Permanent supportive housing combines housing and voluntary support services to help tenants gain independence. Support services are customized to individual needs, available outside regular hours, and funding can adapt over time. The document outlines best practices for permanent supportive housing, including documenting community needs, key components like harm reduction and peer support, evidence-based practices, and types of services provided.

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Permanent Supportive Housing- Best Practices
Intro
Permanent Supportive Housing is the combination of housing and supportive services
which creates a synergy allowing tenants to take steps towards recovery and independence.
Services are voluntary, customized and comprehensive. Services are available outside of
general hours. Service funding sources are flexible enough to allow for the specific services
to change with client needs both daily and throughout life of project. Primary service
provider has established linkages with other service providing organizations to ensure
tenants have access to comprehensive services on an ongoing basis.
Articulating the need for Permanent Supportive Housing (PSH) requires documenting the
need in a precise clear, dependable, consistent and inclusive manner as possible. Start by
identifying the number of folks in your community who receive SSI- then the percentage of
those with mental illness. Document the need for PSH by estimating the number of people
who have mental illness on the streets, in the ER, in homeless shelters, in jails or in
institutions through various estimation methods. Include others in this data collection so
that you may address together the number of folks in need.
Key Components
1. Voluntary Services
2. Youth Focus
3. Harm Reduction Approach
4. Trauma informed Care
5. Team staffing approach
6. Tenant Empowerment and Leadership
7. Peer Support
8. Medicaid funding
9. Stages of Change model use

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Evidence Based Practices (EBP)
1. Housing First: no precondition for housing
2. Motivational Interviewing: enables a provider to take the tenants readiness to change
into account and to reinforce tenants’ own incentives for change
3. Integrated treatment for co-occurring disorders: treating mental health and substance
use disorders concurrently
4. Assertive Community treatment: uses a team approach to meet participants diverse
needs
5. Illness management and recovery: enables tenants to manage their own symptoms
6. Supported Employment: helps tenants take advantage of appropriate opportunities
for mainstream employment
Services-
A combination of these services at your site will produce favorable outcomes for the tenants.
This is a comprehensive list of suggested services found at other similar programs and
suggested by best practice models.
1) Case Management
a) Treatment plans
b) Linkages to resources
c) An initial sense of connectedness
d) Coordination of resources
e) advocacy
2) Mental Health Services
a) Assessment
b) Counseling
c) Referrals
d) Psychiatric care
e) COD
f) Behavioral health services
g) Medication management
h) Therapy, individual group and family
i) Psychosocial rehabilitation

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j) Psychiatric evaluation
3) Independent Living
4) Housing and Tenancy Skills
5) Community Integration
6) Vocational Services
7) Medical Services
a) Basic health care
b) Emergency and crisis intervention
c) HIV treatment and screening
d) Mobile medical care
e) Primary medical care
f) Dental care
g) Home visits
h) Vaccines
i) Routine lab work
j) Discharge planning
k) acupuncture
8) Substance Use Services
a) Detox
b) Outreach and engagement
c) AA/NA
d) Treatment plans
e) Service planning
f) Harm reduction
g) Crisis Services
9) Family Services
a) Referrals and assistance for community based services
b) Advocacy or assistance with accessing legal, financial or school system problems
c) Facilitation of tenant involvement with property management
d) Adult education, employment and skills development and job placement services
e) Healthcare
f) Mental health counseling, therapy, support groups

