of Housing and Urban Development.

Perlman, J., Parvensky, J. (2006). Denver Housing First Collaborative: Cost Benefit Analysis and Program Outcomes Report. Denver: Colorado Coalition for the Homeless.

Pomeroy, S. (2005). The Cost of Homelessness: Analysis of Alternate Responses in Four Canadian Cities. Ottawa, ON: National Secretariat on Homelessness.

Pomeroy, S. (2007). Where’s the Money Gone? An Analysis of Declining Government Housing Expenditures. Ottawa, ON: Canadian Housing and Renewal Association.

Pomeroy, S. (2008). Pro-Active vs. Reactive Responses: the business case for a housing based approach to reduce homelessness in the Region of Waterloo. Waterloo, ON: Region of Waterloo.

Rosenheck, R., Kasprow, W., Frisman, L., & Liu-Mares, W. (2003). Cost-effectiveness of supported housing for homeless persons with mental illness. Archives of General Psychiatry, 60(9), 940-951.

Rosenheck, R. A. (2010). Twelve-month client outcomes and service use in a multisite project for chronically homelessness adults. The Journal of Behavioral Health Services & Research, 37(2), 167-183.

Shapcott, M. (2007). The blueprint to end homelessness in Toronto. Toronto, ON: The Wellesley Institute.

Shern, D. L., Felton, C. J., Hough, R. L., Lehman, A. F., Goldfinger, S., Valencia, E., ... & Wood, P. A. (1997). Housing outcomes for homeless adults with mental illness: results from the second-round McKinney program. Psychiatric services, 48(2), 239-241.

Tsemberis, S., & Eisenberg, R. F. (2000). Pathways to housing: supported housing for street-dwelling homeless individuals with psychiatric disabilities. Psychiatric services, 51(4), 487-493.

Tsemberis, S., Gulcur, L., & Nakae, M. (2004). Housing first, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Journal Information, 94(4), 651-656.

Waegemakers Schiff, J., Rook, J. (2012). Housing First - Where is the Evidence? Toronto: Homeless Hub.

Yanos, P., Barrow, S. & Tsemberis, S. (2004). Community Integration in the Early Phase of Housing Among Homeless Persons Diagnosed with Severe Mental Illness: Successes and Challenges. Community Mental Health Journal, 40(2), 133-150.

ENDNOTES

1. The At Home/Chez Soi project is developing a fidelity scale that can be used by communities to assess the degree to which their program model matches core values and principles of Housing First.

2. The core principles espoused in this document are a slight variation of those cited on the Homeless Hub (Gaetz, 2012), which were adopted by the At Home/Chez Soi project. These principles were in turn shaped by those identified by Sam Tsemberis (Pathways), and by the Calgary Homeless Foundation (See Appendix A).

3. M-DOT is a multidisciplinary team approach that integrates housing and clinical supports. While it borrows from ACT it is time limited in duration. The objective was to transfer care to another ACT or ICM team (based on the level of need), once a client was successfully housed. This would allow access and flow in this highly specialized and well-resourced team. Some participants stayed with M-DOT for 1 year or more, because this is how long it took to engage them and secure appropriate housing. That is, duration of treatment varied based on client needs.

4. The typology of homelessness was first put forward in the United States by Kuhn and Culhane (1998). Later studies by Culhane (2007) and in Canada by Aubry et al. (2013) confirm the view that episodically and chronically homeless persons, while smaller in overall numbers, are major users of emergency and health services.

5. These are adapted from the At Home/Chez Soi project.

Calgary Homeless

Foundation Calgary ALBERTA

Stephen Gaetz & Fiona Scott

Key Messages

• Provides a detailed look at ‘systems-response’ and integrated services.

• Has one of the longest histories in Canada of supporting housing first programs.

• As a foundation it supports a number of Housing First programs but doesn’t provide direct service delivery.

• Has some of the most robust data on successes due to the length of history and foresight.

• Has expanded Housing First to include more than just people experiencing chronic or episodic homelessness.

In 1994, when the City of Calgary began counting the numbers of people experiencing homelessness living in shelters or on its streets, there were approximately 400 homeless people. Subsequent years saw an explosive growth of homelessness, the biggest in Canada at the time, with 3,500 people identified as experiencing homelessness by 2006 (Laird, 2007).

Calgary, like many communities across Canada, had historically responded to the homelessness crisis through a patchwork of community-based emergency services and supports. There was no ‘system’, but rather an ad-hoc collection of service providers, funded by all levels of government and charitable donations. As a community, the response to homelessness was led first by the Calgary Committee to End Homelessness (CCEH) and then by the Calgary Homeless Foundation (CHF). The latter organization became the central force in creating a shift towards the adoption of Housing First strategies in the city.

Around 2006 many working in the homelessness sector began hearing about the concept of a Ten Year Plan to End Homelessness and the success these Plans were having reducing homelessness in many communities in the United States. One component of the Ten Year Plan was the importance of integrating a Housing First systems approach into the Plan and to adopt Housing First as a core philosophy guiding the success of the Ten Year Plan strategy. Housing First was then delivered through a number of programs targeting priority populations.

The outcomes of the application of Housing First in Calgary are impressive. For example, by 2012, the Calgary Homeless Foundation had successfully housed 4,096 people over 4 years, including 894 people who experienced chronic and episodic homelessness, 1,663 individuals in families with children, 690 youth and 1,464 Aboriginal people (CHF, 2012). The success of the Housing First strategy contributed to an 11.4% reduction in the number of homeless individuals in Calgary between 2008 and 2012 (ibid.), reversing a 30% biennial growth trend.

In this case study, we examine the application of Housing First as part of the response to homelessness in Calgary. What makes this example compelling is:

a) How Housing First was incorporated as a philosophy that underpins the community response to homelessness;

b) The link between Housing First principles and programs, and the Ten Year Plan model;

c) The success in creating conduciveness for change in the community;

d) The innovation in Housing First program responses this shift inspired; and

e) The positive outcomes resulting in tangible reductions of homelessness in Calgary.

The purpose of this study is to provide an overview of the Calgary Homeless Foundation’s experience with planning, implementing, and sustaining Housing First programs in Calgary, as well as some of the barriers faced and how they were overcome. Compelling data is presented to demonstrate the effectiveness of Calgary’s Housing First programs in helping people experiencing homelessness to secure and maintain housing, as well as address mental, physical and social health needs. This case study concludes with key lessons learned to help other communities adapt this model.

GETTING STARTED: FRAMING THE ISSUE

Creating ‘systems change’ is a challenge in any service context. Calgary, like most other communities, had a number of different organizations working separately to address homelessness. The move from a community response, characterized by an ad-hoc and loosely organized collection of emergency services, to a coordinated and integrated systems response, with Housing First as a central philosophy, is not an easy outcome to achieve. One cannot simply ‘order’ the community to change, suddenly close services and reopen new ones guided by a new philosophy, or expect organizations to instantly shift their focus. The strong leadership of the CHF was required to establish the conditions needed to create conduciveness for change. The community must be brought along; planning and implementation must necessarily proceed in a way that allows for success and reduces disruption of services. The model of change adopted in Calgary provides an interesting example.

Unlike many other Canadian cities, the response to homelessness is not organized by the municipality, but rather by an independent not-for-profit foundation that receives funds from government and the private sector, and is the lead institution in responding to homelessness in Calgary, thought the Province continues to fund many emergency services such as shelters. The Province of Alberta provides additional supports to the homeless sector by directly funding many services, including large emergency shelters such as the Drop-In1.

Significant features of the CHF contributed to the conduciveness for change. As a not-for-profit foundation the CHF was not entrenched in the status quo and had a certain flexibility and nimbleness that allowed it to inspire and manage change. In addition, with very strong ties to community, all levels of government and the corporate sector, the CHF was poised to help bring along the community to support change. Finally, the leadership of the CHF was focused on comprehensible outcomes (i.e. the reduction of homelessness), innovation and application of the best ideas around. There was a demonstrated interest in learning from others about what works and what does not, when addressing the issue of homelessness.

A key first step to adapting Housing First for many communities is knowing where to start. The CHF wanted to learn from what had been done elsewhere. Research has always been a priority and this evidenced-based orientation is hard-wired into the CHF and the organizations it supports.

Housing First programs have been in the U.S. for 15 years, and only more recently in Canada. However, there was still plenty to learn from those who had already been implementing these programs. This accumulation of experience was important as there was a growing sense that everything communities needed to know could be found among the experts and agencies who have been successfully integrating Housing First programs, from fundraising and program models to job descriptions and budgets. Currently there are many communities across the country to consult with for support in planning and implementing programs.

The important players and staff who needed to be recruited were those with an understanding of the vision and plan to end homelessness and a belief that a new approach, like Housing First, was required.

The Inspiration to Implement Housing First in Calgary

In the summer of 2006, business leaders, the United Way and the Calgary Homeless Foundation brought Philip Mangano, the Director of the United States Interagency Council on Homelessness (referred to by some as the ‘US homelessness policy czar’), to Calgary. Mangano was inspirational in sharing the message about Housing First and Ten Year Plans to End Homelessness to Alberta. At the heart of those plans was the idea of Housing First. Mangano told the group three things:

1) The problem of homelessness seems to be getting worse and worse no matter what we do.

2) The Housing First model is showing results.

3) It is cheaper to fix the problem than to continue doing what we’re doing.

These points were hard to dispute, and the meetings inspired a commitment to build Calgary’s Ten Year Plan to End Homelessness, with Housing First as the guiding philosophy of their plan. In January 2007, the Calgary Committee to End Homeless (CCEH) was formed, which included representatives from direct-service agencies, the private sector, the faith community foundations, the Calgary Health Region, colleges and universities, the Aboriginal community, the City of Calgary, the Province of Alberta and the Government of Canada. Drawing on key research conducted by the City of Calgary on affordable housing and homelessness, they began to shape a plan. The CCEH launched the plan, and chose the Calgary Homeless Foundation to implement it.

Creating Conduciveness within the Sector

One of the challenges faced in Calgary was getting everyone to understand what Housing First really is and how it can help. For some direct-service workers, who have a long history of working with people who have experienced chronic homelessness, the thought of putting someone in private rental market housing and expecting them to be successful took some time to grasp. It was a shift in thinking about people as having too many complex issues to be housed, to understanding anyone would be better equipped to deal with those issues if only they had a safe place to sleep at night.

“At the end of the day when a man or a woman locks the door behind them and they are safe and not worried about being stabbed, assaulted, or ripped off, (that) is when they choose to seek help because they have hope and dignity” (Stacey Peterson, as quoted in Scott, 2012:107).

Don’t Just Tell Them, Show Them

A breakthrough moment in Calgary was the use of a PBS documentary video called Home at Last about the innovative Pathways to Housing in New York City. The video shows the process of meeting a client, engaging with him, providing the support necessary for him to maintain housing and discusses the process along the way. The video allows communities, agencies and staff to conceptualize the program and its processes. By seeing the program for themselves, people began to understand how and why it worked.

This video became a useful tool and was first introduced by the Calgary Committee to End Homelessness. It was used to help the CHF convince its board, key stakeholders in the community, and service providers, that a Housing First approach ‘made sense’, and it could be adapted in the Canadian context.

Prove It – With Data

The Calgary team knew if the Ten Year Plan was going to have credibility, they would have to prove the effectiveness of Housing First. They would need to demonstrate it was possible to help people move from sleeping on the streets to successfully maintaining a tenancy. They brought Dr. Sam Tsemberis, founder of Pathways to Housing in New York, and the acknowledged early leader in implementing Housing First, to Calgary. The Pathways to Housing program had targeted the most challenging people they could find – people experiencing chronic homelessness with mental health and/or addiction issues. Even before they released their 10 Year Plan to End Homelessness, the program had provided people with rapid access to housing. Since then, extensive evaluations of the Pathways to Housing program have been conducted, demonstrating an 85% retention rate even amongst those individuals not considered ‘housing ready’ by other programs (Tsemberis et al., 2000; 2004; Yanos et al., 2004). Housing and support costs were calculated at $22,500 USD a year per client, whereas a shelter bed cost $35,000. “Why wouldn’t you do this?” Dr. Tsemberis asked.

Inspired by Tsemberis and convinced that this could work, the CHF recognized that it was essential to get a pilot off the ground and to start housing people as soon as possible. This would help demonstrate that a central tenet of the Plan to End Homelessness worked. There was a desire to prove the concept in order to build support, and also to begin to demonstrate progress right away.

Making the Business Case

When Calgary was pursuing the idea of implementing Housing First programs, there was an emerging body of research in both Canada and the United States that suggested it was cheaper to actually provide housing to people who experience homelessness, rather than keep them in a state of homelessness. A 2006 article by Malcolm Gladwell in the New Yorker, entitled “Million Dollar Murray,” sparked public debate by raising some important questions about the efficacy of relying on emergency services to respond to homelessness. Other research from Canada emerged that made much the same point; it costs less to provide appropriate housing and support to a person at risk of or experiencing homelessness (i.e. ending homelessness) than it does to provide that same person with short-term and ongoing emergency and institutional responses (managing homelessness) (Pomeroy, 2005; 2007; 2008; Shapcott, 2007). In Calgary, a report released by the Sheldon Chumir Foundation had an impact, pointing out when people are maintained in a state of homelessness, their health declines and their involvement in the criminal justice system increases, leading to higher expenditures in sectors outside the homelessness system (Laird, 2007). Finally, the CHF commissioned its own study (2008) that revealed “the annual costs of supports (including health care, housing, emergency services) [are calculated] to be $72,444 for people who are transiently homelessness, while the cost of chronic homelessness is $134,642 per person”. It was argued this was two to three times higher than the cost of providing housing and support.

“In other words, people experiencing long-term homelessness tend to touch government-funded systems such as the judicial system, hospitals and emergency shelters much more frequently than people who have housing. By continuing to provide housing with support and reducing the number of people currently homeless, we will reduce the burden on taxpayers associated with increased use of institutions” (Calgary Homeless Foundation website).

Making the case for cost effectiveness was necessary to convince funders including (and especially) the province and private donors, as well as the community, that not only was Housing First a good idea, but it also made sense from a financial perspective.

Overcoming Resistance to Change

Every community in Canada is unique in some way; however, the basic needs of most people experiencing homelessness are the same – housing and support. Some communities may be hesitant to adopt Housing First principles, perceiving that no structured program will adequately address the circumstances in their community. Adopting Housing First, as well as a Ten Year Plan to End Homelessness are challenges to the status quo, which can be difficult to change. Even within CHF, there wasn’t unanimous approval or support for the approach; in some quarters there is still resistance to this day.

The CHF’s change management strategies included convincing people of the soundness of the Housing First approach, demonstrating results and assuring them the pending changes would not undermine existing community efforts, cause job losses or have an inconsequential impact on homelessness. This meant constant communications with stakeholders, a media strategy, and frequent engagement and ongoing consultation with community partners.

As a significant funder of community-based programs, the CHF had levers of change at its disposal. The CHF lobbied the provincial government to support and fund its plan. The importance of shifting funding, or having new funding to offer communities, is critical to support implementation and to create change. At the same time, the community engagement strategy was equally important and CHF brought people along by showing them that this was the best strategy for the people they provided services to and an opportunity to do things differently.

MOVING FORWARD: PLANNING

Once people were convinced of the need for change, and a decision was made to do things differently, it became necessary to develop a comprehensive implementation plan. At the time, the Calgary Committee to End Homelessness and the CHF contacted the National Alliance to End Homelessness (NAEH) for the ten most successful examples of planned approaches that incorporate Housing First strategies. A noteworthy message was that Housing First, as a philosophy, was best delivered through an integrated systems planning approach, best exemplified through the Ten Year Plan model. The NAEH recommended the CHF look to Portland, Seattle, Denver, New York, Hennepin County and Minnesota as case studies. For systems planning, the CHF was directed to Columbus Ohio, Washington DC, Chicago, and the state of Utah. Many of these communities were also instrumental in guiding the CHF towards the development of an integrated information system technology (HMIS – Homelessness Management Information Systems).

Integrated systems planning became central, then, to the CHF approach. The organization made it a priority to learn from others, understand what works and to seek evidence for effectiveness of systems plans. This knowledge-based approach meant learning, adapting, and adopting a philosophy of continuous improvement. Change management means recognizing that you might not get everything right at the start, but you must constantly evolve and adapt, using research, evidence and evaluation to guide your progress.

Bringing in the Experts

Based on this knowledge, the CCEH decided it was important to learn from those who had gone down this road before and many leaders from the communities mentioned above were invited to Calgary. This became an exercise in tapping their expertise and establishing relationships that would pave the way for technical assistance in the future. It was an opportunity to move quickly and learn from the mistakes of the original innovators; it was a chance to find out what they might do differently if they could do it all over. Finally, it was an opportunity to further build conduciveness for change by having vital stakeholders in the community learn from people who had already implemented new Housing First programs in other cities. The hope was to lessen the community’s anxiety on the one hand and inspire people about what was possible, on the other.

Crucial experts and innovators such as Nan Roman and Sam Tsemberis were brought in to speak to stakeholder groups. Tsemberis, who is an excellent communicator as well as a strong advocate for Housing First, was invited to speak to the corporate sector and the news media in Calgary.

In March 2007, a Community Summit was held, at which Heather Lyons from Portland, and Marge Whirly from Hennepin County were invited to speak. This event was a pivotal one, and the CHF attempted to draw in as many people from the community as possible, including those from the non-profit sector, politicians, etc. The news media was also engaged to help tell the story of how and why Housing First programs and Ten Year Plans were effective strategies for ending homelessness, and why these could work in communities in Canada.

Housing First as a Central Component of the Calgary Ten Year Plan to End Homelessness

An understanding of Housing First in Calgary requires an understanding of their adoption of the Ten Year Plan to End Homelessness in 20082. Borrowing from the model developed and promoted in the U.S. by the NAEH and the United States Interagency Council on Homelessness (USICH), the plan was adapted to the Canadian context and was replicated by the other six communities3 charged with addressing homelessness in Alberta. Central to the plan was the role of Housing First and the need to create a shift: “I think having a clear mission is very important, and we needed one. Our mission, through the Ten Year Plan, was to get people into housing – not keep them in a state of homelessness while they were waiting for housing. Make housing the first priority” (Tim Richter, 2013).

The Ten Year Plan and Housing First are complementary and interdependent strategies. For instance, the Plan addressed a key factor that could impede the successful implementation of Housing First: the lack of affordable housing in Calgary at the time. As such, the Plan included an aggressive strategy to build up the affordable housing stock, which was largely decimated during the boom years of the 1990s. Additionally, it is an outcomes-based strategy, with targets and phases of implementation. Finally, the CHF is invested in a data-driven approach to coordinate services and measure progress, building on the American version of Homeless Management Information System.

Prior to the introduction of a coordinated system of care in Calgary, organizations were working more independently and using different monitoring and evaluation tools. The CHF established a way of collecting common data from all of its programs in order to evaluate the program’s ability to help people access housing and support housing stabilization. The database system that was implemented across programs – the Homelessness Management Information System (HMIS) – allows for ongoing monitoring and program evaluation in order to inform program effectiveness. The HMIS system is crucial IT infrastructure deemed necessary to support an integrated systems model and a ‘system of care’ approach4.

Here are the strategic directions as outlined in the Plan:

Strategy 1 - Stop homelessness before it begins with effective prevention.

Goal 1 - Create opportunities for people most at-risk to increase incomes in order to gain and retain housing.

Goal 2 - Reinforce emergency prevention.

Goal 3 - Streamline access to services.

Goal 4 - Stop discharging people into homelessness from hospitals, corrections and foster care by December 31, 2011.

Goal 5 - Improve housing opportunities and services for homeless youth.

Strategy 2 - Re-house and provide the necessary support to Calgarians experiencing homelessness.

Goal 1 - Help move people into housing first.

Goal 2 - Help move 1,200 people experiencing chronic and near-chronic homelessness into housing with support within seven years.

Goal 3 - Implement a city-wide common, but physically distributed, intake and assessment process by December 31, 2010.

Goal 4 - Implement city-wide case management by December 31, 2011.

Strategy 3 - Ensure adequate affordable housing, supportive housing and treatment capacity.

Goal 1 - Develop 11,250 new units of affordable housing, including 1,200 supportive housing units and treatment beds.

Goal 2 - Acquire 114 acres of land for affordable housing, supportive housing and treatment capacity.

Strategy 4 - Improve our data and systems knowledge.

Goal 1 - Introduce a mandatory Homeless Management Information System.

Goal 2 - Develop and maintain a detailed services directory.

Goal 3 - Expand, co-ordinate and deepen research capabilities to gain a detailed understanding of homelessness in Calgary, and evaluate performance of our Ten Year Plan.

Strategy 5 - Reinforce non-profit organizations serving Calgarians experiencing or at risk of experiencing homelessness.

Goal 1 - Address the critical human resource issues facing homeless-serving non-profit agencies including wages, benefits and workload.

Goal 2 - Improve efficiency by refining co-ordination and optimizing existing resources.

Goal 3 - Reduce the administrative burden on homeless-serving non-profit organizations.

Goal 4 - Build public support and encourage community action on homelessness.

In 2011, after the third year of The Plan, it was reviewed and revised, and an update was released. 10 Year Plans are living documents and need to be revised on an ongoing basis to reflect changes in the social, political and/or economic environment. Much progress had been made. Over a three year period, 2,000 units of affordable housing were made available, with another 1,000 on the way. Most shelters funded by the provincial government now had a housing strategy, and Housing First as a philosophy and practice was integrated into a broad range of programs, including outreach and day services. Significantly, shelter usage, which had been on a steep rise for years in the City of Calgary, had leveled off and there were signs it was beginning to drop.

THE CHF HOUSING FIRST APPROACH

The Housing First approach adopted in Calgary is deeply integrated into the Ten Year Plan and is underpinned by a core philosophy: all the activities of the homelessness sector should be directed towards moving homeless people into housing and providing them with the supports they need to maintain it. “Housing First puts the priority on a rapid and direct move from homelessness to housing, instead of requiring people to graduate through a series of steps before getting into permanent housing” (CAEH, 2013). Housing First programs in Calgary provide housing first and then offer supportive treatment services to help with mental and physical health, substance abuse, education and employment. Housing First in Calgary is based on 4 core principles:

1. consumer choice and self-determination;

2. immediate access to permanent housing with the support necessary to sustain it;

3. housing is not conditional on sobriety or program participation; and

4. social inclusion, self-sufficiency and improved quality of life and health (Canadian Alliance to End Homelessness, 2012).

The Housing First philosophy of the CHF applies to all people who experience homelessness. This is a critical feature of the CHF approach and something that differentiates it from the original Pathways model (New York) or even the At Home/Chez Soi model (in Canada), both of which target homeless populations beset by mental illness and addictions.

For the CHF, the defining characteristic of the client population receiving Housing First support is that they are experiencing, or are at imminent risk of experiencing, homelessness. That said, there are clear priorities within the plan, and this meant adapting the model to target key sub-populations, including those leaving addiction, youth, families and veterans. This reflected a very deliberate and conscious strategy to innovate and is one of the defining features of the Housing First approach in Calgary.

Service Integration/System of Care

The success of Housing First depends on the program’s ability to provide the range of services required to address the various needs of people experiencing homelessness in addition to housing. As part of its Ten Year Plan, Calgary has implemented an integrated systems approach. This means the services within the sector collaborate, share data and coordinate intake and exit strategies. The service model also seeks to strengthen links between homelessness services and mainstream services, creating a ‘system of care’. Originating in children’s mental health and addictions sectors, the concept can be defined as ‘‘an adaptive network of structures, processes, and relationships grounded in system of care values and principles that provides children and youth with serious emotional disturbance and their families with access to and availability of necessary services and supports across administrative and funding jurisdictions’’ (Hodges et al., 2006:3). This organized system allows for more flexibility to meet the needs of a range of different populations. The CHF learned and adapted its “system of care” approach from communities in the U.S. (such as Columbus, Ohio) that had already applied it to the challenge of homelessness.

According to the CHF’s ‘system of care’ planning framework, programs serving people experiencing homelessness are organized into eight types:

1. Prevention Programs – Designed to reduce the risk of people losing their housing and/or experiencing other forms of homelessness (see Canadian Definition of Homelessness5).

2. Rapid Rehousing – Designed to provide individuals and families who do not have major barriers or high support needs with short-term supports (temporary rent supplements, for instance), to enable housing stability.

3. Housing and Intensive Supports Programs – Designed to serve people with higher barriers, services and supports are considered time limited (12-24 months) and help people move into independent living or permanent housing. This is particularly useful for clients discharged from mainstream services such as corrections, inpatient health care, addiction treatment or child protection services.

4. Short-Term Supportive Housing Programs – Designed to provide housing and intensive supportive services in a more structured, place based environment.

5. Permanent Supportive Housing Programs – Designed as long term housing without length of stay restrictions, for people with significant mental health or addictions challenges, or disabilities.

6. Outreach Services – Designed to provide basic referrals and services for people experiencing chronic homelessness who are considered ‘unsheltered’ (see Canadian Definition of Homelessness6).

7. Emergency Shelters – Designed to provide temporary accommodations and essential services for individuals experiencing homelessness.

8. Support Services – Designed to include day programs, employment and training programs, and health services.

These program elements are intended to work as an integrated system, supported by common assessment and intake, case management and the HMIS. All program areas are intended to support people through their needs and work towards the goal of Housing First. This means the service model of some programs must change. For instance, when fully implemented, shelters will be oriented towards moving people into housing. Likewise, outreach is designed not simply to provide individuals with supports to help them survive or to link them to shelters, but to help them get into housing, with the required supports. Prevention services are designed to ensure people retain their housing or are provided with supports to rapidly move into new accommodations if necessary.

This is Housing First constructed as a philosophy and systems approach, and not simply a program model. The CHF provides funding for services, coordinates the system and provides the infrastructure to support intake, data collection and analysis. The actual programs and services are delivered by agencies in the community.

The CHF funds 35 Housing First programs for people experiencing homelessness, including several sub-populations. Each program has its own intake and assessment based on the type of program. Case management standards were developed by the CHF, which outline case management requirements for each type of program.

As a result of Calgary’s system of care, where shelters, housing programs and supports are connected, individuals can access Housing First programs in a variety of ways including:

Emergency Shelters

Housing First programs are located in all of the emergency shelters with the exception of the youth shelter. Staff, however, are able to refer youth to a Housing First program.

Short-Term/Transitional Housing Programs

Women and families fleeing violence, for instance, in a short-term or transitional housing program can be referred to community housing.

Other Support Services

Other services that work with vulnerable populations might provide health and outreach supports, as well as Housing First options.

Street Outreach

The CHF funds Street Outreach Workers whose job it is to engage people sleeping ‘street rough.’ The Outreach Workers are connected to Housing First programs and can refer individuals to any of the housing programs.

Referrals, Prioritization and Intake

As a condition of funding, the CHF requires agencies to work with a variety of people, including those from shelters and other housing programs. People experiencing chronic homelessness and/or currently sleeping rough are prioritized.

The CHF is currently in the process of implementing a coordinated intake process. Coordinated intake is similar to centralized intake. The big difference is that you can enter the system from multiple points but intake, assessment and prioritization is handled the same way. It is considered by CHF to be a ‘No wrong door’ approach. Clients can be referred between agencies, but with coordinated intake there are assessment tools and the use of a shared database (HMIS).

Programs for Vulnerable Sub-populations7

Through their experience, the CHF has found a ‘one size fits all’ approach does not work for everyone. Sub-populations with different risk factors and pathways into experiencing homelessness require different solutions.

Youth

The CHF funds nine programs for youth under the age of 24. The Infinity Project (see case study in this book) is a Housing First program for youth operated by the Boys and Girls Clubs of Calgary. Using a scattered site approach and rental market housing (rent subsidies are provided), Infinity has demonstrated remarkable results with a 95% housing retention rate after one year. Youth can also access some services in the adult Housing First programs. There can be special challenges working with youth. Some need time in a supportive housing context to have the opportunity to practice life skills, such as buying groceries and paying the rent on time, before they can move into more permanent housing. In addition, young people often experience difficulties accessing housing, as landlords are not always interested in signing a lease with someone who has never held one before. As such, funded programs can make the lease agreement with the landlords easier, as they will enter into an agreement knowing that there is back up and that rent is secured.

Aboriginal Peoples

Like many other Canadian cities, Aboriginal peoples in Calgary are disproportionately represented in the homeless population. The CHF funds six Aboriginal-focused programs, including Aboriginal-serving agencies run by people who identify as Aboriginal, as well as mainstream organizations that support a wide variety of people and cultural backgrounds. These mainstream services have added a cultural component to their programming.

While the feedback has been the majority of Aboriginal people want access to cultural support, this not the case for everyone. Some people lack a cultural connection because they grew up in the city, for instance, while others have had bad experiences with people from their culture. Either way, a range of services is available for Aboriginal people in Calgary. A trauma component is being added to some programs that have clients who suffer from inter-generational trauma as a result of a residential school legacy and/or other historical colonial impacts.

The CHF also supports cultural awareness by mandating yearly Aboriginal training sessions for all staff from funded programs.

Women

Single women experiencing homelessness are particularly vulnerable – they tend to have higher mental health concerns, more chronic physical health concerns and histories of victimization and violence. The CHF funds four programs offering women-only spaces with the goal of providing an environment that feels safe and secure, if this is the preference. This includes the CHF’s permanent supportive housing program with the YWCA, as well as the Discovery House Community Housing Program which applies Housing First to women fleeing domestic violence.

Relationships and Partnerships that Enable Housing First in Calgary

A number of relationships and partnerships with other services are critical in Calgary, including:

Landlords and Building Managers

Partnerships with landlords and building managers are critical in order to help negotiate the presence of clients in their buildings. Building managers are able to report any tenancy issues to housing support workers. The key is in maintaining these relationships and being able to act as an effective mediator between clients and landlords.

Calgary took their lead from Sam Tsemberis in terms of their practices, and also studied the Rapid Exit8 program in Hennepin County. They sold the idea to landlords and building managers by highlighting the advantages, which help to minimize the risk including:

1) The rent is guaranteed.

2) If evictions are necessary, they will be done by the housing agency.

3) Any damages will be covered by the housing agency.

The housing agencies are also responsible for screening and intake. For many landlords, these factors help manage risk.

Calgary had a champion within the housing sector – one of the Board members of the CHF owned Boardwalk Rental Properties. When Calgary introduced its first Housing First program, Pathways to Housing, Boardwalk volunteered the apartments. They were able to get the project going and demonstrate they could manage the risk.

They also approached the Calgary Apartment Association, who were enthusiastic about becoming involved. They recognized that through the program, rent is paid directly to the landlord, intake is facilitated by program staff and damages are repaired, all of which significantly reduces the risk to landlords.

Neighbours and the Community

In Calgary, many Housing First clients are ‘invisibly’ housed, meaning they live in scattered site units, in different buildings, in a variety of communities in the city. As in any tenancy, from time to time there can be problems, so the CHF was intentional about building relationships with neighbours and the community. They met with community associations, usually inviting the police to attend, and told the associations about the CHF, Housing First, and they were looking to develop housing services in the area. The CHF listened to peoples’ concerns about safety and security and discussed the measures in place to deal with community issues and respond to problems. Being responsive to problems and concerns is the key to maintaining good relationships with the community.

Police and Emergency Services

Positive and communicative relationships with police and emergency services can help ensure the security and safety of clients. With the Pathways to Housing program, for example, a system was developed to enable the on-call housing staff to be notified when a Pathways client called 911 (or a call was made about a client) so the housing staff could attend and help mitigate the situation.

Mainstream Services

Many of the needs of people experiencing homelessness involve health or criminal justice issues. As such, relationships with representatives from the health sector and legal services are crucial. With an Intensive Case Management (ICM) model, case managers always are working to connect clients to mainstream services.

Social and Community Supports

One of the biggest challenges with Housing First in Calgary continues to be helping people with reintegration into their communities. People who have experienced homelessness are often at risk of extreme social isolation, once they have accessed housing; should this occur, the situation can exacerbate other issues and barriers to housing stabilization. Housing First programs must include partnerships with recreation centres, religious institutions and other community organizations of interest to the clients.

Risk Management

The complex needs of people who have experienced homelessness, many of whom have addiction and mental health issues, can sometimes result in difficult, if not dangerous situations, including fights, drugs, fires and other antisocial behaviour. Agencies need to prepare staff on how to manage risk and keep themselves safe.

MAKING IT HAPPEN: IMPLEMENTATION

The successful implementation of a systemic approach to Housing First requires attention to a number of factors.

Fidelity to the Housing First Model

Fidelity to Housing First must be maintained at both the systems level and the program level. In the planning section, the four core principles of Calgary’s Housing First philosophy were presented. In order to maintain program fidelity, the CHF needed to be explicit on expectations in relation to the core criteria for Housing First programs. Otherwise, some activities could be deemed as Housing First programs when, in fact, there is no direct access to housing or conditions are placed on the housing that break the core principles of the program. At the same time, a hard focus on producing ‘outputs’ might lead agencies to skew the services in order to produce results acceptable to the funder. This could include providing someone with housing in a remote part of town that is not of the person’s choosing, or failing to put in place supports that would enable successful community engagement, in an effort to state that someone was housed.

Process Alignment

A significant feature of the CHF’s ‘system of care’ model was bringing together agencies that serve people who are experiencing homelessness and ensuring processes are put in place so that as people access the system, they are provided with support to ensure they exit the system into housing, even if they use multiple services. For example, if someone is in a homeless shelter, or is approached through an outreach worker and offered housing, there is a relatively seamless process of first transferring the person’s services to a provider who takes up the task of supporting this transition, and then to another the team who manages the required supports once housing is in place. Anyone moving through the system may be in contact with multiple service providers, so it is imperative to ensure people receive proper assessment, are aligned with necessary services and supports, and if problems occur, interventions are in place to prevent re-experiencing homelessness.

