•  

Intervention Summary

Back to Results Start New Search

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. Treatment and support services are 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. While ACT is the preferred support for persons with severe mental illness, less intensive modalities can be used. Consumers who are recovering or who 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 At least 27 sites have implemented the Housing First program since its inception in 1992. An estimated 4,000 individuals in the United States and 2,800 in Canada, England, and the Netherlands have participated in the program. Eight evaluation studies have been conducted.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
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: 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
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
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.  Pub Med icon

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

Contact Information

To learn more about implementation, contact:
Ana Stefancic, M.A.
(212) 289-0000 ext 1112
stefancic@pathwaystohousing.org

To learn more about research, contact:
Sam Tsemberis, Ph.D.
(212) 289-0000 ext 1101
stsemberis@pathwaystohousing.org

Ana Stefancic, M.A.
(212) 289-0000 ext 1112
stefancic@pathwaystohousing.org

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

Web Site(s):