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Position Statement 38: Supportive Housing and Housing First
Mental Health America (MHA) supports Housing First policies that expedite access to permanent supportive housing for people with mental health and substance use conditions and integrate mental health and substance use treatment with an effective safety net that includes safe and affordable housing, without requiring treatment as a precondition unless the person meets the standards for civil commitment.
Many people with mental health and substance use conditions lose access to housing because of poverty and disruption of personal relationships related to their disability, and between 20 and 33% of homeless people have serious mental illnesses.[i] In addition, according to the Office of National Drug Control Policy, approximately 67% of people experiencing chronic homelessness have a primary substance use disorder or other chronic health condition.[ii] Housing First is a proven approach in which people experiencing homelessness are offered permanent housing with few treatment preconditions, behavioral contingencies, or other barriers.[iii] Although it is sometimes difficult to deal with the behavioral issues presented by people who are under the influence of drugs and experiencing mental health crises, appropriate staffing and safeguards have proven adequate to protect other residents without making sobriety and treatment preconditions to providing shelter. The training and commitment required are the same as those required to eliminate the use of seclusion and restraints in mental health treatment facilities, as advocated in MHA Position Statement 24,[iv] and more relaxed eligibility standards have proven effective in getting and keeping people off of the streets.
Thus, a respected 2004 study found that:
“The Housing First program sustained an approximately 80% housing retention rate, a rate that presents a profound challenge to clinical assumptions held by many Continuum of Care supportive housing providers who regard the chronically homeless as ‘not housing ready.’ More important, the residential stability achieved by the experimental group challenges long-held (but previously untested) clinical assumptions regarding the correlation between mental illness and the ability to maintain an apartment of one’s own. Given that all study participants had been diagnosed with a serious mental illness, the residential stability demonstrated by residents in the Housing First program—which has one of the highest independent housing rates for any formerly homeless population—indicates that a person’s psychiatric diagnosis is not related to his or her ability to obtain or to maintain independent housing. Thus, there is no empirical support for the practice of requiring individuals to participate in psychiatric treatment or attain sobriety before being housed.”[v]
An even more impressive result was achieved in a seminal study published in 2000, in which Tsemberis and Eisenberg reported the effectiveness of a five-year Housing First program on people with severe psychiatric disabilities and addictions in New York City. During that time, the program provided "immediate access to independent scatter-site apartments for individuals with psychiatric disabilities who were homeless and living on the street." With an 88 percent housing retention rate, the program achieved substantially better housing tenure than did the comparison group.[vi]
A comprehensive index of the subsequent studies, confirming and replicating these early findings, is maintained by the Corporation for Supportive Housing.[vii] An impressive 2014 study of five Canadian Cities found that at one-year follow-up, 73% of Housing First participants and 31% of treatment-as-usual participants resided in stable housing (p<.001, odds ratio=6.35, covariate adjusted difference=42%, 95% confidence interval [CI]=36%−48%). Improvement in overall quality of life was significantly greater among Housing First participants compared with treatment-as-usual participants (p<.001, d=.31, CI=.16–.46). Housing First participants also showed greater improvements in community functioning compared with treatment-as-usual participants (p=.003, d=.25, CI=.09–.41).[viii]
Supportive housing, specifically including but not limited to Housing First programs, is supported by a significant body of evidence, summarized by Rog, D.J. et al. in a 2014 review: “Permanent Supportive Housing: Assessing the Evidence.”[ix] The review found that: “The level of evidence for permanent supportive housing was graded as moderate. Substantial literature, including seven randomized controlled trials, demonstrated that components of the model reduced homelessness, increased housing tenure, and decreased emergency room visits and hospitalization. Consumers consistently rated this model more positively than other housing models.”
According to the U. S. Interagency Council on Homelessness (ICH), “Housing First yields higher housing retention rates, reduces the use of crisis services and institutions, and improves people's health and social outcomes.”[x]
Components of the Model
The ICH model includes the following elements:
- Emergency shelter, street outreach providers, and other parts of the crisis response system are aligned with Housing First and recognize that their role encompasses housing advocacy and rapid connection to permanent housing. Staff in crisis response system services believe that all people experiencing homelessness are housing ready.
