Housing First, Work Fast
An Edited Transcript of the PATH National Teleconference
Sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA)
September 5, 2005
Presenters:
Ann V. Denton, M.Ed., Advocates for Human Potential, Inc., Delmar, New York
Gary Shaheen, M.P.A., Advocates for Human Potential, Inc., Delmar, New York
Moderator:
Tammy Bernstein, M.P.A.
Advocates for Human Potential, Inc., Delmar, New York
This telephone/Internet presentation was supported by a technical assistance contract with the Substance Abuse and Mental Health Services Administration (SAMHSA). However, the content of this teleconference does not necessarily reflect the views of SAMHSA or the U.S. Department of Health and Human Services. For further information about this teleconference, please contact Phyllis Liu, Advocates for Human Potential, Inc., (518) 475-9146.
Table of Contents
Welcome and Introductions
Breaking the Cycle of Homelessness and Poverty
The Legal Basis for Community Integration
Values of Housing First and Work Fast
Principles of Permanent Supportive Housing
Housing First
Choice, Integration, and Immediate Access to Housing
Implementing a Housing First Approach
The Impact of Substance Abuse
Housing First Q&A
Work Fast Resources
Work Fast Principles
Work Fast Practices
Developing Motivation for Work
Linking Employment and Housing
Using Evidence-based Practices
Outcomes of Work Fast
Housing First Q&A
Welcome and Introductions
Tammy Bernstein
Welcome to today’s PATH Teleconference. Our topic is Housing First, Work Fast. My name is Tammy Bernstein from Advocates for Human Potential in Albany, New York. With our colleagues at Policy Research Associates, we provide technical assistance to the PATH program. I will be the moderator for today’s presentation.
We are delighted to have with us Ann Denton and Gary Shaheen. Both Ms. Denton and Mr. Shaheen currently are managing directors at AHP and well known as experts in their respective fields. We know this will be an informative and helpful call to those of you who want to know more about recovery issues.
This presentation will be divided into two sections with a Q&A session after each one. And now I’d like to introduce our featured presenters.
Ann Denton is a recognized expert on homelessness, mental illness, system change, and housing issues for people with mental and other disabilities. She provides technical assistance to States and communities in many areas, including the development of continuing care plans, strategic planning, project development and monitoring, prioritization, service coordination, and operation of housing and service systems.
Ms. Denton’s areas of expertise include permanent and supportive housing, discharge planning, prevention strategies, and access to mainstream services. As a managing director of the Albany office of Advocates for Human Potential, Ms. Denton directs projects and activities related to housing, homelessness, mental health, system change, and substance abuse services.
Gary Shaheen has more than 27 years of experience in both the public and private sectors. He is a managing director at Advocates for Human Potential and oversees its national and international employment training and technical assistance work.
Mr. Shaheen has authored numerous curricula on employment services and contributed to publications addressing employment for people with disabilities and those who are homeless, including Work as a Priority: A Resource for Employing People Who Have a Serious Mental Illness and Who Are Homeless.
I’d now like to turn the call over to Ann Denton.
Ann Denton
Thanks, Tammy.
I want to set the stage by saying that what we really are talking about is using housing and jobs as a way to help people who are enrolled in PATH services or who might become enrolled in PATH services make the transition out of homelessness back into the mainstream of our society.
We’ll be talking in some specifics about housing and jobs, but my task is setting the stage for that discussion. So I’m going to talk a little bit about PATH-eligible people, a little bit about ending homelessness and why jobs and housing are so important, and a little bit about community integration. And then I’m going to talk a lot about housing. I know that’s what people are expecting.
Breaking the Cycle of Homelessness and Poverty
So let me start by reviewing what we all know—people with disability, in general, whether that’s mental illness or another disability, have a higher risk of homelessness and a higher risk of poverty than the general population. And once people who are at such risk become homeless, it’s very difficult for them to exit homelessness. I believe that most of the people who are listening to this call know all too well that the majority of people who are served by the PATH program are people who are in the 20 percent of homeless individuals who can be characterized as chronically homeless. We’re really talking about people who, once they enter homelessness, have an extraordinarily difficult time exiting.
Still, too often, I think the only thing that we think about for these individuals at the system level is helping them get Supplemental Security Income (SSI). And I know Gary is going to talk more about that later in his presentation. But even if someone is on SSI, let’s not forget that SSI in some ways is part of the trap. SSI perpetuates poverty.
Simply put, SSI doesn’t pay enough for people to afford housing in any of our communities. That really means that the housing problems of people with mental illnesses, the housing problems of people who are served in the PATH program, are really more about their poverty than about their disability.
In that statement, I think there is some real hope because we can work to bring housing resources to bear so that housing can become affordable for people. You may have heard it said that, “Ending homelessness is easy. All you have to do is get someone housed.” However, helping a person stay in housing is more difficult than helping him or her get housed in the first place.
People with serious mental illnesses and co-occurring substance use disorders face significant ongoing challenges to keeping their housing. But the biggest challenge is the one we’ve already mentioned, which is poverty. If you keep people at a poverty level, they continue to have difficulty retaining housing.
So how do we break the cycle of homelessness and poverty? We break that cycle by helping people get housing and jobs. The Housing First, Work Fast approach emphasizes real and meaningful community integration for people with significant psychiatric disabilities. We’re talking about people who are chronically homeless. We’re talking about people with co-occurring disorders—these are not the easy people in our system. And yet, we’re still talking about real community integration.
