Current and future service
delivery models for single
adults experiencing
homelessness: literature
review
Prepared for the
Queensland Department of
Communities
April 2011
This report was commissioned by the Queensland Department of Communities and
prepared by Deloitte Access Economics.
Disclaimer: The report is an independent review of the literature on current and future
service delivery models for single adults experiencing homelessness. The report cannot be
taken in any way as an expression of government policy.
Deloitte Access Economics
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Contents
Glossary...........................................................................................................................................i
Executive Summary.........................................................................................................................i
1
2
Background, aims and key questions ..................................................................................1
1.1
Homelessness in Queensland and Australia ..........................................................................1
1.2
Policy response to homelessness...........................................................................................2
Methodology .......................................................................................................................3
2.1
3
4
Search strategy.......................................................................................................................4
Types of housing and models of service delivery................................................................7
3.1
Current and alternative service delivery models ...................................................................7
3.2
Service delivery models for specific target groups ..............................................................19
Best practices and recommendations ...............................................................................32
4.1
Key elements of best practice..............................................................................................33
4.2
Best practice models ............................................................................................................37
References ...................................................................................................................................42
Tables
Table 1.1 : Homeless persons by type ...........................................................................................2
Table 2.1 : Key search terms used .................................................................................................4
Table 2.2 : Australian websites searched by category...................................................................5
Table 2.3 : Results of metasearch of databases ............................................................................6
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Service delivery models for single adults
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Glossary
ABS
Australian Bureau of Statistics
ACCESS
Access to Community Care and Effective Services and Supports
ACT
Assertive Community Treatment
AHURI
Australian Housing and Urban Research Institute
AIHW
Australian Institute of Health and Welfare
CICH
Collaborative Initiative to Help End Chronic Homelessness
COAG
Council of Australian Governments
COHP
Coalition on Older Homelessness
DHHS
Department of Health and Human Services
FAHCSIA
Department of Families, Housing, Community Services and
Indigenous Affairs
HASI
Housing and Accommodation Support Initiative
HOME
Household Organisation Management Expenses
NAHA
National Affordable Housing Agreement
NGO
non-governmental organisation
NPAH
National Partnership Agreement on Homelessness
RSI
Rough Sleepers Initiative
RTS-SE
Ruah Tenancy Support: South East
SAAP
Supported Accommodation Assistance Program
S2H
Street to Home
Deloitte Access Economics
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Service delivery models for single adults
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Executive Summary
Deloitte Access Economics was commissioned by the Queensland Department of Communities
(Housing and Homelessness Services) to evaluate the Ozcare crisis accommodation funding
enhancement.
The first stage of the evaluation was to undertake a literature review to inform policy and
program directions in relation to current and emerging models of service delivery for single
adults who are experiencing homeless, including crisis supported accommodation. The key
questions addressed by this literature review are summarised below.
•
What alternative service delivery models are available to meet the needs of single adults
who are homeless?
•
What specific models or approaches are needed to better respond to the needs of
specific target groups including:
•
people with high and/or complex needs, (including mental health needs, disability
and dual disabilities, co-morbidity, acquired brain injury, chronic disease and
primary health needs);
•
•
older people;
•
people with problematic drug and alcohol use;
•
people who are sleeping rough;
•
people who experience chronic homelessness; and
•
Indigenous people.
How can the most effective case management support to single adults who are
homeless be provided? What are the key elements of best practice that should be
considered?
The literature review was informed by:
•
a review of published national and international academic research, published reports
and other documentation such as evaluations;
•
the policy literature; and
•
a scan of reforms or service improvements that have been implemented in other
Australian jurisdictions.
Service delivery models
The direction of homelessness service delivery has changed over the past decade.
Traditionally, services have focused on providing crisis and transitional accommodation for
people experiencing homelessness. However, since the release of the White Paper on
Homelessness and the signing of the National Affordable Housing Agreement (NAHA),
homelessness service provision has shifted towards a more integrated model of support with a
greater focus on prevention and early intervention. In addition, central to the NAHA is that
people experiencing homelessness should be provided with sustainable and permanent
housing as quickly as possible.
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Service delivery models for single adults
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This literature review examines a range of current and emerging service delivery models for
people experiencing homelessness or at risk of homelessness. Table i summarises these
models, their advantages and disadvantages and relevant target client groups.
The literature demonstrates that homelessness services can produce positive outcomes for
clients. However, the homeless population is not homogenous, even within subgroups, and
what is effective for one individual may not be as effective for another. Service delivery
models or programs that aim to address the underlying causes of homelessness are most likely
to reduce homelessness in the long run. Services should aim to assist clients to acquire the
necessary skills to maintain social competence and find permanent housing, as this will help
them to exit homelessness.
Key elements of best practice
Case management
Inherent in all the different service delivery models is the inclusion of case management which
involves a case manager using tools and professional expertise to work with clients to develop
an individualised service plan to meet the needs of clients within available resources, and to
assist them to develop their own capacity for independence. Case management has been an
integral part of homelessness policy in Australia and is the factor most often cited by program
directors as contributing to client success.
Consumer choice and involvement in homelessness programs
Allowing clients to choose whether or not to participate (as in a ‘housing first’ model),
engaging them in development of their services pathway with case managers and support
workers, and incorporating ex-clients in service provision (e.g. through peer models) can
promote client empowerment and contribute to an individualised service environment to
assist in breaking the cycle of homelessness.
Physical environment
The physical environment that is appropriate depends on the characteristics of the client,
reflecting different preferences and needs. Best practice elements relating to the physical
environment of homelessness services generally include:
•
The need for personal space, privacy and safety of service users through the provision of
personal amenities such as individual bedrooms, and a location that is accessible to
public transport and public amenities.
•
It is important to have accommodation options for specific clients, such as women’s
refuges for women and children who are escaping domestic violence that are highly
secure and protected.
•
In both emergency and longer term accommodation it is inappropriate to house
together people with a substance use problem who are trying to abstain and those who
are still using substances, as this makes prevention of relapse among abstainers more
difficult.
•
Accommodation should encourage community engagement and social inclusion as much
as possible through the accommodation design or allocation of private space. For
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example, it is difficult for people who have to share cooking facilities and sanitary
amenities to invite people outside of their accommodation to their homes.
Staffing requirements
Requirements for staffing are as varied as the client needs to which they are catering. The
literature suggests that staff need to be flexible and adapt to changes in service delivery that
best support people who are homeless. Key points from the literature suggest that:
•
The client to worker or case manager ratio depends on the service delivery model, but
the ideal should allow staff to effectively engage each client and develop individualised
service plans.
•
There is some evidence that homelessness programs staffed or operated by previous
clients who have also experienced homelessness are more effective for both the staff
and future service users.
•
Programs should plan for on-the-job training and incorporate ongoing supervision of
staff with regular feedback for professional development. Staff should undergo training
as a team to maintain consistency for service provision.
Best practice models
The evidence base suggests that good practice policies and programs should involve a
combination of prevention, early intervention, crisis intervention and long-term support
services that focus on facilitating independence and moving people into permanent housing.
There is currently a shift from the traditional ‘treatment first’ model (whereby service users
are placed into crisis accommodation then transitional housing before being placed into
permanent housing if they become ‘housing ready’) to a ‘housing first’ model.
Crisis accommodation and ‘treatment first’ models
While the ‘treatment first’ model has its shortcomings, it has been recognised that it can be
effective particularly with people who are willing to engage with rehabilitation programs and
are able to cope with shared housing arrangements. There are situations where crisis
accommodation and transitional housing are necessary, such as for people:
•
left homeless in emergencies including natural disasters;
•
escaping from domestic violence;
•
discharged from institutions such as prisons; and
•
who need a substitute for permanent housing where there are housing shortages or
extremely low housing affordability.
Best practice models of crisis accommodation are those that ensure that crisis accommodation
remains only temporary. Client needs do not necessarily end after leaving crisis or transitional
accommodation and effective case management, service integration and long-term support
are important adjuncts to ensure crisis accommodation services remain a temporary staging
point for those who need them.
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Prevention
A key theme throughout the best practice literature is that homelessness programs and
policies should incorporate prevention in their planning. Prevention may be addressed
through:
•
providing outreach services that identify people most at risk of homelessness and
develop targeted responses to prevent homelessness or assist in preventing long-term
homelessness;
•
capacity building to increase independence, particularly financial stability, to assist
clients to sustain a tenancy and remain in permanent or community housing; and
•
offering care and support, including support for social reintegration of excluded groups
and individuals to address social isolation.
Integrated systems approach
It has been recognised that good practice in the prevention and reduction of homelessness
should incorporate services that target homelessness and all of its causes and consequences,
including housing, health, work, mental health issues, education, vocational skills, life and
social skills. The literature favours an integrated systems approach to homelessness programs
that incorporates both accommodation, as well as mainstream support services across a wide
and diverse range of sectors. An integrated approach can offer many service pathways and
exit options for different subgroups.
There should be an understanding that creating integrated services is complex and requires
time and effort, but will ultimately improve flexibility in the way services are delivered, and
assist in the transition of people from crisis and transitional housing into permanent
accommodation.
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April 2011
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Service delivery models for single adults experiencing homelessness
Table i: Current and emerging models of homelessness service delivery
Model
Description
Advantages/disadvantages
Subgroups model is suitable for
‘Treatment
first’ or
‘pathways’
Standard homelessness service delivery
model involving a pathway of support
that begins with crisis accommodation
followed by a number of transitional
responses and then permanent housing.
May lack exit options for clients and impact on available crisis
accommodation options for the newly homeless
People in certain temporary
situations e.g. people newly arriving
into the country, in cases of
emergency,
people
escaping
domestic violence or relationship
breakdown, people leaving prison
or other institutions.
Focuses on rapid placement of people
experiencing homelessness into
permanent housing, bypassing the need
for emergency or transitional
accommodation.
Clients can access structured, multi-agency support services
‘Housing
first’
Preparation for permanent housing may not be necessary or
possible in temporary housing.
Model is not easily adaptable to people with high and/or
complex needs. Access to permanent housing may depend on
the client meeting certain requirements such as abstinence
from substance abuse or compliance with medications.
that are non-compulsory to ensure they sustain permanent
housing.
There are reported improvements in various aspects of
wellbeing as a result of maintaining stable housing.
Reliance upon availability of appropriate housing stock
Assertive
outreach
Assertive outreach services actively seek
out people who are experiencing
homelessness, engage clients in their
own environment and provide them
with services in the client’s
environment.
For this to be effective, a multidisciplinary team is essential to
provide specialised support that is individualised, flexible and
integrated within a broader service system.
Broadens the reach of services to those disengaged with the
community and the service system, in particular, chronically
homeless people who are unlikely to engage if required to
seek out separate services in different locations.
People with mental health issues.
Rough sleepers.
People
experiencing
chronic
homelessness.
People with substance abuse issues.
People with mental health issues.
Rough sleepers.
People
experiencing
chronic
homelessness.
People with substance abuse issues.
Service delivery models for single adults experiencing homelessness
Model
Common
Ground
Prevention,
early
intervention
Description
Advantages/disadvantages
Subgroups model is suitable for
Similar to ‘housing first’ in that it focuses
on providing people with stable,
affordable and high quality housing.
However, support services are an
integral part of the model.
Provision of well-designed, attractive and safe housing with
People with mental health issues.
Rough sleepers.
People
experiencing
chronic
Prevention and early intervention
models target and intervene when
people are at risk of becoming homeless
and provide support services to prevent
homelessness from occurring.
connections to the community gives service users a sense of
pride in their accommodation and empowers them to rebuild
their lives and become self-sufficient.
homelessness.
May use a vulnerability index that identifies the most
vulnerable groups and reaches out to them, thereby providing
a targeted and individualised response to homelessness.
People with substance abuse issues.
Effective models can prevent homelessness, or the progression
Young people – to prevent them
into long-term homelessness, by identifying vulnerable groups
that are at risk and intervening early.
from leaving home early before
they
acquire
the
necessary
independent living skills
Examples of early intervention approaches include initiatives
to help individuals sustain their tenancies and remain in
permanent housing with successful models including the Ruah
Tenancy Support: South East (RTS-SE) in Western Australia; the
Household Organisation Management Expenses (HOME)
program; and the Reconnect program.
People at risk of defaulting on their
tenancy
People with mental health issues
Older people
Service delivery models for single adults experiencing homelessness
Model
Integrated
networks or
‘joined-up’
service
delivery
Description
Provision of a holistic, integrated
network of homelessness service
delivery that involves both
accommodation and other support
services to provide more tailored
assistance.
Advantages/disadvantages
Subgroups model is suitable for
Improve clients’ sense of stability, which in turn encourages
participation in education, vocational training and community
life.
Indigenous Australians where more
flexible service models offering
outreach, practical support and
referral are required.
Achieves more consistent and sustainable client outcomes
through a ‘whole of life’ approach that is able to meet the
continuum of needs associated with the underlying causes of
homelessness.