- Strong and direct referral linkages and relationships exist between crisis response system (emergency shelters, street outreach, etc.) and rapid rehousing and supportive housing. Crisis response providers are aware and trained in how to assist people experiencing homelessness to apply for and obtain permanent housing.
- The community has a unified, streamlined, and user-friendly community-wide process for applying for rapid re-housing, supportive housing, and/or other housing interventions.
- The community has a coordinated assessment system for matching people experiencing homelessness to the most appropriate housing and services.
- The community has a data-driven approach to prioritizing highest-need cases for housing assistance, whether through an analysis of lengths of stay in Homeless Management Information Systems, vulnerability indices, or data on utilization of crisis services.
- Policymakers, funders, and providers collaboratively conduct planning and align resources to ensure that a range of affordable and supportive housing options and models are available to maximize housing choice among people experiencing homelessness.
- Policies and regulations related to supportive housing, social and health services, benefit and entitlement programs, and other essential services do not inhibit the implementation of the Housing First approach. For instance, eligibility and screening policies for benefit and entitlement programs or housing do not require the completion of treatment or achievement of sobriety as a prerequisite.
- Every effort is made to offer a tenant a transfer from one housing situation to another, if a tenancy is in jeopardy. Whenever possible, eviction back into homelessness is avoided.[xi]
Permanent supportive housing programs differ from other living arrangements by providing a combination of flexible, voluntary supports for maintaining housing and access to individualized evidence-based support services, such as assertive community treatment (ACT). ACT is an interdisciplinary team approach that supports people in recovery in the community with intensive services. ACT teams include social workers, nurses, psychiatrists, and vocational and substance abuse counselors who are available to assist 7 days a week 24 hours a day.[xii] But variants on the ACT model are essential to success in practice. The team must have sensitivity to and knowledge of housing issues and available funding. Just having an ACT team is not enough. It takes a lot of “behind the scenes” work to keep people housed.
The Call to Action lists the required case management services, but it is worth stressing assistance with personal care, housekeeping and cleaning, and pest control, which are essential to avoid eviction, and individual counseling and de-escalation when eviction is threatened. These are the interventions stressed by the practitioners interviewed for the preparation of this position statement. The aim is to maintain permanent housing by interventions that go beyond treatment of the underlying general and mental health and substance use issues to deal with behavioral issues that threaten tenancy.
As noted by the Corporation for Supportive Housing:
“Supportive housing is not affordable housing with resident services. It is a specific intervention for people who, but for the availability of services, do not succeed in housing and who, but for housing, do not succeed in services. The housing in supportive housing is affordable, permanent, and independent. The services are intensive, flexible, tenant-driven, voluntary, and housing-based. The services in supportive housing are tenancy supports that help people access and remain in housing. Supportive housing is also a platform from which health care services can be delivered and received.”[xiii]
The 2014 review, which specifically focused on housing for people with mental health conditions, used a slightly more refined definition of permanent supportive housing:
- Tenants have full rights of tenancy, including a lease in their name; the lease does not have any provisions that would not be found in leases held by someone without a mental disorder.
- Housing is not contingent on service participation.
- Tenants are asked about their housing preferences and provided the same range of choices as are available to others without a mental disorder.
- Housing is affordable, with tenants paying no more than 30% of their income toward rent and utilities.
- Housing is integrated; tenants live in scattered-site units located throughout the community or in buildings in which a majority of units are not reserved for individuals with mental disorders.
- House rules are similar to those found in housing for people without mental disorders.
- Housing is not time limited, so the option to renew leases is with the tenants and owners.
- Tenants can choose from a range of services based on their needs and preferences; the services are adjusted if their needs change over time.
The moderate level of success found by the 2014 review researchers was based on:
- Reduced homelessness
- Increased housing tenure over time
- Reduced emergency room use
- Reduced hospitalizations
- Increased consumer satisfaction
The Corporation for Supportive Housing summarizes the three benefits of supportive housing demonstrated by the research:
- “Supportive Housing Improves Lives. Research has shown that supportive housing has positive effects on housing stability, employment, mental and physical health, and school attendance. People in supportive housing live more stable and productive lives.