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g) Parenting support
h) Conflict resolution between and among tenants
i) Recreation community building and social groups
j) Childcare
k) Children: academic support, after school enrichment, recreation, youth development
and counseling
l) Financial planning
m) Domestic violence
n) Food security
Housing first model encourages participation in services but participation is not a condition
of living in the housing. Tenants choose needs and preferences and cannot be evicted due to
rejecting services. Supportive housing is intended to help tenants define their needs and
preferences, the services come and go rather than the tenants. Supports are specialized
helping tenants accomplish goals, life skills, budgeting, medication management and
behavioral health treatment. Providers adapt the services they provide to accommodate the
population they serve, their service area and consumers stages in recovery. Programs are
built around tenant and are individualized. Programs should be evaluated continuously,
making adjustments as needed. The model must be flexible, everyone dedicated to the cause
while expecting the unexpected
There are many models for Permanent supportive housing key area where there is
considerable variance is voluntary verse mandatory services. Housing first models and Harm
Reduction models support the idea that service participation should not be a condition of
tenancy for permanent supportive housing; an effective strategy being pairing permanent
affordable housing with a proactive voluntary service approach. If there are service gaps
consider partnering with other agencies such as medical professional or employment
specialists. Include children’s goals in service provision. The model is practical relevant
flexible support services that are designed to maximize their independence. Services are
designed to be user friendly and driven by tenant needs and individuals goals. Services in
supportive housing help people reduce the harm associated with their special needs. Services
focuses on helping tenants stay housed by assisting them to meet the obligations of tenancy
(such as paying rent)

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Primary and Mental Health
Permanent Supportive Housing serves folks with chronic health challenges, mental illness or
substance/chemical dependency. Integrated treatment for co-occurring disorders means
treating both mental health and substance use simultaneously. Goal of a PSH is that tenants’
physical and mental health improves, upon entry they receive prompt medical care (including
preventative and mental.) Tenants should report mental health progress since entering; staff
helps tenants obtain information they need so they can take charge of managing their illness.
The most vulnerable folks should be prioritized for housing. For individuals with complex
chronic health conditions supportive housing offers an evidence based solution to improve
health outcomes while reducing crisis service costs. The Affordable Care Act incentivized
integrated primary and behavioral health care by reinforcing the mental health and substance
use treatment parity legislation (2008) this legislation ensures that access to mental health
and substance use treatment is comparable to treatment of medical issues. Critical because
on average people with severe mental illness’ die 25 years earlier than general population. In
states that adopt medical expansion nearly everyone in Supportive housing will qualify. It is
imperative that as many people as possible who are living in supportive housing or who are
homeless are enrolled in health insurance. . Many formerly homeless tenants are crisis
minded and may lack skills in non-crisis living. Some people may create drama and crisis
conditions so they can think clearly others will be numb and unresponsive.
Medicaid
Individuals living in supportive housing who have behavioral health diagnoses and enrolled
in Medicaid are eligible to receive Medicaid services through the outpatient system. Medicaid
eligibility requires a disability determination however many do not qualify (including
chemical dependency as a central diagnosis) or if diagnoses are not severe enough to qualify
for SSI. Medicaid enrollment is connected to SSI enrollment, which can make the process
cumbersome especially with those with a high vulnerability. Providers should make an
ongoing effort to enroll and reenroll tenants in Medicaid. By getting as many folks to enroll
in Medicaid as possible, more programming can be covered by this funding freeing other
funding to cover costs Medicaid does not cover.
Stakeholders in King County’s committee to end homelessness wanted to know if federal
Medicaid money could be brought to the table to increase the effectiveness of these
resources and to create a sustainable supportive housing system. In order for Medicaid to
pay for supportive services the services must be covered within the state Medicaid plan.

