Ep 66: Chronic Homelessness and Housing First with Tim Aubry (Pathways Home pt. 6)

The Housing First approach starts with providing homes to chronically unhoused people, but it doesn’t stop there — and that’s what makes it so effective. Tim Aubry shares findings from a major Housing First study and the keys to a successful program.

Show notes:

• Goering, P., Veldhuizen, S., Watson, A., Adair, C., Kopp, B., Latimer, E., Nelson, G., MacNaughton, E., Streiner, D., Rabouin, D., Ly, A., Powell, G., & Aubry, T., (2014). National Final Report: Cross-Site At Home/Chez Soi Project. Mental Health Commission of Canada.
• UCLA Housing Voice episode 64, with Beth Shinn, talking about effective interventions to family homelessness and a brief mention of Housing First.
• Aubry, T., Bloch, G., Brcic, V., Saad, A., Magwood, O., Abdalla, T., ... & Pottie, K. (2020). Effectiveness of permanent supportive housing and income assistance interventions for homeless individuals in high-income countries: a systematic review. The Lancet Public Health, 5(6), e342-e360.

Transcript

Shane Phillips  0:04  
Hello! This is the UCLA Housing Voice podcast, and I'm your host, Shane Phillips. This is the sixth installment in Pathways Home, our series on research into the causes of and solutions to homelessness. Tim Aubry is our guest this time, talking about the Housing First approach to ending homelessness for people who are chronically unhoused and have a serious mental illness. The Housing First model starts with providing a person with housing they can afford, or with financial assistance to make housing affordable. That is only the first step, and it's complemented by a range of medical, mental health, employment, social, and other services to help residents stay housed permanently. The idea, to put it as simply as possible, is that managing problems like mental illness and addiction are a whole lot easier when you've got a place to call home, and so our efforts to help this population should start there. 

A little more than a decade ago, Tim and a group of colleagues embarked on a major study into the effectiveness of Housing First, funded by a $110 million grant from the Canadian government. The results were exceptionally positive, with people receiving the Housing First treatment staying stably housed at twice the level of people receiving treatment as usual after two years, and similar gaps in self-reports of quality of life. It effectively ended homelessness for about 80% of participants, and a large share of the costs were offset by savings on shelter use medical care, and other public services. Housing First did not improve every outcome, however, which may partly explain why it remains controversial in some circles. As the last research-focused episode in the Pathways Home series, I think this topic really captures the broader challenges with ending homelessness. We have an intervention here that works for many, but not for all; that solves some problems, but not others; that improves people's lives, but needs complementary reforms to fix the structural factors that drive people into housing instability and homelessness in the first place; and that is limited more by our ideas about who deserves help, and who doesn't, and less by the inadequacies of the intervention itself. 

As I said last time, we've expanded this series from six episodes to eight. Next up is a conversation with two members of the Homeless Programs Office at the US Department of Veterans Affairs, and last will be a summarizing episode where we reflect on everything we've heard and learned over the past four months. The Housing Voice podcast is a production of the UCLA Lewis Center for Regional Policy Studies, with production support from Claudia Bustamante, Gavin Carlson, and Jason Sutedja. As always, you can send comments and questions to shanephillips@ucla.edu. With that, here's our conversation with Tim Aubry.

Tim Aubry is a professor in the School of Psychology and senior researcher at the Center for Research on Educational and Community Services at the University of Ottawa and he's with us today to talk about the Housing First model and his research into its effectiveness at addressing chronic homelessness for people with serious mental illness. Tim, thanks for joining us, and welcome to the Housing Voice podcast. 

Tim Aubry  3:34  
Thanks Shane, thanks for having me.

Shane Phillips  3:36  
And my co-host today is Mike Lens. Hey, Mike. 

Michael Lens  3:38  
Hi, Shane. Great to meet you, Tim. And hello out there everybody.

Tim Aubry  3:43  
Nice meeting you. 

Shane Phillips  3:44  
As always, we start the show by asking our guests to give us a tour of a city or a town that they know well. Just a few stops in a hometown or somewhere they've lived since then that they want to highlight. Tim, I think you're gonna take us on a tour of Ottawa. Where are we going?

Tim Aubry  3:58  
You got it. Ottawa, Canada, because there are Ottawas in the US. I think in Kansas, Illinois. Well, Ottawa is the capital capital of Canada, and I think the seventh coldest capital in the world. Yeah. This time of year, that's pretty obvious. But a little over a million people. Couple hours from Montreal, five hours from Toronto to drive. Being the capital. It's got his last offer. He's got all the National Museums National Art Gallery. It has a canal that's quite well known. And in fact, the longest skating rink in the world is the Rideau Canal. It seems appropriate for Canada. Yeah, freeze reasons. It's not open yet though. And it never opened last year now but it will open this year. It's very clear because it's going to be brutally cold here these next few days, and it's a nice place to visit I've been we have Winter Carnival at the end of February. If you skate you might come to that but I'd recommend you come to the Tulip Festival in May we have a lot of festivals here because we are the capital of the country. So I would encourage you to come and see Ottawa.

Shane Phillips  5:17  
I think our California and listeners might be much more interested in the the May Tulip Festival visit than the January or February skating, freezing temperature visit. Yes.

Michael Lens  5:29  
I'm from the capital of Minnesota. I wonder how Ottawa and St. Paul compare in terms of capitals? Yes.

