Housing

First
The Pathways Model to End
Homelessness for People
with Mental Health and
Substance Use Disorders

Sam Tsemberis, phd

Evidence-Based Resources for Behavioral Health

Evidence-Based Resources for Behavioral Health

Hazelden Publishing
Center City, Minnesota 55012
hazelden.org/bookstore

©2010 by Sam Tsemberis

All rights reserved. Published 2010.
Revised and updated for DSM-5 edition published 2015.
Printed in the United States of America

Unless a statement on the page grants permission, no part of this publication, either print
or electronic, may be reproduced in any form or by any means without the express written
permission of the publisher. Failure to comply with these terms may expose you to legal
action and damages for copyright infringement.

Library of Congress Cataloging-in-Publication Data

Tsemberis, Sam J.
Housing first : the Pathways model to end homelessness for people with mental health and
substance use disorders / Sam Tsemberis.
p. cm.
Includes bibliographical references and index.
ISBN 978-1-61649-649-4
1. Homeless persons--Housing--United States. 2. Homeless persons--Housing. 3. Homeless
persons--Services for--United States. 4. Mentally ill homeless persons--Services for--United
States. 5. Homeless persons--Substance use--United States. I. Title.
HV4505.T74 2010
363.5'9740973--dc22
2010035376

20 19 18 17 16 15 123456

Editor’s note: The names, details, and circumstances may have been changed to protect the
privacy of those mentioned in this publication.

The suggestions and model documents in this book are not meant to substitute for the advice
of lawyers, accountants, or other professionals.

Cover design by Terri Kinne

Interior design and typesetting by David Farr, ImageSmythe
Copyediting for DSM-5 update by Jean Cook, ImageSmythe
Evidence-Based Resources for Behavioral Health

Evidence-Based
The DartmouthResources for Behavioral
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was formed as a partnership between
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sion of the Hazelden Betty Ford Foundation—nonprofit leaders in the research and
development of evidence-based resources for behavioral health.
Our mission is to create and publish a comprehensive, state-of-the-art line
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to Cherie, Elena, and Alex
who taught me about love

and for every person who came to Pathways to Housing

from the streets, hospitals, and jails—
and never lost the ability to love
Contents

Foreword xiii
Acknowledgments xv

Introduction 1
Homelessness: A Global Problem  1
About Housing First and This Manual  4
Who Should Read This Manual—and Why  6
How to Use This Manual  6
Chapter Overview  6
Terminology 8

Chapter 1
The Pathways Housing First Program  11
Why It Works  11
The Origins of Housing First: An Alternative
to Linear Residential Treatment  13
The Principles of Housing First  18
Chapter 1 Summary  30
CONTENTS

Chapter 2
Initial Program Steps  33
Client Demographics  33
Determining Eligibility  35
Referrals to phf Programs  36
The Engagement Process  37
Preparing for the Apartment Search  43
Initial and Ongoing Services  44
Chapter 2 Summary  45

Chapter 3
Housing and Housing Support Services  47
Why Housing First?  48
The Two Program Requirements  48
First Steps to Securing Housing  50
Criteria for Choosing an Apartment  52
Leasing or Subleasing through phf 55
Tenant Responsibilities and Rights  56
Security and Safety Issues: The Basics  57
Making a Home: Physical and Emotional Comfort  58
Landlords 61
Collaborative Roles in Housing phf Clients  63
Some Common Property Management Challenges  65
Personal Relationships: Building and Reconnecting  67
When Relocation Is Necessary  69
Chapter 3 Summary  74

viii
 CONTENTS

Chapter 4
An Interdisciplinary Approach: How the ACT and
ICM Teams Serve Clients in a PHF Program  77
A Community-Based Interdisciplinary Approach  77
Matching Clients with the Right Level of Service  78
act and icm Teams: Differences and Similarities  79
Comprehensive Assessment and Treatment Planning  80
The Art and Science of the Home Visit  83
Renewing Team Practice and Team Process  88
Chapter 4 Summary  89

Chapter 5
The PHF Assertive Community Treatment Team  91
Assertive Community Treatment Teams: How They Work
in a phf Program  92
The act Team Members  96
The act Team’s Morning Meeting  116
A Hypothetical Morning Meeting  126
The act Weekly Case Conference  127
Chapter 5 Summary  127

