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What is Housing First?

What is Housing First?

Geoffrey Nelson and Tim Aubry
August 2023

In the field of housing and homelessness, the term Housing First describes an evidence-based approach to ending chronic homelessness. However, there is some confusion about what constitutes Housing First. This resource describes the Canadian Housing First Network’s definition of Housing First by defining “what it is not” and “what it is.”

What Housing First Is Not

Shelters – This is a crisis management approach that does not provide permanent housing. This includes shelters that offer on-site treatment services such as day programs, vocational training, and transitional housing. This is Treatment First, not Housing First.

Transitional housing – This approach is based on the principle that the individual is not ready to live independently and requires residential treatment before s/he can move into their own housing in the community.

Congregate, supportive housing – Many communities have buildings that are exclusively for individuals who are homeless and are experiencing mental illness and addictions. These buildings have staff members who provide services on-site.

Tiny home villages – There is no research on the use of tiny home villages in ending homelessness. Tiny homes are often clustered together in one place, segregated from the community. In addition to not promoting community integration, they do not offer participants choice over their housing.

What Housing First Is

Housing First is an evidence-based program designed to eradicate homelessness among individuals with mental illness and addiction who are experiencing chronic homelessness (Aubry, Nelson, & Tsemberis, 2015; Tsemberis, 2015; Padgett, Henwood, & Tsemberis, 2016). Participants have immediate access to the permanent housing of their choice in the community, facilitated by a portable rent supplement that ensures they pay no more than 30 per cent of their income on their housing (Nelson & Aubry, 2017). The housing can be either private market rentals or social housing, and they receive intensive support aimed at promoting housing stability, recovery, community integration, and achievement of life goals.

Rent supplements and support services are not time-limited and are available for as long as the person needs them. There are no pre-conditions about the level of functioning, participation in treatment, or abstinence from substance use. Housing First programs are designed to move people out of homelessness and into housing as quickly as possible.

Principles of Housing First

Housing First is guided by three principles: free choice, recovery, and community integration (Nelson & Aubry, 2020a & b; Tsemberis, 2015). Professionals help participants decide where they want to live. Research has shown that 84 per cent of people who are homeless want to live independently in regular housing like everyone else (Richter & Hoffman, 2017). Rent supplements give people the means to access this kind of housing. Choice is also important in participants’ support services.

The second principle guiding Housing First programs is intended to guide participants toward recovery. Recovery is a treatment orientation that refers to a participant’s journey of growth and self-improvement to achieve life satisfaction. Pursuing one’s hopes and goals, finding meaning and purpose, while managing one’s mental illness and/or addictions, are all part of recovery.

The third principle is community integration. People with mental illness who are homeless often experience segregation, exclusion, and stigma. The Housing First model separates housing from support, so people live independently in the community in scattered-site apartments. Staff are not present on-site, nor are participants congregated in one building with other participants. In this way, stigma is reduced and people with mental illness are not singled out.

Fidelity and Flexibility

For Housing First to be effective, it must have the key components of rent supplements and support services, be based on the principles of choice, recovery, and community integration, and employ program practices that reflect these principles. Housing First researchers have developed a measure of fidelity that allows programs to assess the extent to which they have the critical ingredients of Housing First. Research has shown that a high level of fidelity to the model is crucial for achieving positive outcomes, such as housing stability and improved quality of life (Goering et al., 2017). The Canadian Housing First Network has developed a manual that helps programs evaluate if they meet Housing First standards of practice (Aubry & Nelson, 2019).

While fidelity is important, Housing First is also adaptable to culture, context, and population. The basic principles and practices of Housing First have been retained and adapted for programs for youth, Indigenous people, racialized populations and women experiencing interpersonal violence.

Housing First is Evidence-Based

The effectiveness of Housing First is supported by extensive, rigorous research conducted in several countries:

In addition, a comparison of the costs of Housing First with usual treatment showed the reduction in use of services in participants exceeded the cost of the Housing First program, in large part because of the significantly reduced hospitalizations and shorter hospital stays compared to individuals receiving usual services (Tinland et al., 2020).

Recent systematic reviews have concluded that Housing First is an evidence-based approach that ends chronic homelessness for people with severe mental illness (Aubry et al., 2020; Jacoby et al., 2022; Kilaspey et al., 2022; Moledina et al., 2022).

Canadian Housing First Network

References

Aubry, T., Bloch, G., Brcic, V., Saad, A., Magwood, O., Abdalla, T.… & Potty, K. (2020). Effectiveness of permanent supportive housing and income assistance interventions for homeless individuals in high-income countries: A systematic review. The Lancet Public Health. 5, e342-360. Available at https://doi.org/10.1016/S2468-2667(20)30055-4

Aubry, T., Goering, P., Veldhuizen, S., Adair, C.E., Bourque, J., Distasio, J., … & Tsemberis, S. (2016). A multiple-city RCT of Housing First with Assertive Community Treatment for homeless Canadians with serious mental illness. Psychiatric Services, 67, 275-281. Available at https://doi.org/10.1176/appi.ps.201400587

Aubry, T., Nelson, G., & Tsemberis, S. (2015). Pathways Housing First for people with severe mental illness who are homeless: A review of the research. Canadian Journal of Psychiatry, 60, 467-474. doi: 10.1177/070674371506001102

Goering, P., Veldhuizen, S., Nelson, G., Stefancic, A., Tsemberis, S., Adair, C., Distasio, J., Aubry, T., Stergiopoulos, V., & Streiner, D. (2016). Further validation of the Pathways Housing First Scale. Psychiatric Services, 67, 111-114. http://dx.doi.org/10.1176/appi.ps.201400359