Clients can access a diverse range of pathways specifically
tailored to their needs and enduring relationships can be
developed with a range of services that may be sustained in
the long run.
People with mental health issues
where community homelessness
and health services with the
development of exit plans can
reduce the risk of people becoming
homeless upon discharge.
People with substance abuse
problems, especially those with
drug offences.
People with a learning disability.
People who experience chronic
homelessness.
Young people.
Service delivery models for single adults
experiencing homelessness
1 Background, aims and key
questions
Deloitte Access Economics was commissioned by the Queensland Department of
Communities (Housing and Homelessness Services) to evaluate the Ozcare crisis
accommodation funding enhancement.
The first stage of the evaluation was to undertake a literature review to inform policy and
program directions in relation to current and emerging models of service delivery for single
adults who are experiencing homeless, including crisis supported accommodation. The key
questions addressed by this literature review are summarised below.
•
What alternative service delivery models are available to meet the needs of single
adults who are homeless?
•
What specific models or approaches are needed to better respond to the needs of
specific target groups including:
•
people with high and/or complex needs, (including mental health needs,
disability and dual disabilities, co-morbidity, acquired brain injury, chronic
disease and primary health needs);
•
older people;
•
people with problematic drug and alcohol use;
•
people who are sleeping rough;
•
people who experience chronic homelessness; and
•
Indigenous people.
•
How can the most effective case management support to single adults who are
homeless be provided? What are the key elements of best practice that should be
considered?
1.1 Homelessness in Queensland and Australia
The ABS uses the cultural definition of homelessness to define and count the homeless
population on census night (Chamberlain & Mackenzie, 1992). This definition describes
three categories of homelessness:
•
primary, which is consistent with the Census category ‘improvised homes, tents and
sleepers out’;
•
secondary, which includes the Census category ‘hostels for the homeless, night
shelters and refuges’ as well as people residing temporarily with other households
because they have no accommodation of their own and people staying in boarding
houses on a short term basis (operationally defined as 12 weeks or less); and
•
tertiary, which refers to people who live in boarding houses on a medium- to longterm basis, operationally defined as 13 weeks or longer.
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It is estimated that 26,782 people were homeless in 2006 in Queensland on census night,
constituting 26% of the total number of homeless people in Australia (Table 1.1). There
were more people living in improvised dwellings and sleepers out, and staying with friends
and relatives in Queensland compared to the national average.
Table 1.1: Homeless persons by type
Australia
Queensland
Persons
%
Persons
%
Boarding houses
21,596
20
5,438
20
SAAP accommodation
19,849
19
3,233
12
Friends and relatives
46,856
45
12,946
49
Improvised dwellings, sleepers out
16,375
16
5,165
19
Total
104,676
100
26,782
100
Source: Chamberlain, C, Mackenzie, D 2009, Counting the homeless 2006: Queensland, Cat no. HOU205,
Canberra: AIHW.
The number of people who were homeless in Queensland increased slightly between 2001
and 2006. However, the rate of homelessness per 10,000 people decreased marginally
from 70 to 69 between 2001 and 2006. Fifty-eight per cent of the homeless population in
Queensland were male in 2006.
The age profile of the homeless population in Queensland was older than that of the
national homeless population, despite 51% of homeless people being less than 34 years of
age. Sixteen per cent of people experiencing homelessness in Queensland were teenagers
aged 12 to 18 years of age, 11% were children under 12 and 10% were young adults aged
19 to 24 years.
1.2 Policy response to homelessness
There has been a shift in Australian homelessness policy directions and homelessness
service delivery models over the last few decades. Traditionally, homelessness programs
such as the Supported Accommodation Assistance Program (SAAP) focused on the
provision of crisis and transitional housing for people experiencing homelessness (Phillips et
al 2011). SAAP services were not easily accessible by people with high and/or complex
needs (such as those with mental health or substance use issues), and did little to reduce
homelessness in the long run (Erebus Consulting Partners 2004).
The release of the White Paper on Homelessness, The Road Home (FaHCSIA 2008), and the
introduction of the National Affordable Housing Agreement (NAHA) in 2009 reflected a shift
in the context of homelessness policy. The White Paper stated that a national response to
homelessness was needed and could be implemented through three strategies.
•
Turning off the tap – services will intervene early to prevent homelessness.
•
Improving and expanding services – services will be more connected and responsive
to achieve sustainable housing, improve economic and social participation and end
homelessness for their clients.
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•
Breaking the cycle – people who become homeless will move quickly through the
crisis system to stable housing with the support they need so that homelessness does
not persevere or recur.
A target to halve homelessness by 2020 was set and the White Paper recommended that
people experiencing homelessness should be provided with access to the full range of
support needed, rather than leaving individuals to navigate a complex system of services.
In addition, the delivery of homelessness services should move towards a more integrated
model of support with a bigger focus on prevention and early intervention to minimise
long-term homelessness. Imperative to the NAHA is the view that people experiencing
homelessness should be provided with sustainable and permanent housing as quickly as
possible, with non-compulsory support services provided to help them maintain their
housing.
As part of The Road Home, the Council of Australian Governments (COAG) established the
National Partnership Agreement on Homelessness (NPAH). Under the NPAH, the Australian
Government provided additional funding for homelessness to the States and Territories.
The State and Territory Governments agreed to match the Commonwealth funding and to
deliver services and capital to contribute to an overall reduction in homelessness.
The NPAH contributes towards Australia’s long-term response to homelessness through
achievement of the following outcomes:
•
fewer people becoming homeless and fewer of these sleeping rough;
•
fewer people will become homeless more than once;
•
people at risk of or experiencing homelessness will maintain or improve connections
with their families and communities, and maintain or improve their education,
training or employment participation; and
•
people at risk of or experiencing homelessness will be supported by quality services,
with improved access to sustainable housing.
The Queensland Government’s Implementation Plan for the National Partnership
Agreement on Homelessness includes funding of $284.6 million over five years (2008-09 to
2012-13) for new or expanded services. The Plan focuses on prevention and early
intervention and the provision of permanent housing solutions with appropriate support.
The Plan also aims to improve service coordination across homelessness and mainstream
agencies and to develop best practice methodology for whole-of-community planning to
reduce homelessness. The Ozcare funding enhancement is a component of the Queensland
Government’s matched funding arrangements under the NPAH.
2 Methodology
The search strategy, search terms and data bases accessed are described in this chapter. In
brief, the literature review was informed by:
•
a review of published national and international academic research, published
reports and other documentation such as evaluations;
•
the policy literature; and
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•
a scan of reforms or service improvements that have been implemented in other
Australian jurisdictions.
2.1 Search strategy
The aim of the literature search was to identify published reports on current and emerging
models of service delivery for single adults experiencing homelessness. It builds upon a
Hostels Review undertaken by Homelessness Programs (Department of Communities
2009). The search was restricted to articles and reports from 2005 onwards reflecting the
need for currency and given the changes in homelessness policy over the past decade.
The search covered databases and websites of homelessness peak bodies and government
departments that provide homelessness services. To ensure all relevant reports were
identified, reference lists from existing documents such as the White Paper were also
searched to identify studies not captured in the literature search and were marked for
retrieval.
2.1.1
Search terms
Table 2.1 details the key search terms, as well as the various combinations used. Search
terms were developed in conjunction with the department to ensure wide coverage.
Table 2.1: Key search terms used
#
Search terms used
21
#19 AND #14
20
#19 AND #14
19
#16 AND #3
18
#9 AND #3
17
#4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10
16
#12 OR #13
15
‘case management’
14
‘Complex needs’
13
hostels
12
‘crisis accommodation’
11
#10 AND #8
10
#6 AND #7
9
#6 OR #7 OR #8
8
Model*
7
Delivery*
6
service*
5
‘Social policy’ OR ‘social intervention’ OR ‘public policy’
4
Evaluation OR ‘economic evaluation’
3
#1 OR #2
2
Homeless OR rough sleeping OR rough sleeper
1
Homelessness
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Databases searched
2.1.2
Australian data bases
For literature specific to Australia, a number of useful databases from relevant government
departments, existing peak bodies, non-governmental organisations (NGOs) associated
with homelessness, and Australian research groups were searched. This is summarised in
Table 2.2.
Table 2.2: Australian websites searched by category
Category
Government departments
Website searched
The Department of Families, Housing, Community Services and
Indigenous Affairs (FaHCSIA)
Australian Institute of Health and Welfare (AIHW)
Service providers
National Shelter (and its state and territory counterparts)
Mission Australia
Homelessness Australia (and its state and territory counterparts)
Aboriginal Hostels
Melbourne Citymission
Women’s Services Network
Youth Accommodation Association
Peak bodies
Australian Council of Social Services
Council to Homeless Persons
Resource websites
NSW Women’s Refuge Resource Centre
Australian Homelessness Clearinghouse
Australian Domestic and Family Violence Clearinghouse
Australian Clearinghouse for Youth Studies
Academic papers
An initial academic literature search was performed on Google Scholar to identify possible
journals and databases. A metasearch was also performed on a number of literature
databases with the most relevant databases being:
•
Academic Research Library;
•
ScienceDirect;
•
JSTOR; and
•
Proquest Social Science Journals.
The search initially included Econlit, PAIS International and Social Science Research Network
and Cochrane Database of Systematic Reviews but no results were found from these
databases. Table 2.3 details the search results of the metasearch.
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Table 2.3: Results of metasearch of databases
Database
Results
Academic Research Library
59
JSTOR
31
Proquest Science Journals
8
APPI Journals
0
Family & Society Studies Worldwide
0
FAMILY-ATSIS
1
Proquest Social Science Journals
35
APAIS-Health
0
ATSIHealth
0
EBM Reviews: Cochrane Database of Systematic Reviews
0
EBM Reviews: NHS Economic Evaluation Database
0
Health & Society Database
0
PsycINFO
8
ScienceDirect
163
Total
305
In total, 305 publications were identified based on the metasearch. Inclusion/exclusion
criteria were pre-specified to select relevant studies from the 305 references. The inclusion
criteria were:
•
service delivery models: research that specifically examines or evaluates specific
service delivery models;
•
population: single adults who were homeless (thereby excluding families and women
and children escaping domestic violence);
Study exclusion/inclusion was made on the basis of the title and abstract alone. Where this
was not possible, the full paper was retrieved and reviewed in more detail. In total, 89
studies were included after one round of inclusion/exclusion. Some studies were retrieved
from reference lists of relevant literature.
International literature
Most of the academic literature search results included literature from international
jurisdictions, mainly the US and the UK. International NGOs and government departments
that deal with homelessness were also searched separately, including:
•
European Federation of National Organisations working with the Homeless;
•
Habitat International Coalition;
•
International Union of Tenants;
•
World Homeless Union;
•
Ministry of Housing (New Zealand);
•
Youth without Shelter (Canada);
•
Shelter, About Rough Sleeping, Homelessness (DHHS) (UK); and
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•
National Alliance to End Homelessness, National Coalition for the Homeless, Coalition
for the Homeless, Coalition on Human Needs, National Center for Homeless
Education (US).
3 Types of housing and models of
service delivery
This chapter examines the different types of housing available for people experiencing
homelessness, and reviews the current and emerging models of homelessness service
delivery. There are three broad types of housing that are specifically targeted to people
experiencing homelessness (Locke et al 2007). These are summarised below.
•
Crisis or emergency accommodation generally provides short-term or temporary
shelter and usually in a group setting. It usually includes low-cost hostels, motels,
caravan parks, boarding houses or similar accommodation. These services may range
from having little referral assistance or support services to more intensive case
management;
•
Transitional housing provides short to medium-term (usually 6-24 months)
accommodation with more intensive support services. The aim is to provide safe and
affordable accommodation combined with support from other agencies to assist
people in addressing the causes that contributed to their homelessness.
•
Permanent supported housing is targeted towards people with multiple and
complex needs or other long-term problems and generally offers intensive support
and referral services on or off site. Permanent supported housing programs include
voucher assistance programs and rental subsidies.
Services associated with each type of housing may be delivered differently, such as
differences in their physical configuration, the expected time a service user spends in
supported housing, the degree of choice service users have, or the way each one is funded
(Locke et al 2007).
3.1 Current and alternative service delivery
models
As mentioned in section 1.2, homelessness policy has moved away from the more
traditional forms of service delivery (such as the ‘treatment first’ or ‘pathways’ model)
towards a more integrated, whole of system approach that aims to assist people
experiencing homelessness to move into permanent housing as quickly as possible.
3.1.1
‘Treatment first’ or ‘pathways’ model
The standard model of providing accommodation to people experiencing homelessness is
the ‘treatment first’ model. It is also known as a ‘pathways’ or ‘continuum of care’ model
because it usually involves a pathway of care, beginning with crisis accommodation
followed by a transitional response and then permanent housing (Urbis 2009; Falvo 2009).
