The vast majority of Safe Havens serve people who are chronically homeless and have been described as service-resistant. More than 300 Safe Haven programs nationwide have received funding from HUDs McKinney-Vento Homeless Assistance Programs. Safe Havens are generally small programs (on average about 16 residents and generally no more than 25) that may be designed to operate as either permanent or transitional housing (Ward Family Foundation, 2005). Transitional programs generally do not set rigid time limits for exit. These programs are usually implemented by, or in partnership, with a mental health center or agency, and about half of these receive some mental health services funding through contracts or grants from state, county, or city agencies.
|Evidence About Housing First/Low Demand Models
Evaluations of housing first and low demand service models have shown increased levels of housing stability when compared with other more high demand models. In one of the most rigorous studies, Tsemberis, Gulcur, and Nakae (2004) randomly assigned participants in New York City with an Axis I diagnosis, a 6-month history of homelessness, and recent street living to receive housing immediately without a treatment prerequisite (housing first group) or to receive housing contingent on sobriety (continuum of care control group). Over a 24-month follow-up period, the housing first group spent less time homeless and more time stably housed compared to the control group. The two groups did not differ on psychiatric symptoms or alcohol and drug use. Findings indicated that participants in the housing first group were able to maintain community housing without jeopardizing psychiatric stability or showing symptoms of substance abuse.
Despite the fact that there were no differences in alcohol or drug use, Tsemberis, Gulcur, and Nakae (2004) found that the control group reported significantly greater use of substance abuse treatment compared to the housing first group. This difference increased over time. While rates of participation in available supportive services may be lower when participation is voluntary, studies show tenants in many low demand programs are likely to participate at fairly high rates if supportive services are tailored to their needs. In the evaluation of the Closer to Home Initiative in New York and California, Barrow, Soto, and Cordova (2004) found that even when service participation was not required, supportive housing tenants were engaged in a wide variety of activities including health care services (81 percent), mental health treatment (80 percent), substance abuse treatment (56 percent), money management (65 percent), assistance in applying for benefits (51 percent), and employment services (41 percent). Similarly, an evaluation of the Choices program in New York City found high rates of participation in the voluntary day program services, which included assistance accessing health care and social services and provided an opportunity for participants to socialize (Shern et al., 2000).
Lipton et al. (2000) provides additional evidence that consumer choice and control has a positive impact on client outcomes. The study examined the effectiveness of a variety of different approaches to supportive housing in New York City. The study followed 2,937 tenants and described their outcomes based on whether they were placed into high-, moderate-, or low-intensity housing. Intensity reflected the amount of structure of the program and the degree of independence that tenants had. High-intensity programs were defined as having the most structure and least amount of tenant independence. Although people were not randomly assigned to the different housing models and some selection bias certainly exists the study found that those placed in the high-intensity models had the lowest level of housing retention 37 percent after five years compared with 56 percent for moderate-intensity programs (mostly women) and 54 percent for low-intensity programs.
Most Safe Havens have a daily structure and offer activities related to behavioral health, including 12-step meetings, counseling, training in daily living skills, medication monitoring and dispensing, and case management services. However, most programs do not require that residents participate. Safe Havens are generally staffed 24 hours a day, 7 days a week. Programs also offer opportunities for residents to participate in program governance through regular meetings or feedback sessions.
Safe Havens operate under a housing first, low demand philosophy. Nearly all Safe Havens have admissions criteria that are designed to target people who are most likely to be chronically homeless. As such, prospective residents generally are not required to be clean and sober, are not excluded if they have a criminal record, and are not required to participate in developing and carrying out an appropriate treatment plan. While nearly all Safe Havens prohibit the use of alcohol or illegal drugs on the premises, most do not prohibit the use of alcohol or illegal drugs away from the facility, and most expect that a significant number of residents will continue to have problems related to substance abuse. Some Safe Havens require that residents participate in weekly meetings, and some programs have more demanding service participation requirements. Program rules also prohibit verbal or physical abuse, violence toward other residents or staff, and illegal or criminal activity.
A primary goal of Safe Havens is to connect consumers to permanent housing, avoiding a return to the streets, shelter, hospital, or jail. While outcome data on the efficacy of Safe Havens is limited, one report has indicated that slightly over half of Safe Havens residents exit to permanent housing (Ward Family Foundation, 2005). According to the Ward Family Foundation report, Safe Havens that have achieved higher rates of referrals into permanent housing, compared to Safe Havens with lower referral rates, are:
- smaller programs that provide private accommodations (usually a private room, and often a private bathroom), and they nearly always operate at full capacity;
- more likely to serve homeless people coming from the streets, more likely to require a diagnosis of severe and persistent mental illness plus a co-occurring disorder, and more likely to have no limit on length of stay;
- more likely to provide a psychiatrist at the program and to provide treatment and supports for mental illness at the program site; more likely to have a higher staffing level (on average .5 full-time staff and .3 part-time staff for every resident);
- more likely to provide linkages to vocational and employment services; and
- more likely to exclude individuals with sexual offender criminal records (and a small minority exclude chronically homeless people with felony criminal records) (Ward Family Foundation, 2005).