The Legal Basis for Community Integration
Why is community integration so important? The legal basis of community integration, as many of you know, comes ultimately from the Americans with Disabilities Act (ADA) and through the Supreme Court’s 1999 decision in Olmstead v. L.C., which strongly supported community integration for people with disabilities. The Supreme Court decision clearly includes housing and jobs because we can’t do community integration if people don’t have a place to live and a place to work.
The ADA was the legal basis of the Olmstead decision, which prohibits the unjustified segregation through institutionalization of individuals who are capable of living in the community. This means that when people are institutionalized without any sort of clinical necessity, that’s a form of discrimination based on disability. The ADA makes clear that individuals with a disability cannot be excluded from, and I’m quoting, “participation in, or be denied the benefits of, services, programs, or activities of a public entity.”
One of the parts of the Olmstead decision that I like best is that the Supreme Court says, “People with disabilities must receive the help they need in the most integrated setting possible.” And in 2001, President Bush issued Executive Order 13217, which confirms that the Federal policy is to provide people with services and supports in the most integrated setting possible.
Housing and work are absolutely essential to community integration. If you are in a State where people can’t get out of the State hospital because they don’t have a place to live, or where people are denied housing because of their disability, then you are in a State that has practices that are in violation of the ADA.
I know that for many States, the State PATH Contact is often a colleague of, or may also be, the Olmstead coordinator. I think it is important for PATH staff to know what Olmstead is all about because when people are exiting homelessness, our goal is not to have them exit homelessness into institutionalization of another sort.
And frankly, people who are chronically homeless are not going to do well in settings that have a lot of requirements. I’m sure I’m getting a resounding “amen” on that one from any outreach workers or case managers who are on the call.
The people who fall into homelessness and can’t get out, and further the people who meet the definition of chronic homelessness, are people who cannot meet the expectations in our treatment systems. We’re talking about people who cannot take their medications and make their appointments with their psychiatrist once every 90 days.
Values of Housing First and Work Fast
I want to move us from the legal basis of community integration to start talking about Housing First and Work Fast. For those of you who are following along on slides, I’m up to slide 14, and I really want you to take a look at that slide.
We have side-by-side principles or values that govern Housing First and the Work Fast approach. And if you read down that slide, and Gary will talk about this again in a few minutes, you can see that the principles and operational practices that underlie Housing First and those that underlie the Work Fast approach are essentially the same.
In both cases, we’re talking about the fact that community integration really is the law of the land. It is a basic right. We can’t do community integration without housing. We can’t do community integration without the opportunity to get a job. The goal in these approaches is community integration. The way we get there is by allowing the person to drive the activity.
Both approaches, I would say, are very respectful about people’s ability to make choices, and I’ll talk more about this in a few minutes. But the bottom line is, people are making choices about accepting or rejecting treatment anyway. We need to understand that and understand that people vote with their feet if they don’t like what we’re offering.
Housing First and Work Fast both recognize the fact that people are going to make choices anyway. We try to facilitate choices that we believe will be helpful for people. We try to set up the situation so that people will make choices that will increase their community integration. But we cannot impose our choices on people.
The final principle, which actually is more of a practice, is that Housing First uses an Assertive Community Treatment (ACT) team or an ACT-like team to provide services and support and the Work Fast approach uses a similar kind of team approach.
Principles of Permanent Supportive Housing
Let me turn to some details about Housing First. First of all, Housing First is part of the large umbrella concept of permanent supportive housing. And all permanent supportive housing—no matter whether it’s in a congregate setting or scattered-site apartments, or whether it’s run by a service provider—is characterized by choice; that is, the individuals have a choice of where they live. It’s also characterized by the concept of “housing as housing.”
Housing as housing means that the housing is independent from compliance with the treatment plan. There’s a separation of services and support from the housing.
In other words, if my treatment plan says that I am not allowed to drink and then someone discovers that I have beer in my refrigerator, I won’t lose my housing just because I have beer in my refrigerator. It separates the treatment plan from the housing itself. It means that I have the right of tenancy in my housing unit no matter who provides it, and I can’t be kicked out for anything that wouldn’t be a lease violation for the general population.
The next principle of supportive housing is integration. I’ve had the privilege of working over the last year on a toolkit for supportive housing and I can tell you that integration is a principle that is absolutely essential to full implementation of the Olmstead Supreme Court decision and the ADA. We’re talking about people having the same opportunity to live in the same kinds of housing that people in the general population live in.
There are many reasons why people end up living together with other people with mental health labels, and we can talk about that in the question and answer period. But the principle for all of permanent supportive housing, not just Housing First, is that people live in the most integrated setting possible.
Another key principle for permanent supportive housing in general is flexibility. I’m hearing an imaginary “amen” from the case managers again. You have to have a certain amount of flexibility built into your programming in order to respond to the daily needs of individuals with mental illnesses.
Finally, we can’t any longer do cookie cutter approaches through permanent supportive housing or any kind of recovery programs at all. Services must be individualized.
Those are the five basic principles and practices of permanent supportive housing in general.
Housing First
Housing First or supported housing has emerged out of the permanent supportive housing umbrella as a distinct approach. And what makes it distinct is that it provides housing on demand from the person who needs the housing, and it has a really high degree of choice, integration, and community inclusion.
The Housing First approach uses scattered sites and frequently uses private landlords in the community, so it can be provider-driven housing or provider-owned housing, but you still have to follow the housing as housing principles.
What Housing First does is provide housing to people with significant functional impairments, and it does not require a demonstration of housing readiness—that’s really the key point. Too often, what we tell people is that as soon as you’ve been sober for 6 months, as soon as you can take your psychiatric medication, and as soon as you can budget your money or cook seven balanced meals, then you can have housing.