Shane Phillips  5:41  
So our discussion today will center around a report that's now approaching 10 years old, published in 2014. For the Mental Health Commission of Canada. It's known as The National Final Report on the Cross-Site At Home / Chez Soi project. And it's authored by Tim and about a dozen others whose names you can find in our show notes online. But we do want to call out by name the study's lead, Paula Goering, who sadly passed away in 2016. The study came about from a $110 million investment by the Canadian federal government, which had the goal of generating knowledge about effective approaches for people experiencing serious mental illness and homelessness at home che sua che sua just means at home in French for the non French speaking listeners, was structured as a randomized controlled trial, which as we've noted before on the show is the gold standard for research design when you want to evaluate the effectiveness of a specific intervention. And in this case, that intervention was Housing First. The idea behind Housing First is that for people experiencing homelessness, who also have significant barriers to returning to stable housing, like mental illness, the most effective approach in most cases is to provide Housing First, once that individual is indoors in a home, you then work to address their other needs. This is in contrast to how we've traditionally approached homelessness in the US and Canada, which is to withhold housing or housing assistance until those other problems are resolved. get sober and we'll give you help with housing, get your mental illness treated, and then we'll help you with housing is essentially the idea. Housing First, proponents argue from a pretty common sense perspective, that these problems are much more challenging to resolve when you're living in a shelter, a car or a tent on the sidewalk. The at home che swap project, which operated in five cities with different contexts, shows quite persuasively that the proponents of Housing First are correct, though the devil as always is in the details. To preview the findings just a bit. The housing related outcomes like days in stable housing and housing quality, were unequivocally and strongly positive for the people who received the Housing First treatment, while health, social and other non housing outcomes were generally positive, but more mixed. We'll be getting into those details over the next hour along with some conversation about the criticisms of Housing First, and what we've learned in the years since this report came out. Now finally, I want to turn it over to you, Tim, to tell us more about the Housing First model generally, and the at home Shay swap project, specifically, starting with Housing First, in the report, you say that housing stability, quality of life and community functioning outcomes were best were the programs operated most closely to these five principles, immediate access to housing with no housing readiness conditions, consumer choice and self determination, recovery orientation, individualized and person driven supports, and social and community integration, adding to what I've already shared, could you provide some further explanation on what the Housing First approach is, and maybe say a bit about how these five principles are applied, and why they're important to the model? 

Tim Aubry  8:58  
Great, thanks Shane. So one way to think about Housing First is there's two big components. There's the housing, and there's the support, and the housing. You know, there's a set of standards that game you know, people are going to pay 30%, towards the housing, they're going to have some choice when it comes to housing to finding a place that that suits their needs, they feel suits their needs. And it's scattered, this is important day this this is what I mean by scattered is people are living integrated in the community, next to other people who are have nothing to do with the program, you know, so there's you've got your community integration. Now, on the support side, typically it's either in the pure model the pathways model of Housing First, for people with highest level of needs. It's a wraparound model called Assertive Community Treatment. Hmm. And for people with more moderate needs, it's intensive case management, and the wraparound. The case loads are smaller for staff. And it's multidisciplinary, whereas the intensive case management, people are referred to the community that you get direct service, ongoing contact, and so on. And so those are the two big pieces that tries to actualize the choice if you mentioned and that's, that's a central part of housing. First, it's recovery based. You know, in mental health, now we talk about recovery, where people even though they may have long term mental health problems, they're still gonna move forward in their lives, they're gonna find things in their life that's important, that satisfying and so on the application of harm reduction. So people with addictions are commonly housed in Housing First programs. And you're exactly right, that you start with the housing and then you work with people to figure out what are their service needs, what are their support needs. And the thing is, when we talk about the support, Assertive Community Treatment, has been around now in mental health, quite frankly, for over 40 years, and has a track record separate from Housing First, and a track record even of ending homelessness without the housing. And similarly, intensive case management is considered evidence based as a form of community support. And it also has a track record of ending homelessness. So what Samson Baris the founder of this model, the creator of the model is he took these kind of tried and true forms of community support that we already had any attach them to housing, but to supports portable. So the housing is in is an institutional, it's not congregated, what we call group housing, it's scattered site housing.

Shane Phillips  12:01  
I actually think it might be helpful with that understanding now to put ourselves in the shoes of someone 20 or 30 years ago, before Housing First was maybe even known, but certainly before it had been studied systematically. Why did they? Or maybe more to the point, why did you and your colleagues believe that this approach might be promising, I shared that one reason about it being more challenging for people to address serious problems like mental illness or substance abuse, when they don't have a safe and stable place in which to live. But what other reasons were there for thinking that this could be a really effective solution for some people experiencing homelessness, especially compared to what we were doing at the time? 

Tim Aubry  12:43  
Well, I will start shaking and say that what we were doing at the time, you know, and for for a long time, wasn't working, people just kept coming back and to be homeless. A lot of them never got off the street. And a lot of them were dying, quite frankly. Now, the story of Housing First, you know, starts with with Samson, Baris who's who's doing outreach work in New York City. And Sam, as I mentioned, is the creator of Housing First. He's a Canadian, I just should mention, who moved. 

Michael Lens  13:17  
I didn't know this. 

Tim Aubry  13:18  
Yeah, he's Canadian. So when he was doing outreach, and he they started asking people, they've never thinking of services, like we, you know, what services do you need that you're not getting? And repeatedly, he heard from people? Well, don't, don't you get what I need. I need housing. Like, that's my first and foremost need. And so he took a risk. And he decided to pilot a small project that essentially put people in housing, and with some support and see, could they manage it? I mean, the thinking at that time, this was the late 80s, early 90s, was that most of those people were not going to be able to stay in their housing just wasn't going to work. They weren't ready, because we were following what's called the staircase model. And people had to they had to work to become equipped to be able to live independently. So they had to move through a series of steps on the staircase, you know, transitional housing group housing to finally merge at the end of it and independent housing. But so he tried the pilot, and it went very well. There weren't a lot of evictions, there weren't a lot of people leaving their housing. And then he went from there and set up some research, including two trials, two randomized controlled trials. And it was those findings that we came across when we were looking at putting together the at home Shea swap project in Canada in 2008. That were promising because there was one article I came across I think it was in the American Journal of Public Health. And Sam's group was reporting that after five years, 84% of people had retained their housing. I didn't believe by the way, those numbers, I just, I mean, again, I was, I was also being influenced by the perception of this group of people, you know, who appear that they would not be able to manage their own place. So based on those promising kind of findings that were in the literature that had been tested in a rigorous manner, we decided to put together a large, multi City Trial In Canada, where we would test it in cities of different sizes, different population composition, we would test it with indigenous people, we would also test it with racialized populations, like in Toronto, we were all really wanted to see could this thing work? Could we take what the model this what's called the pathways model, the housing and support and put it in place in different cities in Canada, and find out, is it effective? Is it cost effective, one of the benefits were the problems. And so that's essentially what we did in this in this very large trial that the government put $110 million towards it. So so it's a big investment. But again, because the visibility of chronic homelessness at the time, and it was actually spurred on this this trial, which is very interesting kind of footnote to this thing. Prior to the Vancouver Olympics in in 2010. There's a downtown neighborhood there, that's infamous, the Downtown Eastside and the government really wanted to do something, you know, to try to try to make Vancouver look better. When all these countries were going to come for a visit for the Olympics. So that was also part of the backstory of this trial. 