Goering, P., Veldhuizen, S., Watson, A. et al. (2014). National At Home/Chez Soi Final Report. Calgary, AB: Mental Health Commission of Canada. National At Home/Chez Soi Final Report (EN)Rapport final du projet pan-canadien Chez Soi (FR)

Gulcur, L., Stefancic, A., Shinn, M., Tsemberis, S., & Fischer, S. (2003). Housing, hospitalization, and cost outcomes for homeless individuals with psychiatric disabilities participating in continuum of care and Housing First programs. Journal of Community and Applied Social Psychology, 13, 171-186. doi: 10.1002/casp.723 

Jacob, V., Chattopadyhay, S.K., Attipoe-Dorcoo, S.A., Peng, Y., Hahn, R.A., Finnie, R., … & the Community Services Preventive Task Force (CSPTF). (2022). Permanent supportive housing with Housing First: Findings from a community guide systematic economic review. American Journal of Preventive Services. March, 62(3):e188-e201. doi: 10.1016/j.amepre.2021.08.009.

Kilaspy, H., Harvey, C., Brasier, C., Brophy, L., Ennals, P., Fletcher, J., & Hamilton, B. (2022). Community-based social interventions for people with severe mental illness: A systematic review and narrative synthesis of recent evidence. World Psychiatry, 21, 96-123. doi:10.1002/wps.20940

Latimer E.A., Rabouin D., Cao Z., Ly, A., Powell G., Aubry T., Distasio J., Hwang S.W., Somers J.M., Bayoumi, A.M., Mitton C., Moodie, E.E.M., Goering, P.N. (2020). Cost-effectiveness of Housing First with Assertive Community Treatment: Results from the Canadian At Home/Chez Soi trial. Psychiatric Services, 71, 1020-1030. doi: 10.1176/appi.ps.202000029

Latimer E.A, Rabouin D, Cao Z, Ly, A., Powell, G., Adair, C.E., Sareen, J., Somers, J M., Stergiopoulos, V., Pinto, A.D., Moodie, E.M., & Veldhuizen, S. R., (2019). Cost-effectiveness of a Housing First intervention with Intensive Case Management compared with treatment as usual for homeless adults with mental illness: Secondary analysis of a randomized clinical trial. JAMA Network Open. 2019; 2(8):e199782. doi:10.1001/jamanetworkopen.2019.9782

Moledina, A., et al. (2022). A comprehensive review of prioritized interventions to improve the health and wellbeing of persons with lived experience of homelessness. Campbell Systematic Reviews, 17: e1154. https://doi.org/10.1002/cl2.1154

Nelson, G., & Aubry, T. (2017). A portable housing benefit as an indispensable component of ending homelessness in Canada. Toronto, ON: Evidence Exchange Network. Available at http://eenet.ca/initiative/housing-first-community-interest#about

Nelson, G., & Aubry, S. (2021, January). Evidence at a glance: Housing First and costs. Toronto: Centre for Addiction and Mental Health, Evidence Exchange Network, Ontario Housing First Regional Network – Community of Interest. Available at https://www.eenet.ca/resource/evidence-glance-housing-first-and-costs

Nelson, G., & Aubry, S. (2020a, July). Evidence at a glance: Housing First and choice. Toronto: Centre for Addiction and Mental Health, Evidence Exchange Network, Ontario Housing First Regional Network – Community of Interest. Available at https://www.eenet.ca/resource/evidence-glance-housing-first-and-choice

Nelson, G., & Aubry, S. (2020b, July). Evidence at a glance: Housing First and community integration. Toronto: Centre for Addiction and Mental Health, Evidence Exchange Network, Ontario Housing First Regional Network – Community of Interest. Available at https://www.eenet.ca/resource/evidence-glance-housing-first-and-community-integration

Padgett, D., Henwood, B.  & Tsemberis, S. (2016). Housing First: Ending homelessness, transforming systems, and changing lives. New York: Oxford University Press.

Richter, D., & Hoffman, H. (2017). Preference of independent housing of persons with mental disorders: Systematic review and meta-analysis. Administration and Policy in Mental Health and Mental Health Services and Research, 44, 817-823.  doi: 10.1007/s10488-017-0791-4

Stefancic, A., & Tsemberis, S. (2007). Housing First for long-term shelter dwellers with psychiatric disabilities in a suburban county: A four-year study of housing access and retention. Journal of Primary Prevention, 28, 265-279.  doi: 10.1007/s10935-007-0093-9

Stergiopoulos, V., Hwang, S.W., Gozdzik, A., Nisenbaum, R., Latimer E., Rabouin, D.,    et al. (2015). Effect of scattered-site housing using rent supplements and intensive case management on housing stability among homeless adults with mental illness: a randomized trial. JAMA Mar 313 (9) 905–915. doi:10.1001/jama.2015.1163

Stergiopoulos, V., Mejia-Lancheros, C., Nisenbaum, R., Wang, R., Lachaud, J., O’Campo, P., & Hwang, S.W. (2019). Long-term effects of rent supplements and mental health support services on housing and health outcomes of homeless adults with mental illness: Extension study of the At Home/Chez Soi randomised controlled trial. The Lancet, 6, 915-925. Available at https://doi.org/10.1016/S2215-0366(19)30371-2

Tinland, A., Loubière, S., Boucekine, M., Boyer, L., Fond, G., Girard, V., & Auquier, P. (2020). Effectiveness of a housing support team intervention with a recovery-oriented approach on hospital and emergency department use by homeless people with severe mental illness: A randomised controlled trial. Epidemiology and Psychiatric Sciences, 29, e169, 1–11. Available at https://doi.org/10.1017/S2045796020000785

Tsemberis, S. (2015). Housing First:  The Pathways model to end homelessness for people with mental illness and addiction. Center City, MN: Hazelden Publications.

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