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The first response in a treatment first model is generally crisis or emergency
accommodation. This usually involves large night shelters, shared bedrooms, dormitories
and/or single rooms (Busch-Geertsema et al 2007). Residents then progress through one or
more stages of transitional housing. Because there is a high chance that residents in
temporary housing share accommodation or some space, there is a higher risk of conflict
compared to self-contained housing or in cases where residents have been given the choice
to share space on the basis of friendship or family relations (Busch-Geertsema et al 2007).
This lack of privacy and space for social interaction with people may reduce the possibility
for residents to reintegrate back into the community outside of the temporary housing.
Busch-Geertsema (2007) identified various underlying shortcomings of the use of
temporary housing such as hostels or transitional accommodation.
•
Hostels fail to serve many of their intended functions, and their lack of exit options
has detrimental effects on people experiencing homelessness.
•
Preparation for permanent housing may not be necessary or possible in hostels, and
this may have counter-productive effects given the primary aim of a ‘treatment first’
model is to prepare service users to move into permanent housing. This is because
staying in a hostel requires special competencies that may be different from
independent living.
•
Relying on hostels as a form of temporary accommodation is costly for the service
user as they are likely to repeatedly transition in and out of temporary housing rather
than develop the capacity to support themselves in permanent housing.
•
There may be stigma attached to people who cycle in and out of temporary housing
and as a consequence, these people may be excluded from permanent housing in the
longer term.
Given these shortcomings, traditional models of crisis and transitional accommodation have
been adapted to provide a more holistic service while at the same time still providing
temporary accommodation for those in need. St Mungo’s is one such example of an
emerging type of hostel that provides homelessness services in London (St Mungo’s 2008)
(see box).
Case study: St Mungo’s
St Mungo’s services for people experiencing homelessness have three components –
prevention, emergency and recovery. Apart from providing hostel beds and temporary
housing for people experiencing homelessness, St Mungo’s also provides support and
outreach services including resettlement, employment and training, drug and alcohol
services and mental health services (St Mungo’s 2008). According to the program’s own
client outcomes measurement tool (Outcomes Star), most clients benefitted from their
time in hostels, but positive outcomes peaked at 6-12 months (St Mungo’s 2008) with those
staying longer experiencing a decline in progress.
Based on the Outcomes Star, the hostels provided by St Mungo’s that were more effective
had the following characteristics.
Stable and clear management applied with an awareness that clients are there
temporarily to engage, make a lifestyle change and move on.
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On-site specialist health services, recreational activities, outings and promotion of life
skills.
A client to worker ratio of around 5 clients to 7 clients per worker to ensure clients
are receiving the tailored services they need.
The opportunity for clients to progress from crisis accommodation to transitional
housing as quickly as possible.
Specialist workers for particular sub-groups of clients who share a similar profile of
needs.
Single sex accommodation that houses fewer people (up to 50 beds per hostel), as
well as the option for individual rooms to provide more privacy between clients and
case management teams (St Mungo’s 2011).
The end-point of any ‘treatment first’ model is placement of clients into independent
housing with minimal support. However, this only occurs if a service user has been
assessed to be ready for permanent housing (Johnsen et al 2010). Falvo (2009) suggests
service users need to be assessed progressively throughout the service pathway by a team
of service providers and must meet compulsory requirements such as abstinence from
substance abuse, and compliance with relevant medications as prescribed by medical
professionals. Progression from temporary to permanent housing is conditional on
compliance with these requirements as well as with relevant treatment and support
programs, and failure to do so may lead to a delay in the transition or expulsion from the
program (Sahlin 2005; Johnsen et al 2010).
Johnsen et al (2010) and Urbis (2009) suggests that a ‘treatment first’ model does not adapt
well to the complex needs of vulnerable people. This is because of the high attrition rate of
service users between stages, which may be attributed to:
•
the stress of constant change as clients transition between stages;
•
the reduction in support at each stage may not be suited to people with high and/or
complex needs;
•
the use of standardised support programs rather than a case management approach
is not effective for people with complex needs; and
•
the ineligibility or expulsion of potentially problematic clients such as those with
violent behaviours or previous incarceration may exclude many people with high
and/or complex needs who have nowhere else to go.
Nevertheless, Busch-Geertsema (2007) argues that temporary housing is necessary in
certain temporary situations such as for people newly arriving into the country, in cases of
emergency (such as natural disasters), for people escaping from domestic violence or
relationship breakdown and people leaving imprisonment or hospital. In addition, some
people may prefer to live in a protected environment such as that provided by hostels due
to social isolation or specific support needs.
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Case study: The Foyer Model and examples of its adoption in Australia
The Foyer Model originated from Europe and is considered a specialised form of a
hostel (Busch-Geertsema 2007). The Foyer Model aims to provide accommodation
for young people experiencing homelessness with integrated skills training and job
search support (AHURI 2006).
A ‘Foyer’ is a facility whereby young people can secure accommodation and live
independently as well as acquire employment and develop life skills. Services are
tailored to individual needs on a case-by-case basis, and in return, young people
entering a Foyer are expected to actively engage and make a positive contribution to
their own development and their community. The premise of the Foyer model is to
empower young people by giving them the opportunity to acquire the tools and
skills they need to secure accommodation and prevent or break their cycle of
homelessness.
In NSW, the Miller Campus was developed based on the Foyer Model, with local
management as one of its defining features. It allows the community to be involved
in the project and increases the employment and education opportunities for
program participants. The Campus provides training and support for young people
along with advice including employment assistance, administrative paperwork and
Centrelink assistance. The Campus has achieved positive outcomes for regional
young people by providing them with secure accommodation and the skills and a
stable environment to focus on their education, training and employment (AHURI
2006).
The Victorian Government, and the Commonwealth and South Australian
governments are partnering with the Australian Football League Players’ Association
to provide a Foyer model called “Ladder”. In Melbourne and Adelaide, buildings
have been purchased to provide young people experiencing homelessness with self
contained accommodation, shared social spaces, and educational spaces. Support
services provided include case management, referral assessment, mentoring and
educational and vocational networks.
The building in Melbourne houses 21 young people. Young people are eligible
if aged 16-25 years old, single and without children, currently at risk of
homelessness or unstable accommodation, have medium to low support
needs and agree to participate in the Ladder programs and casework support.
The program provides for a stay of up to two years. Residents pay $85 per
week rent.
Once renovated, the building in Adelaide will house 23 young people.
3.1.2
Housing first models
Research has increasingly shown the effectiveness of ‘housing first’ approaches to
homelessness service delivery. The ‘housing first’ models represent a shift in paradigm
(Locke et al 2007) because they focus on moving vulnerable groups experiencing or at risk
of homelessness into permanent housing as soon as possible. The key difference between
these models and traditional ‘pathways’ or ‘treatment first’ approaches is that ‘housing
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first’ bypasses the transitional stages (Johnsen et al 2010). Clients are not required to be
‘housing ready’ before being offered housing.
‘Housing first’ models focus on rapid placement of people experiencing homelessness in
permanent housing with no or minimal emergency or transitional accommodation. They
aim to address long-term homelessness in a sustainable way by providing long-term stable
housing as the first and main priority (Urbis 2009). The groups most vulnerable to
homelessness are placed directly from the street or from emergency shelters into
permanent, independent tenancies (Johnsen et al 2010).
The basic premise of a ‘housing first’ approach is that social services that may enhance an
individual’s wellbeing are usually more effective when provided to people in their own
homes (Urbis 2009; Johnsen et al 2010). Hence, in a ‘housing first’ model, service users can
access structured, multi-agency support such as mental health services and drug and
alcohol clinics in order for them to increase their capacity to live independently and sustain
permanent housing (Urbis 2009). However, these support services are not compulsory
(Falvo 2009) and access to permanent housing is generally not dependent on the service
user’s state of being (e.g., clients do not need to be drug or alcohol free) (Urbis 2009).
Examples of programs that have adopted the ‘housing first’ model in the US include the
Pathways to Housing program in New York City, the Downtown Emergency Services Center
(DESC) in Seattle and Reaching Out and Engaging to Achieve Consumer Health (REACH) in
San Diego (Locke et al 2007). Housing configuration may vary from buildings that provide
accommodation to people experiencing homelessness to mixed-occupancy buildings and
scattered-site models (Locke et al 2007). Toronto’s Streets to Homes (S2H) program is an
example of Canada’s version of a ‘housing first’ model, and is summarised below.
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Case Study: Toronto’s Streets to Homes program
Falvo (2009) evaluated Toronto’s Streets to Homes (S2H) program, Canada’s version
of a ‘housing first’ model of service delivery. S2H was introduced in 2005 with the
primary objective of ending street homelessness by moving people experiencing
homelessness directly from the street into permanent housing. Abstinence or
compliance with psychiatric medication is neither a program requirement nor an
expectation; however, clients must agree to participate in a money management
program where they put 30% of their income towards rent, while the remaining 70%
of rent is paid through grants.
S2H has been successful in achieving a range of client outcomes:
•
It was successful in reaching rough sleepers and moving them into permanent
housing.
•
87% of tenants housed through S2H remained in housing (with the follow-up
period being up to one year). 50% of people surveyed had been housed under
S2H for over one year.
•
Once housed, a majority of S2H clients reported improvements in various
aspects of wellbeing, including access to quality food, level of stress, sleep
patterns, personal safety and mental health issues.
•
17% reported quitting alcohol and 33% reported quitting drugs, which was
similar when compared to those in ‘treatment first’ models.
•
Benefits were greatest in individuals placed in independent housing where
clients were not required to share accommodation or other facilities (such as
cooking or amenities) with roommates who were not family-related or friends.
Other flow-on benefits included a reduction in the number of arrests and time spent
in prison, and an increase in the utilisation of health services including GPs and
specialists. The main challenge faced by S2H clients was affordability with 68% of
clients reporting having insufficient money to live on. As well, 30% of clients
reported that they had no choice in the type or location of housing.
Overall, S2H appears an effective model in helping people who are rough sleeping
to access low-cost rental housing. However, according to Falvo (2009), the program
still lacks adequate funding to be able to be sustainable in the long run. The
program cannot afford to place all clients into independent housing, and outcomes
for those in shared housing were generally poorer. Furthermore, greater perception
of choice for clients (e.g. in the location of accommodation or whether it is shared or
private) led to better outcomes according to the survey, but the program lacked
funding to achieve adequate choice for all participants (Falvo 2009).
The ‘housing first’ model has been implemented in Australia, for example via My Place,
which was introduced by the NSW Government to target people experiencing
homelessness in inner city Sydney who alternate between sleeping in public places and
short stays in temporary housing (Urbis 2009). Sixty units of accommodation have been
allocated to three community housing providers by Housing NSW and an evaluation of the
program has found that 90% of clients have been successful in sustaining a tenancy over
the longer term after being placed in permanent housing (Urbis 2009). However, the length
of the follow-up period was unclear in the report.
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3.1.3
Assertive outreach and Street to Home
Assertive outreach services are a key aspect of housing first models and actively seek out
people who are experiencing homelessness, engage clients in their own environment and
provide services in the client’s own environs (Queensland Government 2008, Council to
Homeless Persons 2011). For this to be effective, a multidisciplinary team is essential to
provide specialised support that is individualised, flexible and integrated within a broader
service system (Phillips et al 2011). This may include a team of medical professionals,
mental health clinicians, drug and alcohol clinicians, registered nurses, mediators and
counsellors, and legal advisors or advocates. Conceptually — this system works for the
chronically homeless who are most likely to be disengaged from the service system and
who are also likely to have complex needs. These clients are unlikely to engage if required
to seek out separate services in different locations.
In Canada, an outreach program was initiated in early 2000 called ‘Off the Streets into
Shelters’, which featured 4-5 outreach workers who encouraged rough sleepers to go into
emergency shelters. This was found to be successful in helping people find immediate
shelter or housing (Falvo 2009). Similarly, Toronto’s S2H program (discussed above) has an
outreach component as the first step and involves a street outreach counsellor approaching
rough sleepers to discuss housing (Falvo 2009). This is believed to have contributed to the
ability of the program to broaden its reach.
In the UK, the Rough Sleepers Unit incorporates a component of assertive outreach. As
part of this ongoing program, Contact and Assessment Teams deliver assertive outreach by
maintaining daily contact with clients and persuading or encouraging them to move out of
rough sleeping into accommodation (Phillips et al 2011).
Various adaptations of the assertive outreach models have commenced in different states
in Australia (Phillips et al 2011). All the states and territories have adopted the Street to
Home initiative funded through the NAHA and NPAH. Examples include Way2Home in
NSW, and Micah Projects in Queensland. Underlying the S2H initiatives are assertive
outreach teams that generally consist of a network of specialised but interconnected
services such as medical professionals, mental health services and legal advisors. New
South Wales, Queensland and Victoria use the ‘vulnerability index’ (as discussed above) to
identify rough sleepers and prioritise those with high and complex needs who are most
vulnerable to homelessness (Phillips et al 2011 and Council to Homeless Persons 2011).
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Case study: Reaching Home, Assertive outreach service in Newcastle
Reaching Home is a collaborative partnership involving Housing NSW, NSW
Health, Baptist Community Services and Legal Aid. It is funded for three years
under the National Partnership Agreement on Homelessness and commenced
October 2010.