Measuring Acuity and Linking to Appropriate Supports

Based on the needs of people accessing services, different models of support are offered. Supports are based on the acuity of a person’s needs by measuring the complexity of each individual’s experiences. A person’s level of acuity depends on two factors: the number of individual and systemic issues they are facing and the severity of those issues. Issues can include medical and mental health concerns, addictions, experiences of violence, age, life skills, education and employability, social supports, and so on. The Calgary Homeless Foundation, in partnership with The Alex Community Center have developed a tool for measuring acuity. The Calgary Acuity Scale9 and accompanying toolkit supports organizations in measuring acuity within their client base.

From the perspective of the CHF, an assessment of acuity “is used to determine the appropriate level, intensity and frequency of case managed supports to sustainably end a person/family’s homelessness” (CHF, 2012:11).

This includes:

• Rapid Rehousing: For transitionally homeless clients (low acuity) interventions typically focus on rapid rehousing, prevention and help accessing mainstream supports. They may be provided with short term funding to help secure housing and pay rent.

• Intensive Case Management (ICM): Services and supports are coordinated and help individuals become stabilized as they move towards independence. Unlike more intensive models of support (such as ACT – below), ICM is considered short term, and as the client becomes more stabilized, the level of service declines. ICM is generally suited to people more likely to experience episodic homelessness and with a moderate acuity level. In this case, interventions focus on rent supplements, treatment, housing stabilization and reducing frequency of subsequent occurrences of homelessness.

• Assertive Community Treatment (ACT): This is an intensive and integrated case management approach that usually involves a multidisciplinary team, including nursing support, physicians, housing workers and others. People generally are visited weekly in their home and supports are available around the clock. This level of support is typically required for people who have experienced homelessness and have complex needs in terms of mental health and addictions and high acuity. “This high acuity group requires engagement and stabilization supports distinct from other homeless individuals because of the key role poor health, mental and physical, plays in their homelessness pathways” (CHF, 2012:3).

• Permanent Supportive Housing (PSH): For some people, their needs are so great they will require ongoing supports for an indefinite period. Permanent Supportive Housing is a more intensive model of housing and services for individuals with complex and co-occurring issues who may benefit from tightly linked and supportive social, health and housing supports as a means of maintaining their housing stability.

Clients will have different needs depending on their situation. It is crucial for the success and cost-effectiveness of the program to measure client acuity, in order to properly match them with the level of support they need. Often programs run into problems with mismatches between need and support, and an inflexibility to change as needs change. A client might go to a shelter in the middle of a mental health crisis and have an acuity assessment done indicating high needs, but in 3 months that need might change drastically. Programs need to monitor acuity and respond appropriately.

Portfolio of Housing and Support Options to Meet a Range of Needs and Wishes

Critical to the adoption of Housing First is a system of care that includes a portfolio of housing and support options to meet a range of needs and wishes.

The actual housing stock used for Housing First varies within the Calgary model. There are different types of housing available including scattered-site housing in the private rental marketplace, mixed affordable housing and social housing. Again based on the core Housing First principle of client choice, housing is determined by client needs and desires.

Housing First programs work best when people are in the most appropriate type of housing for their situation. When things do not work out, people might be tempted to conclude the program does not work, when in fact it might have been a bad match. Housing First in Calgary has been adapted to meet the needs of youth, women fleeing domestic violence and Aboriginal people, to best meet people’s unique needs and support housing stabilization.

Housing First is not a perfect response to homelessness, but preliminary evaluations of a national Housing First program, the At Home/Chez Soi project, have shown that 12 months after being housed, 86% of participants remained in their first or second unit (Goering et al., 2012). The vast majority of people can be successful accessing private market rental units, but not necessarily everyone. For others, diverse housing options are required to address different needs and circumstances. In Calgary’s experience, then, Housing First can happen in a range of different housing types, as long as the housing and services are appropriate to the clients’ needs and are consistent with the core principles of Housing First.

Expansion of Affordable Housing Supply

Another factor that shapes the potential applicability of Housing First is the availability of affordable housing. While Calgary has experienced massive population growth over the past several decades, it has not seen a dramatic growth in rental housing stock, and, in fact, some affordable rental housing has disappeared through condominium conversion. More specifically, between 2001-2011, approximately 214-220,000 people moved to the city (City of Calgary, 2011) and 11,000 private market rental units disappeared (City of Calgary, 2013). At the same time, housing prices have continued to rise.

This presented a challenge for the CHF in implementing their Ten Year Plan with Housing First as a guiding philosophy. Without rental housing capacity, non-market rental capacity and supportive housing capacity, it would be difficult to achieve a sustainable reduction of homelessness in Calgary.

Since the Ten Year Plan to End Homelessness was implemented in Calgary in 2008, 3,677 new units were funded. The CHF forecasts nearly 8,500 units of housing are needed to end homelessness (CHF, 2012:12). One of the important lessons learned about the implementation of Housing First is this expansion in housing supply must necessarily include an increase in the size of the Permanent Supportive Housing (PSH) portfolio.

Quality Assurance

From the CHF perspective, when implementing a new program, it is considered important to have standards against which the program is measured in order to ensure it continues to meet the needs of the people accessing it. Communities adapting Housing First programs need to identify evaluation measures that will determine whether the program is being delivered as intended, and whether or not it is consistent with Housing First principles.

When the CHF began implementing its Ten Year Plan, there were no Canadian standards of care for case management, so over a two-year period they developed their own. In consultation with homeless-serving agencies, the academic community and more than 300 people who were at risk of or experiencing homelessness, case management standards were developed that lay out the expected quality of care and services agencies in the homelessness sector will provide. Standards include basic practice standards, including access to 24/7 crisis support, cultural competency of staff and programs (particularly for Aboriginal Peoples), minimum training requirements for case managers, staff to client ratios, client consent to services and grievance processes and client rights (Scott, 2012).

Monitoring

As the Ten Year Plan to End Homelessness began to be realized, the CHF, in consultation with the community, developed performance monitoring standards in order to document program outcomes, maintain quality assurance and measure program effectiveness. The same data is collected for each type of housing program. This includes data markers chosen by a committee to represent meaningful indicators for reducing homelessness.

The data is collected via a shared database system, the Homelessness Management Information System (HMIS), which is used by all CHF-funded programs. The first of its kind in Canada, an HMIS is a data management system that allows information and data to be collected and shared across the sector. HMIS runs on web-based software that can be accessed from anywhere. The system automatically tracks and records access to every client record by use, date and time of access. One of the greatest benefits of HMIS is the ability to create reports describing client characteristics, outcomes of the services they receive and general agency operating information. Agencies can use this data to determine if clients are being improperly referred to their services, when they would be more suited to receive services elsewhere, or to quantify additional need to funders.

HMIS allows agencies and funders to:

• Collect system-wide, standardized data for accurate, real-time reporting on the total number of people experiencing homelessness, the length and causes of homelessness, and their demographic characteristics and needs;

• Better understand people’s longitudinal homeless experiences by tracking the services they receive throughout the duration of their homeless episode(s);

• Better meet people’s needs by improving service co-ordination, determining client outcomes, providing more informed program referrals and reducing their administrative burden;

• Improve research for evidence based decision making, such as program design and policy proposals; and

• Help shorten the length of time people experience homelessness and direct them through the system of care more efficiently.

Any effective Housing First program needs to have a system for ongoing monitoring and data collection with dedicated staff able to measure important outcomes (i.e. re-experiencing homelessness, housing stability).

Thinking about Sustainability: What is Success? Identify the Long Term Goals

Long term funding is a critical piece of the ending homelessness puzzle and is crucial for the sustainability of any program or intervention. An important first step in securing longer term funding in Calgary was identifying what long term sustainability is for the people who experience homelessness in the community. Who needs support, at what level, and for how long? Who will be able to achieve independence? It is important to understand what a ‘graduation rate’10 from supportive programs might look like for different people. In Calgary it is estimated that between 10-20% of clients could graduate if they did not require a rent supplement. These clients are able to live independently of case management supports but need financial support still.

Some people might not require social supports, but may never be able to afford market rent. Some people might need higher levels of support for longer periods of time and it is important to identify the point in time when it might be systemically cheaper to provide housing to these individuals in a different type of housing than private market units, such as Permanent Supportive Housing. At the same time, agencies and funders need to be wary of creating a co-dependence on the support provided, and be mindful of helping people move towards self-sufficiency, so those who might otherwise be independent are not provided with supports they do not really need.

The next challenge becomes figuring out what happens in five years if a client has another crisis. Communities will need to determine how people will maintain their supports to prevent future experiences of homelessness.

Continue to Demonstrate Success

Despite evidence of initial effectiveness, funders and stakeholders will want to know the program is maintaining effectiveness. An initial and sustained commitment to measuring program outcomes is crucial for demonstrating Housing First works. Continuous data collection, via HMIS, allows for regular analyses of data that inform program effectiveness and enables the CHF to report to stakeholders and funders. The CHF publishes updates on the plan, including progress to date and milestones achieved including: number of people housed, housing retention rates and changes in use of other social services.

EVIDENCE OF EFFECTIVENESS OF HOUSING FIRST IN CALGARY

HMIS was implemented in April 2012. The first several months were a learning process for agencies and the CHF. Staff needed familiarize themselves with the system and the data requirements in order to provide meaningful data. According to experts in the U.S., the process does take time – anywhere from 1-3 years to become efficient. Nevertheless, the data currently available demonstrates positive outcomes for people who have accessed Housing First services, many of whom have histories of chronic experiences of homelessness. Data from HMIS has already revealed:

• In the first five years of the Ten Year Plan, 4,500 people have been housed.

• In a sample of 270 people who were housed with supports, 92% retained their housing after one year (CHF, 2013).

In January 2013, the Alberta Secretariat for Action on Homelessness published A Plan for Alberta: Ending Homelessness in 10 Years - 3 Year Progress Report, including the impact of Housing First programs. The report is based on data from across Alberta including data from CHF-funded programs. The report concludes:

• 80% of people who accessed Housing First services have remained housed for at least 12 months.

• Interactions with EMS were reduced by 72%.

• Emergency room visits were reduced by 69%.

• Days in hospital were reduced by 72%.

• Interactions with police were reduced by 66%.

• Days in jail were reduced by 88%.

• Court appearances were reduced by 69% (Alberta Secretariat for Action on Homelessness, 2013).

Cost

The CHF worked with agencies over time to identify the actual costs associated with the different types of housing programs provided.

• Assertive Community Treatment costs approximately $22-24,000 per person, per year.

• The Alex HomeBase Program (e.g. Home Base, Alpha Housing) costs $18,000 per person, per year.

• Permanent Supportive Housing (when no rent subsidy required) costs $10-15,000 per person, per year.

• Rapid access to housing/low intensity case management costs $5-6,000 per person per year.

When calculating costs, the community’s rental context is important. Depending on the availability of the market stock and its affordability, communities may need to increase or decrease the rent subsidies in the program budget.

Cost savings

Compared to the costs of running an emergency shelter system, the cost of providing longer-term housing and support is negligible. However, depending on people’s needs and acuity of those needs, the actual costs vary considerably. Several studies11 on individuals with the highest need show costs of $100,000 or more per year in system costs; two to three times higher than the cost of providing housing and support. Providing housing and support for individuals with complex needs can cost as much as $36,000 per year and providing 24/7 care, similar to a nursing home, only costs $56,000 per year. Individuals with lower levels of need can be access new housing for as little as $4,000 per year (CHF, 2011).

KEY LEARNINGS

The implementation of the Ten Year Plan, with Housing First as a central philosophy, represented a paradigm shift in how Calgary responded to homelessness. Many lessons were learned, both in terms of successes and challenges. Below is a short list of key learnings drawn from the experience of implementing a systems-based approach to Housing First.

1. The Importance of Making the Case

When the CHF was contemplating doing things differently, it was recognized that a central strategy of change management is building support and confidence amongst significant stakeholders. Section I of this case study outlines some of the primary steps, such as bringing in experts to speak to the community, mobilizing the news media, and working with the sector to reduce fears and anxiety. One of the milestone successes of Calgary’s strategy is how they were able to ‘bring people along’.

2. Housing First, Ten Year Plans and Integrated Systems

Housing First alone will not end homelessness; the program must be delivered in the context of a Ten Year Plan to End Homelessness that includes prevention, housing development and changes to systems and policies that contribute to homelessness. All of these elements are interconnected. A Ten Year Plan cannot be effective enough to END homelessness without Housing First principles at its centre. At the same time, it must be built upon an integrated systems model, supported by data management and sharing, common assessment, and effective process alignment.

3. Competition for Funding as a Barrier to Implementing Housing First

The vast majority of the money in the homeless system is dedicated to emergency services. Until the pressure on those services can be relieved, it will be difficult to shift resources towards long-term solutions. There is, understandably, a barrier at the community level, as it becomes a question of who loses funding in order to support Housing First. As popular as it may be, if it looks like a shelter is going to lose money in order to support Housing First, there is probably going to be opposition.

Short-term Additional Investment for Long-term Gain

To shift resources in an emergency system, small amounts of funding must be allocated in the short term, especially to help the people who are stuck in the current homelessness system and accessing the majority of the resources. It is important to make the business case for Housing First.

Public funding is essential to implementing Housing First, and must necessarily involve all levels of government. However, private investment (which is social finance) can augment public funding and is a unique opportunity presented by Housing First. The programs lend themselves to social finance; with the right measurement systems, program models, and role of the broker in the community, it is possible to demonstrate cost reductions. Of all of the different opportunities for social impact bonds, Housing First programs are most suitable.

4. Housing First Needs to be Linked to an Affordable Housing Strategy

Housing First on its own should not be seen as a magic wand. In order to continue to achieve the success Housing First has seen, the availability of different types of housing is be crucial.

The affordable housing supply can be expanded through a combination of direct investment (building new stock), zoning (inclusionary zoning, legalizing and regulating secondary suites), creative financing and incentives for the private sector. Communities need to work together to prioritize housing as an investment. Private market rental units can be utilized in Housing First programs, but then there will always be a need to subsidize most of those rents for people who cannot afford them long term – at what point does it become cheaper to build affordable housing, and for whom? What is affordable for some people may not be affordable for everyone. Some will be working and able to pay, while others will have no income and are unable to pay even minimal rent.

It is important to demonstrate to funders and policy-makers that the status quo – emergency shelter systems and ultimately health, social and correctional services – is not sustainable.

5. Matching Acuity Assessment to Program and Support Models

One of the important lessons learned for the CHF was the challenge of finding appropriate services for specific clients. In some cases, people were offered ICM and actually needed the more comprehensive support of an ACT team. Conversely, some people with ACT team supports needed less services, and for a shorter period of time. This meant some people were inadequately served, and resources were misallocated to others. This example highlights the need for accurate acuity assessment, appropriate follow up and the ability to shift and change the model of support based on an evolving understanding of individual needs.

6. Rent Supplements

The hope for the future is that everyone will be living in housing they can afford and rent supplements enable some people to accomplish this. Rent supplements are an important piece of Housing First programs. In order to find the most appropriate housing for someone, it is important that rent supplements are integrated into program funding, rather than separated. This allows for flexibility in housing type and location, and also reduces the challenge of administering payments.

7. Adapt Housing First to Suit the Needs of the Community

Housing First can be adapted for a range of populations in different communities and can be tailored to a specific community’s housing system and needs. Each program can be adapted based on what is and is not available in the community. For example, in larger cities where there is more public housing the needs may be different.

Consumer choice is one of the pillars of Housing First. It is about helping people access what they feel they need, rather than trying to give someone a treatment or intervention someone else thinks they need. It is important for communities to understand Housing First is not rigid, but rather adaptable, provided the program adheres to the four principles.

There is flexibility in the program model to respond to the needs of unique populations. In order to respond to those needs, it is important to actively consult with members from each group who will access services to identify their needs and allow their support to be consumer-driven.

8. Technical Support

When adopting Housing First, it is important to ensure people have the understanding and capacity to implement quality programs. When quality is lacking, programs and people suffer. Housing First has been successfully implemented in many communities across Canada and the U.S.; experts are available for consultation and data has been gathered to guide new initiatives. Many accomplishments can be replicated and barriers avoided. Successfully building Housing First programs can be learned from the people who are already running them.

Technical support and advice goes hand in hand with having standards for delivery of service, and expectations for program quality and outcomes. There will be risk involved with clients, but this risk can be readily managed through the right relationships, and having information and standards in place to ensure effective programming. Reach out to experts to ensure Housing First programs are being properly implemented.

When the CHF began to implement HMIS, for example, they brought in experts, including David Canavan, who had been active in setting up data management information systems in Canada. They solicited the best candidate to create the database through an RFP process, and worked with the community to develop the most suitable system.

Access to tools and networks that can facilitate implementation of the program in new communities are important for ensuring quality programs.

REFERENCES

Alberta Secretariat for Action on Homelessness. (2013). A Plan for Alberta: Ending Homelessness in 10 Years: 3 Year Progress Report. Human Services Alberta. Retrieved from http://humanservices. alberta.ca/homelessness.html

Calgary Homeless Foundation. (2011). Calgary’s 10-year Plan to End Homelessness: January 2011 Update. Retrieved from http:// calgaryhomeless.com/10-year-plan/

Calgary Homeless Foundation. (2012). Community Leadership.Calgary Homeless Foundation Annual Report, 2012. Calgary, CHF.

Calgary Homeless Foundation. (2013). Five-year Update to Ten-year Plan. Retrieved from http://calgaryhomeless.com/

Canadian Alliance to End Homelessness. (2012). A Plan Not a Dream: How to End Homelessness in 10 Years. Retrieved from http:// www.caeh.ca/a-plan-not-a-dream/

City of Calgary. (2011). 2011 Civic Census Results. Retrieved from http://www.calgary.ca

City of Calgary. (2013). Community and Neighbourhood Services Social Research Unit. Research Summary #1. Retrieved from http://www.calgary.ca

Goering, P., Velhuizen, S., Watson, A., Adair, C., Kopp, B., Latimer, E., & Ly, A. (2012). At Home/Chez Soi Interim Report. Calgary: Mental Health Commission of Canada.

Laird, G. (2007a). Shelter : Homelessness in a Growth Economy: Canada’s 21 Century Paradox. Calgary, AB: Sheldon Chumir Foundation for Ethics in Leadership.

RSM Richter and Associates. (2008). Report on the Cost of Homelessness in the City of Calgary. Calgary Homeless Foundation.

Scott, S. (2012). The beginning of the end: The story of the Calgary Homeless Foundation and one community’s drive to end homelessness. Canada: Calgary Homeless Foundation.

Tsemberis S, Eisenberg RF. (2000). Pathways to housing: supported housing for street-dwelling homeless individuals with psychiatric disabilities. Psychiatric services, 51(4), 487-493.

Tsemberis S, Gulcur L, Nakae M. (2004). Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Am J Public Health, 94(4), 651-656.

Waegemakers Schiff, J. & Rook, J. (2012). Housing First - Where is the Evidence? Toronto: Homeless Hub.

Yanos, P., Barrow, S. & Tsemberis, S. (2004). Community Integration in the Early Phase of Housing Among Homeless Persons Diagnosed with Severe Mental Illness: Successes and Challenges. Community Mental Health Journal, 40(2), 133-150.

ENDNOTES

1. The Calgary Drop-In and Rehab Centre is the largest emergency shelter in North America, and is funded through charitable donations (46%) and through the Government of Alberta’s Ministry of Housing and Urban Affairs (54%).

2. Calgary’s Ten Year Plan to End Homelessness – 2008-18

3. Edmonton, Fort McMurray, Lethbridge, Red Deer, Grande Prairie and Medicine Hat

4. It is important to note that HMIS does not refer to a specific technology, software or provider but rather to an information management system. A number of potential technologies can be used to support an HMIS approach and Calgary used Bowman Systems.

5. http://www.homelesshub.ca/CHRNhomelessdefinition

6. ibid.

7. For a complete list of the CHF’s funded Housing First programs please see http://calgaryhomeless.com/assets/agencies/FundedProgramsCHF2012AnnualReport.pdf

8. http://www.hennepin.us/files/HennepinUS/Public Affairs/PA Info & Media Outreach/Fact Sheets/_Human Services and Public Health/Housing_RapidExit_Homeless_Prevent.pdf

9. http://calgaryhomeless.com/assets/agencies/Calgary-Singles-Acuity-Scale-toolkit.pdf for information on measuring acuity.

10. ‘Graduation’ refers to the ability of a person to live in permanent housing on a relatively independent basis. They may still access community supports but wouldn’t need a high level of dedicated casework management.

11. 2010 Study by U.S. Department of Housing and Urban Development. “Costs Associated with First Time Homelessness by Families and Individuals.”
Commissioned by Calgary Committee to End Homelessness. “2007 RSM Richter Inc. Study on Cost of Homelessness in Calgary.”
National Secretariat on Homelessness (2005) Study. “The Cost of Homelessness: Alternate Responses in Four Canadian Cities (Vancouver, Toronto, Montreal and Halifax).

The Infinity Project

Calgary ALBERTA

Fiona Scott & Sarah Jean Harrison

Key Messages

• A program targeted at youth homelessness and adapted to meet the needs of this specific sub-population.

• Shows how a service organization can adapt its programming to meet client needs.

• If read in conjunction with the Calgary Homeless Foundation case study it will help provide a broader understanding of the ways in which different models can exist in one community.

No young person should be living on the streets. Unfortunately for many youth, intolerable living situations created by family difficulties can make the streets appear to be their better option. According to Calgary’s 2008 Biennial Homeless Count, 355 youth under 18 and 327 youth between 18 and 24 were experiencing homelessness; continuing a serious trend from the previous count in 2006 (304 youth under 18 and 343 youth between 18 and 24) (City of Calgary, 2006). In total, youth homelessness represents approximately 20% of the total population experiencing homelessness in Calgary (Stroik et al., 2008). However, these figures underestimate the size of population experiencing youth homelessness. Many youth are a part of the hidden homeless population and remain undocumented in homeless count statistics; they are couch surfing, staying with friends or remaining out of sight while sleeping outdoors.

GETTING STARTED: FRAMING THE ISSUE

Since 2007 Calgary has been developing a Housing First response to homelessness. Beginning with Calgary’s 10 Year Plan to End Homelessness (2008), the community has created a unified system of response to homelessness administered through the Calgary Homeless Foundation (CHF). CHF, an independent not-for-profit foundation that receives both private and government funding, administers the distribution of funds to most services and programs addressing homelessness in Calgary (see Case Study on CHF).

CHF has also developed a system of care approach to service provision that integrates service delivery. Services collaborate, coordinate and share information, while also bridging the gaps between mainstream and homelessness geared services in the community. Much of this coordination is accomplished through the Homelessness Management Information System (HMIS), a cross-sector data management system that allows agencies to ensure clients are receiving appropriate resources and support. Through CHF’s leadership, the shift to a Housing First model has been implemented with significant success: by 2012, 4,096 people had been housed and an overall 11.4% reduction in the number of individuals experiencing homelessness was achieved between 2008 and 2012 (CHF, 2012).

As the number of youth experiencing homelessness continued to rise despite the successes of Housing First in Calgary, the Boys and Girls Clubs of Calgary (BGCC) explored news ways of addressing youth homelessness. Because young people are still in the developmental stage of their lives, they experience a unique form of homelessness. For most young people, family support is essential to the process of becoming self-sufficient adults. Families often provide basic needs, financial support, one-on-one support and advocacy, social and emotional support and guidance. Young people who leave home are often stripped of these essential experiences. They enter into homelessness with little or no work history and often experience high levels of criminal victimization. Youth who are forced to live on the streets have fewer life skills (i.e. cooking, money management and job searching) and struggle to attend school. It was clear to BGCC that ending youth homelessness required the creation of a Housing First program that offered intensive housing support tailored to the unique needs of young people.

MOVING FORWARD: PLANNING

Since 1939, BGCC has provided safe and supportive space where children and youth can experience new opportunities, overcome barriers, build positive relationships and develop confidence and life skills. When youth homelessness arose as a concern 25 years ago, BGCC responded by opening Calgary’s first youth shelter, Avenue 15. Since then, BGCC have expanded their services for youth experiencing homelessness to include prevention, outreach, two shelters and housing. Youth accessing these programs began expressing to program staff their need for more youth-serving agencies, for a sense of belonging and for a place to call home.

BGCC recognized that youth homelessness was best understood on a continuum of homelessness. The continuum of homelessness acknowledges the multiple layers of hidden homelessness that exist between absolute homelessness and being housed. The CHF’s definition of youth homelessness captures the many ways a young person can experience homelessness:

“A homeless youth is an unaccompanied person aged 24 and under lacking a permanent night time residence. They can be living on the street, in shelters, couch surfing, in unsafe and insecure housing, and living in abusive situations. They may also be about to be discharged without the security of a regular residence from a care, correction, health, or any other facility” (CHF, 2009:4).

In 2008 BGCC piloted The Youth Housing Connection (YHC), a project providing youth with help accessing basic needs and housing. Data from YHC showed that 44% of youth were not fitting into the available youth housing programs. YHC had also quickly revealed new sub-populations of youth, such as parenting teens, young families with one partner older and one younger than 18 years old and pet owners, which were not being served by Calgary’s existing services. Youth from these subgroups were choosing to sleep rough in tent cities and remain together rather than enter existing shelters.

The need for youth-focused, permanent housing demonstrated by YHC, combined with BGCC’s research into the effectiveness of Housing First models in removing barriers to housing, indicated a new form of youth housing service delivery was needed in Calgary. In March 2009 BGCC launched The Infinity Project, a youth-focused Housing First program funded by CHF. Utilizing the Housing First model adopted by Calgary’s 10 Year Plan, the project provides youth (aged 16 to 24) with a permanent home in the community of their choice and the supports they need to maintain housing and become self-sufficient. Since 2009, the project has supported 58 youth in becoming housed.

HOUSING FIRST AT THE INFINITY PROJECT

Aligning with the requirements of CHF, the following Housing First principals are the foundation for The Infinity Project’s services and programs:

• Housing is a human right. Youth do not earn their home through good behaviour and do not need to be ‘housing ready’ to be successful in maintaining their home. Youth should not have to change residences when their service needs change.

• ‘Choice’ and ‘voice’ in one’s own life is essential.

• All youth need time and practice to learn to be good neighbours and to gain the skills and confidence necessary to live as self-sufficient adults.

• Supportive, accepting relationships that youth can count on are essential as youth move out of homelessness and street life.

• Youth need financial and instrumental supports to get started.

• All people, including youth, benefit from connection with community supports and resources that offer a safety net in times of trouble.

Program Framework

The Infinity Project works with up to 30 youth at any given time. The anticipated length of participation in Infinity is 2 years, with the recognition that each youth requires a unique plan with a unique timeline. Approximately 5-10 youth rotate in and out of the program every year.

During intake, consideration is given to ‘right matching’; matching the youth’s needs with Infinity’s services. In the event that the youth is better suited to another program, referrals are made to the appropriate program. The youth is supported by The Infinity Project until they begin to receive case management supports from the new program.

Transition planning, which refers to both the transition to adulthood as well as transition out of Infinity and homelessness-focused services, begins at the time of intake. As part of this transition plan, youth are supported to complete the necessary concrete tasks (as listed in the Graduation Checklist) in preparation for independence.

Participation in the Infinity Project is voluntary and youth retain the right to self-discharge from support services and from the housing that has been arranged for them. Refusal of support services does not result in housing loss.

Housing Support

For most youth who have experienced homelessness, housing in the community is the best option. Many youth have been repeatedly institutionalized, experienced trauma and have attachment and interpersonal challenges. The undermining of their autonomy and the challenges in conforming to the requirements of group living has contributed to keeping them in a state of homelessness. Based on the best practices for youth service delivery identified by the Collaborative Community Health Research Centre (2002), Infinity uses a scattered site model that promotes individual community living where a youth can feel at home and find support long past program involvement. Infinity staff work with youth to find affordable, permanent housing quickly and provide the financial support, through CHF funded rent supplements, to access that housing.

Housing Support Workers (HSW) assist youth in communicating with landlords, reviewing lease agreements, securing convertible leases, responding to landlord concerns, developing budgeting skills and helping youth access additional financial supports (Employment Insurance, Assured Income for the Severely Handicapped (AISH) and student financing). In the event of eviction, Infinity follows CHF policy and procedure using supportive case management. Staff work to rehouse the youth as quickly as possible and minimize the time of housing instability.

As youth acquire the skills for more independent living and experience the challenges of transitioning to adulthood, their service needs may change. Infinity ensures that a change in service needs does not require a change in residence and never warrants being discharged into homelessness. By maintaining a strong zero discharge to homelessness policy and using convertible leases, youth are able to maintain their housing following graduation and develop a strong sense of safety and acceptance.

Support for Achieving Self-sufficiency

Many youth in the Infinity program lack healthy supportive relationships in their lives. The relationship built with their HSW is vital to the youth’s movement out of street-involvement and homelessness. Using Outcome Star, an outcome and goal planning tool, the HSW assists the youth in identifying individual goals and developing action plans in the following areas:

• Motivation and taking responsibility;

• Self care and living skills;

• Managing money and personal administration;

• Social networks and relationships;

• Drug and alcohol misuse;

• Physical health;

• Emotional and mental health;

• Meaningful use of time;

• Managing tenancy and accomodation; and

• Avoiding criminal offending.

HSWs also assist youth in maintaining their housing and achieving self-sufficiency by working with them to:

• Find jobs or enrolling in employability and/or training programs;

• Enroll in school;

• Access financial supports;

• Prepare resumes and practice interview skills;

• Attend the Youth Employment Centre;

• Learn meal preparation and home management (cleaning, organizing, communicating with the landlord);

• Access community life skill development opportunities; and

• Learn parenting skills and relationship building.

HSWs operate from a coaching and mentorship philosophy that mimics one-to-one, parental teaching. This often means ‘doing with’ in the early stages of skill acquisition. The HSW begins transition planning on the day of intake and coordinates resources that wrap around the youth, supporting them in becoming self-sufficient both in their home and in their community. Youth also have access to BGCC Youth Housing 24/7 emergency on-call support from a HSW who is able to respond by phone or in person when necessary.

Program Graduation

Infinity staff support youth in becoming productive adults through permanent housing and intensive support provision. A client has fulfilled the basic criteria for program graduation when they have paid three consecutive months of rent on time and in full, found stable income that enables the youth to meet their financial responsibilities and (when applicable) completed three consecutive months of stable employment with one employer and without reprimand. Consideration is also given to life skill acquisition, mental and emotional stability and the presence of community and natural supports.

MAKING IT HAPPEN: IMPLEMENTATION

Staffing

The Infinity Project is one of BGCC’s programs. While the project has dedicated staff, management of the project is done by staff whose role includes other BGCC projects.

Managing Director of Youth Housing and Shelter

The Infinity Project is one of eight programs in the Managing Director’s portfolio. The responsibilities of this role in relation to the Infinity Project include strategic planning, external advocacy, overseeing program development and maintaining continuity with Calgary’s overall system of care.

Manager of Youth Housing

With support and direction from the Managing Director of Youth Housing and Shelters, the Manager of Youth Housing is responsible for the development, management and oversight of operations of the Infinity Project (approximately one third of their total hours). The Manager of Youth Housing ensures that services are relevant to the needs of the clients and consistent with best practices research in Housing First programming.

Infinity Program Coordinator

The Program Coordinator is a dedicated project staff responsible for all aspects of the operation of the Infinity Project. The Coordinator must ensure that all aspects of the program model are effectively implemented and that the program is effectively integrated within BGCC’s continuum of programs.

Housing Support Workers (HSW)

Four HSWs are dedicated to the project and each help 7-8 youth find and maintain permanent housing. In this case management position, building relationships with the youth is essential as workers are responsible for identifying the appropriate amount of support required by each youth to help them remain housed and accomplish their other goals.

Partnerships

Through BGCC, Infinity participates in CHF’s Systems Planning Advisory Committee (SPAC), which works to develop CHF’s ‘system of care’ through coordinated access and assessment, as well as through the implementation of the System Planning Framework (SPF). As a member of the SPAC, BGCC has aligned its contracts, services and outcomes with the SPF and continues to make changes as the framework evolves.

Currently Infinity/BGCC and SPAC are in the process of adding the 828-HOPE Assessment and Referral service to the HMIS system. Begun in 2008, the 828-HOPE Assessment and Referral is a centralized referral service and interim case management for youth (primarily ages 16 to 24) who are at-risk of or are experiencing homelessness. The service currently provides a 48 hour face-to-face response, basic needs support, assessment and referral matching, interim case management and system navigation. 828-HOPE also provides a coordinated and centralized referral service for concerned sector and community members. Combining 828-HOPE and the HMIS system will allow vulnerable youth to be quickly referred to resources in Calgary and prevent or shorten their time on the streets.

Infinity also collaborates with the Youth Sector, a committee of vulnerable youth-serving agencies that seeks to better coordinate services, advocate as one voice and build a continuum of housing and supports in a variety of areas. As a result, clients can access a variety of services through one organization, rather than coordinating with multiple systems to access all of the supports needed. As a result of being part of this collaboration, as well as Calgary’s system of care, Infinity Project staff are able to access and refer young people to a range of services throughout the city.

Infinity staff report that working within the ‘system of care’ and with the Youth Sector committee lessens the need for formal partnerships. They do however work closely with several organizations, most notably housing providers and their parent organization, BGCC.

Alex Youth Health Centre (YHC) is The Infinity Project’s closest partner and which provides health and wellness supports for youth experiencing homelessness.

Boys and Girls Club of Calgary (BGCC) is The Infinity Project’s parent organization, which provides Infinity clients access to a variety of BGCC’s programs. For example, Infinity staff have found that alternative education and life skills programs offering financial support are extremely successful in engaging youth and helping them gain financial stability. Infinity staff work closely with all of BGCC’s programs to ensure that eligible youth are benefiting from these services.

