Successful use of ACT and Harm Reduction in a Housing First Program 16th St' Housing First Colorado

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Successful use of ACT and Harm Reduction in a
Housing First Program 16th St. Housing
FirstColorado Coalition for the
HomelessDenver, Colorado
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Housing First

• It is a basic human right to have a home.
• Housing First provides permanent housing, vs.
  shelter, immediately then provides services.
• Housing is not contingent on compliance with
  services instead, participants must comply with
  a standard lease agreement and are provided with
  the services and supports that are necessary to
  help them do so successfully.

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ACT(Assertive Community Treatment)

• ACT is a service-delivery model that provides
  comprehensive, locally based treatment to people
  with serious and persistent mental illnesses.
  Unlike other community-based programs, ACT is not
  a linkage or brokerage case-management program
  that connects individuals to mental health,
  housing or rehabilitation agencies or services.
  Rather, it provides highly individualized
  services directly to participants. ACT
  recipients receive the multidisciplinary,
  round-the-clock staffing of a psychiatric unit,
  but within the comfort of their own home and
  community. To have the competencies and skills
  to meet a clients multiple treatment, recovery,
  and support needs, ACT team members are trained
  in the areas of psychiatry, social work, nursing,
  substance abuse, and vocational rehabilitation.
  The ACT team provides these necessary services 24
  hours a day, seven days a week, 365 days a year.

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Harm Reduction

• Reducing the harm one experiences while homeless,
  using substances and/ or dealing with mental
  health issues.
• Housing
• Access to medical care
• Access to psychiatric and therapeutic services
• Access to food, clothing, medication
• Support Education

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Recovery

• Recovery is a deeply personal, unique process of
  changing ones attitudes, values, feelings,
  goals, skills, and/or roles. It is a way of
  living a satisfying, hopeful and contributing
  life even with limitations caused by a
  disability. Recovery involves the development of
  new meaning and purpose in ones life as one
  grows beyond the effects of a disability. Pat
  Risser, Consumer/Survivor Activist

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What are people recovering from?

• Poverty
• Dreams never materialized
• Loss of relationships
• Physical/Sexual/Emotional Abuse
• Addictions
• Mental Health and other Systems
• Stigma and Labels
• University of Kansas, School of Social
  Welfare Strengths Model, Rapp, C.

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Essential Features of ACT

• Transdisciplinary Team
• Team approach/shared caseload
• Nurse and prescriber part of team
• Small caseloads (1/10)
• Services delivered in vivo
• Assertive outreach and engagement

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Essential Features of ACT

• Daily team meetings
• Time unlimited services AVAILABLE
• No rejects
• Individualized, comprehensive services
• 24 hr/day 7 day/week coverage
• Substance abuse treatment, including group
  therapy
• Psychopharmacologic treatment

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Who benefits from the ACT Model?

• Those who have difficulty getting to appointments
  on their own as in the traditional model of case
  management
• Those who have had bad experiences in the
  traditional system
• Those who have limited understanding of their
  need for help

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Primary Provider of Services

• All services directly provided by the team
• Range of disciplines and cross-training make this
  possible

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History of 16th Street Housing First

• In 2005, City of Denver begins the implementation
  of the 10 year plan to end Homelessness
• Downtown businesses, police officers and outreach
  workers identify numbers of chronically homeless
  individuals on 16th Street Mall in downtown
  Denver
• 16th Street Housing First was developed to
  provide comprehensive housing and supportive
  services to 50 individuals who were chronically
  homeless and frequented the 16th Street Mall

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Admission Criteria

• Individual wants housing
• Individual agrees to pay 30 of monthly income
  towards rent per month
• Individual agrees to meet with case management at
  least twice per month
• Most referrals to the program have been
  individuals who were either kicked out or dropped
  out of other case management or treatment type
  programs. This is often due to relapse on
  substances, increase in mental health issues,
  non-compliance with program rules, etc.

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Housing Vouchers

• Federally funded housing vouchers that work like
  Section 8, only with case management
• Individual pays 30 of monthly income for monthly
  rent. This includes SSI, SSDI, SS, OAP, AND, job
  income. If the individual has no income then they
  pay 0.

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Case Management Operating Principles

• Delivered in environment of choice
• Build on strengths, based on choice and attend to
  participants preferences
• Will help people manage and improve their lives
• The cornerstone of services will be the
  development of purposeful, helpful and friendly
  relationships

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Case Management Operating Principles

• Service needs and plans will be determined by and
  with participants and others they choose to
  involve
• Services will be titrated to the most
  accommodating and lowest level possible
• Services will work to build participants natural
  support system

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Services

• There is no predetermined set of services. The
  team is responsible for delivering any services
  or support people need to live in the community
  and reach the goals they have set for recovery.
  There are also no arbitrary time limits on ACT
  services. Interventions are carried out as long
  as they are useful and nothing more beneficial is
  available. Even if a person is hospitalized or
  arrested, the team continues to be the fixed
  point of responsibility for assuring that the
  persons needs are met.