Chapter 6
The PHF Intensive Case Management Team  129
The icm Strengths Model of Service Delivery  129
The icm Team Members  132
The icm Weekly Team Meeting  145
Chapter 6 Summary  145

 ix
CONTENTS

Chapter 7
Incorporating Other Evidence-Based Practices  147
Integrated Dual Disorders Treatment  148
Wellness Management and Recovery 158
Supported Employment  161
Groups and Social Events  163
Community Integration  164
Chapter 7 Summary  165

Chapter 8
Bringing Pathways Housing First to Your Community  167
Assessing the Need and Making the Case for a phf Program  167
A Local Champion: One Key to Successful Implementation  168
Obtaining Funding for the Two phf Program Components  171
Launching a phf Program  174
The Important First Year—and Beyond  176
Chapter 8 Summary  177

Pathways Housing First Institute for Training  179

Appendices
Appendix A: Research and Evaluation  181
Appendix B: Some Administrative Considerations  191
Appendix C: Sample Forms  195
Appendix C-1: The act Team Morning Meeting
Description and Checklist  197
Appendix C-2: Furniture List and Client Shopping List  201
Appendix C-3: Pre-Move-In Apartment Readiness Checklist  205
Appendix C-4: Use and Occupancy Agreement  207
Appendix C-5: Pathways Housing First Program Fidelity:
The Essential Ingredients Checklist  215

x
 CONTENTS

Appendix D: Sample Budget  219

Appendix E Awards Received by Pathways Housing First
and Dr. Sam Tsemberis  223
Appendix F: Two Testimonials  225
Appendix G: Additional Resources  229

Notes 231
References 233
Index 237
About the Author  243

 xi
Foreword

Some people, convinced on principle, “get” the idea of Housing First instantly.
Others are more skeptical, convinced by their training that people with mental
health disorders and substance use disorders are incapable of making wise decisions
for themselves. In 1998, I was part of the team conducting the first experimental
evaluation of Pathways Housing First. Founder Sam Tsemberis—everyone calls him
Sam—had already shown in two published studies that Pathways tenants were more
stable in their housing than clients in other programs designed for people with long
histories of homelessness and serious psychiatric disabilities known as severe mental
disorders. Traditionally trained social service providers from the other programs,
which required clients to be clean and sober and participate in treatment in order to
have a bed of their own in a congregate facility, claimed that Sam must be working
with a different group of people—that their clients could not succeed in a model
where homeless people are given independent apartments with a panoply of services
but without close supervision. It seemed time to put Sam’s model to a more rigorous
test, randomly assigning some people to Pathways to Housing and others to tradi-
tional programs to create a fair comparison.
Recruitment to the study was lagging, so we held a breakfast for outreach
workers to explain the experiment and to urge them to refer more people. One out-
reach worker ate our bagels but argued that it would not be ethical to refer the cli-
ents she worked with to the study: they might get randomly assigned to receive their
own apartment, and that, she insisted, would be setting them up for failure. A couple
weeks later, we caught a break. A study participant who had been randomly assigned
FOREWORD

to Pathways to Housing invited his family and his former outreach worker over to
dinner to show off his new apartment. The outreach worker was so impressed by
the transformation of the disheveled denizen of the street into a gracious host that
he told all the other workers at his agency. They responded by referring dozens of
clients to the study, and we finished up recruitment with a bang.
Of course, the outreach worker’s epiphany could have been based on an
anomalous case. But the evidence from the study was convincing: over the first year,
people randomly assigned to the Pathways program spent ninety-nine fewer days
homeless than individuals in the control group, and they used substances at no
greater rates. Pathways participants got housed faster and stayed housed longer. The
enormous differences between experimental and control groups gradually narrowed
over time as more control group members found their way indoors, but a study
published in 2004 found that the Pathways tenants were still far more likely to be
housed at the end of the four-year experiment. Nonetheless, I have no way of know-
ing whether the skeptical outreach worker at that breakfast was convinced.
By now, Housing First has garnered so much acclaim that everyone claims to
be doing it, no matter how little their programs resemble the Pathways to Housing
model. Pathways Housing First is neither a “housing only” approach, nor does it
offer “worker-knows-best” services coupled with immediate housing. It is a suc-
cessful, rigorously documented, systematic approach to serving homeless people
with substance use and mental health disorders. This manual clarifies the ethos
and practices of Pathways Housing First. We hope it will also begin to change the
standard training that still makes it hard for many social service professionals to give
up coercive control—no matter how artfully it may be disguised—and support the
choices of the people with whom they work.

