Background and Introduction
Heading Home was one of the first organization’s in the Commonwealth of Massachusetts to pioneer ‘Housing First’ as a permanent supportive housing framework more than 15 years ago. Housing First is a recovery-oriented approach to ending homelessness that is not contingent on “compliance,” rather a rights-based intervention rooted in the philosophy that all people deserve housing and that adequate housing is a precondition for recovery. The model centers on quickly moving people experiencing homelessness into independent and permanent housing and providing additional support for physical and mental health, education, employment, substance abuse, and community connections. Grounded in the underlying principle that people are better able to move forward with their lives if they are first housed, the Housing First model is proven to deliver effective mental health and addiction recovery outcomes.
There are five core principles of Housing First:
1. Immediate access to permanent housing with no housing readiness requirements. Housing First involves providing clients with assistance in finding and obtaining safe, secure, and permanent housing as quickly as possible. The key to the Housing First philosophy is that individuals are not required to demonstrate that they are ‘ready’ for housing. Housing is not conditional on sobriety or abstinence. Program participation is also voluntary. This approach runs in contrast to what has been the orthodoxy of ‘treatment first’ approaches whereby people experiencing homeless are placed in emergency services and must address specific personal issues (addictions, mental health) before being deemed ‘ready’ for housing (having received access to health care or treatment).
2. Consumer choice and self-determination. Housing First is a rights-based, client-centered approach that emphasizes client choice in terms of housing and supports.
- Housing – Clients can exercise some choice regarding the location and type of accommodation they receive (e.g., neighborhood, congregate setting, scattered site, etc.). The selection may be constrained by local availability and affordability.
- Supports – Clients have choices in terms of what services they receive and when to start using services.
3. Recovery orientation. Housing First practice is not simply focused on meeting basic client needs but on supporting recovery. A recovery orientation focuses on individual well-being and ensures that clients have access to a range of supports that enable them to nurture and maintain social, recreational, educational, occupational, and vocational activities.
For those with addiction challenges, a recovery orientation also means access to a harm reduction environment. Harm reduction aims to reduce the risks and harmful effects of substance use and addictive behaviors for the individual, the community, and society as a whole, without requiring abstinence. However, as part of the spectrum of choices that underlies both Housing First and harm reduction, people may desire and choose ‘abstinence-only’ housing.
4. Individualized and client-driven supports. A client-driven approach recognizes that individuals are unique, and so are their needs. Once housed, some people will need minimum supports while other people will need supports for the rest of their lives (this could range from case management to assertive community treatment). Individuals are provided with “a range of treatment and support services that are voluntary, individualized, culturally-appropriate, and portable (e.g., in mental health, substance use, physical health, employment, education)” (Goering et al., 2012:12).
Income supports and rent supplements are often an important part of providing client-driven supports. If clients do not have the necessary income to support their housing, their tenancy, health, and well-being may be at risk. Rent supplements should ensure that individuals do not pay more than 30% of their income on rent.
5. Social and community integration. Part of the Housing First strategy is to help people integrate into their community, and this requires socially supportive engagement and the opportunity to participate in meaningful activities. If people are housed and become or remain socially isolated, their housing stability may be compromised.
Housing as a Social Determinant of Health Outcomes
Data shows that early experiences with homelessness and their contribution to adverse childhood experiences (ACEs) are high indicators of future trauma experiences. Homelessness often diminishes hope and self-efficacy and may be accompanied by substance abuse. Recovery from mental illness has been documented as much more challenging when homelessness is experienced prolonged and frequently, often leading to psychiatric distress and inadequate or harmful coping strategies. Housing First provides housing to safeguard against those adversities, address complex trauma, and mitigate compounding harm.
It has been widely documented that Housing First is a less costly model than supporting those living in shelters or on the street. Once individuals have a permanent home with supportive services, the need for expensive state-funded emergency services drops dramatically, improving health and reducing health care costs. The NIH estimates that emergency department visits and general inpatient hospitalizations decrease between 50-75% once someone is housed. The Massachusetts Housing and Shelter Alliance (MHSA) published a report in December 2017 that details an individual’s annual cost before entering permanent supported housing and their annual cost while housed. According to MHSA, the estimated annual cost per person before entering housing was $37,434. Once permanently housed, the annual cost is $25,633; this equates to a total savings of $11,801. The estimated medical expenses would be $30,669; once housed, that number is reduced to $10,029.
 Massachusetts Housing and Shelter Alliance. 2017. Permanent Supportive Housing: A Solution-Driven Model. Boston, MA: Massachusetts Housing and Shelter Alliance. http://archives.lib.state.ma.us/bitstream/handle/2452/782511/ocn887735103-2017.pdf?sequence=1&isAllowed=y.