Reaching Home operates using a housing first model. Outreach support
services are offered to people in their usual and familiar environment. Clients
must be wiling to accept a minimal amount of support to assist with
maintaining their tenancy.
Reaching Home’s referral criteria prioritises people sleeping rough, people who
are couch surfing who have complex needs, and people at risk of homelessness
with complex needs (Council to Homeless Persons, 2011).
3.1.4
Common Ground
The Common Ground model originated in New York and the Common Ground not-for-profit
organisation currently operates nearly 1,700 units of supportive housing in seven different
sites across the city (Urbis 2009). It is a specific type of the ‘housing first’ approach in that
its main focus is to provide people experiencing homelessness with stable, affordable and
high quality housing. The model has three main components (Common Ground 2010):
•
affordable housing – a range of housing options that are attractive and affordable,
and linked to support services that people experiencing homelessness require to
reintegrate back into the community;
•
outreach – the groups most vulnerable to homelessness are identified and given
priority in housing. These include those who have experienced long-term, chronic
homelessness, have one or multiple disabilities and those who have mental health
problems; and
•
prevention – the model aims to address the underlying multiple and complex factors
that cause homelessness through its range of support and outreach services.
One of the most significant features of the Common Ground model is that it aims to provide
well-designed, attractive and safe housing for people experiencing homelessness to give
service users a sense of pride in their accommodation and empower them to rebuild their
lives and become self-sufficient (Urbis 2009). The model aims to create a community that
enables people experiencing homelessness to reintegrate back into society (Johnsen et al
2010) with attention given to features such as diverse mix of residents, high quality
property management, high quality support services, good design, connections to the wider
community and committed staff (Urbis 2009).
Another important feature of the Common Ground model is that it targets the most
vulnerable groups with the aid of a ‘vulnerability index’ (Johnsen et al 2010). The
‘vulnerability index’ is a tool that categorises vulnerable groups according to their fragility
of health and mortality risk. For those who have been homeless for at least six months, the
following health problems were identified as placing them at increased risk of mortality:
•
more than three hospitalisations or emergency room visits in a year;
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•
more than three emergency room visits in the previous three months;
•
aged 60 or older;
•
cirrhosis of the liver;
•
end-stage renal disease;
•
history of frostbite, immersion foot (a medical condition caused by prolonged
exposure of the feet to damp, unsanitary and cold conditions), or hypothermia;
•
HIV/AIDS; and
•
tri-morbidity of a co-occurring psychiatric condition, substance abuse and chronic
medical condition (Common Ground 2011a).
The index allows service providers to target and prioritise those most in need of homeless
services, and allows them to plan and develop a tailored service plan most suited to the
client’s needs (Johnsen et al 2010).
The Common Ground model has been replicated in other North American cities and is
rapidly expanding in Australia (Johnsen et al 2010). The main example is the Australian
Common Ground Alliance (ACGA), which is a network of organisations that promote and
deliver innovative supportive housing solutions based on the New York Common Ground
model. Common Ground Supportive Housing arising out of the ACGA are designed to be
permanent housing solutions for people experiencing homelessness rather than a
temporary homeless shelter. A number of new initiatives have arisen from the ACGA in
Australia and these are summarised below.
•
Common Ground on Franklin was the ACGA’s first Common Ground building in
Adelaide, with 37 units housing a mix of people who were formally homeless and low
income tenants. According to the ACGA website, Common Ground on Franklin has
housed 52 people since February 2008, with 58% being people who were
experiencing housing vulnerability and 13% sleeping rough. More recently, Common
Ground Adelaide has built Light Square, consisting of 52 units in a 4 storey heritagelisted building. The building contains communal spaces for tenants, community area
with computers, café style common area and kitchen, dental treatment room, allied
health services, welfare and vocational support services.
•
Elizabeth Street Common Ground Supportive Housing in Melbourne, Victoria
opened in August 2010 and provides affordable and safe housing combined with
long-term tailored support services. The building has 131 studio apartments of which
65 are rented to people who are experiencing long-term homelessness and 66 to low
income households. There are also 30 two-bedroom apartments for low income
families. The building has environmentally sustainable design features, making it high
quality and comfortable accommodation for clients with reduced utility costs. There
are a number of support services for clients such as mental health services,
employment assistance and medical referrals. The building also includes a 24 hour
concierge service to ensure the safety of tenants. Other services include cooking
classes, breakfast clubs, health and wellbeing, literacy, numeracy and writing skills
and individual careers counselling to assist clients in reintegrating back into the
community and maintaining independent living.
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3.1.5
Prevention and early intervention
Consistent with the White Paper on Homelessness (FAHCSIA 2009), there has been a shift in
the homelessness service system towards prevention and early intervention. Relevant
models target and intervene when people are at risk of becoming homeless and provide
support services to prevent homelessness from occurring. Some of these services identify
people at risk using tools similar to or adapted from the vulnerability index (as discussed
above).
Prevention models identify people who are at risk of becoming homeless and provide them
with targeted and tailored support services. Quilgars et al (2005) evaluated Safe Moves, a
youth prevention model piloted in the UK, which offers young people support with life
skills, peer mentoring and family mediation (similar to the Foyer model). Safe Moves
targets young people before they become homeless. This is achieved through a referrals
service whereby young people who are still living at home but were at risk of becoming
homeless were referred to Safe Moves.
One of Safe Moves main achievements is helping young people to remain safely in the
parental home or move to more secure accommodation rather than onto the street
(Quilgars et al 2005). Quilgars et al (2005) concluded that the short timeframe of the pilot
program made it difficult to establish and develop highly localised services. However, by
the end of the pilot period, the programs were delivering services to young people of
varying housing needs. As well, the pilot project cost approximately £300,000 (with an
average total cost per client of £1,000), which Quilgars et al (2005) compared with the
average cost of a hostel bed (£400 a week), the cost of processing a local authority
homelessness application (£650) and the cost of a failed tenancy (£2,800).
Examples of early intervention approaches in Australia include initiatives to help individuals
sustain their tenancies and remain in permanent housing:
•
the Ruah Tenancy Support: South East (RTS-SE) in Western Australia, which provides
individualised support services and outreach to individuals at risk of defaulting on
their tenancies in the Perth private rental market (Flatau et al 2009);
•
the Household Organisation Management Expenses (HOME) Advice Program, which
has achieved positive outcomes for families who are experiencing difficulties in
maintaining tenancies or home ownership as a result of difficult personal or financial
circumstances (Phillips 2008); and
•
the national Reconnect program which facilitates family reconciliation for young
people and their families using community-based intervention services (Phillips
2008).
3.1.6
Integrated networks or ‘joined-up’ models
One of the main aims of the White Paper on Homelessness (FaHCSIA 2009) was improving
and expanding homelessness services so that they are more connected and responsive to
achieve sustainable housing, improve economic and social participation and end
homelessness for their clients. The vision of the White Paper is for more integrated service
delivery that incorporates supported accommodation, housing services and mainstream
services, as well as encompassing a wide range of sectors including:
•
mental health;
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•
drug and alcohol abuse support;
•
domestic violence assistance; and
•
juvenile justice and the wider criminal justice system (Urbis 2009).
Selected examples of service integration strategies in Australia
The Victorian Government developed the Opening Doors program a few years ago.
Opening Doors is an area-based service coordination framework with the aim of
providing timely and effective access to homelessness and social housing services to
people seeking assistance. Opening Doors brings together homelessness service
providers through the establishment of Local Area Service Networks (LASNs), to
develop a shared approach to assessment and referral processes, resource allocation
and service system development. LASNs are responsible for developing,
implementing and maintaining the Opening Doors model within their own local
catchment areas with the assistance of Victorian Department of Human Services
Regions.
The South Australian Government is establishing Regional Forums — round tables
which will bring together specialist homelessness services, housing, health and other
key human service agencies to help implement integrated service planning across
regional areas.
Regional Homelessness Action Plans covering the period 2010-2014 have been
developed in NSW to translate reform directions into action at the regional level.
One of the aims of these plans is to facilitate more integrated service system
responses and build cross sector and cross agency cooperation in responding to
homelessness. Regional Homelessness Committees have been established to
support the development and implementation of Regional Homelessness Action
Plans and will act as a point of referral for existing local homelessness committees
and interagency groups on systemic issues. Local committees and groups will also
provide advice and information to Regional Homelessness Committees on local
service provision and emerging issues. At State level there is also the NSW
Homelessness Interagency Committee which includes key agencies in the Human
Services, Justice and Attorney General’s, Heath, Education and Premier and Cabinet
departments. The Committee is responsible for coordinating the implementation for
the NSW Homelessness Action Plan and the National Partnership Agreement on
Homelessness NSW Implementation Plan.
There has been evidence that integrated networks or holistic ‘joined-up’ service provision
models of homelessness service delivery improve clients’ sense of stability which in turn
encourages participation in education, vocational training and community life (Cameron
2009; Boland 2009; Lake 2005).
Strengthening integration throughout the various government and community managed
agencies is a productive and beneficial approach to address homelessness (Lake 2005). A
number of pilot projects have identified further target groups that are likely to benefit from
better coordination between accommodation provision and services to provide tailored
assistance. These include:
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•
Indigenous people whose tenancies are at risk due to significant arrears or
challenging behaviours and where more flexible service models offering outreach,
practical support and referral are required;
•
people with a mental illness where community homelessness services with the
development of exit plans can reduce the risk of people becoming homeless post
discharge; and
•
people escaping family violence requiring an integrated whole-of-government
response (Lake 2005).
Boland (2009) and Cameron (2009) argue that an integrated service delivery model is likely
to achieve more consistent and sustainable client outcomes through a ‘whole of life’
approach that is able to meet the continuum of needs associated with the underlying
causes of homelessness. Integrated service delivery enables clients to access a diverse
range of pathways specifically tailored to their needs via an extensive network of referral
services, and enduring relationships can be developed with a range of services. Providing
support services that are based on the clients’ needs is more effective than providing
separate, uncoordinated services (Boland 2009).
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A ‘Joined-Up’ Government Approach in Victoria
The Victorian Homelessness Strategy aims to improve collaboration between
government programs (including housing, health, justice, education and
employment sectors) to assist in the prevention of homelessness and ensure there is
early intervention for people at risk with multiple and complex needs. Through the
various ‘joined-up’ homelessness pathway initiatives, there is now a greater range of
entry points where intake, assessment and referral processes are consistent and
deliver support that aims to follow the client (Lake 2005).
One example of a ‘joined-up’ approach is the Drug Court initiative in Victoria where
specialised drug courts have the power to issue Drug Treatment Orders (DTOs)
requiring drug offenders to go into treatment as a condition of suspending their
imprisonment sentence. As part of the initiative, the Drug Court Homelessness
Assistance Program (DCHAP) provides housing in dedicated Transitional Housing
Management properties and other support services to assist clients with DTOs or
leaving custody (that resulted from drug-related offences) to obtain long-term,
affordable and safe accommodation that suits the requirements and conditions
placed on the clients as part of their DTO.
Based on an evaluation by King et al (2004), clients of the Drug Court initiative
experienced reduced recidivism as their cycle of drug dependence improved, leading
to lower re-offending and imprisonment. Only 53% of clients on DTOs re-offended,
compared to 92% of those whose DTOs were cancelled (DTOs may be cancelled and
the offender required to serve their suspended imprisonment if they do not respond
to drug treatment or if they re-offend). All clients with DTOs found stable,
independent accommodation with those living on their own rising from 29% before
entering the program to 41% six months after the program. Other benefits for
people on DTOs include improved health and wellbeing, increased engagement and
retention in substance abuse programs, employment stabilisation and decreased use
of drugs and alcohol.
3.2 Service delivery models for specific target
groups
Some groups may be more vulnerable to the underlying causes of homelessness than
others and their pathways into and out of homelessness may vary. Hence, services and
policies aimed at preventing homelessness need to be innovative and flexible and adapt to
the specific needs of a diverse range of subgroups (Minnery 2007). The target groups
discussed in this section are:
•
people with high and/or complex needs;
•
older people;
•
people with problems associated with drug and alcohol use;
•
people who are sleeping rough;
•
people who experience chronic homelessness;
•
Indigenous people;
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•
women; and
•
youth.
3.2.1
People with high and/or complex needs
The literature regarding people experiencing homelessness with complex needs commonly
focuses on people with a mental illness. There was also limited information about people
with a learning disability who experience homelessness.
People with a learning disability
A survey of professionals working with people who are both homeless and in contact with
learning disability services indicated that their clients have a range of complex personal,
health and social needs that are often not met by crisis accommodation, and people with
learning disabilities may also be vulnerable to exploitation by other clients (Colman et al
2007). Colman et al (2007) note that separate accommodation provision specifically
designed for people with learning difficulties might be a more ethical and effective way of
meeting their needs. Such accommodation should offer on-site support that meets both
social and practical needs as well as creating links to external support (Colman et al 2007).