The Treehouse building, a 10-unit apartment building in Crescent Heights owned by BGCC, is also available as affordable housing for youth from Infinity’s housing programs. The building is managed by BGCC’s internal Building Management System and has two units currently being renovated to allow for barrier free access. The residents of the building include youth from all BGCC Youth Housing programs and alumni youth who still qualify for affordable housing, as well as one community resident. The youth in the building, along with the housing staff and building management, organize “community” suppers and grounds clean-up events to promote youth community engagement.

Relationships with housing providers, such as landlords and property managers, are crucial to ensuring that young people can access housing. Infinity staff invest in relationships with housing providers from all types of housing options and provide them with access to the BGCC Youth Housing 24/7 Emergency On-call Support Worker. For example, agreements with Arlington Realty and Swordsman Properties ensure that a certain number of units are rented exclusively to Infinity clients. This type of relationship has been particularly helpful in ensuring that youth under 18 have access to safe and affordable housing options where they may be able to sign their own leases, take ownership over their homes and practice important life skills.

Despite Calgary’s shortage of affordable housing stock for youth, The Infinity Project has been able to grow its housing portfolio by forming close ties with housing providers and renting blocks of apartments. The use of convertible leases also increases Infinity’s ability to access housing. Landlords are often more willing to rent to Infinity because they are guaranteed rent, supported with tenant challenges and can seek restitution for damages.

Cost and Funding

The Infinity Project is fully funded by CHF. The total annual budget for the April 2012 to March 2013 fiscal year is $608,221.00. The project serves 30 youth at a time and anticipates serving 37 unique clients this year.

EVIDENCE OF EFFECTIVENESS

The Infinity Project has been collecting data on outcomes for all of its participants since the beginning of the program and has recently implemented the HMIS, a shared database that is used in the Calgary homelessness sector. Staff also use the Outcome Star as a service planning and outcome tracking tool. The following data has been collected to demonstrate Infinity’s success in achieving its three main goals: housing retention, self-sufficiency and access to services to actively prepare youth for productive adult living.

Housing Retention

Housing retention rates are based on all program participants from the beginning of the program to October 2012.

Of those who had been in the program for one year as of October 2012 (n=48):

• 44 youth were known to be housed (two were unknown, two had lost contact).1

Of those who had been in the program for two years as of October 2012 (n=37):

• 32 were known to be housed (five were unknown).

Stable Income

Of youth who have been in the program six months or more:

• 63% of those over 18 and 87% of those under 18 have stable income either through employment, alternative funding and education and/or employability programs.

It should be noted that although youth have stable and consistent income, it was found to be insufficient to cover monthly living expenses and these individuals still require substantial rental subsidies (BGCC, 2012).

Access to Services

Of the youth served since April 2011 and who have been in the program six months or more, 100% have engaged in community activities and supports. 84% of youth under 18 and 94% of youth over 18 reported that Infinity supported them in accessing community resources. In the last year [2011]:

• 50% of the youth accessed mental health and addictions supports in the community (four of those youth attended a residential treatment program).

Cost-Benefit Analysis

The Infinity Project’s success can also be demonstrated financially. As part of the pilot project, the program engaged in a cost analysis exercise in order to demonstrate a decrease in the average cost of services per youth per day. The average cost per day for youth in their first month was $143.94 and by six months, the cost had decreased to $23.96 per day. Raising the Roof’s Youth Homelessness in Canada: The Road to Solutions (2009) estimates that the daily cost to house youth in a shelter is $82 and $250 in a detention center. In the first year of the Infinity Project, the average cost to help support an Infinity youth was $38.81 per day.

Satisfaction Survey and Focus Group Feedback

Infinity staff have regularly collected feedback from program participants via satisfaction surveys and focus groups. Participants are asked: What’s one thing that’s changed since entering the project? Responses have included:

“I am now connected with counseling thanks to The Infinity Project. What I like about this program is that staff encourages you to look for community resources with their support; staff do it with you not for you. I have gained independence from having to learn how to find resources and I now feel more confident in my ability”.

“I feel like I am more aware of what is available in the city. I finally have a therapist and it’s one that I really like. I am now aware of how to access the food bank when I need it. If I need to know about resources, staff is always willing to help me find them”.

“I just need to get ahead financially. I am ready to live on my own because I have learned how to pay rent, maintain a job, get out of debt and the importance education has on my life”.

“I am very happy to have people who are willing to help me as I am becoming independent. I know that I have medical issues that hold me back and I wouldn’t be able to do it without support. I now know what it takes to live on your own and I am more aware of what I need to be doing”.

KEY LEARNINGS

‘Choice’ and ‘Voice’ in One’s Life is Essential

The guiding mission of The Infinity Project is based on a literature review of best practices for transitional youth services. The University of Victoria (Collaborative Community Health Research Centre, 2002) identified key factors that contribute to the effectiveness of supportive housing services for youth, as well as the factors that keep them housed. The research revealed the critical importance of choice in young people’s lives. Choice empowers youth and provides the conditions to make them happier and better able to address their other needs. Young people need to be able to choose the neighbourhood they live in so that they can access other services including education, employment and being close to family. Choice also gives youth the opportunity to make mistakes and to learn from them. Giving young people a choice allows them to learn that their ideas have to be self-generated, rather than a response to the presence of a caregiver or enforcer. As a result, young people will be more self-sufficient and able to help themselves.

Need for Adequate Supply of Affordable Housing

Housing is a human right and although Calgary City Council has recently approved plans to increase the housing stock, there is still a lack of safe and affordable housing in Calgary. Youth face additional barriers to accessing housing because many landlords are hesitant to rent to youth, especially those under the age of 18. Not having a home makes it difficult for youth to attend school and maintain a job. Affordable housing and/or adequate income supports for students who have experienced homelessness would be beneficial in ending homelessness in Calgary. Infinity staff have been able to develop positive ongoing relationships with housing providers who have agreed to rent to a number of the projects’ under 18 youth.

Need for Intensive Case Management and Long-term Support

Connections with friends, family and other social supports are important for everyone’s health and wellbeing. Many youth experiencing homelessness lack these positive relationships. In addition, the earlier they leave home, the fewer opportunities young people have to develop the skills necessary to self-sufficiency and the longer they may need to practice these skills. Infinity staff found that youth under 18 require more intensive advocacy, as well as assistance with education and employment, system and benefit navigation, as well as health and wellness training. They also require extra financial assistance, including longer and additional rental and living subsidies.

An increasing number of youth are also struggling with mental health and addiction challenges, requiring intensive case management and ongoing support to help them become self-sufficient and avoid a return to homelessness. However there is a lack of appropriate treatment options and housing with intensive supports that can respond to complex mental health needs. Staff continue to advocate for housing and support options for youth struggling with mental health and recognize the importance of early assessment and intervention. Infinity has also implemented the CHF’s Case Management Standards and successfully completed the international accreditation through the Commission on Accreditation of Rehabilitation Facilities (CARF).

Reduce Barriers to Education, Training, Employment, Financial Supports and Skill Development Opportunities

A number of barriers prevent young people from accessing opportunities that would help them get off the streets. Some youth struggle to maintain employment and are likely to experience periods of unemployment, often because of a lack of communication and conflict resolution skills. These youth also have fewer opportunities to develop skill sets that will lead to sustainable employment. Infinity has been able to refer participants to a variety of programs that address the vast range of young people’s complex needs.

Lack of adequate employment options that pay a living wage has been a significant challenge for The Infinity Project. The youth are only qualified for minimum wage employment opportunities due to their lack of experience, age and skill level. This creates challenges in completing educational goals as youth struggle to meet their financial obligations. Staff have identified that minimum wage is substantially less than a living wage. Higher and longer term subsidies for rent and living expenses are required for this population.

Additionally, student financing is dependent on a minimum of 20 hours of weekly classroom attendance, as well as passing grades. Unfortunately, youth face many challenges that prevent them from fully participating in educational opportunities. An inability to meet student financing requirements can result in immediate termination of funding. An additional challenge to accessing this funding is the system backlogs that significantly delay processing. Too often policy and programming focuses on what the youth are not doing, rather than addressing the barriers that prevent them from attending or completing school. Additional advocacy and leniency in funding requirements would be beneficial for this population.

Small Caseloads

Maintaining small caseloads in recognition of the developmental stages of youth has been beneficial in stabilizing and maintaining housing, as well as working towards goal planning. Small staff to client ratio (currently 7 or 8 participants to one HSW) ensures that youth are supported in both the development of life skills and in accessing resources and services that will allow them to transition successfully into adulthood. Ideally caseloads are even smaller (5 or 6), if funding permits. This is especially crucial for staff that have a full caseload of clients with the highest acuity needs resulting from chronic homelessness, challenges with mental health, addictions and criminal involvement.

Youth Need a Housing First Plan

The Infinity Project’s success in providing housing for youth experiencing homelessness in Calgary provided a model demonstrating that Housing First could be effectively adapted for young people. Drawing on The Infinity Project’s example and with BGCC’s contribution, CHF responded to the community’s call for action on youth homelessness in its updated 10 Year Plan to End Homelessness in Calgary (2011). The updated 10 Year Plan incorporated the Plan to End Youth Homelessness in Calgary, the first Housing First, city-wide plan to end youth homelessness in Canada (CHF, 2011). The Youth Plan included three strategies:

• Build a coordinated system to prevent and end youth homelessness in Calgary;

• Develop an adequate number of housing units and supportive homes dedicated to youth at risk of or currently experiencing homelessness; and

• Improve data and systems knowledge and influence public policy (CHF, 2011).

The Youth Plan also identified three goals:

• Reduce the length of shelter stays for youth;

• Implement a Homeless Management Information System (HMIS); and

• Ensure that no more than 10% of young people served by Housing First programs return to homelessness.

Young people experiencing homelessness in Calgary needed effective housing and support services. The Youth Plan presented a comprehensive systems view of young people who are at risk of or experiencing homelessness, placing special emphasis on preventing youth homelessness and providing young people with timely support and intervention services through a Housing First model.

REFERENCES

Boys and Girls Clubs of Calgary. (2012). Infinity Program Over 18 Final Report.

Boys and Girls Clubs of Calgary. (2012). Infinity Program Under 18 Final Report.

Calgary Homeless Foundation. (2012). Community Leadership. Calgary Homeless Foundation Annual Report, 2012. Retrieved from http://calgaryhomeless.com/assets/Progress/Year4/CHF2012AnnualReport.pdf

Calgary Homeless Foundation. (2011). Plan to End Youth Homelessness in Calgary. Retrieved from http://calgaryhomeless.com/10-year-plan/

Calgary Homeless Foundation. (2009). Setting the Course: A Blueprint to End Youth Homelessness in Calgary. Retrieved from http://calgaryhomeless.com/10-year-plan/

Collaborative Community Health Research Centre. (2002). Research Review of Best Practices for Provision of Youth Services. Retrieved from http://www.mcf.gov.bc.ca/youth/pdf/best_practices_provision_of_youth_services.pdf

Raising the Roof (2009). Youth Homelessness in Canada: The Road to Solutions. Retrieved from http://www.raisingtheroof.org/RaisingTheRoof/media/RaisingTheRoofMedia/Documents/RoadtoSolutions_fullrept_english.pdf

Stroick, SM., Hubac, L., & Richter-Salomons, S. (2008). Biennial Count of Homeless Persons in Calgary. City of Calgary. Retrieved from http://www.calgary.ca/CSPS/CNS/Documents/homelessness/2008_count_full_report.pdf

The City of Calgary, Community and Neighbourhood Services, Policy and Planning. (2006). Results of the 2006 Count of Homeless Persons in Calgary: Enumerated in Emergency and Transitional Facilities, by Service Agencies and On the Streets– 2006 May 10. Retrieved from http://intraspec.ca/2006_calgary_homeless_count.pdf

ENDNOTES

1. Housing retention rates may be higher as youth may still be housed, but have lost contact with Infinity staff so their housing status is unknown.

The Vivian

RainCity Housing and Support Society

Vancouver BRITISH COLUMBIA

Fiona Scott

Key Messages

• It is a Housing First program run by women, for women, including trans women.

• It uses a congregate housing model.

• They employ harm reduction strategies.

• It embeds Housing First principles and beliefs with a transitional housing model.

• The program works with several sub-populations of homeless women including those leaving correctional facilities, working in the sex trade industry and those women with severe mental health issues, those with cognitive disabilities such as Fetal Alcohol Syndrome/Fetal Alcohol Exposure, acquired brain injury, and/or significant substance use issues.

For women vulnerable to experiencing homelessness in Canada the Highway of Tears and Vancouver’s Downtown East Side (DTES) represent two of the most dangerous and deadly areas in British Columbia. The Highway of Tears, an 800km stretch of Highway 16 between Prince Rupert and Prince George, is named for the at least 18 young women who have disappeared since 1969 (Highway of Tears Murders, 2013). Vancouver’s DTES is one of Canada’s most marginalized neighbourhoods and struggles with high rates of drug use and crime. While services have improved greatly over the years, in the mid-2000s, the area offered very few supports for vulnerable women in the area.

Many women in the DTES experience marginalization as a result of intersecting social oppressions including racism, intolerance, discrimination and stigma. Poverty, abuse and other traumas may lead to mental and/or physical health problems, addiction issues and/or involvement in the sex trade. Considered part of the ‘hidden homeless’ population women may couch surf, stay in abusive situations and/or trade sex for shelter. Often avoiding traditional shelters for people experiencing homelessness because they do not feel safe in places where men are staying, women in the DTES face multiple barriers in accessing relevant services, let alone receiving adequate support for their particular needs and futures. Despite these barriers, many women also do not feel safe leaving the DTES to access other services.

Leslie Remund, manager of Triage Shelter, the local co-ed shelter for people experiencing homelessness, noticed that men were staying up to 30 days in the shelter and connecting with other services that supported them in transitioning out of homelessness. Women, however, were continually falling through the cracks; they did not stay as long at the shelter and were not getting connected to support services.

Part of the problem was a lack of transitional housing that provided a community of care for women and a lack of appropriate supports available to address the unique problems the women of the DTES faced. Concerned about the number of women going missing in the DTES and the lack of support services tailored for women, Remund dreamed of a program exclusively for women that would support them in getting off the streets, into housing and back on their feet. An organization was needed that worked with women involved in sex work, had mental health problems and/or addictions and was grounded in a harm reduction approach.

In 2004 funding from a private donor gave Remund the opportunity to draw on her experience in developing a Housing First program modelled on New York City’s Pathways to Housing and pilot an 18 month project that would bring women indoors, house them and work with them on their individual needs. In late 2004, under the umbrella of RainCity Housing and Support Society, Remund opened the doors of The Vivian: a harm reduction based, minimal barrier housing provider for women in Vancouver’s DTES.

This case study provides an overview of RainCity Housing and Support Society’s experience of planning, implementing and sustaining The Vivian as a Housing First program, as well as some of the barriers faced and how they were overcome. The data included demonstrates that RainCity’s Housing First program and The Vivian effectively supports women experiencing vulnerability and homelessness in securing and maintain housing.

GETTING STARTED: FRAMING THE ISSUE

The common misconception that people experiencing homelessness cannot be housed presents the most significant challenge to breaking down the barriers to accessing housing. The stereotype is particularly applied to women in this region of British Columbia, many of whom have complex needs including involvement in the sex trade, drug use and trauma from exposure to violence. The Housing First approach steps outside of these misconceptions and stereotypes with the central premise that everyone deserves a home and is house-able.

When The Vivian opened there was some resistance and concern from neighbours in this primarily commercial neighbourhood. Educating the community about the truths and myths of vulnerable populations was crucial in creating positive relationships with neighbours. The central concept shared with community members in Vancouver was that women in the DTES were chronically under-served but could be housed, given the right opportunities and support. It was also important to educate the community about the broader social benefits of supporting vulnerable women rather than ignoring them. The Vivian’s staff members recognized that sex work, drug use and chaotic behaviours were often survival strategies and by not supporting women in the situations that called for these survival strategies, problems were far more likely to arise.

Working to build bridges in the community, Vivian staff connected with neighbours by holding community meetings to discuss neighbours’ and other stakeholders’ concerns and to develop solutions to these concerns. Community members learned that by providing a safe place for women to address their needs and situations, many common concerns would also be addressed; drug paraphernalia left on the streets would reduce and the sex trade was less likely to occur outside their doors.

The Vivian developed a ‘Good Neighbour Policy’ that requires all residents to sign a Neighbouring Agreement. The terms of this agreement were negotiated with neighbours in order to ensure that women staying at The Vivian were committed to maintaining good relationships with the community. Currently, when problems do arise, neighbours are open, understanding and communicate with Vivian staff to resolve the issue. This is an indicator, for Vivian staff, of the program’s success.

MOVING FORWARD: PLANNING

Extensive planning took place before The Vivian opened its doors, which included identifying a philosophy of practice that was relational-based and client-centered. Establishing these fundamental philosophies early allowed all staff and stakeholders to work together from a common vision and understanding from the beginning.

The next step was to secure a building for the program. An old Single Room Occupancy (SRO) hotel with 24 rooms was purchased with the funding and was renovated to create an open concept space. The building was intentionally small in order to create a welcoming, personable and trusting environment for the women.

Staffing was another consideration in planning the program. High staffing levels were important to ensure that the women would feel safe and supported at all times. A minimum of two female staff would be available 24 hours per day. These support workers manage a caseload and coordinate services with a variety of partners depending upon the individual resident’s needs. They also provide on-site safety and security. Chosen staff would be required to demonstrate understanding and tolerance of the issues faced by the women in the program. For example, as outlined in a program description by Wave Consulting,

“Vivian staff members do not blame women for the choices they have been forced to make, rather they hold society and the hegemonic system of privilege and oppression, which continues to exist in a very pervasive form, accountable for the abuses and injustices suffered by Aboriginal women, women of colour, women living in extreme poverty and trans women in our culture. The women who come to the Vivian are the victims of colonization, sexism and oppression which have played out in residential schools, foster care and the criminal justice system. Many of the Vivian clients are Aboriginal women who have experienced first-hand the violence and trauma wrought by the colonial enterprise” (Wave Consulting, 2010:2).

Planning the program also required staying up to date on the political climate that drives funding and programming, particularly because the program supported women involved in sex work. Initially, staff were not fully confident that the program would succeed because of its controversial nature. In order to prevent any surprises and to ensure program effectiveness, staff were proactive in building relationships with police and worked closely with a police liaison throughout the implementation of the program.

One of the final steps before The Vivian opened was spreading the word about this new program. Connecting with other services in the community (clinics, mental health teams, shelters), letting them know about the program and making sure that others understood The Vivian’s mandate to work with the most hard-to-house and vulnerable women who were slipping through the cracks. The Vivian’s first residents were chosen by staff working with the community to identify women who would most benefit from the program.

HOUSING FIRST AT THE VIVIAN1

The Vivian is a Housing First program run by women, for women, including trans women. The program provides housing and support to women who have experienced multiple barriers including mental or physical health problems, addictions, fetal alcohol exposure/fetal alcohol syndrome, acquired brain injury, have a history of trauma and exposure to violence, demonstrate chaotic behaviour, engage in sex work or have a history of evictions. The program helps women access information, resources and services to improve their housing, health and social circumstances. The Vivian is based on the following principles:

• It is the fundamental belief of The Vivian program and the RainCity organization that the first step to stability and improved health is appropriate, safe housing.

• The program has adopted a philosophy that does not require prospective tenants to achieve a predetermined measure of ‘housing readiness’ before moving in.

• The program is essentially a harm reduction approach in that its first goal is to provide a safe refuge that helps mitigate the effects of living a high-risk street lifestyle. There is no abstinence required in order to access housing, although women are supported to address addictions issues if they choose.

Women in the Vivian program are supported to:

• Set and work towards attaining goals.

• Access harm reduction supplies and information.

• Self-advocate.

• Access safe, stable housing.

• Have opportunities to improve their overall health.

Eligibility

The Vivian works to support the most vulnerable and hard-to-house women in the community. The minimum age is 19 and the average age is 38. Primary consideration is given to:

• Women who have a long history homelessness and/or an inability to sustain housing.

• Women who work in the sex trade.

• Women who use drugs.

• Women who are particularly vulnerable to violence and exploitation and/or have a history of violence themselves.

• Women who have multiple barriers to housing such as mental illness, physical health issues, experience of transphobia and trauma.

• Women who exhibit behaviours that result in their being hard to house.

• Women who have been marginalized by systemic oppression.

Intake Process

Women can self-refer or be referred from any other service. Rather than maintain a prioritized waitlist, when a bed becomes available the staff team decide from their list of women who match their eligibility criteria who is in the highest need for a bed at that moment.

Health Promotion

Onsite nurses and doctors are available through the Vancouver Coastal Health Authority Clinical Housing Team for Vivian residents as needed. They hold regular clinics and are available on an outreach basis as well (for more information see partnerships). Women who are involved in sex work or who have addictions are provided with supplies and information. Residents receive regular gynaecological exams and information about sexual health. Residents can also be referred to other health services including addiction treatment, mental health services, support groups and community programs.

Advocacy

The Vivian staff advocate for women in order to help them get fair treatment and to assist them in accessing other services they are entitled to. This includes assisting clients with:

• Keeping track of appointments;

• Helping them get proper identification;

• Accessing educational opportunities;

• Accessing leisure activities; and

• Facilitating meetings with government bodies.

Programming and Events

Several activities and events are available for tenants including community kitchens, seasonal events, group outings, common interest groups and regular tenant input meetings.

Length of Stay

The optimal length of stay at The Vivian is two years, with the average being 16-22 months. However, each client’s discharge depends on their needs and the availability of appropriate, next-step housing.

Organizational Structure

The Vivian employs 11 staff (a mix of full and part time), including one manager, one supervisor, one Service Plan Coordinator, one Home Support Worker/Janitor, six Housing First Support Workers and one Community Integration Worker.

Service Plan Coordinator

The Service Plan Coordinator oversees all of the service planning and case management for The Vivian.

Housing First Support Workers

Housing First Support Workers are responsible for client engagement and relationship building, identifying residents’ goals and supporting them in achieving those goals.

Community Integration Worker

The Community Integration Worker connects clients with other services in the community including health, income, employment, training and recreation in order to support the client in successfully integrating back into the community.

MAKING IT HAPPEN: IMPLEMENTATION

When the program opened it quickly became clear that the service was needed. Women were often found sleeping in front of the building, saying that they ‘needed’ to live at The Vivian. News had spread quickly that there was a new, unique service for women and many women were self-referring.

Staff first needed to connect with the women, get them housed and then begin to build relationships. Recognition of the residents’ challenges and tolerance for behaviours related to drug use and trauma was required, rather than maintaining high expectations that housing would instantly solve all of a woman’s troubles. It was important that, particularly in the beginning of a residents’ tenancy, very little was required of them.

As a result, The Vivian’s staff let the women set the pace and the tone of their work. Most clients’ experience with service providers had been formulaic and disempowering. Women seeking treatment or services are often told “you should…” or “you have to…” statements; however, not everyone is ready to follow orders or perform according to others’ expectations. It can also take time for residents to adjust to living indoors. Staff recognized these needs and allowed the women to get settled at their own pace and in their own manner.

Staff have continued to develop and add services when needed and where possible. For instance, they received funding for a unique peer program to help introduce life skills, training and job activities for the residents. The program adapts to the needs and skills of the residents and provides women with the opportunity to teach others in the program any skills or abilities they may have.

Overall, The Vivian’s staff and stakeholders were pleasantly surprised that the implementation of the program went as smoothly as it did. This type of intervention had not been tried in the community before and staff were unsure of how it would work in practice. This uncertainty created opportunities to collaborate with the women to get their feedback. Tenant meetings were held that allowed residents and staff to discuss the strengths and challenges of the program, issues that needed to be dealt with and solutions to these issues. These opportunities for open dialogue were important part of assuring women that staff were keen to have residents’ input in order to make the program a success.

Building Staff Capacity

Management of The Vivian are keen to ensure the health and wellness of the staff team in order to best serve the residents. They have continued to build each of the staff members’ capacity including providing space and opportunities to access additional training. Recently work has been done on developing staff’s skills for working with women with Fetal Alcohol Spectrum Disorder (FASD).

The Need for Access to Services 24/7

Although The Vivian is able to facilitate access to other services including mental and physical health, these services are not always available when a resident needs them. For example, the service that provides mental health crisis response is only available until 3:30am. This speaks to the need for a fully integrated systems-response and remains a problem that The Vivian is still working to solve.

Transitioning Out of The Vivian

The support that is provided by The Vivian is significantly higher than what most of the residents have experienced before. As a result, when women leave the program they sometimes experience a sense of isolation. Planning for a resident’s discharge requires setting up the largest support network as possible in order to increase their chances of success. This support network includes The Vivian and its staff, as well as the possibility of returning to The Vivian if a woman encounters issues at their new location.

Lack of Appropriate Housing for Discharged Residents

One of the challenges in discharging women from the program is the lack of appropriate, next-step housing. While there is no fixed length of stay, The Vivian is not intended to offer long-term housing. Despite efforts to find appropriate housing some of the women have been at The Vivian since the beginning, highlighting the lack of housing options for women. Staff are not always able to confidently refer residents to suitable housing, particularly when none exists. There are few programs that support women with so many challenges and those that do often have multi-year waitlists. Staff members work with residents to educate them about transitioning out of The Vivian, including discussing the reality of their housing options. However, some women have no option but to move into unsupported SROs in the DTES.

The Need for Partnerships

Several community partnerships provide supports that are crucial to the ongoing operation of The Vivian and its services. Community partners include:

Strathcona Mental Health Team (SMHT)

This is a community-based mental health team run by the Vancouver Coastal Health Authority (VCHA). Their mandate is to serve clients in the DTES catchment area and, when possible, conduct outreach to access hard-to-reach clients.

Many of the women at The Vivian have disengaged with mental health services (either by choice or otherwise) or have untreated mental health concerns. The SMHT provides outreach and case management concerning diagnosis and medications, administers on-site psychiatric inter-muscular injections and make referrals to other agencies (many treatment centres will only take mental health team referrals). The SMHT is a central partner in community-based client case management.

Vancouver Coastal Health Authority (VCHA)

The VCHA operates several clinical outreach teams. The Clinical Health Team (CHT) at The Vivian consists of a nurse, nurse practitioner, doctor, social worker, outreach worker and a counsellor. All members of the team do outreach and come into the building to meet and treat the women. Because the women are often disengaged from services or have never accessed services outside of emergency rooms, the CHT serve as primary health care providers. The team’s doctor is the primary physician for most of the women and provides standard medical care such as physical health assessment, prescription medication including methadone and specialist referrals. Female specific health services, such as well-women’s exams for Sexually Transmitted Infections (STIs) and pap smears, can be conducted on-site.

The CHT social worker helps the women with tasks such as coordinating with government ministries regarding additional assistance funds, dealing with identity theft or accessing status cards. The outreach worker assists staff in providing direct support to the women, which may range from informal check-ins and chats, accompanying a woman to a hospital or court appointment and providing support with visiting children. A counsellor is also available to women wanting a therapeutic connection. Collaborating with the CHT is an essential piece of the ‘wraparound’ approach The Vivian uses in working with the women.

Dr. Bill MacEwan – Roaming Psychiatrist

Dr. Bill MacEwan is associated with a number of organizations: Providence Health (St. Paul’s Hospital where most of the DTES residents are referred for psychiatric emergencies and treatment); a private practice in White Rock, BC; Vancouver Intensive Supervision Unit (VISU), which is connected to Downtown Community Courts and offers intensive case management for individuals on probation; as well as other supportive housing organizations in the DTES.

Dr. MacEwan may follow a woman, continuing to support her mental health needs, when she transitions into The Vivian (either from other housing, through VISU, or through his outreach efforts). Eventually care is often transferred to SMHT.

Probation Officers

Some women have been mandated by their parole conditions to live at The Vivian. Vivian staff liaise with parole/probation officers around court appointment reminders and working with a woman on her conditions to ensure that she is safe, the community is safe and that she is not returned to jail.

Elizabeth Fry Society

The Elizabeth Fry Society is an organization that supports women leaving the penal system. They offer a range of services, including prison visits and housing referrals. The Elizabeth Fry Society will also provide weekly money management and assistance with budgeting skills to women leaving The Vivian with mandated financial administration.

An Evaluation of Sex Workers’ Health Access (AESHA) Project

AESHA is a central project within the Gender and Sexual Health Initiative (GSHI). AESHA is a longitudinal study of female sex workers’ health and safety both on and off the street. AESHA recruits many of its study subjects from The Vivian and does follow-up interviews with current subjects.

Triage Shelter

Triage refers appropriate women to The Vivian and offers beds to women on respite. Respite may be based on individual choice, on the need to do significant room repairs or bug control, or in response to behavioural issues and/or violence against other tenants and staff.

Princess Rooms

The Princess Rooms is a co-ed long-term, low-barrier housing similar in mandate to The Vivian. Clients are referred to The Vivian if appropriate or referred from The Vivian to the Princess Rooms. The Vivian has a similar partnership with other RainCity sites, The Lux Transitional Program and The Lux Apartments.

Sheway

Sheway provides comprehensive health and social services to women who are either pregnant or parenting children less than 18 months old and who are experiencing current or previous issues with substance use. The program consists of prenatal, postnatal and infant health care, education and counselling for nutrition, child development, addictions, HIV and Hepatitis C, housing and parenting. Sheway also assists in fulfilling basic needs such as providing daily nutritious lunches, food coupons, food bags, nutritional supplements, formula, and clothing.

WISH/Mobile Access Project (MAP) Van

WISH/MAP Van is a 24-hour drop-in centre for sex workers that provides meals, showers, make-up and hygiene products, clothing, on-site nursing care and referrals. The organization offers a Supported Employment program, a learning centre and also compiles and distributes a list of bad date reports2 for Vancouver.

The MAP Van, an overnight support van created in partnership by WISH and PACE (see below), supports women engaging in sex work at night when there are few support services/options available to them. The van travels to all areas of Vancouver. Residents of The Vivian benefit from this partnership by accessing basic hygiene services and support through bad date reporting. Referrals to The Vivian also come from the WISH/MAP van.

Vancouver Intensive Supervision Unit (VISU)

The VISU provides intensive supervision and services to clients with mental illnesses serving adult sentences in the community. Assistance with treatment, housing, life skills, financial management and health care is provided in addition to supervision of court orders. VISU is also a source of referrals for The Vivian.

Community Living BC (CLBC)

Community Living BC works with people with developmental disabilities including FASD. CLBC facilitates support services such as one-to-one care and home-share opportunities. Some of The Vivian’s clients have a one-to-one worker that assists with visits, appointments, social interaction, life-skills training and advocating with other services (such as court). Two Vivian residents have also been placed in a home share environment where the woman lives with a family in a supported environment.

Providing Alternatives Counselling and Education Society (PACE)

PACE is a sex worker led organization offering low-barrier programming, support and advocacy for survival sex workers in Vancouver. Women from The Vivian can access one-to-one counselling and have also attended several workshops over the year on topics including safer sex worker practices and self-defence.

AIDS Vancouver

AIDS Vancouver is a non-profit and community-based health organization whose mission is to alleviate collective vulnerability to HIV and AIDS through support, public education and community-based research. They also run a free twice-monthly grocery program where members can collect a hamper of fresh food goods; some of the residents of The Vivian receive this twice-monthly food hamper.

Other partners that make a significant contribution to the operations of The Vivian include:

Western Institute for the Deaf and Hard of Hearing and the CNIB provide home support, companionship or group activities for women with sight or hearing issues. They also order materials to make a woman’s room safer and accessible (including bathroom materials, special fire and smoke detectors, canes, hearing aids, etc.).

Forest & the Femme provide opportunities for outdoor recreation and support for women with cognitive barriers including FASD, addictions, poverty, racial oppression and involvement in the sex trade.

Quest Food Exchange reduces food insecurity by allowing Vivian residents to access their low-cost grocery store.

A Loving Spoonful provides free, nutritious meals to people living with HIV/AIDS in Greater Vancouver, on a short-term basis.

The Living Room is a drop-in centre for people experiencing mental illness that provides social and recreational activities.

Local Donors who regularly collect donations of much-needed items, filling the gap in resources that other programming cannot provide, including food or hygiene products or other needed items.

EVIDENCE OF EFFECTIVENESS

The Vivian maintains a database of client information in order to:

• Provide workers with a tool to document their work (in accordance with the requirements of the health records legislation).

• Assist all workers in using a client-centered, goal-oriented approach to working with clients.

• Ensure maximum continuity of care information between Vivian workers and other service providers.

• Note patterns that might suggest the need for other services or approaches.

• Provide statistics about the program for the on-going development and accountability of the RainCity organization.

• Provide statistics for the development of new RainCity programs.

Since the program opened in 2004, 124 women have been resident at The Vivian. From April 2009 – March 2013, 31 women have moved into The Vivian while 29 have moved out. Of those who have been discharged from the program:

• 45% of residents were homeless or living on the streets when they entered the program however no residents were discharged to the streets. 10% were discharged to live with relatives or friends.

• 3% of residents came from subsidized housing while 28% were discharged to subsidized housing.

• 6% of residents were living in supported housing at entry while 24% were discharged to supportive housing.

• 20% of residents were living in shelters before entering the program and 17% were discharged to shelters.

• 20% came from unsupported SROs while 4% were discharged to SROs.

• 6% of residents came from tertiary care and hospitals while 16% were discharged to such facilities (including 6% discharged to drug and alcohol treatment).

Reason for leaving the program:

• 50% of residents were discharged to a decreased level of care.

• 24% of residents were discharged to an increased level of care.

• 17% or residents were evicted.

• 6% of residents were discharged to hospital.

