2005 APA Gold Award: Providing Housing First and Recovery Services for Homeless Adults With Severe Mental Illness

Pathways to Housing, Inc., pioneered the Housing First program that is changing systems of care for individuals in recovery from homelessness, serious mental illness, and substance use disorders. As a nationally recognized model, Pathways provides immediate, independent permanent housing along with client-driven treatment and support for clients' recovery and for their community integration.

The Pathways to Housing program values consumer choice and is based on the belief that housing is a basic right. Pathways seeks out the most vulnerable segment of the homeless population, persons who have lived on the streets or institutions for a long time and who have psychiatric disabilities, co-occurring addiction disorders, and other health and hardship challenges. Pathways provides immediate access to permanent, scatter-site housing and extensive ongoing treatment and support services through multidisciplinary assertive community treatment teams. Through client choice and intensive support by their assertive community treatment teams, clients end homelessness, achieve successful outcomes in their own homes, stabilize their illness, and establish their own community connections.

Most programs designed to serve this population focus first on providing psychiatric and substance abuse treatment. Clients in these programs typically move through a continuum of transitional housing placements until they demonstrate they are "ready" for permanent housing by maintaining a period of sobriety and complying with psychiatric treatment and other program rules. Clients who have difficulty in complying with admission criteria or program rules have remained homeless because program requirements effectively restrict their access to housing.

Pathways' Housing First model separates treatment from housing. Program founders decided not to require treatment participation or sobriety as a precondition to housing. The founding principles of the Housing First program remain its guiding beliefs: consumers can make competent choices, housing is a fundamental human right, and recovery from mental illness is possible. Consumer choice lies at the center of every program intervention, beginning with housing and continuing with services that may include psychiatric and substance abuse treatment, supported employment, or other recovery-focused supports.

In recognition of its innovative Housing First program for homeless persons with severe mental illness and substance use disorders, Pathways to Housing, Inc., was selected as winner of the 2005 Gold Achievement Award in the category of community-based programs. The winner in the category of academically or institutionally sponsored programs is described on page 1306. The awards will be presented on October 5 during the opening session of the Institute on Psychiatric Services in San Diego. Each Gold Award winner will receive a plaque and a $10,000 prize made possible by a grant from Pfizer, Inc.

Innovations

All of Pathways' clients are homeless and have severe mental illness, and three-quarters of them have a co-occurring substance use disorder. The Pathways program incorporates several innovative features to treat this population. First, the program allows clients to set the sequence of services (virtually all clients choose housing first). Second, because housing is considered a basic right, the program separates housing from treatment. That is, the program offers clients housing as an immediate and practical solution to their homelessness, not as a reward or incentive for participation in treatment. The program uses assertive community treatment teams to address problems associated with mental illness, addiction, and unemployment. Consistent with its client choice philosophy, the team uses a harm-reduction approach for clients with dual diagnoses. If clients are symptomatic or actively addicted they are provided with support or treatment. Third, Pathways' clinical staff practice with a recovery focus. They will seek out the most difficult to reach clients—those who have failed in other programs, shelters, hospital, and jails—and base their approach on the belief that trust and relationship building are key to client success. The team puts the decision-making authority in the hands of clients, providing clients the opportunity to gain control over their lives and to determine their own path of healing and recovery. The team's commitment is long term, and housing is permanent.

Growth

In 1993 Pathways to Housing employed five staff members and served 50 clients. As a testament to the program's effectiveness, 12 years later, there are 95 full-time staff members on seven assertive community treatment teams in New York, and two in Washington, D.C., with more than 550 clients housed in their own apartments. Pathways continues to expand the services of its assertive community treatment teams in New York and Washington, D.C. In the past two years, the Pathways model has been replicated in 11 other cities.

Collaboration

The team

Pathways uses assertive community treatment teams that meet fidelity standards set by this evidence-based practice. Teams comprise social workers, psychiatrists, nurses, supported employment specialists, peer counselors, substance abuse counselors, and an administrative assistant. Each team consists of eight staff members who provide clinical and support services to 70 clients. The clinical staffing ratio is 1:10 and the psychiatrists' ratio is 1:100. Pathways currently employs six psychiatrists and one psychiatric nurse practitioner. Teams spend 80 percent of their time in the field, seeing clients an average of six times per month. Each team provides individually tailored services, including psychiatric and medical treatment, individual and group counseling, housing placement, supported employment, self-help groups, assistance with maintaining housing and with budgeting and managing funds, assistance with obtaining entitlements and benefits, and opportunities for artistic and social expression through art, photography, and writing classes and through recreation events.

Psychiatrists

The role of the psychiatrist is critical to the function of the assertive community treatment teams. The psychiatrist facilitates the clients' capacity to address their own treatment needs, provides psychiatric treatment, prevents hospital admission, and coordinates discharge from hospitals and other institutions. As a team member, the psychiatrist provides evaluations of clients, medication management, crisis intervention, and referrals for medical treatment and participates in the formulation and review of all service plans. The psychiatrist also provides ongoing training and consultation to team members.

Clients

Meeting clients' priorities drives the Pathways program; in fact, this client-driven focus is the main reason for its success. Clients are involved in the planning, implementation, and monitoring of all Pathways programs. It is one of the few programs in which clients have direct access to the executive director, who knows many clients by name. Clients are employed by most of the agency's departments, including the assertive community treatment teams; they serve on advisory committees and on the board of directors. Each team also has a client advocate, elected by his or her peers, who is paid to represent other clients and client-related issues to the team and to the agency's advisory council that reports to the board of directors. The voice and the power of the clients are heard and honored on every level.

Obstacles overcome

Allowing clients to make their own decisions and lead the treatment process is a new experience for most clinicians, especially for those in public health settings. (Pathways' clinicians intervene without client consent only in rare instances when the client presents danger to self or others).