Hebblethwaite et al (2007) report on the experiences of people who have been homeless
and in contact with learning disability services in a city in the North East of England.
Interview data indicated that breakdown of social support was the main cause of
homelessness for people with a learning disability. People with a learning disability
experienced more problems dealing with support services than other homeless people
because they may have difficulties keeping appointments, being articulate and
concentrating (Hebblethwaite et al 2007). Mediation services are likely to be useful in
preventing people with a learning disability from becoming homeless through relationship
breakdown.
People with a mental illness
Mental illness refers to conditions characterised by a clinically significant disturbance of
thought, mood, perception or memory, and can be both a cause of and a reaction to being
homeless (Edwards et al 2009). When homelessness co-exists with mental illness, the
provision of support for very vulnerable people can be significantly complicated. Living
homeless with a mental illness profoundly impacts on physical, psychological and social
wellbeing, and reduces the likelihood of finding and sustaining stable accommodation
(Edwards et al 2009).
Provision of effective support for people experiencing mental health problems who are
homeless has presented a continuing challenge to both policy makers and practitioners
since de-institutionalisation (Padgett et al 2006). People with long-term mental health
problems are more likely than the rest of the population to experience poor housing
conditions and homelessness due to the lack of support for families caring for relatives with
mental illness and permanent supported housing options (Bowpitt and Jepson 2007). The
incidence of mental illness in people experiencing homelessness far exceeds that of the
general population (Lee et al 2010). There are debates in the literature about which occurs
first; homelessness or mental health issues. Through their analysis of over 4,200 people
experiencing homelessness in Melbourne, Chamberlain et al (2007) concluded that the
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longer people are homeless the more likely they are to develop a mental illness. These
findings highlight the importance of prevention and early intervention services.
Housing support for people with mental health issues can vary from full support in hostels
with staff on site 24 hours per day, through to independent living with occasional home
visits by support workers. The literature regarding services for people experiencing
homelessness and who have a mental illness can generally be divided into two categories:
models of support that provide an integrated treatment first approach (Craig & Timms
2000; Lee et al 2010; Rosenheck et al 2002) and those that suggest stabilising clients in
housing before commencing treatment, (Atherton & Nicholls 2008; Foster et al 2010;
Greenburg & Rosenheck 2010; Martinez & Burt 2006; Muir et al 2008; Padgett et al 2006;
Pearson et al 2007).
Research suggests that people experiencing homelessness are significantly less likely to
engage with formal outpatient mental health services, but have higher rates of emergency
health service usage (Lee et al 2010). Institutions such as emergency night shelters provide
a crucial safety net for many people with mental illness who are homeless. While crisis
accommodation is an effective means of securing shelter and food, more support is needed
to address the mental health issues of people experiencing homelessness (Craig and Timms
2000).
Lee et al (2010) suggest multidisciplinary teams are necessary to co-ordinate the support
and management of people with mental illness, and note that an assertive outreach model
can achieve this. Assertive outreach involves the integration of mental health workers with
other community services staff so they work closely together to engage people who are
homeless. This enables improved identification and prevention of mental illness through
supporting a more rapid mental health response (Lee et al 2010). The co-location of mental
health and community service staff allows them to work together to holistically identify and
address consumers’ often complex needs.
Having mental health workers onsite also facilitates the gradual building of therapeutic
relationships with people who are experiencing a mental illness, to provide support for
their transition into more ongoing support (Lee et al 2010). In their study of integration
and outcomes for people with a mental illness experiencing homelessness, Rosenheck et al
(2002) conclude that clients at sites that have become more integrated have progressively
better housing outcomes. As well, Lee et al (2010) note that combining assertive outreach
programs with housing programs has been shown to produce better outcomes than
assertive outreach alone.
Research provides evidence that many people who are currently homeless would be quite
capable of maintaining a tenancy if given the opportunity and, crucially, the support to do
so (Atherton and Nicholls 2008; Padgett et al 2006). Burt and Anderson (2005) note that
consumers with complex needs are not necessarily harder to house or keep in housing, and
evidence suggests that stable housing is an important step on the road to recovery for
people with mental illness.
The Housing First model of support places an emphasis on getting clients into housing at an
early stage under the assumption that people experiencing mental illness or drug and
alcohol problems are capable of coping in their own tenancy (Atherton & Nicholls 2008).
Johnsen and Teixeira (2010), note that a move towards the housing first model of support is
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becoming more widespread in countries such as the UK and Australia, where the treatment
first approach has typically prevailed. Evidence from the North American experience of
Housing First suggests that people with multiple problems, including drug misuse and
mental illness, can maintain stable tenancies even if their other problems remain
unresolved (Atherton & Nicholls 2008; Johnsen & Teixeira 2010; Padgett et al 2006;
Martinez & Burt 2006). Martinez & Burt (2006) go further to suggest that supportive
housing for people with mental illness can reduce emergency department and inpatient
hospital visits, therefore creating public hospital savings which can offset part of the costs
of providing supportive housing.
Housing first does not attempt to ‘fix’ clients to make them ‘housing ready’, but rather is
premised on the assumption that the best place to prepare for independent living is in
independent accommodation (Atherton & Nicholls 2008). Pearson et al (2007) note that
while housing first can increase housing stability and afford the opportunity to receive
treatment, housing on its own is not a solution and having a secure residence should be
seen as a part of an integrated support package.
An evaluation of the US Collaborative Initiative to Help End Chronic Homelessness (CICH)
demonstrated that this initiative encouraged system integration as well as joint planning
and coordination (Greenburg & Rosenheck 2010). The CICH focuses on improving
outcomes for chronically homeless people by making funding available to core services
including permanent supportive housing, mental health treatment and substance abuse
treatment. Greenburg and Rosenheck (2010) note that CICH projects tended to focus at
the outset on stabilizing clients by placing them in housing and addressing their basic
needs. Once needs were met, CICH teams then focused on helping clients move towards
treatment and providing services that encompassed one or more interventions as needed
by each client (Greenburg & Rosenheck, 2010). Foster et al (2010) note that central to the
CICH integrated approach for caring for people with co-occurring disorders, is the concept
that treatment intervention should correspond to the client’s stage of recovery. The
success of the CICH is still being monitored (Foster et al 2010).
Rosenheck et al (2002) evaluated the Access to Community Care and Effective Services and
Supports (ACCESS) which was designed to test whether integrated service systems can
improve individual functioning, quality of life, and housing outcomes for people with
serious mental illnesses who are homeless. One community in each American State was
designated an experimental site and given additional funding to support systems
integration activities. Results revealed that systems integration has a positive impact on
housing outcomes for people with serious mental illnesses (Rosenheck et al 2002). In
addition to improved residential stability, individuals who received integrated case
management, treatment, and support services showed a marked decrease in mental health
symptoms (Rosenheck et al, 2002).
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Housing and Accommodation Support Initiative (HASI) in New South Wales
The Housing and Accommodation Support Initiative (HASI) is an innovative program funded
by the New South Wales Government that utilises a housing first approach with integrated
support.. The HASI program is delivered through a three-way partnership between NSW
Health, the Department of Housing and the non-government (NGO) sector. It provides
three types of support to people with high levels of psychiatric disabilities: social housing;
support within and outside the home to develop living skills and participate in the
community; and clinical mental health case management (Muir et al 2008). A co-ordinated,
client-centred approach is used to provide this holistic support. The Muir et al (2008)
longitudinal evaluation of the HASI program found that most clients (70%) had maintained
stable housing since starting the program and 84% of clients had spent less time in hospital
with mental health issues, compared to the immediate year prior to joining HASI.
In a study of homeless men with a variety of mental health needs, Bowpitt and Jepson
(2007) revealed that common elements of successful homelessness programs were
engagement and creating a sense of community, stability in services and housing, and
promoting client independence. These key elements are also noted in other literature
regarding homelessness services for people with mental illness (Foster et al 2010, Muir
et al 2008, Sylvester et al 2007; Wong et al 2006). Homelessness programs should
factor in these elements when planning for services in the future.
3.2.2
Older people
The Coalition on Older Homelessness (COHP) in the UK aims to raise awareness of older
people’s homelessness and to improve services for the client group. The COHP defines
older people experiencing homelessness as those over the age of 50 years, reflecting the
fact that people experiencing homelessness are likely to age prematurely (Gorton 2007).
Older people who are homeless have diverse needs differing to those of younger people
experiencing homelessness, and are often less assertive than younger residents (RotaBartelink 2006). For these reasons, Pannell and Palmer (2004) suggest that housing and
support services should monitor the age of clients and provide staff training to
appropriately assist older people.
Evidence from audits conducted by Pannell and Palmer (2004) show that while hostels are
generally seen as temporary places to live, they have become permanent residences for
some older people. Warnes and Crane (2000) report that findings from an analysis of a UK
support program for older people indicate that resettlement support is a crucial component
for moving residents into long-term housing and releasing hostel beds for others. An
evaluation of the successful Mission Australia Centre (Pressnell and Chamberlain 2006) also
identified that a combination of integrated community based support services was most
effective in assisting older people experiencing homelessness.
Rota-Bartelink (2006) notes that a paradigm shift is required, whereby mainstream services
need to be more flexible, accessible and creative when supporting older people
experiencing homelessness, particularly for those with enduring mental illness. Factors
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identified as important to establishing and maintaining effective support services include
(Rota-Bartelink 2006):
•
a capacity for continuity offered by a key worker or team approach;
•
the establishment of a long-term relationship with clients, including persisting with
clients in spite of the circumstances;
•
a capacity for an intensive response, based on appropriate staff: client ratios,
extended time limits, and continuity of service provision;
•
a capacity for development of goals and contracts;
•
a harm minimisation philosophy underpinning practice;
•
practical and concrete assistance and support to access recreation and ‘non-welfare’
activities and supports; and
•
a community based approach, as distinct from a clinical model.
3.2.3
People with problems associated with drug and/or alcohol
use
The literature finds that people with problems associated with drug and/or alcohol use can,
and need to be, divided into two separate groups — according to whether they are on a
harm minimisation or an abstinence pathway. More simply put these are people who are
currently using or are abstaining from use, respectively. The needs of these two groups
differ quite dramatically in terms of their accommodation requirements, and reflect where
they are located on their current treatment continuum. In addition, best practice dictates
that all people with problems associated with drug and/or alcohol use who are accessing
accommodation services should have access to additional support services such as
counselling, treatment or case management for their substance use problem
Chamberlain et al (2007) note that when people first become homeless and are introduced
to people who are chronically homeless, they tend to develop new social networks and
become involved in a ‘homeless sub-culture’. Chamberlain et al (2007) go on to estimate
that 66% of people living homeless in Melbourne developed problems associated with drug
and/or alcohol use after they become homeless. There is however ongoing debate in the
homeless literature as to whether homelessness causes problematic drug and/or alcohol
use, or vice versa (Chamberlain et al 2007).
In both emergency and longer term accommodation it is inappropriate to house together
people with a substance use problem who are trying to abstain alongside those who are
still using substances, as this makes prevention of relapse among abstainers more difficult.
However, this does not mean that all accommodation services should have a zero tolerance
approach to substance use. The needs of people who are still using substances are quite
different, and a zero tolerance approach for them may result in evictions or bans at a time
when support is most needed. Ultimately, bans are unlikely to lead to recovery among this
group (Duffin 2007).
As such, it is important that people with problems associated with drug and/or alcohol use
have access to an accommodation service that best supports their needs at whatever stage
of the recovery pathway they are on. For people who are abstaining, this will mean
accommodation services where they are not exposed to people who are using substances.
For the latter group, this will mean access to accommodation that, ideally, has a drug policy
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which is regularly reviewed in consultation with service users, with a view to safeguarding
people with problems associated with drug and/or alcohol use , rather than excluding them
(Duffin 2007).
Models of permanent long-term accommodation have been shown to lead to beneficial
outcomes for people with problems associated with drug and/or alcohol use. Atherton and
Nicholls (2008) find that the Housing First model is an effective means of addressing
homelessness among people with substance misuse problems. The greatest benefits are
achieved when this model is implemented as part of a localised strategy that responds to
markets to obtain properties for target clients and when implemented as part of an
integrated service approach. Similarly, Martinez et al (2006) find that permanent
supportive housing can improve stability for people with problems associated with
substance use as well as reducing their use of hospital emergency departments and
inpatient services.
Adequate support services are also important to people with problems associated with
drug and/or alcohol use in breaking the perpetuating cycle of substance use and
homelessness that some people find difficult to escape. Essentially, this is a cycle where
substance use triggers homelessness, which then creates vulnerability that exacerbates
drug use, which can limit access to housing thereby intensifying the problem of
homelessness, and so on (McKeown 2007).
A holistic approach to support services and a continuum of care approach are seen as the
most effective approach for people with substance use problems (Rayner 2006; Bowpitt &
Harding 2008; Duffin 2007). Rayner’s (2006) study of the three-year Homeless and Drug
Dependency Trial at the Crisis Supported Accommodation Services in inner-city Melbourne
found that clients were able to successfully participate in treatment and maintain beneficial
outcomes as a result of continuous case management as they moved from crisis
accommodation into transitional or permanent housing. Support services that are provided
to clients in their own homes or at their place of accommodation were also identified as a
successful example of a continuous case management approach (Duffin 2007).
