Consistent with the principles of consumer choice, Housing First uses the harm reduction approach in its clinical services to address both substance abuse and psychiatric issues. The treatment team recognizes that consumers can be at different stages of recovery and that interventions should be tailored to each consumer's stage. Consumers' tenancy is not dependent on their adherence to clinical treatment, although they must meet the obligations of a standard lease. The team works with consumers through housing loss, hospitalization, or incarceration and helps consumers obtain housing after these episodes. While consumers can refuse formal clinical services, the program requires them to meet with a team member at least four to six times per month to ensure their safety and well-being.
Quality of Research
Review Date: November 2007
Documents Reviewed
The documents below were reviewed for Quality of Research. The research point of
contact can provide information regarding the studies reviewed and the availability
of additional materials, including those from more recent studies that may have been conducted.
Study 1Greenwood, R. M., Schaefer-McDaniel, N. J., Winkel, G., & Tsemberis, S. J. (2005). Decreasing psychiatric symptoms by increasing choice in services for adults with histories of homelessness. American Journal of Community Psychology, 36(3/4), 223-238. 
Gulcur, L., Stefancic, A., Shinn, M., Tsemberis, S., & Fischer, S. N. (2003). Housing, hospitalization, and cost outcomes for homeless individuals with psychiatric disabilities participating in Continuum of Care and Housing First programmes. Journal of Community and Applied Social Psychology, 13, 171-186.
Tsemberis, S., Gulcur, L., & Nakae, M. (2004). Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal of Public Health, 94(4), 651-656.
Tsemberis, S. J., Moran, L., Shinn, M., Asmussen, S. M., & Shern, D. (2003). Consumer preference programs for individuals who are homeless and have psychiatric disabilities: A drop-in center and a supported housing program. American Journal of Community Psychology, 32(3/4), 305-317.
Supplementary Materials Padgett, D. K. (2007). There is no place like (a) home: Ontological security among persons with serious mental illness in the United States. Social Science and Medicine, 64(9), 1925-1936.
Perlman, J., & Parvensky, J. (2006, December 11). Denver Housing First Collaborative. Cost benefit analysis and program outcomes report. Denver, CO: Colorado Coalition for the Homeless. Retrieved October 29, 2007, from http://www.shnny.org/documents/FinalDHFCCostStudy.pdf
Stefancic, A., & Tsemberis, S. (2007). Housing First for long-term shelter dwellers with psychiatric disabilities in a suburban county: A four-year study of housing access and retention. Journal of Primary Prevention, 28(3/4), 265-279.
Tsemberis, S. (1999). From streets to homes: An innovative approach to supported housing for homeless adults with psychiatric disabilities. Journal of Community Psychology, 27(2), 225-241.
Tsemberis, S., & Eisenberg, R. F. (2000). Pathways to Housing: Supported housing for street-dwelling homeless individuals with psychiatric disabilities. Psychiatric Services, 51(4), 487-493.
Yanos, P. T., Barrow, S. M., & Tsemberis, S. (2004). Community integration in the early phase of housing among homeless persons diagnosed with severe mental illness: Successes and challenges. Community Mental Health Journal, 40(2), 133-150.
Outcomes
| Outcome 1: Residential stability |
|
Description of Measures
|
Residential stability was assessed using the Residential Follow-Back Calendar developed by the New Hampshire Dartmouth Psychiatric Research Center. The interviewer assessed the participant's location for each day during the past 6 months. From this information, the proportion of time spent homeless (living on the streets, in public places, or in shelter-type accommodations) and the proportion of time spent in stable housing (residing in one's own apartment, having a room or studio apartment in a supportive housing program, etc.) were calculated. The number of days spent in any of the locations categorized as "homeless" and the number spent in locations categorized as "stably housed" were each summed and divided by the total number of days of residency reported at the interview.
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Key Findings
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From baseline to 2-year follow-up, Housing First participants spent approximately 80% of their time stably housed, versus 30% for participants in the comparison group, who were assigned to traditional programs that made treatment and sobriety prerequisites for housing (p < .001). Similarly, from baseline to 3-year follow-up, Housing First participants spent significantly less time homeless than the comparison group (p < .001).
