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Integrating Housing, Healthcare and Employment Supports to Solve Homelessness

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Integrating Housing, Healthcare and Employment Supports to Solve Homelessness Integrating Housing, Healthcare and Employment Supports to Solve Homelessness Kerry Lange, MPA candidate School of Public Administration University of Victoria March 2016 Client: Rob Turnbull, Chief Executive Officer Streetohome Foundation Supervisor: Dr. Barton Cunningham School of Public Administration, University of Victoria Second Reader: Dr. Budd L. Hall School of Public Administration, University of Victoria Chair: Dr. Rebecca Warburton School of Public Administration, University of Victoria ACKNOWLEDGEMENTS The author would like to express his sincere gratitude to the following people and organizations: The Streetohome Foundation—for providing the opportunity to research best practices in integrated service delivery to homeless people. Dr. Rob Turnbull, CEO—for the opportunity to write this research and for his feedback and encouragement. Writing this research has been an enlightening and eye-opening journey—one I am glad to have made. Dr. Kimberley Speers—for recommending Streetohome Foundation as a client and for her encouragement to move forward with my project. Dr. Barton Cunningham—for being a calm and encouraging supervisor, who kept in touch even when I forgot and did not flinch when presented with an issue. My wife, Cornelia—for unselfishly giving me the days, evenings, weekends, and holidays to lock myself away to complete this research. Although locked away, I could always feel your support. When I came out of my “cave,” you were always there. I could not have worked day-to-day and also completed this research without your endless patience, understanding, and support. Thank you to everyone who contributed. You were generous with your time. I enjoyed listening to everyone and learning. Cara Colantouono – Support Homeless Veterans, Inc. Jane Slessor – Boyle Street Community Services Lauren Hall – Delivering Innovation in Supportive Housing (DISH) Dr. Sam Tsemberis – Pathways to Housing John Berger – St. Bartholomew’s House Giri Puligandla – Homeward Trust Shayne Williams – The Lookout Society Kim Stacey – McLaren Housing Society of British Columbia Joanne Williams – Byamee Proclaimed Place, Inc. Patricia O’Connell – Sistering [i] EXECUTIVE SUMMARY INTRODUCTION Homelessness is a complex problem with far-reaching negative impacts in western economies, including Canada’s provinces and territories. Homeless people suffer: high mortality, multiple morbidities, anxiety, depression, and behavioural problems; foregone economic and social contributions; poor nutrition and health; increased risk of substance abuse; lost social connections; isolation; loneliness; and incarceration. Being a complex issue, homelessness requires an array of responses delivered in unison. Unfortunately, few if any responses or solutions reside with a single organization or authority. As a result, cooperation across organizations and authorities is a minimum requirement for addressing homelessness. Yet, services are separated (Hughes, 2012, p. 8). One federal department addresses housing and other separate entities deal with health, employment, and justice. Provincially, similar independent silos exist (Hughes, 2012, p. 11). To complicate matters further, a myriad of non-profit, municipal, and provincial government agencies provide front line supports. Although billions of dollars have been spent managing homelessness over the last 35 years, there is little progress to show for it. In 2009, while assessing the results of $1 billion directly funded to the Federal government’s primary homelessness program between 2000 and 2010, Human Resources and Skills Development Canada (HRSDC) reported homelessness actually increased (Hughes, 2012, pp. 6-7). Still, amidst discouraging data and disheartening results are strong threads of hope and progress. Some people present a convincing argument that homelessness can be successfully addressed (Gaetz, Gulliver, & Richter, 2014, p. 3) using tools and resources at our disposal right now (Hughes, 2012, p. 1). Gaetz et al. say the following six strategies can successfully address Canadian homelessness (2014, p. 7): 1. A new federal, provincial, and territorial affordable housing framework agreement; 2. Investments to target chronically and episodically homeless people; 3. Direct investments in affordable housing programs; 4. A housing benefit to assist those who face severe affordability problems in their current accommodation; 5. A new affordable housing tax credit; and 6. Investments in Aboriginal housing both on and off reserve. For at least the last 50 years it has generally been agreed that health care is required, in addition to housing. Access to these services has been through a hard-to-navigate mix of federal, provincial, municipal, non-profit, religious, and philanthropic organizations. Those needing services have been left alone to navigate service-to-service. Available health services focus on housing, health, and supportive services—historically associated with the homeless’ needs. Each service provides multidisciplinary support to a range of people: from those experiencing chronic homelessness to people in immediate crisis. However, these services usually do not place a primary focus on employment services, despite it being a key piece of the homelessness puzzle (Putnam, Shamseldin, Rumpf, Wertheimer, & Rio, 2007, p. 2; Rio, Ware, Tucker, & Martinez, [ii] 2008, p. 1; Serge, Kraus, & Eberle, 2006, pp. 20-22; Shaheen & Rio, 2007, p. 343; U.S. Department of Health and Human Services, 2003b, p. 12). The Streetohome Foundation (“Streetohome”) is a non-profit organization whose mission is to solve homelessness in Vancouver, British Columbia. Streetohome uses funds raised to leverage housing projects specifically geared toward the homeless population. For example, it might raise $3 million to build a $30 million housing project including programming for building residents. Driven by evidence, Streetohome seeks to integrate employment into the services and programs it facilitates. As it has done with existing services, Streetohome also seeks to ensure such integration is done effectively. Effective employment integration is a key to improving results for Streetohome clients. To address Streetohome’s mission, this research seeks to answer the question “What are international best practices of bringing housing, healthcare and employment supports together in planning and practice to meet the needs of the formerly homeless, sheltered and at risk for homelessness” (Turnbull, 2014, p. 6) METHODS This research looks to three information sources to determine best practices: a literature review, document review, and survey. The literature review examines scholarly and grey literature to determine what established or upcoming best practices are used for habilitating and rehabilitating homeless people. Additionally, literature is reviewed to gather principles for integrating services for the homeless. This research considers four characteristics to determine whether a method or process is a best practice: • There is a body of evidence supporting efficacy of the model. • The method has been tested across a diverse population in many locations. • It has been accepted as a best practice by practitioners and professionals in the field and by government bodies. • Tools are available to ensure the best practice is used correctly in diverse circumstances and populations. The document review examines two handbooks, a guidebook and a report related to developing an employment service for homeless people. The documents are based on American vocational programs, and the lessons learned are reviewed for potential application in Streetohome’s effort to solve homelessness. A thematic analysis is performed on best practices to identify repeating and important topics. The survey was designed to solicit responses based on practitioner experiences. It asks participants what best practices they use or have seen in their work and also solicits information on the challenges they face in planning and operating a service for homeless people. A thematic analysis is performed on the survey results. Best practices, lessons learned, and integration principles are combined in an integration framework and presented as a list or integration “tree.” [iii] Recommendations and options based on the best practices, lessons learned, and integration principles are offered at the conclusion. FINDINGS From a scientific point of view, there is no best practice when it comes to providing services to homeless people. Although research and data support some practices more than others, there simply is not enough empirical evidence to indicate any method is worthy of the moniker “best practice.” Without a doubt, a single thread weaves through the research. Clients are central to all best practices and service integration. This would be a trite statement were it not for the extent clients are integrated into programs. Clients are an integral part of best practice programs, as well as the target of supports. They participate in planning and operation and are given ownership of many aspects, especially their own direction. Using the four characteristics from the Methods section to determine best practices, the following practices are identified: Assertive Community Treatment—a widely accepted best practice for dealing with people having multiple issues, such as mental illness and substance abuse. Combined with Housing First, it has proven successful. Comprehensive, Continuous, Integrated System of Care—a systemic approach to providing care to people with
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