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Housing First: Defining and Analyzing a New Rt Eatment Paradigm for Homelessness in the United States

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Housing First: Defining and Analyzing a New Rt Eatment Paradigm for Homelessness in the United States University of Massachusetts Boston ScholarWorks at UMass Boston Graduate Doctoral Dissertations Doctoral Dissertations and Masters Theses 8-2020 Housing First: Defining and Analyzing a New rT eatment Paradigm for Homelessness in the United States Caitlin A. Carey Follow this and additional works at: https://scholarworks.umb.edu/doctoral_dissertations Part of the Public Policy Commons HOUSING FIRST: DEFINING AND ANALYZING A NEW TREATMENT PARADIGM FOR HOMELESSNESS IN THE UNITED STATES A Dissertation Presented by CAITLIN A. CAREY Submitted to the Office of Graduate Studies, University of Massachusetts Boston, in partiaL fulfiLLment of the requirements for the degree of DOCTOR OF PHILOSOPHY August 2020 Public Policy PhD Program © 2020 by CaitLin A. Carey ALL rights reserved HOUSING FIRST: DEFINING AND ANALYZING A NEW TREATMENT PARADIGM FOR HOMELESSNESS IN THE UNITED STATES A Dissertation Presented by CAITLIN A. CAREY Approved as to style and content by: MichaeL P. Johnson, Professor Chairperson of Committee Susan R. CrandaLL, ClinicaL Professor Member RusseLL K. Schutt, Professor Member Heather MacIndoe, Program Director Public Policy PhD Program MichaeL P. Johnson, Chair Department of Public Policy and Public Affairs ABSTRACT HOUSING FIRST: DEFINING AND ANALYZING A NEW TREATMENT PARADIGM FOR HOMELESSNESS IN THE UNITED STATES August 2020 Caitlin A. Carey, A.A., GreEnfiEld Community CollEge B.A., Southern NEw Hampshire University M.S., University of MassachusEtts Boston Ph.D., University of MassachusEtts Boston DirectEd by Professor MichaEl P. Johnson As the Housing First approach to homElEss sErvicE provision has proliferatEd in the UnitEd States in recEnt years, variEd understandings of the model have emErged and a wide range of outcomEs have beEn reportEd. This study sEEks to bettEr understand the variation in the implEmEntation of Housing First, to identify outcomEs of intErest to stakeholders to improve future evaluations of the model, and to compare Housing First in practicE to Housing First in theory. In order to achiEve thesE goals, this study utilizEs an exploratory sEquential mixed mEthods resEarch design beginning with a qualitative casE study of Housing First programs in the GreatEr Boston area of MassachusEtts followEd by the design and distribution of an original online survey to a national samplE of organizations operating Housing First programs (n=283) to collEct data for quantitative analysis. Qualitative data suggest that the implEmEntation of Housing First is largely detErmined by the history of the organization, iv whethEr the organization chosE to transition to Housing First or was compellEd to do so by a funder, and the lEvel of staff enthusiasm for the model. KEy outcomE mEasures identifiEd by stakeholders include percEnt of program participants exiting to homElEssness, percEnt of program participants evictEd or involuntarily tErminatEd, life satisfaction among program participants, ability of program participants to perform activitiEs of daily living, and program participant progress toward achiEving goals beyond attaining and maintaining housing. Quantitative analysis of survey data reveals that in general, practitioners adhere closEly to Housing First in theory as it is broadly defined by the UnitEd StatEs IntEragency Council on HomElEssness. There is also widespread adoption of the narrowly defined Pathways Housing First model, with Housing First practitioners most commonly operating scattEred-site permanent supportive housing programs that sErve peoplE experiEncing chronic homElEssness. Regression models show that broadly, fidelity to Housing First in theory, lEvel of staff enthusiasm for Housing First, whether the organization chosE to utilizE a Housing First approach or was compellEd to do so by a funder, and the lEngth of timE that an organization has beEn utilizing a Housing First approach are all significantly correlatEd with key outcomEs. v ACKNOWLEDGEMENTS Thank you to my committEE for their feEdback and EncouragemEnt throughout the dissErtation procEss. Thank you to my family for their unending support. A special thank you to my partner, DaniEl Carey, who was my unofficial resEarch assistant and editor. vi DEDICATION For the residents, sheltEr guests, and staff of PreblE StreEt’s FlorencE HousE, who inspired this resEarch. vii TABLE OF CONTENTS ACKNOWLEDGEMENTS ..................................................................................................... vi DEDICATION ........................................................................................................................ vii LIST OF FIGURES ................................................................................................................. xi LIST OF TABLES ................................................................................................................. xiii CHAPTER Page 1. INTRODUCTION .....................................................................................................1 OverviEw ............................................................................................................1 LitErature ReviEw ...............................................................................................5 A BriEf History of HomElEssness in the UnitEd StatEs ..........................5 Origins of Housing First in the UnitEd StatEs ........................................9 Housing First Today ............................................................................13 The Range of OutcomEs from Housing First .......................................15 Critiques of Housing First ....................................................................18 ResEarch Questions ..........................................................................................19 ResEarch Contributions ....................................................................................20 Motivation ........................................................................................................21 2. METHODOLOGY ..................................................................................................22 OverviEw ..........................................................................................................22 QualitativE CasE Study of GreatEr Boston .......................................................24 Qualitative Data CollEction ..................................................................25 Analysis of Qualitative Data ................................................................30 National Survey of Housing First Providers ....................................................30 Survey DEsign ......................................................................................31 Logistics of Survey ..............................................................................33 Validation of Survey ............................................................................34 SamplE SElEction ..................................................................................35 Analysis of Survey Data ......................................................................39 Study Validity ..................................................................................................40 Study GEneralizability .....................................................................................41 MEthodological Limitations .............................................................................42 Ethical Considerations .....................................................................................43 viii CHAPTER Page 3. HOUSING FIRST IN GREATER BOSTON: A QUALITATIVE CASE STUDY ....................................................................................................................44 OverviEw ..........................................................................................................44 Expert IntErviEws .............................................................................................44 GracE Mission ..................................................................................................49 A Pathway HomE .............................................................................................57 HomEs Now .....................................................................................................67 Synthesis of Value-FocusEd Thinking Logic Structures .................................77 Discussion ........................................................................................................81 4. NATIONAL SURVEY OF HOUSING FIRST PROVIDERS ................................85 DEvelopmEnt of Survey Questions ..................................................................85 Results ..............................................................................................................86 DEscriptive Statistics ............................................................................87 Regression Models ...............................................................................97 Discussion ......................................................................................................117 5. CONCLUSION ......................................................................................................120 OverviEw ........................................................................................................120 AnswErs to ResEarch Questions .....................................................................121 RQ1: How do different groups of stakeholders define, understand,
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