3.2. Health and Well-Being
3.2.1. Organising Support
The health and well-being of Housing First service users tends to be managed using one of two main approaches. Housing First services may offer both these forms of support, or may only provide one of the two:
- Intensive case management (ICM) or a similar form of high-intensity case management, which provides some support and creates connections between service users and treatment and support provided by other health, support and social work services.
- An assertive community treatment (ACT) team, or another multidisciplinary team that directly provides treatment for many needs, including mental health problems, drug/alcohol problems and poor physical health, and provides the case management needed to help the person access treatment from other services as required. This approach tends to be used for homeless people with very high support needs.
- A Housing First service offering both ICM and an interdisciplinary team, which is the basis of the original model of Housing First, has the flexibility to allow service users to move from ACT (or equivalent) levels of support to ICM (or equivalent) and vice versa((Tsemberis, S. (2010) Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction Minnesota: Hazelden.)).
There is no completely set way of providing support in Housing First. Where Housing First is an intensive case management-led service, support with treatment will centre on a single worker, who may or may not be trained in social work, who will provide some direct support and arrange access to requested health, welfare and other support services on behalf of a Housing First service user. Housing First services may have specialists in addiction, peer support workers, health professionals or other specialists in this case-management role. The Housing First worker will also provide the service user with housing related support to sustain their housing (1. Housing Sustainment) and also help them move towards social integration (3. Social Integration).
When a Housing First service is using a multidisciplinary team, it can employ a psychiatrist, a drug and alcohol worker, a doctor, a nurse, a trained peer-support worker who promotes recovery (based on having been through similar life experiences) and specialists in employment and reconnection with family. Sometimes, all of this treatment and support might be provided directly, but where suitable external services exist and are accessible, case management can be used.
Housing First can, potentially, function as an entire welfare state in miniature, providing all required treatment and support by itself. Housing First can also offer a mixture of directly-provided treatment and case management, or Housing First can mainly or entirely arrange access to external treatment via intensive case management. Sometimes, a single Housing First service is able to operate at different levels and in different ways depending on what the user’s needs are, which closely reflects the original design of Housing First.
The people working for a Housing First service can have a wide range of training and competency. The exact composition of the team will vary, but it can include people who are social-work trained, qualified and experienced in the provision of homelessness support services and, where an ACT or similar multidisciplinary team is used, a mix of health, mental health and drug and alcohol professionals. Housing First may also provide specialists in employment and in peer support, including trained support workers who have had life experience of homelessness prior to working for Housing First.
In 2015, most of the Housing First services working in Europe, though not all, used an intensive case-management only model. This is because Housing First has so far tended to be developed by European countries where the state provides a lot of services, with extensive, freely available, health, mental health and drug and alcohol services that can be easily or relatively easily accessed via case management. However, there are some European countries where public health systems are much less well developed and, as Housing First becomes more widespread, some European Housing First services may find that they need to provide treatment directly, rather than being able to rely on case management.
It is worth noting that even in some highly developed social welfare states like Denmark, France, Sweden and Norway, ACT teams are used in some Housing First services((A majority of Housing First services are ICM or high-intensity case management-based.)). In part, this is because the service user has not requested treatment – only housing – even though the person may well need treatment. It may be easier to engage a person in treatment once they are comfortable and know the treatment provider. In these instances, it can be very useful, for example, to have a psychiatrist make a house call or sit in a park and have a coffee with the service user, building trust before treatment is discussed.
A multidisciplinary team may be necessary when Housing First is working with homeless people with very high and complex needs. Mainstream services may be unable to effectively meet the very complex and/or challenging needs of Housing First service users, for example because they are office-based and will not visit people at home. Some mainstream services also still work in ‘silos’ (are operationally separate from each other). A good example of this is when Housing First service users need a combination of health, drug/alcohol and mental health services. Mainstream services can be provided separately and it can be challenging to coordinate them, whereas a multidisciplinary Housing First team is designed to provide a mix of support and treatment.
In some European countries, all the health services a Housing First service user needs should be freely available to them as a citizen. However, there can be barriers to publicly-funded health services that include negative popular attitudes to homeless people, or relatively complex bureaucracy. Homeless people may also avoid publicly-funded health services as they feel stigmatised and expect to be refused treatment, even if in practice they would almost certainly be treated((Quilgars, D. and Pleace, N. (2003) Delivering Health Care to Homeless People: An Effectiveness Review Edinburgh: NHS Scotland. http://www.healthscotland.com/uploads/documents/425-RE04120022003Final.pdf)). Housing First can work well in these situations, because it can advocate for and arrange access to all the health services a Housing First service user wishes to use, via case management. As noted, European Housing First services quite often just provide case management, on the basis that all the health services needed are already freely available. Then, the key role of Housing First is to ensure access is properly organised.
