Back to Basics – What Exactly is Housing First & Rapid Re-Housing?

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A lot of the time I find “Housing First” and “Rapid Re-Housing” to be misused terms. When asked to assist organizations or communities realign their service delivery to be more effective or to evaluate their housing programs, this is the understanding of Housing First and Rapid Re-Housing that I try to generate awareness of in the community. As this is a blog and not a two or three day training seminar, I am focusing on hitting the high points.

As a philosophy, housing first focuses on any attempt to help people who have experienced homelessness to access housing before providing assistance and support with any other life issues. In this orientation, the intervention of Housing First and Rapid Re-Housing both fit. Given housing is the only known cure to homelessness, the success comes with helping ideal candidates achieve the cure sooner rather than later.

As an intervention, HOUSING FIRST is a specific type of service delivery. Delivered through Intensive Case Management or Assertive Community Treatment, fidelity to the core aspects of the service can be measured. Housing First is specifically not a “first come, first served” intervention. Housing First intentionally seeks out chronically homeless individuals that have complex, and co-occurring issues, and serves those with the highest acuity first. The individual (family) served through Housing First is homeless and has most often been homeless for quite some time, usually as a result of these issues and the failure of the human and health service delivery spectrum to address these issues in order to solve the person’s homelessness.

Participation in Housing First is voluntary – people cannot be forced or coerced to participate in a Housing First intervention. 
Individuals who consent to receive a Housing First intervention are provided assistance with accessing housing of their choosing (subject to affordability, action-ability and appropriateness) and supports for at least 12-18 months in an ICM approach (subject to the ability to integrate clients with longer-term community supports) and longer in an ACT approach.

There is no expectation of sobriety, treatment, compliance or mandated service pathways. Service participants do not need to participate in psychiatric services if they do not want to; they do not need to participate in things like anger management classes if they don’t want to; they do not need to attend life skills classes if they do not want to; they do not need to attend parenting classes if they do not want to; they do not need to address their physical health issues if they do not want to – and I could go on. 
The only real expectations of Housing First, which the individual agrees to prior to starting with the program, is to agree to have their support workers visit them in their home – usually multiple times per week in the early days of program participation, to pay their rent on time and in full (or agree to third party payment of their rent), and to work hard to avoid disrupting the reasonable enjoyment of other tenants in the same building that would cause their eviction.

There are many “tricks of the trade” that help folks in achieving residential stability in Housing First. For one, caseloads are kept at a reasonable size, with an emphasis on Housing First as a quality intervention, not a quantity intervention. In ICM service delivery, one case manager works with 15-20 clients depending on where the clients are at in their journey to stability and level of complexity. Another “trick of the trade” is working with the client to develop a personal guest policy, where the client themselves determine when they think it is a good idea to have guests over, how many guests they think it is reasonable to have over at any one time, the types of activities they think are appropriate to engage in within their apartment, and what they think is appropriate should they find their actions in conflict with their guest policy. Yet another “trick of the trade” is to infuse the “responsible tenant” discussion into conversation with the client at least three times in the early stages of the program whereby the client themselves articulates what they think it means to be a responsible tenant.

Services in HOUSING FIRST are offered through a harm reduction philosophy, in a non-judgmental manner and from a client-centered position. Supports are provided in vivo, and there is an expectation that individuals served through the intervention will access a broader range of community resources, have meaningful daily activities, and work towards greater independence and improved life satisfaction. The support worker in Housing First can expect to model and teach skills and behavior in the client’s apartment and in the community. It is not uncommon for the support worker to have one-on-one time with the client to teach things like cooking, cleaning, laundry, grocery shopping, and the like. It is not uncommon for the support worker to accompany the client to appointments in the community like working with welfare, shopping, doctor appointments, etc.

There is intentional case planning that occurs in Housing First. The first focus of the case planning is on housing stability…primarily paying attention to meeting basic needs, understanding how relationships can impact tenancy, ensuring that the individual feels safe in their apartment, and understanding the supports available to help them maintain housing. Momentum gained in these areas translates into the development of an Individualized Service Plan where specific goals are identified and an action plan is put in place for each of them. Through this service plan, the emphasis is on greater life stability overall.

Housing First is not a “first come, first served” approach to service delivery. Regardless of whether the Housing First supports are provided through Intensive Case Management or Assertive Community Treatment, access should be coordinated on a system-wide basis. With Housing First, supports are de-linked from staying housed, and as such if an individual loses their housing they do not lose their supports and will be re-housed as many times as necessary until the person achieves housing stability. There are no limits on the number of times that a person can be re-housed. Re-housing is not seen as a failure. It is seen as an opportunity to learn, adapt, grow and try again.

Service participants supported through Housing First often have a history of considerable interaction with health, mental health, addiction, police, criminal justice, ambulances – and other types of emergency services and institutions. Through the housing and support work, most often one will see a decrease in this degree of interaction with emergency services, and a more deliberate and strategic engagement with more appropriate services. It is still possible that Housing First program participants end up in hospital or accessing treatment services, but the supports remain active during these periods of time, with assistance provided in discharge planning as much as possible, and active support in the implementation of treatment protocols as much as possible.

Housing First relies on a number of proven practices and evidence-informed service delivery. Examples of the types of professional skills a Housing First practitioner is likely going to have mastery of include: Motivational Interviewing; Assertive Engagement; Wellness Recovery Action Plans; Illness Management Recovery; Integrated Dual Disorder Treatment; Trauma Informed Service Delivery; Harm Reduction Practices; Crisis Planning; Supported Employment; etc.

