Preventing Chronic Homelessness: Effective Approaches Emphasize Flexibility

By Francine Williams and Deborah Dennis

This decade is experiencing a renewed national focus on preventing and ending chronic homelessness among people who have mental illnesses and co-occurring substance abuse disorders.  This has led to an increased emphasis on implementing evidence-based and promising practices.  Providing intensive supports to connect people with services that meet their treatment, housing and other support needs has long been known to be a key step toward achieving community tenure and stability.  This is particularly true during critical transition periods, such as when people are moving from shelters, the streets, jails or hospitals to community living.  The Critical Time Intervention (CTI) model is an evidence-based practice that demonstrates this.

Recent studies suggest that adapting evidence-based practice models, Assertive Community Treatment (ACT) in particular, offer promise for people experiencing chronic homelessness by increasing their retention in housing and access to mainstream services.  Such adaptations demonstrate that supports need to be highly flexible in terms of meeting consumer needs and preferences.  Furthermore, much like CTI, services do not have to be provided on a long term basis to have lasting effects.

A case for transitional support

Critical Time Intervention (CTI) was developed at New York City’s Ft. Washington Shelter during the late 1980s in response to the high recurrence of homelessness among those discharged from the shelter’s mental health program.  CTI focuses on transitioning people from institution to community where continuity of care often breaks down in the absence of effective discharge planning.  It emphasizes intensive, short-term (six to nine months) support during critical transitions to help people connect and develop relationships with community providers who can, in turn, offer continuous care.

CTI caseworkers provide mobile outreach and case management, housing placement, direct clinical and other support services, and linkage to mainstream community providers.  This is accomplished by accompanying clients to appointments and helping them develop relationships with providers, increasing the likelihood that they will keep future appointments.  By taking an active role, caseworkers help people build strong relationships with community supports rather than becoming their primary support.

Studies of the effectiveness of CTI in preventing homelessness among people who have serious mental illnesses, including those with co-occurring substance use and chronic health disorders such as HIV/AIDS, have found that CTI significantly reduces new episodes of homelessness.  Moreover, the positive effects of the intervention are sustained over time after CTI services are withdrawn. 

Intensive but flexible

The idea of providing short-term, intensive services to help people make transitions has been successfully used in other best practices approaches as well. Assertive Community Treatment (ACT) uses a multi-disciplinary team approach with low caseloads (about 10:1) to provide intensive supports that meet the clinical, housing and other rehabilitative supports of people who have mental illnesses.  It has proven effective in reducing inpatients hospitalization, promoting continuity of care, and increasing community tenure and stability.

The ACT model has traditionally emphasized the provision of long-term, continuous care, but new evidence suggest that ACT services can be effectively provided for shorter periods of time.  During the Center for Mental Health Services’ Access to Community Care and Effective Services and Supports (ACCESS) program, researchers and clinicians found that many people with serious mental illnesses who are homeless can be discharged or transferred from ACT to other services without losing ground in mental health status, substance abuse recovery, housing or employment.  In ACCESS, 18 communities in nine states were required to serve 100 new individuals with serious mental illnesses who were homeless each year.  In order to continue providing services to new people, clients were transitioned to other services when they and/or their clinician believed they were ready—usually within a year. 

In the ACCESS program, one of the keys to successfully using ACT as a time-limited intervention was a shift in the values that staff held about their work and the people they served.  Faced with wanting to serve new people in need, ACT staff became committed to keeping the front door open by making sure that strong connections were formed between people who were leaving and community providers.  This required a fundamental shift in thinking.  It meant starting early to prepare people for the transition, an emphasis on educating them about how to manage their illness, and developing new or stronger relationships with mainstream providers.

Combining supports with housing

Pathways to Housing in New York City brings together a modified ACT approach with immediate access to housing.  By wrapping supports around people who are homeless and have serious mental illnesses and co-occurring substance use disorders, Pathways is able to place people directly from the streets into permanent independent housing.  In doing so, the program drastically reduces chronic homelessness among the individuals it serves. 

Key to the program’s success is a philosophy that emphasizes housing as a basic right.  To be eligible for Pathways to Housing, people are not required to graduate from a more structured setting, to accept services, or to be abstinent.  Rather, individuals enter the program through outreach conducted by Pathways staff.  The first thing they are offered is a scattered site apartment in one of New York City’s neighborhoods.  Health, mental health, substance abuse, employment and other services are then offered by an ACT team where the type and intensity of services are determined by consumer needs and preferences. 

By combining consumer choice with housing and support services that are intensive enough to help people remain housed and flexible enough to facilitate recovery at one’s own pace, the program represents an effective model for ending homelessness among people with serious mental illnesses and co-occurring substance use disorders.

References

Rosenheck, R., Dennis, D. Assertive community treatment for homeless person with severe mental illness.  Archives of General Psychiatry 58(11): 1073-1080, 2001.

Susser, E., Valencia, E., Conover, S., Felix, A., Tsai, W., Wyatt, R.J.  Preventing recurrent homelessness among mentally ill men: A “critical time” intervention after discharge from a shelter.  American Journal of Public Health 87(2): 256-263, 1997.

Tsemberis, S., Eisenberg, R. Pathways to housing: Supported housing for street-dwelling homeless individuals with psychiatric disabilities.  Psychiatric Services 51(4): 487-493, 2000.