People Who Are Vulnerable, Complex & Chronically Homeless


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International Initiatives for Homelessness
Inner City Mental Health Conference April 2008

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People Who Are Vulnerable, Complex & Chronically Homeless

  1. 1. PEOPLE WHO ARE VULNERABLE, COMPLEX & CHRONICALLY HOMELESS International Initiatives for Homelessness Inner City Mental Health Conference April 2008 Felicity Reynolds Churchill Fellow 2007
  2. 2. Fellowship Program <ul><li>To examine programs that assist vulnerable and complex chronically homeless people. </li></ul><ul><li>15 October - 25 November 2007 </li></ul><ul><li>New York, USA </li></ul><ul><li>Philadelphia, USA </li></ul><ul><li>Washington DC, USA </li></ul><ul><li>Toronto, Canada </li></ul><ul><li>London, UK </li></ul><ul><li>Until 29 February 2008 - Manager Community Support and Access at the City of Sydney. </li></ul><ul><li>From 26 March 2008 - Chief Executive Officer, Mercy Foundation. </li></ul>
  3. 4. Who are the ‘vulnerable and complex’ chronically homeless? <ul><li>People who have experienced multiple episodes of homelessness over a year or people who have experienced ongoing ‘street’ homelessness for at least 6 months. </li></ul><ul><li>AND </li></ul><ul><li>Who have multiple conditions, such as a mental illness, substance abuse, brain damage, disability, physical health problems. </li></ul><ul><li>(Approximately 15 – 25% of homeless population). </li></ul>
  4. 5. Chronic homelessness much more than chronic houselessness <ul><li>Disconnectedness and social exclusion. </li></ul><ul><li>Often a background of trauma and abuse. </li></ul><ul><li>Trust of other people and services. </li></ul><ul><li>May develop social connections, networks and supports and become ‘entrenched’. </li></ul>
  5. 6. Key themes and findings <ul><li>Vision – We can plan to end chronic homelessness - policy direction and change must come from above. </li></ul><ul><li>Measure outcomes - we must be accountable, use effective data systems with data linked (with consumer consent). This includes ‘street counts’. </li></ul><ul><li>Champions - There must be political will and drive to change things. </li></ul><ul><li>continued next page </li></ul>
  6. 7. Key themes and findings <ul><li>Cost effectiveness – high cost of not ending chronic homelessness. Supported housing is significantly more cost effective than people remaining on the streets, using multiple mainstream services. </li></ul><ul><li>‘ Housing First’ - works with this group of people (numerous examples). People can and do move successfully straight from the street into permanent housing. </li></ul><ul><li>Street outreach can be effective – but must be consumer directed and able to provide people with real options out of homelessness. </li></ul><ul><li>continued next page </li></ul>
  7. 8. Key themes and findings <ul><li>Other Service models - There is a place for lots of service models. </li></ul><ul><li>Harm minimisation; Abstinence based programs; </li></ul><ul><li>Programs for older people etc. </li></ul><ul><li>Traumatic Brain Injury (TBI) – evidence of significant incidence within the street homeless population. </li></ul><ul><li>Respect and dignity – the best organisations foster this culture throughout, with consumers and staff. </li></ul>
  8. 9. Vision - Ending chronic homelessness <ul><li>The idea of ending chronic homelessness was a ‘crazy’ notion about 5 years ago in the USA. </li></ul><ul><li>It is now accepted as an achievable (and desirable) goal. </li></ul><ul><li>It is also now accepted as both a socially and financially responsible goal. </li></ul><ul><li>Must be able to measure success (or lack of success) of programs and strategy. </li></ul><ul><li>Britain reduced number of rough sleepers by two thirds 1998 – 2002. </li></ul>
  9. 10. <ul><li>10 Steps recommended by the NAEH – USA </li></ul><ul><ul><li>Plan (envision and plan to end chronic homelessness) </li></ul></ul><ul><ul><li>Data (measure outcomes; be accountable for your services and actions) </li></ul></ul><ul><ul><li>Emergency prevention (close the front door) </li></ul></ul><ul><ul><li>Systems prevention (close the front door) </li></ul></ul><ul><ul><li>Outreach (open the back door) </li></ul></ul><ul><ul><li>Shorten homelessness (open the back door) </li></ul></ul><ul><ul><li>Rapid re-housing (open the back door) </li></ul></ul><ul><ul><li>Services (sustain) </li></ul></ul><ul><ul><li>Permanent housing (sustain) </li></ul></ul><ul><ul><li>Income (sustain) </li></ul></ul>
  10. 11. Counting people and measuring outcomes <ul><li>People always ask ‘How many people are homeless?’ Why? </li></ul><ul><li>However, if you don’t know how many homeless people there are to start with, we won’t know if our policies and programs are effective. </li></ul><ul><li>Lots of methodologies – some debate: </li></ul><ul><ul><li>NYC – use of decoys </li></ul></ul><ul><ul><li>Toronto – street needs assessment </li></ul></ul><ul><ul><li>UK – have been doing it a long time </li></ul></ul>
  11. 12. Champions and leadership <ul><li>This was the most constant theme in all places visited. </li></ul><ul><li>Nothing changes regarding street homelessness unless there is a ‘champion’ at a very high level (commonly a politician, but can also be a high level bureaucrat). </li></ul><ul><li>Other examples: Rosanne Haggerty; Sam Tsemberis. </li></ul>
  12. 13. Cost effectiveness <ul><li>It is expensive to continue to not assist people who are chronically homeless into stable housing. </li></ul><ul><li>Numerous cost/benefit studies done in USA and Canada which prove this point. </li></ul><ul><li>People who are long term homeless and who have multiple needs are often high users of acute mental health care, emergency departments, temporary accommodation, police and court involvement and other crisis services. </li></ul><ul><li>Evidence that service use reduces once people are in stable housing and have adequate support. </li></ul>