While Housing First is most frequently delivered through scattered site housing units integrated within “regular” apartment buildings throughout a city, it is possible to have congregate Permanent Supportive Housing that practices Housing First. But, there really is no such thing as “Housing First Housing”. When I hear that, and break it down with people, most often what they really are trying to say is a low-barrier congregate PSH environment that practices all the aspects of a Housing First intervention.

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The place a participant lives in Housing First must be permanent housing, where “permanent” means that if they follow the lease, pay rent and don’t disrupt the reasonable enjoyment of others they have the same security of tenure as any other renter. The lease is “standard” – meaning it contains no language or stipulations different than any other renter. This does not preclude the use of Master Leasing or Head Leasing where an organization leases the apartment unit and legally sub-leases to a program participant, with an understanding that there can be no impediments to the program participant taking on the lease in full in the future.

When asked to set up an evaluation framework for Housing First, it is my contention that 80% or more of the individuals served should remain housed long term. I also tend to look at reductions in use of emergency services and engagement with the criminal justice system. Then, I focus my attention on how the acuity of the individual decreases overtime, as well as changes in quality of life as a result of the intervention.

Rapid Re-Housing is a support intervention intended to serve longer-term episodically homeless people with mid-range acuity; these clients typically have co-occurring issues that are at the core of their frequent returns to homelessness and/or long-standing patterns of precarious housing. The individual or family is homeless and usually has two or three life areas where assistance in accessing community-based resources should improve their life and housing stability on a go-forward basis. Usually recipients of Rapid Re-Housing are aware of a range of community supports; they simply have not been meaningfully and sustainably connected with those resources.

One of the first mistakes in how people talk about Rapid Re-Housing is that they refer to it as “Housing First Light”. It is not. It is a different type of intervention that happens to have a lot of similarities to Housing First. Secondly, some organizations and communities erroneously lump any program that assists with rapid access to housing as being Rapid Re-Housing. This, as well, is false. There can be some awesome approaches to helping people access housing quickly, which are not Rapid Re-Housing.

With mid-range acuity at time of program entry, Rapid Re-Housing recipients usually receive supports for a minimum of six months, with possibility of renewal of service in three month increments based upon traction in sustainably meeting needs that will enhance housing and life stability (and should there be persistent barriers to improved stability, the client may be more accurately considered a Housing First client).

The supports delivered in Rapid Re-Housing are typically case management supports, but are neither Intensive Case Management nor Assertive Community Treatment – though there are typically time periods of support that are more intensive than others. Supports are delivered in community. There is an expectation that the individual (family) will be supported in accessing community resources, have meaningful daily activities, and work towards greater independence and improved life satisfaction. There will be teaching and modeling in Rapid Re-Housing, like Housing First, but the intensity of this and the duration of it is quite often (though not always) less than what one would experience in Housing First.

Importantly, Rapid Re-Housing is more than a financial assistance program; it comes with the expectation that the client will engage with support services. However, the support services have no expectation of engagement in treatment, compliance or mandated service pathways. Like Housing First, Rapid Re-Housing is offered through a harm reduction philosophy, in a non-judgmental fashion and from a client-centered position.

Rapid Re-Housing is almost exclusively delivered through scattered site apartments. Participants sign a standard tenancy agreement. Nowhere in the lease does it stipulate that an individual has to participate in programming or will be evicted. For all intents and purposes, the housing is permanent. So long as the individual follows the lease and pays their rent they have the same security of tenure as any other renter.

Rapid Re-Housing also features structured case planning with goal identification and an action plan put into place to assist with reaching these goals. Compared to Housing First, Rapid Re-Housing clients are usually more able to engage in the process of goal identification and attainment quicker given their acuity is not as high and their time spent homeless has not been chronic.

It is best if people gain access to Rapid Re-Housing through a coordinated access function within a community. This will ensure the best fit of mid-range acuity clients to the appropriate intervention. It should weed out those clients that would be better served through a more intensive and longer-term intervention like Housing First. It should also week out those individuals and families that ultimately can resolve their own homelessness without case management supports of any kind (which make up the majority of people in any community).

When I set up evaluation frameworks for Rapid Re-Housing, I tend to look for a housing stability rate in the 90% range. Like Housing First, I also want to focus some attention on decreasing acuity over time and improved quality of life as a result of the intervention.

There are certain things that Housing First and Rapid Re-Housing both are not. First of all, Housing First is NOT “housing only”. I would posit that in most instances getting people housed is relatively easy compared to the hard work of supporting them to stay housed. 
Neither Housing First nor Rapid Re-Housing are a fad. They each are proven to be successful when practiced in a certain manner with a specific client group. 
There is no such thing as a “sober” or “dry” Housing First or Rapid Re-Housing program. Participants may choose to abstain, but abstinence cannot be a pre-requisite for program participation. 
There is no such thing as a transitional housing program that is Housing First or Rapid Re-Housing because one of the core elements of both interventions is that the housing that people secure is permanent. 
Neither Housing First nor Rapid Re-Housing are the only forms of effective housing interventions. There are plenty of good approaches to helping homeless individuals and families access housing that I have seen in my travels that seem to demonstrate positive outputs. Organizations and communities should feel compelled to call these programs something that they are not. 
Neither Housing First nor Rapid Re-Housing “fix” or “heal” people. The job in Housing First and Rapid Re-Housing is to support the individual access and maintain housing regardless of their history or life issues. Both acknowledge that people may still have active addictions, compromised mental wellness, difficulties budgeting, issues with impulse control, problematic social behaviors, physical ailments, etc. – yet people with these or any other life issues can have the issues and have a life without any future homelessness.

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