I’m exaggerating to make the point—certainly most of our housing programs don’t do that—but too often we require that people meet some standard of housing readiness. What Housing First does is offer individuals their housing first. People need housing and people who are chronically homeless definitely need housing.
So instead of setting the bar too high, we make the housing available immediately. When you offer Housing First to people with significant functional impairments and no demonstration of readiness is required, what happens? Those people become housed and exit homelessness by definition immediately.
Now, as I’ve said before, this is not all that hard. We can, in many places, find housing for people if we have some financial support. The trick is to use the housing financial assistance to offer the services and support that enable people with significant functional impairment to stay in their housing.
Housing First is part of this call because it is an important tool to help communities end chronic homelessness. If you look at Dennis Culhane’s research, most of the people who are chronically homeless have been in mainstream services at one point or another, but the service delivery system they were in couldn’t hold them, frequently because they have service needs that cross service boundaries and require extensive coordination.
The point is that Housing First is almost by definition for people who are not well served by programs that require things like sobriety, compliance with treatment regimens, a spotless housing history, and other kinds of requirements that we put on people.
Having been a housing provider myself and done residential treatment, I certainly understand that there are good reasons to have entrance requirements to certain types of housing. When I’m discussing Housing First, I’m not saying those other forms of permanent supportive housing don’t work. I am saying that Housing First seems to be an effective approach for people who are chronically homeless or people who don’t respond well to traditional programs. They’re the people that the service delivery system has failed.
So for that group—and it’s a relatively small group—Housing First is a very effective way to engage people and slowly bring them back into the fold.
Choice, Integration, and Immediate Access to Housing
Let me talk for a minute about choice in Housing First. I’ve already talked a little bit about choice in general because it is a key principle of permanent supportive housing.
But for Housing First, we’re really talking about people who have significant functional impairments—people with serious mental illnesses and probably co-occurring substance use disorders who, despite their ability to live and survive on the streets, have not been good navigators of what we would consider to be mainstream society. Despite this fact, we’re talking about offering people a choice of their housing unit and a choice of services and support.
As I noted earlier, people are making choices anyway. The people who have been in the homeless shelter for a year, the people who drop in and out of homelessness because they can’t stay in services—those people are already making the choice that they are not able to meet the requirements of those programs, and they go away.
But what we say to people is, “It’s up to you. Where do you want to live and what will it take for you to stay there?” Those are the two basic questions.
Let me talk for just another minute about integration. What we mean by integration is a mix of populations in housing. For those of you with a housing background, we are saying that mixed-income units are the new gold standard in the housing world.
Long gone are the days when it was public policy in this country to segregate people by income. Everybody probably knows about Cabrini-Green in Chicago, the big high-rise public housing units that have been destroyed. What we did in those housing units was took everybody who was extremely poor in the community and put them all in one environment, and then it was very difficult for that group to generate enough rent and enough income so that the housing could be maintained properly and the tenants’ standard of living could rise to an acceptable level.
Segregation by income has been discarded as part of public housing policy in this country and mixed-income is the way to go. If you’re doing housing development for people with mental illnesses, and you segregate people based on their income, one of the things that you’ve done is violated the principle of how we do affordable housing in this country.
So I’m just offering you the idea that integration is not all about philosophy and civil rights, but it’s also a principle of the public housing industry. Mixed-income is a guiding principle of the affordable housing industry, and true integration is really the use of scattered-site housing. I’m expecting questions on that when we get to the question and answer period.
The next principle I want to discuss is immediate access to housing. This is related to the point I made a minute ago about access to housing not being dependent on traditional predictors of readiness. In other words, we’re saying that people have a right to services and support to be successful in housing regardless of whether or not they meet traditional predictors of readiness.
So, requiring someone to be sober, requiring them to be medication compliant, and requiring them to be able to shop and cook before they get into housing is an impossibly high standard for many people and certainly for people who are chronically homeless.
Housing First doesn’t require participation in psychiatric treatment or sobriety as the condition for the housing. This doesn’t mean we’re not working with people on those issues. We are working with people to help them achieve some stability in their psychiatric illness and to achieve sobriety, but it’s not a requirement.
Housing First provides people with places of their own and with ongoing support from an ACT team, which is sort of the Cadillac model, or some sort of continuous treatment team that can provide services to support people in housing. Housing First takes people directly from outreach into permanent, independent, scattered-site apartments.
People have rights and responsibilities that are outlined in the standard lease. We’re not making a case that this person should be allowed into housing because they have a disability and it would be a nice thing for the landlord to give them a housing unit. We’re saying this person can be a responsible tenant, and he or she has the same rights and responsibilities as any other tenant. Stability and safe, affordable, mainstream housing is our goal.
Implementing a Housing First Approach
Let me turn for a minute to what it actually would take to do this. If you’re thinking about doing something like Housing First in your community, the first question that you should ask yourself is, “Why should we do this?” And you should only do this if you have a group of people who are not well served by what you’re offering now.
To determine whether or not you’ve got this group, look at data in your community on people who are chronically homeless. If you can get the information, you want to know how many times, for example, individuals in that group have been placed in a housing program and not done well, or been placed in substance abuse treatment and dropped out, or been placed in community case management and gotten lost.
So, do you have an underserved group that is bouncing in and out of a number of services? If you do, you might want to look at Housing First.
If you’re going to do Housing First, remember, we have to fix a couple of things in order for people to retain housing. One is we have to make the housing affordable. So you’ve got to find a way to come up with some financial assistance to make the unit affordable.
You also have to have a realistic level of services and support. It will not do to put someone with significant functional impairments in the housing unit that they’ve chosen and then offer them case management where the case manager has a caseload of 50 to 100 people—that’s not intensive enough for this group.
