Voices from the Field Blog: Planning Low-Demand Housing for People Living with HIV/AIDS and Experiencing Homelessness

by Darby Penney
January 21, 2015

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Homeless and Housing Resource Network contributing writer Darby Penney describes how the Damien Center in Albany, New York is rebuilding after a devastating fire, expanding its services to include low-demand housing for people living with HIV/AIDS who are experiencing homelessness.

When the Albany (New York) Damien Center, a grassroots support program for people living with HIV/AIDS, lost its building to fire in August 2013, no one envisioned that a vital new service for its members might someday be born out of the ashes. Staff and members struggled to rebuild the sense of safety and community that the Damien Center had provided since 1990, hastily setting up temporary operations in the First Lutheran Church. For months, everyone was in shock, working to slowly replace what was lost and attempting to reconnect with members, many of whom stayed away after the fire damaged the only place where they felt safe. As a new board member, I was in shock, too, trying to provide practical help, but not yet quite clear how I could be most useful.

Months passed with no settlement from the insurance company. While extremely grateful for the church’s hospitality, Executive Director Perry Junjulas felt like the organization was in a holding pattern, unable to plan for the future. Staff, members, volunteers, and board members were traumatized by the many losses, and the strain took a toll on everyone. It was a trying time for our community.

Amidst this uncertainty, Tracy Neitzel, a visionary leader in homeless services in New York’s Capital District, began a conversation with Junjulas about the possibility of branching out to provide low-demand permanent supportive housing for people living with HIV/AIDS. Junjulas was well aware of the desperate need for stable housing among Damien Center members, about 40 percent of whom are homeless or precariously housed. However with no experience administering housing programs, initially this idea seemed like a stretch. But Neitzel, recently retired after 22 years as executive director of Joseph’s House and Shelter in Troy, New York, was persistent and encouraging. A pioneer in harm reduction and Housing First approaches to homelessness, she noted that the Damien Center’s practice of accepting members as they are, without imposing extensive rules, was in sync with low-demand housing models for people experiencing homelessness.

Junjulas, too, recognized the commonality in the approaches and became intrigued by the possibility of redefining the organization’s mission to include housing. “There is a big need for this approach to housing for our members. They struggle with lots of challenges beyond HIV/AIDS, like poverty, mental health, and substance abuse disorders,” he said. “There are other local housing programs for people with HIV/AIDS, but they impose strict rules that many of our members are incapable of meeting, because their lives are often in chaos. Many members are trauma survivors, and these kinds of rules kick up their trauma responses.”

The turning point came when Neitzel arranged for Damien Center board members to tour Hill Street Inn, a low-demand permanent supportive housing program for people unable to deal with rule-bound housing. The building—funded by state and federal money and designed by architect Owen Neitzel, Tracy’s husband—offers 18 studio apartments and two one-bedroom apartments for couples. “We believe in no rules without reasons,” Neitzel said, “and all of our rules are safety-based. People don’t need to be sober to live here; people can smoke in their own apartments, just like anyone else. We find that people often make changes in their behavior when they know it improves their chances of keeping their apartments, because having their own place is very important to them. But we don’t ask people to adhere to rules except those that ensure everyone’s safety.”

The tour opened board members’ eyes to new opportunities. Talking with tenants at the Inn, we saw first-hand the dramatic effect that having a safe place to call one’s own had on people with long histories of homelessness who had trouble with arbitrary rules. We also learned about the intersection of HIV/AIDS and homelessness. The numbers of people living with HIV/AIDS who move into Joseph’s House supported housing is disproportionally high, without any outreach or active recruitment.

As the National AIDS Housing Coalition (NAHC) points out, people experiencing homelessness have higher rates of HIV infection than the population at large, and people living with HIV/AIDS are at greater risk of homelessness than the population at large. NAHC has also demonstrated that “housing assistance is a powerful and cost-effective way to improve HIV health outcomes and prevent new infections” (National AIDS Housing Coalition, 2013).

With the board energized and committed to the new vision, plans moved fast. The insurance company settled and a new property, located close to Albany Medical Center, the regional HIV/AIDS treatment center, is under contract to be purchased. The Damien Center proposes to build a new center there, designed by architect Owen Neitzel, which will include its agency headquarters and program space, as well as 20 units of low-demand permanent supportive housing to serve 22 people living with HIV/AIDS.

New York State’s Homeless Housing and Assistance Program (HHAP) has funds available for capital construction costs. Tracy Neitzel helped the Damien Center prepare and submit a HHAP grant in the fall of 2014; a decision on this grant is expected soon. Beyond capital costs, the major concern is how operating costs will be sustained. The Damien Center will have access to some housing subsidies for eligible people, which recently became available after other local programs closed. Without such subsidies, the monthly rent would not be affordable for people who rely on disability benefits.