Shane Phillips  17:11  
Not the most noble motivation in that regard, but a good outcome nonetheless, I suppose. 

Michael Lens  17:17  
No, but and it's obviously very relevant to the upcoming years here in Los Angeles. Tim, I wanted to follow up quickly with, you know, a question that I think is probably hard to answer. But in your experience, what do you think, is the reason or set of reasons why there's always been so much skepticism that housing is really the main problem here, if I may, you know, I'm a housing researcher. I've kind of helicoptered into homelessness policy and research a little bit later, but I come from housing. And so to me, it's obvious we call it homelessness, we don't call it you know, mental health, we don't call it substance use problems, generally, like we refer to this population in various ways. But homelessness is obviously the key word. Why is there always so so much skepticism about the fact that that housing is really the thing people need first and foremost?

Tim Aubry  18:17  
I mean, I think it's stigma that's operating in the general population. I think, if you look, historically, we relied on psychiatric institutions. And people were very much stigmatized when they were in the psychiatric institution. But when you think about it, the psychiatric institution is very clear what the message is, because people were spending their lives in psychiatric institutions, they can't live in the community, they just don't have the competencies. And you know, and of course, in their sphere of danger, if we if we let them out, and so on. But but you know, we got past that, to the point of closing psychiatric institutions, both in the US and Canada. You folks started in the 1960s, we were about 10 years after that. But I think the stigma that operated in those institutions followed people into the community. And you know, with stigma, there's discomfort, and so on. And it's very true, this idea that, you know, why do we focus on symptoms, functioning addictions? And think we can we need to fix those first, before getting to the housing. I think it's just it's just the way we have thought about people with severe and persistent mental illness that continues to this day. And that requires, quite frankly, a lot of public education we need to do, because even though the evidence is pretty unequivocally that Housing First ends homelessness for most people, even though that's the case, I don't think the public believes that. In fact, I would go even further and I know for a fact that there's service from voters out there that work with people in shelters in drop in centers. They don't believe that either. So so this is this is part of the challenge of trying to scale up this approach in communities.

Michael Lens  20:14  
Yeah, that's the thing. I think it resonates today as a problem, right? This is not just like, Oh, why were we skeptical about this in the 80s? And 90s? It's like this is, this is what typical people believe. Right now. I agree completely. 

Shane Phillips  20:26  
Yeah. And, you know, I think beyond the the mental illness element of this or the the stigma, I think there's also just the deservingness, Aspen's and this feeling of, you know, why are we giving people free housing, when it's, you know, I'm working so hard to afford it myself. I think I understand it to some extent, and I think it's something we have to move past, but it is a hard thing to do. And, you know, I think people, again, this is a public education thing, to some extent where there's a little bit of a misunderstanding, I think about what Housing First really is, and what is being, quote, unquote, given away. And I think we'll get to that in a few questions. But I want to move on here and talk about the at home Shea swap project itself, if you can just say a little bit about how the study was structured, and in particular, who participated in it?

Tim Aubry  21:19  
Yeah, so as I mentioned, five cities, there were over 1000 people, it was 11 foot 1150, who got Housing First, there was a random assignment to get either Housing First, or what's called treatment as usual. treatment as usual, by the way was everything else that community offered other than Housing First, in each city, at least for the five, I'll get to the fifth city mungkin in a second. But in for the cities, we had three variations of Housing First, we had one with Assertive Community Treatment. That's where people with the highest level of needs, these were people who possibly had a hospitalization history, they had concurrent disorders, which I think in the US has dual diagnosis had mental health problems and addictions, they had more severe kind of mental health diagnoses, and in particular, psychotic disorders. So those are the highest level of needs, and they were gonna go in and get support through a sort of community treatment, along with the housing. The second variation was with intensive case management. These were individuals who had more moderate level of needs long term depression, they were obviously functioning better. But still, the mental health, the mental health issues were real challenging for them. They also anxiety disorders, but they were still at a more moderate level of need. And there was a way of assessing their functioning that also came into play. And they got for support intensive case management, which is the less intensive, but it's still it's still quite intensive. And then the third variation, which is pretty interesting, and I, you know, you mentioned Polidori, really Polidori, who led this project, who was just a master, and had a career in community mental health, she devised this idea that every city would get to put together their own Housing First program, they would put together whatever they want, but it had to involve the implementation of Housing First principles. So this is where in Toronto, they decided, let's do a program that has a good dose of anti racism, anti oppression, with an agency that works with racialized populations across boundaries. In Winnipeg, they decided what they would want to do is they wanted to put together an indigenous version of Housing First, as there's third variation, and then out in Vancouver. Their third variation was actually a congregate or single site form of Housing First, and then Montreal decided their version would include supported employment, which is kind of interesting. So what's your house? What's next? Well, a lot of people say, you know, I'd like to either work or go back to school or do something. And then finally, in Monkton, there was only because it's a small population, there was one program with assertive community treatment, and then the the local variation was a rural arm of Housing First. So this was a chance really to test Housing First in a in a bunch of different forms, but also to populations with different level of needs.

Shane Phillips  24:36  
And just to add a little bit there, in terms of demographics, I think one thing to call out here is that the average time that participants in either group the treatment as usual or the Housing First, their average time of homelessness was about five years. And you know, just to underscore the vulnerability of this population, the participants reported an average of four to five types of adverse Childhood Experiences out of a list of seven. Those seven were emotional, physical and sexual abuse directed at them, or in their living situation being exposed to domestic violence, neglect, exposure at home to substance misuse, or having a household member in prison. So, you know, again, the average person had four to five of those seven experiences during childhood, which greatly increase your risk of homelessness as an adult. So this is really a very challenging population to house really the most difficult to house among the homeless population. And there was a lot of variation otherwise in terms of age, ethnic background, gender identity, education, etc, as you know, about I think two thirds men but a third women. Can you say a little bit more, though about the services? I understand there's the difference between assertive community treatment and then intensive case management? I think we haven't made clear though, how those services are delivered. Those are on site services, essentially, right? You have people in the facility, particularly with the AC T, the high need population, there's someone there all the time, correct.