• 3% of residents were discharged to the same level of care.

Length of Stay:

• 21% of residents stayed less than 6 months.

• 18% of residents stayed 7-12 months.

• 34% of residents stayed 13-24 months.

• 3% of residents stayed 25-36 months.

• 10% of residents stayed 37-48 months.

• 6% of residents stayed 49-60 months.

• 6% of residents stayed 61-72 months.

Current Research

The Vivian is currently involved in an external evaluation of RainCity Housing’s three Housing First projects (The Vivian, The Lux and Princess Rooms). The purpose of the evaluation is to:

• Determine the effectiveness of RainCity’s Housing First model.

• Describe and measure the outcomes and achievements of RainCity’s Housing First Program.

• Inform the development and improvement of the Housing First model.

• Enable RainCity staff to report on program outcomes to funders, stakeholders and other service providers.

The evaluation is based on a set of indicators and data collection tools that were developed in consultation with RainCity staff and management. The tools and indicators that were identified reflect RainCity’s client-centered approach and program model that recognizes the individualized nature of tenant outcomes. In particular, the indicators and evaluation framework acknowledge that each tenant will measure success relative to their own starting point and circumstances; their outcomes cannot necessarily be compared to a pre-determined notion of success or how other tenants are doing. Baseline data for year one of the study has recently been collected.

Research Study Community Advisory Board

The board consists of committee members from the City of Vancouver, the Health Authority and a range of people who are directly involved in the program. Board members provide input to the development and process of the research study.

Sustainability

The Vivian was originally funded by the David Ash family and the Vivian Grace Ash Benevolent Fund. The initial funding allowed for the purchase of the building, as well as all operational costs until 2006 when the project received funding from the Ministry of Employment and Income Assistance (MEIA). The Vivian is currently funded through a partnership of BC Housing, Vancouver Coastal Health and private donors.

Donations from companies and philanthropic organizations, such as food, bedding and towels, also contribute to the program’s operations and sustainability.

Changes in government can mean changes in funding priorities, making it important to diversify funding for The Vivian. It is an ongoing challenge for the whole organization to increase its sustainability, however staff are confident that there is ample evidence of the desperate need for the service and The Vivian capacity to change women’s lives.

KEY LEARNINGS

Managing Expectations and the Need for a Minimal Barrier Approach

Most people who have not experienced a life of trauma are unable to truly understand the impact that abuse, poverty, mental health and other severe stress can have on a person’s ability to lead a productive life. Working with women with these extensive histories requires a non-judgmental approach and an understanding of The Vivian’s fundamental belief that “these women have been failed by society and the few choices they have left are not choices at all but survival tactics” (Wave Consulting, 2010:2).

Rather than forcing women to stop using substances or stop working in the sex trade, the program supports women in accessing the information, resources and services that enable them to improve their health and to live in a manner that does not require on alcohol, drugs or sex work in order to survive. “Most importantly, the Vivian program is about building a community of women helping women through shared experience and empathetic understanding” (Wave Consulting, 2010:3). Many women tend to hide their drug use or involvement in the sex trade when they initially come into the building because The Vivian is the first place they have experienced such an empathetic attitude. It is important to break down these barriers from the beginning and make sure the women understand that the staff are not there to judge but rather to support.

The Importance of Tenant Input

The women who live at The Vivian are the best judges of what is and what is not working. In order to build a program mandate that is successful and promotes the engagement of all tenants, it is important that the women are included in planning and implementing programs or services they will access. Involving tenants in program development is crucial for building community and reducing isolation.

Adaptability and Flexibility

Programs for women, particularly those working with vulnerable women, need to be responsive to participants’ needs. Simply asking for their input is not enough. Program staff must show that they are listening and are willing to be flexible in order to address the issues a woman is experiencing in a manner that is comfortable for her. There are few hard and fast rules at The Vivian because everything is client-centered and must adapt to changing circumstances and needs of the community.

Build Partnerships with External Stakeholders and Have Regular Dialogue

Vivian staff believe that strong partnerships are essential to ensuring the success of the women who live at The Vivian. It is not possible for The Vivian on its own to provide all of the services that are needed to support tenants. Regular communication with stakeholders ensures that they are kept up-to-date about the successes and challenges of the program, and that everyone can work together to determine appropriate solutions to any problems that arise.

Focus on Relationship-building With Tenants

Many of the women who come through The Vivian’s doors do not have a history of successful relationships, either with men or women. Their experiences have often meant that they have rarely enjoyed trusting relationships; many have been used and abused by the people in their lives. In order for women to succeed, they need relationships with people they can trust and rely on.

Self-determination as a Core Concept in the Program Mandate (Strengths-based Approach)

Any intervention that aims to change peoples’ behaviours is more likely to be successful by promoting strengths rather than simply trying to change deficits. By supporting women in developing their skills and abilities, The Vivian’s tenants are empowered and build the capacity to change their lives.

Working Towards Creating as Much Safety as Possible for the Women

Many of the traditional services for vulnerable people lack a focus on the unique needs of women. For example, safety is something that is often overlooked as an important factor in spaces that work to support women.

Many of the women who come to The Vivian have had negative and traumatic experiences with men and often find it difficult to feel safe in an environment where men are free to come and go. As much as possible, a dedicated service for women must focus on creating the safest environment possible.

Optimism and Hope Create Change

Changing the circumstances of vulnerable women is the only way they will become less vulnerable, but without others believing in their capacity to change the women are unlikely to believe in themselves. Instilling optimism and hope in women’s lives can create the environment and situations where the women believe, and act on that belief, that they can change their lives.

REFERENCES

Highway of Tears Murders. (2013). In Wikipedia, the free encyclopedia. Retrieved June 1st, 2013 from http://en.wikipedia.org/wiki/Highway_of_Tears_murders

Wave Consulting. (2010). The Vivian Transitional Housing Program for Women. Program Description.

ENDNOTES

1. Information about The Vivian’s model and accompanying services is adapted from a report entitled The Vivian Transitional Housing Program for Women by Wave Consulting.

2. A Bad Date Report is a list of (usually) men who have committed an offense against a sex worker (including physical or sexual assault, kidnapping or failure to pay). The ‘bad dates’ are reported by sex workers to the organization and may or may not have been reported to the police.

Transitions to Home

Hamilton ONTARIO

Fiona Scott

Key Messages

• The case study explains how the program was built based on the success of a pilot program in Hamilton ‘Hostels to Homes’ that housed 80 people.

• Profiles unique partnerships developed with police services resulting in coordination with the EMS Social Navigator who works closely with the Transitions to Home (T2H) program to identify individuals with high needs.

• The program is currently undergoing a cost-benefit analysis to determine the program’s return on investment. Results will be available in the spring of 2014.

Hamilton, like most major Canadian cities, has struggled with the growing problem of homelessness since the 1990s. The first response was to develop emergency services, including shelters and day programs. As the City moved forward to develop a more strategic response to homelessness, there was growing consensus that relying on emergency shelters was not only an ineffective response to the needs of people experiencing homelessness, but also seemed to have little impact on the broader problem of homelessness in the community.

A city of just over 500,000, Hamilton is the fourth largest city in the Province of Ontario, yet it struggles with almost the same rate of people experiencing homelessness as the largest city in Canada.

In the 1990s and into the past decade, Hamilton had a rapid increase in its homeless population. Between 1995 and 2004, the number of people needing emergency shelter almost doubled (City of Hamilton, 2007b). The number of families seeking emergency shelter also increased dramatically from 5 in 1998 to 378 in the year 2000 (HRSDC, 2007).

Following a planning process that culminated in the report, The Blueprint for Emergency Shelter Services, Hamilton committed to developing and implementing a Housing First strategy. Building upon a successful pilot project, Hostels to Homes (H2H), a new Housing First program Transitions to Home (T2H) was developed.

The Transitions to Home program implements two unique aspects of service not shared by all Housing First programs. Firstly, relationships with police services were developed, including a connection to the EMS Social Navigator who works closely with T2H staff to identify individuals who are street involved with high needs, and could be excellent candidates for the program. Secondly, the T2H program separates the roles of case manager and housing support worker, providing clarity and transparency of service; this important distinction fosters empowerment and trust for people accessing the program.

The results of T2H to date have proven extremely positive; 74% of people remained housed after 6 months and, of those 74%, 90% remained housing after 12 months.

This case study presents an analysis of the Transitions to Home Housing First program. As a review of a specific program model, we focus on the underlying principles of the program, the process of building support for the initiative, planning and implementation challenges, and evidence of success. The case study concludes with a consideration of key learnings from this Housing First program.

GETTING STARTED: FRAMING THE ISSUE

In the early 2000s, a few years prior to the development of Hamilton’s new strategy to address homelessness, there was talk in the community about the pressure on the emergency shelter system. The shelters were operating on a per diem funding model, which is counter-productive given that funding is therefore dependent on having people in the beds. Hamilton needed a different way of doing business in order to accomplish their goal of eliminating homelessness. Not only were the facts revealing (i.e. the current system was undeniably unsustainable), but keeping people in shelter beds was not what people wanted for the citizens of Hamilton.

As is the case in other communities across Canada, the rise in homelessness throughout the 1990s led to efforts to develop effective responses to the problem. In 2004, the City of Hamilton published its first housing strategy. Keys to the Home: A Housing Strategy for Hamilton outlined four effective solutions for reducing homelessness in the future:

1) There is no one ‘quick fix’ or ‘silver bullet’ to address the housing needs of the citizens of this community. A balance and range of responses are required from many organizations that recognize the context of the local housing market and the complexities and linkages of housing needs;

2) Partnership must be the modus operandi;

3) Housing is not a ‘cost’; it is an investment that will allow people to lead more independent and fulfilling lives now and in the future. It is the building block for stable healthy communities and families, and enhances access to educational and employment opportunities for society’s most vulnerable members; and,

4) Housing is a catalyst for economic growth (City of Hamilton, 2004).

In 2006-2007, The City of Hamilton and the Social Planning and Research Council of Hamilton conducted research on homelessness throughout city to inform their strategic planning process. The report, entitled On Any Given Night, highlighted the problem of people experiencing chronic homelessness who face many barriers obtaining and maintaining housing and, as a result, cycle through the emergency shelter system (City of Hamilton, 2007a).

The report concluded that while an emergency response was important, and would remain necessary, in the end emergency shelters cannot be considered a solution. While shelters provide a place to sleep for a night, they are not able to adequately provide other services many people require in order to access and maintain housing. There were enough beds in Hamilton’s emergency shelter system, but the number of people who needed the service was not decreasing, and too many people were unable to make the transition from shelter to housing because of complications unaddressed and under-serviced in supporting housing stabilization and positive landlord-tenant relations.

The City recognized the need to provide more than emergency shelter to its citizens experiencing low-income vulnerabilities – they needed a more effective way of helping people move into long-term affordable housing. This required a plan and strategy, focusing on case management and supports.

DEVELOPING A PLAN TO ADDRESS HOMELESSNESS

The City gathered representatives from government, social service agencies, advocacy groups, City staff and those with lived experiences of homelessness for a series of community consultations, including a Homelessness Summit in 2006, focus groups and individual interviews to provide input into the plan. Representatives from these sectors were also part of the two advisory committees established to provide input to the Plan’s development. These consultations and advisory groups formed the basis for the plan.

It was clear the status quo was not the solution. Changes were needed in the delivery of programs and services if the goals of the plan were to be achieved.

The importance of collaboration between people and agencies was also a recurring theme from these consultations. It was recognized that everyone needed to work together to develop new partnerships and mobilize resources. A Community Check-in was held on September 12, 2006, to review a draft of the Plan.

The Plan

In 2007, Everyone Has a Home: A Strategic Plan to Address Homelessness was launched. The desire for Hamilton to be “a community where everyone has a home” was to be achieved by focusing on what the community wants for its citizens, rather than reacting to people’s immediate circumstances. The system planning framework is designed to:

• Engage the entire community in addressing homelessness.

• Provide a continuum of supportive housing that help residents achieve their potential.

• Provide supports that help residents obtain and maintain housing.

• Help citizens secure adequate income.

• Illustrate how to make use of community resources efficiently and effectively (City of Hamilton, 2007a).

The Evolution of Housing First in Hamilton

From 2007 – 2009 the H2H program was piloted. A collaborative effort, funded by the province, the program aimed to help move people dependent upon the shelter system as long-term housing into more permanent, affordable, and sustainable housing. The program included an Integrated Mobile Case Management Team (IMCMT) that provided enhanced case management, 24/7 mobile supports, help accessing sustainable housing options and referrals to appropriate employment supports and linkages to community-based services (City of Hamilton, 2007).

The H2H model, similar to a Housing First approach, had already been successful supporting people with histories of chronic homelessness move into more permanent housing. That program stemmed from “the realization that almost 25% of people using emergency shelters were spending more than 42-days a year in emergency shelter beds” (City of Hamilton, 2009a). The pilot program helped 80 individuals find and sustain safe affordable housing. Stakeholders had been skeptical, but once they learned the housing retention rates were over 80% one year after discharge, they were on board.

Despite its success and a desire to keep the program running, funding for the pilot was coming to an end. At the time, the City of Hamilton was undergoing a review of its emergency shelter services. The report, entitled Homelessness Blueprint for Emergency Shelter Services, sought to develop a sustainable system to better support people experiencing homelessness as they move to permanent housing. The report recommended that partners would “collaborate in the development of an integrated network of emergency shelters that work towards achieving the vision and goals of the Blueprint and support compliance with the Emergency Shelter Standards” (City of Hamilton, 2009a).

Agencies working in the homelessness sector, including all emergency shelters, came together to devise a system to work collectively. As a result, the T2H program was developed and would be led by Wesley Urban Ministries.

THE TRANSITIONS TO HOME PROGRAM MODEL

T2H works with men experiencing long term shelter use and homelessness in order to help them acquire and maintain safe, affordable and long term housing in the community (Supporting our Sisters supports women experiencing homelessness). The program operates under five ‘program anchors’ that align with the core principles outlined in A Framework for Housing First (Gaetz, 2013:11). These program anchors demonstrate the program’s fidelity to the Housing First model:

1. Long term shelter users and people living on the streets move into housing directly from streets and shelters without a requirement of mental health or substance abuse treatment prior to participation in the program. The immediacy of moving to a housing unit is based upon the availability of financial supports, housing units and each individual participant’s needs.

2. Transitions to Home provides ongoing case management supports without a time limit. T2H participants must commit to receiving case management supports through a mutually developed case plan with a Case Manager.

3. Transitions to Home uses a harm reduction approach to addictions. Clients do not need to be abstinent in order to access services, but are instead supported in reducing the harm associated with their addiction.

4. Residents have leases and tenant protections under the law. Transitions to Home works primarily with private market landlords to identify permanent housing for the programs’ participants.

5. Once housed, continued tenancy is not conditional upon participation in services. In addition, in circumstances where tenancies deteriorate to the point of eviction, T2H will help participants find another housing unit and offer continued supports.

Core Supports

Mobile Intensive Case Management –PLUS

A mobile Intensive Case Management (ICM) team provides direct supports to help people reliant upon the shelter system as long-term housing achieve successful tenancy in affordable private apartments. In addition, vulnerable people living on the street receive help finding affordable apartments and creating successful tenancies.

The team is composed of 15 Intensive Case Managers, one addictions worker, one Therapeutic Recreation Therapist, one housing worker, one supervisor and one manager. There is also part of a nurse’s time at the Wesley Centre that is allocated to assisting T2H participants. There are also three Social Workers who provide support to clients but not directly affiliated with the T2H program.

The caseload size is on average 18-20 active clients per case manager. Case Managers also have a number of clients in ‘maintenance’, which essentially means that these clients are not receiving ongoing ‘active’ case management supports but may reconnect with T2H should they have an issue relating to housing.

The PLUS component consists of a team of 5 clinicians who provide supportive trauma-informed therapy, addictions counselling, and therapeutic recreation to program participants. Case managers and clinicians also connect program participants to primary health care services through the accessible drop-in Shelter Health Integration network.

Follow up Support – Housing Support Workers

Transitions to Home currently helps over 250 people formerly accessing shelter services and people living on the street to maintain successful tenancies throughout the City of Hamilton. Housing Support Workers are able to quickly intervene when issues arise between landlord and tenants, negotiating and mediating the relationship as a strategy for eviction prevention. Housing Support Workers focus on supporting the tenancy by remaining impartial, while Intensive Case Managers are advocates and counsellors for the individuals accessing the T2H program.

Recreation

Transitions to Home also operates community wide recreation programs for people experiencing homelessness as a means of facilitating a connection to the program and providing healthy recreation time. The Hamilton Homeless Baseball League, Bowling League and other events are provided with the help of program participants.

Recruitment

Clients are recruited mainly through Hamilton’s emergency men’s shelters and also through the Hamilton Police Services Social Navigator (more details on page 10). Case management staff spend 2-4 hours a week in every emergency shelter in order to recruit clients. Referrals to T2H are made on a first come, first served basis.

How the Program Works

The program closely aligns with the At Home/Chez Soi model of Housing First. They have also adopted the Ontario Ministry of Health guidelines for Intensive Case Management. Everyone on the active caseload is seen a minimum of once per week, and individuals are visited at their home at least once per month.

T2H currently works with approximately 250 individuals, 170 of which receive ICM. Another 75 receive ‘maintenance care,’ having developed a successful tenancy and deciding they no longer need the weekly support. These individuals receive a visit every 3 months for a one-year period, at which time they receive yearly contact. The program is flexible and clients can reactivate support at any time. There are also no defined time limits on ICM.

Other than support received from social assistance (approximately 55% of clients are on Ontario Works, and approximately 45% receive financial aid from the Ontario Disability Support Program), the majority of clients do not receive rental supplements from T2H. The City of Hamilton provides approximately 90 housing allowances through the Investments in Affordable Housing program to T2H.

Affordable Housing in Hamilton

The housing situation in Hamilton is relatively better than it is in cities like Toronto – there is a fairly healthy vacancy rate of 3.5% compared to Toronto’s 1.7% – although the quality of housing stock is still an issue (State of Homelessness in Canada). The challenge is less about housing availability and more about identifying and recruiting landlords willing to work with a Housing Support Worker if issues arise. Similar to the At Home/Chez Soi and Pathways to Homes Housing First programs, T2H decided to separate the housing management role from that of case management, thus allowing the case manager to focus on the provision of supports, while the housing support worker is free to focus on property management and landlord liaison. People who experience low-income vulnerabilities are often stigmatized as irresponsible and violent. Housing Support Workers spend a considerable amount of time destigmatizing potential tenants to recruit landlords and explaining the benefits of the T2H programs to landlords, tenants and the community as a whole.

MOVING FORWARD: PLANNING

Those involved in setting up Transitions to Home identified the following key issues as having an impact on planning:

Changing the Current System

In order for this program to be successful, there had to be willingness from the agencies serving people experiencing homelessness. Difficult conversations amongst the groups involved ensued. Eventually it was decided the Wesley Centre, which had more shelter beds than needed, would close the shelter and take over the Integrated Mobile Case Management Team, becoming a Housing First model program.

Setting up the Program

In order to address a broad range of questions, establishing the program involved a considerable amount of planning and input. Where were clients going to be housed? How many staff were required? What was the right client to case manager ratio? What did case management look like? How many times would clients be seen per week? Staff looked to experts who had successfully implemented Housing First, including Sam Tsemberis from Pathways in New York. Case management standards were drawn from existing provincial guidelines.

Since the H2H program was coming to an end, the T2H team had the added complication of dealing with participants who needed to be discharged from the program. Clients were offered the opportunity to participate in the Transitions to Home program.

Human Resources

Those who were already working in the housing system in Hamilton, who believed in a new approach to homelessness (including the Housing First model) and who had compassion, empathy, and patience, were sought to develop and implement the program. This also helped to keep the collaborative spirit behind what was being created.

The Importance of Landlord Relationships

The program uses scattered site housing, and as such, relationships with private market landlords and other housing providers are a critical component to its success. A Housing Support Worker acts as a mediator between landlords, tenants, and case managers and builds relationships with landlords, in order to effectively deal with problems as they arise. The Housing Support Worker also supports the tenants and empowers them with tools to solve their own housing issues.

Consumer Input in Program Development and Implementation

Homeless-serving staff in Hamilton recognized in order for programs to be effective, they needed to meet the needs of the people they are designed to serve. Consultations with people who have experienced homelessness were crucial to the development of Hamilton’s plan to address the issue.

Initial Investment/Funding

Funding has been and continues to be the biggest challenge to implementing and sustaining Housing First in Hamilton. The program is funded through the Homelessness Partnering Strategy (HPS) and the Community Homelessness Prevention Initiative (CPHI). T2H also receives some municipal funding from the City of Hamilton. Ensuring ongoing funding for the program in a context of shifting government priorities is a continual concern.

MAKING IT HAPPEN: IMPLEMENTATION

Hamilton is a relatively small community and homeless-serving agencies are inter-connected. The agencies, including the City of Hamilton and all of the community partners, sit at a number of different systems planning tables to address the issues of housing and homelessness, including the Hamilton Emergency Shelter Integration and Coordination Committee and the Housing and Homelessness Planning Group.

Transitions to Home was developed by the Hamilton Emergency Shelter Services Integration and Coordination Committee (HESICC). HESICC is a partnership between the City of Hamilton, Good Shepherd Centres, Hamilton Housing Help Centre, Mission Services, Salvation Army and Wesley Urban Ministries. Wesley Urban Ministries administers the program and acts as the employer for staff in the Transitions to Home program. These agencies have met since 2007 and continue to meet to discuss what has been successful and what remains in need of improvement.

All of the City’s project charters, terms of reference and the Blueprint for Emergency Shelters report highlight the need for agencies to work together. This philosophy is shared by the people working in the homelessness sector in Hamilton; the only way to make a significant impact is to work together and leverage one another’s strengths.

Hamilton’s collaborative nature towards services for vulnerable people created a culture of willingness to partner. City and agency staff connected with other sectors, told them what they were trying to accomplish, how they shared similar clients and highlighted the potential benefits and ways they could work together. There was recognition that no one agency or service can be all things to all people.

Key Partnerships That Enable the Success of Housing First in Hamilton

Everyone has a role to play in addressing homelessness. Hamilton’s plan clearly indicates collaborations between organizations, agencies and sectors are key to addressing the range of issues faced by people experiencing homelessness. The homelessness sector is intentional about developing relationships with police, health and mental health sectors, as well as organizations that administer financial assistance.

Hamilton Police Service

Staff from Hamilton Police Service attend monthly shelter standards meeting, where the focus is on operational issues in the emergency shelter system. At these meetings, the police provide information on trends they are seeing within Hamilton, specifically the downtown core. Police are familiar with many of the people accessing emergency services and try to develop relationships to facilitate a good resolution for public space in the downtown core. Police and T2H work together to tackle issues that arise and require police presence.

Ontario Disability Support Program (ODSP)

The ODSP branch in Hamilton has a manager representative who takes part in the monthly shelter standards meetings. Their role is to provide insight into new processes and legislation that may directly affect people accessing the emergency shelters and in the T2H program, and answer ODSP-related questions from shelter managers/T2H case managers.

Hamilton EMS Social Navigator

The Hamilton Police Service developed this unique staff position to manage a caseload of high-needs individuals who are living unsheltered or precariously housed and who have high contact with police, EMS and emergency services. EMS staff attend Hamilton’s bi-weekly shelter case conferences, where challenges with specific clients are discussed. Through these case conferences the Social Navigator is able to discuss specific clients’ needs. The Social Navigator works alongside shelter/T2H staff to develop case planning and referrals for these clients. The Social Navigator is able to build relationships with individuals on the street, which builds the foundation for relationships with the T2H program.

The Good Shepherd HOMES Program

HOMES is a housing and support services program for people experiencing homelessness and living with mental illness. Program staff provide consultation to other agencies working with clients with mental health challenges and are also a necessary partner in providing housing for clients.

Monitoring and Data Collection

The T2H program uses the Client Outcome Tracking System (COTS) to collect data. The database was chosen through an RFP process and deemed most useful for the case managers working with, and collecting information about, clients. The City monitors and measures indicators from both the emergency sector and the T2H program. With emergency services, for example, they monitor the reduction in number of nights people stay in shelters and shelter usage in general. With T2H, they monitor housing placements and housing retention rates.

Questions of Sustainability

The best argument for the sustainability of a Housing First approach in Hamilton is that the Transitions to Home program is cheaper than the per diem approach under which emergency services currently operate. The impetus for Hostels to Homes and Transitions to Home was not due to funding pressures, but rather the community’s commitment to ensure people accessing the shelter services are equipped to move from the emergency system to more sustainable and permanent forms of housing. Part of the purpose for the Blueprint for Emergency Shelter Services report was to help find solutions to both long term shelter stays and financial pressures (City of Hamilton, 2009a). The per diem rates encourage occupancy, thus the objective was counter-intuitive to the funding model.

With the recent changes to provincial homelessness funding, City staff are currently leading an assessment with the Community Homelessness Prevention Initiative (CHPI). This involves reviewing provincial funding opportunities, the City’s core homeless services and what is needed to sustain the successes they have experienced with their current system, all in order to make future funding recommendations for CHPI funded programs, including emergency shelters.

The city’s strategic plan is comprehensive and as such requires additional resources beyond operational funding to support data collection, planning and community development.

Costs

Transitions to Home is funded through federal-provincial-municipal contributions. The City of Hamilton has committed a portion of their housing allowance (funded through the Provincial Investment in Affordable Housing for Ontario Program) to T2H. The T2H program leverages from their agencies fundraising contributions and other supports/services in the community. Overall, T2H costs $911,537 per year – not including the Housing Allowances or all of the clinical supports – or approximately $3700 per person annually.

EVIDENCE OF EFFECTIVENESS

Transitions to Home collects data on the housing outcomes of participants in the program via the Client Outcome Tracking System (COTS). The most recent data collected from the Transitions to Home program (from January 1, 2012 – December 31, 2012 inclusive) showed that:

• 74% of clients remained housed after 6 months.

Of those 74%:

• 90% remained housed after 12 months.

T2H was recently awarded a federal research grant in order to conduct a cost-benefit analysis of the program. The results of the research project with McMaster University will help identify the cost-effectiveness of the program in order to demonstrate to funders the return on investment and effectiveness of the T2H program in ending homelessness in Hamilton. A final report is expected in March 2014.

KEY LEARNINGS

As with other Housing First programs, there are key learnings that can help support communities in planning and implementing Housing First.

1. Appropriate (affordable, suitable and safe) housing is essential for a Housing First approach to work in any community.

Without places for people to live, the program will not be effective. In the next 20 years Hamilton is projected to grow by approximately 26%. The City’s Urban Official Plan identified that Hamilton needs to create 629 new rental units each year to meet this demand (City of Hamilton, 2009).

2. The homelessness and housing systems need to work in a collaborative manner.

In order to provide housing to individuals experiencing homelessness, relationships between organizations providing emergency services, as well as those providing housing, are important. Many issues are created as a result of the complexities within these systems rather than due to the complex situations of individuals. Community partners and stakeholders in housing and homelessness need to work together to ensure sustainable housing.

Given the need to create sustainability within the emergency shelter system, Hamilton chose to close a shelter, thus creating more revenue for the remaining services. This only worked, however, if occupancy remained reasonably low which meant that T2H was a critical part to support people leaving the shelter.

Hamilton’s Housing and Homelessness Action Plan outlines how the city will effectively address homelessness and housing over a ten year period. The plan covers the housing continuum, including homelessness prevention and services, emergency shelters, transitional and supportive housing, rent-geared-to-income housing, market rental housing and affordable homeownership. A Housing and Homelessness Planning Group, co-sponsored by the City of Hamilton and the Affordable Housing Flagship and comprised of more than 20 representatives from the housing and homelessness sectors, works together to achieve the vision that “everyone has a home” (City of Hamilton, 2007c).

3. Do not give up on people.

Everyone has the right to a home. Many people have not had the appropriate life experiences or access to supports that would give them the skills to manage their own home, so sometimes they make mistakes. Additionally they have often lived through traumatic events, addictions, mental illness and physical health problems, further complicated by, and complicating, their housing-related struggles. For the most part, programs place unrealistic conditions on people to stay in the program or remain housed. Realistically, many people will need support for a long time. If it does not work out the first, second, or even third time, it is important not to abandon that person.

4. Housing First is not the only answer.

People have various risk and protective factors related to housing security; some will have no experience of managing a home and will need regular support, while others will be fully capable of taking care of paying bills and cleaning, yet may need assistance with accessing health services, finding a job, and/or integrating into the community. Any Housing First program needs to be responsive in the range of supports it provides. The program does not have to deliver all those supports directly, but should leverage resources found in the community.

5. Landlord relationships are just as important as relationships with program participants.

There will be issues with tenancies. Empower the tenants and work closely with the landlords. In Hamilton, they have learned keeping these roles separate helps maintain the trust built between the tenant and their case manager. There is a separate staff person who acts as a landlord liaison to deal with any issues that arise.

REFERENCES

City of Hamilton. (2004). Keys to the Home: A Housing Strategy for Hamilton. Retrieved from http://www.hamilton.ca/Common/Search%20Results?txt0=0%7ckeys%20to%20the%20home%7c0&s=COH

City of Hamilton. (2007a). On Any Given Night. Retrieved from http://www.hamilton.ca/NR/rdonlyres/A85A4701-C327-459D-A66E-19D81CFA6A99/0/OnAnyGivenNight2007.pdf

City of Hamilton. (2007b). Information Report. Retrieved from http://www.hamilton.ca/NR/rdonlyres/7EB6F5E3-C25D-452B-AA4B-1E5BB337D45F/0/Oct22Item54ECS08047INFOREPORTHostelstoHomesUpdate.pdf

City of Hamilton. (2007c). Everyone Has a Home: A Strategic Plan to Address Homelessness. Retrieved from http://www.hamilton.ca/Common/Search%20Results?txt0=0%7ceveryone%20has%20a%20home%7c0&s=COH

City of Hamilton. (2009a). Blueprint for Emergency Shelter Services. Retrieved from http://www.wesleyurbanministries.com/cmfiles/Blueprint%20for%20Emergency%20Shelter%20Services%20-%20Council%20Report.pdf

City of Hamilton. (2009b). Urban Hamilton Official Plan. Retrieved from http://www.hamilton.ca/CityDepartments/PlanningEcDev/Divisions/StrategicServicesSpecialProjects/Policy+Planning/HamiltonNewOfficialPlan/Council+Adopted+Urban+Hamilton+Official+Plan.htm

Gaetz, S. (2013). A Framework for Housing First. Canadian Homelessness Research Network.

Gaetz, S., Donaldson, J., Richter, T. & Gulliver, T. (2013): The State of Homelessness in Canada 2013. Toronto: Canadian Homelessness Research Network Press.

Human Resources and Skills Development Canada. (2007). Community Plan 2007-2009. Retrieved from http://www.hamilton.ca/HealthandSocialServices/SocialServices/Homelessness/

City of Lethbridge &

Social Housing in Action

Lethbridge ALBERTA

Fiona Scott & Stephen Gaetz

Key Messages

• The staff team has been documenting the key lessons learned in the implementation of a Housing First program. A set of 10 lessons are included in this case study.

• Several experts in Housing First – from Canada and the U.S. – have informed the development and adaptation of the model in Lethbridge.

• Lethbridge was one of the first cities in Canada to develop a Plan to End Homelessness in 2009 and is coming up to the end of the initial 5 Year Plan.

• As an early adopter of a Plan to End Homelessness Lethbridge has seen a significant decrease in absolute homelessness, as well as a decrease in shelter usage.

In 2008 Alberta became the first province in Canada to develop a 10 Year Plan to End Homelessness. Upon receiving provincial funding, the City of Lethbridge developed Bringing Lethbridge Home − the 5 Year Plan to End Homelessness (2009-2014), a community plan fully aligned and integrated with Alberta’s 10 Year Plan and augmented the Community Plan developed for Human Resources and Skills Development Canada. Bringing Lethbridge Home is based on a Housing First approach that addresses the root causes of homelessness through participant-focused support and service, prevention, rapid re-housing, diversion and integrated community support services.

Seven guiding principles frame Bringing Lethbridge Home:

1. Ending homelessness depends on visionary, innovative and brave leadership from all orders of government.

2. Housing is a basic human right. An adequate stock of housing must be accessible, safe and affordable.

3. All responses to ending homelessness are based on the Housing First approach.

4. Our community is strengthened socially and economically when all people are safely and securely housed.

5. Creation of opportunities for self-reliance, social integration and community participation supports people in successfully sustaining their housing.

6. Continuous learning and improvement, which includes evidence based practice, is necessary.

7. Strong collaborative partnerships are essential to best serve the community.

Since the city’s implementation of Bringing Lethbridge Home and the sixth annual homelessness census in 2008, Lethbridge has seen a progressive decrease in its rate of homelessness including a 93% decrease in absolute (street) homelessness. The latest homelessness census in 2012 showed a 27% decrease in the total number of people experiencing homelessness since the previous year (136 people in 2011 to 99 in 2012), a 25% decrease in the sheltered population and a 50% decrease in the number of people categorized as experiencing absolute homelessness (SHIA, 2012).

Responses to the 2012 census indicated that 22% of respondents declared “their health-related issues” as the main barrier in obtaining permanent affordable housing. An additional 21% of respondents indicated that their inability to pay rent prevented them from accessing housing. More than half (54%) of respondents reported that they had experienced homelessness for a year or more, suggesting that chronic homelessness is still an issue that needs addressing in Lethbridge.

The City of Lethbridge is one of the seven community-based organizations in Alberta that work with the provincial Ministry of Human Services to implement the strategies established in Alberta’s 10 Year Plan to End Homelessness. The Social Housing in Action (SHIA) group functions as the community advisory board. In 2009 the City of Lethbridge began introducing Housing First teams into the community. This case study provides an overview of Lethbridge’s experience of planning, implementing and sustaining a Housing First approach including ten embedded principal lessons, as well as some of the barriers faced and how they were overcome. The data from Lethbridge demonstrates that Housing First is an effective means of supporting people experiencing homelessness in securing and maintaining housing.

