Almas, Inês

Duarte, Teresa

English

Repositório do ISPA

Homelessness as unfairness 113Chapter IXCasas Primeiro Program: Ten years of Housing First in PortugalTeresa Duarte1 & Inês Almas11 AEIPS – Associação para o Estudo e Integração Psicossocial, Av. António José de Almeida, 26, 1000-043 Lisboa,  Portugal, teresa.duarte@aeips.ptAbstractCasas Primeiro is a Housing First program that offers immediate access to independent and permanent with mental illness living on the streets. The program was implemented in 2009, in the city of Lisboa, as In this chapter we provide an overview of the program implementation and subsequent developments particularly regarding housing retention and wellness. Finally, we appraise the subsequent developments related with the program dissemination and scaling up, and its policy impacts at the city and national levels.KeywordsHousing First, Homelessness, Mental Illness, Public PolicesIntroductionimplemented by AEIPS-Association for the Study and Psychosocial Integration, in collaboration with support services to promote recovery and community integration of people with mental illness, including supported employment and education programs, mutual-help groups and advocacy. The collaboration established from the earliest years with ISPA-University Institute has been essential to link intervention with evaluation and research, and to enhance the organization’s capacity to be more effective and innovation-driven.114 Homelessness as unfairnessIntegration of Homeless People (ENIPSA) was being designed. In this context, the Social Security Institute, the government body responsible for drafting the Strategy, met with various organizations to collect their input and comments. At that time, Portuguese homelessness responses were largely emergency based, including shelter accommodations, social canteens, public baths, food distribution vans, and outreach street teams. Policymakers recognized the limitations of these approaches and sought more effective solutions. AEIPS and ISPA-University Institute took advantage of this window of political opportunity to present a Housing First project, which was welcomed by policymakers (Ornelas & Duarte, 2018). The Casas Primeiro project was designed as a two-year pilot experiment to test and evaluate the innovative Housing First methodology in the national context. In March 2009, the project was announced at the the implementation of the Casas Primeiro project was signed by AEIPS (the project operator), the Social Security Institute, IP (the funding entity), ISPA-University Institute (the project evaluator) and the two consultants, Sam Tsemberis and Marybeth Shinn. The project was implemented in Lisboa and addressed long-term homeless people with mental illness, often with alcohol or drug use, who were more likely to be excluded from other services that require participation in treatment as a condition.Description of Casas Primeiro programThe Casas Primeiro program offers access to independent and permanent housing combined with the approaches because of its emphasis on rapidly housing long term homeless people without requiring psychiatric treatment compliance or sobriety as preconditions. Housing is provided up front, rather than last, as it is considered a requisite to address appropriately health, social or other issues and needs people may have. Moreover, housing is not transitory as people can remain as long as they need.homeless for over 6 years, and 7% for more than 16 years (Ornelas, Duarte, Almas, & Madeira, 2011). The collaboration with the city outreach teams facilitated the initial contacts between the project team and future tenants. In the initial encounters, the team presented the program and invited them to visit one of the available apartments, explaining that if they like it they can move in immediately, or they can stay there while looking for an apartment that met their preferences. The apartments are independent, ranging from studios to one-bedroom units. Tenants can decide if they want to live on their own or share their home with someone of their choice. Apartments are not congregated in the same building or street but are spread over 20 residential neighborhoods of Lisboa, trying to match the tenants’ choice as much as possible. All apartments are furnished and equipped with appliances and essential household items.The apartments are rented from the private housing market, which offers a wider choice to tenants and more integrated living environments. Research has shown that scatter-site apartments, blended into integrated neighborhoods facilitates tenants’ community integration (Barnes, 2012; Ornelas, Martins, Zilhão, & Duarte, 2014; Yanos et al., 2007). In Lisboa, social housing tends to be concentrated in socially Homelessness as unfairness 115isolated areas on city limits, and presented huge waiting lists. Therefore, private rental market ensures that people may move more easily and quickly into housing, and provides access to apartments with better quality. The lease agreements are signed by AEIPS and the landlords, which facilitates the accommodation of homeless people who are undocumented or don´t have any source of income. Having AEIPS as the leaseholder also facilitates the negotiation