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Studies Measuring Outcome
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Study 1
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Study Designs
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Experimental
|
|
Quality of Research Rating
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3.7
(0.0-4.0 scale)
|
| Outcome 2: Perceived consumer choice in housing and other services |
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Description of Measures
|
Perceived consumer choice was assessed using a modified version of Consumer Choice, a 16-item instrument developed by Srebnik, Livingston, Gordon, and King. Participants were asked to indicate their perceived level of choice for aspects of housing services, such as the place where they live or how they spend their day. Responses were given on a 5-point scale ranging from "no choice at all" to "completely my choice." Responses were used to determine (1) how important it was for the participant to have a choice at baseline (in location, neighbors, housemates, visitors, etc.) and (2) how much choice the participant actually had at subsequent time points.
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Key Findings
|
At 2-year follow-up, participants assigned to Housing First reported significantly more choice with respect to their housing, treatment, and daily living than participants in the comparison group, who were assigned to traditional programs that made treatment and sobriety prerequisites for housing (p < .001). This effect was maintained at 3-year follow-up.
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Studies Measuring Outcome
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Study 1
|
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Study Designs
|
Experimental
|
|
Quality of Research Rating
|
2.4
(0.0-4.0 scale)
|
| Outcome 3: Cost of supportive housing and services |
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Description of Measures
|
Using the Residential Follow-Back Calendar, the total number of days each participant spent in different locations was calculated for each time point. The cost per person per day was then calculated by multiplying the number of days in each location with the cost associated with each location, then dividing the product by the total number of days.
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Key Findings
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From baseline to 2-year follow-up, participants assigned to Housing First accrued significantly lower supportive housing and services costs than participants in the comparison group, who were assigned to traditional programs that made treatment and sobriety prerequisites for housing (p < .05).
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Studies Measuring Outcome
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Study 1
|
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Study Designs
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Experimental
|
|
Quality of Research Rating
|
3.5
(0.0-4.0 scale)
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| Outcome 4: Use of support services |
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Description of Measures
|
Use of support services was assessed with:
- The substance use treatment subscale of a modified version of the Treatment Services Review. Participants were asked whether they had used any of seven different types of services in the past 2 weeks (e.g., use of a detox program; consultation with a counselor to talk about substance problems; attendance at Alcoholics Anonymous, Narcotics Anonymous, or other substance abuse self-help groups). Use was calculated as the average of this 7-item measure.
- Residential Follow-Back Calendar. The proportion of time participants spent in psychiatric hospitals was calculated by dividing the number of days each participant spent in psychiatric hospitals by the total number of days in the assessment period.
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Key Findings
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From baseline to 2-year follow-up, participants in the comparison group (who were assigned to traditional programs that made treatment and sobriety prerequisites for housing) reported significantly higher use of substance abuse treatment programs (p < .05) and a significantly larger proportion of time in psychiatric institutions (p < .01) than participants assigned to the Housing First group.
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Studies Measuring Outcome
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Study 1
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Study Designs
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Experimental
|
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Quality of Research Rating
|
3.3
(0.0-4.0 scale)
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Study Populations
The following populations were identified in the studies reviewed for Quality of
Research.
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Study
|
Age
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Gender
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Race/Ethnicity
|
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Study 1
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18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
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77% Male
23% Female
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48% Black or African American
30% White
14% Hispanic or Latino
8% Race/ethnicity unspecified
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Quality of Research Ratings by Criteria (0.0-4.0 scale)
External reviewers independently evaluate the Quality of Research for an intervention's
reported results using six criteria:
For more information about these criteria and the meaning of the ratings, see Quality of Research.
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Outcome
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Reliability
of Measures
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Validity
of Measures
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Fidelity
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Missing
Data/Attrition
|
Confounding
Variables
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Data
Analysis
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Overall
Rating
|
|
1: Residential stability
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3.5
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4.0
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3.0
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3.8
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3.8
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4.0
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3.7
|
|
2: Perceived consumer choice in housing and other services
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1.0
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1.0
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3.0
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3.5
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2.0
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4.0
|
2.4
|
|
3: Cost of supportive housing and services
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3.5
|
4.0
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3.0
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3.5
|
3.5
|
3.5
|
3.5
|
|
4: Use of support services
|
3.0
|
3.5
|
3.0
|
3.5
|
3.5
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3.5
|
3.3
|
Study Strengths Most of the measures used have acceptable psychometric properties. The study employed appropriate analyses to determine differential attrition and to address hypotheses. The follow-up rates were excellent. Random assignment after baseline data collection helped control confounding variables.
Study Weaknesses Inadequate information was provided on the psychometric properties of the modified version of Consumer Choice that was used to measure perceived consumer choice. Intervention fidelity was not adequately addressed. For example, no explicit match was made between the program's core components and the fidelity measures, and the authors did not clearly state how the fidelity of the supports provided should be assessed as part of the intervention.