GETTING STARTED: FRAMING THE ISSUE

Securing community support for a Housing First approach is an ongoing process in Lethbridge that focuses on education. Many people have heard of the Housing First concept, but few understand what it really entails.

Lesson #1: Housing First versus housing first

Lethbridge as a community, both people and organizations, has widely embraced the Housing First philosophy. However, in terms of delivery it is important to identify the Housing First agencies that have both the required mandate and the necessary expertise. Housing First is not a simple task, particularly because it goes beyond just housing; case management is equally important.

In order to be considered a Housing First team in Lethbridge, an agency must be actively establishing relationships with landlords, providing Intensive Case Management (ICM) that includes stringent follow-up support and continually working with clients in developing the skills and relationships necessary to maintain their housing. Lethbridge’s qualifying teams are grounded in research-based evidence that has identified effective Housing First strategies and policies, such as maintaining a consistent focus on program orientation, client criteria and core principles.

An important component in implementing Housing First in Lethbridge is the continued effort to educate the community around the differences between case management and ICM. These differences are most clearly seen in the level of support provided to clients around skill development and barrier elimination. Wally Czech, Housing First Specialist with the City of Lethbridge, explains why ensuring that the community knows the difference between Housing First and ‘housing, first’ can avoid having teams develop bad reputations for incidents unrelated to their work:

“We received some feedback from a housing organization, that they were getting damage to property from our Housing First clients. We found out that it wasn’t us who facilitated the housing but instead it was people referred by the homeless shelter. They believe in Housing First and try to support it, but they aren’t funded to do it and intense follow is not part of their mandate. You need to know who is funded to do it and who has the skills and the training to do the follow-up”.

In Lethbridge, the process of educating people about Housing First has included consultations with experts and the community, public workshops and meetings with landlords in the community to explain the program and its benefits.

The Housing First team is now in the process of planning and preparing a complete education and social marketing community-wide campaign to further educate the community.

Lesson #2: Tell the Community about Homelessness: People Experiencing Homelessness are Human Too

Lethbridge believes that helping people understand the realities of homelessness is an important part of increasing the public’s understanding of what is required to end homelessness. Homelessness results from a variety of intersecting personal and systemic issues including lack of income, lack of supports and lack of access to supportive housing. As Czech explains, there is never one singular event that causes homelessness:

“People don’t snap. All kinds of things happen in a person’s environment that accumulate and contribute to the choices people make. All of these negative things can make it easy for people to become homeless. There is no one who wakes up and says, ‘I want to be homeless for a while’. If people learn to see the homeless as real people, ‘human beings’, then they have more empathy and more willingness to join in the efforts to assist them”.

When the public understands that people experiencing homelessness are humans too, they are more committed to providing those experiencing homelessness with housing. Housing First teams in Lethbridge continue to talk to community members around the basic human right to housing, as recognized under the Universal Declaration of Human Rights1. They work to dismantle the belief that people experiencing homelessness have to prove themselves before they are provided with housing.

Challenges in addressing homelessness in Lethbridge exist in many aspects. ‘Not in my back yard’ or NIMBYism continues to be a barrier to implementing effective solutions, as is achieving complete community support. However, Lethbridge is working hard to educate the community about its teams and benefits. Through community outreach and media campaigns, combined with engaging municipal council, landlords and community members, the teams are raising awareness about Housing First.

MOVING FORWARD: PLANNING

Lesson #3: Understand Your Community

Understanding Lethbridge’s demographics and trends was important in identifying the specialized supports and interventions that would be required to make the Housing First model effective. According to Lethbridge Census: Count Yourself In, Lethbridge has a population of 90,417 people and a 5.9% vacancy rate. It is bordered by two large Aboriginal reserves: Blood Indian Reserve No. 148 and Pikani No. 147. Students represent a significant portion of the population for a city of its size. It is also an economic hub, with a high level of transiency as people move around for work.

Approximately 50% of jobs in Lethbridge are in health, retail, hospitality and education including the university and college level. With such a large population of the workforce employed in education, Lethbridge has developed a strong community education focus.

Understanding the cultural make-up of Lethbridge was also crucial to program development. Lethbridge is a diverse city made up of many different cultures with a recent influx of Bhutanese refugees. In order to provide appropriate services, Housing First teams have created partnerships with different cultural organizations in the city (such as the Aboriginal Council of Lethbridge and Lethbridge Immigrant Services) and calls upon the Inclusion Consultant at the City of Lethbridge for advice on cultural matters. Partnerships with outside organizations allow workers to draw upon these organizations’ expertise when identifying the cultural needs of a client within a service plan. Professional development for staff has also been provided regarding how to work respectively with other cultures.

As with many other communities, Lethbridge’s population experiencing homelessness has a disproportionate number of Aboriginal persons. Housing First staff recently met with leaders of nearby reserves to discuss things like housing, employment, education and others reasons that lead people to migrate from the reserves to the city. It has been important for both staff and clients to understand the differences between reserve and city life in order to best support those wanting to move. For example, income assistance rules can be different for those living on reserve – there are sometimes different expectations from those living in the city compared to the reserve – which many are not aware of until they arrive in Lethbridge. This includes stricter guidelines for receiving income support, landlords not allowing long-term guests based on lease agreements or no tolerance in the city for multiple guests or overcrowding. Housing First teams have been educating on-reserve communities before they move to the city, making sure individuals have all of the information required for a successful transition. Lethbridge found that a transition period between leaving the reserve and being housed completely independent in the city is often helpful for Aboriginal people making the shift. This provides time to learn and understand how life in the city works and to make appropriate connections. It is important to note however, that this transition time only occurs when it is possible and if the individual chooses that option.

Racism is an ongoing issue for Aboriginal people in Lethbridge. The situation is so difficult that when Aboriginal people contact a landlord that have been forced to make it part of their process to ask the landlord if they ‘rent to natives.’ Lethbridge Housing First teams want to change that. Ongoing public education about the causes of homelessness and the effectiveness of solutions like Housing First are crucial in dismantling this racism.

Lesson #4: Identify Who Your Champions Are

Taking Housing First from a concept to creation requires commitment and leadership from diverse sectors in the community. The involvement of key individuals from diverse sectors in the community keeps the projects moving forward, providing stability and strength in the effort to end homelessness. In Lethbridge these champions include Dr. Gary Bowie, Chair of the SHIA and Diane Randell, Manager of Community & Social Development at the City of Lethbridge. Both were instrumental leaders in developing Housing First programming. Francis First Charger, Blackfoot Elder, has been heavily involved in program development as well as making connections between the City of Lethbridge and its neighbouring reserves. Several other members of the public sector, service providers, community leaders, as well as business and real estate leaders and have all contributed and support the plan to end homelessness in Lethbridge.

Lethbridge also has a champion on the inside. Wally Czech, the Housing First Specialist, oversees all Housing First teams funded by the City of Lethbridge. Czech is responsible for ensuring fidelity to the Housing First model, as well as ensuring that clinical best practices are used. Having one staff member who specializes in Housing First and is responsible for all of the teams has been critical in guiding the development of programs in Lethbridge, identifying gaps and programming needs and promoting continuity among Housing First teams in Lethbridge.

Lesson #5: Get Help

When implementing a new approach to ending homelessness, quickly building community capacity and asking for outside help are essential tasks. Drawing upon the knowledge of earlier programs and perspectives and bringing in expertise from outside of the community on programming and implementation were valuable strategies in Lethbridge’s Housing First development.

A number of experts came to Lethbridge to talk about Housing First and its related components. Sam Tsemberis, Pathways to Housing in New York City, provided education on Housing First, including its framework, strategies and procedures. Tsemberis helped solidify the necessary steps in successfully planning and implementing Housing First teams. Iain de Jong, Consultant on Housing First with OrgCode, was also brought in to discuss Housing First implementation.

Outside expertise in support services provided professional development in areas such as motivational interviewing, trauma and addictions. While some similar resources were available within Lethbridge, particularly around motivational interviewing, existing resources did not focus on the homelessness sector or within a framework for Housing First. They are now seeking to take advantage of experts like people from t3 in Seattle and others to have training such as motivational interviewing to be more applicable to working with the homeless population. Dr. Gabor Mate, who specializes in trauma, mental health and addictions, instructed other community partners and professionals on effective ways of supporting clients experiencing these issues. Ongoing collaboration occurs with the other six cities in Alberta to develop and share training including the development of an online training site available to all seven cities.

Finally, staff were assisted with ‘systems thinking’ by David Stroh and John McGah from Bridgeway Partners in Massachusetts. Stroh and McGah specialize in helping organizations solve complex social problems through planning, change management and systems thinking; an area identified as needing additional support within Lethbridge’s Housing First teams.

HOUSING FIRST MODEL IN LETHBRIDGE

Housing First in Lethbridge is directed and monitored by The City of Lethbridge with SHIA acting as an advisory board. Housing First teams are funded both provincially through Human Services and the Outreach Support Services Initiative (OSS) as well as from the federal government through the Homelessness Partnering Strategy (HPS). All Housing First teams in Lethbridge share the following critical elements:

• A prioritization of the most complex cases being served first.

• A focus on helping individuals and families access and sustain permanent housing as quickly as possible. The housing is not time-limited.

• A variety of services including objective-based ICM are delivered following a housing placement to promote housing stability and individual well-being.

• Services are time-limited or long-term depending upon individual need and complexity.

• Supports or services from Housing First Teams are not contingent on compliance to such conditions as treatment or abstinence. Instead, participants will be subject to a standard lease agreement and are provided with the services and supports that are necessary to help them be successful.

The following Housing First agencies and support programs are funded by SHIA to provide Housing First activities in Lethbridge. In order to avoid duplication, each one has a specific mandate.

Community Outreach is the original Housing First team established in Lethbridge and is based out of the Canadian Mental Health Association (CMHA). The agency focuses on people experiencing chronic homelessness with complex, multiple-barriers to housing. They work with both men and women in an ICM model providing housing and supports in market housing. They also have a team specific to working with complex youth ages 18-24.

Diversion is located within the Lethbridge Emergency Shelter with the mandate to connect immediately with new to shelter clients. If deemed to likely be Housing First eligible they will connect them to centralized intake for assessment. If they are not Housing First they will work with that individual to create an action plan in effort to divert them from the shelter as quickly as possible. Lastly, they provide ICM supports to individuals or families needing eviction prevention support.

The Aboriginal Housing First Team provides interim supportive housing in a residence setting for Aboriginal women with our without children. They also provide Housing First supports including outreach and ICM to Aboriginal women, men, and families with our without children transitioning from the Reserve to urban life.

YWCA Residence is a 30 unit permanent supportive housing facility for women, with or without children (depending upon age and gender), who have complex needs. This facility can be an individual’s permanent home and includes Residence Counsellors. They provide day-to-day support through ICM, as well as continued support if an individual leaves the residence. They make it a priority to reserve vacant units for Housing First eligible clients.

HESTIA Homes is permanent supportive living for youth ages 18-24 who are homeless, or at risk of being homeless, as they transition to adulthood. HESTIA is a type of foyer model with three homes each having three rooms available for the youth with a live in mentor to help with life skills and daily living. They also each have a follow-up worker providing ICM.

Woods Youth Shelter is an emergency youth shelter designed for youth 13-18 years of age. The shelter can house 8 youth, each with separate sleeping quarters and a shared kitchen and facilities. Twenty-four hour staff includes a new daytime staff position. The shelter works regularly with Children’s Services and other community organizations to assist youth in family mediation, referrals, onsite support and housing (SHIA, 2012). In cooperation with the Housing First Specialist, Woods has now developed a Housing First team for youth under 18. With a motto of ‘Family First then Housing First’, and incorporating ICM, the Housing First team are housing these youth in market rentals and providing intense follow-up supports.

The Intake Process

All Housing First teams take their referrals from HomeBASE – a new centralized intake, triage and referral team in Lethbridge. Clients are referred to HomeBASE where they undertake initial screening using the Service Prioritization Decision Assistance Tool (SPDAT). SPDAT determines a client’s eligibility and identifies their major barriers to maintaining housing, which allows clients with the most complex cases to be served first. Once a client’s eligibility is determined, additional in-depth screening and intake determines the most appropriate housing avenue based on housing and caseload availability. The information collected with SPDAT also informs the nature of a client’s comprehensive service plan once they are housed. A Universal Intake form eliminates the need for a client to repeat the intake process when they are referred to a program; instead the information collected with Universal Intake, SPDAT summary accompanies them to the appropriate agency. This is all transferred through a warm transfer process which includes the HomeBASE intake worker, the new agency, and the client and guardian if applicable.

The HomeBASE Universal Intake was created based on intake best practices research. Intake forms from each agency were combined to create a universal and centralized intake form. Czech explains the benefits of this new centralized intake:

“We have a variety of teams all with different mandates and we did not like the idea of people bouncing around the community from agency to agency telling and retelling their story only because they did not know the most appropriate agency to serve them. We also wanted to eliminate the potential and already occurring problem of agencies veering away from their mandates which made things complicated later on when justifying why certain individuals were being served and others were not. We also knew it would provide a great venue for gathering data centrally and discovering gaps in our services. So HomeBASE helps us to determine Housing First eligibility and then if they are eligible they can be immediately referred to the appropriate agency to serve them. If they are not Housing First, they still receive a referral to the most appropriate place in the community to help them. We try to not let them leave empty handed.”

Each agency has its own team of outreach and follow-up workers which helps lower case loads. After intake and referral to the appropriate agency an Outreach Worker is assigned to the client, helping them find housing and stabilize income. Once a client accesses housing they are connected to a Follow-Up Workers (FUW) from the Housing First team that provides SPDAT based and objective based ICM. The FUW spends up to three months helping the client stabilize their housing, orienting to their surroundings and learning how to take care of their responsibilities including rent and utilities.

The FUW then works with the client to create a service plan, identifying barriers to maintaining their housing and discussing ways that the worker can support the client in addressing those barriers. The FUW assists the client in accessing additional supports and services, as well as learning skills necessary to maintain permanent housing. Czech explains the importance of FUWs:

“This follow-up support is key to the long-term success of the participant. First, they obtain a sense of security and safety by getting a roof over their head. Then, they increase their level of self-esteem and confidence by having a home. Lastly, they maintain that home by having consistent, intensive, long-term support to assist them in becoming self-sustaining. This Housing First recipe is the foundation to Bringing Lethbridge Home. We house them and then we wrap them up with what they need to stay housed.”

Meaningful Daily Activity

Lethbridge believes that meaningful daily activity and social connections are essential in helping clients maintain housing. People often lose housing because they are not used to the rules and regulations that come with permanent housing. For example, newly housed clients may try to help others who are experiencing homelessness, or are precariously housed, by giving them a place to stay; unfortunately this can put the client at risk of losing their housing. It is important to help clients find ways to stay socially connected in a manner that does not jeopardize their housing. FUWs advocate for the client and stay connected with the landlord to deal with any such issues. In an effort to assist teams and help clients with options for meaningful daily activity, other programs have been created. These would include Clean Sweep which is a downtown workforce for Housing First participants and Real Artists at Work (RAW), which is Housing First art/dance program.

A follow-up assessment and the SPDAT are completed every three months to assess progress. The goal is to keep the client active in the program and help them reach graduation. Clients graduate from the program when they have fulfilled the following three criteria:

1. They have been active for a year or more and have maintained housing for six consecutive months of the year while in the program.

2. SPDAT scores have consistently gone down.

3. The client and case manager mutually determine that supports are no longer needed.

If these criteria are not all fulfilled work with the client continues.

MAKING IT HAPPEN: IMPLEMENTATION

Lesson #6: Collaboration, Collaboration, Collaboration

Implementing an effective Housing First team requires drawing upon all the ideas, connections and networks available in the community. Lethbridge has benefited from high levels of collaboration, as well as connections with organizations that have not historically been a part of the solution to end homelessness. Relationships have been developed with the Aboriginal Council of Lethbridge, Children’s Services, Persons with Developmental Disabilities (PDD), Mental Health, Seniors Mental Health, Covenant Health and many more. Funding has been provided to Lethbridge Legal Guidance to provide specific support to Housing First clients and landlords to educate and assist with landlord tenancy issues.

Peter Block, expert on community development, speaks of the need to bring together key stakeholders to resolve complex community issues. This means including program users; people experiencing homelessness know what they need and what will help. There is often concern that such collaborative processes are too slow, however in Lethbridge bringing people together has actually sped up the process rather than slowing it down.

An example of this collaboration in Lethbridge is Project Connect. Project Connect serves as an annual trade fair for people experiencing homelessness or other issues in their lives that have kept them from being connected to services and programs. Individuals and families who are struggling can come together and meet service providers in the areas of employment, counselling, health services, youth services, government information, legal advice, housing outreach and tax advice.

Housing First in Lethbridge has also developed partnerships with the following key organizations in the community:

Police Services

Collaboration with Lethbridge Police Services has resulted in several positive changes. After providing education on Housing First for the police, a relationship was established with Police Services Sergeant Tiffany Housworth of the Downtown Policing Unit who has spearheaded initiatives in collaboration with the Housing First teams. This new department was created to address the issues causing problems for the police and community in Lethbridge’s downtown core. Since the partnership began, the police have nearly stopped issuing tickets to people experiencing homelessness and are instead working with Housing First staff.

An innovative example of this collaboration between the police and Housing First staff is the Housing First ID Card, and a Housing First data base created by the police which allows them to flag Housing First participants for the entire police force which potentially will create alternative courses of actions when dealing with these individuals. Many officers found it difficult to know how to handle people experiencing homelessness they encountered on the streets. To address this issue a Housing First Card was created for clients. The card will contain the clients name, photo, the agency they work with and their key worker and contact information. So if an officer see this ID card, it will trigger them to look up the client in their data base and they will be able to see if this person is housed, what their address is and any other pertinent information they need to assist this client and possibly avoid more punitive alternatives.

If a client is involved in a situation with police presence, the card can be presented to the officer who is then able to contact a client’s FUW and help the client get home.

Income Support Programs

From the outset of Lethbridge’s relationships with income support programs such as Alberta Works Income Support (IS), Assured Income for the Severely Handicapped (AISH) and Persons with Developmental Disabilities (PDD) were developed. Many clients experiencing homelessness have spent considerable time living on the street and may have been exposed to trauma and/or brain damage; two situations that may qualify a client for income support. In order to streamline the eligibility process, which includes undergoing neuropsychological testing, the P12 Lethbridge Homeless Outreach Support Services Test Centre was created as a partnership between the Common Access Service Implementation Office (CASIO), the Family Violence Prevention and Homeless Supports Division and the City of Lethbridge. The P12 Test Centre also supports two of the strategies highlighted in Alberta’s 10 Year Plan to End Homelessness: 1) reformulate Alberta’s government assistance programs to ensure they achieve the coordinated objective of providing Albertans with housing stability and 2) make it easier for clients to connect with Alberta’s government programs and services.

Developing The P12 Test Centre provided an opportunity to work collaboratively with several partners on improving outcomes for individuals experiencing homelessness in the Lethbridge area. While the original intention was to streamline applications and eligibility determination for income support services, the initiative has since been expanded to include eligibility determination for the Office of the Public Guardian (OPG) and the Office of the Public Trustee (OPT).

Landlords

Partnerships with landlords are crucial for the teams’ ability to maintain and increase housing availability. Housing First in Lethbridge provides training on landlord relations for its agencies. Czech explains how they work with landlords:

“We support the landlords by keeping them informed about what they need to know regarding the status and progress of the client. With landlords you need to be honest with them, let them know what is going to happen, but also that you will be there to provide supports for them and the individual living in their apartment. They need to see that you are working for the benefit of all involved and that you will be there to help with issues as they arise. But it is always a work in progress.”

Alberta Health Services

Collaborating with Alberta Health Services is an essential part of supporting existing teams and developing new ones. SHIA meets with Alberta Health Services monthly to discuss programming issues and solutions. Alberta Health Services is also a funder of Housing First projects including the new Brassard House, a 12 bed permanent supportive housing facility through Covenant House and based out of St. Michael’s hospital. Using a harm reduction approach, Brassard House provides health care through St. Michael’s to seniors and those who are functionally geriatric due to chronic disease and other health issues, and chronic addictions and mental health issues who as a result would not be successful in market housing.

Mental Health

Staff from the Alberta Health Services (AHS) mental health clinic are a part of ongoing meetings with Housing First staff where working with clients experiencing both mental health issues and homelessness is discussed.

Complex Case Consultations

A number of partners from Housing First and other agencies, including AHS addiction and mental health, meet weekly to discuss complex cases that FUWs are handling. Alberta Works, AISH, Downtown Policing Unit, and Lethbridge Emergency Shelter are also included. Others will be added as desired.

Workers present a client’s comprehensive story using a formalized consultation template, which is followed by discussion and brainstorming of ways to assist the client. The last portion of this meeting is a round table for all Housing First agencies and partners discuss other questions and concerns around common clients, processes, and other ways to improve the work with this population Czech describes the process:

“So we get everybody and anybody together. If you aren’t sure whether they should be involved, invite them anyway. One of the greatest advantages of collaboration, especially in the early stages, but is important throughout, is that those at the table and part of the discussion now have a vested interest, when they feel like they are part of something bigger than they are and have influence they become supporters instead of antagonists. But I would suggest even involving the naysayers. Most of the time they are the way they are because they care about their community. Get them involved in a way that shows that their opinions and ideas matter to you.”

Lesson # 7: Housing First Must be Evolutionary

A constant theme in Housing First programming is the need to adapt. Learning from process – ideas will be tried, some will work and some will not – is essential to a team’s success. Even successful implementations will need ongoing modifications in order to best serve clients.

Additionally, the broader social context within which a Housing First team is operating may change as a result of a variety of factors. The economy may weaken, housing prices may shift or there may be important demographic changes that require adaptation. As learning continues and grows, so too may the need for new program options. In Lethbridge, the following changes and developments have occurred since Housing First began there in 2009:

Adapting to a Changing Demographic

During the last several years the demographic of Aboriginal people migrating from reserves changed from mostly women with or without children to an increasing number of men and families with or with out children. Housing First staff adapted funding and shifted the focus and mandate of a Housing First team in order to better address this emerging demographic. In addition, housing units for Aboriginal men and their families are currently being developed that will be made available to Aboriginal tenants who are transitioning off of reserve.

Creating a Furniture Bank

Most people who are experiencing homelessness do not have furniture or the funds to buy furniture. Lethbridge has created a furniture bank dedicated solely for Housing First clients. When first housed they are able to pick out furnishings and other items to make their house a home at no cost.

Centralized Intake

Centralized Intake evolved from the need to better assess and monitor eligibility for Housing First supports and streamline entrance into the appropriate Housing First team. The centralized Intake prevents clients from bouncing around the community looking for the appropriate connection and becomes information gatekeepers, which in turn allows gaps to be identified.

It has also benefited agencies and funders and was an important development in enabling Housing First to be information gatekeepers, which in turn allowed for gaps in service to be identified.

Stabilization Units

A number of permanently leased units are allocated to the Housing First teams in order to provide clients with a short-term transitional home where they can complete some of the final pieces of stabilization necessary before being ready to be independent. This might include final efforts to establish income, or take care of some legal matters and so forth. If the transitional unit suits the client well, they will be able to take over the lease. Another unit will be acquired to keep a constant stock of stabilization units.

Post-Release Housing First Team

The Post-Release/Discharge Housing First Team is specifically designed to house and support individuals being released from corrections and hospital psychiatric and acute care units. Such individuals often do not qualify for ‘traditional’ Housing First teams because they would be seen as transient due to their short time in the community. The Post-Release Housing First Team will address these barriers by working on the process of release when a client enters one of these facilities and begin discharge planning and assessing as soon as possible. The Team will also conduct both outreach and ICM.

St. Joan’s Haven

St Joan’s Haven will be a 40-bed harm reduction based facility that will provide housing and health care for people who have extreme mental health, addictions, and/or physical needs, require 24-hour support and are not appropriate for market housing (regardless of support level) due to these chronic conditions. Brassard House is the interim program set up until the complete project is completed. It houses 12.

Castle Apartments

One floor of the Castle Apartments building will be strictly for Housing First clients experiencing complex needs, are looking to transition away from the influences of addictions, mental health and homelessness and would benefit from intense on-site support.

Lesson #8: Develop Housing First Fidelity

Adhering to the principles of Housing First is an important consideration in Lethbridge’s Housing First teams. Housing First was designed to address the needs of the most vulnerable population – people experiencing chronic homelessness with high levels of acuity. In addition to the core principles, Lethbridge has identified the following factors as important prerequisites for effective programming:

Caseload Numbers

In Lethbridge, staff have a client load of 10 – 15 people (outreach is higher at 20) that contains a balanced mix of complexities. It is recognized that case loads that exceed these levels compromise the effectiveness of a staff person’s work.

Remain True to Staffing Roles

Outreach and FUW staff must only be responsible for their specific tasks. Outreach is strictly about stabilizing income and finding housing, whereas FUW involves ICM and wrap-around supports.

Follow-up is Objective-based

In order to move clients toward self-sufficiency, a case plan must include specific goals and avenues for achieving these goals, informed by the challenges and successes of the client’s SPDAT analysis.

Follow-ups are Planned, Purposeful and Based on Tasks Set Out in Service Plan

The activities and services that a client is referred to should relate to the goals and barriers identified by the SPDAT.

Tool for Measuring Acuity

A reliable, valid and consistent tool is important for measuring acuity in order to guide and prioritize clients, as well as to develop goals that can be achieved by the client. In Lethbridge the use of the SPDAT is crucial in monitoring improvement. ICM is also based on and driven by the SPDAT.

Affordable Housing

Access to affordable housing continues to be a priority in the City of Lethbridge’s Social Policy (2008) and Affordable Housing Policy (2008). The need for affordable housing is demonstrated by the 623 households that are currently on waiting lists for subsidy services. Community trends suggest that more rental properties will be needed in the community, based on number of retirees and others that face challenges in managing their own property. Even when affordable housing is available, NIMBYism attitudes present a significant barrier, particularly for the Aboriginal population.

Although Lethbridge has the highest vacancy rate amongst Alberta’s major cities at 8.8%, the properties that are available are not affordable for everyone. Because of the city’s high number of students, the number of people becoming landlords as a side business has grown. Rental properties generate income for landlords and there is no incentive to reduce their rents. It is therefore essential to continue finding ways to encourage private landlords to work with Housing First teams in Lethbridge.

Sustainability

Integrated Approach

Lethbridge’s Community Plan and Bringing Lethbridge Home: The Plan to End Homelessness 2009-2014 will only be possible with support from a variety of stakeholders including all levels of government, the public and private sectors and the community.

Prove it With Data

Continuing to collect data and disseminate information about the outcomes for Housing First clients is crucial in validating the work. Housing First staff continue to inform funders about the numbers of people housed, maintaining housing, and other areas such as improvement in quality of life, as well as reduction in the use of emergency services.through all of their funded agencies.

Creating Innovative Ways of Using the Cost-savings to Fund Housing First

Client’s reduced utilization of emergency services, reduced substance use and improved health status are the result of participating in Housing First which in turn produce cost savings. In the long term, Housing First staff in Lethbridge would like to see a method of using the money saved in the health, social and justice sectors by Housing First programming to be funneled back into supplementing program costs. This could include, for example, giving landlords reductions on property taxes for renting to Housing First clients. In order to achieve this, the City of Lethbridge needs a means of recuperating their costs and as of yet there is no plan in place to facilitate this goal.

Lobbying and Education

Sustaining Housing First also means making sure that community members continue to be aware of both the program and Lethbridge’s need for Housing First. Teams continue to educate and re-educate the community on these needs, as well as lobby at both the provincial and federal levels.

EVIDENCE OF EFFECTIVENESS

All of the Bringing Lethbridge Home teams use a specialized assessment tool called the Service Prioritization Decision Assistance Tool (SPDAT), which measures 15 specific items that have been identified in the research as indicators for maintaining permanent housing. The SPDAT is completed every three months in order to continually and consistently inform the needs and progress of each client. Data collected from the implementation of Housing First in 2009 show that:

• Over 864 households have been permanently housed and in 2012-2013 90% remain housed through Housing First.

In 2011-12:

• 199 households have ended their experience with homelessness and are now permanently housed.

• Over 205 people received intensive Follow-up Support.

• Overall, there was a 25% reduction in shelter occupancy and over 70% fewer people are living in absolute homelessness (SHIA, 2012a).

ADDITIONAL KEY MESSAGES

Lesson #9: Housing First: One Size Does Not Fit All

While there are core principles to Housing First, there is not a single program model that applies to every situation. Every community is different and what has worked in Lethbridge may not work in Regina. Flexibility is essential to building a program based on local needs.

For some communities core need and priority may be permanent, supportive housing. For others the priority may be subsidized housing or rapid rehousing. A strong community assessment completed with solid data and community-wide collaboration is essential to determining the specific set of needs required in each context.

Lesson #10: Build It and They Will Come

Paying attention to the service delivery model and how people access services is central in planning successful teams. An integrated service delivery model is essential, but is often misunderstood as a centralized service where all programs are run out of the same building. In fact, overly centralized service delivery can undermine efforts to move people out of homelessness. The separation of services is very important.

Czech describes the potential problems with centralizing services at shelters for people experiencing homelessness:

“In the movie Field of Dreams, there is the famous line ‘Build it and they will come’. At the shelter in Lethbridge the next line would more likely be ‘The problem is that I built it, you came, more keep coming and nobody wants to leave’. One of the things we thought years ago was to have a one-stop shop at the emergency shelter. Everything in one place. But this became a problem at a time when we were trying to eliminate shelters or shelter beds as opposed to building more of them. The problem, in our experience, is that when you create shelters as the central hubs for all services for people who are homeless, the shelter becomes like a vacuum. The longer people spend time at the shelter, the longer they stay homeless. One of our team’s ‘resource centre’ was in a shelter, and they brought in other resources and services. The Centre focused on rapid rehousing for people with low acuity, less complex cases. But here is the thing – individuals would get housed, and come back time to time to meet the worker or to access services. Then they meet old buddy Joe, and they decide to stay in the shelter to hang out. Then they stay for a week, then give up their housing, then stay for a month, then a year or more, they get sucked back in.”

As a result of this situation, all of the programming was moved out of the shelter and back into the community. The housing team began to be transitioned into a ‘Diversion Program’ based at the shelter, but with a mandate to create a connection with individuals as soon as they enter the shelter system for the first time. This helped divert clients away from the emergency shelter system. Clients were also connected to HomeBASE and other mainstream services in order to access the help they need.

REFERENCES

Social Housing in Action (2009). Bringing Lethbridge Home 5 Year Community Plan to End Homelessness (2009-2014). Retrieved from http://www.bringinglethbridgehome.ca/resources.cfm

Social Housing in Action. (2012a). “Until Everyone Has a Home”. Bringing Lethbridge Home: Our 5 Year Plan to End Homelessness. Annual Progress Report 2011-2012. Retrieved from http://www.bringinglethbridgehome.ca/resources.cfm

Social Housing in Action. (2012b). Bringing Lethbridge Home: 2012 Lethbridge Homeless Census. Retrieved from http://www.bringinglethbridgehome.ca/resources.cfm

ENDNOTES

1. The Universal Declaration of Human Rights, Article 25 1: “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”

Streets to Homes

Victoria BRITISH COLUMBIA

Fiona Scott

Key Messages

• Shows how a program from a large city can be adapted and replicated in a smaller community.

• Provides options for providing housing in a tight housing market including a unique Private-Public Housing Initiative.

• Focuses on episodic and chronically homeless individuals with a mental health and/or addictions issue.

In Victoria, British Columbia, one of Canada’s most expensive cities, high rents and low vacancy rates means homelessness is a critical issue for the city. In 2007, a Mayor’s Task Force was established to explore improving how some of the city’s social problems were addressed. The report, Breaking the Cycle of Mental Illness, Addictions and Homelessness, identified an annual expenditure of $76 million on over 200 organizations addressing the needs of individuals experiencing homelessness and/or mental health and addiction challenges. At least $62 million in additional funding was spent on additional services, such as policing, jails, hospital services and emergency shelters (Mayor’s Task Force, 2007). Despite this spending, many needs remained unmet.

Breaking the Cycle established a plan to address the disparity between spending and outcome, mandating that

“[t]he outcome of the work will be the identification and costing of options for a comprehensive, integrated, client-centered model to support those most vulnerable to homelessness, inadequate housing, poverty, mental illness and addictions, along with recommended next steps for implementation” (Mayor’s Task Force, 2007:4).

In 2008, resulting from Breaking the Cycle’s recommendations, the Greater Victoria Coalition to End Homelessness was formed. The Coalition is a community-based partnership of local service providers, non-profit organizations, all levels of government, businesses and post-secondary and faith communities. The Coalition’s goal is to end homelessness in the Capital Region by 2018.

The Coalition brought together different partners and jurisdictions to create an integrated and coordinated service delivery model addressing chronic homelessness in Victoria. The Coalition also wanted to complement significant investments already made in the region, such as Assertive Community Treatment (ACT), the Victoria Integrated Community Outreach Team (VICOT), the Ministry of Social Development’s Homelessness Intervention Project (HIP) and other non-profit programming in the sector.

When exploring how other jurisdictions across Canada were organizing to end homelessness, the Coalition found Toronto’s Streets to Home program. Established in 2005, the program was having great success in housing people and supporting them in remaining housed. Based on Toronto’s example, the Coalition initiated the Greater Victoria Streets to Homes (S2H) Program pilot project in April 2010. While Pacifica Housing has taken over administrative responsibility for S2H it is essentially the same program with minor changes and innovations as the program evolves.

