Housing comes first

The method hailed as the best way to end chronic homelessness was born of desperation more than two decades ago on the streets of New York City: Psychologist Sam Tsemberis despaired seeing his severely mentally ill, drug addicted or alcoholic patients cycle from the streets to jail, psychiatric wards, homeless shelters and back to the streets.

He knew that what they needed most was a permanent home — a simple, decent rental in the neighborhood. But the standard protocol at the time would never get them there, because the client had to stop drinking, for example, to be deemed "housing ready." Tsemberis flipped that model: He moved homeless people straight into their own apartments and simultaneously offered intensive treatment to help them achieve mental stability, lead healthier lives and join the broader community. Rather than "if you do this, you can come inside," the message was "come inside, and let’s do this."

Pioneered by Pathways to Housing, Inc., the nonprofit Tsemberis founded in 1992, the model became known as Housing First. Its success — 85 percent of Pathways’ clients maintained residency — has been replicated worldwide, including in 40 U.S. cities. It is cited by the U.S. Interagency Council on Homelessness as a proven method for ending all types of homelessness and the most effective way to end chronic homelessness, characterized by long-term or repeated periods of homelessness, often in tandem with mental illness and disabling substance abuse.

Hawaii has recently adopted the philosophy in two pilot projects, including one focused on homeless veterans, and is beginning to implement the broader Hawaii Pathways Project, thanks to a $2.1 million federal grant and a collaboration among city, state and federal housing partners, said Colin Kippen, chairman of the Hawaii Interagency Council on Homelessness.

The goal is to get at least 120 of Hawaii’s most vulnerable homeless people into permanent housing over the next three years and bring them the medical and social services they need. While reaching just a fraction of the at least 692 chronically homeless people on Oahu, according to the annual statewide count last year, and an even smaller percentage of the island’s overall homeless population of at least 4,556 people, it is a ray of hope amid a string of deaths among shelterless men on Oahu, including five homicides in the past six months.

"We have committed on Oahu to doubling the rate at which we house the chronically homeless. This is an extremely vulnerable population," Kippen said. "But this is not a crisis that government will solve alone. We need private industry and everyone in the community to join us in this cause."

Late last fall, the Hawaii Department of Health’s Adult Drug and Alcohol Division was awarded the three-year grant from the Substance Abuse and Mental Health Services Administration (SAMHSA), a branch of the U.S. Department of Housing and Urban Development to implement the Pathways project, one of 11 states so funded. Outreach will begin early this spring with 40 homeless individuals, who will receive vouchers for public housing or other affordable rentals and be supported by social services including drug treatment, medical care and psychiatric treatment, said Nancy Haag, administrator of DOH’s Alcohol and Drug Abuse Division.

Tsemberis, Pathways to Housing’s CEO, and Juliana Walker, the nonprofit’s training director, will lead training sessions with outreach workers in mid-February, explaining the finer points of the noncoercive "assertive engagement" with the chronically homeless that is a hallmark of Housing First. Tsemberis also looks forwarding to meeting a diverse cross-section of the community at a presentation that is open to the public (see box).

"Too often the conversation about the solutions to homelessness becomes a narrow conversation among service providers," he said in a telephone interview. "Unless we have a much larger community conversation, these people, our fellow human beings, are left to fend for themselves on the streets."

Tsemberis, a clinical community psychologist who holds a doctorate from New York University, is driven by a moral imperative to help society’s most vulnerable members "enjoy the simple dignities of life." However, he also acknowledges Housing First’s economic appeal: "Getting people with complex diagnoses into their own place turns out to be much cheaper than keeping them homeless."

Once housed, individuals who are not already enrolled generally qualify for federal benefits such as Medicaid, Social Security Disability Insurance and the Supplemental Nutrition Assistance Program, popularly known as food stamps. Thirty percent of their adjusted household income goes toward rent, as other government-subsidized tenants pay. According to the USICH, the price of subsidizing housing, mental health, educational and employment services pales compared to the higher expenses associated with prolonged homelessness, including the cost of law enforcement, incarceration, use of hospital emergency rooms and other crisis interventions. As some costs shift to the federal government, state and local municipalities can redirect their own limited resources.

"And that’s just in terms of actual dollars," Tsemberis noted. "There’s a much higher toll when homelessness is allowed to persist. Every time someone passes a homeless person on the street and simply looks away, we are losing our humanity."

Other cities have made great strides with a combination of public and private resources, he said. In Philadelphia and Salt Lake City, for example, private donors and religious groups help cover expenses not paid for by the government-funded rental vouchers, such as furniture. Developers or landowners could partner with the government in the construction or conversion of affordable rental units and major donors can help galvanize and sustain successful initiatives. Individual apartment units and shared houses both work well in the Housing First model, depending on the clients’ needs and desires, he said. "Cities all over the world are getting this done," he said. "Mostly what it takes is the will of the people."

Haag said staffers are eager to replicate Pathway’s success, saying "We are looking forward to the same positive outcomes here, both for the individuals involved and our overall community health."

Oahu’s homeless population has risen continuously since 2009, when 3,638 people were tallied in the annual count, including 486 chronically homeless. This rise does not go unnoticed in Waikiki, where visiting tourists decry unsightly encampments that clash with their vision of paradise, and human rights activists respond that homeless people unable or unwilling to bunk in the close confines of shelters have virtually no place left to go but the public sidewalks, having been driven from Kapiolani Park and other sites at night.

The Waikiki Business Improvement District Association, which commissioned the comprehensive study "Homeless in Waikiki" in 2006, is among the groups seeking solutions along a three-pronged approach emphasizing permanent housing for the homeless, increased social services, and enforcement of city and state ordinances designed to keep public spaces available and appealing to everyone.

Among other things, the association funds a case-management position at Waikiki Health, a group of clinics that provides medical and dental care and social services to all, regardless of ability to pay; the client base includes many homeless people. Waikiki Health also operates the Next Step homeless shelter in Kakaako.

Sheila Beckham, CEO of Waikiki Health, and Jan Yamane, executive director of the Waikiki Business Improvement District Association, both said they were heartened that the city and state governments have coalesced around Housing First. If the approach proves successful among the chronically homeless, it could be modified for other subsets of the homeless population, such as families who urgently need affordable rental housing and job training, but perhaps not such intensive mental-health services.

"Really effective leadership and coordination of existing resources is of paramount importance, and we are seeing that now at both the city and the state level," said Yamane. "Everyone realizes that the status quo cannot continue."