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Readiness for Dissemination
Review Date: November 2007
Materials Reviewed
The materials below were reviewed for Readiness for Dissemination. The implementation
point of contact can provide information regarding implementation of the intervention
and the availability of additional, updated, or new materials.
Consumer Chart Review Form
Description of quality assurance protocols
Felton, B. J. (2004). Continued participation review process. [description of Pathways to Housing utilization review process]
Luminosity Pictures, Inc. (n.d.). ACT in action [VHS].
Overview of Housing First training services/Housing First Partnership training faculty
Pathways to Housing: From Streets to Homes [VHS]
Pathways to Housing: Journeys in Recovery [VHS]
Pathways to Housing Manual: A Practitioner's and Program Planner's Guide to Housing First (Draft Version 2)
Program Web site, http://www.pathwaystohousing.org
Service Plan Log Template [spreadsheet for tracking comprehensive service plans]
Siceloff, J. (Executive Producer). (2007). NOW with David Brancaccio: Home at last? A look inside the Housing First program [DVD of television broadcast first aired on February 2, 2007]. New York: JumpStart Productions, LLC, in association with Thirteen/WNET New York. Distributed by Public Broadcasting Service Home Video. Video and transcript available online at http://www.pbs.org/now/shows/305/index.html
Tenant Repair Procedure [statement of policies/procedures for handling apartment repair requests]
Tsemberis, S. (n.d.). Housing First: Ending homelessness for individuals with co-occurring diagnoses.
Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)
External reviewers independently evaluate the intervention's Readiness for Dissemination
using three criteria:
- Availability of implementation materials
- Availability of training and support resources
- Availability of quality assurance procedures
For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.
Implementation
Materials
|
Training and Support
Resources
|
Quality Assurance
Procedures
|
Overall
Rating
|
|
3.3
|
3.3
|
1.5
|
2.7
|
Dissemination Strengths Program materials are comprehensive and user-friendly. Staff roles and responsibilities are nicely explicated. The developer provides on-site training that addresses program philosophies and implementation challenges.
Dissemination Weaknesses The manual appears to be in the draft stage. Further information is needed to guide implementers in accessing affordable, safe housing for the target population. No fidelity measures or program impact indicators are provided to assist implementers in monitoring quality assurance.
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Costs
The cost information below was provided by the developer. Although this cost information
may have been updated by the developer since the time of review, it may not reflect
the current costs or availability of items (including newly developed or discontinued
items). The implementation point of contact can provide current information and
discuss implementation requirements.
|
Item Description
|
Cost
|
Required by Developer
|
|
Program manual
|
Contact the developer
|
Yes
|
|
1-day, on-site training
|
$700-$1,500 per day
|
Contact the developer
|
|
Training video package
|
$75
|
Contact the developer
|
|
Off-site consultation (New York, NY, or Washington, DC)
|
$200-$400 per day
|
Contact the developer
|
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Ongoing technical support
|
$75 per hour
|
No
|
Additional Information The average cost to implement the program is estimated at $24,281 per participant per year (based on market prices in New York City, where the program was first implemented). Overall implementation costs vary by region and in accordance with local housing costs. Training fees may be waived if agencies demonstrate financial need.
|
Replications
Selected citations are presented below. An asterisk indicates that the document
was reviewed for Quality of Research.
Mares, A. S., & Rosenheck, R. A. (2007). HUD/HHS/VA Collaborative Initiative To Help End Chronic Homelessness. National Performance Outcomes Assessment: Preliminary client outcomes report.
Meschede, T. (2006, August). Moving here saved my life: The experience of formerly chronically homeless women and men in Quincy's Housing First Projects [Interim report]. University of Massachusetts, The Center for Social Policy. Available at http://www.mccormack.umb.edu/centers/csp/publications/QuincyHousingFirstInterimReport2006.pdf
Perlman, J., & Parvensky, J. (2006, December 11). Denver Housing First Collaborative. Cost benefit analysis and programs outcomes report. Denver, CO: Colorado Coalition for the Homeless. Available at http://www.shnny.org/documents/FinalDHFCCostStudy.pdf
Stefancic, A., & Tsemberis, S. (2007). Housing First for long-term shelter dwellers with psychiatric disabilities in a suburban county: A four-year study of housing access and retention. Journal of Primary Prevention, 28(3/4), 265-279.
U.S. Department of Housing and Urban Development. (2007, July). The applicability of Housing First models to homeless persons with serious mental illness: Final report. Available at http://www.huduser.org/Publications/pdf/hsgfirst.pdf
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