We really need to look at structuring a package of services and support that allows staff to be available to tenants 24 hours a day, 7 days a week, and has some real expertise in dealing with the kinds of issues that come up for people in housing. Remember that we’re targeting these services to people with significant functional impairments. If people already are capable of independent living, we have other programs that can help them. This is for your group that is not well served by what you’re doing now.
You also need to have a really good outreach and engagement component. People who are chronically homeless have been approached before and may feel they’ve been burned by the system, so it takes some real skill to provide effective outreach for people in this group.
Also, the PATH teams or other staff that are doing this kind of work really need training and support. We’re asking people who are doing Housing First to do something that is almost counterintuitive to the way that we normally run a service delivery system. So people need training, support, the ability to bounce ideas off one another, and some clinical supervision from a skilled supervisor so they have the support they need to do this difficult work.
Finally, in terms of what it takes to do Housing First, first and foremost you have to be able to demonstrate the need. You need data to show that you have a group of people who may be costing you a significant amount of money and for whom what you’re doing now is not working.
Beyond that you need to look at whether the leadership of your organization is up to the challenge because this is not easy work to do. You really need buy-in from management, including your board of directors, executive director, and clinical director. They need to have some consensus about what the goal is and how you’re going to get there.
You need to understand and be able to accept managed risk. Community health centers and other service providers already understand that there’s risk inherent in the work we do. There is not a greater risk in doing Housing First, but it may look more daunting to leaders who have to think about how to take normal risk management approaches and apply them to a Housing First program.
There are things that you can do with personnel policies, job descriptions, and program descriptions that will help support staff and the consumers in a Housing First approach.
Further, you need partners if you’re going to do this. The most obvious partner that you need is someone to come up with the money for the housing. Your housing authority, city or county, neighborhood housing office, or community development office that has access to hard funds can help you make the housing affordable.
Other partners that you may need, depending on how your system is structured, are substance abuse providers and housing providers in your community.
Finally, you need to think about how to modify quality assurance procedures in such a way that those procedures support quality in a Housing First approach.
The Impact of Substance Abuse
I think I’ve said enough about what it takes to adapt the Housing First approach. Let’s talk briefly in the time I have left about substance abuse, because that’s the difficult issue you have to confront.
We’re not going to require individuals to be sober before they can get into housing. The fear, of course, is that people are going to run amok, and that is not what the Housing First approach is about.
The fact that Housing First approaches do not require sobriety as a precondition for housing comes out of an understanding that addiction is an illness that, for many people, includes relapse. Particularly, if we have someone with a co-occurring mental disorder, it is more likely than not that they will experience a relapse of their substance use disorder.
If people lose their housing when they relapse, we are setting them up to fail. We’re asking for trouble because we’re setting it up in such a way that we know isn’t going to work for this population. So we really need to find a way to support people in housing as they move incrementally toward recovery.
The goal for anyone with an addictive disorder is abstinence and our goal for people in Housing First programs is no exception. Abstinence is the goal. What we’re not doing is punishing people for relapse, which is part of the illness, by kicking them out of their housing.
Another basic principle is that an improvement in quality of life is a success. If someone has been chronically homeless and is going in and out of emergency shelters, jails, and psychiatric hospitals, breaking that cycle is a successful outcome.
Remember that helping people move incrementally toward recovery is a well-established approach and that people can be successful when you incorporate principles of harm reduction. You’re not breaking new ground; you are following a well established clinical path.
To sum up, I would say that the good outcome that you get from Housing First is success for people who are chronically homeless. They have better housing retention and better community integration. They experience choice, access, integration, and flexibility.
Further, they have really improved their self-esteem and confidence. They have a sense of personal stability. They finally have a handle on hope and recovery in a way that has not been possible for them before. So what you’re doing is fulfilling the dream implied by the title of PATH, which is transition from homelessness.
That said, I’ll pause for questions.
Housing First Q&A
Caller
First, I wanted to say that I think this presentation has been great so far and very much needed. There was a mention of a toolkit for supportive housing being developed, and I was wondering if there’s any more information available on that.
Ann Denton
That’s a great question, and it has been a real privilege to work on the toolkit this year. It is in its final stages, but I’m guessing that we won’t have publication by SAMHSA for another 10 or 12 months. We have to go through a governmental approval process before it can be put on the Web. So we’re close, but we’re not there yet.
Tammy Bernstein
I have an e-mail question from North Carolina that says, “How can we expect someone who is not housing ready to be a good tenant?”
Ann Denton
Someone who is not considered housing ready can be a good tenant if we do the services and supports correctly. If you think about it, the normal requirements of tenancy are that the person has legal rights to the unit, so they have a key. They must pay their rent, they can’t destroy the property, and they can’t be a nuisance to their neighbors.
Those are things that apply to everyone. And one of the things about Housing First is when people get into housing and it’s housing that they’ve chosen for themselves, there’s an investment in trying to keep that housing.
So you’re approaching people and saying to them, “You shouldn’t be up at 2 o’clock in the morning playing your stereo at top volume, not because it increases your hallucinations (or whatever psychiatric or clinical reason we would use), but because the landlord will kick you out for a lease violation.” You use a very practical approach to talk about how the person can respond to the requirements of the landlord; it’s not about the fact that you want them to improve their behavior because you don’t think they should be doing something. It’s a totally different conversation.
That said, sometimes people do get evicted, and if you can explain to them that if they don’t pay their rent, the landlord is going to kick them out, you can help individuals understand that they’re not in a mental health program that’s going to prevent them from being evicted if they violate the lease. I hope that answered the question.
