Reflections on the Finnish Experience from a US Perspective

Dennis P. Culhane

University of Pennsylvania

Overview

Housing First! In the US: Policy or Program?

Current Debates on Siting

Emerging Models for Floating Support

Structural and Policy Perspectives

Housing First: Policy or Program?

Consumer-led Movement by People with SMI Became an Evidence-based Practice in Pathways Adopted as Official US Policy in 2009 Applies to Chronic and Crisis Homelessness In field – as much a philosophy as a policy – room

for interpretation

Current Debates on Siting

Model has emphasized “consumer choice” and “housing as housing” not a residential program

Congregate siting emerged in NYC and elsewhere “Olmstead” Supreme Court Decision – states are

interpreting unit concentration threshold Consumers continue to advocate choice and “normalized”

apartments Experience has shown some need and want more structure:

“Permanent” Safe Haven Models

Emerging Models for Floating Support

HF model originated with Assertive Community Treatment (ACT)

Recent research finds ACT no better than intensive case management (ICM), and ICM no better than Peer Support (quite lower cost)

High fixed costs for support limits growth in units Critical Time Intervention as bridge to mainstream

supports – Possibility for sustainable growth

Structural and Policy Perspectives

Commitment to HF! Policy – but Scaling Issues Remain

Cost Argument has been Critical to Policy Adoption

Aging of Adult Homeless Population is Key Factor for Future

Integrating Evaluation into Programs Necessary for Sustaining Political Support

Commitment to HF! But Scaling Issues Remain

Approximately 100,000 CH in the US Flat HUD Homeless Budgets from 2010 to present Veterans are the Exception: 70,000 units since

2009: Veteran Homelessness down 35% Affordable Care Act (ACA) with Medicaid

Expansion Holds Major Promise for Services Funding (But States Must Adopt and Adapt)

Gap: Who will pay housing cost for nonVets?

Cost Offsets Critical to Policy Adoption

Research has indicated that especially for people with SMI, PSH/HF may be budget neutral over time

For people with chronic substance abuse – evidence is less robust

For people in service-poor states, not likely offsets For aging homeless population, case may be

stronger

Aging of Adult Homeless Population a Key Factor for Future

Adult Homelessness in the US reflects an “Easterlin Cohort Effect”

Increased Costs Predicted with Aging Cost Offset Opportunities Increase – Avoidance

of Unnecessary Nursing Home Care US Budget Provision Allows Accounting for Cost

Avoidance in Allocating New Housing Expenditure

A Cohort Phenomenon

31-33 40-42 49-51

Source: Culhane et al. (2013)/ U.S. Census Bureau Decennial Census Special Tabulation

Integrating Evaluation into Programs Necessary for Political Support

Evidence and Cost Research has been key to Sustaining Political Support

Mandatory Data Collection for Homeless Programs (HMIS) Has Created Infrastructure

Mandatory Performance Measurement Immanent (Housing Placement Rates and Returns to Homelessness- at Program & Community Levels)

Data Integration – Linking HMIS and Mainstream Service Data – a Growing Capacity with Impact

Concluding Thoughts “Olmstead” (Supreme Court ruling) may drive siting issue

debates, but some structured environments appear needed New and low cost service models needed: CTI, Peers, and

Mainstream Supports? Federal housing spending a problem for capacity Aging issue a key factor for future Integrating data collection into programs, and linking data

across systems a future potential