Lesson Plan

Benefits of Supported Housing for People with Psychiatric Disabilities

Introduction

Tell:

•	  In 2008 the Center for Psychiatric Rehabilitation at Boston University conducted a comprehensive and systematic review of published studies that focused on supported housing interventions and outcomes.

•	  Center research staff selected sixty studies that met rigorous standards for relevance to the field and methodological soundness.

•	  Experimental, quasi-experimental, correctional studies and needs-preferences-satisfaction surveys were included in the review.

•	  Although there is still a need to develop a consensus on the measure of housing stability and a core set of related outcomes, e.g., time to first housing placement, number of residential moves within a given time period, and a need to develop a consensus on an operational definition of supported housing interventions, enough reliable research based outcome evidence exists to draw important conclusions about how Supported Housing benefits people with psychiatric disabilities.

•	  This presentation is based on the findings from that review and analysis.

Show: Slide 2 – Learning Objectives

Tell:

•	The learning objectives for this presentation are to increase your understanding about what supported housing is, what the factors are that contribute to positive outcomes in a supported housing program, and what the positive outcomes are for individuals who receive supported housing services.

•	There are no assumptions that you don’t have an understanding of what a Supported Housing program is and of what the benefits are for individuals being served by these programs.

•	This presentation is intended to add to your current knowledge.
 
•	Supported Housing as a service model was first described in the mental health literature over twenty years ago, and for an even longer time a variety of housing services and models have been developed and implemented.

•	While understanding of the features that distinguish Supported Housing from other residential service models are more prevalent today than in the past, not everyone has had the opportunity to learn about what makes this model unique.

•	Often times there is a very significant lag time , as long as 20 years, between  mental health research based knowledge being published and that knowledge actually being made available and applied by people who work in the field.

•	This presentation is intended to provide you with the best research based knowledge available at this time about the benefits of Supported Housing for individuals who receive this service.

•	It is hoped that this increase in knowledge will result in your feeling more hopeful about how this service could benefit the people you serve.

Tell:

•	  There are four learning activities planned.

Show:  Slide 3 – Learning Activities

Tell:

•	The review section of the training is intended to facilitate a discussing about your understanding of Supported Housing and what your experiences have been with this service model, either as a staff member in a Supported Housing program, a staff member who has interacted with but not worked in a Supported Housing program or as a person who has received Supported Housing services.

•	The better I understand your perspectives and experiences, the better I can tailor the presentation to your needs.

•	 Following the review, I have planned presentations of the principles that distinguish supported housing from other residential programs, factors that are associated with positive outcomes for individuals served in supported housing, and then the benefits to those individuals.

•	Following each presentation, I’ll ask you to participate in a brief small group exercise in which you discuss the points made in the presentation and what the implications are for your own practice or program. Then I’ll facilitate a large group discussion of the points made in the small groups.
(Alternative is individual, or dyad exercises)
Show: Slide 4 – Review of Supported Housing Knowledge and Experiences

Tell: 

•	Let’s begin with a review of your experiences and what you know about supported housing.

Ask/Discuss: 

•	How many of you have had some direct experience with a supported housing program either as a provider of supported housing, a provider of another service, or as a recipient of supported housing services?

•	What has been the overall goal or purpose of these housing services?

•	What have been the most positive outcomes and benefits for the individuals served?

•	Have these outcomes and benefits occurred for most or a few of the people served?

•	What have been the most significant challenges to producing these outcomes and benefits?

•	What are the guiding principles or characteristics that make Supported Housing different from other types of housing service models?

Show:  Slide 5 – Supported Housing Principles

Tell: 

•	Supported housing can be distinguished from other types of housing programs by a set of core principles that guide how the program is organized and delivered.

•	Next I’ll present each of these eight principles and then ask you to discuss in small groups how these principles relate to your practice.

Show: Slide 6 – Supported Housing Principles (Housing in Permanent)

Tell:

•	In a supported housing program, individuals are not expected to move from one setting to another based on staff assessments that the person is functionally ready to move to a “less restrictive” setting.

•	Supported housing is permanent, not transitional.

•	Just like anyone else who owns a house or holds a lease on an apartment, people in supported housing programs may move for a variety of reasons, but not because housing is expected to be a temporary stop in what could be a series to moves before attaining “independent housing”.

Show: Slide 7 – Supported Housing Principles (Clinical and Housing Services are Separate)

Tell:

•	Services to help people choose, get, and keep housing and services to treat mental illness and substance abuse are provided by different agencies working in collaboration.

Show: Slide 8 – Supported Housing Principles (Housing is Integrated into the Community)

Tell:

•	Supported housing programs assist people to live in settings that do not differentiate based on the presence or absence of a psychiatric disability.

Show: Slide 9 – Supported Housing Principles (Housing is Affordable)

Tell:

•	In order for most people to afford “permanent” housing, subsidies and vouchers are usually needed to assure that the housing is affordable.

Show:  Slide 10 – Supported Housing Principles (Mental Health Services are Offered, Not Mandated)

Tell:

•	There is no pre-condition that the person has to agree to receive any service, even medication. 
•	There is a belief that the individual deserves decent housing independent of her/his participation in services. 