Tim Aubry  26:08  
Actually, though, the services are delivered in the community generally, okay, they do come they do come to the agency, though, to be clear. But that's, that's why we refer to them as portable. And the minimum that people had to agree with was one visit per week. Okay. So it depends on what was going on. But the philosophy of the services, whether it's assertive community treatment, or intensive case management, was to go to people rather than them to come to you, you know, that it wasn't office based. So you know, a lot of the services were delivered in people's homes, actually, or they, you know, they'd go to coffee shops, they would do things depending on what issues if they got assistance to go to appointments in some cases. Now, the distinction though, between assertive community treatment and intensive case management is important, because I mentioned earlier that you've got these multiple disciplines that are part of a team for intensive case management, typically led by a psychiatrists who is the clinical lead, but then you've got psychiatric nurses, you've got social workers, you've got occupational therapists, you can have an addictions treatment specialists. And they work together and share the case loads. So you see, so that's a little different. intensive case management, the case manager has, will be the primary case manager for a caseload a typically it's in the range of 12 to 15, we were at the lower end, probably more around 12. And then typically, Assertive Community Treatment is eight to 10. So you can see the difference in terms of in terms of intensity, intensive case management, you're going to refer people a lot more into the community for the service, because you're there's only you, again, no, there's a minimum expectation of a visit a week, people are followed very closely in these programs. There's checking in going on continually. The service planning involves a set of goals that are worked up in collaboration with the clients. There's a heavy emphasis you mentioned earlier about choice. It's not only choice of housing, but it's also choice of services. Part of the early stage of working with people of delivering support is just engaging them. I mean, these are people who've had no some of them, I've had nobody in their lives for years, and they're very nervous can be suspicious of service providers. So there's a period of time at the beginning, it could be a few months, it could be six months, it could be a year or more, where people just have to be engaged and start to develop a trusting relationship with their case manager with their service provider.

Shane Phillips  28:59  
One of the seven main messages in your executive summary is quote, It is Housing First. It is not housing only. Beth Shinn said the same thing in our conversation a couple of years ago, which is the episode we re aired just a couple earlier in the series. And I think a lot of the criticism of Housing First seems to derive from that misunderstanding of Housing First versus housing only. Could you tease out that distinction? Or is there anything about that you want to underscore for our audience?

Tim Aubry  29:29  
Yeah, I mean, this has been, you know, part of the problem reputation lately with programs using the term Housing First, even though they're not following the model, and in particular, they're not delivering necessary support to people. And quite frankly, it's a recipe for disaster if you don't have support and good support for people. I mean, these programs have a set of fidelity standards, and typically are assessed on some kind of semi regular have a basis to make sure that things like support are being delivered. And it's actually intensive case management or it's assertive community treatment, people are being seen regularly. They're also being monitored in the way with it. When the teams get together, they talk about where is a person at, what do they need, they flag if people are in a crisis, and so on. So this idea of not either having support or not having sufficient support, it's been a real problem, and it has hurt the reputation of Housing First.

Shane Phillips  30:33  
Okay, so getting really into the study, you measured a bunch of housing outcomes, social and health outcomes, and service use and cost outcomes. And I think we can just go through those three categories sequentially. Starting with housing outcomes, as I said, the Housing First treatment was unequivocally positive compared to treatment. As usual. What findings in the housing section do you think are particularly worth highlighting here?

Tim Aubry  30:58  
The gap between people who are in the treatment as usual group, and people in Housing First is very large, what you see is you see people getting housed in the first six months. So there's a spike in the Housing First group, and then there's a plateau that carries on for two years, our main outcome we looked at was percentage of time stably housed among the two groups. It's a very large difference. Now, interestingly, if we stay with that housing outcome, Toronto actually followed people for six years, because you know, one of the questions always with studies is well, are the benefits sustained. And they found that the people with high level of needs never changed. There was still this gap, the people in treatment, as usual, were not getting housed. And the people in Housing First were staying house. Interestingly, in the people with medium needs, there was a catching up that went on with the trip people in treatment, as usual, but they still weren't there, there was a narrow gap at six years. So these housing outcomes, you know, they're very large, and quite frankly, they're sustained. And they're at the level that you don't see that often in, in the psychosocial interventions, quite frankly, you know, certainly, they would rival any of the best interventions in medicine, and so on, when we talk about what's called in the research world effect size, these are very, very large effects. That's been replicated in programs. And what we're seeing out in the field in programs, typically, programs have success with 80 to 90% of people. Some programs, you know, depends on their population and so on. There is a group of people, though, I don't want to, you know, kind of sugarcoat this, who run into trouble in Housing First, it doesn't fit with their needs. We sometimes talk about it as a 10 to 20% of people. And we saw that in the at home che SUA a project, and we had to do some work to try to figure out well, if after, you know, a couple of years, people have still not settled in their housing, should we be looking at other options for them?

Michael Lens  33:24  
I think some of the misconception might also be related to that 10 to 20% number, because I think most people would think that that hardest to reach population is probably a lot larger than that as well.

Tim Aubry  33:38  
Absolutely, absolutely. I mean, I was especially involved in Monckton, and it was interesting, they used to talk about the 12 people in the 100 participants who were receiving Housing First, there was about 12 people that weren't settling. And the difficulty was they talked about it, how they took up a lot of time. And it color's your perception of the program, the success of the program, and so on. They were very clever. They actually came up with an alternative model. That was a group model, but people still had their own apartments, but they were put together in small apartment blocks. And there was a pure couple who oversaw kind of acted as superintendents in the building. So the 12 people, they actually went into those. I think it was into two buildings, and they had pretty good success. And those programs still exist today, actually, in Moncton. 

Shane Phillips  34:32  
Just to put some numbers to this. So folks have a sense for how big an effect we're talking about. I should clarify. I think Tim kind of hinted at this a little bit. This was a two year study. I think the researchers have continued to follow up with--

Tim Aubry  34:45  
And Toronto, I mentioned Toronto did, yeah. 

