Case studies: How it works on the ground

Information about the Housing First Case Studies

This page includes a description of a few select Housing First (HF) programs. Many programs use various forms of providing housing, clinical and complementary supports. Most do not use a pure form of Assertive Community Treatment (ACT) or Intensive Case Management (ICM), but combine elements of both. Virtually all of them use some level of existing resources, and a few are largely based on coordinating supports that were already available before the implementation of HF.

Most of the activities being undertaken in each of these programs would be considered eligible for funding under the Homelessness Partnering Strategy (HPS). The major exceptions are those programs with fully serviced ACT teams that provide direct clinical supports. The direct provision of clinical supports is not eligible for funding under the HPS and therefore the creation of new ACT teams would be considered an ineligible activity.

The following case studies are meant to showcase a wide range of HF programs across the country:

Toronto, Ontario – Streets to Homes

As the name implies, the aim of Streets to Homes is to link individuals on the street with permanent housing. Originally established in 2005, the program attempts to help clients secure housing as quickly as possible and then provide a range of supports to make the transition from the streets a success. Supports include rent checks, life skills development, links to employment and training, connections with health professionals and social recreational activities among others.

This approach primarily includes Street Outreach Workers who travel the streets to engage with people living outside and offer a range of housing options. Most clients are served through this approach. More recently, a specialized Multi-disciplinary Outreach Team (MDOT) has been called in to work with people experiencing more significant mental health and concurrent disorders. The MDOT team, with the exception of the psychiatrist and concurrent disorders therapist, is funded through HPS funding.

The primary tasks of the MDOT are to accept referrals from street outreach providers in Toronto to:

  • intensively engage the most challenged homeless individuals who have health needs;
  • assess and treat those living on the street with significant illness or disability related to a health, mental health or substance use issue;
  • access appropriate services within the mental health, primary care and addiction sectors;
  • assist in achieving appropriate housing and address barriers to maintaining housing; and
  • connect with a range of appropriate ongoing supports such as case management and follow-up supports.

Everyone housed through the Streets to Homes program is connected to a follow-up worker for at least one year in their new community.

Some major characteristics of this program include:

  • specialized services for youth, Aboriginal people, people leaving incarceration and newcomers;
    • outreach workers who provide the following direct services to their clients: support obtaining ID; access to income supports; accompaniment and referrals to services; support finding an apartment; and
    • negotiating the lease with the landlord; furniture; moving.
  • There is one specialized outreach team for very hard to serve clients—the MDOT, which consists of a senior outreach worker, a registered nurse, a housing support worker, part-time psychiatrists and a part-time concurrent disorders therapist.

Since 2005, outreach workers have helped more than 4 000 people move into housing directly from the street; 80 percent remain in housing at the 12-month mark.

For more information, see Streets to Homes.

Lethbridge, Alberta – The City and Community to "Bring Lethbridge Home"

Housing First in Lethbridge is managed through a partnership of Social Housing in Action (SHIA) and the City of Lethbridge. Together they serve as the community-based organization that works with the provincial Ministry of Human Services to implement strategies set out in the Alberta government's 10-year plan to end homelessness. The Housing First philosophy was officially implemented in 2009. In consultation with SHIA, the role of the City of Lethbridge is to administer and oversee the implementation of the five-year plan to end homelessness, and the service agreements with the Housing First and prevention programs, to monitor their effectiveness and fidelity to Housing First principles.

The SHIA which serves as the community advisory board, is made up of over 100 members of the community, social service and housing agencies, public sector, government and the Aboriginal community. Currently, Lethbridge funds an integrated model, including five Housing First teams and prevention and community integration services. Utilizing centralized and coordinated intake, triage and referral, Housing First teams have different mandates based on the needs of the population served to improve client-focused outcomes, reduce duplication and focus on the sustainability of permanent housing. These include various housing options, including market housing, permanent supportive housing, eviction prevention and diversion initiatives. The various populations would include First Nations people transitioning from reserve to urban life, chronically homeless multi-barriered adults, multi-barriered youth ages 18 to 24 that are homeless or at risk of homelessness during transition to adulthood, youth under 18, new to shelter, eviction prevention clients and homeless individuals being discharged from hospital and corrections.

Other programs funded to support the Housing First work include permanent supportive housing facilities for the aging and for chronic homeless people, programs to provide meaningful daily activity, employment and job training opportunities. Housing First teams and participants are further supported through a Housing First furniture bank. The Clinical Intervention and Support program provides additional clinical support and consultation services to the Housing First teams and service participants. This team consists of professionals in the fields of psychiatric nursing, addiction, police liaison and social work.

The funding of these programs comes from federal, provincial, municipal and service funders.

Results collected from the beginning of the program in 2009 show that over 864 households have been permanently housed, and this year more than 90 percent remain housed through Housing First.

In 2011–12:

  • Overall, there was a 25 percent reduction in shelter occupancy and over 70 percent fewer people are living rough.