Marybeth Shinn, phd

Professor and Chair
Department of Human and Organizational Development
Vanderbilt University

xiv
Acknowledgments

This book owes its existence to the many remarkable people, past and present,
whom I met as clients served by Pathways to Housing and its predecessors, Choices
Unlimited and the 44th Street Independence Support Center drop-in centers. By
bringing together the essential elements of our many heated and passionate conver-
sations about choice, power, rights, poverty, privacy, disabilities, and abilities, we
were able to develop, design, implement, and operate the Pathways Housing First
program. I had the good fortune to have Bill Anthony, David Shern, Mikal Cohen,
and Howie the Harp as early collaborators in our “taking psych rehab to the streets”
grant. Our 44th Street drop-in center was modeled after Howie’s consumer-operated
Independence Support Center in Oakland. Rachel Efron, Hilary Melton, and Ed
Rooney were influential staff members who ensured that our priority lay in taking
care of the needs of our clients, and not of the programs.
In the early nineties, when Housing First was considered a risky venture, Bert
Pepper, Mary Brosnahan, and Elmer Struening, national experts in mental health
and advocates for ending homelessness, risked their reputations in order to sup-
port our work by joining our board. Since then, Housing First has been replicated
in hundreds of cities by innumerable local champions who have started Pathways
programs in their own communities, and as of 2011, Pathways to Housing became
Pathways to Housing National. We've had welcome support from Philip Mangano,
Ann O’Hara, and Nan Roman, all of whom have been prolific advocates for using
Housing First as a means of abolishing what Mangano has called “the national
disgrace of homelessness.”
ACKNOWLEDGMENTS

There were many lessons learned from early program replications, the ones
that took place when most providers could still not believe that with the right
support people with mental health disorders could live on their own in their own
apartments. These replications—the ones created before the evidence base was
available—were the most challenging and required the greatest investment from our
stakeholders. It took enormous courage for Nancy Travers to import the program
into Westchester County. Marti Kinsley had the political will and willingness to risk
importing Pathways to Washington, dc. The program in the nation’s capital would
not have been possible without Nan Roman’s advocacy and the generosity of the
Abell Foundation. In the early years, my friend and writing mentor Jay Neugeboren
put our program on the national map by describing it in his book Transforming
Madness: New Lives for People Living with Mental Illness.
This book would not have been possible without the ingenious researchers who
conducted the rigorous longitudinal randomized controlled trials that have charted
the development and effectiveness of Pathways as an evidence-based program.
This group includes Sara Asmussen, Beth Shinn, and especially Ana Stefancic, our
director of research, who also provided the research summary for this volume.
Their articles led to program dissemination that created hundreds of Housing First
programs that have, across the country, succeeded in ending homelessness for many
thousands of people.
In 2010, the Mental Health Commission of Canada was at the midpoint of
a $110 million, longitudinal randomized controlled trial to test the effectiveness
of our Housing First program in five Canadian cities. This continues to be an
unprecedented and enormous social science experiment, and it is a great honor
to be working with a talented Canadian team that includes Paula Goering, who
directs the research, and Jayne Barker and Cam Keller, who direct the project at
the Commission. I am grateful to Tim Richter, director of the Calgary Homeless
Foundation and advocate for the Housing First approach. With Tim’s able assistance
and the collaboration of our colleagues at the Alex Community Health Centre, we
were awarded a knowledge dissemination grant from the Canadian government. I
am extremely indebted to all my Canadian compatriots because my participation in
their projects, and what I learned as a participant, have helped make the writing of
this book possible.

