The issue of the chronically homeless, which includes hard-to-house subpopulations, is a common problem in cities across the U.S. A new way of addressing this problem was first developed about 25 years ago and is called Housing First. Housing First provides housing for chronically homeless people in their own permanent housing units at the very outset, rather than initially treating their underlying problems (e.g., substance abuse, mental illness, etc.) to make them "housing ready." The concept of this type of housing was developed in the late 1980s with a series of projects in several U.S. cities; the term "Housing First" was originally used beginning around 2000. The Pathways to Housing project, implemented in New York City in 1992, was the first to focus specifically on homeless substance abusers with psychiatric disabilities.
The Housing First approach has met with success. In San Francisco, for example, over a 3-year period the use of Housing First resulted in a 41 percent drop in the number of people living on the streets. Over 1,000 units of "permanent supportive housing" were established, and 95 percent of those who moved into the units remained housed. New York experimented with placing chronically homeless people with severe mental illness into supportive housing. This led to significantly fewer visits to emergency rooms, psychiatric wards, shelters, and jail. Overall, about 95 percent of the cost of providing the housing was made up for by reductions in public service expenditures.
In a 2009 study that matched Seattle residents of permanent housing with non-housed chronic public inebriates, researchers found that the residents drank less over time, had fewer visits to the hospital emergency room and jail, and spent fewer nights at the homeless shelter or sobering center. In the course of a year, the median monthly cost of services per individual dropped from just over $4,000 to under $1,000. It is estimated that housing these 75 individuals resulted in a savings of $4 million in just one year (See "For Further Reading"-Larimer, et al., 2009).
One of the most intensively evaluated Housing First facilities is 1811 Eastlake in Seattle. This facility is run by the Downtown Emergency Service Center (DESC), one of the largest providers of psychiatric services in Washington state. 1811 Eastlake is located in the Denny Triangle area of Seattle (south of Lake Union) and permanently houses 75 chronically homeless alcoholics, most of whom are end-stage alcoholics and experience mental illness in some degree. Forty percent of residents have a non-situational mental illness, such as alcohol-related dementia or bipolar disorder.
1811 Eastlake opened in 2005. It cost $11.6 million to begin the project, including purchasing the land and constructing the building. Annual operating costs of 1811 Eastlake are about $1 million (or $1,120 per person per month), and reflect the intensive level of staffing, including a full-time on-site Registered Nurse (RN), and five clinical social workers.
The facility operator, DESC, is one of the largest providers of psychiatric services in Washington State. It operates nearly 600 units of supportive housing in seven facilities, an emergency shelter with 279 beds, and state-licensed mental health and substance abuse treatment programs serving 1,000 clients. DESC employs 310 people and has an operating budget of $20 million. Only five percent of this budget comes from charitable giving. Funding for 1811 Eastlake comes in part from the City of Seattle; the rest is from rent payments from residents, who pay 30 percent of their income. Most of this income comes from various forms of social assistance, such as SSI (Supplemental Security Income) or SSD (Social Security Disability). In addition, one-third of residents have Section 8 housing subsidies. One of DECS's major focuses is connecting residents to appropriate governmental benefits.
1811 Eastlake is not a treatment facility-it is an example of supportive housing that employs a harm reduction model with an intensive level of services for residents. DESC's stated goal is "to improve the lives of its residents through reduced alcohol consumption, better health care, and increased stability. It will also reduce residents' use of the community's crisis response system, reduce public nuisances and encourage residents to undertake and follow through with alcohol treatment" (www.desc.org/1811.html).
Residents are not required to take substance abuse treatment or avail themselves of any other services. While services are available for those who want them, the residents are essentially tenants, with the same rights and responsibilities as tenants elsewhere. Residents are expected to adhere to a "good neighbor" policy, but essentially the only grounds for eviction are fighting and failing to assign funds for rent.
Alcohol is not provided to residents, although this is done in other Housing First projects, most notably in Canada. At 1811 Eastlake, residents purchase their own alcohol. They are taken by van to grocery stores and warehouse stores to buy food, alcohol, and other goods, and about half of the residents voluntarily participate in a managed alcohol distribution program through which staff members dispense to a resident upon request the alcohol that has been purchased.
One-third of the 75 units are cubicles. The rest are private rooms, each with a bathroom and efficiency kitchen with a stove, sink, and small refrigerator. As a safety measure to prevent cooking fires and burned food, the stoves only operate for a limited period of time before they must be reset. Residents are responsible for keeping their own rooms clean, though some need help with housekeeping skill development.
The on-site Registered Nurse and five clinical social workers are termed Clinical Support Specialists (CSS) and work individually with residents to develop residential service plans. Such a plan details problems and challenges, and how they will be addressed using the resident's strengths. Residential service plans are reviewed every 90 days. These on-site social workers differentiate 1811 Eastlake from other Housing First projects, which typically have visiting case workers available during limited office hours. On-site staff have greater availability to engage and interact with residents, most of whom rarely seek help on their own. The social workers at 1811 Eastlake use "assertive engagement" wherein they seek out residents and draw them in. Residents are not forced into treatment (which is in fundamental opposition to the Housing First philosophy). Treatment providers seek to attract residents into treatment programs by demonstrating how the providers and their services can be useful to them.
Along with the social workers and RN, there are also two or three Residential Counselors (RC) on duty at any time. The RCs carry out functions related to security, rule enforcement, crisis intervention, and counseling. 1811 Eastlake makes no rigid distinction between staff positions. RCs, in their routine contacts with residents, see things that are critical to the CSSs' understanding of their clients, and by sharing information with the CSSs the team can provide comprehensive integrated care. In some Housing First programs, two different organizations staff the RC and CSS positions, or else two distinct branches of the same organization are assigned to do this.
This facility in the Denny Triangle area is located in a diverse, primarily commercial neighborhood bordered on two sides by the I-5 freeway and an overpass. According to DESC's Executive Director, Bill Hobson, stable neighborhoods are preferable for a facility like 1811 Eastlake. Locating such housing in areas with a concentration of social problems that contribute to chronic substance abuse would not be as effective. To develop social stability, individuals need to be in a stable environment.
1811 Eastlake is one example of the Housing First philosophy in Seattle. The construction and maintenance of this facility and other affordable housing in Seattle is partly supported by a housing levy. Recently passed by 63 percent of voters, the levy adds $3.60 per $1,000 of assessed valuation, and will raise $145 million over the next seven years. In addition, in King County there is a one-tenth of one percent sales tax (on top of the existing sales tax) that is directly applied to fund services for those with substance abuse problems and mental illness. This tax is expected to bring in $54 million annually. DESC and 1811 Eastlake both receive funds from these sources.
Sharon Chamard is an Associate Professor of the Justice Center.