- Supportive Housing Generates Significant Cost Savings to Public Systems. Cost studies in six different states and cities found that supportive housing results in tenants’ decreased use of homeless shelters, hospitals, emergency rooms, jails and prisons.
- Supportive Housing Benefits Communities. Further evidence shows that supportive housing benefits communities by improving the safety of neighborhoods, beautifying city blocks with new or rehabilitated properties, and increasing or stabilizing property values over time.”[xiv]
Shelters are rarely equipped to provide adequate supports to qualify as supportive housing and are transitional responses to get people off the streets. Group living facilities and psychiatric hospitals are needed by some people experiencing mental health crises, but are also transitional, since most people cannot tolerate indefinitely the degree of supervision inherent in such residences. Thus, shelters, group homes, and clinical facilities, while necessary, should be deemphasized as much as possible in favor of development of scattered-site supportive housing that is fully integrated into the community and permanently available to its residents, so that the people living there can identify it as their home.
It is not uncommon that people start out only wanting housing and not services. Housing First accepts such people, rejected in the past, and provides the services they need to help them keep their housing, while offering to increase services as the need becomes apparent. Case managers meet people where and as they are and start building trust, which, in practice, works much better than insisting on providing services as a condition of providing housing.
The greatest ongoing difficulty encountered in Housing First programs is in maintaining enough vacant units to minimize waiting periods while guaranteeing ongoing availability of permanent housing to people already being served. This requires ongoing development of new housing, which in turn requires surmounting funding and zoning barriers. Denver, CO[xv] and Salt Lake City, UT[xvi] are examples of communities that have had greater success than others in increasing housing options for people with mental health and substance use disorders.
Supportive housing requires a substantial investment by state and local governments, which bear the burden of funding housing, with some support from the federal government, particularly through the “Section 8” program that provides rental assistance. Most rental assistance is federally funded, yet only one in four eligible low-income households receives assistance.[xvii] In addition, programs like the Low-Income Housing Tax Credit (LIHTC) should be expanded, which provide incentives for real estate developers to invest in housing that is accessible to low-income individuals.[xviii] Communities should review zoning, transportation, and related policies to ensure that low-income housing developed in inclusive and promotes economic mobility for individuals with mental health conditions.
Significantly, the federal Medicaid program, which matches state funds for mental health and substance use treatment, pays for licensed facilities but is prohibited by statute from funding other forms of housing. However, in recent years, the Center for Medicare and Medicaid Services (CMS) and SAMHSA have stressed the availability of Medicaid funding for the ancillary services required for supportive housing. For example, a 2015 CMS informational bulletin detailed how Medicaid funds could be used for “(1) Individual Housing Transition Services – services that support an individual’s ability to prepare for and transition to housing; (2) Individual Housing & Tenancy Sustaining Services - services that support the individual in being a successful tenant in his/her housing arrangement and thus able to sustain tenancy; and (3) State level Housing Related Collaborative Activities - services that support collaborative efforts across public agencies and the private sector that assist a state in identifying and securing housing options for individuals with disabilities, older adults needing LTSS, and those experiencing chronic homelessness.”[xix]
A 2014 SAMHSA-funded Corporation for Supportive Housing (CSH) white paper, “Creating a Medicaid Supportive Housing Services Benefit: A Framework for Washington and Other States,”[xx] is the best blueprint of the policy changes needed. See also, CSH’s 2015 “A Quick Guide to Improving Medicaid Coverage for Supportive Housing Services”[xxi] The Center for Budget and Policy Priorities’ 2016 white paper, “Supportive Housing Helps Vulnerable People Live and Thrive in the Community,”[xxii] and CMS’ 2015 Informational Bulletin, “Coverage of Housing-Related Activities and Services for Individuals with Disabilities.”[xxiii]
The 1915i State Plan Amendment for Home and Community-Based Services offers the opportunity to implement supportive housing services state-wide (no geographical limits are permitted), without limits on the population to be served so long as all are served who meet needs-based criteria. People being served need not be at risk of institutionalization. Thus, the 1115i waiver does not require that implementation be “cost neutral” to the federal government.[xxiv] Independent evaluations are required to demonstrate outcomes. The CSH white paper discusses the pros and cons of alternative CMS waiver strategies.