General characteristics of the program include:

  • A centralized intake, assessment and triage to determine eligibility and referral of clients to the appropriate Housing First team and or appropriate community service.
  • The Service Prioritization Decision Assistance Tool is utilized to determine the needs of the service participant and a warm transfer is used to connect the individuals to the appropriate team.
  • An Intensive Case Management team for each Housing First program consisting of an outreach worker to access housing, stabilize income and commence securing support services and a Follow-up Support Worker (FSW) to provide the long-term support required to sustain permanent housing.
  • The FSW provides the following:
    • up to three months assisting clients with stabilizing their housing, orienting them to their surroundings and neighbourhood and supporting them in the activities of daily living and their tenancy requirements, such as payment of rent and utilities;
    • working with the client to create an individual service plan, identifying barriers and discussing ways the worker can support the participant in addressing those barriers; and
    • assisting the client to access other community supports and services, as well as learn the skills necessary to maintain permanent housing.

The priority of the Lethbridge Housing First Initiative is the chronically homeless. The Housing First Specialist consults and provides feedback regarding fidelity to Housing First, as well as gives direction on best practices and appropriate case management and training. A critical component of the service delivery for Housing First is a weekly complex case consultation facilitated by the Housing First Specialist. This meeting brings multiple community partners and professionals together to prioritize, consult and review individual cases from the Housing First teams. Partners at that table include representative from Alberta Works, Assured Income for the Severely Handicapped, Addiction and Mental Health, Lethbridge Emergency Shelter, Downtown Policing Unit, Lethbridge Housing Authority and other community support agencies as required.

Extensive collaboration with the broader community also occurs, including:

  • Direct contacts with Lethbridge Police Services, which promotes de-escalation of potential conflict with Housing First clients.
  • Direct links to income support programs that make it easier for clients to access needed supports.
  • Partnerships with landlords and the provision of training by the City on landlord relations for all Housing First agencies.

For more information, see Bringing Lethbridge Home.

Hamilton, Ontario – Transitions to Home (T2H)

This Housing First program, which started in 2009, is administered by Wesley Urban Street Ministries. It supports individuals experiencing long-term shelter use and homelessness in acquiring and maintaining safe and affordable, long-term housing in the community. It grew out of the success of a 2007–2009 pilot program—Hostels to Homes—that helped 80 individuals find and sustain safe, affordable housing and that maintained housing retention rates over 80 percent one year after discharge.

Transitions to Home is a program that is based on extensive community collaboration—including that of emergency shelters. This collaboration has been formalized in the Hamilton Emergency Shelter Services Integration and Coordination Committee (HESICC). HESICC is a partnership of the City of Hamilton, Good Shepherd Centres, Hamilton Housing Help Centre, Mission Services, the Salvation Army and Wesley Urban Ministries. Importantly, the primary impetus for Transitions to Home was the community's proactive commitment to ensure that people accessing the shelter move from the emergency system to more sustainable and permanent forms of housing.

T2H is primarily funded through the Homelessness Partnering Strategy as a Community Entity sub-project. It also receives some funding from the Ontario Ministry of Municipal Affairs and Housing under the Community Homelessness Prevention Initiative that the City of Hamilton administers.

The most recent data collected (from January 1, 2012, to December 31, 2012, inclusive) showed that of the approximately 250 clients that the program works with:

  • 74 percent of clients remained housed after 6 months

Of those clients:

  • 90 percent remained housed after 12 months

In terms of supports received, approximately 170 clients receive weekly Intensive Case Management while another 75 receive "maintenance care" having developed a successful tenancy and deciding they no longer need the weekly support. These individuals receive a visit every three months for a one-year period, at which time they receive yearly contact. The program is flexible and clients can reactivate support at any time.

Transitions to Home uses a mobile Intensive Case Management–PLUS approach. A mobile Intensive Case Management team is used to provide direct supports to assist:

  • long-term shelter users to leave the shelter system and create a successful tenancy in an affordable private apartment; and
  • vulnerable people living on the street to leave the streets by finding an affordable apartment and creating a successful tenancy.

The PLUS component consists of a team of non-clinical case managers that provide access to:

  • trauma informed therapy;
  • addictions counseling; and
  • therapeutic recreation.

Case managers work with nursing and other clinical staff to provide these PLUS supports. Clinical supports are funded by the Community Homelessness Prevention Initiative of the Government of Ontario.

Case managers also seek to directly connect program participants to primary health care services through the accessible, drop-in based primary health care services of the Shelter Health Integration network.

Transitions to Home also operates community-wide recreation programs for the homeless community as a means to facilitate a connection to the program and provide healthy recreation time. The Hamilton Homeless Baseball league, Bowling League and other events are provided with the help of program participants in the administration and planning.

For more information, see Wesley Urban Ministries.

Edmonton, Alberta – Homeward Trust

Originally established in 1999, Homeward Trust is a community-based organization that coordinates responses to housing needs by working with local agencies and all orders of government. It administratively oversees the Housing First Support Program that is delivered by various agencies in Edmonton, in addition to other support programs such as permanent supportive housing. In the Housing First Support Program, agencies deliver case management and clinical services using the Assertive Community Treatment (ACT) team and Intensive Case Management (ICM) service delivery models. Housing supports are provided or coordinated by Homeward Trust.

