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Martin Laplante

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Fri, 24 Oct 2008

Streets To Home: Down With Continuum of Care!

I usually don't talk about my work in this blog so that my clients needn't worry, but this is different. I went to a very interesting conference yesterday. The theme was "Housing First", the revolutionary and extremely effective method developed by Pathways to Housing in New York City. It has been used in dozens of cities in the US, usually with amazing outcomes. Not so much in Canada. Where it has been claimed to be applied, the claim usually doesn't stand up to scrutiny. But now I've learned that Toronto's Streets to Home program is true to all the basic tenets of Housing First, including the ones that go against the grain. And Iain de Jong, the manager of the program and former urban planner, uses blunt language to tell homelessness practitioners to drop other types of programs.

A lot of homelessness groups are asking for Housing First to be implemented. I suspect that they don't realize just how radical it is, because they often also advocate for programs that are the antithesis of Housing First. And unfortunately, research shows that any adaptation of a Housing First program to fit into a Continuum of Care model brings the effectiveness all the way back down.

A brief background. The Continuum of Care model is composed of a number of distinct services, starting from outreach to drop-ins and shelters, addiction recovery, skills training and employment assistance, going through transitional housing to supportive housing, that gradually ease people through a progression from homeless to housed. A wide variety of agencies, staffed with volunteers or professionals, provide a variety of services. All of these services require locations, so recently most of these agencies have turned into real estate developers, with sites as big as their capital budget or grant will allow and using tactics to overcome objections by neighbours and to ensure that city council votes go their way.

Housing First, on the other hand, starts from the premise that no transition is required: the first thing that is offered to a chronically homeless person is the key to his new apartment, that this apartment is a regular apartment in a regular building with a regular landlord in the neighbourhood of his choice, which is seldom downtown. No group homes (apart from exceptional circumstances), no public housing unless that actually suits the person better, and especially no transitional housing nor skills training while staying in a shelter. Case management is intensive and takes place in the client's new apartment. Addiction and mental health problems get addressed after the person is housed, on a voluntary basis, not before. Statistics in the US show that housing alone is more effective at addiction recovery than drug/alcohol treatment alone. Of course, housing plus treatment work best. de Jong has banned the use of the terms "housing ready" and "service resistant". Everyone is ready for housing and it is up to the front line workers to find the right kind for each person.

One of the more difficult aspects of implementation in Canadian cities is the "Scattered Site" element. Clients must be housed in a neighbourhood of their choice, never more than a few per building. But as opposed to the US, here there are no Section 8 vouchers, no Gautreaux programs, no Scattered Site public housing, no Fair Share Criteria. That means that public and subsidized housing as well as homelessness programs tend to be concentrated in poor downtown areas. That really cuts down the effectiveness of all these programs. The geographic concentration of poverty has effects that can be even more severe than the poverty of individuals. Coming up with a Scattered Site approach in Canada is a heroic effort that must be applauded.

Also to be applauded is the change in metrics for program evaluation. Housing First measures outcomes, not just activities. What matters is, of the homeless people that we approached, what percentage is housed now? And they don't just take the easy cases. In fact they don't take the easy cases at all. They concentrate on the chronic homeless, typically people with both a mental health problem and an addiction. Unlike many homelessness programs, they don't just measure outputs: how many people are in my case list, how many referrals are made to a program that may help them, how many graduate to the next level of the continuum. The unfortunate effect of that approach is that failure gives the best numbers.

The beauty of this very effective program is not only that it is more effective and cheaper, but that capital costs are very low. These programs aren't buying real estate and building institutions, they are renting regular apartments and, once they help with the paperwork of applying for public assistance or disability, it mostly doesn't come out of the program's own budget. But the best part is by using a scattered site approach they never have to deal with zoning and city council votes. As long as they give their clients a choice of locations and don't take over entire buildings or even large parts of them they can not be challenged on legal or constitutional grounds. Unlike the agencies that face more political resistance in middle-class neighbourhoods than in poor ones, this type of program works as well in suburban locations as downtown. Concentration of poverty is addressed without spending a penny. Drug dealers don't know where to find these victims. Landlords like them because they are more reliable tenants that the average and because they have someone to complain to if things don't work out. Case management is completely separate from property management. Everybody wins.

Almost everybody. A lot of agencies are left with group homes and service locations that may become white elephants. Politicians have no ribbon-cutting to attend, no multi-million dollar capital announcements to make. Volunteers and do-gooders are kept well away from the clients, whose mental health and social problems are complex enough that only professionals can address them. Basic christian charity and ministering to the inner city's fallen souls is no longer part of the solution. They were just stopgaps compensating for the absence of solutions anyway. Hopefully all these well-meaning people and agencies will not stand in the way of real solutions with about 90% effectiveness.

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