When using a multidisciplinary team, Housing First exercises more direct control over the package of treatment and support being delivered to a service user than when using ICM. This is because all of the members of the interdisciplinary team are employees of the Housing First service. When following an ICM approach, there is not the same level of control, as the people in the team mainly work for other services.
Cooperation with other services may require careful management and may present some challenges for Housing First services. The effectiveness of Housing First services in delivering the required treatment and support is dependent in part on external organisations over which a Housing First service may not exercise any control. If these external services refuse to cooperate with a Housing First service or face funding cuts, the Housing First service may find itself encountering operational difficulties. This risk is lower when Housing First services are part of a strategic plan or policy to reduce homelessness and there is an expectation on services to cooperate with one another (see Chapter 6).
3.2.2. Managing Needs
There will be some individuals whose needs are too high for Housing First. Where this is the case, procedures need to be in place to ensure they are able to move on to more suitable services. Approximately eight out of ten homeless people with high support needs are successfully housed by Housing First services, based on current (2015) European and North American evidence (see Chapter 1).
The reasons why it may not be possible to support someone through Housing First include risk management. For example, someone living in ordinary housing may need a very high level of monitoring to safeguard their well-being, for example because they are at high risk of suicide or overdose. This may be beyond a Housing First service’s capacity to provide, as a member of staff might need to be constantly with an individual for a long period of time.
3.2.3. The Treatment and Support Provided
Treatment and support, either provided directly by a Housing First multidisciplinary team, or arranged in cooperation with external services through case management, can include:
- Psychiatric and mental health services. These will be needed as there is clear evidence that homeless people with high support needs – throughout Europe – have high rates of mental health problems((Busch-Geertsema, V., Edgar, W., O’Sullivan, E. and Pleace, N. (2010) Homelessness and Homeless Policies in Europe: Lessons from Research, Brussels, Directorate-General for Employment, Social Affairs and Equal Opportunities. http://ec.europa.eu/social/BlobServlet?docId=6442&langId=en)). The treatment available to a homeless person may vary significantly in quality and some will not have been able to access treatment at all prior to starting to use Housing First. The type of support provided will depend on the individual’s needs and the preferences of each service user, but Housing First should be able to access a psychiatrist, psychologist, mental health nurses and specialist mental health social work support as required.
- Drug and alcohol services. These will be needed as there is pan-European evidence that homelessness among people with high support needs can be associated with problematic drug and alcohol use((Ibidem)). Again, the exact type of support provided will depend on what a service user chooses, but will usually involve a drug and alcohol specialist who will work within a harm-reduction framework (see Chapter 2). Harm reduction seeks to minimise the damage caused by drug and alcohol use through support and encouragement, rather than using detoxification and abstinence in an attempt to bring use under control. Housing First is a service that uses harm reduction, but it is also a service that promotes choice and uses person-centred planning. This means that if someone using Housing First decides for themselves that they want detoxification or to try an abstinence-based approach, Housing First should arrange that service for them.
- Clinical services. A Housing First service user may need access to a nurse who can monitor their health, help them administer their medication and follow treatment. A Housing First service user will also require access to a family doctor/general practitioner for medical services. Support may be needed when attending outpatient treatments at a hospital, which might include a Housing First staff member attending an appointment with a service user. Housing First may also need to advocate on someone’s behalf to ensure that they have access to the proper treatments. When someone using Housing First is admitted to hospital for treatment, Housing First and the hospital should work together to ensure that their needs are being met when they are discharged from (leave) hospital.
- Personal care services that provide physical assistance someone with a limiting illness or disability. Some Housing First service users may need help with dressing, washing and preparation of meals.
- Occupational Therapy. This provides equipment and physical adaptations to housing to enable people with limiting illness and disability to live more independently. A Housing First service user may need modifications to their kitchen or bathroom or changes that enable them to enter and exit their home more easily, or access to equipment that makes their home more useable.
- Twenty-four-hour coverage. This should be available to someone with high support needs using Housing First. This means there are Housing First services available during working hours and someone will answer the phone outside working hours and respond to an emergency.
- Advice and information on health, which will be provided by Housing First staff, possibly including a peer support worker. A peer support worker is someone with direct experience of homelessness involving high support needs, who is a trained Housing First staff member. European Housing First services may sometimes employ former service users, or people with similar histories as part of an ACT team or similar arrangement or to provide case-management/ICM services.