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Intervention Summary

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Pathways' Housing First Program

Housing First, a program developed by Pathways to Housing, Inc., is designed to end homelessness and support recovery for individuals who are homeless and have severe psychiatric disabilities and co-occurring substance use disorders. Pathways' Housing First model is based on the belief that housing is a basic right and on a theoretical foundation that emphasizes consumer choice, psychiatric rehabilitation, and harm reduction. The program addresses homeless individuals' needs from a consumer perspective, encouraging them to define their own needs and goals, and provides immediate housing (in the form of apartments located in scattered sites) without any prerequisites for psychiatric treatment or sobriety. For consumers with high needs, treatment and support services are typically provided through an Assertive Community Treatment (ACT) team consisting of social workers, nurses, psychiatrists, vocational and substance abuse counselors, peer counselors, and other professionals. These services may include psychiatric and substance use treatment, supported employment, illness management, and recovery services. Consumers who have more moderate needs, are further along in recovery, or participate in smaller programs may receive support through an intensive case management approach, obtaining services both directly from their own program and through referrals to other agencies.

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.

Descriptive Information

Areas of Interest Mental health treatment
Substance abuse treatment
Co-occurring disorders
Outcomes Review Date: November 2007
1: Residential stability
2: Perceived consumer choice in housing and other services
3: Cost of supportive housing and services
4: Use of support services
Outcome Categories Alcohol
Cost
Drugs
Homelessness
Mental health
Treatment/recovery
Ages 18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
Genders Male
Female
Races/Ethnicities Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
Settings Inpatient
Residential
Outpatient
Home
Other community settings
Geographic Locations Urban
Suburban
Implementation History Over 100 sites have implemented Housing First since its inception in 1992. More than 8,000 individuals in 28 States and the District of Columbia have participated in the program, and internationally, more than 2,800 individuals in Australia, Belgium, Canada, Denmark, England, Finland, France, Ireland, the Netherlands, Portugal, Scotland, and Sweden have participated. More than 20 evaluation studies have been conducted.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

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 1

Greenwood, 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.  Pub Med icon

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.  Pub Med icon

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.  Pub Med icon

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.  Pub Med icon

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.  Pub Med icon

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.  Pub Med icon

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.  Pub Med icon

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.
Key Findings 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).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.7 (0.0-4.0 scale)
Outcome 2: Perceived consumer choice in housing and other services
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.
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.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.4 (0.0-4.0 scale)
Outcome 3: Cost of supportive housing and services
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.
Key Findings 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).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.5 (0.0-4.0 scale)
Outcome 4: Use of support services
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.
Key Findings 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.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.3 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
77% Male
23% Female
48% Black or African American
30% White
14% Hispanic or Latino
8% Race/ethnicity unspecified

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:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Residential stability 3.5 4.0 3.0 3.8 3.8 4.0 3.7
2: Perceived consumer choice in housing and other services 1.0 1.0 3.0 3.5 2.0 4.0 2.4
3: Cost of supportive housing and services 3.5 4.0 3.0 3.5 3.5 3.5 3.5
4: Use of support services 3.0 3.5 3.0 3.5 3.5 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.

Readiness for Dissemination
Review Date: January 2014

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.

Forms and tools:

  • ACT Case Review
  • ACT Chart Review Checklist
  • ACT Team Morning Meeting Checklist
  • Assistant Team Leader Task List--Assertive Community Treatment (ACT)
  • Assistant Team Leader Task List--Supported Housing
  • Case Review Checklist--Assertive Community Treatment (ACT)
  • Housing First Agency Training and Consultation Program
  • New Employee Team Site Orientation Check List
  • Pathways Housing First Fidelity Scale (ACT Version)
  • Pathways Housing First Fidelity Scale (ICM Version)
  • Psychiatric Assessment--Supported Housing
  • Routine Apartment Inspection
  • Strengths Assessment
  • Strengths Assessment--6 Month Update
  • Supervision Notes
  • Team Leader Task List

Pathways to Housing, Inc. (n.d.). Clinical services and property management coordination [PowerPoint slides].

Pathways to Housing, Inc. (n.d.). Housing First & harm reduction [PowerPoint slides].

Pathways to Housing, Inc. (n.d.). Housing First 101 [PowerPoint slides].

Pathways' Housing First Training Institute [Information sheet]

Program Web site, http://www.pathwaystohousing.org

Tsemberis, S. (2010). Housing First: The Pathways model to end homelessness for people with mental illness and addiction. Center City, MN: Hazelden.

