What is Housing First?
Geoffrey Nelson and Tim Aubry
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:
- The original Pathways Housing First program in New York City and its expansion into suburban New York was shown through rigorous research to end homelessness for participants more quickly compared to typical services (Gulcur et al., 2003; Stefancic & Tsemberis, 2007; Tsemberis & Eisenberg, 2000). More than 80 per cent of those in Housing First remained housed compared with less than 50 per cent of those receiving usual care.
- The Canadian At Home / Chez Soi study examined Housing First programs in five Canadian cities (Vancouver, Winnipeg, Toronto, Montreal, Moncton) with more than 2,000 participants experiencing homelessness and mental illness. Housing First proved to be more effective than usual treatment in all five communities in ending homelessness for participants and helping them to achieve housing stability. Over the two years of the study, Housing First participants spent 73 per cent of their time stably housed compared to only 32 per cent for those receiving treatment as usual (Aubry et al., 2016; Goering et al., 2014; Stergiopoulos et al., 2015). A six-year follow-up of the Toronto site participants showed that these outcomes persisted over time (Stergiopoulos et al., 2019).
- Analyses of cost offsets associated with Housing First programs found that they offset 46 per cent of the costs of serving people with moderate needs and 69 per cent of the costs of serving people with high needs through reduction of health and social services and reduction of involvement in the judicial system (Latimer et al., 2019; Latimer et al., 2020; Nelson & Aubry, 2021).
- Researchers in France randomly assigned 700 participants experiencing mental illness and homelessness in four cities to Housing First or usual treatments. Interviews of participants were conducted over a period of 24 months. Compared with those in usual treatment, the Housing First group experienced greater housing stability, had significantly fewer days in in-patient hospital admissions, and scored significantly better on a measure of quality of life over the two years of the study (Tinland et al., 2020).
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).
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.