Shane Phillips  34:48  
Right, right. But overall, each of these places was studied for two years. And that's the findings that we're reporting on. And so, in the last six months of the study 62% of the Housing First participants were housed all of the time compared to only 31% of the treatment as usual participants, and that's after they had quite a bit of time to converge. This was kind of their closest convergence. And it was still twice as many Housing First participants were housed all the time. And on the other side of the ledger, only 16% of Housing First participants were housed none of the time compared to 46% of the treatment as usual. So about three times as many were housed none of the time. So these are really, really significant effects that again, as Tim said, you don't see that kind of impact from programs very often or that kind of difference relative to existing services or existing programs. So let's move on to health and social outcomes. And I have a little more of a challenging question here. I think more good participants in the Housing First group self reported higher quality of life and received somewhat higher community functioning scores. And in interviews, they reported being less survival oriented and more secure, peaceful and less stuck. The qualitative interviews were especially positive with 61% of Housing First participants describing a positive life course since the start of the study, compared to only 28% of treatment as usual participants again, about twice as many treatment as usual participants, on the other hand, were about more than four times as likely to describe a negative life course over the study period. That is all very positive news. At the same time, while both the Housing First and treatment, as usual groups saw overall improvements in mental health and substance related problems over time, the Housing First participants did not perform meaningfully better, not statistically significantly better. My view on this is that the improvements in those areas are not essential for considering Housing First to success given all of these other positive outcomes, particularly with housing itself. But it does seem to call into question the idea that providing people with housing makes it easier to solve their other problems in the Lancet in 2020. This is another publication, you and co authors published a systematic review of studies of permanent supportive housing interventions in high income countries. And while you found substantial improvements to housing stability, as you did here, there was no measurable effect on severity of psychiatric symptoms, substance use income or employment outcomes, I actually came across that review article in a conservative critique of Housing First, and I imagine you would disagree strongly with many of its conclusions. So I'm curious to hear your thoughts on those criticisms, and, you know, some of these perceived shortcomings of the Housing First model, and how that has factored into support or opposition for this approach.

Tim Aubry  37:45  
Yeah, yeah, let's unpack those. Because it's, there's a lot going on there. You know, overall, when we get over 1100, people, the 1150 people getting Housing First versus about 950. of treatment, as usual, to see you put the two groups together across the five cities, you see, relatively, it's really more of a small effect, small, modest effect around like you said, quality of life and community functioning that was assessed as part of the trial. But if you disentangle the two groups, you only see greater improvements in quality of life, in the variation of the trial, where people are getting intensive case management, you don't see it over two years with a sort of shape and you see it at one year, but not at two years. 

Shane Phillips  38:34  
So just to be clear, the high need population is not really seeing improvement in quality of life and community functioning, but the moderate need group is.

Tim Aubry  38:43  
It's greater improvements to treatment as usual. As you said, both groups improve in these areas, including mental health and substance use, but they're not differentiated, you know, with Housing First, doing better. So we were puzzled. We were very puzzled by these findings. And it's not only our trial, I mean, these are findings that you see in other trials. That's why, you know, I summarized the literature in the Lancet like that. The psychosocial outcomes, they're just there. We call it mixed, because there's some that show up as being better in Housing First, but it's not consistent across the studies. And it seems to depend on context and so on. Now, we had a discussion, you know, what the heck is going on here? Is it a methodological issue or measures aren't sensitive enough? Because as you said, we've got this qualitative study. 200 people were interviewed 100 in each of the groups to Housing First and treatment as usual. At 18 months, they were asked to do a retrospective of the extent their life had changed since coming into the study in 13 life domains and as you put handed out. There's a big difference between what Housing First people said about the 18 months versus the treatment as usual, you know, over 60%, I mean, I think it was 61% of the Housing First people said, Hey, this has been really good this 18 months, you know, like we're talking transformative when when you've got good things happening in 13 life domains, and then it's around half of that left in the treatment, as usual. So there's something going on. Now, this is qualitative, is it the more in depth kind of questioning that's getting at the differences. So that was kind of puzzling. But we also think, and I continue to think this from my contact, you know, ongoing contact with Housing First programs, I think Housing First solves the homelessness problem for most people. But I don't think the supports and services are intensive enough, are targeted enough to really, you know, make a difference in these different psychosocial outcome areas. And I, quite frankly, and I've said this, so you know, when I present about this issue, I think Housing First programs have to enrich the support they're providing. And I also think it has to be more targeted around how we're going to try to help people, I'll give you a very small example, we're doing a study right now here in Ottawa, with two Housing First programs. And we're trying to we're doing a pilot of social prescribing. If you know about social prescribing, it's really kind of taking off it came from the UK. And the whole idea is to get people to engage in activities in the community, recreational, you know, well being kind of activities, they could go to a yoga class, cultural, they could do painting or something, or social, you know, kind of social stuff, we want the programs to be quite specific about working with clients to put those in place. That's an example. That's a small example. But I think there's other areas, we need to be more targeted, including addictions, treatment, some programs have an addiction treatment specialist as part of their assertive community treatment team, others don't. And then people don't get very much, if anything, and we know that's a really tough area to make a difference. The only other thing I'll say, too, about the it may take longer as well than two years. I mean, when you think about it, you said, you know, these people, the average was five years of homelessness, there's a lot of kind of work to get back to a place where you're comfortable in the community, you're going to want to go out, and then you know, work on things as you go.

Michael Lens  42:44  
That all makes a lot of sense, to put voice to at least one of the conservative criticisms that I think Shane was alluding to. There is a perception that there's a lot of permissibility I think in some supportive housing, units, complexes, and housing, Housing First, I think the model as I understand it, is not necessarily going to police people's behavior, right. And so when you have a mix of people with various, I guess, substance use issues and various desires to clean up or not, you can I think, put people together who are, as I said, who had this mix. And so, you know, people who are trying to get clean are living next to people who are actively using and this is not has not only been something that conservatives have pointed out, you know, I can think of Chris herring who's a sociologist here at UCLA, who's done at the graphic work in San Francisco, and is seeing this on a day to day basis. So what are some of the solutions and ideas that people have to deal with that conflict?