It is also critical that public benefit design and administration, such as Social Security Insurance, reinforce Housing First approaches. Benefits must be sufficient and accessible enough to support an individual in supported but independent and permanent housing. They must take into account additional costs related to any rent and upkeep of housing in that geographic market, and must be coordinated with Housing First programs to ensure that the full benefits are received when first needed. During transitions in housing or after a period of institutionalization, such as hospitalization or incarceration, public benefits should immediately consider the full costs of housing and avoid any “look back” that disadvantages Housing First. Benefits administration should be coordinated with institutions to ensure that benefits immediately consider changes in living situation when an individual returns to the community.
Call to Action
It is imperative that mental health and substance use treatment providers expand their reach to include permanent supportive housing, whether as part of clinical community support outreach and ACT programs, or in partnership with housing providers. To accomplish this, federal, state and local funding policy must be changed:
Based on the current estimates of the unserved need, federal rental housing assistance should be quadrupled, and states and localities should recognize the imperative to develop a robust array of government-sponsored housing alternatives to respond to the nationwide epidemic of homelessness. Part of this will also need to include concomitant increases in programs like the Low-Income Housing Tax Credit to ensure the availability of low-income housing options in different communities, and review of zoning, transportation, and other policies that promote inclusive development.
States should follow the roadmap sketched out in the 2014 SAMHSA-funded CSH white paper, “Creating a Medicaid Supportive Housing Services Benefit: A Framework for Washington and Other States”[xxv] and the CMS information bulletin “Coverage of Housing-Related Activities and Services for Individuals with
Disabilities,” [xxvi] and substantially increase the federal contribution to supportive housing available under current law. Specifically, since only people who are eligible for Medicaid services on the basis of medical necessity are eligible for the Medicaid supportive housing services benefit, health eligibility criteria can be based on:
Primary severe and persistent mental illness (SPMI)
Primary mental health diagnosis but not at the SPMI level
Primary substance use diagnosis
Complex health needs (disability, at risk of institutional care, or multiple chronic illnesses)
Benefit eligibility criteria should include housing status to ensure that the benefit serves only those people who need supportive housing services (as opposed to general affordable housing and/or other non-housing based services or “resident services”). Specifically, eligibility criteria can be based on the following housing situations:
Chronically homeless (HUD definition)
At risk of chronic homelessness
Living in institutions or at risk of institutional care
Currently living in supportive housing
Benefits should not include look back periods that disadvantage transitions to housing from homelessness or institutionalization, and should be coordinated to reinforce Housing First.
The package of supportive services to be funded must be robust to be effective, and should include as many of the following services as can be afforded:
Outreach and engagement
Housing search assistance
Collecting documents to apply for housing
Completing housing applications
Subsidy applications and recertifications
Advocacy with landlords to rent units
Purchasing cleaning supplies, dishes, linens, etc.
Moving assistance if first or second housing situation does not work out
Tenancy rights and responsibilities education
Eviction prevention (paying rent on time)
Eviction prevention (conflict resolution)
Eviction prevention (lease behavior requirements)
Eviction prevention (utilities management)
Landlord relationship maintenance
Subsidy provider relationship maintenance
- HOUSING CASE MANAGEMENT
Service plan development
Coordination with primary care and health homes
Coordination with substance use treatment providers
Coordination with mental health providers
Coordination of vision and dental providers
Coordination with hospitals/emergency departments
Crisis interventions and Critical Time Intervention
Trauma Informed Care
Transportation to appointments
Independent living skills coaching, specifically including:
Assistance with personal care
Assistance with housekeeping and cleaning
Individual counseling and de-escalation
Linkages to education, job skills training, and employment
CMS approval will be required to implement any program of supportive housing using Medicaid funds. The 1915i State Plan Amendment for Home and Community-Based Services offers a good opportunity to draw down additional Medicaid funds for supportive housing.