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Team Approach

• The team approach is facilitated by daily team
  meetings in which the team is briefly updated on
  each individual. Activities for the day are
  organized and team members are available to one
  another throughout the day to provide
  consultation or assistance. This close
  monitoring allows the team to quickly adjust the
  nature and intensity of services in response to
  individuals changing needs.

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Team members expectations

• Communicate their professional assessment of
  peoples needs and suggest treatment strategies
  based upon their professional knowledge
• Teach team mates as much as possible about their
  area of expertise
• Ask other team members questions and learn as
  much as possible about their areas of expertise
• Pitch in and help when needed, even if it means
  doing something that draws on their life
  experience rather than professional expertise
• Be innovative and creative
• Focus on problem solving

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Advantages of ACT Harm Reduction in a Housing
1st Program

• Flexibility
• Continuity of care
• Multiple points of view
• Shared responsibility
• Capacity to match staff to participants needs at
  a particular moment
• Reduces stress and turnover among staff

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Advantages of ACT Harm Reduction in a Housing
1st Program

• Daily meetings provide mechanism for data
  tracking requirements
• Logistical efficiencies
• Coordinated/Integrated care
• No cracks to fall through
• Participants form multiple relationships
• Historical perspective

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Advantages of ACT Harm Reduction in a Housing
1st Program

• Staff support each other
• Team becomes sensitive to stressors and warning
  signs of potential trouble and can implement
  prevention strategies
• Can involve natural supports (e.g. family members
  biological or street family) on an ongoing basis

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Range of Services

• Service coordination
• Crisis assessment intervention
• Integrated co-occurring disorders treatment
• Vocational services
• Peer support
• Wellness management recovery
• Working with families natural supports
• Symptom assessment management
• Medication prescription, administration,
  monitoring
• Housing acquisition and maintenance
• Activities of daily living
• Community social integration

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What the data say across studies

• Decreased hospital use
• More independent living housing stability
• Retention in treatment
• Participant and family satisfaction
• Reduced psychiatric symptoms
• Improved quality of life

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Research Findings with homeless

• A New York City study tracking 5,000 individuals
  with mental illness two years pre and two years
  post placement in supported housing found a
  reduced utilization of publicly funded services
  by an average of 16,282 annually, of which 72
  were accounted for by health services (Culhane,
  Metraux Hadley, 2001).

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How it Helps the Participants

• Provides a home. (Over 150 individuals have
  been housed with an 83 housing retention rate)
• Reestablishes dignity
• Reduces Harm in the way of easier access to
  medical care, mental health care, and reduction
  in substance use
• Non-judgmental approach allows for honesty which
  in turn results in stronger client/staff
  relationships. This also reduces burn-out among
  staff, and retains the clients.
• Decreases crime on the streets reduces hospital,
  jail and detox visits.

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Promoting Recovery

• DO
• Focus on individual strengths rather than illness
  or addiction
• Treat individuals with respect
• Normalize their experience
• Express optimism and hope
• Speak directly to people, adult to adult
• Offer to shake hands when introduced
• Ask individuals for their opinion
• Ask what has worked in the past
• Work from a motivational perspective what do
  they want for themselves? What are they willing
  to do to get it?
• University of Kansas, School of Social Welfare
  Strengths Model

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How it helps the Community

• Decreases crime on the streets
• Increases business for downtown businesses
• Increases tourism bringing in more money to the
  city
• Decreases tax payer money being paid for
  hospital, jail and detox stays

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DHFC Cost Study

• The average cost per person to do nothing over a
  two year period is 37,354.31 (This includes
  detox, incarceration, ER, inpatient and
  outpatient medical) (This does not include
  sheltering people, because this data is not
  available)

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DHFC Cost Study Preview (N19) Medical

• 64 reduction in the number of Emergency Room
  visits post DHFC as compared to the two years
  prior to program entry
• 41 reduction in the number of inpatient nights
  post DHFC as compared to the two years prior to
  program entry

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Denver Housing First 16th Street Housing First
Annual Report

• An important study conducted by CCH looked at
  participants for 24 months prior to obtaining
  housing and for 24 months after obtaining
  housing. Results show an average savings to
  taxpayers of 31,545 per participant from
  significantly reduced utilization of emergency
  room care, inpatient medical and psychiatric
  care, detox services, incarceration, and
  emergency shelter. Factoring in the 207 formerly
  homeless clients, that is an estimated total
  savings of 6,529,815 to Denver taxpayers in
  2007.
• CCH 2008 Annual report

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Thank You

• Elissa Hardy, LCSW
• Kevin Genter, BA
• Other members of the team shown in the video
• Jessica Oshier, LPC
• Doug Calkin, LPC
• Gloria Lee, MA
• Marcy McIntire, CAC II
• Aubrey Lavizzo
• Members not shown
• Nelson Kincaid
• Dan Harter
• Caitlyn Dorris
• Julia Grubb