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However, Medicaid doesn’t pay for chronic health issues in those without a mental health
diagnosis. Providers must help all eligible folks enroll in Medicaid so as much as possible is
paid by Medicaid. Supportive housing covers essential needs, but little of the services
provided in King County supportive housing are currently covered by Medicaid. Services
that are covered are not reimbursed at the level needed and available only to a limited
number of people in supportive housing.
Harm Reduction
The National Harm Reduction Coalition defines harm reduction as “a set of practical
strategies and ideas aimed at reducing negative consequences associated with drug use. Harm
Reduction is also a movement for social justice built on a belief in, and respect for, the rights
of people who use drugs.” Harm reduction approach wants to support tenants at all stages
of recovery. These strategies can significantly increase housing retention among individuals
and families.
Harm reduction approach fosters an environment where individuals can openly discuss
substance use without fear of judgment or reprisal and does not condone or condemn drug
use. Model has been expanded to include HIV/AIDS and mental health issues. Families
deserve housing regardless of their special needs. In an open non-judgmental atmosphere
tenants are encouraged to explore the obstacles to achievement of their goals.
Tenant Empowerment and Peer Support
Areas for Peer Engagement and Tenant Empowerment include:
1. Involving tenants in program design
2. Initiating community specific councils (i.e. parents, youth)
3. Offer leadership opportunities
4. Foster peer support
5. Support civic activism and political engagement
6. Tenant representation on boards of organizations that serve the population
7. Participation in faith communities or volunteer opportunities
8. Paticipation in focus groups for the orgainzations that serve them
9. Consultation of tenants on issues that affect them
Peer support is gaining rapid recognition as a best practice model in supportive housing.
“Nothing about us without us” there is a need for tenant involvement in planning, design,
implementation, policy formation and evaluation of services. The service design and staffing

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plan includes the opportunity for tenants to receive services and support from peers.
Supportive housing partners support or promote the development of community wide
(local, regional or statewide) association of housing tenants that meets regularly and is tenant
lead. Each supportive housing partner has a tenant on their board. Residents input are
considered in helping providers think about potential housing. Housing is a person’s home
and not a residential treatment program.
Families/Women/Youth
Children can be an entry way to engaging parents. Design programming for youth and soon
the parents will become involved. Homeless children are 66% more likely to have at least
one major mental disability. Youth in FSH are 150% more likely to experience anxiety
depression or withdrawal. Effective family supportive housing needs space activities and
staff dedicated to children and youth as an essential component of services. In addition to
health and mental health, foci for programming for youth are:
1. self-esteem
2. community
3. leadership
4. academic supports
5. vocational supports
6. Social supports.
Supportive Housing for families should be a sanctuary for young tenants-where they can feel
good about themselves and let go of the stress they’ve been carrying. Build community
within the project as a foundation for parents to take harm reducing measures themselves
such as asking a neighbor to take care of the children when they are under the influence
themselves. Acknowledge that there can exist inter-relatedness between child neglect and
substance use. Make parenting support, training and childcare available. Safe, engaging
children’s services are essential in harm reduction environments.
Guidelines that support families may look like:
a) alcohol use or drug use and public intoxication are not permitted in community areas
of building or in front of building,
b) selling or distribution of drugs is not allowed in the building or in front of the
building,

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c) behaviors that disturb other tenants are unacceptable,
d) Tenants are responsible for paying their rent.
Supportive housing for families provides an opportunity to end cycle of violence many
studies indicate that domestic violence is both cause and consequence of homelessness
especially among families with children. If tenants fear that domestic violence will be
considered grounds for eviction they face a dilemma over whether or not to disclose
violence and ask for help. Raising awareness facilitates abuse identification and service
access. Tenants enforce a community rule of non-violence in this way tenants can hold each
other accountable to a peer based culture of non-violence. Cultivate active community
voices peer leaders and community wide holding of the nonviolent ideals. Create venues for
tenants to take advantage of the wisdom and security that peers can provide for each other.
Have successful families serve as role models for newcomers. Engage parents in ongoing
conversations about the possible effects of their drug use or alcohol on their children.
Involve parents and community as a whole in setting rules and guidelines for the express
purpose of protecting their children.
Staff
Service Staff
a) Supervisor and or team leader
b) Case manager
c) Vocation counselor
d) Housing specialist
e) Job developer
f) Peer specialist
g) Substance use specialist
h) Recreational specialist
i) Activities of Daily Living (ADL) specialist
j) HIV/AIDS specialist/ Disability specialist
k) Youth specialist
l) Mental Health Specialist
m) School Liaison
Questions to Ask
1. Will service staff be available on site or at a centralized office off site?