The Mental Health America (MHA) Board of Directors approved this policy on September 8, 2018. It is reviewed as required by the Mental Health America (MHA) Public Policy Committee.
Expiration: December 31, 2023
[i] Compare http://www.nationalhomeless.org/factsheets/Mental_Illness.pdf and http://www.treatmentadvocacycenter.org/fixing-the-system/features-and-news/2596-how-many-people-with-serious-mental-illness-are-homeless
[iii] Although ongoing sobriety is not a precondition, and no minimum period of sobriety is required, people with substance use disorders ordinarily must go through detoxification and receive a thirty-day injection of Vivitrol (extended release naltrexone to help prevent relapse) prior to housing placement.
[v] Tsemberis, S., Gulcur, L & Nakai, M., “Housing First, Consumer Choice, and Harm Reduction for Homeless Individuals With a Dual Diagnosis,” Am J Public Health 94(4):651–656 (2004) (emphasis supplied), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448313/?_escaped_fragment_=po=64.1447 .
[vi] Tsemberis, S. & Eisenberg, R.F., "Pathways to Housing: Supported Housing for Street-Dwelling Homeless Individuals with Psychiatric Disabilities," Psychiatric Services 51(4):487–493 (2000), https://www.ncbi.nlm.nih.gov/pubmed/?term=10737824 .
[viii] Aubry, T., Tsemberis, S., Adair, C.E., et al., “One-Year Outcomes of a Randomized Controlled Trial of Housing First With ACT in Five Canadian Cities,” Psychiatric Services 66(5):463-9. doi: 10.1176/appi.ps.201400167. Epub 2015 Feb 2, https://www.ncbi.nlm.nih.gov/pubmed/?term=PMID%3A+25639993 , https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201400167?utm_source=TrendMD&utm_medium=cpc&utm_campaign=Psychiatric_Services_TrendMD_0
[ix] Psychiatric Services 65(3):287-294 (2014), https://www.ncbi.nlm.nih.gov/pubmed/?term=24343350 , full text available at http://www.coloradocoalition.org/sites/default/files/2017-01/287.pdf
[xii] Described in MHA Position Statement 12, Evidence-based Healthcare, http://www.mentalhealthamerica.net/positions/evidence-based-healthcare
[xiv] http://www.csh.org/supportive-housing-facts/evidence/ . Eighteen mental health and substance use studies are cited in support of these conclusions: http://www.csh.org/wp-content/uploads/2017/04/CSH-Lit-Review-MH-Outcomes.pdf
[xvii] See Part VI of Barbara Sard and Will Fischer, “Chart Book: Federal Housing Spending Is Poorly Matched to Need,” Center on Budget and Policy Priorities, December 18, 2013, http://www.cbpp.org/research/chart-book-federal-housing-spending-is-poorly-matched-to-need .
[xx] Creating a Medicaid Supportive Housing Services Benefit: A Framework for Washington and Other States, http://www.csh.org/wp-content/uploads/2014/08/Creating_Medicaid_Supportive_Housing_Servcies_Benefit_WashingtonState.pdf
[xxiv] The 2014 CMS Regulation provides: “While HCBS provided through section 1915(c) waivers must be “cost-neutral”, as compared to institutional services, no cost neutrality requirement applies to the section 1915(i) State plan HCBS benefit. States are not required to produce comparative cost estimates of institutional care and the State plan HCBS benefit. This significant distinction allows states to offer HCBS to individuals whose needs are substantial, but not severe enough to qualify them for institutional or waiver services, and to individuals for whom there is not an offset for cost savings in NFs, ICFs/MR, or hospitals.” 42 CFR 440, https://www.federalregister.gov/documents/2014/01/16/2014-00487/medicaid-program-state-plan-home-and-community-based-services-5-year-period-for-waivers-provider Section II.B.4 General Provisions.
[xxv] Creating a Medicaid Supportive Housing Services Benefit: A Framework for Washington and Other States, http://www.csh.org/wp-content/uploads/2014/08/Creating_Medicaid_Supportive_Housing_Servcies_Benefit_WashingtonState.pdf