Tammy Bernstein
I have one more e-mail question. This one is from Texas, and it says, “The main point of contention I’ve seen is regarding people who use illegal drugs, as opposed to alcohol users. If you house people who are using illegal drugs at the time of their admittance, this should be a clear violation of most rental contracts. How is this resolved in Housing First?”
Ann Denton
That’s a great question and it sounds like it’s from someone who’s actually done this.
The way that you resolve that is when you’re looking for housing through the housing authority or you’re looking for private landlords, you make it clear that the individual is going to have to meet the standards required of anyone else in that community with regard to illegal drugs.
My experience is that illegal drug use is not so much a barrier to access as it is to housing retention. Once the person is in the housing and is using illegal drugs, they risk arrest and exploitation by their colleagues. So it becomes a services and support issue. Landlords can’t test people for drugs before they get into housing unless they test everyone who comes to their front door. It’s illegal for someone to require sobriety of a tenant with a mental illness when they don’t require sobriety of other tenants.
Finally, for housing authorities, one of the tricks is to know that the hard rules about criminal history actually are fairly minimal. They are absolutely restricted from housing only people who commit a few serious offenses. Local housing authorities, frequently in an attempt to protect their own operations, say that if you have any kind of a criminal record, you can’t be housed here. But the key to working with the housing authority is to know which of those rules are local and which of those rules come from HUD. The rules that come from HUD, you can’t adapt. You have an opportunity for advocacy with the rules that are local.
Tammy Bernstein
Thank you, Ann. At this time, we’re going to switch over to Gary Shaheen.
Work Fast Resources
Gary Shaheen
Thank you, Tammy, and thank you, Ann.
Let me start by saying that almost everything Ann talked about in her introductory comments also applies to the concept of work.
I think that as we look at the way employment has been viewed for folks who are homeless—and many of you out there who are PATH providers might be finding this a struggle within your own agencies—we find that it’s always been an all-or-nothing strategy.
In other words, if your agency has a contract with the State rehabilitation agency, and folks that you’re working with coming off the streets into housing are not able to meet standards of sobriety or have a clearly defined job goal, or they are not able to engage directly into mainstream competitive employment, they’ve often not had a chance to even test work or have conversations around work. Work hasn’t really been on the provider’s radar screen.
We’ve known for a long time that helping people get into safe and affordable housing quickly is a way to end homelessness. And we’re just lately recognizing that it’s important for people to have access to income and to jobs as a way out of poverty and as a way to reduce recurrence of homelessness. So that sets the stage for some of what I want to discuss.
On my third slide you’re going to see a whole host of resources that are available to you. The first is the one that Tammy mentioned, Work as a Priority. This continues to be the SAMHSA document that most directly addresses issues of employment for folks with psychiatric disabilities who are homeless. The guidebook is available for download through the SAMHSA Web site at www.samhsa.gov. Enter “Work as a Priority” as a search term.
And to piggyback on what Ann was talking about in terms of the supportive housing toolkit, if you go to the SAMHSA Web site, you’ll see a toolkit there on supported employment, an evidence-based practice for people with mental illnesses. I’ll be referencing that a bit later in this discussion. But just to let you know, the toolkit on supported employment doesn’t have a lot to say about conditions that affect the employment of people who are homeless. So at SAMHSA’s request, we’ll be doing some updates to give practical guidance to PATH programs that want to add work to their repertoire of services.
As you move down the list on slide 3, you’ll see a number of items that have to do with the mainstream workforce system. Often we’ve often looked internally to the mental health system to fund employment that is primarily related to a person’s disability. But there’s another new player on the scene these days and that’s the U.S. Department of Labor.
And while all systems are slow to change, we are beginning to see some very interesting developments in helping folks who are homeless get access to some of these mainstream employment and training options. I’ll go into that a little bit later in this telecast.
The last item on slide 3 has to do with the Chronic Homelessness Employment Technical Assistance Center, otherwise called CHETA, funded by the U.S. Department of Labor and housed at the Corporation for Supportive Housing. Advocates for Human Potential is a partner in this effort. You’ll find a number of publications listed on the CHETA Web site at www.csh.org/CHETA that will be helpful for you.
Work Fast Principles
So let’s think about, in addition to what Ann talked about, the principles and practices that are shared by Housing First and Work Fast by expanding that a little bit.
In fact, what we know is that most folks who are homeless are working. They collect bottles and may be donating blood; they may be panhandling; they may be doing day labor. But to get by in their daily life, many people are doing some sort of work.
So, that’s one of the first principles that we need to consider. Despite what we think about people who are homeless and the rate of unemployment for people with serious mental illnesses—typically listed at somewhere around 90 percent, many folks who are out there now are earning some sort of income through some type of work.
We must also look at what we mean by job readiness. It might be very true that some folks are not ready to take that 9-to-5 job downtown at the local RadioShack. But in fact, similar to Housing First, by offering people an opportunity to do some sort of work when they ask for it, we find new sources of readiness and new sources of employment strengths.
We must recognize that the skills and strengths derived through just surviving on the streets are strengths that may be important to work. Homelessness is hard work, and people have to adhere to some sort of a schedule even if it’s coming in and out of shelters. They leave early in the morning and they have to find their way back in the evening.
Because surviving on the streets requires a host of skills and strengths, don’t forget to take a look at what they have done in their life just to survive on a day-to-day basis when you’re assessing what kind of experiences and strengths they have related to work.
One of the other things that we have faced in the employment field is that, as I said earlier, it’s an all-or-nothing approach. People need to be able to jump directly into a 9-to-5, 30 or 40-hour-a-week job. And what we’re finding that really works is to give people a slower entry ramp, an opportunity to work half an hour a day or an hour a day at perhaps some in-house jobs and opportunities to work with an employment case manager and have conversations around work.
