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Substance Abuse and Mental Health Services Administration
"Ask the Expert" Welcomes Deborah De Santis
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“Ask the Expert” features an interview with a leading expert on homelessness or co-occurring mental and substance use disorders. The following is an interview with Deborah De Santis, president and CEO of the Corporation for Supportive Housing (CSH).
We are pleased to welcome Deborah De Santis who joined CSH in 2003 as director of its New Jersey program. CSH is the only national intermediary organization dedicated to supportive housing developments. CSH helps communities create permanent affordable housing with services that prevent and end homelessness. While acting as director of CSH’s New Jersey program, Ms. De Santis tripled the state program’s lending portfolio, successfully advocated for the creation of New Jersey’s $200 million Special Needs Housing Trust Fund, and helped launch a statewide grassroots organization to advance the development of 100,000 units of affordable housing over 10 years, including 10,000 units of supportive housing. Under her leadership as president, CSH created the Consulting Group, a flexible and mobile group of experts who travel the country assisting communities with supportive housing development. During her tenure, CSH surpassed the halfway mark in its goal to create 150,000 new units of supportive housing throughout the United States. Ms. De Santis’ has guided the development of initiatives that bring the benefits of supportive housing to many more people at risk of chronic homelessness including veterans, those reentering society from hospitals and correctional facilities, youth, and the elderly.

Question: What is the Housing First model, how did it come to be, and does it mean no services, no treatment?

Answer: The Housing First model is a specific approach to providing permanent supportive housing where homeless individuals or families are given housing and services without first requiring them to stabilize their mental health illness, complete treatment, or demonstrate evidence of sobriety.

The model arose as an alternative to approaches in which homeless people were turned down from permanent supportive housing—and thus left to remain homeless—because they had not successfully completed mental health or substance use treatment. That model, sometimes referred to as the ‘housing readiness’ approach would, before accepting an individual or family into housing, identify the “problems” that individual or family had, attempt to fix the problem (or refer them to another program to fix the problem), and only once deemed ”housing ready” was the client placed into housing. Housing First reorients this model by recognizing that without housing, it’s hard to address other things in your life.

In no way does Housing First mean that tenants are not provided with services or even offered treatment. In fact, our experience with providers shows that many successful Housing First supportive housing models are even more service intensive than their ”housing readiness” counterparts. In Housing First, however, the focus of the services are much more driven by the tenants rather than based on service providers’ sense of what tenants should do. It is a misconception that if people have a choice, they won’t access services. We have found that residents are more receptive to services when they are deciding which services they need.

Question: Do people have to be clean and sober before entering into a Housing First model?

Answer: The Housing First model acknowledges that people who have an addiction disorder and who are poor and homeless often have a very long road to overcoming their addiction. And often, the addiction problem is a coping mechanism for life on the streets or a co-occurring disorder. Confronting this reality makes it untenable to deny people safe and affordable housing because of their addiction issues, since doing so will only perpetuate their homelessness, addiction, and in many cases their mental illness. Housing should not be a reward for good behavior, it is a basic necessity and without it people find it difficult to address any other life issues. With this in mind, Housing First programs place clients in housing and, using evidence-based models such as motivational interviewing and education on alcohol and drug use, measure treatment success for clients by analyzing how alcohol and drug use reduces over time. While sobriety is achieved by some, for others reducing use and thereby improving their health, ability to gain employment and ability to pay their rent this is a success.

Question: What role does substance abuse treatment play in supportive housing?

Answer: Substance abuse treatment is absolutely integral to supportive housing. Addiction and substance abuse are significant barriers to ongoing housing stability among homeless and chronically homeless tenants. Since a key element of supportive housing is a tenant’s ability to access services when they are ready, connecting tenants to treatment is usually provided through referrals and linkages to existing outpatient programs in the community. In some cases, tenants may seek longer-term residential treatment and providers should try to link tenants to those programs as well. Unfortunately, such treatment is not always readily available in communities, or the treatment that is available is not experienced with working with formerly homeless people. We see a significant need to increase quality substance use treatment programs, particularly those that have experience working with formerly homeless clients and which may be low-threshold, tolerant of relapse, and longer processes of recovery.

In some cases, substance use treatment providers also develop and operate their own supportive housing, often as a continuum of housing options. Those situations facilitate the connection of supportive housing tenants to treatment.

Referrals and connection to substance abuse treatment are also part of Housing First models and harm reduction services approaches as well. Contrary to popular misconception, Housing First and harm reduction views substance use treatment as a part of the overall set of services which should be available to clients.

In New York City, CSH has been working with the National Center on Addiction and Substance Abuse at Columbia University and the City of New York to evaluate and provide technical assistance to nine providers of Housing First supportive housing funded under the New York/New York III Initiative. These supportive housing providers explicitly target chronically homeless individuals who have disabling and active substance use conditions and who have failed prior attempts at treatment. What we’ve been finding in these programs is that many tenants, who seemed like they would never stop using, are indeed reducing or managing their use, many have sought substance abuse treatment, and some are on path to sobriety. Others may be on a longer road to recovery, but have made significant gains in housing stability and connection to health and mental health services. They have confronted their lifestyles, behaviors, and choices to a degree that they would never have been able to while on the streets, in shelters, jails, or hospitals.