Furthermore, the study notes the importance of providing flexible housing and support
services for people with problems associated with drug and/or alcohol use in order to deal
with potential relapses and setbacks (McKeown 2007).
In terms of emerging practices, Gillis et al (2010) find that recovery-based approaches to
services are showing promise and may offer an effective means of support for people with
problems associated with drug and/or alcohol use. This is a holistic abstinence-focused
approach that also emphasises the importance of gaining information, increasing selfawareness, developing skills for sober living and following a program of change.
There are no hard and fast solutions for the type of model or models that work best for
people with problems associated with drug and/or alcohol use. The literature suggests that
further research is required to identify the different models of housing and support that
work best for people with problems associated with drug and/or alcohol use at different
stages of their engagement with treatment and other support services. However, where
evidence does exist, it indicates that appropriate housing and support can be successful in
bringing about benefits for even the most vulnerable service users (McKeown 2007).
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3.2.4
People who are sleeping rough (primary homelessness)
Literature that outlines successful approaches specific to rough sleepers is an emerging
area of research in Australia. For example, Phillips et al (2011) have recently released a
Positioning Paper for research into the adoption of assertive outreach models in Australia
targeted at rough sleepers.
In the UK, Homeless Link, a peak organisation representing 500 organisations working with
people living homeless, provides information on good practice for reducing the number of
people who are sleeping rough. Homeless Link (2009) notes that good practice involves
multi-agency collaboration and a case management approach to working with people
sleeping rough. Services should be configured to meet the needs of individual clients,
including procuring accommodation and support, to help them move away from sleeping
rough (Homeless Link 2009). The UK Department for Communities and Local Government
has also produced a good practice guide for preventing rough sleeping. This guide suggests
that the longer someone sleeps rough, the more difficult it becomes to help them, so the
time a person first becomes homeless to the time they receive support should be
minimised wherever possible (Department for Communities and Local Government, 2001).
The Department of Communities and Local Government recommends various
homelessness programs for people sleeping rough, including the St Mungo’s model, which
is profiled in a case study under section 3.1.1 Treatment first’ or ‘pathways’ model.
Also, internationally, both the Rough Sleepers Initiative (RSI) in Scotland and the S2H
program in Canada have been shown to support beneficial outcomes for their clients.
The RSI in Scotland provides a practical example of a targeted effort by government to
fund initiatives towards reducing the number of people sleeping rough. Anderson (2007)
undertook a retrospective policy critique of available evidence from evaluations and
research on the RSI program and summarised some of the key lessons and elements of best
practice for the provision of services to rough sleepers. Anderson (2007) noted that, due to
the complex needs of people who are sleeping rough, an emphasis on holistic solutions and
multi-agency networks is required. Anderson (2007) also recommended that housing
services and support services should work together to ensure a successful transition for
people who were previously sleeping rough into stable housing. In addition other support
services, such as help to re-engage with the labour market, are also important in helping
service users to achieve a stable long-term outcome.
The S2H program in Canada is a version of the Housing First model discussed in section
3.1.2. It has successfully helped rough sleepers to move into permanent housing. The
benefit of helping this group to maintain permanent housing has been shown to lead to
other benefits. For example, the majority of people who sustained their housing reported
improvements in other areas of their lives such as health, amount and quality of food being
consumed, levels of stress, sleep, personal safety and mental health. This also coincided
with fewer relapses into problem behaviour, fewer calls to 911, fewer arrests, less time in
jail and reduced use of hospital emergency rooms compared to before they participated in
the program. However, it was also found that further improvements to this service delivery
model could be made. Some notable examples of improvements include the provision of
financial assistance, as many clients had little money for their livelihood after paying their
rent and more flexible housing options. Shared accommodation approaches were found to
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be less effective as noted in section 3.1.2, and roughly 30% of clients felt they had no choice
in the type or location of their housing (Falvo 2009).
Further research specific to rough sleepers in Australia is required before conclusive
recommendations for best practice can be made. The research being undertaken by
Phillips et al (2011) will be important as it will provide a better understanding of successful
approaches in an Australian context.
3.2.5
People who experience chronic homelessness
The U.S. Department of Health and Human Services (DHHS) defines chronic homelessness
as ‘an unaccompanied homeless individual with a disabling condition who has either a)
been continuously homeless for a year or more or b) has had at least four episodes of
homelessness in the past three years’(DHHS 2003). Some agencies have expanded this
definition to include families that meet these criteria (Caton et al 2007). Disabling
conditions usually include poor mental health, severe and persistent drug and/or alcohol
abuse and chronic physical health problems (Caton et al 2007; Styles 2009).
Chronically homeless adults constitute a small but significant subgroup of the homeless
population and often experience psychological, physical, and social vulnerabilities (Caton et
al 2007). People entrenched in homelessness have high levels of problematic alcohol and
other drug use, and other serious mental and physical health needs (Gronda 2009a).
People who have experienced homelessness for extended periods of time are hardest to
assist, particularly if they have other needs such as mental health needs and disabilities or
other conditions. Hence, it is important to prevent long-term homelessness at earlier
stages using service delivery models that focus on prevention and early intervention (DHHS
2003).
The DHHS (2003) state that integrated service systems are essential for individuals who are
chronically homeless to have access to all the mainstream benefits and services for which
they are eligible. The DHHS (2003) also note the importance of making a variety of safe,
affordable housing options available because, without housing, services and supports
cannot be effective. The costs of subsidised housing (and access to services necessary to
maintain housing) can be wholly or partially offset by reducing the use of emergency
shelters as well as other acute care services (Culhane & Metraux 2008). Moving people
experiencing chronic homelessness into supportive housing can also free up services for
those people needing short-term shelter, such as for individuals recently discharged from
institutions.
Rickards et al (2010), Kresky-Wolff et al (2010) and Mares and Rosenheck (2010) all
describe findings from the Collaborative Initiative to Help End Homelessness (CICH).
Rickards et al (2010) note there has been a shift towards an integrated approach in service
delivery throughout the CICH. This finding is exemplified by Kresky-Wolff et al (2010) who
noted visits to specific CICH projects showed that additional client support and
interventions can be made by housing property managers.
Most clients (86%) of the CICH had been homeless for a year or longer, and 69% had four or
more episodes of homelessness during the prior 3 years, indicating that the majority of
clients to use the CICH were chronically homeless (Rosenheck and Mares 2010). The
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proportion of core services received, such as case management, mental health care and
substance abuse treatment, all increased from 64% at baseline to 80% once clients had
entered the CICH, indicating that clients had accessed needed services and remained
engaged in treatment for the duration of their first year in the program (Rosenheck and
Mares 2010). The central finding of Rosenheck and Mares (2010) study is that the vast
majority (89%) of chronically homeless single adults in the CICH program were in stable
housing throughout their first year in the program, thus showing the merit in an integrated
approach to housing the chronically homeless.
3.2.6
Indigenous people
According to Chamberlain and McKenzie (2009), Indigenous people were overrepresented
in all sections of the homeless population in Queensland in 2006, making up 8.1% of the
total homeless population. By comparison, the Indigenous population made up only 3.5%
of the total population in Queensland in 2006 (Chamberlain and McKenzie 2009).
According to Urbis (2009), the definition of homelessness for Aboriginal and Torres Strait
Islander groups needs to be expanded to encompass the importance of culture to include:
•
spiritual homelessness – defined as a separation from traditional land, from family
and kinship;
•
habitation in accommodation that is overcrowded;
•
relocation and transient homelessness;
•
escaping from an unsafe or unstable home; and
•
lack of access to any stable shelter (Urbis 2009).
In light of the different cultural and social contexts that contribute to the underlying causes
of homelessness amongst Indigenous Australians, it is necessary to develop homeless
services that are sensitive to their particular needs (Urbis 2009). Furthermore, the complex
social housing administrative processes, especially for those involved in a traditional
‘treatment first’ or pathways model can negatively and unnecessarily impact on the
effectiveness of housing services in reducing homelessness among Indigenous people
(Gronda 2009a).
One of the main issues associated with homelessness services is accessibility for Indigenous
Australians. According to Flatau et al (2005), there are a number of barriers to Indigenous
Australians accessing and maintaining housing, including:
•
discrimination against Indigenous tenants or applicants, or providers adopting
policies that indirectly discriminate against Indigenous Australians;
•
different cultural beliefs as Indigenous Australians tend to be more mobile in terms
of accommodation and have large extended families. The supply of housing stock for
larger families, particularly in remote areas, is inadequate. Overcrowding places
extra demand on housing structures and equipment. Large maintenance bills,
neighbourhood complaints and possible eviction can result;
•
spiritual homelessness when Indigenous Australians are separated from their
traditional and sacred land or their families over time;
•
Indigenous Australians may not have the tenancy management skills required to
maintain permanent housing in the private rental market, leading to increased
defaults on private tenancies; and
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•
the complex needs of some Indigenous Australians including poverty, domestic and
family violence, incarceration, problems associated with drug and alcohol use1 and
mental health problems are often neglected in housing policies and prevent them
from accessing and sustaining tenancies in mainstream public and community
housing programs (Flatau et al 2005).
In order to improve access to housing services for Indigenous Australians, existing service
delivery models need to be better adapted to cultural, physical and social needs. Culturally
appropriate service delivery mechanisms are required, along with appropriate training for
staff and volunteers and the establishment of links with the local community and support
services. Service models need to incorporate case management as the individual needs of
Indigenous Australians differ and a ‘one size fits all’ model will not be effective in
addressing the often complex and interconnected causes of homelessness (Flatau et al
2005a). Case management for Indigenous Australians should include the following
characteristics:
•
be proactive;
•
include a needs assessment;
•
one-to-one client contact; and
•
use of referrals linking clients to specific external agencies, along with direct
transportation to external agencies (Flatau et al 2005a).
Flatau et al (2005) identifies improvements that could be made to the current system:
•
addressing the supply-side (i.e., the existing housing stock) as well as better targeting
existing housing stock for Indigenous Australians to resolve overcrowding issues;
•
developing mechanisms to assess and identify Indigenous Australians who are most
vulnerable to homelessness and targeting these people with the necessary support
to exit into home ownership or permanent, private tenancies;
•
ensuring services targeted towards Indigenous Australians are staffed by Indigenous
people or ensuring that Indigenous Australians are integrated into decision making
processes in order for service delivery to be more tailored to the needs of Indigenous
people;
•
developing admission policies that ensure Indigenous people are not excluded based
purely on past histories; and
•
extending housing services to include support and assistance post-housing to ensure
Indigenous people remain in permanent housing.
3.2.7
Women
There is a growing literature about the specific needs of single women in their access to
homelessness accommodation services. The SAAP National Data Collection Annual Report
that more females (57%) than males (43%) used specialist homelessness services in
Australia in 2010-11 (Australian Institute of Health and Welfare, 2011). However, women
are generally an ‘invisible’ group, particularly for crisis accommodation, because they tend
1
Public intoxication and public space services were beyond the scope of this literature review. Phillips et al
(2001) provide an overview of Australian assertive outreach services that target Indigenous people who are
publicly intoxicated.
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to experience secondary or tertiary homelessness, rather than primary homelessness.
Young women with complex needs also comprise an increasing proportion of people who
are homeless (Robinson et al 2007). As such, there tends to be an undersupply of
accommodation services targeted towards the specific needs of female service users,
particularly in suburban areas (Robinson et al 2007; Adkins et al 2003).
Robinson et al (2007) suggest that women’s homelessness is often related to multiple
issues over a period of time that leads them in and out of homelessness. Financial
difficulties such as loss of economic support are one of the main causes of homelessness
among women (Robinson et al 2007). This is mainly due to limited access to paid
employment, as well as caring responsibilities for either children or other family members.
Robinson et al (2007) suggest that this pathway into homelessness for women is often
compounded by other factors:
•
Women have a poor position in the housing market due to the current Australian
housing system. This is due to factors such as a lack of public housing, the high costs
of private home ownership, as well as difficulties for women to maintain housing in
the private rental market due to insecurity of tenure associated with short term
leases, establishment costs and lack of available rental houses.
•
Domestic and family violence is another significant factor that may cause women to
become homeless. In addition, the way women respond to or manage their
experiences of sexual abuse and violence may lead to dependency on drugs and
alcohol as well as mental health disorders that further entrench them into
homelessness.
•
Women are more likely to experience ‘hidden homelessness’ in that they are not
visible or are not counted as homeless and therefore are not recognised as a group
requiring access to homelessness services. Women’s ‘invisibility’ is largely due to the
ways they cope with homelessness, such as by ‘couch surfing’, trading sex for shelter
or sleeping rough. In addition, they may suffer from feelings of loss, guilt and shame
due to their homelessness, which leads them to conceal their homelessness by
avoiding homelessness services.