We need some way for people to develop the motivation and the awareness that work can be possible in their lives, rather than just focusing on the end result, which is what we all want—that somebody will have a job at a living wage with benefits and enough hours a week that they can sustain themselves in their communities.
We have to celebrate every success. A good example of that might be that if I were working on a job—maybe one of these set-aside jobs that we’ll talk about—and I was able to work half an hour today and maybe an hour and a half the next day, that’s a great success.
This may not necessarily be a standard of success in the workforce development system of the One-Stop Career Centers that look at other measures of success, and it may not be a standard of success in a mental health supported employment program that’s funded through a vocational rehabilitation agency. But for me, it may be the longest period of time that I was able to work under supervision and attend to a task in quite a long time, so it’s a cause for celebration.
We have to customize the employment experience to meet people where they are rather than developing cookie cutter jobs into which we place individuals. We need to take a look at the types of jobs that we can create or leverage and help people access those jobs so we can build that employment potential up over a slower period of time.
Work Fast Practices
So what about the practices? If you’re an outreach worker, you’re working with folks living on the street and underneath the bridge. Maybe if you’re in Boston, you’re working somewhere near the Big Dig, but you’re out there. You’re talking with folks about accessing benefits, offering them opportunities for housing and providing access to blankets and food and other necessities.
However, part of your job could be talking to them about work, including what your agency has to offer in terms of employment and training services or temp jobs to which your agency might have access. Or simply talk to them about that temp labor job they may be doing; ask how they’re treated, what they like about it, and what don’t they like about it. Engaging people in a conversation about work at the earliest stages is one of the ways that we get people thinking about it.
We need to continue to talk about and test work once people are in their own place. One thing we’ve heard from consumers all over the country is that once they get housing, there they are. They’re either in a day treatment program of some type or sitting in their room watching TV.
But when people are in housing and there’s an opportunity for more stability in their life, continue the conversation about work by having the housing staff talk with them about their employment aspirations or have peers talk with them about the jobs that they’re doing. This keeps the prospect of work alive and helps develop motivation.
Let me also say that not every moment is a competitive job placement moment; instead, you may need to talk about substance abuse difficulties that people are having. We would be remiss in our job as clinicians to try immediately to place somebody who is still using and is unlikely to pass a drug test for employment in a competitive job.
We have to continue to offer different opportunities for folks that help them shift from a pre-contemplation phase to a sense of motivation that allows them to address their substance abuse issues so they can have the job they really want.
One way to do this is to use a standing offer of employment, which means that your agency has access to a lot of flexible jobs that are available when people are ready to move into them.
So what else is important about outreach? PATH outreach workers, as I said, make work part of the conversation; they prompt and listen to people’s stories about jobs that they’ve had and jobs that they may want.
Take a look at the types of skills they say they have when you ask them, “What did you do to survive on the streets?” “Where do you have to be to get the most pocket change in the morning?” “Who are your best customers?” “What kind of approach do you use to engage customers and get money?” Believe it or not, they are using some sort of rudimentary marketing approach to get the money they need. But it’s not usually the way that we look at employment services, so it shapes our thinking in a different way.
If you’re doing outreach, you need to provide real-time information about the job services your agency has. Perhaps people might want to talk with a peer or a staff person on the park bench about the job search services or the jobs that the agency has available.
Developing Motivation for Work
Most of you probably are familiar with the stages of change. You can use this approach to help people move from a state of denial in which work has no place in their life to a sense that, “Yes, I can work, I can do a job, I understand what my skills are, I understand what supports I need, and work absolutely is possible in my life.” Some principles and practices designed to help develop motivation for work are highlighted in my next slide.
What are we dealing with when we’re trying to get people involved with work at the earliest opportunity? There are a whole host of challenges. Prime among these is a sense of hopelessness.
Many people have had bad employment experiences in the past. Perhaps they lost their job and it was one of the factors that precipitated their homelessness. They may have gone through another employment program and were unable to meet the demands of the job because the standards were too rigid for where they were at the time. There are a whole host of things that can lead them to believe that they have no hope of working, so that’s a challenge.
They’ve likely had a number of those types of setbacks. Many think of jobs that historically have been available. The usual janitorial and flower arranging and filing jobs are entry-level jobs that don’t pay enough to help them out of poverty and to sustain themselves in their own places. So having a range of jobs available in your agency and information about other jobs and training programs is one way to help folks think that there are other options available to them.
A number of clinical factors are barriers to work, including depression, substance abuse issues, and life stresses.
And one of the things that we do know is that many consumers have a fear of going back to work because of the impact on their benefits. Case managers are doing their job by trying to get people on benefits. It helps them establish a stable source of income. But one of the things that we need to continue to do is to help people see getting benefits as only the first step.
We need to tell them, “It’s only the first step toward self-sufficiency. It’s almost an island of safety. It’s a way to help you get needed services, including medical and support services and daily income. But from then on, if we’re ever truly going to help you out of homelessness and into a life that you say you want, we need to talk to you about work.”
So if you’re a PATH program contemplating employment services, you must have access to benefits management and advising. You need staff available in your agency who can talk to folks about things like the earned income disregard and the various work incentives provided through the Social Security Administration, as well as the 1619b Medicaid waivers that allow people to work and earn a reasonable income but retain their Medicaid benefits.
Also, many of your States are now Medicaid Buy-in States. If this has been actualized in your State, you have another tool. All of these disability benefits-related incentives to work reflect a Federal understanding that we really need to start with benefits and then give people the support they need to develop true self-sufficiency at jobs with a living wage.