Meanwhile, Junjulas has cultivated relationships with neighbors, civic groups, and politicians to educate them about the need for and benefits of the proposed housing project. These efforts have been successful in building strong community backing, including the support of the neighborhood association and Common Council members. The zoning board approved the project, and groundbreaking is anticipated in the spring of 2015. When the program opens, hopefully in spring 2016, it will be the only Housing First model available in Albany for people living with HIV/AIDS.  

National AIDS Housing Coalition (2013). Housing is HIV Prevention & Care (fact sheet). Available at http://nationalaidshousing.org/PDF/FactSheet.pdf

More information about the Albany Damien Center is available at http://www.albanydamiencenter.org/

More information about Joseph’s House and Shelter is available at http://www.josephshousetroy.org/

Interested in being an HRC Guest Blogger? Email us at HomelessPrograms@samhsa.hhs.gov.

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Category: General | Guest Entry

Voices From the Field Blog: Alcohol Management: Reducing seizures, falls, and brain injury among alcohol dependent people

by Livia Davis
March 25, 2014

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Homeless and Housing Resource contributing writer Livia Davis details the work of Downtown Emergency Service Center (DESC) in Seattle, Washington in implementing Alcohol Management as a harm reduction strategy and the need for research to determine if Alcohol Management results in better health outcomes, improved safety, and less victimization.

To limit potentially life-threatening effects of alcohol withdrawal, including seizures, hallucinations, falls resulting in head trauma or broken bones, and victimization due to acute intoxication, Downtown Emergency Service Center (DESC) in Seattle, Washington decided to implement Alcohol Management as a harm reduction strategy for eligible residents in their 1811 Eastlake supportive housing facility that serves “formally homeless men and women with chronic alcohol addiction.” Alcohol Management is offered to residents who are at risk of harm during periods of alcohol withdrawal or other dangerous behavior associated with their alcohol use. Not without controversy in the local community, DESC is committed to improving the quality of life for program participants, increasing their housing stability, and reducing the harm of alcohol withdrawal. Currently, about 16 out of 75 residents at 1811 participate in Alcohol Management indicating it's not an intervention best suited for everybody. At the Housing First Partners Conference in Chicago held on March 13, 2014, DESC explained how Alcohol Management works.

Using Motivational Interviewing, staff members first approach potential program candidates to facilitate the completion of a client’s alcohol intake goals. Questions are asked to develop an agreement for each participant, including: Do you drink more in the morning to stave off withdrawals? How many drinks do you need to avoid feeling sick? How long between drinks do you begin to go into withdrawal? What is your goal? Do you want to cut back? Based on responses, an individual alcohol management plan is developed and signed by the participant and DESC.

The plan details the dosage of alcohol to be administered by staff at certain intervals. For example, the plan may detail 2 beers at 8 a.m., 12 noon, 4 p.m., and 8 p.m. every day. At the agreed-upon times, the Alcohol Management participant then proceeds to the staff desk and is given the agreed-upon amount of beer.

To implement Alcohol Management, a number of processes and infrastructure and training need to be developed or be in place. Clients need to have a steady income source and a payee. Program funds are not used to purchase alcohol, and both the participant and their payee agree to provide needed funds according to the alcohol-purchasing schedule. Purchasing, storing, and dispensing alcohol dosages also require a number of processes and safeguards that 1811 Eastlake has developed over the last seven years, including locked cabinets, training of staff, and dosage tracking charts.

DESC collects anecdotal data on outcomes from the Alcohol Management program and reports the following:

  1. Increases stability: The chaos of binging and withdrawing occurs less often and provides participants with a sense of stability and control they have not experienced in a long time. This increased stability is often associated with the development of new goals, including changing long standing drinking patterns;
  2. Allows for intervention in case of alcohol withdrawal: With dosage tracking documentation sheets (e.g., if a participant misses his/her dosage for 24 hours) staff will go and check to be sure that the person is not experiencing harmful effects due to withdrawal;
  3. Fosters engagement: Regular conversations can be maintained that increase awareness and stimulate articulation of goals, and allows for engagement around alcohol use to be a centerpiece of ongoing treatment planning;
  4. Slows health decline: Alcohol management is not a magic bullet but getting less intoxicated means more engagement with health providers to address chronic and acute health need;
  5. Likelihood of a decrease in alcohol use over time for some participants. While often not the inital goal, a number of residents participating in alcohol management have cut back or even stopped drinking altogether; and 
  6. Risk of loss of independence: Some participants get dependent on staff through structured alcohol dosage, and DESC recognizes that loss of independence is not necessarily a positive outcome, although has seen the same participants rediscover abilities to better integrate with community members or service providers through the stability afforded by participating in alcohol management.

