This document discusses key questions about what comes after initially providing housing to homeless individuals through the Housing First approach. It addresses this question from the perspective of program participants, programs/services, housing programs, and policymakers. For program participants, maintaining social connections while also addressing issues like health, finances, substance use, and employment is important. Programs need to adopt more consumer-driven, community-based support services. Housing programs may need to redefine the role of transitional housing and adopt more principles of Housing First. And for policymakers, implementing Housing First at scale requires continued funding and evaluation while maintaining fidelity to the model.

1. Housing First!
What is Second?
Sam Tsemberis, PhD
20 September, 2013

2. Several ways to answer this question
1. Consumer/participant: what happens after
housing?
2. Programs: given what we have learned from HF,
what changes can programs make to be more
effective?
3. Systems: What are the policy implications
informed by Housing First?
4. How can we ensure that the widespread
adoption of the term HF will not result in
dissolution and program drift?

3. HF, What is second for
Program Participants?

4. Social Networks:
Friends, family, children, partners
• +Positive reconnections
• +New social possibilities
• - Dis/Continuity of street life
Social:
Friends
• +Reconnection family and
children
• +New roles and responsibilities
• - Revisiting conflicts
Children &
Family

5. After housing…
Health &Wellness/Weight Loss/Exercise
Finances/Budgeting/
Money Management
Alcohol/Drug -- Use Abuse
Mental Health Issues
JOB, JOB, JOB
eviction

7. HF, What is second for
Services and supports?
System change for housing

8. Services (1) service philosophy and array
• Most mental health services are primarily clinician
driven, office based, specialized, and risk aversive
• Peer support is scarce
• Most effective treatment is consumer directed,
community based, holistic
• What is second is surprising – prepare for a wide array
• Manage new power differential effectively
• Peer support must be integrated a vital component of
service/support

9. Services (2) service definition and
approach
• Expand definition of services to include clinical,
non-clinical, and other supports
• Expand definition service location and intensity
(this work is up close and personal)
• Use a harm reduction approach for addiction and
for mental health (and for everything other issue
requiring long term strategies
• Stages of change is issue specific not person
• Planning is person centered

10. Services (3) Recovery support services
• Seek out (outreach) those who have been least engaged
and may be most vulnerable
• Welcome , not intake (affect is important component of
the service
• Is there a palpable message of hope?
• We need define recovery (mental health) in participant “s
terms , i.e., improved quality of life (not the reduction of
symptoms) -increased social ties, improved health and
wellness, feeling of belonging, a part of the community,
satisfied with living situation, etc.

11. HF, What is second for
Housing Programs?
System change possibilities for
housing programs

12. Housing (1) The place of transitional in
the age of permanent
• If we know that going directly into
permanent housing with supports is the
most efficient and effective way to end
homelessness what is the role of
transitional housing and shelter programs?

13. Housing (2) Introducing elements of HF
into traditional programs
• Can existing programs begin to introduce elements of HF?
• Change must be desired by all levels of agency
• 4 key cost neutral changes to adopt:
1) target the most difficult to serve
2) do not make access or retention dependent on
sobriety or treatment compliance
3) separate housing from treatment, and
4) hold units for participants who have to leave for
short periods

14. Housing (3) Additional system changes
• Stop using diagnosis or psycho-social history or
other clinical information to determine the best
type housing for a consumer
• Every consumer should have the right to make
their own choice about where to live and who to
live with
• Give everyone a home and be prepared to support
the person as needed

15. Housing (4) Long term – assume greater
risk on behalf of consumers
• Most participants prefer scatter site and independent than
single site apartments (RENT STIPENS AND MOBILE
FLEXIBLE SUPPORTS)
• Most programs (esp. for poor with mental health issues)
are single site group homes
• Scatter site model has positive impact on social inclusion
• HF rentals have blurred the distinction between social
housing and private market (challenges the long held
assumptions upon which social housing is based)
• HF challenges traditional clinicians, agencies, and
government to increase their willingness to take risks and
assume greater liability on behalf of program participants

16. HF, What is second for
Policy Makers?
How can we take HF to scale?

17. Housing First is an evidence based
practice
• Numerous studies conducted by a variety of
researchers across a myriad of settings with
different populations all provide powerful
evidence of the effectiveness and cost savings of
the HF approach.
• Over time, this evidence resulted in change in
government policy in the US and Canada
adopting HF as the recommended approach to
ending chronic homlessness (US) and
homlessness (Canada).

18. Implementing policy change
• Having an official federal endorsement is a first step
in creating system change, however funding for
programs to implelement or adapt to HF, change in
practice will not occur any time soon.
• Funding must be tied to policy and performance
outcomes.
• Do we have enough affordable housing to implement
HF? Yes. There are also implications here to inform
houisng policy and how we go ahead with building
much needed affordable houisng.

19. Continuous quality improvement,
program evaluation, and research
• Eiji Toyoda applied a manufacturing culture based
on continuous quality improvement and he used
the Japanese concept of “kaizen,” a commitment
to continuous improvements suggested by the
workers themselves.
• “Workers work with their hands and their minds”
• Program participants are not passive recipients
we must actively contribute to program
improvements and research studies

20. If everything is called
HF,
Hey! Wait a second…
Maintaining program fidelity in the
face of widespread dissemination

21. HF Program and HF Approach
• Actions must follow words, walk the talk.
• Choice
• Separation
• Social Inclusion
• -------
• Consumer choice – in a shelter
• Scatter site apartments – shared, sobriety
• No treatment admission requirements – in a
single site building

22. Homeless
Rapid-rehousing
prevention
Low support
Low needs
(families)
Moderate support
& moderate needs
High support &
high needs
Limits of Housing
First Program
Definition

23. We cannot afford not to end
homelessness for those on the streets.

24. www.pathwaystohousing.org
or
info@pathwaystohousing.org