In clinical psychology we sometimes encounter pernicious problems when common best practices are not getting the job done. Some call them treatment resistant cases. From a cost perspective, it is these relatively rare cases that account for the majority of treatment costs for community mental health centers and hospitals. The most common mistake we clinicians make in these situations is to do more of the same of what is not working. We add assessments and treatments from our expert stance. The research, however, is clear that something different is required. The question is, of course, what is this different ingredient, when our very best professional know-how is not working? The answer is surprising but backed by decades of robust research. When your best standard of care isn’t working, shift toward the client’s model of the problem and the client’s model of change, even when the client’s model is dramatically contrary to your professional instinct and training. This boosts treatment effectiveness and provides huge savings on treatment costs.
When I learned of Oliver Apartments a couple years ago, I discovered a parallel approach being implemented to address the most pernicious cases of homelessness with the highest public cost. To learn more, I interviewed Marco Mariani, Executive Director of Heritage Foundation, who developed Oliver Apartments with a Housing First approach. Oliver Apartments have been so successful, it will be replicated near Corby Homes, as announced the Tribune this past weekend.
How different is Oliver Apartments from your other work at Heritage Foundation?
Here at Oliver we are working to house a very specific population. Our other housing development with South Bend Heritage focuses on families, single moms, seniors. It is varied. At Oliver Apartments we are focused on housing the most vulnerable in our community, those who are homeless and who have mental illness or addiction. They are frequent users of public services like hospital emergency rooms, jail, ambulance and police service. The effort to help them improve their lives is also an effort to reduce cost to society. It also enhances perception and functioning of our community in a positive way.
This is a Housing First program. Residents are given housing first, and their use of social-health services beyond that are optional. What appealed to us about Housing First at South Bend Heritage is that it seemed like a simple and good idea in that it breaks a cycle of homelessness you see sometimes in the Shelter Model. In a shelter model, people can stay for a limited time. There are barriers to entry. You often have to be sober or participate in a program. Maybe you have to participate in church service. There are times you cannot be in the shelter and you are then exposed to the negative environmental factors that may put your eligibility for shelter in jeopardy.
With Housing First, we eliminate most barriers to entry. Once you come into the community of Oliver Apartments, you have the opportunity to engage in community and service in whatever way you choose to begin to improve your life.
You mentioned reducing cost to society. How do you measure that?
We can track utilization of costly community services by those who are most vulnerable. We measure the cost at baseline and we will measure the utilization after they have housing. But it’s not about just reduction of cost. We will also look at the extent they are engaging in primary healthcare in productive and preventative ways. Are they going to AA or NA? What other aspects of their life have improved in tangible ways?
Has anybody calculated the average cost of High Utilizers of public services in South Bend?
We don’t have an average but we know what the cost is for an ER visit, for example, and we have baseline data on most residents.
Your residents have a lot of freedom of choice in whether or not they will engage in service. Why do you trust that when, presumably, they have not done well in even structured environments?
The data has shown the idea of forcing people to participate in program as a requirement of shelter stay was unproductive. The data began to show that people don’t engage and go down a particular path of recovery when it is mandated as a requirement for shelter. Housing First flips the script providing housing with voluntary engagement of service, meeting people where they are. We will provide housing first, not on a contingency. We begin with housing as a launching pad. They can know that they have a good place to stay in a community, their own private apartment. They can begin to reach toward new opportunity from there. Here you have an apartment with your own bedroom, kitchen, bathroom, and shower. It is yours for as long as you want to stay.
Housing First, Harm Reduction, and Eviction Prevention doesn’t mean it is a free-for-all. It doesn’t mean you can come in here and smoke weed and drink to your heart’s content and misbehave and be threatening to people and come back home and get some free macaroni and cheese. We have not evicted anyone yet but we have had some drug deals, threats of violence, inappropriate behavior, minor damage to apartment units, unauthorized overnight visitors. Several residents have put themselves in a situation where they risk eviction. Depending on the circumstance, we can provide 72 hours or 30 days notice regarding eviction. Each time we provide formal written notice to residents but also let them know that the Resident Selection Committee will consider their petition to prevent eviction. Eviction Prevention Plans are part of the process in a supportive housing environment as a means to help residents mediate the behavior that put them at risk of losing their housing.
This is a community. We wrap our arms around you and hopefully you open up. We will make an effort to help you. But if you make bad decisions in an environment set up to help you succeed where you have plenty of choice, we will help you re-enter another housing or shelter situation. We will not abandon you but we will evict you and help you begin again elsewhere.
You mention the community aspect. Is the community simply an artifact of living next door to each other?
We have an Oaklawn Case Management staff, property management staff, South Bend Heritage Foundation, Indiana Health Center, homeless advocates like Michiana Five and other volunteers. All these people come in here. We know where you are now. We know you are safe. We can be in relationship with you and keep some of the “wolves” away, things and people that might contribute to exploiting your trauma. It is an informal family that is beginning to form around you. You can accept that or not.
We built into the budget, splitting the cost with Oaklawn, what we call a Peer Support Specialist. They’ve found in the research that if you have a non-professional person with some lay training who has deep personal experience living on the street and has found stability, it is helpful in a way professional services fall short. We have someone hired who is going through certification now. They will not live here but they will be introduced to the community as a resource.
Also, the residents meet once a month as a resident council. They met yesterday and I think there were 15 or 17 out of 32 residents who took time to sit together for an hour and discuss community. I don’t know the specific agenda of that meeting. But Oaklawn is there. Property management staff is there. Indiana Health Center is there. I imagine there is a list of concerns and wishes they have.
How are residents selected for this opportunity? Can you walk me through the process?
There is a selection committee. We looked at frequent visits to ER and if they are homeless? We looked at their vulnerability index which is a research based index derived from interviews by outreach workers. Our threshold was 8 or 9, indicating very vulnerable. If they had a high score and a disability diagnosis, we sought them out to interview them. Some had passed away. Some we could not locate. Others were interviewed to ensure they met criteria. We brought the prospective resident here. When they gave consent, we e did a leasing process. The state has to interview them and then they get a key.
Bradley Company manages this property?
Yes, they are here Monday, Wednesday, Friday but they are also on call if something needs to be addressed. They are cross trained to understand the residents’ life circumstances. The two staff here today are handling a mess in the lobby that is atypical of other apartment complexes. Why would the management company want this? Aside from doing good for the community, they may have a business interest in reducing homelessness downtown. But they are doing this as a community partnership.
Four months into this project with residents, are you still hopeful? Are you getting discouraged?
I’m very emboldened by it and encouraged by what I’ve seen. From Bradley taking ownership of the process to how residents are beginning to engage in a new community. Oaklawn has also done a magnificent job bringing people to the building, presenting them with the opportunity to be housed, and following up with them on a regular basis. I think most residents are fully embracing their opportunity.