This case study presents an analysis of Victoria’s S2H Housing First program. The study focuses on the underlying principles of the program, the process of building support for the initiative, planning and implementation challenges and evidence of success. The case study concludes with the central findings learned from this Housing First program.

GETTING STARTED: FRAMING THE ISSUE

Housing First, as a concept, had been operating in Victoria on a small scale since the early 1990s. Pacifica Housing had operated low-barrier, harm reduction-based supportive housing programs in four buildings beginning in 1988 with Medewiwin, a project of The Victoria Street Community Association (Pacifica took over management in 1999). They added Waterview in 2008, Clover Place in 2010 and Camas Gardens in 2011. The idea of providing housing plus supports to address homelessness was not a new approach in Victoria, however it had not been implemented on a large scale as the main intervention format.

The Mayor’s Task Force Report Breaking the Cycle (2007) demonstrated the need to change the status quo of service delivery to people experiencing homelessness, mental health and/or addiction challenges. At the same time, there was growing frustration around the number of people cycling in and out of the shelter system. The community wanted change for its citizens experiencing homelessness.

It was clear to those planning and delivering services in Victoria that Housing First would be an integral part of solving homelessness in Victoria. Because there was no capital funding available to provide new housing, the Coalition team knew that rent supplements delivered through the program were essential to providing housing. Pacifica Housing’s experience with managing private market landlord relationships also informed the city’s programs.

Increasing support for the Housing First model required involving multiple sectors of the community in education outreach and dialogue. Frontline service workers from a variety of housing-related organizations were brought together to learn about the program and its goals and to participate in community discussions. The team also held sessions with landlords that asked for their involvement and shared with them how the Housing First model would work in Victoria. The success of Housing First programs in other areas, including New York, validated investment in Victoria’s program.

The shortage of affordable, next-step housing was another factor framing Victoria’s Housing First approach. Supportive housing providers and stakeholders were aware that some people living in supported housing no longer needed intensive supports. However, because of the lack of affordable, next-step market housing clients would remain in supportive housing unnecessarily. Implementing the Housing First model with flexible program delivery would allow those no longer needing supportive housing to move into market housing and free up spaces for those who needing support.

Improved access to affordable market housing was facilitated by the Rental Owners and Managers Society of BC (ROMs). Based on Pacifica Housing’s programs that provided support to both the landlord and resident, ROMs saw an existing and successful Housing First model that they could support.

MOVING FORWARD: PLANNING

Learn From Other Housing First Programs…

One of the Coalition’s first steps in developing city-wide Housing First in Victoria was looking at the models other communities had used to effectively reduce homelessness amongst vulnerable populations. In 2009, research and stakeholder discussions revealed a variety of programs active in a number of jurisdictions across North America. Toronto’s Streets to Homes program had impressive outcomes in terms of reducing homelessness and was an excellent example of using strong private market partnerships to access housing for clients.

…But Adapt to the Local Context

Toronto’s Streets to Homes program was chosen as Victoria’s Housing First model because it offered a Canadian program functioning in a political climate similar to Victoria. However, despite these similarities there were a number of differences that emerged from the context of program planning and implementation. The planning team knew that the housing markets in Victoria and Toronto were different: there were far more housing options and housing stock at lower rent levels in Toronto. Housing people in Victoria was going to present a challenge and would require building a relationship with an organization that could provide funding for rent supplements. The team partnered with BC Housing to cover these costs.

Attracting Landlords and Housing Providers

In order to secure housing for their clients, Housing First providers in Victoria had to build relationships with local landlords and housing providers. They had learned that landlords, as business-owners, were hesitant to accept clients who had been living on the streets. Landlords wanted to know that Housing First would benefit them and not just the client. Staff also discovered that rather than trying to convince landlords to support Housing First for the good of the community, landlords needed to hear that the initiative would not present a significant risk to them.

S2H staff conducted outreach with landlords by finding buildings, talking to landlords and learning about their common frustrations. Often landlords cited problem tenants as a barrier to participating in a Housing First program. To overcome this barrier, staff worked alongside clients and landlords to develop good relationships and ensure that supports were in place to remedy any potential negative situations.

THE STREETS TO HOME HOUSING FIRST MODEL IN VICTORIA1

The S2H program enables clients to find private market housing and provides rent subsidies and supports to maintain housing. S2H is based on the following principles, in line with those outlined in the A Framework for Housing First (Gaetz, 2013):

• Housing is a right and everyone is ready to be housed regardless of his or her circumstances and behaviours;

• Clients are not required to abstain from drugs/alcohol in order to be housed; and

• Clients need unique supports in order to stabilize and progress after being housed.

Target Population

S2H targets individuals who are experiencing chronic homelessness and who face barriers to stable housing including affordability, mental health and/or substance use challenges. To qualify for S2H, potential tenants must:

• Have experienced homelessness for at least 12 months in the past two years.

• Have an observable mental health or substance-use challenge.

• Accept the supports and terms of the program.

A network of agencies works together to address a client’s range of needs including:

• Help finding permanent private market housing;

• Providing a rent subsidy of up to $300;

• Assistance in building capacity to meet and sustain housing needs;

• Support and training in building capacity to navigate complex systems and self-advocate in order to meet personal needs;

• Case planning, community referrals and direct support services to address mental and physical health and/or substance use challenges;

• Assistance with obtaining new or increased benefits and subsidies;

• Access to support and training to increase skills including financial literacy, budgeting, general life skills and employability skills;

• Support in accessing recreational and social activities; and

• Assistance in finding meaningful ways to strengthen social inclusion.

Intake Process

In June 2012, the Greater Victoria Centralized Access to Supported Housing (CASH) was implemented. CASH is a centralized intake system that includes all supportive housing providers in Victoria, including non-Housing First programs. CASH is an administrative hub which can be accessed through most community service providers including hospitals, shelters, food banks health clinics, detox facilities and outreach programs.

The CASH system was developed in response to the identification of an administrative barrier to supportive housing in Victoria. Before centralization, clients applied directly to each of the housing providers in the city, completing a number of forms for each provider. Over eight months the intake criteria, assessment, infrastructure and funding were developed to create a centralized hub where anyone working with someone or directly experiencing barriers to stable housing could complete a single application and access the most appropriate housing, depending on vacancies, through the city’s various supportive housing providers including Housing First providers.

The S2H Frontline Service Worker Group (comprised of representatives from the Victoria Cool Aid Shelter, the Salvation Army and other partner agencies) meets weekly to review S2H referrals from CASH. The committee makes recommendations based on the applications and availability of housing.

Staffing

Follow up Support Workers (5)

Each client is assigned a Follow-up Support Worker (FSW), who works closely with the S2H Landlord Liaison and client to identify and secure a suitable and appropriate private market unit. FSWs also support clients in maintaining their housing by assisting in areas such as budgeting, apartment maintenance and facilitating access to community support. Two FSWs are funded and employed by the Victoria Native Friendship Centre (VNCF) while the other three are employed by Pacifica Housing.

Program Coordinator

The S2H Program Coordinator is responsible for areas such as financial management, program monitoring, data collection and reporting, policy development and program evaluation. This position is part of Pacifica Housing and reports to Pacifica’s Director of Support Services. The Service Integration Committee of the Coalition provides high level oversight for the program.

Landlord Liaison

The Landlord Liaison is an employee of Pacifica Housing who works to identify and build relationships with potential landlords in order to increase access to housing for participants. The Landlord Liaison also works with landlords to address any problems that arise.

MAKING IT HAPPEN: IMPLEMENTATION

The S2H program was based on Toronto’s successful Housing First model. However, the different housing and socio-economic situation in Victoria, including a low vacancy rate and lack of affordable private market rentals, meant that program adaptations were needed to address these challenges.

Extremely Low Vacancy Rate

Victoria generally experiences a very low vacancy rate (ranging between 0.5%-2.5% observed between 2005-2011) (Crewson, 2011). Although there is always tenant turnover, with rates so low in Victoria finding suitable housing can be a slow process.

Lack of Affordable Private Market Rentals

In response to high market demand, rental prices have risen beyond what is affordable for people living in poverty. The result is a significant lack of options for people who are experiencing homelessness or at risk. Greater Victoria, in contrast to many other cities, also has few other housing options such as Single Room Occupancy (SRO) hotels. This is in part because of the municipality’s closure of a number of poorly maintained, low-rent buildings. The Toronto S2H program also had the advantage of accessing public housing stock that included rent-geared-to-income social housing.

One Solution: the Private-Public Housing Initiative (PPHI)

In response to the challenges of finding affordable housing, the Victoria Private-Public Housing Initiative (PPHI) was created as an alternative way of accessing housing. The initiative is a partnership between the ROMs of BC and S2H. The partnership works to increase housing stock by moving people no longer needing intensive supports out of supportive housing, into private market housing. This in turn opens up spaces in supportive housing for those currently in need. S2H facilitates a smooth transition by providing the resources for less intensive supports and subsidies. Involving landlords in housing people with a greater level of stability meant that landlords were less concerned about the potential risks. This initiative increased the number of housing units available while improving relations between housing organizations and landlords. Al Kemp, CEO of ROMs BC, stated that:

“This pilot project was not only a success in that its result was ‘creating’ 15 units of subsidized social housing, but also it demonstrated that a private-public partnership can cause effective change in our community. I sincerely hope the creating of these 15 units and the successful housing of 15 people in private sector accommodation will serve as a bellwether for continuing this partnership” (Crewson, 2011:14).

Maintaining Landlord Relationships and Mitigating Risks

Private landlords are often understandably concerned about the risks associated with housing people experiencing a variety of challenges. The S2H program helps to mitigate many of these risks. For example, once a client is housed the rent payment goes directly from the S2H administration at Pacifica Housing to the landlord, eliminating the risk of nonpayment. Another common concern from landlords was the potential for property damage. S2H staff have found that Housing First must have the financial resources available to pay for any damage repair. Another important aspect is dedicating a staff member to working with landlords to build trusting relationships, just as they would with clients, and to deal with issues as they arise. For landlords the reassurance of knowing they can call a dedicated staff member to address their concerns is essential to building a long-term and trusting relationship with S2H. The Landlord Liaison and FSW manage the majority of S2H tenancy issues. Clients are also empowered to take on progressively more responsibility.

Landlords in Victoria had also been exposed to a number of different housing programs at work in Victoria. On some occasions when S2H staff called landlords to inquire about availability, landlords would report issues with a previous tenant from the S2H program. Further conversations would reveal that the tenant was from a non-S2H program. This points to the potential for further collaboration amongst service providers who work with landlords in the private market.

The relationship-building aspect of partnering with landlords was crucial in Victoria’s S2H program development. The team has secured 20 landlords with 50 buildings who are willing to work with S2H to access and maintain housing for clients. All 20 landlords have been retained since the beginning of the program.

High Support Need

Given Housing First’s focus on the most vulnerable citizens, clients in the program can experience significant social and behavioural challenges. As Brad Crewson, S2H Coordinator explains

“…structural and systemic factors associated with homelessness in Greater Victoria, including lack of rental affordability, low minimum wage ($8 at the time of writing) and income assistance rates, limited substance use treatment resources and more, have resulted in a disproportionately large number of participants with a range of chronically unmet health and social needs” (Crewson, 2011:13).

People who have experienced long-term street involvement, substance use and/or mental health challenges can display disruptive behaviours. In Victoria, S2H staff found that some clients needed significantly more time to adjust to their new situation than others. Change is difficult for everyone. For those adjusting to a new manner of living, with new rules and responsibilities, it can be overwhelming and difficult to control emotions and behaviours. Some participants who were stable during their initial assessment became more aggressive or destructive after getting housing.

“The coping mechanisms that keep them alive on the street become deeply ingrained as they adapt to extreme demands. When they become housed, many of these stressors disappear and some participants show a tendency to react instinctively by acting out or resorting to behaviours that increase the levels of stress and crisis that are more familiar to them. While S2H was well aware of the potential for these behaviours, with only four FSWs2 who provided off-site support services, there was limited capacity to respond efficiently to the range of behaviours and needs of the participants” (Crewson, 2011:13).

Another potential problem is a participants’ capacity to manage guests. Many people who formerly experienced homelessness have broad social networks with others who are currently experiencing homelessness. When one person becomes housed they are sometimes pressured to assist their friends who are still experiencing homelessness. Parties, noise and overcrowding that result from this pressure can cause problems with neighbours. Having a staff member working with clients and landlords to deal with these issues has been essential to the success of the S2H program.

Adjust Staffing Models to Suit Needs

During the pilot project the existing S2H staffing model did not allow for the intensive levels of support sometimes required and needed adaptation. The pilot program’s staffing model included a Landlord Liaison, a Program Facilitator and a Program Coordinator. Not all of these roles were found to be necessary and were subsequently revised. In the revised model, the Program Coordinator took on some of the Facilitator’s tasks. Additionally, the number of FSWs was expanded to five based on increased rent subsidises and best practices regarding client-worker ratios.

Maximum Caseload

As the program grew and more subsidies became available, more staff were hired in order to maintain a client caseload of 24 people or less for each worker. The maximum caseload ensures that clients receive the support they need to obtain and maintain housing.

Remuneration

Salaries in the nonprofit sector are notoriously low, however S2H in Victoria understands that talented workers increase the effectiveness of the program and budgets for the necessary costs of attracting and retaining quality staff. S2H works to offer wages and incentives that attract high quality support workers who are experienced and knowledgeable.

Continuous Monitoring and Evaluation to Inform Program Adaptation

Successfully adapting programs to suit client needs was essential to improving S2H outcomes. Information collected and documented during the pilot project identified the challenges needing to be addressed and was used to inform the program going forward. Staff continue to refine and adapt best practices, integrating recommendations learned in program delivery, as well as from program evaluations.

Need for Collaboration and Integration of Services

There is a strong belief in Victoria that ending homelessness requires a community effort; it cannot be done without the support of Victoria’s major players in the homelessness, health and social care sectors. The S2H program was initiated by the Coalition and is currently administered by Pacifica Housing, but relies on other agencies’ contributions to the program’s success.

Central Partnerships that Enable Housing First in Victoria

S2H is a partnership and collaboration between the Coalition and a variety of organizations. Since the coalition’s mandate did not include direct service delivery an agency was chosen that had existing administrative infrastructure (payroll, physical office space, communications, accounting etc.) to administer the program on behalf of the community. While Pacifica Housing and VNFC provide the structure, pay for staff etc. all partners identify as part of the S2H team. Each plays a key role as outlined below:

• BC Housing provides funding for S2H rent subsidies.

• Victoria Cool Aid Society, Our Place Society and The Salvation Army provides shelter and transitional housing services, as well as referrals. They also send representatives to the Frontline Service Worker Group that is responsible for S2H intake decisions.

• Pacifica Housing provides the administrative infrastructure for Victoria’s S2H program as well as employing the Program Coordinator, Landlord Liaison and 3 FSWs.

• Victoria Native Friendship Centre employs two of S2H’s five support workers who have access to additional agency expertise, particularly regarding Aboriginal issues.

• Vancouver Island Health Authority has provided a ‘one-time-only’ operations grant.

• The Ministry of Social Development provides staff support, information access and policy provisions that facilitate service provision for S2H clients.

• The United Way of Greater Victoria provides the majority of the operational funding for the Victoria S2H program.

EVIDENCE OF EFFECTIVENESS

An evaluation of S2H was conducted in the summer of 2011 with the support of the Community Social Planning Council. The evaluation’s goal was to provide evidence of S2H’s effectiveness by documenting both individual outcomes of participants, as well as system-level changes relevant to addressing homelessness amongst people with multiple barriers to housing in Greater Victoria. A subsequent internal evaluation in 2012 provided updated data on outcomes for all clients since the program began.

From the beginning of the program (August 2010) until December 2012:

• 130 participants have been housed; and

• 63 of the 86 (73%) participants who were housed, prior to and including Jan 1st 2012, are known to be housed (clients who have left the program may still be adequately housed but S2H is unable to confirm their housing status).

Of the 35 housed participants who have exited the program since it began:

• 13 were transitioned to supported housing or a higher level of support;

• 4 left for other housing opportunities before completion;

• 7 completed the program (attained stable housing and income);

• 6 exited due to non-compliance;

• 3 with whereabouts unknown; and

• 2 are deceased.

Surveys were also administered to clients about their perceptions of the program and its impact on their lives. Responses included:

• 36 of 57 (63%) of those participants responding to the survey reported increased access to mental health and addictions support;

• 22 of 95 (23%) of current participants received some kind of new employment income in addition to their existing benefits and subsidies;

• 26 of 95 (27%) of current participants are involved in volunteer activities; and

• 39 of 95 (41%) of current participants are involved in pre-employment training, employment training or educational upgrading.

Sustainability

Greater Victoria’s S2H model has evolved into a cost-effective, efficient alternative for people experiencing homelessness and multiple barriers to accessing stable, affordable housing. The cost of running the program is approximately $7,000 per participant, per year; much less than the costs of operating purpose-built supported housing.

Funding

At the end of the two-year pilot project, S2H received three year funding from the United Way of Greater Victoria, as well as grants from BC Housing, The City of Victoria, The Victoria Foundation and the Coalition. In January 2012 S2H transitioned into a permanent program and ongoing administrative responsibility moved to one of its community partners, Pacifica Housing. The core service delivery model remains the same; changes were noted in the ‘making it happen’ section.

Sustaining the program will rely on maintaining the momentum of the program’s success and effectiveness within the community and amongst stakeholders. Securing diverse sources of funding is also necessary to achieving long-term sustainability.

The Importance of Knowledge Mobilization in Sustaining S2H

Raising awareness about the success of the program is integral to its sustainability. It is essential that knowledge of Victoria’s successful Housing First program be spread amongst community members, funders and broader Canadian society. Leaders from within the community are taking the opportunity to speak, for example at a recent BC Non-Profit Housing Association Conference, with other groups and communities about Housing First and Victoria’s S2H program. S2H staff feel that as people hear about successful Housing First programs occurring in different communities overall support for S2H, both in Victoria and elsewhere, will inevitably grow.

Diverse Multi-source Funding

Programs reliant on one or two funding sources are at risk of program instability if one funder decides to remove their financial support. Having multiple and diverse sources of funding in Victoria has also proven to be a form of leverage; multiple funders demonstrates that organizations are already supporting the program, which in turn encourages others to do the same.

KEY LEARNINGS

A Home is Foundational

Regardless of the level of support a person receives in the community, until they have a their own home it is very difficult, and sometimes impossible, for a person to focus on other needs such as finding a job or maintaining sobriety. Having a home promotes stability, health and social inclusion. If homeless reduction programs in Victoria are going to be successful, providing housing is essential.

Context Matters

Every community is unique. What makes Housing First a viable option is its adaptability to a specific community’s needs and its capacity to address existing service gaps. Although Victoria’s S2H program is based on Toronto’s model, adaptations were made in response to Victoria’s particular rental market. As long as a program is based on the core Housing First principles, the specific supports and activities that are offered can be modified to suit the needs of the clients and the community.

The Importance of Rent Supplements

The Victoria S2H program provides participants with a maximum $300 monthly rent supplement. Without the supplement staff feel they would be far more restricted in terms of where people could be housed, that it would take longer to find housing and that fewer people would be able to access housing.

Early in 2013, BC Housing planned on gradually eliminating the rent subsidies through attrition, however the rental market in Victoria remained too expensive for many of its citizens to afford. The community rallied together and convinced the funder to renew their commitment to funding. Rent subsidies was clearly an aspect of the program that all stakeholders felt was important for the success of the program.

Public Education

The data on homelessness in Canada indicates that anyone can experience homelessness. Many people experiencing homelessness have faced significant difficulties in their lives that have resulted in homelessness; some have lost their jobs, been the victim of a fire or other tragedies. Traditional methods of managing homelessness are not working because they consistently lack a key aspect: housing. People experiencing homelessness need a home and they need support in finding and maintaining that home.

Education that works to break down the stereotypes around homelessness and helps the public understand the realities of homelessness is an essential component of Housing First. As communities come to understand the philosophy of Housing First and see the evidence of success among Housing First programs, both locally and nationally, their capacity and propensity to support these programs will increase.

REFERENCES

Crewson, B. (2012). Greater Victoria Streets to Homes Program Evaluation and Report. Pacifica Housing.

Brad Crewson, B., Moreno, A., Thompson, D., Kerr-Southin, M. (2011). Streets to Homes Pilot Project Evaluation.

Mayor’s Task Force on Breaking the Cycle of Mental Illness, Addictions and Homelessness. (2007). Breaking the Cycle of Mental Illness, Addictions and Homelessness. Retrieved from http://www.victoria.ca/EN/main/city/mayor-council-committees/task-forces/homelessness.html

ENDNOTES

1. The description of Victoria’s Streets to Home program is adapted from a document entitled Streets to Homes Pilot Program Evaluation (2011).

2. During the pilot there were four FSWs, but this was increased to five.

Community Action Group on Homelessness

Fredericton NEW BRUNSWICK

Fiona Scott

Key Messages

• This is a case study of a developing systems response to Housing First thus providing a glimpse of a very different stage of development.

• Smaller and more rural city than many of the other case studies profiled.

• Includes information about how different groups are responding to the same issue within the city.

Fredericton is a small city in New Brunswick on Canada’s east coast with a population of 125,000 in the Greater Fredericton Area. The city has the highest average cost of rental accommodation in the province and the lowest vacancy rates (CAGH, 2012).

In 2012 there were 262 individuals who accessed the City’s shelter system (Ross, Personal Communication, 2013). Between 2008 and 2012, there was a 40% drop in shelter use in Fredericton from 432 individuals in 2008 (Ross, 2013), despite declining rental vacancy and increasing rents. This marks the fifth consecutive year that shelter utilization has decreased. One factor in the reduction of shelter usage is the work being done by outreach social workers and the community on Housing Loss prevention, which has reduced the return rate to shelters of previous residents.

However, guidelines provided by the Wellesley Institute’s report, Precarious Housing in Canada (2010), mean that as many as 1,300 people could be considered part of the hidden homeless population in Fredericton.

The Province’s housing strategy report, entitled Hope is a Home, as well as the accompanying homelessness framework (Government of New Brunswick, 2010) in 2009-2010, resulted in a number of changes to the way homelessness was addressed that contributed to the decrease in shelter use. Strategies outlined in the report included: an increase in the creation of new affordable housing, the creation of a supportive housing network, a focus on ‘organized’ departures, and a move towards a Housing First systems approach. The publication of Overcoming Poverty Together: The New Brunswick Economic and Social Inclusion Plan, set a significant goal that could further contribute to success in Fredericton. This plan states that “by 2015, New Brunswick will have reduced income poverty by 25% and deep income poverty by 50%, and will have made significant progress in achieving sustained economic and social inclusion” (Government of New Brunswick, 2009).

Despite the decline in shelter use, the problem of homelessness is not going away just yet. Several indicators suggest hidden homelessness continues to rise, including1:

• There are few housing options for individuals with addiction issues or other complex needs (for example, Fredericton only has dry shelters and lacks sufficient harm reduction service models).

• There is increasing demand for access to Chrysalis House, a transitional housing program for female youth.

• There are no emergency shelter options for male youth in Fredericton.

• There is increasing demand for the food bank and community kitchen as food insecurity increases.

• Housing insecurity is on the rise. More people are at risk of homelessness due to precarious housing situations (for example, paying more than 30% of their income towards the rental cost of a unit).

Traditional services for people experiencing homelessness in Fredericton, much like the rest of the country, were originally focused on supporting people with other issues, including mental health and addictions, before providing housing. The success of other Housing First programs in Canada, with Moncton, New Brunswick, as one of the pilot sites of the At Home/Chez Soi project, has helped to increase awareness and support for the model. As a guiding philosophy, Housing First is emerging as the motto of the organizations addressing homelessness in Fredericton.

Overall, reducing and preventing homelessness in Fredericton will depend on a number of significant factors, including a continued investment in affordable housing and the provincial housing and homelessness frameworks (which include a Housing First approach). To date, the Province’s Poverty Reduction Strategy has reformed New Brunswick’s income supports and social assistance policy which has contributed to the declining numbers.

There are multiple groups working on the development of the Housing First model in Fredericton including the Supportive Network (SUN), a group of front-line service providers and government partners, as well as the Community Action Group on Homelessness (CAGH), a network of frontline service providers, government liaisons, and community leaders, who are working to address homelessness. CAGH was born out of the National Homelessness Initiative’s Supporting Community Partnership Initiatives (SCPI), renamed the Homelessness Partnering Strategy (HPS) as of 2007. These two groups have allowed for systems planning and visioning towards ending homelessness in Fredericton. CAGH believes one of the fundamental principles of ending homelessness is “a system built around Housing First works best” (CAGH, 2012:3).

Although a Housing First systems approach has been adopted in Fredericton, the planning and implementation of Housing First programs vary; some are in the planning stages and others in early years of operation. In late June 2013, CAGH convened a large-scale systems planning table to revise the mission, vision and objectives of the model, and to develop a multi-year plan to end homelessness, based on a coordinated system of care that utilizes both prevention and Housing First strategies. CAGH plans to have completed the development of this new approach by the fall of 2014.

One of the most important tools of development for this plan has been community engagement and education. The housing and homelessness sectors are on-board in terms of Housing First implementation. An ongoing dialogue about the Housing First framework has been significant in fostering support and funding for the important changes to the housing and homelessness system of care within the city.

The success of the John Howard Society’s permanent supportive housing program, created in 2010, and the work of the Supportive Network are both strong indicators of how Housing First strategies can impact the issue of homelessness in Fredericton.

The purpose of this study is to provide an overview of CAGH’s experience with planning new Housing First strategies, as well as some of the barriers they anticipate and how they plan to address them.

GETTING STARTED: FRAMING THE ISSUE

The growth of other Housing First program models and demonstrated effectiveness, in Canada and internationally, highlight the humanitarian and moral arguments for providing people with housing; housing is a basic human right, a right everyone deserves. The evidence increasingly indicates without a home, it is often much more difficult for people to address other issues contributing to their circumstances. Stakeholders and communities alike are beginning to see the cost benefits of providing housing, particularly in relation to health.

In his column entitled ‘Poverty Matters’ in the Fredericton Daily Gleaner, Brian Duplessis, former Executive Director of the United Way/Centraide of Central New Brunswick wrote:

"When we know that providing emergency service to a homeless person can run as high as $100,000 per year, and we also know that following the Housing First approach can reduce that to as little as $14,000 per year, why aren’t we rushing to implement it?"

Based on the province’s homelessness framework and housing policy, several initiatives in the city moved towards a different approach to homelessness, an approach that resembled the philosophy of Housing First. For example, in the summer of 2010, the 'Supportive Network' was established by community partners in an effort to support people forced to use the shelter system as long term housing into permanent affordable housing. The network includes a cross section of workers from social organizations including social workers, outreach staff, mental health and addiction help providers, income support institutions, occupational therapists and staff from long-term care facilities. Since early 2010, 52 people who were living in shelters or were at-risk of becoming homeless were provided with affordable housing and ongoing support (John Sharpe, Personal Communication, 2013). In addition, as part of the framework, shelters were given additional resources to help individuals achieve ‘organized departures’, rather than evictions. An ‘organized departure’ means helping people find housing and providing them with the supports they need to get out of homelessness.

The two other big components of the community plan believed to have made a significant reduction in shelter use, are:

1) An investment in housing-focused outreach services that connects individuals with access to housing as soon as possible, helping them gain an income and access to community supports. Since 2010 this service has been successfully developed and operated by Partners for Youth Inc. (P4Y). This program includes three full-time registered social workers who connect with clients in the emergency shelter system, the soup kitchen and various community based locations. One social worker provides support to clients once they are housed. The other two work as a triage system (one working with clients under 36 years of age, the other with clients above 36 years of age) to help move people out of the shelter system very quickly. Ongoing supports and connections to partner agencies are provided once housing has been established. Funding for this approach is provided by the Federal Homelessness Partnering Strategy and the Provincial Department of Social Development. The partnership with the Fredericton Homeless Shelters and the provincial government has been significant in terms of communications and the sharing of resources. This partnership has been a key component to the overall success of outreach services in the community.

2) There was a lack of permanent supportive housing (PSH) in the area which created a gap in services. In October 2010, the John Howard Society opened the doors of a new 12 unit affordable housing program that was based on the philosophy of Housing First.

Data was collected with people upon entry to the program, as well as one year later. The data showed a significant reduction in: emergency health use (from 136 nights in hospital to 17), justice system interactions (from 465 to 30) and stays in detoxification units (from 98 to 12). These results suggest a significant cost savings in other social services as a result of providing housing and support (Ross, 2012).

Over the last few years CAGH has leveraged an unprecedented level of support in ending homelessness. One of the events that contributed to this change was a tragic rooming house fire in 2012 in which 26 people lost their homes. Key partners in the housing sector pulled together to house them in 55 days. Given this success, community members and organizations realized if it could be done for those 26 people, it could be done for others.

“What a difference there was between finding suitable accommodations for all 26 within 55 days and the grim stories of homelessness we were dealing with such a short time ago one man in his 50s in the homeless shelter for 19 years; several others in the shelter for five to seven years. The capacity to respond to the aftermath of the fire evolved out of the collaborative work done to reduce the use of the shelters by 30% – work by members of the Community Action Group on Homelessness (CAGH), local churches and other volunteers. We know it’s possible to end homelessness, not just manage it as we have for the last few decades” (Brian Duplessis, Former Executive Director, United Way/Centraide of Central New Brunswick).

After the fire, CAGH began an awareness campaign which culminated in a public engagement fundraiser. In March 2013, the fundraiser, a community discussion, entitled Let’s Get Frank About Homelessness, was held. The event featured keynote speaker Frank McKenna, former premier of New Brunswick, and a panel that included Tim Richter, then Director of the Calgary Homeless Foundation (CHF). The proceeds went towards affordable supportive housing in Fredericton, which included a pledge of $100,000 by Frank McKenna that helped to leverage corporate sponsorships.

Since then, more people have begun to embrace the Housing First philosophy. The more people who understand the program and its potential, the easier it will be to make it a successful program. Community engagement will therefore continue to be an important part of planning Housing First services in Fredericton.

MOVING FORWARD: PLANNING

Agencies within the City of Fredericton are at a mixed stage in the development and enhancement of a city-wide Housing First philosophy. The next steps and potential challenges have been identified to include:

Agreement and Understanding of the Housing First Model

There appears to be explicit agreement among all homelessness sector and housing organization that Housing First is the right approach to solving homelessness in Fredericton. Expanding this to other areas including health, education, emergency response, corrections and the general community will involve more dialogue and education to increase understanding of Housing First and its principles. CAGH has strengthened the network and community understanding about a plan to end homelessness in Fredericton and will leverage this network to access the required support and resources. The work will be guided by templates for ending homelessness developed by the CHF and the Canadian Alliance to End Homelessness (CAEH). These include four strategies (one being Housing First) and 10 essential elements of Plans to End Homelessness (for more information see Calgary’s 10 Year Plan to End Homelessness and the CAEH’s planning framework A Plan, Not A Dream).

Coordinated Entry

In recent years, there have been increased communication and referrals between sectors. While there is not a coordinated system of care to address homelessness in Fredericton in terms of a common intake or assessment program, partners are working together to share information. Each new client to a shelter must contact a social worker (provided through Partners for Youth) within 48 hours of arrival in the shelter. When a hospital or jail makes a referral to a shelter, they also provide information to Partners for Youth about the new, incoming client.

A database or comprehensive coordinated entry system – in other words developing one centralized point of access to all programs in the community that are working to address homelessness – will be an essential next step. Also known as coordinated intake or assessment, coordinated entry means everyone seeking assistance with housing completes the same assessment process, enabling service providers to match the level of housing and supports to an individual’s need. CAGH continues to work to bring the key players together, and will seek expert consultation on the development of coordinated entry. Some members of the Supportive Network use HIFIS, an information management system to collect data on clients but it isn’t a pure coordinated entry intake. Social Workers gather ‘tombstone information’ (e.g. name, age, gender, date of birth) as well as information about education, employment history, addictions, mental health etc. Partners for Youth and shelter staff work with each client to establish weekly short and long term goals as part of the exit plan from the shelter system and recovery plan.

Consumer Choice and Developing Landlord Relationships

The principle of consumer choice is currently difficult to achieve based on the housing available in Fredericton. Increasing access to different types of housing, in different locations, will require a concerted effort to develop relationships with landlords. Social workers have built several successful partnerships with landlords. The limited numbers of landlords within the city means that a new building may still be run by a known landlord, although the property manager/superintendent may be different. CAGH intends to consult with other Housing First programs and experts to create a plan to successfully recruit willing new landlords and maintain tenancies with them in order to fulfill this principle.

Poverty and Barriers to Increasing Income

Providing people with housing will not necessarily address some of the underlying issues that contribute to homelessness, such as low income and poverty. As a small city, access to income and employment opportunities continue to be serious issues in Fredericton (CAGH, 2012). While there are also fewer opportunities for training and education, particularly for people experiencing low-income vulnerabilities, an increasing number of a training and education programs have been developed in recent years.

Low literacy levels also contribute to unemployment in Fredericton and throughout the province. Among the adult population in New Brunswick, more than half have “literacy skills that are considered to be below the level that enables them to function adequately at home, at work and in their communities, and to deal with the demands of a knowledge-based economy” (Government of New Brunswick, 2009:5).

Food security is a significant problem for many families in Fredericton, indicating the lack of buying power and prevalence of low income and poverty in the city. Recent research found food security is a problem across the province with New Brunswick having the third highest level of food insecurity in Canada (25%) (Tarasuk et al., 2011).

In order to support some people in maintaining their housing, there will need to be increased opportunities to develop skills, access training, education and more employment opportunities will be necessary.