xvi
 ACKNOWLEDGMENTS

The Canadian programs have fewer fiscal constraints then those in the United
States. In part because Canadians have national health insurance, the financial
operations of our programs in Canada have few restrictions placed upon them.
This creates an environment where funding does not impinge upon clinical prac-
tice (e.g., requiring a fixed number of visits per client in order to be reimbursed).
It became easy to see, and thus to be able to describe, how it is possible for the
Pathways Housing First program to operate across a wide variety of settings.
Juliana Walker, who has served as our director of training and worked with me on
the Canadian projects, contributed enormously to this volume by writing early
drafts, editing others, and helping to clarify and describe various aspects of team
operations. (Since 2011, the Mental Health Commission of Canada made Housing
First a national policy for its At Home/Chez Soi project, requiring 65 percent of
homelessness funding monies be used for such Housing First activities.)
Bob Drake, my friend and colleague at Dartmouth, has been supportive of our
program. Among other things, Bob helped Ana Stefancic and me as we shaped the
research on program fidelity. But a book needs a publisher, and Bob introduced
me to Sid Farrar of Hazelden Publishing. Sid’s enthusiasm, and his professional-
ism, made the process painless and efficient. I am most grateful to Cynthia Orange,
my editor at Hazelden who suggested changes in structure and content that have
improved the book and made it readable, and who offered invaluable guidance,
along with a gentle therapeutic touch, throughout our collaboration. Thank you, too,
to Mindy Keskinen—you brought it all together and took it to the finish line.
Above all, I want to acknowledge the support and love I receive from my wife,
Cherie, and our children Elena and Alex. Their patience during family vacations
and other times that I have had to spend away from them, and their acceptance and
understanding, have made it possible for me to complete this project. Most sum-
mers we visit yiayia (my mother; my children’s grandmother) in Skoura, a village in
southern Greece. In this village of some five hundred people, everyone is included in
kafenio at the center of town: old and young, rich and poor, some with mental health
problems and some without. It is a place where there is respect and acceptance of
all—just as it is at Pathways to Housing.

All royalties from the sale of this book will be contributed to Pathways to Housing.

 xvii
Introduction

“
As originators of Housing First, Pathways to Housing National’s
mission is to transform lives by ending homelessness and
supporting recovery for those with mental health challenges.

We believe housing is a basic human right and aspire to

change the practice of mental health and homeless services by
•• providing immediate access to permanent housing,
without preconditions

”
•• providing support and treatment based on choice and
services that support recovery, social inclusion, and
community integration
•• and conducting research and training to develop best
practices for recovery-oriented care
Pathways to Housing National mission statement

Homelessness: A Global Problem

People with mental health disorders who are also homeless can be found worldwide.
Their characteristics vary from country to country, and so do the reasons for their
homelessness. But the problems they face because of their shared conditions give

 1
INTRODUCTION

them more in common than the differences that divide them. Access to affordable
housing and treatment is an almost universal barrier for this population worldwide.
Estimating the number of people who are homeless and who have mental health
disorders presents complex methodological and epidemiological challenges because
definitions of homelessness and mental disorders vary across countries and across
cultures. In 2004, the United Nations provided a practical and useful definition:

The correct definition of a homeless household should be. . . “those house-

holds [or individuals] without a shelter that would fall within the scope of
living quarters. They carry their few possessions with them, sleeping in
streets, in doorways, or on piers, or in any other space, on a more or less
random basis.” 1

Further complications arise because counting the number of people who are
homeless and have mental health disorders is not simply a matter of identifying indi-
vidual or demographic characteristics of this population. This number can also be
viewed as an index of a nation’s failed social service, housing, and mental health poli-
cies. Thus, the number of people who are homeless can be seen as a consequence
of larger social problems. Research on the Gini coefficient is one way to illustrate
this point. This coefficient is a commonly used measure of a nation’s income
disparity—the distance between rich and poor. A 2000 World Health Organization
study reported that developed European countries and Canada had Gini indices
between .24 and .36, while the United States and Mexico were both at .46 and Brazil
and South Africa at .61. Of relevance here is that social scientists report that there is
a negative correlation between the Gini coefficient and the percentage of a nation’s
budget spent on social and mental health services.2 Countries whose social and
mental health policies provide financial and other support to those at the bottom of
the income distribution are also the countries with lower levels of homelessness.3 It
is not surprising that, in general, advocates accuse governments of underestimating
the number of homeless, and government representatives say that advocates tend
to overestimate. For example, the United States Department of Housing and Urban
Development (hud) conducts a nationwide “one-night count” of the homeless every
year. The count is conducted late at night in the middle of winter. In 2014, the most
recent year for which data is available, hud estimated more than 578,000 people