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2. Will service staff be available 24 hours a day or limited hours per day?
3. Will service staff representation be on call 24 hours a day?
4. Will service staff meet with tenants in office, at home or both?
5. What is maximum frequency of contact the program can accommodate per
tenant?
6. What is the minimum frequency of contact the program will allow per tenant?
7. Will we need more specified staff?
8. Will we need fewer/more case managers?
9. Are different skill levels needed?
10. Will staff have to reapply for their positions?
Evidence Based Practice: Motivational Interviewing enables provider to take the tenants
readiness to change into account and to reinforce tenants own incentives for chance,
Assertive Community Treatment uses a team approach to meet participants’ diverse needs.
Train all staff on the nature and manifestations of trauma in human life so as to ensure that
both housing and services are offered in safe, nonthreatening environments. Staff should be
trained in cultural competency- language supports/translation services, reading documents
aloud, and bilingual materials. A large challenge of this work is high staff turnover. Create a
supportive staffing network to attract and retain staff, proper support in tenant
empowerment will also provide a safety net for staff turnover.
Provide staff with training throughout program to increase effectiveness. There should be
regular staff communication between all levels and roles. A plan for 24-hour crisis coverage
exists to address urgent issues. Housing and support services staff are distinct, do not share
files/staff. Staff works with tenants to make reasonable payment plans when they miss rent.
Soon after housing entry, staff assists all tenants in applying for relevant benefits. Staff
provides tenant with community resources and neighborhood orientation. Staff supports
tenants in identifying and accessing community resources and activities and peers and friends
and family.
Staff should be trained on fair housing law and tenant engagement. Ensure staff reflect
community demographics and fluency in other languages when relevant. Staff should take
steps not to alienate tenants or cause them to hide substance use or psychiatric symptoms. In
helping people achieve their goals a trusting relationship is formed. Staff respond directly to
negative behavior whether related to substance use or not. Create a collaborative relationship
including a basic orientation for all staff on domestic violence and its dynamics, forms of

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abuse and safety planning. Ensure that your FSH team is comfortable with the organization
philosophy and approach especially around values of voluntary services, harm reduction,
tenant empowerment and youth development. As a team members can focus on areas of
specialty. Teams can be made up entirely of site staff or can include outside consultants
and/or collaborative partners. This way staff turnover does not leave such a gaping hole for
tenants. Team model allows for specialists in lieu of generalists which brings more expertise
to the team.
Financing
Enterprise Case Study
Enterprise provided and CSH analyzed financial data for 10 AH and 10 PSH projects that
have operated for at least two years. All projects were financed with 9 percent low-income
housing tax credits syndicated by enterprise community investment Inc. Data is from 2007-
2009
Enterprises cost analysis of Permanent supportive housing found that PSH is financially
solid. Their study found that revenues are 9% lower for PSH rather than affordable housing.
This is primarily due to rental income. Vacancy loss is generally comparable. In most cases
the major reason rent was late was because of problems receiving benefits- for this reason
service staff acts as an advocate for tenant.
Operating expenses were 11% higher for PSH than for affordable housing (with security
accounting for a large part of that difference.) PSH incurred $613/ unit more than
affordable housing. Legal, administration, security, payroll, property management on average
were 53% higher for PSH. Accounting/bookkeeping real estate taxes and insurance
expenses were on average 37% lower in PSH. Security payroll/contract expenses were
significantly higher for PSH.
All but one PSH reported having security. Seven projects had 24/7 security and two had
security between 8-12 hours. One factor contributing to higher costs for PSH is
security/front desk coverage. Another is expensive legal fees for complicated evictions,
because tenants have all the rights and responsibilities as other tenants, when an eviction
case is necessary there are more logistics.
Payroll, supplies, contracts, repairs and maintenance costs were 4% lower for PSH. Cash
flow- other debt services and replacement reserve deposit is higher for permanent