Data and Technology

CAGH is keen to develop systems to monitor and evaluate the effectiveness of the Housing First approach in reducing homelessness in Fredericton. There are currently no solid data systems in place to accurately measure the outcomes of housing interventions. HIFIS and the ad-hoc data systems used by outreach social workers and SUN track some data but not all. The network plans to identify the key indicators that will be used to measure the outcomes of the program in the fall of 2013, and plans to bring in experts to implement a data monitoring system, such as the Service Prioritization Decision Assistance Tool (SPDAT) currently being used in other jurisdictions.

The SPDAT was originally developed for Housing First programs to prioritize who needed to be served next. It is a tool that assesses 15 different aspects of a person’s needs, including mental health and wellness, substance abuse, history of housing and homelessness, interaction with emergency services, self-care and daily living skills, and managing of tenancies.

Expert Advice

CAGH is aware of the extensive expertise already available in terms of planning and implementing Housing First systems and plans to make use of expert advice from across the country. The Canadian Homelessness Research Network (CHRN) has already been a valuable resource for knowledge mobilization tools and resources that will help with planning and implementation. The team feels like they don’t need to reinvent the wheel and can build on existing programs and practices from across Canada. The work being done by SUN has been replicated in Moncton and further plans are to replicate the approach in other regions as well.

To date, CAGH has brought Brigitte Witowski, Executive Director of Toronto’s Mainstay Housing, to Fredericton to talk about their programs and to learn about the supportive housing aspect of Housing First and the strategic partnerships required to sustain these programs. Tim Richter from CAEH has travelled twice to Fredericton to provide training and public awareness. Additionally, CAGH has participated in the Canadian Housing and Renewal Association’s Homelessness Learning Network for two years. This has enabled them to develop pan-Canadian connections to people with experience and expertise in this work.

Community Engagement

Community and stakeholder support is crucial for building and sustaining a Housing First program. In order to leverage more involvement and buy-in from community members, CAGH will be developing a community engagement process. The team will consult with other Housing First program providers and experts to develop an effective plan.

Accessing Funding for Rent Supplements

As in most other communities there is a lack of affordable housing in Fredericton, and many people face significant challenges in paying their rent. The average rental price in the housing market rose from $730 in 2010 to $747 in 2011. The City’s wait list for affordable housing also continues to rise: from 800 in 2010 to 982 in 2011 (CAGH, 2012).

Results from successful Housing First programs, including the initial results of the Mental Health Commission of Canada’s At Home/Chez Soi project, identify rent supplements as an essential component of Housing First. CAGH is also aware of the importance of rent supplements in order for people to access affordable housing. The rent supplements must be portable, or in other words, applicable to a range of housing options. Accessing funding for rent supplements is one of the key priorities for CAGH in planning their Housing First model.

Balancing Prevention and a Change in Service Delivery

Any kind of change can be difficult, particularly a significant change in the way an entire system functions. A Housing First approach is a major change from managing homelessness to reducing, and ideally preventing, it. In order to put significant and multiple resources into a new approach, existing services need to continue to evolve to address changes in programming required by a Housing First approach. In Fredericton, CAGH is conscious of this struggle to balance prevention strategies with an effective response to chronic homelessness. The team is currently trying to figure out how to go through that change process without sacrificing other effective interventions.

Strengths of the Approach in Fredericton

The advantage of planning and implementing a new system response to homelessness in Fredericton is the size of the community. Although a smaller city lacks big city resources, there is potential for a more cohesive network. Currently all of the major players in the homelessness system of care are at the systems planning table – outreach services, emergency shelters, social development agencies, housing providers, and mental health and addiction services are becoming more coordinated in a formalized way.

THE HOUSING FIRST MODEL IN FREDERICTON

The Housing First Model in Fredericton will be based on the following core principles, in line with the Canadian Homelessness Research Network’s A Framework for Housing First (Gaetz, 2013):

1) Immediate or rapid access to housing, with supports to maintain it.

2) Consumer choice and self-determination.

3) Not conditional on sobriety.

4) Community inclusion.

As with most other Housing First programs, the initial focus will be on supporting people experiencing chronic homelessness as a starting point. The goal will be: if someone accesses a system of care that responds to homelessness, this person will not be without support and/or housing, or will not stay in shelters or sleep on the streets, for more than 14-21 days. This figure will guide the analysis of the effectiveness of the new response to homelessness.

NEXT STEPS: IMPLEMENTING AND SUSTAINING HOUSING FIRST IN FREDERICTON

Although the development of the Housing First systems model and programming is in the early stages in Fredericton, success of the SUN program shows that Housing First can work in Fredericton. SUN reports a 93.5% housing success rate after 6 months of occupancy (Sharpe, 2013). CAGH is confident the recent renewal of the federal government’s HPS five-year plan, as well as Fredericton’s commitment to affordable housing, will help continue the momentum to implement effective interventions that will change the focus from managing to solving homelessness.

The heightened level of awareness of the problem of homelessness in Fredericton, and effective solutions, will ideally lead to more capital being leveraged from charitable markets, allowing the development and implementation of more Housing First programs.

The CAGH team believes all the resources are available to implement a coherent and coordinated systems approach that will effectively reduce and eventually eliminate homelessness in Fredericton.

REFERENCES

Community Action Group on Homelessness. (2010). Experiencing Homelessness: The 3rd Report Card on Homelessness in New Brunswick. Retrieved from http://www.cagh.ca.

Community Action Group on Homelessness (2012). Experiencing Homelessness: The 4th Report Card on Homelessness in New Brunswick. Retrieved from http://www.cagh.ca.

Duplessis, Brian. (2013). McKenna gets frank about homelessness. Fredericton Daily Gleaner. March 7th 2013. Retrieved from http://www.cagh.ca.

Government of New Brunswick. (2009). Working Together for Adult Literacy: An Adult Literacy Strategy for New Brunswick. Retrieved from www.gnb.ca.

Government of New Brunswick. Economic and Social Inclusion Corporation. (2009 ). Overcoming Poverty Together: The New Brunswick Economic and Social Inclusion Plan. Retrieved from http://www2.gnb.ca/content/dam/gnb/Departments/esic/pdf/Plan-e.pdf .

Government of New Brunswick. New Brunswick Housing Corporation, Department of Social Development. (2010). Hope is a Home: New Brunswick’s Housing Strategy. Retrieved from www.gnb.ca.

Ross, T. (2012). Homelessness in a big town, small city: Supportive housing network in Fredericton, NB. Retrieved from http://www.chra-achru.ca/media/content/SUN%20presentation%20-%20May%204%20-%20CHRA%20Tim%20Ross.pdf

Ross, T. (2013). Personal Communication.

Sharpe, J. (2013). Personal Communication.

Tarasuk, V., Mitchell, A., Dachner, N. Research to identify policy options to reduce food insecurity (PROOF). (2013). Household food insecurity in Canada 2011. Retrieved from http://nutritionalsciences.lamp.utoronto.ca/

ENDNOTES

1. Adapted from Experiencing Homelessness: the 3rd Report Card on Homelessness in New Brunswick. Fredericton Edition. http://intraspec.ca/CAGH_Fredericton_Report-Card-on-Homelessness.pdf

Nikihk Housing First/Homeward Trust Edmonton ALBERTA

Fiona Scott

Key Messages

• It is a model designed to address the over-representation of Aboriginal people in Edmonton’s homeless population.

• It shows the ways in which housing is just one part of a Housing First program.

• It highlights what Aboriginal and non-Aboriginal agencies can do to integrate culture into a Housing First program.

• The program is an example of how to create an inclusive governance structure to address the needs of different sub-populations.

The rising problem of homelessness in Edmonton, Alberta’s capital city, made headlines in 2007 when more than 200 people experiencing homelessness set up tents in a vacant lot that became known as ‘Tent City’. In the absence of other affordable housing options, the residents of Tent City believed in their right to sleep in a public space. Three months later they were forced to move. With the help of government officials 58 residents found some form of housing, while the remainder maintained ‘no fixed address’.

Several factors contributed to the housing crisis in Edmonton that led to Tent City. Beginning in the early 2000’s an economic boom brought thousands of people looking for work from outside the city into Edmonton. Soaring rents, conversion of rental units to condos and a desperate lack of affordable housing limited the housing options for many people (Edmonton Committee to End Homelessness, 2009).

After Tent City, it was obvious that something had to be done to improve the situation of people experiencing homelessness in Edmonton. Calgary had recently started developing their 10 Year Plan to End Homelessness and challenged by the same issues, Edmonton started their own plan.

In late 2007, Sam Tsemberis, Executive Director of Pathways to Housing in New York, and Phil Mangano, the Director of the United States Interagency Council on Homelessness (USHIC) – referred to by some as the U.S.’ homelessness policy czar – spoke at a Housing First conference in Red Deer, Alberta. Their charismatic presentations on the value of 10 Year Plans to End Homelessness and the Housing First model had an impact on all of the communities present, many of whom were ready for a new way of addressing homelessness.

The continued support of the city’s current mayor, Stephen Mandel, was crucial in making a significant change in Edmonton’s response to homelessness. Mandel was eager for an innovative approach to homelessness and established the Edmonton Leadership Committee to End Homelessness, which was comprised of representatives from businesses, philanthropic organizations, social agencies, government and faith-based organizations.

In 2009, Edmonton’s plan A Place to Call Home: Edmonton’s 10 Year Plan to End Homelessness was adopted. The 10 Year Plan focuses on ending chronic homelessness and is based on the Housing First model. The 10 Year Plan has the following 5 goals:

• Provide permanent housing options for all people living on the street and in public places;

• Ensure an adequate supply of permanent, affordable housing with appropriate supports for people who are experiencing homelessness;

• Ensure emergency accommodation is available when needed, but transition people quickly into permanent housing;

• Prevent people from experiencing homeless; and

• Establish a governance structure and an implementation process for the Plan that builds on the strengths of the community, develops capacity, promotes collaboration, innovation and cost-effectiveness and measures progress.

The most recent count of homelessness in Edmonton, conducted in 2012, found 2,174 people experiencing homelessness. This represents a 30% reduction from the 2008 – the last one prior to implementation of the 10 Year Plan – and the lowest number since 2002. It was the second consecutive count that registered a decrease, following 2010’s, which reversed a steady increase registered in counts from 1999 through 2008. However, of those experiencing homelessness, 46% were Aboriginal, despite Aboriginal peoples comprising only 5% of the city’s population (Homeward Trust, 2012).

Housing First – Perfect for Adapting to Sub-populations

The city saw a need to change the response to Aboriginal peoples experiencing homelessness in a manner that recognized the structural and systemic barriers faced by Aboriginal peoples and integrated housing with social and cultural approaches to solving homelessness. The Housing First model has the capacity to fulfill these needs and is adaptable to the contexts and needs of Aboriginal communities.

The 10 Year Plan lays out several strategies to address Aboriginal peoples experiencing homelessness including:

“[working] with the Aboriginal community to develop the capacity of an Aboriginal agency or agencies to deliver Aboriginal specific services in support of the Housing First program by Aboriginal peoples to Aboriginal peoples when requested. Work with the Aboriginal and existing service communities to ensure services provided to Aboriginal people are relevant, respectful and effective in helping Aboriginal people secure and maintain a home” (A Place to Call Home, 2009).

Once the 10 Year Plan was adopted, the City of Edmonton created the Homeless Commission, comprising many of the members of the Edmonton Committee to End Homelessness. The mandate of the commission has been to maintain and ensure continued support for the plan to end homelessness and report to council on the community’s progress. The plan also identified Homeward Trust Edmonton as the management body responsible for implementation.

Homeward Trust

Homeward Trust, established in 2008, has a mandate to:

• Increase access to housing by funding the development of new units and accessing market units.

• Coordinate the provision of support services.

• Undertake community planning and research.

• Raise awareness in the community through events and initiatives that promote ending homelessness in Edmonton (Homeward Trust, 2012).

Housing First as a philosophy guides all of the work of Homeward Trust. While Homeward Trust functions as an independent entity it maintains positive lines of communications with all orders of government, including working closely with Aboriginal governments and communities. Homeward Trust functions as both a direct service provider and an overseer of funded project for both capital and support services.

Addressing Aboriginal Homelessness in Edmonton

In 2006, before the 10 Year Plan was established, an examination of the challenges faced by the Aboriginal community was presented in The Your City, Your Voice Report on the Edmonton Urban Aboriginal Dialogue (YCYV). The report was a result of an initiative by the Edmonton Urban Aboriginal Accord Initiative, the Edmonton Urban Aboriginal Affairs Committee (EAUAC) and the City of Edmonton that brought together over 1800 Aboriginal community members and leaders in a dialogue about the central issues facing urban Aboriginal peoples.

This report and several of the priorities identified in the YCYV provided insight into the need for Aboriginal community members to be key players in solving an issue like homelessness where a high percentage of the homeless population was and still is Aboriginal. The YCYV was one of several sources the Homeward Trust Community Planning community used to inform Edmonton Area Community Plan on Housing and Supports: 2011-2015.

The community needed to adapt their response to Aboriginal homelessness in a manner which included a coordinated approach to integrated, culturally-informed services. With the over-representation of Aboriginal peoples experiencing homelessness in Edmonton, new solutions had to be a part of the city’s 10 Year Plan.

An Inclusive Governance Structure

Addressing homelessness within the Aboriginal populations required the participation of Aboriginal community groups and networks. These groups and networks were essential in creating an approach to homelessness that focused on the systemic cultural and social forces contributing to the over-representation of Aboriginal peoples experiencing homelessness.

Of the nine Directors on Homeward Trust’s Board, four are chosen from within Aboriginal communities, by Aboriginal stakeholders. These four directors are chosen through an Aboriginal Nominating Committee, composed of a member of the Homeward Trust Board, one appointee each from the Métis Nation of Alberta, Treaty 6 First Nations of Alberta, Treaty 8 First Nations of Alberta and the Canadian Native Friendship Centre.1

The work of Homeward Trust is also informed by the Aboriginal Advisory Council (AAC), comprised of community leaders. This council is a critical component of Homeward Trust’s Indenture model. In order to have the intended impact on ending homelessness that was desired it was clear that the Aboriginal community needed be a long-term ingredient in the unique governance model and functions of the organization. The Council advises Homeward Trust on matters relating to Aboriginal issues and projects by:

• Encouraging innovative solutions to promote the building of Aboriginal organizations, groups and communities in Edmonton;

• Providing awareness of the Urban Aboriginal experiences, knowledge and cultural perspectives;

• Ensuring Aboriginal-focused projects are led by or supported by organizations that have a proven track record of serving Urban Aboriginal people in a productive and successful manner. For example, Homeward Trust is currently working with community partners to establish Indigenous Indicators for Success. It has long been proven that Western models of assessment and evaluation do not include the Indigenous worldview. As a result, there is the potential for skewing of outcomes.

In addition to creating an Aboriginal-inclusive governance structure for its own organization, Homeward Trust is often recruited by other local and national organizations that are interested in re-creating Homeward Trust’s governance model. Homeward Trust offers strong examples of Aboriginal Board member and leadership role recruitment, as well as the importance of engaging a range of people in order to increase the sustainability of the relationship.

Homeward Trust also advises on who, where and how to establish connections with the Aboriginal community, including relationship building with Aboriginal groups and Aboriginal-serving agencies. This may include extending invitations to annual pow-wows or community gatherings. Finally, Homeward Trust offers methods of improving outcomes for Aboriginal clients through the inclusion of more culturally informed services.

Funded by Homeward Trust, the Housing First team, named Nikihk (meaning ‘home’) is administered by the Bent Arrow Traditional Healing Society which provides programming for Aboriginal children and families based on traditional Indigenous teachings.

The purpose of this case study is to provide an overview of Homeward Trust and Bent Arrow’s experience of planning, implementing and sustaining Housing First for Aboriginal peoples in Edmonton, as well as some of the barriers faced and how they were overcome. Included are examples of data that demonstrate the effectiveness of Edmonton’s Housing First programs in supporting Aboriginal peoples experiencing homelessness in securing and maintaining housing, as well as the program’s effectiveness in addressing their cultural, spiritual, mental, physical and social health needs. It concludes with a discussion of the central lessons learned in creating a Housing First program for Aboriginal peoples.

GETTING STARTED: FRAMING THE ISSUE

Public perception of the issues facing people who are experiencing homelessness can sometimes get in the way of implementing Housing First. For example, the misconception that addiction is a matter of personal choice rather than a result of complex issues supports services that have historically been abstinence-focused.

Edmonton’s 10 Year Plan calls for a fundamental change in addressing homelessness that moves away from simply managing the issue to solving it. The Plan highlights the “overwhelming evidence” that this new approach, Housing First, is both effective and financially sound. The Plan lays out the financial case for investing in Housing First:

“Assuming a growth rate of 8% per year, (the average from the last 3 homeless counts), there would be approximately 6,500 homeless Edmontonians in 2018. Assuming that we provide emergency shelter space to 40% of that population, as we now do, the annual cost of 2,627 shelter spaces alone would be $54.3 million, not including all the additional costs of health care and other services. And those costs would grow unabated. By comparison, the operating costs of implementing this Plan will be $90 million a year” (10 Year Plan, 2009).

It is clear from the significant over-representation of Aboriginal peoples in local homelessness counts that solving homelessness within Aboriginal populations requires a new strategy that addresses the unique cultural needs of Aboriginal peoples.

Initially some community members did not agree with the Housing First model and expressed cynicism about the availability of housing stock and the ability to engage landlords. However, as the program developed and the successes and positive outcomes of the programs were shared, community support became inevitable. The collaborations that developed over the course of community meetings created a basis of trust that allowed people to discuss what was and was not working.

Reversing and Addressing the Effects of Colonialism for Aboriginal Peoples

Aboriginal peoples in Canada (and in other countries) have faced a number of unjust systemic barriers and traumatic experiences. The colonization of Aboriginal peoples has been described as “the primary form of oppression because it affects Aboriginals’ consciousness, self-worth, self-identity, community identity and cultural identity” (McKenzie & Morrisette, 2002 as cited in Verniest, n.d.:6). Gagne also suggests that “colonialism is at the root of trauma because it has led to the dependency of Aboriginal peoples to settlers and then to cultural genocide, racism and alcoholism” (Gagne, 1998 as cited in Quinn, 2007:73). Residential schools, the ‘60s scoop’2, colonization, racism and discrimination have resulted in a generation of Aboriginal peoples who may have few family ties, limited sources of support, have been forced to disconnect from their culture and experience increased vulnerability.

MOVING FORWARD: PLANNING

Do Not Wait for the Perfect Conditions to Implement Housing First: Just Do It

The only real requirement for implementing Housing First is a commitment to end homelessness. Beginning the work leads to the relationships, partnerships and conditions needed for a successful Housing First program. Based on the success of 10 Year Plans and Housing First models in the U.S., Homeward Trust staff knew that Housing First needed to be tried in Edmonton and they could not wait for the perfect conditions for program implementation. An increase in affordable housing or good relationships with landlords was unlikely unless staff started creating and delivering programs.

There were a number of pilot projects in Edmonton at the time, funded through the Government of Alberta, similar to the Housing First model in their delivery of Intensive Case Management (ICM). Programs with the capacity to commit to delivering the new Housing First framework migrated to the new model over an 18 month period. A key component of this is ensuring that Housing First is serving the right population, one that both requires the intervention and can be expected to succeed in the program. More intensive supports are required for populations with the highest needs.

The Pathways to Housing program had also been implemented since the launch of the Plan, meaning that Housing First was not entirely new to Edmonton. In addition to this local example of Housing First, a team of service providers went to Toronto to learn about its Streets to Homes Program. Additionally, Pathways conducted an evaluation of the Edmonton program.

Program versus Team

In Edmonton, there is an important differentiation between a program and a team. Homeward Trust delivers a Housing First program through teams with varying mandates to serve particular sub-populations. Some teams deliver ICM while others focus on Assertive Community Treatment (ACT). There are seven ICM teams, 2 ACT teams, as well as two Rapid Exit management teams and two Permanent Supportive Housing teams. Each team has resources specific to the service they are delivering. The Bent Arrow Nikihk team is part of Homeward Trust’s Housing First program and delivers services to Aboriginal populations within Edmonton. In order to address the overrepresentation of Aboriginal peoples, every Housing First team is expected to have a minimum of 40% Aboriginal clients as part of its case load. Through Team Lead meetings, Bent Arrow contributes to a community of practice, sharing learnings and serving as a resource for other teams. Team members are expected to complete Cultural Diversity Training.

THE HOUSING FIRST MODEL AT BENT ARROW

Bent Arrow Traditional Healing Society provides culturally-informed Housing First and support services to Aboriginal peoples (First Nations, Metis, Inuit and non-status individuals and families) who are experiencing chronic homelessness. The team’s program was designed to foster life skills that enable people to maintain their housing and to connect or re-connect clients with their culture. The program provides an integrated model using conventional and trans-cultural support services.

Bent Arrow’s Principles Align with Edmonton’s Housing First philosophy3 by including:

• A harm reduction approach to reducing the negative consequences to substance use and other potentially high risk behaviors such as sex work;

• A culturally relevant sobriety option like Wellbriety – a journey for addictions recovery;

• In vivo services that are delivered in the home and community;

• Clients have choice in receiving service, as well as the frequency, intensity, duration and type of services;

• There is no coercion in the delivery of the services;

• Services are strength-based;

• Services support greater independence;

• A client-centered service delivery approach;

• Services for individuals who experience mental health challenges have a recovery and healing orientation;

• There is a commitment to re-house any clients who lose their housing and they will receive a continuation of support services should that occur;

• Practices are evidence-based, aligned with healing and respectful of Aboriginal traditional ways;

• Motivational interviewing is practiced.

The Housing First model for Aboriginal peoples in Edmonton maintains the core principles of the approach. It includes unique support services that recognize cultural and spiritual Aboriginal practices and traditions as avenues for improving the sustainability of an individual’s housing.

Housing First services for Aboriginal Peoples will:

• Be accessible to any self-identified Aboriginal individual or family experiencing chronic homelessness;

• Model flexibility and be client-centered, focusing on the journey of the individual;

• Be established on the principles of anti-oppressive practice, including do no harm;

• Provide for the health and safety of all program participants;

• Be representative of the many and diverse Aboriginal teachings recognizing the reality that Aboriginal peoples are a diverse population of distinct peoples with unique heritages, languages, cultural practices and spiritual beliefs;

• Have strong and vibrant relationships with the Edmonton Urban Aboriginal community which is accountable, respectful and honouring;

• Recognize the importance of family and community.

Intake Process

Clients can access the Housing First program directly through Bent Arrow, through Coordinated Access or by referral from another agency. Clients are required to complete an application, including the Service Prioritization Decision Assistance Tool (SPDAT), in order to assess a client’s needs.

When a client is deemed eligible and accepted into the program, they are connected to a Housing Outreach Worker. After the Housing Outreach Worker (HOW) has the tools in place that can best assure successful housing (furniture, utility hook up, groceries, and other start-up items), the HOW worker then transferred the participant to a Follow-Up Support Worker who will guide those families and individuals on the remainder of their journey to housing stability.

The SPDAT, which identifies challenges and barriers, assists the client and the frontline support worker in determining areas they wish to address in the next 12 months including employment, training, education and/or family or cultural reconnection. To help clients set and achieve goals, the Follow-Up Support Workers use the Specific Measurable Achievable Realistic Timeline (SMART) approach. This helps clients identify their goals, how they can be addressed and make a realistic plan with an attached timeline. The Follow-up Support Worker assists the client to meet their goals and access needed resources through referrals. The client can also access programming in support of their goals that includes involvement in cultural events and ceremonies, meeting with elders to discuss reconnecting with cultural identity and receiving advice on meaning, spirituality and becoming whole.

Life Skills

The Bent Arrow team has put together a 10-week life skills course that covers topics including healthy communication, relationships, maintaining a home, addictions and lifestyles. Clients have reported that the program has been very useful and have expressed an interest in exploring many of the themes further. Staff are currently planning a second part to the course in order to further develop clients’ life skills. At its heart, Life Skills Training takes a very proactive approach to barriers which commonly arise for newly housed Nikihk participants.

Housing First Staff

All Bent Arrow Nikihk staff must be open to and have an understanding of Aboriginal cultures. Bent Arrow’s Housing First staff include:

Team Lead

The Team Lead is the liaison between the Aboriginal Housing Team and the Housing First service sector and participates in Team Lead meetings, working groups and committees. The Team Leader is responsible for the recruitment, supervision and evaluation of team members and ensuring the outcomes of the Aboriginal Housing First Team are met.

Housing Outreach Workers

Housing Outreach Workers support clients in accessing housing, or being re-housed, as well as items necessary for the clients’ homes. Outreach workers also assist clients in connecting to their local community, including identifying community resources and free community events that develop a sense of community belonging.

Follow-up Support Workers

Follow-up Support Workers assist clients in maintaining their housing by providing ongoing support services and facilitating access to additional mainstream services or services specific to Aboriginal peoples. A Follow-up Support Worker offers ICM to clients until they graduate from the program.

Trauma Support Worker

The Trauma Support Worker provides trauma support services to clients by providing recovery services, assisting the client in building relationships within the community or facilitating access to other specialists in the field of trauma. The impact of trauma can have significant influence on a client’s behaviour and ability to maintain their housing. Having a Trauma Support Worker attached to the Housing First team can help clients avoid eviction.

Aboriginal Cultural and Spiritual Educator

The Aboriginal Cultural and Spiritual Educator assists clients who are interested in connecting or re-connecting with Aboriginal traditions and people through events, activities and resources, such as elders.

The Cultural and Spiritual Educator also provides opportunities for clients to learn about historical events and their impacts on Aboriginal cultures. Topics such as residential schools, prisons, protocols, cultural resources, ceremonies and cultural events are discussed in relation to how these topics apply to a client’s daily life.

Support and Cultural Services Outside of Staff Roles

Clients are able to access other supports such as cultural leaders, pipe carriers, traditional healers and psychologists outside of those offered by staff. These opportunities also include participating in a variety of cultural activities such as medicine picking and teachings, smudge teachings, home blessings and cleansings, cultural camps, storytelling, preparation for ceremonies, sweat lodges, drumming circles, pipe ceremonies, round dances and pow-wows, cultural teaching and advice from elders.

Client to Worker Ratio

The ratio of clients to worker was originally set at 1:20. This number has since been adapted to 1:15 to 1:20 to better serve clients.

MAKING IT HAPPEN: IMPLEMENTATION

What Is and Is Not Housing First

Housing First programs that are funded by Homeward Trust are obliged to adhere to the program’s core principles. The effectiveness of Homeward Trust’s Housing First approach is based on more than housing. Support services are crucial in addressing the various reasons people experience homelessness and in assisting clients in maintaining their housing. Programs that only offer housing services and do not have ICM or ACT teams are not Housing First programs. The importance of support lies not only in improving client outcomes but also in maintaining positive relationships with landlords. If clients are housed but not getting the support they need, problems can develop for landlords and housing associations. All Homeward Trust Housing First programs must provide appropriate support services.

Housing Availability

The current housing vacancy in Edmonton is approximately 1.8%. However, of the available housing stock few are affordable for Housing First clients, effectively creating a zero vacancy rate. Lack of access to an adequate supply of a variety of affordable housing types is an acknowledged gap in Edmonton. Part of the Housing Outreach Worker role is working to fill this gap by approaching new landlords and building the relationships necessary to recruit additional housing.

This lack of housing options decreases the program’s ability to adhere to the principle of choice in Housing First. When housing stock is not available, clients are sometimes required to take the first place they see rather than wait for something potentially more suitable; a situation that can negatively affect their long-term housing stability.

The lack of affordable housing makes the program’s rent supplements an important part of Housing First in Edmonton. The program also offers a graduate’s rental assistance program for clients who have maintained stable housing but are unable to pay market rent. Clients are able to graduate from the program but continue receiving a rent supplement.

Access to Support – Location

Bent Arrow offers a variety of services to clients and has become aware of the significance of service location. Initially not all services were provided on-site. Staff noticed problems developing around client service use. For example, program staff developed a partnership with a psychologist providing therapy for clients. Despite wanting the service, clients were not always showing up for appointments. Program staff began offering clients the opportunity to see the psychologist in Bent Arrow’s cultural room, which increased their participation in the service.

Assessment and Acuity Matching

The capacity to assess clients and matching their acuity to supports is an area of growth for Homeward Trust. Sometimes problems arise due to a lack of assessment, such as when an agency knows that a client needs help but have not performed a full assessment in order to match the client’s needs to the available supports. Systematic use of the SPDAT will continue to improve assessment and acuity matching.

Coordinated Access and Intake

Homeward Trust provides a coordinated point of access and intake for its Housing First programs. This allows clients to be referred from one team to another in order to provide the most appropriate services. It also helps avoid mismatch in acuity and support. Currently the focus of Housing First programs is on addressing chronic homelessness. However, the challenges regarding community response to family homelessness means that families are being referred to Housing First when they are not experiencing chronic homelessness. Coordinated intake helps Housing First programs avoid drifting away from their focus demographic.

Complexity of Client Needs

Addictions and mental health challenges are very prevalent among the populations experiencing homelessness, including Aboriginal peoples. These challenges, combined with homelessness, create complex cases requiring multiple interventions. Bent Arrow has employed a cultural and spiritual advisor with a background in addictions support. Homeward Trust has also been brainstorming ways that Follow-Up Support Workers could be more dynamically connected to different organizations, not only those they are employed with. Follow-Up Support Workers ideally would have relationships with other agencies and organizations to provide any type of support a client lacks.

Ongoing Review and Evaluation

The Bent Arrow Nikihk Housing First Team Leader is a part of the Housing First Advisory Council, which meets monthly to discuss improvements needing implementation in Edmonton’s Housing First programs. The team identifies potential program components that would add value for clients and stakeholders. For example, the team started to create improved access to short-term housing for clients waiting for permanent housing. Short-term housing provided the client with a more stable environment than a shelter while the search for more permanent housing continued.

Homeward Trust also meets regularly with Bent Arrow to discuss processes the team has created, to identify successes and to identify the barriers experienced by people who are having less success in accessing housing.

The Cost of Repairing Units

One of the biggest surprises in Edmonton has been the cost of repairing damaged units; in serious cases costing as much as $20,000. The team knew mitigating such risks for landlords was required, however they did not accurately forecast the amount that would need to be put aside. Initially each Housing First team had a budget to cover the costs of repairs, however some teams experienced more damage than others, resulting in the creation of a central fund that all teams can access.

Addressing Other Housing-related Needs: Furniture

Most people experiencing homelessness have few personal possessions and generally no furniture, which makes furnishing a home difficult. Inspired by the Toronto Streets to Homes program’s relationship with a furniture bank, Homeward Trust established FIND, a furniture market that is free for clients. In 2011, FIND became a social enterprise. It continues to serve clients, while also selling furniture to the public and re-investing the proceeds into housing and support programs.

Collaboration/Partnerships

Housing First is about accessing housing and supports for clients and making relationships with other service providing agencies crucial to the program’s success. The following partnerships support Homeward Trust and Bent Arrow’s Nikihk Housing First programs:

Housing First Advisory Council

All agency Team Leads managing Housing First programs in Edmonton are a part of the Team Lead meeting. Additionally, the Executive Directors of each agency are part of the Housing First Advisory Council. The council meets monthly to discuss challenges and barriers in program implementation as well as ways to address those challenges.

Landlord and Housing Providers

A full-time staff position of Manager, Landlord Relations at Homeward Trust works with all Housing First Teams to respond to landlord concerns, address issues and continue to build relationships with housing providers. Team Leads and Follow-Up Support Workers are also able to work directly with landlords and respond quickly to their concerns. The team also works with the Edmonton Apartments Association, Capital Regional Housing Association (the management body for social housing in Edmonton) and HomeEd Properties (non-profit housing for low-income people).

Community Plan Committee

The Community Plan Committee of Homeward Trust includes representatives from the for-profit housing sector. The Committee is tasked with preparing and updating Edmonton’s 10 Year Plan, which guides the overall direction, resource commitments and priorities of Homeward Trust.

Boardwalk Rental Communities

As a result of the Community Plan Committee a relationship with Boardwalk Rental Communities was developed. Boardwalk offered $150 reduction in rent to Homeward Trust clients, one-third of whom are in a Boardwalk unit. The program makes sense to Boardwalk economically because there are support workers that ensure rent is paid and are available to call if there is a problem.

Alberta Health Services

Homeward Trust works with Alberta Health Services (AHS) to ensure the province’s input and commitment to understanding and decreasing barriers to health services for Aboriginal clients.

Education and Training on Aboriginal Issues

Homeward Trust delivers several trainings and workshops for all staff on a variety of topics including Aboriginal Diversity, Residential School Survivors, the Sixties Scoop, Circles Process, as well as Colonization and Decolonization.

The Importance of Rent Supplements

Poverty is the common denominator among people experiencing homelessness and assisting people out of poverty often means providing financial assistance that lower an individual’s costs. Rental assistance means that landlords receive market rent for their apartments and clients can afford to live in market properties. Without rent supplements, it would be very difficult to house clients.

Sustainability

Sustaining Housing First in Edmonton requires financial investment; an investment that will pay significant social dividends. It also requires cooperation among all orders of government, the business community, faith communities, educators, service providers and all Edmontonians.

Homeward Trust continually works to engage the community and maintain focus on the intervention process of Housing First. Making a commitment to end homelessness places pressures on a community to deliver quick and visible changes. Some will not be convinced there is no longer a homelessness crisis until there is no one living on the street. Others understand that despite the strongest commitments, it takes time and significant investment to reach the point where no one is experiencing a housing crisis for longer than a couple of weeks.

Alternative Streams of Funding

The creation of the social enterprise FIND has been important in generating revenue outside standard funding avenues. FIND is a large used furniture store which currently generates approximately $50,000 per month. As part of the business model this money allows Housing First participants to access furniture, dishes and other household supplies at no cost to them.