•	Although it is the person’s choice as to whether s/he participates in services, honoring the person’s choice does not mean neglecting the person. Active and respectful engagement of the person in clinical services is expected.

•	The type(s) and intensity of service are responsive to the individual’s needs and preferences at any given time.

Show: Slide 11 – Supported Housing Principles (The Individual Chooses the Housing and Mental Health Services.)

Tell:

•	Individual choice of where s/he lives and choice of which services s/he receives is a fundamental characteristic of supported housing programs.

•	Although the person’s ideal choice of the place to live can’t be guaranteed, the individual must be offered options and a choice about which setting s/he wants to move to

•	Moving to a particular setting must be based on the person’s choice to do so.

Show: Slide 12 – Supported Housing Principles (Services are Community Based)

Tell:

•	Although staff may provide services in the person’s apartment or house, they must not have offices on the premises.

Show: Slide 13 – Supported Housing Principles (Crises Services are Available)

Tell:

•	The individual has to have access to crises services at all times.

Ask/Discuss:

•	Which of these principles is most similar to the services you provide?
•	Which are least similar?
•	Which principles do you think are most important?
•	Least important?

Show: Slide 15 - Factors that Appear to Positively Effect Supported Housing Outcomes (Choice of Housing)

Tell:

•	Overall, individuals prefer and are more satisfied with independent housing.

•	There is evidence that having more than one option correlates with a desire to stay in  the residence, stability, and a greater match between the needs of the respondents and the demands (and supports) of the housing situation.

Show: Slide 16 - Factors that Appear to Positively Effect Supported Housing Outcomes (Rapid Entry into Housing)

Tell:

•	Individuals with delayed entry into housing and those placed in commercial housing were more likely to terminate and those with delayed entry had less likelihood of being independently housed or being employed. 

Show:  Slide 17 – Factors that Appear to Positively Effect Outcomes (Housing Subsidies and Vouchers)

Tell:

•	In one study, Section 8 vouchers, versus no vouchers, led to faster achievement of independent housing regardless of the level of intensity of case management services.

•	 A large pre-post study examined Section 8 vouchers on individuals who were homeless and mentally ill, total of 90% of the 299 individuals in the study moved from the streets and group homes generally to living alone.

•	Having a case manager directly assist with obtaining financial support for housing is important in order to attain positive outcomes.

Show: Slide 18 - Factors that Appear to Positively Effect Supported Housing Outcomes (Intensive Services)

Tell:

•	Although not a consistent factor in all studies, those studies that demonstrated a decline in housing retention over time seemed to suffer from the same problem: lack of consistent and intensive case management for a large percentage of their study cohort.

Show: Slide 19 - Factors that Appear to Positively Effect Outcomes (Integrated Services)

Tell:

•	All experimental and comparison sites received funding to support ACT teams, but only the experimental sites received $250,000 per year and technical assistance to improve system integration. 

•	Although this study found no differences between experimental sites and comparison sites on mental health symptoms or housing status, individuals receiving services from agencies whose services became more integrated had progressively better outcomes. 

Show: Slide 20 – Factors that Appear to Positively Effect Outcomes (Practical Services)

Tell:

•	These are services may be provided directly by the supported housing staff or case managers.

Exercise: (Small group or Individual)

•	Ask participants to rank order the factors from “most important for improving housing services my agency provides” to “least important for improving housing services my agency provides”.

•	Facilitate large group discussion of participant rankings.

Show: Slide 22 – Supported Housing Benefits to the Individual (Residential Status)

Tell:

•	This conclusion is supported by strong evidence from both randomized trials and quasi-experimental studies. 

Show: Slide 23 - Supported Housing Benefits to the Individual (Housing Stability)

Tell:

•	Studies did not always show that housing retention rates were not always better in supported housing programs than “continuum of care” approaches, but were consistently better than services as usual.

•	It should be noted that the longer the follow-up period, the greater the decline in housing retention rates, as might be expected.

•	 Achieving the rate of 80% over several years occurred in only one program model.

•	Housing stability can be disrupted by clinical symptoms.

Show: Slide 24 - Supported Housing Benefits to the Individual (Quality of Life Can be Improved)

Tell:

•	An individual’s preference for housing correlates with the person’s quality of life, and by and large people with psychiatric disabilities want decent places to live that they can call their own.

Slide 25 – Supported Housing Benefits to the Individual (Decreased Hospitalizations)

Tell:

•	It appears that having a permanent place to live and a place that one wants to live in along with flexible and responsive services, including crises intervention availability at all times, reduces the need for hospitalization.

Exercise: (Small group or Individual)

•	Ask participants to rank order from “benefits that are most lacking for the people my agency serves” to benefits that are most prevalent for people my agency serves”.

•	Facilitate large group discussion of participant rankings.

Show: Slide 26 & 27 – Supported Housing Benefits to the Individual (Other Findings)

Tell:

•	These two slides list some of the other conclusions about supported housing based on the review of the research.

Ask/Discuss:

•	What is the most meaningful information that you’ve learned about supported housing?

•	Are you more or less encouraged about providing supported housing and what are the reasons?