Tim Aubry  43:55  
Well, I mean, I think we need to look at, you know, kind of what works. We do have br instance, integrated concurrent disorder treatment. These group programs that can make a difference. One of the agencies I work with that says one of the largest Housing First programs in Canada, it actually has an integrated concurrent disorders treatment program. It's evidence based, so it makes a difference. It's based on the stages of change as per Chaska stages of change. So there's those groups depending on where you're at. That's just one example. But point being I think we have to be more targeted how we address the issues. Yes, Housing First does harm reduction. And I know harm reduction is different a in Canada than the US, and it would probably depend on what part of the US and so on. But having said that, the challenge with harm reduction is getting people past the harm reduction and into treatment. There's a real challenge for people that you touched on, which involves people kind of not being able to lead network street networks. And that causes all sorts of problems that that leads to loss of apartments, apartment takeovers, and evictions and so on. So you know, it's it's a work in progress to try to get into those psychosocial outcomes those, quite frankly, those health outcomes and make a difference in people's lives. And I think again, I would say, and it may sound simplistic, but we have to enrich the support, and we have to make it more targeted.

Shane Phillips  45:36  
And for anyone who's not familiar with the term harm reduction, I'll just give an example of what that means. I think probably the most well known example of this is, rather than saying, you know, we're going to require you to stop using heroin, we're going to supervise your use, we're going to provide clean needles, and you know, the intent there is not to encourage you to continue using, but so long as you are to make sure it is as safe as possible, as we try to work with you. And you know, over time, hopefully convince you to or, you know, wait until you are at the point where you are ready to stop using and then go all in on helping you do so is that a fair description? Yeah.

Tim Aubry  46:21  
Yeah, yeah. I mean, it's trying to prevent the sliding back. But it's also trying to prevent people from overdosing. And it's trying to minimize the, you know, all the risks that are associated with, certainly drug use and alcohol consumption, quite frankly.

Shane Phillips  46:38  
Yeah. So we've talked about housing outcomes. We've talked about social and health outcomes. Let's talk about the third category that you studied, which is public service use and cost outcomes. Yes, people experiencing homelessness often use a lot of public services, particularly in health care, and justice or criminal systems. So this is hospitals and ers, police and jails and courts, that kind of thing. The idea here is that providing housing and wraparound services does come at substantial cost, and we should talk about what that cost was. But it may also reduce expenditures on those other public services. As you put it in the report, part of the goal of Housing First is to shift people from crisis and institutional services to community based services. Not only are the former are often less effective, they're also usually more expensive. Whereas the latter, the community based services are more prevention oriented, generally, and very often more effective, and in many ways, less costly. What were the key findings in this part of the study? 

Tim Aubry  47:40  
Yeah, so this is quite interesting. And just to set it up for listeners, you know, a lot of them will be familiar with Malcolm Gladwell 's work. It was in the book Outliers. But it was also a New Yorker article that talked about million dollar Murray, who was a person on the street in Reno, Nevada, who over a small amount of time, it might have been a couple of years, I can't remember the exact timeline, but pretty quickly used up a million dollars of services because of hospitalization. So the thinking was, well, if million dollar Marie was housed, wow, you could save a lot of money. But it's more complicated than that. And that's what came out of our study. First of all the cost when we had Eric Latimer, who's a health economist at McGill University, he did some really, really good work on this in this project. His estimate of the costs of Housing First with intensive case management was around for this is 20 $16 $14,000. Okay, with an assertive community treatment, it was between 20 and $21,000. And this is per year, per year. That's all in that's the rent supplement. So that's the housing cost. It's the support costs. Okay? So just just think about that. This is what it costs to get somebody off the street. I mean, I don't even think my view is you don't even need the cost offsets for this to be a no brainer, but we'll talk about that in a minute. 

Shane Phillips  49:13  
It's not too different from what we spend per housing voucher here in Los Angeles, for people who are just very low income and are not homeless. Usually not homeless. 

Tim Aubry  49:23  
Yeah, you have lots of things you compare to now costs, what we did and what Eric led the group was to costs all the services that people were receiving, so we call it comprehensive costing, health care is a biggie, okay, social services, when we even costed and people were getting Social Assistance checks. Obviously, if they were using shelters, if they were going to any kind of vocational training, these were all costed comprehensive costing. And then the final one was involvement in the justice system, getting arrested, going to court spending time in prison. These can be very expensive as well. Right? So what Eric reported in terms of cost, what are called cost offsets. So to what extent does the $14,000 that posing first with intensive case management costs get offset by a reduction in those services. And he found that it was about 46% of the cost was offset because of a reduction. And you compare it to treatment, as usual. There's a calculation that's done for assertive community treatment, it was 69%. So this is not million dollar burry. The money's not falling from the sky. But two things. One is the simple cost of the program all in is very modest. Okay, when you think of what it accomplishes, we just end homelessness. And the second thing is, is you are saving money. It's not as much as everybody thought. But it's still it's still a saving. And there's some replication by the way of that research elsewhere. Although, interestingly, they did a trial in France in four cities, we actually helped them out, you know, because we kind of collaborated with them. And they found their costs of the Housing First programs were offset completely and then some, and in part because their system is different than ours. They still do hospitalizations, for instance, psychiatric hospitalizations. So there's there's costs they have that we don't have in our health care and social service and injustice related systems. But that's kind of the picture that emerged.

Shane Phillips  51:46  
You might imagine, and maybe this explains why in some cases, I think, some analyses in the US have found a full cost offset, is healthcare is just so much more expensive here. And so if you're able to reduce those costs, you know, there's there's a lot of savings to be had.

Tim Aubry  52:02  
You're bang on, eh, Shane, because costs are context specific. And even the cost vary depending on on our cities, you know, to because certain cities have more services available for people, and that's going to up the costs, and so on. So it's going to be it's going to be variable, but like I said, bottom line, modest costs, and cost offsets. That was a conclusion. It's in the report that investing in Housing First was a wise investment for, you know, our social care systems. 