Funding available for all programs administered by Homeward Trust comes from all three levels of government, the private and not-for-profit sectors.

Since 2009, more than 2 500 people have found housing through the Housing First Support Program; more than 80 percent successfully remain in housing. Clients are living in more than 800 supported units across Edmonton and the Capital Region.

Assertive Community Treatment

Assertive Community Treatment (ACT) teams funded by the province serve individual clients who require the most intensive services to stay housed. Housing and clinical supports are included on one team. Clinicians and non-professionals act as one team and have the same status. All resources that Homeward Trust provides for the ACT team are funded by the Government of Alberta.

Members of the ACT teams are as follows:

  • team lead – clinical expert;
  • occupational therapist;
  • access to physicians;
  • access to psychiatrist; and
  • nurses on staff.

Intensive Case Management

Intensive Case Management (ICM) serves clients who require less intensive services to stay housed. The structure of the ICM is made up of the following workers who have a case load of 15 to 17 persons each:

  • team lead to coordinate services;
  • housing worker to provide home search and move-in services; and
  • follow-up support workers who help the client maintain housing.

The support worker takes over from the housing worker once housing is found and move in is completed. The support worker is therefore the main case worker with whom the client works under ICM. The support worker aims to transition the client to self-sufficiency within 12 months.

ICM teams—and mostly the support worker—broker access to clinicians via the community-based Clinical Access Team (CAT). Note that the CAT does not have a caseload; its sole task is to serve the ICM team.

Clinical Access Team

The Clinical Access Team (CAT):

  • provides access to clinicians and permanent supportive housing; and
  • makes assessments re: graduation of clients.

Role of Homeward Trust

To support agencies in their ACT and ICM work, Homeward Trust provides the following:

  • Housing First Worker Training: Workers regularly attend workshops and training sessions, where they learn best practices and refine required skills.
  • Rental Assistance: With support from the Government of Alberta, Human Services, clients receive partial funding towards their rent.
  • Furniture: Through the social enterprise, Find, clients in the Housing First Support Program receive essential household items including furniture and small household items before moving into their home.
  • Efforts to Outcomes: This case management and data collection system tracks client progress and information, enabling Homeward Trust and its partners to better meet the needs of clients in the Housing First Support Program.
  • Performance Monitoring: Ensuring that Housing First teams are meeting targets such as case load, efforts and graduation of clients, and working with teams to address challenges that exist to meeting those targets.

Homeward Trust also provides the following related services:

  • funds and oversees the construction of new housing units;
  • accesses market housing units for clients by working with landlords and property management companies to secure rental units;
  • works with proponents building new housing developments to be able to attract and provide additional investment from partners;
  • monitors properties for 10 to 20 years to ensure developments meet their intended need—serving clients in the best way possible—and to ensure that funds are being used appropriately; and when required
  • operates and manages properties in need of improvement and support; and
  • coordinates the development of a community plan, and supports research and awareness initiatives.

For more information, see Homeward Trust Edmonton.

Pathways Vermont, USA

This HF program is based on the Pathways to Housing model in New York City, adapted for a rural and remote setting. It uses a virtual, modified ACT team approach to provide case management and clinical supports, and also to provide and link up with housing supports. A virtual approach means that interaction with the client and between ACT team members occurs via a combination of in-person and virtual meetings—for example, using Google hang-outs (similar to Skype). Clients are also able to contact ACT team members and access resources using the iCloud network. ACT team members also use iCloud to share real-time client file information, including recent assessments undertaken.

Pathways Vermont is a non-profit organization operating throughout the state of Vermont. It began providing its services in January 2010 with funding from the federal Substance Abuse and Mental Health Services Administration as well as from the state government to help realize the Pathways Vermont goal of creating a statewide system of Housing First services. State funding comes from the Vermont State Department of Corrections and Department of Mental Health.

The Pathways model has been remarkably successful in addressing chronic homelessness. The program maintains an 85 percent housing retention rate even amongst those individuals not considered "housing ready" by other programs (source: Pathways to Housing Model).

The modified ACT team members are dispersed throughout the state and are composed as follows:

One statewide team that oversees intake of clients and coordinates ACT delivered services per client. Members of that team include:

  • medical director;
  • project manager;
  • intake coordinator; and
  • administrative staff.

Six Pathways to Housing offices throughout the state that include:

  • one to three service coordinators; and
  • 20 to 70 clients for each office.

Two regional teams, each of which serves clients in three Pathways offices. Members include:

  • supportive employment specialist;
  • computer literacy specialist;
  • substance abuse specialist;
  • Peer specialist;
  • nurse; and
  • psychiatry/nurse practitioner.

Two Red Clover Properties offices, one of which serves four Pathways to Housing Offices and the other which serves two Pathways offices. A total of 182 tenants are served. Members include one to three housing specialists respectively.

For more information, see Pathways Vermont.

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