Question: What is the Keeping Families Together program being piloted in New York?

Answer: CSH, thanks to funding from the Robert Wood Johnson Foundation, has partnered with several New York City non-profit supportive housing providers and five N.Y. Government agencies to house families engaged with the child welfare system. These families meet the definition of chronic homelessness and are at risk of losing custody of their children for a variety of reasons. Our evaluation of the Keeping Families Together pilot, has found that 80 percent of the enrolled families have substance use disorders.

Through Keeping Families Together, CSH has housed 29 extremely vulnerable families in permanent supportive housing with great success. Ninety percent have remained housed, 62 percent of the open child welfare cases are closed and 90 percent of the 105 kids in these families have improved school performance.

For the small percentage of families who experience chronic homelessness, permanent supportive housing ends the cycle of homelessness, improves family stability, and helps the children thrive.

Question: What trends do you see in funding for permanent supportive housing?

Answer: At all levels, integrating funding streams is the most exciting trend I see in permanent supportive housing. Supportive housing has three legs that keep it balanced. There are funds necessary for developing the housing (via single site, scattered site, new construction, or rental assistance programs), maintaining building operations, and providing supportive services. In most communities, supportive housing providers still have to patch together funding from multiple funding streams to these costs. What we have seen is continued recognition that to build the amount of supportive housing needed to end chronic homelessness, these funding streams need to be better coordinated to ensure projects move forward.  Many of the States and communities in which CSH works or has worked such as Connecticut, New York, Seattle, Portland/Multnomah County now have not only invested significant state and local funding, but also have developed, streamlined, and coordinated collaborative systems for financing supportive housing that offer capital, operating, and services funding in a single or coordinated requests for proposals with coordinated timeframes and regulation.

This trend towards coordinated and integrated funding systems is now emerging at the Federal level as well. The new Federal Housing and Services for Homeless Persons Demonstration is an exciting effort by the Federal Government to coordinate housing vouchers and services funding. This demonstration will coordinate Section 8 vouchers with SAMHSA and Medicaid funding and will provide a model for how HUD and HHS can work together to end homelessness. In addition, it will help Medicaid evaluate the potential cost savings to be realized by housing Medicaid eligible, chronically homeless populations who frequently use health services.

Question: How has the role of supportive housing changed over time?

Answer: During the past two decades, supportive housing has developed from a somewhat experimental concept into a refined and robust model, backed by a sizeable body of evidence regarding its cost-effectiveness. Supportive housing is now widely accepted as the primary vehicle for ending chronic homelessness. Supportive housing is a central part of local community plans to end homelessness, as well as in Opening Doors, the Federal strategic plan to end homelessness.

As our understanding of both homelessness and supportive housing has evolved, so has the role of supportive housing. CSH along with many communities across the country have begun to recognize that supportive housing is an intervention that has broader applications and promise, reaching many other vulnerable populations and solving policy problems for many other sectors beyond the homeless assistance system. Research in the late 1990s had shown that many homeless people did not simply reside in shelters or the streets, but actually lived on an institutional circuit comprised of jails, emergency rooms, hospitals, and psychiatric centers. Furthermore, evaluations of supportive housing found that supportive housing reduced homeless people’s use of emergency public services, making supportive housing a cost-effective solution to the institutional circuit.

Based on this research, CSH began working to adapt supportive housing more explicitly to reach vulnerable populations who were found in various institutional settings. One of these institutional settings is the criminal justice system. Several years ago, we began an effort to create models of “re-entry” supportive housing, tailored for people with chronic health challenges leaving jails and prisons. Our work in this area has found that supportive housing has dramatic impacts on reducing recidivism to corrections. We have also worked with communities to create supportive housing for frequent users of hospitals and emergency health services, and found impressive reductions in emergency room use, hospitalizations, and the associated costs of each.

Supportive housing also has a growing role in reaching vulnerable families. While research has found that many homeless families can successfully exit homelessness with rental assistance and very light services interventions, we also know that a small but significant subset of families experiencing homelessness are highly vulnerable and at risk of persistent housing crisis, public system involvement, and disruption. These families are involved in the child welfare system, criminal justice, the behavioral health system, and cash and non-cash benefit systems, and moreover, are usually the most troubled clients of these systems. Three years ago, we launched a supportive housing initiative that specifically targets families involved in the child welfare system, and where supportive housing is designed to prevent neglect, abuse, and out-of-home placement of children. Early results from that effort, Keeping Families Together, are showing that supportive housing is a solution to the child welfare system as well.

Finally, there is an increasing trend towards seeing supportive housing as a mainstream part of housing systems, rather than as a kind of boutique program. Housing finance agencies are beginning to require or incentivize the inclusion of supportive housing units in their funding competitions. Public housing authorities are beginning to see supportive housing as part of their housing stock and development portfolios, as well as targeted supportive services for vulnerable families residing in their public and assisted housing.

Question: Has there been a change in the consumers within the past five years (age, ethnicity, issues…)?

Answer: As we house people who have been on the street for longer periods of time, we are finding that the population we are serving is older, has more mental and physical health issues, has higher levels of public system involvement, and higher rates of substance use than they did 10 – 15 years ago. This means the intensity of the case management services has increased. In addition, we are working with a wider network of partners, such as, corrections departments and nursing homes.

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2010