DESC staff discussed the need for research to determine if Alcohol Management results in better health outcomes such as improved safety (e.g., fewer falls and reduction of instances of brain injury) and less victimization.

For additional information, please click on www.DESC.org or contact
Noah Fay at NFay@DESC.org or Hector Herrera at HHerrera@DESC.org.
Sources for this article include: www.DESC.org and the Housing First Partnership Conference workshop on March 13, 2014: Alcohol Management: A Practical Harm Reduction Intervention conducted by Noah Fay and Hector Herrera from DESC.

Interested in being a HRC Guest Blogger? E-mail us at generalinquiry@center4si.com.

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Nashville Changes Strategy to End Homelessness

by Steven Samra
August 06, 2013

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In 2005 Nashville joined many other cities in the development and implementation of a 10-year plan to end homelessness. Unfortunately, despite the best intentions, Nashville has, like many American cities, struggled to accomplish the goal. A cadre of obstacles and barriers, including, but certainly not limited to scarce resources, reliance on “readiness” as a precursor to obtaining housing, a closed Homeless Management Information System, lack of affordable units and housing vouchers, all contributed to the challenge of procuring housing.  A lack of coordination among area behavioral health providers exacerbated these challenges, and frustration and hopelessness were increasing within the homeless community with each passing year.  

Thanks to the efforts of a new Executive Director at the Nashville Metropolitan Homelessness Commission and a committed team of Commissioners, partners, and volunteers, a partnership with the 100,000 Homes Campaign, and a collaboration of several local providers and faith-based organizations, the situation appears to be changing for the better.  

On May 29-31, 2013, twenty teams comprised of over 100 community volunteers canvassed the streets and campsites of Nashville, Tennessee, using the Vulnerability Index to survey and create a priority list of individuals experiencing street homelessness who are most at risk of premature death if they remain homeless. The Vulnerability Index, created by Dr. Jim O’Connell, President of the Boston Healthcare for the Homeless program, identifies those who have been homeless the longest and are the most vulnerable. In addition to gathering the names, pictures, and dates of birth of individuals sleeping on the streets, the teams also captured data on their health status, institutional history (jail, prison, hospital, and military), length of homelessness, patterns of shelter use, and their previous housing histories.

A heavily attended community meeting was held on June 4, 2013, to discuss the results of the survey and kick off the start of a new campaign, “How’s Nashville”. The immediate goal of the campaign is to house 200 of the most vulnerable and chronically homeless into housing within 100 days. Once this is completed, How’s Nashville will continue the effort to house the city’s most vulnerable members with the ultimate goal of ending homelessness within the city by 2015.  Although using a Housing First approach is often more cost effective than alternate methods, and certainly more so than managing homelessness on the street, there are still costs associated with providing housing to those experiencing homelessness.  

Community members rose to the financial challenge associated with the campaign, donating $36,000 during the June meeting to help defray move-in costs associated with the transition from street to home.  Outreach workers began immediately moving individuals identified as high priority into housing at the end of the meeting, and invited attendees to walk with them to a welcome home celebration. Through the city’s efforts, one individual was identified as “most vulnerable” and was moved into housing after more than 7 years of life on the street.

The campaign is off to a strong start with 43 people successfully housed and supported during the month of June.  Conversely, from January to May 2013, just 19 people experiencing homelessness were placed into housing.  uly is also off to a solid start and should meet or exceed the minimum number of placements needed to meet the final housing goal of 200 people housed within 100 days.  

Nashville’s homeless population may finally have reason for optimism instead of pessimism.  There will continue to be challenges associated with scarce resources and the city’s approach is far from perfect.  Clearly however, Nashville has turned a corner and embraced a new approach that is proven to dramatically reduce homelessness.  With the momentum of the How’s Nashville campaign firmly pushing the effort forward, for the first time in many years, Nashville is housing those experiencing homelessness in a systematic, logical, and coordinated manner. The future appears brighter for the city’s most vulnerable residents than it has been for a very long time.

Interested in being a HRC Guest Blogger? Email us at generalinquiry@center4si.com.