Strategies of service provision that are diverse and offer an integrated approach to support
are recommended for single women experiencing homelessness (Robinson et al 2007;
Adkins et al 2003). Robinson et al (2007) examined the need for crisis accommodation for
women in the western suburbs of Sydney. They found that the assumptions underpinning
crisis accommodation were based on the idea that ‘crisis’ is temporary, but in reality this is
often not the case. The most vulnerable women with complex needs are also those who
are most likely to be without safe accommodation and who are in the greatest need of high
level support at the time when they seek crisis accommodation. However, there is an
apparent shortage of crisis accommodation targeted at single women, particularly in
suburban areas, which can force women to seek services away from their local support
networks. Shortages of accommodation appropriate to women may also contribute to
their vulnerability and lack of safety, reinforcing trauma and cycles of homelessness
(Robinson et al 2007).
Further, housing and homelessness issues for women can stem from loss of economic
support and other financial difficulties, (Robinson et al 2007). Despite the progress made in
incorporating women into the workforce, the average female wage remains lower than
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their male counterparts. Single women are particularly vulnerable as they do not have
economic support from partners (Robinson et al 2007).
Robinson et al (2007) recommend that more varied and flexible service responses which
target single women should be provided, with support services that include the teaching of
basic survival skills as well as intensive support for possible mental health or developmental
issues and other trauma.
3.2.8
Young People
The focus of this literature review is on the provision of homelessness services to single
adults and, as such, much of the literature on young people experiencing homelessness is
peripheral as it focuses on the experience of minors. However, other strains of this
literature also cover homeless service provision to young adults, typically those aged 18 to
25 years. Research in this area is the focus of this section of the literature review.
As for most other sub-groups of people experiencing homelessness, the literature suggests
that a holistic approach to support services is essential for achieving positive outcomes for
young people experiencing homelessness. This is particularly important in helping to
address young people’s experiences, which tend to be defined by identity issues such as
gender, cultural group, sexuality or health status (AHURI 2006; Bond 2010; Mission
Australia 2007).
A service delivery approach that facilitates the co-location or integration of youth services is
favoured by the literature (Bond 2010; Cameron 2009; AHURI 2006; Beer et al 2005). In an
assessment of their own integrated service delivery model, Frontyard, Melbourne
Citymission found that this approach helped to create opportunity pathways for their
clients (Cameron 2009). The presence of early intervention Reconnect program workers
was noted as a key element of this model. This correlates with the results of Mission
Australia’s annual youth survey (Mission 2007), which found that early intervention
programs, particularly Reconnect, are seen to work well. Other notable lessons for best
practice derived from the experience of the Frontyard service include using an easily
accessible and centrally located purpose-built premises, employing skilled staff (including
for reception which involves a triage function as part of the meet and greet role), having an
independent, non-partisan operating platform and, importantly, an understanding that
creating an integrated service is complex and will require time and effort (Cameron 2009).
The Foyer model has also been identified as a successful model for young people by several
studies. AHURI (2006) and Beer et al (2005) suggest that the introduction of a Supported
Learning Tenancy that is based on the Foyer model, would be an appropriate service model
for young people experiencing homelessness in rural settings, as it provides effective
integrated accommodation, skills training and job search support. Advantages of this
model specific to a regional setting include its local management approach and group living
focus, as these take advantage of the high levels of social capital that are typically present
in regional communities. On the other hand, pioneering such a service in rural areas may
lead to apprehension among the local community, which could lead to social stigmatisation
(AHURI 2006).
An independent community inquiry into youth homelessness in Australia by the National
Youth Commission (2008) also found that the Foyer would be appropriate for young
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Australians in general, as it links accommodation with other support services. Similarly,
Wilks et al (2008) emphasise the need to create a ‘web’ of support for young people by
establishing connections between service providers and institutions in the broader
community.
The Twenty-Ten Association Incorporated (2007) made similar recommendations in their
report into the service needs of young homeless gay, lesbian, bisexual and transgender
young people. This group was identified as being more at risk of homelessness than their
heterosexual counterparts due to the potential for family estrangement, breakdown of
support relationships and limited education and employment opportunities as a result of
their sexual identity. Many of the recommendations regarding service needs were
comparable to those made for homeless young people in general and included a continuum
of care approach from crisis accommodation to long-term supported accommodation and
exit points, as well as strengthening inter-agency links and developing integrated and
coordinated case management to respond to complex mental health needs. The authors
also recommend that sexual and gender diversity and anti-homophobia training and
resources be developed and disseminated throughout the specialist homelessness sector.
4 Best practices and
recommendations
The literature from this review demonstrates that specialist homelessness services can
produce positive outcomes for clients, and even the wider community. However, rigorous,
evidence-based research facilitating definitive conclusions is — according to Locke et al
(2007) — rare and difficult to implement. This is because the homeless population is not
homogenous, even within subgroups and what is effective for one individual may not be
effective for another (Minnery 2007).
This section draws on the literature review and other recommendations for best or good
practice (Flatau et al 2006; Gronda 2009; Gronda 2009a; Johnston & More 2007; McGraw
et al 2010; Olivet et al 2010; The University of Queensland Social Research Centre 2009;
Edwards et al 2009) to identify specific service delivery models or programs that are
considered appropriate and adequate in addressing the underlying causes of homelessness
and hence reducing homelessness in the long run (Minnery 2007).
Good practice models should be based on an understanding of the underlying causes of
homelessness, as well as the events or circumstances that may trigger homelessness
(Minnery 2007). In this way, homelessness services can be targeted to individual
circumstances in order to break their cycle of homelessness. It has been recognised in the
White Paper on Homelessness (FaHCSIA 2009) that homelessness service delivery should
aim to provide services that focus on clients acquiring the necessary skills to maintain social
competence and permanent housing and to exit homelessness.
For homelessness services to be able to reach those in need of assistance there needs to be
an improvement in the way people experiencing homelessness are identified and counted.
For example, the pathway into homelessness for Indigenous Australians is different to that
of the general population. As discussed earlier, Indigenous Australians may become
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spiritually homeless when they are separated from their traditional land. Overcrowded
conditions are also a form of homelessness experienced by many Indigenous Australians.
These differences in the pathways into and out of homelessness need to be recognised in
order for homelessness services to adequately address their needs (Flatau et al 2005). The
UK has moved towards good practice in this way by extending the definition of priority
need to recognise an increasing number of the ‘new homeless’ (Minnery 2007) including
people leaving support or institutions, and people experiencing repeat homelessness (for
example, gypsies).
4.1 Key elements of best practice
This section details some of the common themes and key elements of best practice that
have emerged from the literature.
4.1.1
Case management
Inherent in all the different service delivery models is the inclusion of case management.
According to Gronda (2009), case management involves a case manager using tools and
professional expertise to develop an individualised service plan to meet the needs of clients
and to assist them to develop their own capacity for independence. Urbis (2009) found
that services need to be provided on a case-by-case basis and that case management
should ensure that clients are involved in both the planning and the service plan. A primary
focus of case management is not only to meet the needs of individuals, but also to develop
their capacity to self-manage their own access to appropriate support services (Gronda
2009).
Case management has been an integral part of homelessness policy in Australia and is the
factor most often cited by program directors as contributing to client success (Novak et al
2009). However, the definition of case management and the mechanisms by which it is
effective are often poorly described (Novak et al 2009; Gronda 2009).
In a synthesis of the existing evidence base, Gronda (2009) found that the case
management approaches that achieved the best outcomes were those that provide a
persistent and reliable relationship between the case management team and the client
characterised by rapport and respect, and involving comprehensive and practical support.
As well, the provision of individualised support services tailored to the client’s needs is
more suited for people with high and/or complex needs such as those with mental health
issues and substance abuse issues (Johnsen et al 2010). Studies of the outcomes of a
‘housing first’ model with case management components have shown that, compared to
the ‘usual care’ group (i.e. those clients who were placed in the ‘treatment first’ or
‘pathways’ model), clients spent fewer days in hospital and emergency departments
(Johnsen et al 2010).
Key elements of case management should include:
•
direct provision of comprehensive and practical support by the case management
team (rather than the provision of brokerage and referrals without case management
support);
•
access to housing resources and specialist supports;
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•
case management continuity even once a person has been housed to assist them in
sustaining permanent housing and ensuring their relationship with the case manager
is not broken ;
•
individually determined support durations, taking into account the client’s
preferences and needs; and
•
case management staff with advanced assessment, communication and relationship
skills, as well as regular support and supervision of case management staff to ensure
they are able to emotionally connect with their clients without compromising their
professionalism (Gronda 2009).
It has been acknowledged that case management requires time and is extremely resourceintensive (Gronda 2009) because of the necessity to form a relationship between the case
manager and the client. However, if done properly, case management can be cost-effective
because it has the potential to reduce expenditure in other sectors by, for example,
lowering hospitalisation rates and reducing visits to emergency departments (Gronda
2009). Conversely, case management may increase the use of health services by people
who may have under-utilised them previously. It is therefore important for cost
effectiveness studies to factor in the potential benefits to clients’ health and quality of life
and the broader benefits to the community as well as the impact on what governments
spend on service provision alone.
4.1.2
Consumer choice and involvement in homelessness programs
One of the underlying elements of many emerging homelessness service delivery models is
consumer integration, which can manifest itself in several ways. Two examples include:
•
Consumer choice: allowing consumers to choose whether or not to participate in the
support services that are provided to them (as in a ‘housing first’ model); and
•
Consumer participation: involving current or previous consumers in delivery of services
to their peers.
Consumer choice and participation are not necessarily mutually exclusive and there are
many examples where they co-exist.
Consumer integration promotes client empowerment and contributes to an individualised
program environment to assist in breaking the cycle of homelessness. Greenwood et al
(2005) followed 197 homeless and mentally ill adults who were randomised into one of two
groups — a consumer-driven ‘Housing First’ program or ‘treatment as usual’ requiring
compliance with psychiatric treatment and sobriety before adults were determined to be
‘housing ready’. The Housing First approach was associated with increased perceived
choice and reductions in the time that people were homeless.
The ‘Recovery’ model of service delivery, currently more common in health rather than
homelessness circles, is based on the premise that individuals can learn to accept their own
limitations so that they are able to identify the supports they need to mitigate symptoms
(Gillis et al 2010). Empowerment is an integral aspect of Recovery. Peer support is often an
important element of Recovery models helping to transform the organisational culture,
adapt service delivery models and promote empowerment (Gillis et al 2010). According to
Salyers and Tsemberis (2007), consumer choice and recovery work effectively together,
particularly for people with mental health problems. Their study examined Assertive
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Community Treatment (ACT) teams which are based on the recovery model while still
retaining consumer choice and flexibility. ACTs are multidisciplinary and clients have the
flexibility to negotiate and set their own pace for treatment and graduation in their
pathway to recovery. Salyers and Tsemberis (2007) found that consumer choice had
positive impacts on reducing psychiatric symptoms. In addition, Salyers and Tsemberis
(2007) have also suggested that hiring consumers as ACT team staff members can have
positive outcomes for service recipients.
The Projects for Assistance in Transition from Homelessness (PATH) Consumer Involvement
Workgroup is another example. Consumer practitioners have been integrated into PATH
programs (which are based on the Recovery model) to provide positive messages to other
clients that individuals with mental illness who experience homelessness can recover and
deliver similar services to assist their peers (Gillis et al 2010). .
In addition, consumer integration can build and develop the skills of clients, leading to
improved employment outcomes. An example of consumer participation in homelessness
services and service delivery include the peer support model, which encourages consumer
participation in service design, delivery and evaluation (Gillis et al 2010). It may involve
services operated or staffed by previous program clients who have experienced
homelessness (Gillis et al 2010). Barrow et al (2007) suggests that personal experiences of
homelessness allowed clients to more effectively provide outreach to their peers. Gillis et
al (2010) suggest this is mainly due to:
•
client-peer insights into the streets and service systems;
•
their flexibility and openness to new approaches;
•
their understanding of and responsiveness to client preferences and needs;
•
their ability to empathise and build rapport with people experiencing homelessness;
and
•
they can act as a positive role model.
Client participation is especially prevalent in outreach teams in the UK. According to
Homeless Link (2008), the Night Centre run by Tyneside Cyrenians in Newcastle employs a
high number of previous rough sleepers in their night centre as well as for their outreach
teams. This is beneficial because they have knowledge in where to locate rough sleepers as
well as how to engage with them (Homeless Link 2008).
Barrow et al (2007) suggest increases in consumer integration promise beneficial outcomes
for clients — producing more responsive and effective policies and creating and validating
useful service approaches.
4.1.3
Physical environment
Best practice elements relating to the physical environment of homelessness services may
include the size of the shelter, privacy and engagement with the community, sleeping
arrangements and security of the premises. The physical environment that is appropriate
depends on the characteristics of the client, reflecting different preferences and needs.
•
The Common Ground model is based on the premise that residential buildings for
homeless clients are well designed, attractive and practical. This has been shown to
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improve outcomes for clients, as they are proud of where they live and feel
empowered in other aspects of life (Urbis 2009).