2
 INTRODUCTION

were homeless—staying on the streets or in drop-in centers, shelters, or temporary

housing.4 This number is nearly the population of cities like Boston, Memphis, or
Baltimore. The advocacy organization National Law Center on Homelessness and
Poverty estimates the number of homeless at 2.5 million to 3.5 million, with an
additional 7.4 million who have lost their homes since the 2008 recession living
with family or friends out of financial necessity.5 In another national survey of the
prevalence of homelessness, Bruce Link and his colleagues estimated that 26 million
people had been homeless at one point in their lives.6 As for the subpopulation that
is the focus of this manual, hud estimated in 2008 that 28 percent of the people
who are homeless have severe mental disorders; 39 percent have chronic substance
use issues; and 18 percent are considered “chronically homeless,” which means they
have been continuously homeless for more than one year and suffer from mental or
physical disabilities.7 Those figures are consistent with other studies that estimate a
30 to 70 percent incidence of mental health problems among the homeless, with the
highest percentages among the chronically homeless.
A 2007 study of mental health and homelessness by the Canadian Institute for
Health Information estimated that more than 10,000 people are homeless on any
given night across Canada.8 The report also found that mental disorders accounted
for 52 percent of acute care hospitalizations among Canadian homeless in 2005 and
2006. Because of the data collection complexities in its many member countries,
measuring homelessness in the European Union (eu) is even more difficult than in
the United States. However, the European Federation of National Organizations
Working with the Homeless (feantsa) estimated that at least 3 million Western
Europeans were homeless during the winter of 2003.9
From our perspective as clinicians and advocates, any number of people
who have severe mental health disabilities and are living on the streets is too big a
number. When people enter into homelessness, they are at greatly increased risk
for health problems, victimization, malnutrition, exhaustion, and exacerbation of
mental health and substance use disorders. Their physical and mental health dete-
riorates rapidly, and those who remain chronically homeless are among the most
vulnerable. Fortunately, as Pathways to Housing has discovered and this manual will
show, the problems encountered by people who have remained homeless and who
have multiple or co-occurring conditions are problems with a proven solution—
a solution called “Housing First.”

 3
INTRODUCTION

“”
About Housing First and This Manual

Housing First ends homelessness. It’s that simple.

—Sam Tsemberis, founder and ceo
of Pathways to Housing National

Founded in 1992 in New York City, Pathways to Housing, Inc. is a nonprofit cor-
poration that is widely credited as being the originator of the Housing First model
of addressing homelessness among people with mental health and substance use
disorders. Put simply, Pathways’ unique approach is this: provide housing first,
and then combine that housing with supportive services and treatment services.
Research studies examining this model have shown that it dramatically reduces
homelessness and is significantly more effective than traditional treatment and
housing models. Because the Pathways model is so distinctive—providing services
through a consumer-driven treatment philosophy and providing scattered-site
housing in independent apartments—we refer to it as the Pathways Housing First
(phf) program to distinguish it from other programs that also identify with the
Housing First approach. The phf program is built on more than two decades of
clinical and operational experience, manuals, fidelity standards, and research find-
ings, attesting to the model’s effectiveness. After a 2007 peer review of these stud-
ies and other materials, the phf program was entered into the National Registry
of Evidence-based Programs maintained by samhsa, the Substance Abuse and
Mental Health Services Administration of the U.S. Department of Health and
Human Services.
Today, the phf program has been replicated in more than one hundred cities
across the United States, and a growing number of programs are in place in Europe,
Australia, and through the At Home/Chez Soi project, nationally in Canada.
The Pathways to Housing success has not gone unnoticed. Among its many
honors, Pathways to Housing was awarded the Excellence in Innovation Award
from the National Council for Community Behavioral Health Care, which rep-
resents 1,300 U.S. organizations that provide treatment and rehabilitation for
people with mental health and substance use disorders. The phf program also
earned the American Psychiatric Association’s Gold Award, ranking it first among

