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Housing the homeless: the “traditional approach” versus “housing first” for grant writers

We’ve been writing grant proposals for housing and supportive services for people experiencing homelessness (this is the PC phrase, but “homeless” is used in the rest of this post) since 1993, so we’ve been at it for long enough to see changing funder and client preferences around approaches come and go. For many reasons that are beyond the scope of this post, homelessness remains a growing and in some respects an intractable challenge in much of urban and rural America; essentially, homelessness is a housing shortage problem. Until we address housing abundance, we’re not going to be able to solve or substantially ameliorate homelessness as a problem.

Recently, we wrote a post on the emerging trend toward harm reduction instead of traditional SUD/OUD treatment. A similar phenomenon is going on with respect to providing housing and supportive services for homeless folks. This is the concept of “Housing First:”

Housing First is a homeless assistance approach that prioritizes providing permanent housing to people experiencing homelessness, thus ending their homelessness and serving as a platform from which they can pursue personal goals and improve their quality of life. This approach is guided by the belief that people need basic necessities like food and a place to live before attending to anything less critical, such as getting a job, budgeting properly, or attending to substance use issues.

At first glance, Housing First looks like a reasonable and compassionate approach. In the 1980s, when homelessness as an issue entered public discourse, the sentiment was that Mary and her two kids live in their car because she got laid off from the Piggly Wiggly and was evicted from her apartment. While there are many people who find themselves in this sort of predicament, the majority of homeless have SUD/OUD and, in many cases, are co-diagnosed with serious and persistent mental illness (SPMI). But homelessness is easier to avoid, even for people with SUD, OUD, and/or SPMI, when rents are low. That’s why “it’s not the case that homelessness is high where vacancy rates are high. Indeed, it’s the opposite — the vacancy rate is lower in places with more homelessness.”

Housing for the homeless initiatives have traditionally focussed on a step-down approach similar to that which we described in the post on OUD/SUD treatment versus harm reduction. In the traditional paradigm, homeless people receive housing and other services along a continuum of care starting with a high level of care, and then they “step down” to lower care levels in increments, leading to eventual independent living. Following engagement, referral, or self-presentation and development of an individual housing assistance plan (“IHTP”), the step-down levels often proceed something like:

  • Detoxification/stabilization (if needed)
  • Shelter bed in an emergency shelter (usually limited to 30 to 60 days). Significantly, most shelters are “dry,” meaning that drinking and drugging aren’t allowed in the facility. Still, after breakfast, most people living in shelters spend their days out of the shelter on the street, with the idea that they’ll look for a job, attend treatment sessions, etc., and return at night to sleep. While this is more or less “two hots and a cot,” treatment and other supportive services are sometimes provided in-house and/or by referral.
  • Placement in a single room occupancy (SRO) hotel, transitional housing, or supportive housing unit with in-house and referral supportive services (e.g. SUD/OUD and SPMI treatment, legal assistance, workforce development, primary/dental care, etc.) usually provided in the latter two. In supportive housing, such services are usually case-managed and these facilities are usually dry. While there is typically no length of residency cap for SRO units, there is usually a 12 to 24 month max for transitional and supportive housing facilities. Unfortunately, SROs are largely illegal under the modern zoning regime, which may forces many precariously housed people on the street.
  • Independent living, usually with a Housing Choice Voucher (formerly called Section 8) or in another subsidized housing development, or with family.

The levels can be broken down further, but the above was the common approach and was formalized in the 1987 passage of the McKinney–Vento Homeless Assistance Act (McKinney-Vento), administered by HUD. The problem is, though, is that even if a person gets clean and sober, if he or she can’t afford rent, that person is likely to end up back on the street—and thus in high-stress, difficult situations that encourages coping via substance abuse. Covering $700/month in rent is much easier for a person with mental illness and substance abuse challenges than $2,000 a month.

Although McKinney-Vento funds 15 programs with a spectrum of services, the most significant ones are Supportive Housing, Shelter Plus Care (provides site-specific HCVs for the housing development and on-site services), SRO, and Emergency Shelter. One of the first large funded grants S + A wrote was a $4M Shelter Plus Care proposal for a nonprofit in Northern California to convert a vacant motel into a supportive housing facility in 1994. Over the years, McKinney-Vento has disappeared from public view, as these programs have been folded into HUD’s very confusing Continuum of Care (CoC) system. McKinney-Vento programs still form the structure for most federal efforts to help the homeless, but applications are made to the local CoC agency, not directly to HUD—which means local politics come into play, along with typical quiet deals cut among local players. Good luck breaking into CoC funding without an “in.” Well-meaning people in a given community often want to find something to do to help with the issue of homelessness, and they try to find sustainable for it, only to run into the local power structure.

For our first 20 years, most of the proposals we wrote for homeless housing and supportive services followed the above model: the emphasis was always on working with the homeless people to get them clean and sober, with SPMI under control, before moving from a shelter to longer term housing. About 10 years ago, we began to work with clients who wanted to use the Housing First approach: in this approach, underlying SUD/OUD and SPMI challenges are addressed, to an extent, but the overall goal is to provide fast housing—hence the term “Housing First.” This paradigm treats housing as the first step for life improvement and enables access to housing without conditions beyond those of a typical renter. Although supportive services are usually offered, participation is not required. This means the formerly homeless can continue to drink and drug and/or not comply with the SPMI treatment protocols. Utah was the first major state proponent of this approach, in part because Utah allows housing to be built relatively easily, but even Utah has run into problems.

This shift to the Housing Fist model has created something of a battle between the traditional homeless services providers like the faith-based “missions” that are found in most major cities, and the new Housing First kids on the block. This battle is being played out on social media and, most importantly, in public hearings and applications for CoC and other grants. Like any local structured grant system, such as CoC, Ryan White grants for people living with HIV/A, or Title 10 family planning, a “mafia” soon emerges. The mafia is composed of the existing agencies being funded, advocacy groups, and local politicians who have an interest in making sure favored nonprofits get funded. The mafia structure makes it harder for new, innovative agencies to secure a spot at the grant feeding trough. We’ve heard from some of our clients that the Housing First crowd has taken over CoC processes to the detriment of traditional providers. Housing First is clearly the church of what’s happening now.

We’re just grant writers, so we don’t have an immediate opinion as to whether the traditional approach or Housing First is more efficacious, though neither is likely to be highly effective without land-use reform that increases the total number of housing units. Without an abundance agenda, we’re merely reallocating slices of the pie, rather than increasing the pie’s size. Extensive homelessness is a symptom of deeper problems, and it can’t be effectively addressed without dealing with the root cause. Most studies on the subject of “traditional” and “Housing First” are somewhat questionable. While I’ve been in many shelters and other homeless housing settings over the years, I’ve never been in a Housing First facility, but I imagine that things might get a bit out of control come Saturday night. I also don’t know how housekeeping is handled. Also, most people with SUD/OUD and/or SPMI will relapse multiple times, which may send them back to the streets, jail, or residential treatment/hospitalization, meaning that their Housing First unit is actually their Housing Last unit.