In understanding how to deal with some of these motivational issues, it helps to recognize that motivation is a state not a trait; lack of motivation, which can change, doesn’t necessarily characterize individuals as people.
We can change their motivation by offering information and options for services. We can help people address both sides of their fear, both what it’s going to cost them to make a change personally and what are the benefits of that.
Also, realize that people who have suffered many losses have also perhaps relinquished the hope to survive, and that the hope of having a job with a future potentially is one of the casualties of homelessness.
Linking Employment and Housing
Ann talked quite a bit about helping people access housing. My next slide links employment and housing in some practical ways.
Oftentimes, once people are established in a place of their own, they just want to have a place to be. They don’t necessarily want to talk about work right away. They may not be interested in services. So, when you establish the hook early on, as you’re helping people realize that they can have access to a home of their own, in the same conversation you tie in the ability to work.
You also give people an opportunity to experience work through observation by helping them look at jobs that other consumers might have. It may be easier for your housing case managers to continue this conversation after folks are in housing.
What are the other responses that we have to consider to help people establish a stronger link to employment once they’re in housing?
Remember that you should try to “vocationalize” the housing environment. In other words, all staff—including case managers and housing staff and not just the employment specialists in your agency—should understand the employment services that your agency operates and be prepared to talk to folks about the value of work and work opportunities.
Now, that doesn’t mean that every staff in your agency is a job developer, with links to employers and the ability to help people get job interviews. But it does mean that if I’m a housing case manager and I’m talking with somebody about what it might take to maintain his or her housing, I might also use that as an opportunity to say, “I understand that you’re working at a part-time job. How is that going? Can you tell me a little bit about it? Are your wages enough to move you to that better place you talked about?”
In other words, your agency lives and breathes employment as well as housing, all focused on what Ann talked about—full community integration, having a home of your own, a job of your own, and being self-sufficient.
When you vocationalize the housing environment, you create a culture that expects work. You arrange things and activities and resources to include or support employment.
To visualize this, imagine that I walk in the front door of your agency and sit in the waiting room. Do I see job postings there? Do I see information about where the local One-Stop is? Do I see job applications? Is there a computer terminal over in the corner where I can get the job listings from the Department of Labor?
If your agency has an employment specialist, is that person’s name posted in a visible spot? Or perhaps, if your agency has drop-in facilities, can you post a flyer inviting guests to hear from a former client who will speak for half an hour about what it took to overcome his fear and move on to have a job? That’s part of vocationalizing and also tracking employment outcomes in a flexible way.
When Ann talked about what it would take to introduce and sustain Housing First, she talked about the need for support from management and the importance of policies and procedures. Those things also apply for employment services in your agency, in particular having an operations manual and a clear understanding of what it is you offer and the outcomes you propose to track.
Now let’s talk about what it means to have a standing offer of work.
Typically, our agencies provide a lot of services. If you’re a housing provider, perhaps you have apartments, or if you’re a housing developer, you may be renovating homes. The principle is that you should consider every opportunity you have to provide flexible, part-time jobs that are owned by your agency to give people an early opportunity to test work.
In other words, if you are a housing developer contracting out for minor repair and renovations, what would happen if you set aside jobs and had them available in your agency? One agency developed a lawn care service and redirected $190,000 a year back into the agency for jobs.
Using Evidence-based Practices
In the next few slides, I’ve given you a glimpse into how these early opportunities for work link well with the evidence-based practice of supported employment.
Evidence-based supported employment is competitive employment based on consumer choices. The goal is to get people into jobs as quickly as possible. You can read the six principles of supported employment on slide 12.
The principles of supported employment are consistent with the Work Fast approach in that we have zero exclusion of people who want to work. We look for opportunities in-house or through contracts to give people an opportunity to try to work. We look at jobs as transitions and provide follow-along supports.
And again, as with the Housing First approach, services need to be integrated so that your employment case managers are talking to your housing case managers or to your clinical case managers around the interface between housing support services and employment.
In the interest of time, I’m going to move ahead to slide 16, where you’ll see a diagram I call the “no wrong door” approach to employment. You can use this as a checklist.
Ask yourself and then your program, “Do we have services that help people at outreach and engagement around work?” “Do we provide an intake and assessment process that looks at people’s strengths and abilities?” “Are there opportunities for people to try that slow entry ramp, having discussions around work, perhaps, or becoming involved in business enterprises our agencies has?” “Do we also offer rapid access to the competitive job market?”
Outcomes of Work Fast
The next slide lists some outcomes of a Work Fast approach. One of the things we hear from consumers is that when people are working, they’re feeling better. They also are developing self-confidence and skills as well as a source of income, and those are all good reasons to look at this approach.
It’s particularly important to look at what Work Fast is NOT, some of which you can see on slide 19. Work Fast does not mean work that becomes a reward for attending a treatment group. It doesn’t mean that you finally get to talk to somebody about work after you’ve given evidence of 3 consecutive months of sobriety.
It doesn’t mean that after you’ve stayed in your housing for a certain length of time, then you get to talk to an employment counselor or work in a sheltered workshop. And Work Fast doesn’t mean that people get rapid competitive placement into employment when they’re not quite ready to pass the drug test or meet the needs of the employer.
What it does mean is giving people opportunity to talk about and engage in work in a flexible way all along the spectrum.
Finally, I’d like to cite a few examples. Lamp Village in Los Angeles is a place that has developed contracts with the City of Los Angeles. They operate a Laundromat, where they do the linens for a whole number of shelters in their area and provide flexible jobs for men and women with serious mental illnesses who have been homeless.