Consistent with client-driven treatment, the teams apply principles of harm-reduction, helping to minimize adverse consequences of substance use if clients choose to continue using substances or to minimize the adverse consequences resulting from psychiatric symptoms if clients choose not to take medication. When traditionally trained psychiatrists and clinicians, unaccustomed to this stance, join the Pathways team, they receive training in harm-reduction practice and in techniques such as motivational interviewing. A team approach is extremely useful when applying a harm-reduction approach. Team members can support each other when confronted with difficult situations and can continue to allow clients to direct their treatment even when there is a risk of failure. When these difficult situations are confronted in this manner, successful outcomes build clients' confidence in managing their crisis and reinforces the continued use of client-directed interventions by the team.

Because many clients have a significant history of institutionalization, team members may initially be met with distrust. Enormous flexibility is exercised to build trust, as team members follow each client's lead on which intervention he or she is willing to accept, arranging and rearranging services that best fit the client's choice and working with those who refuse medication or other treatment.

Funding

The Pathways program has been found to cost no more than conventional treatment programs. A recent cost analysis in New York City found that a homeless person with mental illness living on the street costs approximately $41,000 each year. A bed in a New York City shelter costs between $27,000 and $35,000 per year. However, the Pathways program costs $22,000 per client per year for both housing and treatment. Most of the agency's funding is from government funding. In most cases clients receive Supplemental Security Income, and Pathways' clients pay 30 percent of their income toward their rent.

In addition to funding from government benefits programs, Pathways receives funds from the New York State Office of Mental Health, the U.S. Department of Housing and Urban Development, Medicaid, the Westchester County Department of Social Services, the New York City Department of Mental Health, foundation grants, and individual contributions.

Demonstrated effectiveness

Although all Pathways assertive community treatment teams meet the fidelity standards for assertive community treatment, what distinguishes them and accounts for their unprecedented success is their philosophy. Indeed, Pathways' clients have achieved results that were considered unattainable: clients living on the streets for years and deemed "not housing ready" are now living comfortably in apartments of their own; clients deemed "treatment resistant" are now choosing to take medication and actively participating in their own recovery; clients who were severely addicted are now choosing to stay clean and sober, and others who had long ago lost hope are now working toward personal goals that they had previously imagined were impossible. Pathways has been able to successfully engage into housing and treatment individuals who have remained outside the system and to maintain people in the community in their own housing. Within the team approach, the program came up with multiple, supportive approaches that encourage recovery and avert hospitalization.

Pathways' Housing First program has achieved an unprecedented 85 percent housing entry and retention for clients who could be not be served in traditional housing programs. In addition to achieving housing stability, Pathways' clients voluntarily seek treatment for psychiatric symptoms and addiction and achieve the same level of stability as clients in programs that require treatment and sobriety as a precondition for housing.

Several recent studies demonstrate the effectiveness of this program. First, the Pathways program in Brooklyn is composed of clients who have a longer history of institutionalization than in other Pathways programs. To study the effectiveness of the program, Alexa Whoriskey, M.D., and colleagues examined data for 57 clients who entered Pathways between July 2002 and February 2005. Clients averaged a total of 327 days for the hospitalization just before admission to Pathways. Two years after being referred to Pathways, the clients' average length of hospitalization was reduced to 27 days, a 92 percent reduction. These averages include 20 clients who have not returned to the hospital at all during their time with Pathways; among the 20 are seven clients who spent more than a year in the hospital before to coming to Pathways.

Other evidence for Pathways' effectiveness can be seen in a federally funded longitudinal study by Sam Tsemberis, Ph.D., the founder of Pathways, and his colleagues, published in the American Journal of Public Health in 2004. A total of 225 homeless persons with severe mental illness were randomly assigned to two groups and followed for 24 months: 126 were assigned to the control group that followed the continuum of care model, and 99 were assigned to the group that followed the Housing First model. Although a diagnosis or history of substance use disorder was not an eligibility criterion, 90 percent of the participants had such a disorder. Participants in the Housing First program were able to obtain and maintain an 80 percent housing rate, compared with 34 percent for the participants in the control group.

A third study, published in Psychiatric Services in 2000, examined the housing retention rates for 1,842 homeless individuals with psychiatric disabilities housed in New York City between 1993 and 1997. The housing retention for the 242 Pathways clients was 88 percent, compared with 47 percent among those who entered other New York City programs.

Model system

In 2003 the United States Interagency Council on Homelessness allocated $35 million in funding for Housing First programs to address chronic homelessness. Every one of the 101 applicants for these funds referenced Pathways to Housing. Programs from all over the country continue to request information and training from Pathways, recognizing this model as an effective way to respond to the national call to end long-term homelessness. In response, Pathways has created a training faculty to support replications under way across the country. Pathways staff are currently providing technical assistance to eight of the 11 replications that have sprung up throughout the country. Preliminary results over 12 months indicate that these replication programs are as effective as the original Pathways to Housing program. In addition, in 2003 the New York State Office of Mental Health selected Pathways to operate the New York State ACT Institute and provide training in the assertive community treatment model to the states' more than 70 teams.

Pathways' Housing First model is a unique and effective treatment for individuals who are not engaged in treatment, who have remained chronically homeless, and who have been traditionally seen as noncompliant, treatment resistant, and not ready for housing. The belief that recovery from mental illness is possible, that consumers can make competent choices, and that housing is a fundamental human right are the core values of Pathways' program model.

For more information, contact Sam Tsemberis, Ph.D., 55 West 125th Street, 10th Floor, New York, New York 10027; e-mail [email protected] or visit www. pathwaystohousing.org.