•
Wilks et al (2008) placed an emphasis on, particularly for homelessness services
targeted at young people, the need for personal space, privacy (including single sex
accommodation) and safety of service users through the provision of personal
amenities such as individual bedrooms, a fridge and stove and other intangible
qualities such as safety, a location that is accessible to public transport and public
amenities and a welcoming environment (Wilks et al 2008).
•
It is important to have accommodation options for specific clients, such as women’s
refuges for women and children who are escaping domestic violence that are highly
secure and protected (Bell 2006).
•
Residences that are self-contained, or where clients have agreed to share some space
and equipment, tend to have less conflict (Busch-Geertsema 2007).
•
Best practice models are generally centrally located purpose-built premises that
incorporate both accommodation and on-site support services (Cameron 2009).
However, it is recognised that some residents prefer to live in scattered-site housing
as it provides them with privacy, and contributes to their feelings of independence
(Locke et al 2007).
•
In both emergency and longer term accommodation it is inappropriate to house
together people with a substance use problem who are trying to abstain alongside
those who are still using substances, as this makes prevention of relapse among
abstainers more difficult. However, this does not mean that all accommodation
services should have a zero tolerance approach to substance use as this is unlikely to
lead to recovery among people with problematic drug and/or alcohol use (Duffin
2007).
•
Accommodation which allows clients to bring their pets may contribute to their sense
of companionship and general well being (Victorian Government Department of
Human Services 2006).
•
Accommodation should encourage as much as possible community engagement and
social inclusion through the accommodation design or allocation of private space.
For example, it is difficult for people who share cooking facilities and/or sanitary
amenities to host visitors (Busch-Geertsema 2007).
•
Colman et al (2007) notes that for people with learning difficulties, separate
accommodation provision should be specifically designed. It should offer on-site
support that meets both social and practical needs as well as creating links to
external support.
4.1.4
Staffing requirements
Requirements for staffing are as varied as the client needs for which they are catering. The
literature suggests that staff need to be flexible and adapt to changes in program delivery
that best support people who are homeless. Key points from the literature suggest that:
•
When hiring staff, the relative advantages of hiring people with greater or less
experience should be considered. Experienced staff can provide a wealth of
knowledge to the program, but may have strong views that conflict with newer
elements of best practice (McGraw et al 2010).
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•
To achieve the best results, the staff should undergo training as a team to maintain
consistency for service provision (McGraw et al 2010).
•
Staff employed should be skilled in homelessness service delivery, including for
reception which involves a triage function as part of the meet and greet role (as
discussed in section 3.2.8).
•
The client to worker or case manager ratio depends on the service delivery model,
but the ideal should allow staff to effectively engage each client and develop
individualised service plans. According to findings based on St Mungo’s Outcomes
Star (discussed in section 3.1.1), the hostels recording the best outcomes for clients
were those with 5 to 7 clients per worker. In another evaluation by Mission Australia
(2009), a client to staff ratio of 19:1 was found to be too high for effective case
management and was associated with poor client outcomes.
•
There is some evidence that homelessness programs staffed or operated by previous
clients who have also experienced homelessness are more effective for both the staff
and future service users. Staff who have similar experiences to their clients may be
sensitive and responsive to the needs of their clients and may also become good role
models, as they have shown they can recover and help their peers (Gillis et al 2010).
•
The skill requirements of staff are high. Programs should plan for on-the-job training
for staff, and incorporate ongoing supervision of staff with regular feedback for
professional development. Day to day skills required of staff can include (Johnston &
Moore 2007):
•
managing challenging behaviour;
•
providing support to clients with mental illness and drug and/or alcohol
dependency;
•
client needs assessment and case management, including knowledge of the
array of services available to which clients can be referred for support;
•
counselling skills, including for victims of trauma and abuse;
•
group-work, and team and community building strategies; and
•
information technology and database skills.
4.2 Best practice models
The evidence base above suggests that good practice policies and programs should involve
a combination of prevention, early intervention, crisis intervention and long-term support
services that focus on facilitating independence and moving people into permanent
housing. There is a shift from the traditional ‘treatment first’ model whereby service users
are placed into crisis accommodation then transitional housing before being placed into
permanent housing if they become ‘housing ready’.
This section summarises some of the best practice models, and their key features according
to the literature described above.
4.2.1
Crisis accommodation and ‘treatment first’ models
While the ‘treatment first’ model has its shortcomings (these are discussed in section
3.1.1), it has been recognised that it can be effective particularly with people who are
willing to engage with rehabilitation programs and are able to cope with shared housing
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arrangements (Johnsen et al 2010). Busch-Geertsema (2007) identifies situations where
crisis accommodation and transitional housing are necessary, such as for people becoming
homeless in emergencies including natural disasters or women and children escaping from
domestic violence, or for people discharged from institutions such as medical facilities or
prisons. In addition, young people experiencing homelessness may require transitional
housing in the first instance as they need to acquire the necessary skills to live
independently and establish income support before being placed into permanent housing.
Crisis and transitional accommodation are also necessary as a substitute for permanent
housing in cases where there are housing shortages or extremely low housing affordability
(Busch-Geertsema 2007).
Best practice models of crisis accommodation are those that ensure that crisis
accommodation remains only temporary. One of the main concerns with the ‘treatment
first’ model is that people often transition in and out of temporary housing without ever
finding a permanent home. As a result, temporary housing often becomes long-term
housing for some people (Busch-Geertsema 2007). Client needs do not necessarily end
after leaving crisis or transitional accommodation and effective case management, service
integration and long-term support are important adjuncts to ensure crisis accommodation
services remain a temporary staging point for those who need them.
Busch-Geertsema (2007) identifies a number of service standards for temporary and crisis
accommodation in an ‘ideal’ setting:
•
availability outside business hours;
•
provision of emergency supports such as clothing, medical professionals and financial
assistance;
•
minimum standards of quality including cleanliness and hygiene;
•
minimum privacy standards, including the option for some individuals to have single
rooms, separation of the sexes and individual sanitary and cooking facilities ;
•
a ‘team approach’ with wide-ranging multidisciplinary services (for example
substance abuse counselling, legal aid, abuse or sexual assault counselling, and
primary health care);
•
clear eviction rules offering reasonable notice and alternative accommodation
options;
•
a range of exit options from temporary housing including permanent housing at the
end of the program; and
•
charging residents a reasonable and affordable fee can develop a sense of selfsufficiency and encourage clients to move into independent housing.
The literature suggests that the ‘treatment first’ model needs to be substantially modified
for clients with complex needs, particularly Indigenous Australians and those with mental
health issues. Complex needs may not be well met by mainstream treatment pathways and
further, Johnsen et al (2010) suggest the treatment first model is too rigid for people trying
to recover from substance abuse and mental health issues.
4.2.2
Prevention
A key theme throughout the best practice literature is that homelessness programs and
policies should incorporate prevention in their planning.
People experiencing
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homelessness make more use of emergency services (including crisis accommodation and
hospitals) than the general population. Prevention of this long-term chronic use of
emergency services is often less costly to government and society than the provision of
integrated housing and support (Gronda 2009). This is because homelessness programs
may improve the health and wellbeing of clients, which in turn results in decreased costs to
the government in the form of:
•
reduced utilisation of hospital, justice and other services;
•
reduced child residential support costs;
•
lower social housing and private rental management costs from the avoidance of
evictions;
•
lower income support payments; and
•
higher revenue from increased income tax payments (Flatau et al 2008).
Flatau et al (2008) however, also note that the provision of homelessness support may lead
to an increase rather than a decrease in the utilisation of services. This is the case if clients
enter homelessness services with a pre-existing health condition for which they have not
received appropriate treatment. Access to homelessness services may in turn lead to
improved access to health care for their otherwise untreated health conditions, thus
increasing health utilisation and related costs as a result of the provision of homelessness
services.
The literature canvassed above suggests that prevention models are particularly effective
for young people at risk due to conflict or violence in the parental home, and with
Indigenous Australians who may be especially vulnerable to homelessness for the reasons
explained in section 3.2.6 (Flatau 2005). As discussed in section 3.2.8, early intervention
programs such as Reconnect have been seen to work well with young people.
Prevention may be addressed through:
•
providing outreach services that identify people most at risk of homelessness and
develop targeted responses to prevent homelessness or assist in preventing longterm homelessness (Phillips et al 2011);
•
providing assistance to young people who may leave their parental home without the
necessary skills to live independently in permanent housing (Crane et al 1996);
•
offering care and support, including support for social reintegration of excluded
groups and individuals to address social isolation, which is one of the underlying
causes of homelessness among vulnerable groups especially those with mental
health issues and people with an intellectual disability;
•
capacity building to increase independence, particularly financial stability in
Indigenous Australians in order for them to sustain a tenancy and remain in
permanent or community housing (Flatau 2005); and
•
ensuring programs and services are integrated and avoiding silos.
4.2.3
Integrated systems approach
It has been recognised that good practice in the prevention and reduction of homelessness
should incorporate services that address homelessness in all of its multidimensional
aspects, including housing, health, work, mental health issues, education, vocational skills
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and life and social skills. A key objective of the White Paper on Homelessness was to
provide a holistic, joined-up service provision model in Australia. A best practice integrated
model would incorporate both accommodation and mainstream support services across a
wide and diverse range of sectors that offer many service pathways and exit options for
different subgroups (Urbis 2009). However, more specific support services may be required
for people with high and/or complex needs.
•
People with learning disabilities experienced more problems dealing with
mainstream support services and more social support breakdowns than other people
experiencing homelessness because they may have difficulties keeping
appointments, being articulate and concentrating (Hebblethewaite et al 2007).
•
For people with mental health issues, mainstream services (including treatment
interventions) should correspond to the cilent’s stage of recovery. As discussed in
section 3.2.1, this is a central element to the CICH integrated approach of caring for
people with co-occurring disorders.
•
For older clients who are experiencing homelessness, mainstream services need to
be more flexible, accessible and creative, especially for those with enduring mental
illness (as discussed in section 3.2.2).
Cameron (2009) notes there should be an understanding that creating an integrated
systems model is complex and will require time and effort. An integrated systems model
needs to focus on three components – prevention, outreach and recovery – and has been
found to be most effective for specific subgroups that have highly diverse and specialised
needs that require an integrated, whole of systems approach with intensive case
management in order to address all the underlying and often interconnected issues. Best
practice dictates that:
•
people with high and/or complex needs;
•
Indigenous Australians; and
•
people abusing substances should receive some form of integrated service delivery,
meaning that in addition to accommodation services, they should also receive
counselling, treatment or case management for their substance use problem (Rayner
2006; Bowpitt & Harding 2008; Duffin 2007; Gillis et al 2010; Flatau 2005).
The NAHA and the associated National Partnership Agreement on Homelessness constitute
a shift in direction towards a more integrated model in homelessness policy. The NAHA
aims to develop a coordinated response to homelessness service delivery by bringing
together a range of initiatives relating to housing assistance and homelessness. It is
designed to improve flexibility in the way services are delivered, with a primary focus on
transitioning people quickly out of crisis and transitional housing into permanent housing
(Urbis 2009).
Thus, the ideal integrated model envisioned by the NAHA would have an end goal of
supporting people and building their capacity to transition from crisis and temporary
accommodation into more secure, permanent forms of accommodation (Urbis 2009). The
literature has shown that an integrated network of community service providers has the
capacity to develop service users’ educational, employment and training needs while they
are being housed. As noted earlier, client needs do not necessarily end after leaving crisis
or transitional accommodation, and furthermore, their needs are often not for housing
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alone but substantially broader and more complex, so ongoing relationships with support
services are required after clients exit into permanent housing.
The literature favoured an integrated systems approach to homelessness service delivery,
with guidelines for best practice models of support including (Johnston & Moore 2007;
Cameron 2009; Boland 2009; Lake 2005; Bond 2010):
•
a combination of prevention, early intervention, crisis intervention and long-term
support strategies aimed at facilitating independence;
•
a focus on moving vulnerable people permanently out of homelessness, rather than
services that sustain people in temporary accommodation;
•
flexible entry criteria that do not place unnecessary barriers on the homeless
person’s participation;
•
a holistic approach that is able to address the diverse range of issues experienced by
different clients;
•
use of innovative approaches to assist people who do not respond to conventional
service models;
•
integrated models of support and service collaboration that offer continuous support
which does not end when they exit crisis or transitional accommodation;
•
building client participation in planning, implementation and evaluation;
•
skilled and experienced workers with strong case management capabilities and the
ability to work and refer clients across different sectors (such as health, employment
and financial stability);
•
provision of a range of treatment services preferably that are community based and
that can be provided on an outreach basis;
•
an emphasis on building community connections and establishing independent living
and social skills in concert with seeking out employment opportunities;
•
using evidence based practice in service planning and ongoing monitoring and
evaluation; and
•
comprehensive data collection and information management systems to improve
documenting and measuring of homelessness program outcomes.
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