Yale researcher Jack Tsai, Ph.D., and his colleagues helped prove that a Housing First strategy can be an effective path to housing for people with substance use disorders. Now, he and his colleagues are shifting their focus to what comes next: how to help people with substance use disorders once they have housing.
A recent study on alcohol and drug use disorders among homeless veterans by Dr. Tsai and his colleagues looked at the housing outcomes of about 30,000 veterans entering the Department of Housing and Urban Development-Veterans Affairs Supported Housing program (HUD-VASH). More than half of the participants had substance use disorders. These people had more extensive histories of homelessness or more recent stays in transitional housing or treatment facilities, yet the study found no difference in housing outcomes among participants with or without substance use disorders after six months in the program. The results were consistent with results from other studies that show Housing First is an effective way to get people with substance use disorders into housing.
“Housing First is great because it helps with housing, but what comes second?” said Dr. Tsai, who has dual appointments at the Yale School of Medicine and the Department of Veterans Affairs (VA) Connecticut Healthcare System.
Once housed, people who entered from the HUD-VASH program with a history of substance use disorders continued to report issues with substance use. Dr. Tsai and his colleagues performed another study titled, Does Active Substance Use at Housing Entry Impair Outcomes in Supported Housing for Chronically Homeless Persons? In this study, comparing users with nonusers found that residents who use substances continued to use and have poorer mental health than nonusers in Housing First programs. But the substance use conditions did not worsen. Dr. Tsai explained that this finding raises questions about when and how to incorporate treatment into these programs. He noted some clinicians report the need for interventions to reduce social isolation or help people reintegrate into their communities.
“Clinicians tell us a lot of clients [in these programs] are really lonely,” Dr. Tsai explained. “When they are lonely and have a history of substance use disorders, they start to use substances.”
Case Manager Involvement Is Critical
Often, case managers play a key role in trying to help participants rebuild their lives. Having a case manager to work with participants is a core component of Housing First programs, Dr. Tsai explained. There are different approaches to case management. Many programs that have been studied involve case managers handling residents’ rent payments, which may boost housing success. He noted that some clinicians worry about the lack of treatment requirements in the programs and whether participants are learning what they need to become independent.
“There are a lot of independent living skills besides housing,” Dr. Tsai said.
But the best ways to impart those necessary skills are not yet clear. The VA is considering tailoring case management to the needs of the residents of its programs, according to Dr. Tsai.
“Tailoring case management to the needs of the client would be appropriate,” Dr. Tsai said. “But no one has come up with a formula for that yet.”
One way to help participants in Housing First programs may be to supplement one-on-one case management with group case management. Dr. Tsai and his colleagues are testing such a model at the VA. The groups work together on issues like getting housing vouchers, staying sober, and other steps to reintegration. The program helped combat social isolation among participants, according to Dr. Tsai.
“It worked out great for some folks,” Dr. Tsai said. “People were helping each other move and talking about ways to avoid triggers for substance use.”
Housing First Model Not a One-Size Solution
The Housing First model may not be a “one-size-fits-all” solution for all types of substance use. Two studies, one study on substance use and housing stability and another study on stimulant use and housing outcomes, have shown that people who use cocaine do not fare as well in housing as those who drink excessive amounts of alcohol. Many people who use stimulants end up losing housing, the studies found.
“Not all substance use disorders are the same,” Dr. Tsai explained. “Housing first may be more effective for people who use certain substances.”
To make Housing First programs as effective as possible, Dr. Tsai recommended that service providers include the services designed to keep participants housed and help them successfully reintegrate.
“We know Housing First isn’t the be-all, end-all,” he said. “A lot of times, other services are needed to help them maintain housing over time.”
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