4
 INTRODUCTION

community mental health programs. (A list of other awards can be found in this
book’s appendix E.)
The phf program is a proven, effective, cost-saving approach for both the
street-dwelling homeless and those staying in shelters, jails, state hospitals, or
other institutions. The problem of homelessness among adults with severe mental
disorders still persists, of course, but with the phf approach, this issue can now be
effectively addressed on a large scale. In June 2010, the U.S. Interagency Council on
Homelessness (www.usich.gov) unveiled the federal five-year plan to end homeless-
ness, and this plan includes Housing First as one of its five core strategies.
This manual was created after Pathways to Housing received countless inqui-
ries from agencies and individuals wanting to replicate the successful phf program
in their own countries and communities. Written from the point of view of phf staff,
this manual describes the fundamentals of the phf program—including the phi-
losophy, principles, and values that guide its thought, operation, and administration.
Because the needs, goals, and capabilities of each agency and potential program
implementer are so varied, this manual is intended not only for readers planning to
introduce the phf model into new locations, but also for those seeking to integrate
phf’s ideals into more traditional programs. Those who intend to adopt and operate
a phf program will want to seek more specific direction from qualified phf experts
on launching and operating the program.
Although phf sounds very simple and practical, it is actually a complex clinical
and housing intervention. As with other complex clinical interventions, master-
ing this program requires practice and supervision. Because phf is based on the
principles of consumer choice and individualized treatment, it is impossible to
anticipate or describe how the program will unfold for each and every client. This
manual offers guidance, principles, procedures, and clinical experience as a frame-
work. Translating these principles and procedures into day-to-day decisions based
on input from each client requires training and supervised practice. Because every
client makes unique choices, no two days in a phf program are ever alike. Even if
your community lacks the capacity to begin a full-scale phf program, this manual
can help you begin a practice or a small program that respects and responds to the
voices of men, women, and families who want nothing more than to attain what
should always be attainable: a home.

 5
INTRODUCTION

Who Should Read This Manual—and Why

This manual explains phf practices in detail, including staffing patterns, finances,
and operations. By laying bare the program, we hope that administrators, advo-
cates, policy makers, educators, and others may find it useful for implementing (or
contemplating) a phf program in their communities. We also hope it will prove
useful to researchers interested in studying particular elements of the program that
account for its success. Beyond its instructional and educational purposes, we hope
this manual will serve as an affirmation to those who work in traditional programs
but believe in consumer-driven programs at heart. Finally, we hope that this
manual will inspire the broader adoption of practices that foster client dignity and
empowerment.

How to Use This Manual

Most of this book addresses the what, why, and how of the Housing First model. But
it also covers the if—that is, if readers are ready to launch a phf program in their
own community.
Because many readers may not be familiar with the Housing First model, this
book begins with a general description of the model, followed by a detailed discus-
sion of the unique Pathways Housing First approach (chapters 1 and 2). Chapters 3
through 6 offer a nuts-and-bolts description of phf’s team approach to housing and
treatment services. Chapter 7 discusses some of the other evidence-based practices
integrated within the phf program; this discussion can help readers determine
whether phf is a good fit for their agency or program. Chapter 8 offers guidance
on what steps need to be taken next for those who want to go forward with a phf
program—including information on possible funding sources and other avenues of
support. (You’ll find a more detailed chapter overview next.)
If readers are already familiar with the precepts of Housing First and know they
want to launch a phf program, they may want to read chapter 8 first before delving
into the more detailed chapters that precede it.

Chapter Overview
Chapter 1, “The Pathways Housing First Program,” introduces the phf approach,
describing the origins of the model and its clinical and philosophical foundations.