  13. 14. Housing First <ul><li>Straight from street to permanent housing (one complex or individual leases) – support provided, if required. </li></ul><ul><li>Strong evidence that other issues are better managed once in stable housing. </li></ul><ul><li>Lots of examples of ‘Housing First’ – NYC; Toronto etc. </li></ul><ul><li>Requires good supply of affordable housing. </li></ul>
  14. 15. Toronto Street Needs Assessment <ul><li>“ When we conducted the first Street Needs Assessment in April 2006, homeless people told us overwhelmingly they wanted permanent housing and the help to make this happen.” </li></ul>
  15. 16. Key components of ‘Housing First’ <ul><li>People do not have to be assessed as ‘Housing Ready’. </li></ul><ul><li>Housing is provided as quickly as possible. </li></ul><ul><li>People are provided with adequate and appropriate support services in their home. </li></ul><ul><li>People with alcohol or other drug addictions can access housing. </li></ul><ul><li>People do not need to be ‘compliant’ with mental health treatment – separate the behaviour from the diagnoses </li></ul><ul><li>Separate the management of the housing from the support. </li></ul>
  16. 17. Common Ground – NYC <ul><li>Common Ground as an example of a service that provides Housing First makes it clear that they do not ask anything more of their lease holder tenants than any other landlord asks. No other private landlord would feel they could ask if someone is drinking in their apartment or not taking their prescribed medication. However, as Rosanne Haggerty states, “ But we’re very strict about behaviour. If someone behaves badly we get on it very quickly, figuring out what needs to be changed. We have few rules but we enforce them vigorously .” </li></ul>
  17. 18. Street outreach <ul><li>Must be done with purpose. </li></ul><ul><li>Relationship building is still very important to developing trust and assisting people but it is not an end in itself. </li></ul><ul><li>Toronto S2H changed from saying ‘How can we help you?’ to ‘How can we help you access housing?’ </li></ul><ul><li>Must be persistent and must follow through. No hollow offers of assistance . </li></ul>
  18. 19. Some strategies for effective outreach <ul><li>Target ‘anchors’ </li></ul><ul><li>Use ‘Housing First’ </li></ul><ul><li>Tackle hotspots </li></ul><ul><li>Co-ordinate actions </li></ul><ul><li>Make sure there is good data collection and counts </li></ul>
  19. 20. A range of service models for a range of people <ul><li>‘ Safe havens’ – a useful model for some. </li></ul><ul><li>Harm minimisation accommodation services work very well with this group (Seaton House Annex a good example). </li></ul><ul><li>‘ Ready, Willing and Able (The Doe Fund) in NYC is a good example of an abstinence based, work skills residential program. </li></ul><ul><li>Transitional housing for older women. </li></ul><ul><li>‘ Court to Home’ - NYC </li></ul><ul><li>People shouldn’t be encouraged to be part of the ‘homeless system’ forever – using mainstream services essential. </li></ul><ul><li>Identity as ‘homeless’ not helpful. </li></ul>
  20. 21. Seaton House Annex – managed residential drinking program
  21. 22. Traumatic Brain Injury <ul><li>Evidence that TBI has very high incidence in chronically homeless population. </li></ul><ul><li>May have come from abuse/childhood trauma or from adult violence, chronic intoxication (eg. falling down a lot). </li></ul><ul><li>TBI impacts on ‘executive functions’ – such as decision making, memory and impulse control. </li></ul><ul><li>Workers with greater understanding of TBI can adjust their working methods to accommodate these problems. </li></ul>
  22. 23. Respect and dignity <ul><li>All the best services have a culture of respect and dignity amongst staff and service users. </li></ul><ul><li>Peer support programs work. </li></ul><ul><li>Good example ‘Ambassador’ project at PARC in Toronto. </li></ul>
  23. 24. ‘Joined up’ and co-ordinated services <ul><li>Nothing works if services don’t work co-operatively together. </li></ul><ul><li>Most important that mental health and drug and alcohol services must provide services in co-ordination. This particular dual diagnosis is the most common in people who experience long term homelessness. </li></ul><ul><li>Multi-disciplinary teams on the street can work very well and in a co-ordinated way with people who have multiple needs. </li></ul><ul><li>‘ Multiple needs’ seem to reduce once people have improved housing stability and better community connections and support. </li></ul>
  24. 25. Recommendations <ul><li>Plan to end chronic homelessness – from the top and the bottom. High level political will is required. </li></ul><ul><li>Plan to prevent homelessness (better co-ordination – MH, D&A, Disability support, criminal justice system etc). </li></ul><ul><li>New/re-configured funding to be put into ‘Housing First’ programs (using a variety of models) PLUS funding for support services. </li></ul><ul><li>Urgent research required on the Australian prevalence of TBI in the chronically homeless population. </li></ul>
  25. 26. Recommendations <ul><li>Education/training on working with people with TBI. </li></ul><ul><li>Better data management systems and outcomes analysis – co-ordinated service provision (with consumer consent). </li></ul><ul><li>Allow people to leave the ‘homelessness services system’. </li></ul><ul><li>Disconnectedness is the issue; connectedness is a key part of the solution. We are all responsible for implementing this recommendation. </li></ul>