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supportive housing than for affordable housing. On average PSH had net operating income
of $1287 less per unit per year but had cash flow of $360 more per year than affordable
housing. Stronger cash flow occurred despite PSH receiving lower total revenue and having
higher expenses due to lower debt service and replacement reserve deposits. 8 PSH paid
little to hard debt service, while all for the AHP carried hard debt service ranging from 13-
64% of their total budgets. Real estate taxes were about 62% lower for PSH.
Despite lower NOI PSHP performed well overall. Of years analyzed 85% showed positive
operations. Those with negative NOI there was moderately negative cash flow, usually
covered by reserves. PSHP successfully maintained operating subsidies and offer services
over time. In looking forward to next five years, 7/10 respondents said primary concerns
was maintaining service funding contracts at their current levels. 5/10 said service contracts
were cut average of 8% over last few years which lead to service providers having to increase
fundraising from private sources and reduced hours of operation. PSH finds private funding
to be an important tool to meet funding shortfalls. The survey provided powerful evidence
that PSH is a safe investment despite somewhat lower revenues and higher operation costs.
Primary reason for these projects having stronger cash flow due to significant lower debt
service obligations. A strong service partnership is crucial to maximizing housing stability
which in turn leads to increase rental income, reduced repair and maintenance expenses.
Regressive Tax
2017 regressive taxing of document recording expires so$42 million a year in funding goes
away. Document recording fee revenue funds homeless services that have resulted in 29%
decrease in homelessness generally and 74% decrease in unsheltered family homelessness
since 2006. Funds from the document recording fees are the biggest single source of
homeless funding in our state. Consolidated homeless grand added incentive payments to
focus on people facing homelessness who are:
o Disabled and chronically homeless
o Youth exiting foster care
o Discharged from psychiatric hospitals, jails, prisons and regular hospitals
In 2014 incentives will be added to reward reducing the rate of return to homelessness after
exit from foster care and for reducing number of days people spend in homeless. These
align with new federal homeless emergency assistance and rapid transition to housing
(HEARTH) act measure of community performance. BY removing the sunset in RCW

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36.22.179 which expires 6/30/17 we will be able to continue our states progress to end
homelessness.
Funding Analysis
Once you have committed to implementing a PSH agenda it is important to assemble the
various resources needed to finance this agenda. This would include both analyzing authority
resources for possible restricting and establishing strong working partnerships with housing
organization to leverage mainstream
Look at each of your primary sources of capital, operating and service funding and
determine whether it will continue to be available to you if you change your program design
to PSH. Consider undertaking a significant education campaign to explain to funders why
you are considering conversion. Also assess individual donor base to see if their giving might
be altered. Also begin exploring alternate funding streams including ones specific to PSH.
o Build a solid case through research
o Contact key funders-either for input or to inform them
o If converting to HUD funding SHP contact HUD to confirm that funding
will allow conversion and to ascertain timing necessary to convert their
funding to PSH
o Hold forums for board, donors to educate on issue, our decision and what it
means for agency
Operating Budget Analysis
Operational budget includes maintenance, utilities, insurance, security, debt service and loan
payment reserves. Budget impacts may include change in charges in rent and collection rates,
opportunities for subsidies, increased or shifted costs due to reorganizing, housing
administration function, increased operating costs (Security or 24 hour front desk), changes
in staffing patterns, allocation of costs between services and operation budgets.
Supportive Housing Program (SHP) Funds
Many transitional housing programs are funded through HUD supportive housing
programs. SHP funds can be used either for transitional housing or PSH so it’s possible to