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One Size Does Not Fit All: Lessons Learned in Baltimore, MD

by Laura Winn
July 06, 2011

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A couple weeks ago I attended a SAMHSA workgroup meeting for programs offering sober housing and treatment options for women experiencing homelessness. The workgroup began as a technical assistance (TA) request from Lori Criss of Amethyst Programs, a program in Columbus, Ohio. Amethyst offers integrated sober housing and treatment to women experiencing homelessness and substance use issues. Amethyst staff have sometimes felt isolated because this integrated approach is a unique model in their community. Lori knew that there was interest among other programs across the country, and was seeking an opportunity to begin this dialogue on a national level.

In response, SAMHSA’s Homelessness Resource Center helped to convene a workgroup of similar programs, along with SAMHSA’s Women, Children, and Families TA Center. With such a strong national focus on Housing First, sober living models often struggle to find their place. Programs find themselves straddling a divide between housing and addictions treatment. Some identify primarily as housing providers, some as treatment providers, and others as both, adding to the difficulty of seeking funding in various continuums of care. However, sober housing can be a tremendously beneficial model for women with children, trauma histories, and safety concerns.

Based on the clear desire of workgroup members to connect in person and further define key elements of this integrated model, SAMHSA convened a meeting in Baltimore, MD. Sixteen representatives of sober housing and treatment programs for women attended. The group shared their program designs, discussed what works (and what doesn’t), and explored commonalities, challenges, and promising strategies.

Having worked in this field for a year and half, it has become clear that there are no one-size-fits-all models for individuals experiencing homelessness, substance use disorders, or mental health issues. However, I’ve never seen this so clearly illustrated as I did at the workgroup meeting. Not only were providers recognizing a need for alternatives to Housing First for some individuals and families, but they were also highlighting differences among their own gender-specific sober housing models. For some women, being allowed to live with their children and within a community is an important step toward recovery. This demanded more restrictive relapse policies, in recognition of the safety and recovery of children and other families. For others, living independently, becoming economically stable, and thriving in healthy relationships is central to success.

Programs differed on drug testing policies, services for fathers and children, relapse policies, and approaches to treatment. However, it was clear that these programs were each finding success with their participants. I spend a lot of my time trying to understand what works in homeless services. Through the process, I sometimes forget that there are many paths to success. Flexibility to respond to the needs of consumers is essential.

I was inspired by the providers I met in Baltimore. They were committed to finding the best individualized options for women. These providers, many of whom were in recovery themselves, exemplified that fact that one-size-fits-all is not always possible – or necessary – when working with individuals and families.

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Category: HRC Insight | HRC Insight

Ed Blackburn: What Gives Me Hope

by Wendy Grace Evans
May 16, 2011

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Ed Blackburn is the Executive Director of Central City Concern in Portland, Oregon, a SAMHSA grantee that provides pathways to self-sufficiency through active intervention in poverty and homelessness. In a conversation with HRC Writer, Wendy Grace Evans, Ed talks about what inspires hope in his daily work.

What gives me hope is when I see a family that has been reunited. This is a very practical kind of hope. The children are happy because they are with their parents who have overcome substance use and trauma. To see that kind of happiness certainly motivates me.

I am also amazed to see a person who has experienced homelessness for a long time move into housing and find a sustainable job, or to see a person who has been disabled come back to health. I have the opportunity to see the communities that people build together as active citizens, attending city meetings, and that is my constant source of hope. Hope is a powerful response, and the experience of transformation is a powerful antidote to some of the political negativity that can surround the struggle to get funding support for safety net services and housing, as the news isn’t always good on that front.

When you can continue to see hope in humans, it helps to sustain our work. Angela is a single mother who had been living on the streets for years. She lost her baby to foster care, but once she was able to get into Central City Concern’s Hooper Detox Center, she was able to be reunited with her child. She joined our program for families in recovery, is now working, and has gone back to school. I had the privilege of hearing her story and meeting her. I will never forget her story. It was inspiring and a clear reminder of why we are doing what we are doing.

There was also a young man I knew who was heavily involved in street drug dealing. He had been in and out of the criminal justice system. After a couple of times, he entered into our Recovery Mentor Program. Three mentors run the program and mentor others. He has done very well and is now involved in our community volunteer corps to help people who are recovering from substance use. We have teams in the community working on projects for eighty dollars a month for a few hours a week to improve senior centers, parks, recycling centers, and to work with Habitat for Humanity and other small non-profits. Eighty-two percent of participants complete the program. They also work with Supported Employment and serve as inspiring examples to others.

The endless creativity that people have to solve serious problems, to heal people in the community, and to lead the way towards successful solutions demonstrates a limitless spirit. It is great to be a part of something so all encompassing. At Central City Concern we have approximately 650 employees. Fifty percent of our employees are in recovery from substance use and homelessness. I have the gift of participating in an organization that has the highest sense of commitment to its mission.

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Category: HRC Insight