6
 INTRODUCTION

Chapter 2, “Initial Program Steps,” discusses the population served by phf; it

also describes how eligibility is determined, how clients are referred and engaged in
the program, how housing preferences are determined, the use of interim housing,
and what initial services might be needed.
Chapter 3, “Housing and Housing Support Services,” discusses the program’s
philosophy on housing and how it practices that philosophy with clients, including
the process of searching for an apartment, signing a lease, furnishing the apartment,
and moving in. This chapter also covers property management issues, noting some
of the phf program’s benefits for landlords, and offers solutions to some common
housing challenges clients face.
Chapter 4, “An Interdisciplinary Approach: How the act and icm Teams
Serve Clients,” describes the community-based treatment and support services
offered in a phf program. Two types of teams can work in this framework: the
assertive community treatment (act) team (for clients with severe mental dis-
orders) and the intensive case management (icm) team (for those with more
moderate mental health disorders). This chapter also covers the treatment planning
process and the home visit.
Chapter 5, “The phf Assertive Community Treatment Team,” details some
of the act team’s clinical operations, including staff roles and the essential daily
“morning meeting” for the act team in a phf setting, complete with sample sched-
ules, other essential forms, and a hypothetical meeting outline. The weekly confer-
ence review is also briefly discussed.
Chapter 6, “The phf Intensive Case Management Team,” discusses the icm
team’s strengths model approach to services and some of its operational matters in a
phf setting, such as staff roles and meeting procedures.
Chapter 7, “Incorporating Other Evidence-Based Practices,” provides a broad
overview of integrated dual disorders treatment (iddt) and its core elements, which
include harm reduction, Stages of Change, and Motivational Interviewing. It also
addresses the principle of Wellness Management and Recovery and the Supported
Employment approach. In the phf context, act and icm teams use these evidence-
based practices in their client interactions and as they assist clients with recovery
and community integration.
Chapter 8, “Bringing phf to Your Community,” offers guidance to prospective
program implementers who, after reviewing this manual, want to take the next

 7
INTRODUCTION

steps toward launching a phf program in their area. It includes a brief discussion of
possible funding sources and offers some advice on connecting and working with
various governmental and not-for-profit agencies.
Each chapter ends with a summary of the key points discussed. The manual
concludes with information about the Pathways Housing First Institute for training
and technical assistance. This manual’s appendices contain reviews of the quan-
titative and qualitative research on the phf program and provide the results of
several cost-effectiveness studies from several cities. They also contain a sample of
some of the documents and forms commonly used in phf programs; a discussion
of common administrative concerns; and a list of awards honoring Pathways to
Housing and its founder, Dr. Sam Tsemberis.

Terminology
This glossary explains some terms commonly used in phf programs.

ACT team: For clients with severe mental disorders and multiple needs, assertive
community treatment (ACT) teams are composed of multidisciplinary staff
members who directly provide clinical and support services. The act team as
a whole is the service provider, offering around-the-clock on-call services and
maintaining a low participant-to-staff ratio.

ICM team: For moderately disabled clients, intensive case management (ICM)
teams are composed of clinicians or other caseworkers. icm teams use a “case-
load” practice model with a ratio of about ten to twenty participants per staff
member. Staff are available on call; the phf model recommends that one case
manager be available twenty-four hours a day, seven days a week. (Many other
Housing First programs offer twelve-hour coverage, perhaps using another
crisis line service to implement around-the-clock on-call service.)

Client: A person receiving services in the phf program, also referred to as consumer,
participant, or tenant.

Consumer-driven (client-driven): With this approach, phf invites its clients

(consumers) to be their own decision makers—to drive the process themselves.
Clients in large measure determine how housing, clinical support, and services

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 INTRODUCTION

will be delivered to them. Clients are asked for their preference in type of
housing (almost all choose an apartment of their own), location, furnishings,
and other personal amenities. Clients also determine the type, sequence, and
intensity of services and treatment options (rather than the clinician or pro-
vider dictating these). While the phf program offers many choices, it also has
two requirements: (1) participants must agree to a weekly apartment visit by
program staff, and (2) they must agree to the terms and conditions of a stan-
dard lease, including paying 30 percent of their income toward rent.

Harm reduction: This is a practical, client-directed approach that uses multiple

strategies, including abstinence, to help clients manage their substance use
disorders and psychiatric symptoms. Harm reduction focuses on reducing the
negative consequences of harmful behaviors related to drug and alcohol use
or untreated psychiatric symptoms. With harm reduction, staff “meet clients
where they are” and start the treatment process from there, helping them
gradually gain control over their harmful behaviors.

Pathways Housing First (phf): This term is used throughout the manual to refer to
the Pathways Housing First program.

Pathways to Housing or Pathways to Housing National: Since July 2011, this is

the name of the not-for-profit corporation founded as Pathways to Housing,
Inc., in 1992 in New York City by Dr. Sam Tsemberis, credited as the originator
of the Housing First model and creator of the unique Pathways Housing First
program.

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