Shane Phillips  52:35  
So as you mentioned, most of the housing provided to participants in this study was in private market rental units, not housing that was purpose built for supporting the needs of people with serious mental health problems, or we're providing on site wraparound services. That's correct. Yeah. You know, does that affect your results at all? It seems like the common practice nowadays, certainly here in California, at least, is to build or sometimes acquire entire buildings with dozens of units and operate them entirely as supportive housing for formerly homeless individuals, or at least as a mix of housing for lower income households, and formerly homeless people. And that sounds kind of contrary to what you were talking about, of a more scattered approach. Is there evidence that this kind of purpose built Supportive Housing leads to better outcomes? Or is it maybe just more cost effective or easier to manage?

Tim Aubry  53:28  
Yeah, there's no there's no evidence that it has better outcomes. The evidence suggests it's more costly, because typically, there's on site support. And we don't have research where much research is starting to happen that compares a congregate housing and what's called scattered site housing, we know that if you ask people who are homeless, we have research on that, what kind of housing do they want to live in, they will say, you know, 85% of people will say I just want to live in regular housing, I don't want to live with other people that are leaving homelessness or that have difficulties and so on. So the preferences there for those people. We also know anecdotally that, you know, some of this single site housing can be difficult to manage, if it's all people who are leaving homelessness, we need that kind of housing. No, we you know, certainly as an option I'm not suggesting otherwise. But I think we're gonna have to figure out how much of it we need versus a scattered site housing, right now that we're building a lot of this purpose built single site supportive housing in Canada. And we're not growing the scattered site Housing First, we just completed a survey of Housing First programs across Canada, the Canadian Housing First network, and we found that were probably in the range of about 80 Maybe to 100 programs across can housing for As programs across Canada, that would be kind of our best estimate. And if we look at the level of chronic homelessness, our last point in time count found over 20,000 people who are chronically homeless, this was this was the most recent one, we need to probably triple the number of Housing First programs. But again, we need the other kind of housing. But the problem is we, we don't have much of any research on that housing, there's no model of that housing, some of the housing is a lot of units, some of it is small. So we do need to take a look at what's optimal, if we're gonna go that route with with single site housing, what should the support involve? Does it have to be on site, you know, or not? So it raises a lot of questions. And, you know, we, we need to do the work to understand it better.

Shane Phillips  55:51  
Yeah, it sounds like that needs to be the next $110 million at home Chase Law Project. I mean, it really is, this is really intriguing to me just how strong the shift seems to have been to this purpose built, congregate, not congregate as in people all living in the same units, but you know, all living in the same building, at least, and it's really dedicated to supportive housing, because I think the thing I hear here in California is that that is preferred because you're able to provide on site services, because people don't have to travel to visit a clinic or what have you. And so, you know, it doesn't sound like there's evidence that that approaches is worse. It's just I'm surprised to hear that there's not really evidence that it's better either.

Tim Aubry  56:34  
Correct. From the standpoint of housing outcomes, not the satisfaction part that we do have some research shows people are more satisfied in scattered site, and they feel obviously more in control and so on. But you're right, from the standpoint of housing outcomes, it's similar. I do think, though, it gets back to the early discussion we had, which is why people why can't they believe that somebody can live in their own housing, I wonder if part of what's at play is people can still thinking, Oh, we can't put those people out into the community in regular housing. It'll be a circus, you know, and it'll it'll introduce all sorts of risk in the community, and so on.

Shane Phillips  57:16  
Could you say a little bit about what the landlords had to say, because you were essentially working with private market landlords, again, not folks who were operating a building, you know, with some mission of helping formerly homeless people, or people with mental illness. And so I know, there were challenges and bad experiences. But it sounds like largely, it was pretty positive.

Tim Aubry  57:38  
It was I mean, we interviewed landlords and Monckton, about these issues. And then we did interviews of landlords, in fact, in the different cities, because you know, they're a very important player, if you're gonna have success in, in Housing First. So since they liked about housing, first, you know, the rent was going to be paid, they'd have to chase anybody for the rent, there were also damages were going to be covered, if there were damages in the building, that was also part of the agreement. They liked the mediation, that there's somebody that they could call it the program, if there was problems, if, you know, tenants were encountering problems. Obviously, if things blew up, you know, apartment takeovers, if people didn't take care of their unit, these would pose some challenges. So it was mixed. But I mean, given the success that we've had in housing people in the study in the five cities, I mean, it suggests it's something you can do something you can negotiate with landlords and make it work. But you've got to be vigilant, and you have to support your landlords, their business people, you know, they're always thinking, I don't want to empty units, I don't want units that I'm going to have to fix up and spend money on and so on. But the other just add one other thing about the landlords, which we wouldn't have thought of, and we heard from them, when we interviewed them. Some of them did it for altruistic reasons, for pro social reasons. They said, Look, you know, some of them would say, I have a family member, you know, who's been through some rough times and has been on the street and so on. I've had a good business, I've done well, you know, this is a way of giving back. So it's important. I will say, though, that Housing First in the implementation of it varies by countries, and some of them use a lot more social housing or public housing, where there is public housing. So the Nordic countries, for instance, will be used because they have more social housing. I think that's even in the case in places like England, and you can do Housing First, as long as you keep the percentage of people in an apartment building, who are leaving homelessness under 20%. That's the standard the ability standard? 

Shane Phillips  1:00:01  
Yeah, I do think people might be thinking, you know, of landlords being asked to rent out 10 Out of the 20 units or, you know, a good chunk of their building to the people participating in the Housing First program. But when it's the scattered site approach, what you're probably actually doing is just, you know, in a given building, it might just be one or two, or as you say, no more than 20%. And so we're not talking about having a whole building kind of change over in that way. And I think that does make a really big difference. 