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convert the contract. Because PSH is for folks who are HUD defined disabled you will need
an amendment to the SHP grant agreement.
Substance Abuse and Mental Health Services Administration (SAMSHA)
Knowledge Informing Transformation (KIT)
Because PSH integrates housing and services for extremely low-income people with
disabilities it has more funding components than other types of affordable housing.
Depending on how the housing is provided either 2 or 3 separate funding components in
PSH projects exist as follows
Willingness to direct authority resources means finding ways to ensure that existing
resources are targeted for PSH whenever possible- both for housing and services. This may
include shifting current resources to make certain service and supports are flexible and
available to people moving into PSH. This may also include established partnership to gain
access to housing resources or influence housing options for people with psychiatric
illnesses.
Capital
Supports purchasing, constructing or rehabilitating housing for project based PSH. This is
one time funding needed to “capitalize” new PSH. This type of funding comes primarily
from government housing programs. Often as many as 5 sources of funding are needed to
make PSH development financially feasible. In addition to local and state funding, some of
the most common sources of capital finance for PSH come from the following HUD
programs
 CDBG
 HOME
 Low income housing tax credit
 Section 811 supportive housing for persons with disabilities
 Housing opportunities for people with AIDS
 Supportive housing programs
 State and local government resources such as affordable housing trust funds
Subsidies

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Rental subsidies or operating subsidies are needed ion PSH to ensure that the housing
remains affordable to people with the lowest incomes. Because the tenants of PSH are
extremely poor their rent payments (30% of their income) are not actually enough to cover
the costs of operating the housing (utilities, maintenance etc.)
Operating or rent subsidies pay the difference between the rents the tenants pay and the
actual monthly cost of the housing.
Subsidies are below market rate loans and grants that cover the difference between the
project costs and its ability to carry debt. Subsidies are generally given from government
sources in return for serving a public good. PSH usually uses subsidies to reduce or eliminate
the need for a mortgage as well as paying for the operating and service costs. Market rate
projects usually do not have subsidies developers simply pay the rents to pay for the costs.
Most projects require multiple funding sources referred to in the housing industry as
“layered” financing.
Facilities/Property Management/Legal
Development Team
o Architect/Engineer
o Property Manager
o Construction Manager
o Accountant
o Lawyer
o Supportive Service Partner
o Project Manager
o Marketing and Public Relations
o Lenders and Other Funders
Property Management
 Property or Resident Manager
 Assistant Manager
 Superintendent
 Maintenance
 Intake Specialist
 Accountant

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Delineated roles: housing logistics staff is different from services staff.
Housing meets basic needs (kitchen, bathroom, bedrooms.) There are common rooms
where tenants car interact and housing is ADA accessible. Housing is attractive in
appearance and meets or exceeds community standards. Environmental design is
incorporated including water conservation, recycling, green design and durable materials.
If you own the property analyze the restrictions that govern the property. Another issue that
might impact conversion is zoning and/or conditional lease agreements with a lawyer or
development consultant. Identify if restrictions can be changed. If necessary go to your
planning and zoning department and or consult with architect to determine whether you
need to change any use permits
Tenants will need to know their rights and provider will need to follow fair housing laws-
collecting rent, security deposits and completing tenant screenings. Consult with an attorney
about what kinds of legal documents you will need. Operating costs increase in PSH because
of legal costs due to complicated evictions, you might also expect a decrease in unit prep
cost because of reduction in turn over.
Identify and address physical problems in the building and improve safety and security. Hold
monthly meetings between tenants and property manager. One strike eviction rules should
not apply to victims of domestic violence whose abuse leads to violation of housing policy;
this will only continue the cycle of abuse. Establish a strong policy against Domestic
violence in leases community rules and other documents.
Measuring Outcomes
The most important outcome is housing stability, other outcomes that are meaningful to
tenants and many policy makers include
1. Employment
2. Participation in other meaningful activities
3. Reduced use of emergency services ((E.R.’s and crisis mental health services)
4. Reductions in arrests or time spent in jail
Individual outcomes
1. Symptom relief
2. Personal safety

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3. Services accessed
4. Role functioning
5. Self-development
6. Equal opportunity
7. Assurance of personal survival
8. Empowerment
A community living skills scale can be used to assess
1. personal care
2. socialization and relationships,
3. activities and leisure time use
4. And vocational skills.
A quality of life inventory would include
1. Self-efficacy and esteem
2. Goal identification and pursuit
3. Quality relationships
4. Community integration
5. Intimacy
6. Creativity
7. Spirituality