SEARCH in Houston is another example. This is a homeless services agency that actually operates its own Department of Labor One-Stop Career Center. The agency does homeless outreach and links people to the mainstream workforce system through its One-Stop services.
My final slide features some additional resources for you, including Web sites for the U.S. Department of Labor and the Roberts Economic Development Fund, for any agencies that are interested in starting their own social purpose ventures or small businesses.
In conclusion, let me say that throughout the country, both the U.S. Departments of Labor and Housing and Urban Development, and especially SAMHSA, have begun to understand and have been strong supporters of the idea that housing alone is not enough to end homelessness; people need also to have a job and a chance to earn an income.
All of these Federal agencies, as well as communities throughout the country, are beginning to look at ways to do that by engaging people into work quickly, by having work as a thread of hope and opportunity running through all of their services, and by helping people really escape homelessness to the mix of permanent supportive housing and a job to call their own.
Housing First Q&A
Tammy Bernstein
Thank you, Gary.
We have time now for a few questions, and I have one from before that I had to save. This question is from Massachusetts and it says, “One of the problems we are experiencing in our Housing First program is that our clients often like to assist their friends who may still be experiencing homelessness. Landlords often notify us that the traffic in the apartment is disruptive to the building. How have you dealt with this issue?”
Ann Denton
The first point is that the person can be evicted for a standard lease violation, which includes being a nuisance to the neighbors. So part of the approach is to remind people that they’re risking their own housing by trying to help others.
Members of your service team have to be on the same page. They might say to the individual, “This is the kind of thing that happened to you before. We know you want to help Johnny, but if you keep letting him sleep over and bring all his friends, the landlord is going to evict you and there won’t be anything we can do to stop it.” Research has shown that people do respond to the very practical approach of saying, “This is a lease violation; you can’t keep doing this.”
We also know that housing retention rates for people in Housing First are extremely high. So more often than not, your practical approach to people in addressing issues in terms of a lease violation is going to be successful.
Caller
I have a question for Gary. One of the biggest challenges I deal with, and I’m wondering if you have faced this as well, is what do you do when you have substance abusers who are very talented, but as soon as they get a paycheck, they are triggered to go back to substance abuse? This starts the whole ball rolling again where they lose their job, they lose their housing, and everything falls apart. Then what you’ll hear as the employment specialist is your colleagues saying, “Well, you know, it’s not good for that person to work because you’re enabling the substance abuse by providing a regular source of income.”
Gary Shaheen
This is very similar to what Ann talked about earlier in that employment services aren’t a standalone service, and it’s really a negotiation process with the individual. I’m sure if you’re versed in the harm reduction approach, you know it’s a matter of helping people develop a stronger motivation for working than they might have for relapse. So rather than focusing on the fact that the person is abusing substances again and you both agreed he wasn’t going to do that, focus on the implication that his substance abuse has on his ability to hold a job.
This needs to be tied together with strong case management services. And one of the things that some providers are trying is an option that’s almost like a “step-in, step-back, step-up” approach.
In other words, when people do relapse, they may end up losing their job, but it doesn’t necessarily mean that they’ve lost all contact with employment services. They may be able to work with an employment case manager or employment counselor and continue to be involved in some readiness services or perhaps do some more flexible types of work activities. But definitely, what you want to do is make sure that the person is engaged throughout the period of relapse as well.
As you can guess, there are no easy answers to this. It’s really about exchanging what people value and what they want with what they are willing to commit to when they are ready to do so.
Caller
The concept of job customization is a wonderful one, especially for the people we’ve worked with. But when we’re talking from the employer side, how do you best sell that to them? How could we begin to build bridges with employers to help them see what’s in it for them?
Gary Shaheen
One of my slides has a link to the U.S. Department of Labor’s Office of Disability Employment Policy. If you go to their Web site, you will see a whole number of articles and tools for the practice of customized employment.
Your task really is twofold. One is that you have to develop a good employer marketing strategy, working with employers to help them realize that the folks that are promoting themselves with your support are the best workers they can possibly get for that job.
One of the ways you do that is by developing relationships with employers and taking a look at the work they have to see whether or not there’s any opportunity to either carve out jobs or negotiate job positions.
You might find an employer, for instance, who’s having a lot of difficulty filling a particular job. But if you’ve established a relationship with that employer and you’re able to look at the tasks that job entails, you may find that one of your clients might be able to perform two or three of those tasks exceedingly well, but maybe he can’t do the other two.
So you’ve found a good fit for the jobseeker, because he is doing the tasks he is currently able to do, and for the employer, because they’ve been able to fill that job and then look for other resources within their business to assume some of the other tasks.
Ultimately, it all begins with having a good relationship with the employer, as well as having a broad array of services in your agency that include job readiness and job placement services and especially follow-along support services.
Was that a complete enough answer for you?
Caller
Yes, thank you. The resources especially will be great to access.
Gary Shaheen
There’s another Web site I want to mention. If you go to the National Center on Workforce and Disability/Adult, NCWDA, which is at the Institute for Community Inclusion in Boston, they also have a whole host of information on customized employment and employer marketing.
Conclusion
Tammy Bernstein
We’re just about out of time so if we don’t have any other questions, it’s time to conclude today’s program.
I’d like to remind everyone to please complete and return their evaluation forms and to visit the PATH Web site at www.pathprogram.samhsa.gov for other resources.
And finally, thanks once again to Ann and Gary, our featured presenters. Please watch for announcement of future teleconferences, which will be sent out on the PATH listserv.
With that our call is concluded. Thank you all for participating.