To date there has been success in achieving the targets laid out by the 10 Year Plan, but people are still living on the street. If shelter use is going to decline, there must be investment in the other services crucial to avoiding the need for anyone to stay in a shelter in the first place.

Cost

For intensive case management teams in Edmonton, the costs for a client in the first year of Housing First are in the range of $15,000 – $20,000. This includes the start-up costs of housing, case management and rental assistance. In the long term, the cost of ending homelessness is more sustainable than the cost of managing it.

EVIDENCE OF EFFECTIVENESS

Efforts to Outcomes (ETO) is a case management and data collection system used in Edmonton that tracks client progress, housing and outcomes. Information is collected via the SPDAT to assist in identifying the individuals and families with the greatest need and to track their success over time. SPADT is administered at intake, when the client is housed and ongoing at regular intervals to allow staff to see improvements in a client’s overall housing score, as well as in relation to issues like mental health.

Data collected since the beginning of Homeward Trust’s Housing First program (April 1, 2009) until December 31, 2012 demonstrates that:

• 2,325 individuals were housed;

• 786 of those were Aboriginal; and

• 86% of those housed retained their housing (percentage of clients served in the period who have successfully exited the program or remain housed as program clients. Calculation excludes exits due to death or incarceration).

The data also shows that compared to the non-Aboriginal population, a greater portion of Aboriginal clients are women (59% compared to 32% of non-Aboriginal clients). In addition, Aboriginal participants were more likely to be housed as a family (46% of clients housed by ICM teams are Aboriginal, 58% of families housed are Aboriginal and 60% of children and adult dependents housed are Aboriginal). Lastly Aboriginal families that are housed tend to be slightly larger than non-Aboriginal families (average size of Aboriginal family housed = 3.3 people compared to 2.6 people in non-Aboriginal families) (Homeward Trust, 2013).

Qualitative Research

In 2011, Homeward Trust engaged the Blue Quills First Nations College in a qualitative program evaluation of Housing First for Aboriginal peoples. The evaluation was to assess the success of the program and to identify gaps in services and challenges in delivering services for Aboriginal peoples. The report, Perspectives on the Housing First Program with Indigenous Participants, highlights the need for Indigenous identity development through life skills training, mentorship, access to elders and therapy to address trauma in order to support Aboriginal peoples in accessing and maintaining housing. The findings of this report helped inform the development of an Aboriginal Housing First team.

Developing Aboriginal-specific Indicators

The Aboriginal Advisory Council put forward the observation that tools adequately measuring the impact of culture-specific programming on client outcomes were lacking. As a result, Homeward Trust has begun a process of developing tools to assess these outcomes. Aboriginal staff were eager to measure the extent to which a worker has helped a client access their culture, develop more meaning in their life or to identify the impact of traditional ceremony on a client’s healing or recovery process. Some measures are currently being piloted in Aboriginal-specific programs including availability of services in Indigenous languages and the introduction of appropriate protocol in processes.

KEY LEARNINGS

An Aboriginal Team is One Part of the Solution to Ending Aboriginal Homelessness

Simply ensuring Aboriginal teams are working to end homelessness in a community is not enough to eliminate the problem. Successfully addressing Aboriginal peoples experiencing homelessness also means reducing racism and discrimination, dealing with the effects of trauma, providing culturally-informed, relevant, respectful and appropriate support, along with the active involvement of the entire community.

There are many facets of Aboriginal life that need to be taken into account when working to end homelessness. There is no single pan-Aboriginal identity; each Aboriginal nation represents a particular culture. Simply providing one elder on staff to assist with generic cultural re-connection is insufficient. Instead, there must be a community navigator who is aware of traditional processes and existing relationships within a broad range of Aboriginal nations and communities.

Context Matters in Governance

Effective solutions evolve when those most directly impacted are a part of the input process. When creating and delivering services for Aboriginal peoples, the manner in which they are engaged in decision-making and governance will impact the effectiveness of the service. Addressing the needs of Aboriginal peoples experiencing homelessness is not limited to service delivery; engaging Aboriginal peoples in creating the solutions to homelessness is an essential component to ending homelessness.

Do Not Underestimate the Transformative Role of Education and Teachings

Supporting people in changing their lives is not solely about providing the required information. It is a process that requires everyone involved to model the healthy conversations and behaviours that they want to see in others. The problem of homelessness will not be solved by simply delivering workshops. The effects of colonization must be viscerally understood; we cannot think ourselves out of colonized systems, we must act ourselves into decolonized systems.

Set Targets to Assess Reduction of a Sub-Population’s Homelessness

The over-representation of Aboriginal peoples experiencing homelessness requires a unique solution. For Homeward Trust part of that solution involves setting a goal for all contracted agencies to maintain a minimum caseload of 40% Aboriginal clients. By setting these goals, Homeward Trust is not just housing people, they are also reducing the disproportionate representation of Aboriginal peoples experiencing homelessness. This minimum caseload, as well as cultural diversity training, also demonstrates Homeward Trust’s belief that both mainstream and Aboriginal-specific agencies have a responsibility to provide diverse and culturally appropriate services.

REFERENCES

Bodor, R., Chewka, D., Smith-Windsor, M., Conley, S., and Pereira, N. (2011). Perspectives on the Housing First Program with Indigenous Participants. Blue Quills First Nations College Research and Program Evaluation Partnership. Retrieved from: http://www.homewardtrust.ca/images/resources/2012-07-05-10-26BlueQuillsWEB3.pdf

City of Edmonton. (2006). The Your City, Your Voice Report on the Edmonton Aboriginal Dialogue. Retrieved from: http://www.edmonton.ca/city_government/documents/PDF/YCYV_report.pdf

Edmonton Committee to End Homelessness. (2009). A Place to Call Home: Edmonton’s 10 Year Plan to End Homelessness. Retrieved from: http://www.edmonton.ca/10-YearPlantoendHomelessness-jan26-2009.pdf

Homeward Trust. (2012). 2012 Edmonton Homeless Count. Retrieved from: http://www.homewardtrust.ca/announcements/index.php?id=67

Homeward Trust. (2013). Edmonton Housing First Support Program Key Statistics, 2009-2012. Internal document.

ENDNOTES

1. Treaty 6 and 8 refer to geographic areas of land based on treaties signed between First Nations communities and the Queen and continue to frame the relationships between the Nations and the federal government. Treaty 6 was signed in 1876 at Fort Carlton; it includes 50 First Nations in Alberta, Saskatchewan and Manitoba. Treaty 8 was signed in 1899; it includes 39 First Nation communities and the territory covers Northern Alberta, Northwestern Saskatchewan, Northeastern British Columbia, and the Southwest portion of the Northwest Territories. See http://www.treatysix.org and http://www.treaty8.ca for more information.

2. The 60s scoop (or sweep), beginning in the 1960s and lasting until the mid-1980s, refers to the forced and systematic removal of Aboriginal children from their homes and their placements with primarily white families for the purpose of fostering and/or adoption.

3. Principles adapted from Bent Arrow’s funding proposal for Housing First. Retrieved from www.homewardtrust.ca.

Conclusion

Lessons Learned

Stephen Gaetz & Tanya Gulliver

The evidence for the success of Housing First as a strategy for addressing homelessness is well established by extensive research in Canada and elsewhere. Housing First clearly works, even for the most challenging, chronically homeless individuals and families. Yet in spite of the apparent success of Housing First in many communities, there are barriers to buy-in and implementation. Claims such as ‘it’s a fad or a trend’, or ‘it’s an American model, so why would we want it?’ should be discounted as ideological and not based in evidence. Likewise, when people draw anecdotal examples of poor individual outcomes (people being housed in isolated or remote areas, or paying 80% of their income on rent, for example), such examples have more to do with very real problems with implementation, program design or lack of fidelity to the model, rather than with the principles or philosophy of Housing First itself.

In providing both a framework and the eight case studies contained in this book, we are aiming to address the ongoing concerns about the adaptability of Housing First to different community contexts, as well as apprehensions about ‘how it works,’ that can become barriers to implementation. Fortunately, the more we are learning about Housing First the easier it is for us to address these concerns.

This concluding section pulls from literature, the eight case studies and our understanding of Housing First in different contexts including the At Home/Chez Soi project from the Mental Health Commission of Canada to summarize best practices and lessons learned. It is our intention to synthesize the content of the book in order to help communities reduce obstacles in implementing Housing First in their own communities.

UNDERSTANDING BARRIERS TO IMPLEMENTATION

Making the shift from traditional ‘managing the problem’ responses to homelessness is an important exercise in change management. Central to facilitating the shift is addressing concerns and perceived barriers. Some common questions about Housing First include:

How can we implement Housing First with so little affordable housing?

Housing First, on its own, does not add to the affordable housing stock. Organizations must confront the challenge of housing people in a tight rental market when there is not sufficient housing stock while not sacrificing the core principle of consumer choice. Shifting the emphasis to Housing First without a concurrent investment in affordable housing may appear to merely shift the focus of our efforts from the larger and more challenging problem of housing affordability. For most people who become homeless, the underlying problem is a lack of affordable housing supply (and access) and inadequate income levels to pay for housing. An effective response must invariably address these issues.

However, Housing First can still be applied even when the lack of affordable housing seems to be a challenge. Communities such as Toronto, Calgary, Edmonton and Vancouver have some of the tightest housing markets in the country and most certainly have the highest housing prices. Yet in all of these communities Housing First has been successfully applied. Admittedly, in each case, the move to Housing First has usually been accompanied by an investment in increasing the affordable housing supply. At the end of the day, the scalability of Housing First may depend on there being an adequate supply of affordable, safe housing, or on there being robust programs of rent supplements to enable housing people in market housing. Rent supplements address the issue of affordability within a tight rental market without necessitating the development and construction of new housing. Even in communities like Hamilton which doesn’t have as tight of a market, the use of rental supplements has been necessary to make Housing First work.

Can Housing First work in small towns or rural areas?

Most of the best-known examples of Housing First have been applied in large cities in Canada and the United States. Most academic research on Housing First has also been conducted in such contexts. The challenges of small towns and rural areas in terms of infrastructure and supports, on the one hand, and on the availability of rental housing on the other, may become barriers to making the shift to a Housing First orientation.

Housing First can be applied in communities of different sizes. The Moncton site of the At Home/Chez Soi study is an important example of how Housing First can be adapted to work in a smaller city with a weak homelessness infrastructure, and importantly, extend to surrounding rural communities. The success of Housing First in Lethbridge and Victoria likewise demonstrates how smaller communities can create innovative Housing First strategies and programs. In Fredericton, the case study shows that implementing a system response to homelessness is enabled by the smaller size of the community. While it may lack big-city resources there is the possibility of a more cohesive network. Through coordination and formalization of connection, a system of care is being developed with all of the major players needed to address homelessness.

Being from a small community need not be a barrier to application, and in fact, smallness may be an asset in terms of establishing relationships and service coordination necessary for effective service delivery. Context does matter, but shouldn’t become a barrier to adaptation.

How are the needs of sub-populations met through Housing First?

One of the key learnings is that one size does not fit all. Different communities and sub-populations have different needs and a Housing First model must be tailored to meet them. Young people experiencing homelessness often have no independent living experience and therefore require a model of Housing First that includes key elements of transitional housing. Aboriginal people, new Canadians and racialized minorities also have different needs that must be taken into account. Other considerations may need to be given to women (concerns for safety) and families (community integration). Furthermore, there is some evidence that people with severe addictions may not fare as well in Housing First, particularly if there are not sufficient supports put in place.

There are a lot of lessons learned regarding how to deliver Housing First to different sub-populations. One of the key innovations of the Housing First strategy employed in Calgary and Edmonton was to adapt the approach to meet the needs of subpopulations such as youth or Aboriginal people. By recognizing that there are different needs and challenges of working with specific sub-populations, and that Housing First may not necessarily be an immediate and practical solution for all individuals (younger teens, women fleeing family violence), communities can develop targeted Housing First programs designed to incorporate social and cultural sensitivity and knowledge as part of their service delivery model.

The case study from The Vivian in Vancouver showcases the way in which the special needs of women can be addressed through the development of a program ‘for women, by women’. In Edmonton, the Nikihk Housing First team at Bent Arrow case study highlights how cultural sensitivity and cultural awareness to Aboriginal issues can help form an important part of the program development. These lessons can be modified to fit newcomer and racialized communities. The Infinity Project in Calgary describes how the unique needs of youth can be addressed in a Housing First Model. Each of these case studies provides lessons about developing a unique program to meet the needs of a distinct sub-population in their housing programs.

Additional questions that may become barriers to the adoption of Housing First include concerns about attracting landlords, funding arrangements that make the shift from ‘treatment as usual’ to Housing First problematic and locally-based resistance to change, both from mainstream services and ironically, from within the homelessness sector itself.

GETTING STARTED

In moving towards planning and implementing Housing First, where does one begin? The case studies carried out by the Canadian Homelessness Research Network, augmented by learnings from the At Home/Chez Soi project, identify many of the opportunities and challenges to promoting the adoption and adaptation of Housing First at the local, regional and national levels. The success of Housing First as a response to homelessness is well established. What is less understood is how communities can make the shift from ‘treatment as usual’ to this new approach. In the following section, key learnings from communities across Canada are discussed. These learnings provide a framework for adoption (and adaptation) of Housing First to different community contexts.

Establish the Context for Change

Adopting Housing First is an issue of change management. It requires leadership, community support, and conduciveness for change, evidence to address barriers and concerns, and resources to make it happen. In most instances where Housing First has been applied, there was local resistance to doing things differently. This was true even in the beginning of Housing First, as this story from Pathways to Housing illustrates:

“Sam’s team was originally told that implementing Housing First would be too risky, enabling, impossible, ineffective, delusional, and that they were fools to take on such a huge liability on behalf of their clients. Fighting past personal fears, professional prejudices, and staying true to the commitment of helping clients realize their own goals, Pathways to Housing housed 60 people in the first year” (Tsemberis, as quoted in Evans, 2012).

Creating an atmosphere for change includes disseminating knowledge so that it can be understood by service providers, the general public, politicians and policy makers. Each audience has different needs and uses for information. Communities should be prepared to share information about their programs or the need for Housing First to address all of the knowledge needs of the end-user.

Sharing research and the use of evidence-based practice is one key area for helping to create change. While communities may not have their own data to prove the effectiveness of implementing Housing First there is extensive research on successes stemming from the At Home/Chez Soi project as well as the different models outlined in case studies section of this book.

The use of pilot projects – as outlined in Victoria, Calgary, Vancouver and Hamilton – can also contribute to the development of data as well provide an example of how Housing First can work in a local community, thus building conduciveness for change. In Fredericton, this happened by happenstance when a project to rehouse people after a fire showed the community how feasible housing people experiencing homelessness actually was.

Partnerships are key

The importance of partnerships in enabling the success of Housing First cannot be underestimated. Addressing homelessness and implementing Housing First cannot be achieved solely through the efforts of the homelessness sector alone. The best examples of implementation of Housing First include strong collaboration between different sectors (including homelessness, health and housing). In some cases, drawing in the ‘unusual suspects,’ such as police, creates new models for outreach and support. Hamilton’s unique partnership with the EMS Navigator position provides a strong example of a community-police connection that enables the success of a Housing First program. The Vivian, in Vancouver, relies heavily on an extensive network of partnerships that are outlined in their case study.

The development of partnerships should occur early in the planning process.

“So we get everybody and anybody together. If you aren’t sure whether they should be involved, invite them anyway. One of the greatest advantages of collaboration, especially in the early stages, but is important throughout, is that those at the table and part of the development now have a vested interest, when they feel like they are part of something bigger than they are and have influence they become supporters instead of antagonists. But I would suggest even involving the naysayers. Most of the time they are the way they are because they care about their community. Get them involved in a way that shows that their opinions and ideas matter to you” (Wally Czech, as quoted in Scott & Gaetz, 2013:125).

Bring in the experts

Much can be learned from those who have gone before, and communities should avail themselves of technical support by those who have gone before them. The Calgary Homeless Foundation, in establishing its systems-based approach to Housing First, brought in individuals from a range of communities that had successfully implemented the model. These people provided local inspiration, convinced skeptics and addressed concerns that could become barriers to implementation. The other benefit of bringing in such experts is that relationships are established, and these individuals/communities can become a form of technical support during planning and implementation, when unforeseen challenges emerge. While early adopters of Housing First relied heavily on American experts such as Nan Roman from the National Alliance to End Homelessness and Sam Tsemberis from Pathways, later Housing First converts were able to use Canadian expertise. Tim Richter of the Canadian Alliance to End Homelessness (formerly with the Calgary Homeless Foundation), Brigitte Witowski, from Toronto’s Mainstay Housing, Toronto’s Streets to Homes project and Iain De Jong were all named in the case studies as innovators in Housing First whose expertise was relied upon.

One size doesn’t fit all

While there are core principles to Housing First, there is not a single program model that applies to every situation. Context always matters (city size, vacancy rate, local economy, demographics, etc.) and every community is different. What has worked in Lethbridge may not work in Regina and it is important to realize that flexibility is important to build a program based on local needs. This may mean programs have to be modified to suit the local context or the needs of a specific sub-population. For instance, the availability of low rent housing will have an impact on consumer choice. Providing rent supplements, partnerships with landlords or beginning to increase the supply of affordable housing are potential solutions to handling this in a tight housing market.

Embed Housing First in a broader planning framework

Housing First on its own will not end homelessness; rather, it must be embedded within a broader strategy. A thorough planning process is important to ensure the success of implementation and long term sustainability of the program. The places that seem to be making the most progress in reducing homelessness through Housing First tend to have an integrated systems plan. Communities in Alberta, such as Edmonton, Calgary and Lethbridge are all examples of this. Housing First is not simply a program offered in the community, but is part of a broader philosophy that all service providers are expected to support. This coordination becomes a key feature of integrated systems planning:

“Within a ‘system of care’ approach, all services and program elements within the homelessness sector – including many mainstream services – are guided by the principles of the model. As such, each program and service is expected to support and operationalize Housing First, each having a specific role to play in the larger system. While the service providers in the system are not Housing First programs on their own, they form different parts of a larger system that works towards achieving the goals of a Housing First program” (Gaetz, 2013:15).

Existing services can be retooled to be Housing First programs

New programs aren’t always needed. Existing support services – especially shelters, counselling and outreach services – can be redesigned to accommodate some of the needs of Housing First programming. In Hamilton, a decision was made to close one of the emergency shelters in order to dedicate resources to the Housing First program. This meant that other agencies needed to address the gap left by the closure of that shelter.

This re-tooling may need adjustments as the program evolves. In Lethbridge, one of the original goals was ‘one-stop shopping’; having all of the services available in one place; in this case, housing a resource center at a shelter. This centralization of services meant that Housing First clients were constantly returning to the shelter to meet with their worker or to participate in the program. Their familiarity with the shelter and companionship of other residents drew people back into the shelter system. In response, the programming transitioned back into the community from the shelter so that Housing First residents didn’t need to visit the shelter for their supports. Clients were also connected to mainstream services to further minimize their contact with the homelessness sector.

PROGRAM ISSUES

Fidelity to the core principles of Housing First is necessary

In a context where funders say they want to see more Housing First, it may be tempting to stretch the definition in order to access resources. For instance, programs that offer access to housing but provide little or no supports may be renamed Housing First. However, the provision of supports is absolutely key to the development of a Housing First program.

During program development key goals and a strong philosophy must be developed that fit with the guiding principles of Housing First. Without this it is hard to ascertain the degree to which a program really follows the core principles of Housing First (as outlined in the framework). Evidence of fidelity to the Housing First model is key to a program being an actual Housing First program or just a philosophy/program that shares a common goal with Housing First. While there are many different approaches how far you stray from the core principles really affects the ability of a program to be named Housing First. Fidelity to the core principles of Housing First is therefore important at all levels of the system. Providers of Housing First must be held accountable to demonstrate fidelity to these principles.

Housing First or housing, first?

It is not enough to just put people into housing and consider the job done, the other pieces must be in place, including necessary supports. The necessary skills of ICM and ACT teams cannot be replaced with minimal supports provided by untrained service providers.

Wally Czech, Housing First Specialist with the City of Lethbridge explains why ensuring that the community knows the difference between Housing First (as a program model) and housing first (a philosophy), can avoid having the entire program criticized for issues outside of their control:

“We received some feedback from a housing organization, that they were getting damage to property from our Housing First clients. We found out that it wasn’t us who facilitated the housing but instead it was people referred by the homeless shelter. They believe in Housing First and try to support it, but they aren’t funded to do it and intense follow-up is not part of their mandate. You need to know who is funded to do it, and who has the skills and the training to do the follow-up” (Czech, as quoted in Scott & Gaetz, 2013:114).

It is important to prioritize populations for Housing First. In many cases, it is people who are chronically homeless who should be prioritized. Research on homelessness in Canada and the U.S. has shown that while only a small percentage of the overall population of people experiencing homelessness are chronically homeless, they consume the majority of the resources. This includes not just use of shelter services but also health care, emergency services and the criminal justice system. Prioritizing people who are chronically homeless results in a faster cost-savings.

One of the lessons from case studies in Calgary and Edmonton is that it is also possible to adapt Housing First in prioritizing other sub-populations, including youth, Aboriginal people and families, for instance. While Housing First developed as a response to chronic homelessness and individuals with complex mental health and addictions issues, it clearly can and should work for other sub-populations as well.

Effective working relations with landlords are important

Whether a community is using a scattered site approach in which units are rented in the private sector or is housing people in social housing or permanent supportive housing, developing and nurturing effective relationships with landlords and housing providers is a critical component of success. In the Hamilton case study, they suggest that landlord relationships are just as important as relationships with program participants. Building trust with the landlords is key, and helping to strengthen relationships between landlord and client is important for both parties.

Bringing private landlords into the picture is a critical factor in a tight rental housing market, and perhaps not as challenging as people might imagine. Our case studies and the At Home/Chez Soi study identify that some landlords buy in because the funding and supports offered by the Housing First program offer a kind of guarantee of tenancy. In other cases, some landlords want to get involved because they are interested in making a contribution to solutions to homelessness. The key point is that even in tight housing markets, landlords can be persuaded to be partners in Housing First.

Quality Assurance matters

When implementing a new program, it is important to have standards for delivery of service, and expectations for program quality and outcomes. It is against these standards that the program is measured in order to ensure that it continues to meet the needs of clients. Communities adapting Housing First need to identify evaluation measures that will determine whether the program is being delivered as intended, and whether or not it is consistent with Housing First principles. Assessment of the success of a program needs to move beyond measurable outcomes – although use of data is critical in determining success – to include qualitative research that incorporates the perspectives of a variety of stakeholders including service users, community agency staff, landlords and the general public.

FINANCIAL CONSIDERATIONS

Budgeting must include a multiplicity of factors

In determining the cost of Housing First programs one needs to consider a comprehensive budget that includes:

• Program staff, including ICM and ACT teams, taking into account case loads.

• Rent supplements – for how many people, for how long, and when (and if) people can eventually be weaned off rent supplements.

• Cost of repairing units – One of the biggest surprises in Edmonton has been the cost of repairing damaged units, and Homeward Trust didn’t accurately forecast the amount that would need to be put aside.

Short term initial investments may be required

One of the promises of Housing First is that it will lead to a reconfiguring and eventual reduction in emergency services. This should be the case particularly if chronic and episodically homeless individuals are targeted, as they are the greatest users of emergency services. However, the savings (through the reduction of emergency services) will not be accrued immediately, so communities may have a challenge of ramping up new Housing First programs without being able to draw down other services at the same time. There may be a need for an initial investment, then, to ramp up the Housing First services.

Rent Supplements are important to Housing First success

Poverty is the common denominator among the homeless population and getting people out of poverty often means providing financial assistance to lower an individual’s costs. Rental assistance means that landlords get market rent for their apartments, and clients can afford to live in market properties. Some Housing First programs (following the Pathways model) ensure that no one pays more than 30% of their income on rent, and make rent subsidies available. If that is not in place, and clients pay a high percentage of their income on rent, other things are sacrificed, most notably food. Nutritional vulnerability is both a health and mental health risk factor, and can undermine social and community engagement.

Managing rent supplements is a challenge in many communities. Making a determination of how long an individual or family can or will need a rent supplement has an impact on program planning and resources. External bodies that fund rent supplements will have their own terms and conditions, and may jeopardise an individual’s housing if they are not able to maintain rent supplements for as long as they will need them (for some individuals this may be over their lifetime). In the Victoria case study (page 131), the original goal had been to reduce rent supplements through attrition but the lack of affordability in the housing market meant that cancellation of this aspect of the program would have a severe negative impact.

Rent supplements can also present a capacity issue, for over the years, as more and more individuals are housed through Housing First, the demand for rent supplements may eventually overtake the supply, unless some individuals can be weaned off. This circles back to the need for the development of affordable housing options to help meet demand and need.

Other material supports matter

People moving from homelessness into housing have few possessions if any. It therefore becomes important to help people furnish their apartments if possible. Inspired by the Toronto Streets to Homes program’s relationship with a furniture bank, Homeward Trust established FIND, a furniture market that is free for clients. In 2011 FIND became a social enterprise. It continues to serve clients, but also sells furniture to the public, re-investing the proceeds into housing and support programs.

SYSTEMS ISSUES

There is a real need for Affordable Housing

Housing First is not a magic wand that will solve homelessness. Effective implementation of the approach can be hampered by a lack of affordable housing. As such, implementation of Housing First must be linked to an affordable housing strategy. In order to continue to achieve the success that Housing First has seen, the availability of different types of housing will be crucial. The affordable housing supply can be expanded through a combination of direct investment (building new stock), zoning (inclusionary zoning, legalizing and regulating secondary suites), creative financing and incentives for the private sector. Communities need to work together to prioritize housing investment.

The homelessness sector and housing systems need to work in a collaborative manner

In the Hamilton case study (page 95), it was pointed out that many challenges that clients face are “as a result of the complexities within these systems rather than due to the complex situations of individual(s).” Community partners and stakeholders in housing and homelessness need to work together to ensure sustainable housing. This further strengthens the argument for integrated systems models when addressing homelessness.

Managing change helps build success

In order for Housing First to be successful and to take root, there must be buy-in to the Housing First philosophy by existing service providers and a willingness to do things differently. Housing First should not be seen as a threat, but as an opportunity, even if this means changing the mission and roles of existing services.

In the Calgary Homeless Foundation (CHF) case study (page 31), creating systems change was identified as a key challenge, yet one that was effectively managed.

Clarity of roles is important

A systems approach to Housing First, where all organizations are expected to support the philosophy of Housing First, does not necessarily mean that all providers actually do the work of Housing First. Within a partnership model each organization will deliver the services to the clients based on their functions. The Vivian program in Vancouver relies heavily on its partners to share the work. Vivian staff provide expertise housing clients and providing support to residents, but other partners address issues such as healthcare, harm reduction and food insecurity.

Several of the case studies indicated that it is critical to divide up landlord support/financial support to clients from those workers providing emotional or programmatic support to clients. It is challenging to be both the landlord and the counsellor. In order to develop trust with the clients it is best to separate these functions.

ACT and ICM teams possess a high level skill set and should therefore be responsible for delivering the intervention and providing the necessary supports for which they have the mandate and expertise. There are key skills and competencies associated with ICM and ACT teams, which other providers do not possess. Similarly, a needle exchange program or a food bank will provide supports to a client, not considered to be part of the services of an ACT or ICM team.

CLIENT ISSUES

The importance of matching supports to client needs and acuity is a key part of case management

The CHF found that acuity assessments are key in terms of ensuring resources are used appropriately. For instance, some clients with high needs were receiving inadequate supports, and should have an ACT team involved. Failure to do so leads to problems and can make housing stability precarious. Likewise, some clients who were assigned an ACT team really didn’t need that support in the long run – an ICM team may have been more appropriate to help them become stabilized. Susan McGee from Homeward Trust in Edmonton says,

“Sometimes when a client is housed their issues and support needs don’t present right away and someone that seems quite ‘stable’ may have significant mental health issues that become more clear once other things like housing and physical health improve. Or conversely someone may have been on the street a very long time and the assumption is they are complex but once the daily survival challenges of homelessness abate they do very well” (McGee, 2013).

Matching the type of housing to client need is also important

Some people do fine with the scattered site model, and prefer it to being in housing that is identified with homelessness, mental health problems or other marginalizing statuses. Other people may prefer institutional or congregate models and find them to be less stigmatizing. Again, it comes down to client choice, a core principle of Housing First.

The first three months is a crucial transitional period

For clients housed through Housing First, the first three months are often the most challenging as clients stabilize and adjust to a new mode of living. Many clients have become institutionalized after long-term shelter use and struggle with independent living. The At Home/Chez Soi team has found that this is often when housing stability is most fragile and then after that, things start to smooth out. This is a key time to ensure that the client is receiving regular support and that attempts are made to integrate the client into their new community. Providing both emotional support and access to community services and activities is key at this moment, especially if a client has moved into a new location. Susan McGee of Homeward Trust in Edmonton also remarked that it can take “several months to get the right match between client needs and appropriate supports” (McGee, 2013).

If evictions are a possibility, manage the process

Once again, effective partnerships with landlords and building managers are key. It is helpful to have a different person providing support to the client from the staff members who will deal with housing eviction, damage, later payments etc. Following the approach of Pathways in New York, and the Rapid Exit program in Hennepin County, the CHF was able to bring landlords and building managers on board through demonstrating that they could act as effective mediators between clients and landlords to reduce risk of eviction. Other key strategies that appeal to landlords and reduce the risk of eviction:

• The rent is guaranteed.

• If evictions are necessary, they will be done by the housing agency.

• Any damages will be covered by the housing agency.

Don’t give up on clients

A zero-discharge-into-homelessness policy is important. For all clients in the first three months, and for those with complex mental health and addictions issues, eviction or loss of housing is always a risk. Teams must be ready to engage in eviction prevention and to find people alternative forms of housing when staying in the current dwelling is no longer possible.

Some clients can be challenging

Some individuals, including those with histories of arson or who are violent, may prove to be challenging to house and to keep housed. They may also undermine relations with landlords. Finding appropriate housing and supports for such individuals is possible, but it may require extraordinary effort.

Consumer input in program development and implementation is essential

When you are making decisions about peoples’ lives, the most effective solutions require input from those very people. One size doesn’t fit all. What works for one won’t work for another so creating opportunities for clients to engage – from the planning through to implementation – is critical.

As demonstrated in the Edmonton case, if you are creating and delivering services for Aboriginal people, the manner in which they are engaged in decision-making and governance will impact the effectiveness of the program or service in engaging the population. It is important not to think about Aboriginal homelessness just in terms of service delivery but also to think about how they can be engaged with solutions to homelessness.

SUSTAINABILITY

The issue of sustainability must be addressed at both the programmatic and individual level in order for the program to succeed. A commitment to an increased investment is also necessary.

Program level sustainability

Funding for Housing First programs must be multi-year, as it becomes a disaster in waiting if a program is not able to guarantee longer term support for the people it houses. A three year Housing First project with no funding sustainability after that time leaves many people vulnerable who could otherwise be housed.

Individual level sustainability

The needs of clients in a Housing First program differ. Some will have low needs, and may only need help obtaining housing and support with rent in the short term. At the other extreme, others will need ACT team support or supportive housing for the rest of their lives. An effective Housing First program must identify how needs are met, who provides them and who pays for them. Rent supplements become an issue for some people, and so programs that provide support for a year only, for instance, will need to address how to maintain tenancy.

An initial investment will likely be required

Before savings are seen it will be necessary for an additional investment to be made into the homelessness sector. One of the challenges of Housing First is that it requires new money up front, with the promise that it will reduce the cost of emergency services in the long run. However, it may be several years before there is an impact on the numbers of people using emergency services, allowing for a draw down in those services and a reallocation of resources to Housing First. The decrease in expenditures will be dependent upon many factors including partnerships, an increase in affordable housing stock, the use of rent supplements and an effective homelessness prevention program.

DATA MANAGEMENT AND EVALUATION

Program evaluation should be part of any planning process

Program evaluation is not only important for demonstrating program effectiveness and social return on investment, but is a key to continuous program improvement. Program evaluation identifies where the program is experiencing challenges and helps increase understanding of the effectiveness of the program for different sub-populations. Evaluation must address what works and for whom, and under what conditions? It is important that funders recognize the need for evaluation and that tools and resources are built in to the funding model allow evaluation to occur.

Data systems with key indicators are important for measuring progress

Communities that have developed and implemented integrated systems typically have information management systems, whether the Homeless Individuals and Families Information System, the Service Prioritization Decision Assistance Tool, or the Homeless Management Information System (HMIS). Such systems can automatically track and record access to every client record by use, date, and time of access. One of the greatest benefits of HMIS is the ability to create reports describing client characteristics, outcomes of the services they receive, and general agency operating information. Communities should be mindful of key performance indicators and take the time to develop their own, based on their priorities and local circumstances. Data management systems also allow:

• The collection of system wide, standardized data.

• The ability to better understand longitudinal experiences, or experiences over time.

• Services to better meet client needs through service coordination.

Point in Time Counts should be adopted

Such counts allow for communities to develop accurate measurements of their progress as they implement their Housing First programs. Without having a baseline measurement it is very challenging, if not impossible, for communities to know whether or not their efforts are being effective. Point In Time Counts create the numbers, 10 Year Plans create the goals and Housing First is the answer to reducing homelessness.

REFERENCES

Evans, W. G. (2012). Housing First: An Interview with Sam Tsemberis. Rockville, Md. SAMSA

Gaetz, S., Fiona S., & Tanya G. (Eds.) (2013). Housing First in Canada: Supporting Communities to End Homelessness. Toronto: Canadian Homelessness Research Network Press.

McGee, S. (2013). Personal Communication.