2-Day Training Agenda

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. 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
3.8 4.0 2.8 3.5

Dissemination Strengths

The manual clearly articulates the philosophy of the program and describes program components and other details that support both the adoption decision and implementation itself. A number of program materials are provided to directly support implementation. The importance of training and consultation to assist new sites with program start-up and implementation, particularly through the first year of operation, is emphasized in both the manual and on the program Web site. Initial training is provided at new implementation sites, and consultation on program start-up and implementation is available both on site and by phone. Implementers have the option to participate in annual peer learning opportunities by attending workshops at other sites successfully delivering the program. Several tools are provided to facilitate quality assurance, and a thorough program fidelity assessment and evaluation are available through the developer for periodic use.

Dissemination Weaknesses

No information is provided on the specific clinical, interpersonal, and problem-solving skills required for staff to implement the intervention effectively. There is no observation tool for supervisors to use in assessing staff skill in delivering the program. No written instruction is provided on using the quality assurance tools or interpreting data in an effort to improve program delivery.

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:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. 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.

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
Housing First: The Pathways Model To End Homelessness for People With Mental Illness and Addiction
  • Manual with supplemental DVD: $189 each
  • Manual without DVD: $49.95 each
Yes
On-site training (includes meetings with community and system stakeholders, agency leadership, and program service providers) Varies depending on site needs No
Program fidelity assessment Varies depending on site needs No
Housing First operating program workshops at sites in DC, NY, PA, and VT Varies depending on site needs No
Virtual training and consultation (e.g., online learning, Webinars, remote training) Varies depending on site needs No
Training video package Varies depending on site needs No
Ongoing technical support (includes on-site consultation, phone consultation, and other ongoing support) Varies depending on site needs No
Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

Greenwood, R. M., Stefancic, A., Tsemberis, S., & Busch-Geertsma, V. (2013). Implementations of Housing First in Europe: Successes and challenges in maintaining model fidelity. American Journal of Psychiatric Rehabilitation, 16(4), 290-312.

Nelson, G., Stefancic, A., Rae, J., Townley, G., Tsemberis, S., Macnaughton, E., et al. (2014). Early implementation evaluation of a multi-site Housing First intervention for homeless people with mental illness: A mixed methods approach. Evaluation and Program Planning, 43, 16-26.

Patterson, M., Moniruzzaman, A., Palepu, A., Zabkiewicz, D., Frankish, C. J., Krausz, M., et al. (2013). Housing First improves subjective quality of life among homeless adults with mental illness: 12-month findings from a randomized controlled trial in Vancouver, British Columbia. Social Psychiatry and Psychiatric Epidemiology, 48(8), 1245-1259.  Pub Med icon

Russolillo, A., Patterson, M., McCandless, L., Moniruzzaman, A., & Somers, J. (2014). Emergency department utilisation among formerly homeless adults with mental disorders after one year of Housing First interventions: A randomised controlled trial. International Journal of Housing Policy, 14(1), 79-97.

Stefancic, A., Henwood, B. F., Melton, H., Shin, S.-M., Lawrence-Gomez, R., & Tsemberis, S. (2013). Implementing Housing First in rural areas: Pathways Vermont. American Journal of Public Health, 103(Suppl. 2), S206-S209.  Pub Med icon

Stergiopoulos, V., O'Campo, P., Gozdzik, A., Jeyaratnam, J., Corneau, S., Sarang, A., et al. (2012). Moving from rhetoric to reality: Adapting Housing First for homeless individuals with mental illness from ethno-racial groups. BMC Health Services Research, 12, 345.  Pub Med icon

Tsai, J., Mares, A. S., & Rosenheck, R. A. (2010). A multi-site comparison of supported housing for chronically homeless adults: "Housing First" versus "residential treatment first." Psychological Services, 7(4), 219-232.  Pub Med icon

Contact Information

To learn more about implementation, contact:
Juliana Walker, LCSW
(212) 289-0000 ext 1180
julianawalker@pathwaystohousing.org

Sam Tsemberis, Ph.D.
(212) 289-0000 ext 1142
stsemberis@pathwaystohousing.org

To learn more about research, contact:
Ana Stefancic, M.A.
(212) 289-0000 ext 1142
stefancic@pathwaystohousing.org

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

Web Site(s):