Michael Lens  1:00:30  
So Tim, we've we've learned a lot about the effectiveness of Housing First and permanent supportive housing since this report was published in 2014, you've added a lot to our knowledge of this policy area for sure. What are some of your main takeaways for what makes a successful Housing First program we've talked about? You know, there's a great diversity in how these programs are implemented? What do you see is kind of some of the core elements that lead to success? And what should our expectations about what success looks like? Because

Tim Aubry  1:01:04  
it wasn't evident, it's an evidence based program, there's been worked on on, you know, what are the critical elements of Housing First, that make up what's called fidelity? There's about 40 standards that make up kind of housing, first fidelity that are most critical elements. But if I were to distill it, you know, I think there's ones that for me, are particularly critical. I mean, I think you have to start with the rent subsidy, you have to make sure people can pay the rent and afford the housing. Because, you know, when it's all said and done, housing is first and foremost a poverty problem, regardless of who's experiencing it. So that's really important. I also think, and Samsung Bear says this, that, you know, he always says, Well, you know, Housing First is actually not a housing program. It's a relationship building program. And I think what he's getting at is, you have to get people engaged with you around the support, around planning around figuring out what they want, what they want to pursue, the support has to be, it really has to coincide with people's needs as they define them. That's really important. I also think for Housing First programs to be successful. You need community partnerships. I mean, obviously, we talked about landlords, you need landlords that are willing to rent to you. But beyond that, because Housing First programs can't do it all on their own. And particularly if it's intensive case management, the form of support, you need community services, whether it's addictions, whether it's employment focus, that's really important. I think another element that's even going beyond the fidelity standards, is if clients can engage and become better integrated in the community, and participate in activities and get to know people above and beyond the housing for staff, they're more likely to have success. I think that's also very important. The last thing I'll say is more of an operational thing. But certainly, in my travels, the programs that really shine Housing First programs, they really follow closely and know their participants, their tenants, and there's a standard in on a fidelity scale, which involves kind of weekly meetings, where you do a review of everybody in your program. So, you know, close follow up attending, addressing when problems come up quickly. This, you know, obviously is going to help people succeed in Housing First programs. 

Shane Phillips  1:04:00  
As the last question, I want to follow up on who Housing First is really most appropriate for and maybe less well suited toward either because it's too little or too much. What have we learned there over the past 10 years, you know, for example, as you said, there about 10 to 20% of folks who just ended up not being stably housed really, at all, despite being offered housing, and having that option. Do we know anything? Or have we learned anything about how to help those people and kind of close that gap?

Tim Aubry  1:04:32  
You know, one thing we did chain is we because, you know, it's a big database when you've got over 1100 people receiving Housing First, we tried to kind of sort out, look at what predicted stable housing. So to some extent, what are the kinds of predictors that you know, is related to people either being stably housed and you know, kind of it works to people right against the problems being unstable. How's that? And it's interesting what emerged, first of all, the findings don't explain what we call enough of the variance. So the you know, what we see and to be saying, Oh, this particular person shouldn't go in Housing First, this type of person should this type of person will succeed. But I do think the findings, they suggest what I call risk factors. So for instance, younger people have more difficulty in housing. First, there's an age relationship between, you know, Housing First and stable housing, people who have had longer periods of homelessness in their life, I mean, it's kind of obvious, they also have less success in Housing First, okay, the substance use does emerge, income emerges, which is kind of interesting, people have have even more money above and beyond the little, they have the most definitely success, the perceived quality of their housing, people who perceive the quality of their housing as being better, these are kind of contextual factors you can see. But then the one which we never predicted, and it was the strongest predictor of all, was whether or not people had a family doctor, if you had a family doctor, you were more likely to be stably housed. And it seems that the family doctor maybe is acting as kind of a an agent, you know, again, helping people sort out what they need on the health care front, and help them you know, to some extent, head towards a more towards a state of well being because they're getting the services they need. In Canada, the family doctor can open doors, you know, for services. So that was one that kind of surprised us. As I said, we kind of call these things risk factors. And I always remember when I was, you know, we'd go visit the Housing First program in Monckton and sit in on their case conferences where they would review cases, and every now and then they'd say, Oh, my God, this person is, has been in their housing a year, they've been there for 18 months. I never expected this, I wouldn't have predicted this when they came in the door. Because you know, people are at their, at their worst when they're, you know, they're in crisis. They're homeless, and it may could have been a long time. So it's, it's a very difficult thing to predict, from that standpoint, but like I said, I, you know, I think the things that I mentioned, I think, should be treated as as risk factors. And maybe, you know, you look to provide people more support, if they're older, if they've had longer lifetime period of homelessness, certainly, if they have substance use problems, you should do something about that. And I think the idea of getting finding people, family doctors makes a lot of sense.

Shane Phillips  1:07:58  
In our conversation with Beth Shinn, she made this point that stuck with me about how, when you see someone living on the street, you know, on the sidewalk having a mental health episode, they are, in most cases at essentially the worst point in their life. And in many cases, I'm sure people coming into this study, were at one of the lowest points in their lives. And so to judge their potential at that point is just, you're never going to really know until you've given them a chance to recover. And to have that stability. 

Tim Aubry  1:08:32  
Our challenge, I think, is to educate people about the model, and about its success. And we got to continue doing that. And I say, I'm like a broken record. And I I'm, I'm only too happy to talk about Housing First. That's why I appreciate the opportunity to come on your podcast.

Shane Phillips  1:08:52  
Are there any operators any programs that you would point to as sort of a gold standard as a best practice that folks in the US or Canada or elsewhere should look to reach out to and try to learn from?

Tim Aubry  1:09:04  
Well, Washington, DC has very good original programs, the Pathways Programs, so they're very interesting. From a rural standpoint, Vermont has also original Pathways programs. And it's quite remarkable the kind of work they're doing. They also they work with people when they come out of prison and put them in Housing First programs, among other other things. So that's that I would certainly point to those two areas, a city that has gone you know, big time into Housing First, and done it in a real collaborative way. Is Milwaukee taking a look at what's going there and and the other one, which has been in the media that has that has housed like 1000s of people is Euston. So there's there's lots of nice examples out there for you know, for community Nice and then they can check in with, you know with people who run the programs are in place like Milwaukee with the with the city or the county officials who are behind them. These Housing First initiatives. 

Shane Phillips  1:10:12  
All right. Tim Aubry, thank you for your work on this subject, and thank you for sharing your knowledge here on the Housing Voice podcast.

Tim Aubry  1:10:19  
It's been a real pleasure, Shane. Thank you for doing the podcast, and for asking such good questions. Makes it easy for me.

Shane Phillips  1:10:31  
You can read more about Tim's work on our website, lewis.ucla.edu. Show notes and a transcript of the interview are there too. The Lewis Center is on social media, I'm on Twitter at @shanedphillips and Mike is there at @mc_lens. Thanks for listening, we'll see you in two weeks with the next installment of Pathways Home.