with landlords, because the organization ensures timely rental payments, good maintenance of the apartments and support to tenants. To all landlords is provided the team’s cell phone number that is available 24/7 and communicated that the team will respond to any issue that might arise. The program team is composed by professionals from social and human sciences. One of its members has a lived experience of homelessness. The staff – tenant ratio is 1 to 10. An agreement is signed between the program team and the tenants, setting the commitment of both parties. Tenants’ commitment includes receiving a weekly visit from the program team, to pay 30% of his/her income towards rent, and to abide support, according to tenants’ needs and preferences and for as long as they need and want. Support services are provided in tenants’ apartments (at least 1 weekly home visit, previously scheduled) and in the community contexts. Support is also available on call 24/7, as tenants can contact a team member who, on a rotation basis, ensures the support on nights and weekends.The team uses an ecological and collaborative approach to intervention, focused on housing stability, recovery and community integration. At the housing level, the team assists tenants to manage their apartments, daily routine tasks such as cooking, cleaning, laundering, personal care, money management, shopping, decoration, and with neighbors’ relationships. A recovery approach requires that staff and tenants work collaboratively. Recovery is a process of regaining personal strengths and control over one’s own life, involving engagement in meaningful activities and community participation (Ornelas, Duarte, & Jorge-Monteiro, 2014; Tondora, Miller, Slade, & Davidson, 2014). The team assists tenants to identify their goals, get relevant information, evaluate different options, and provides opportunities for people to make their choices and decisions about the services and activities they consider more suitable for them. This includes the development of personal strategies to increase and maintain physical and mental health. Community integration involves the access to community resources and activities in the same way as other citizens (Ornelas, Martins et al., 2014; Salzer & Baron, 2014). Support is provided in the process of social and health services. The team brokers’ access to services that tenants identify as needed, and accompanies them to those meetings and appointments when necessary. The team also assists tenants Biweekly group meetings are held with tenants and team members to discuss issues of general interest and to regularly review the activities carried out. These meetings also provide moments of camaraderie and peer support, which play an important role in the recovery process, and in community living. 116 Homelessness as unfairnessThe team meets weekly to take stock of the work done the previous week and to plan activities for the following week. Team members also participate in the weekly sessions of the AEIPS’ Ongoing Training Program which is open to all service professionals and users. Since Housing First activities are challenging, ongoing training is essential for staff to build advance expertise, and enhance capabilities over time. Program ResultsThe evaluation outcomes of Casas Primeiro program are similar to those described in the international literature. Over the years, the program has demonstrated a high housing retention rate (% of tenants that even people who have been homeless for many years, often referred to as “chronic”, can move directly from the street to permanent and independent housing.Having access to an apartment of their own was the major factor that led tenants to join the project. Tenants reported that previously they only had used night shelters occasionally because of lack of privacy, health risks and the feeling of insecurity experienced in those contexts (Ornelas et al., 2011). suggest that people remained on the streets for many years because the accommodation facilities that had been offered to them were not adjusted to their needs.The program also has positive effects in tenants’ quality of life (Ornelas et al., 2011). Tenants reported that having a home increased their personal safety and afforded them to eat healthier meals, to rest more and sleep better, to maintain personal hygiene habits, and to obtain a regular monthly income.The program also facilitated tenants' access to health services in their residential areas which contributed in their physical and mental health. Compared with the previous year where they lived on the street, the use of emergency services (line 112) and psychiatric hospitalizations, decreased by 90% (Ornelas et al., 2011).Access to independent and scattered site housing is also associated with better community integration outcomes (Ornelas, Martins et al., 2014). Tenants reported that since they have been living in their own homes, they have started to carry out various activities in their neighborhoods, have met other people and established new social relations with their neighbors or with other members of the community. Some have resumed contact and relationships with their families. Housing stability has also increased tenants’ range of opportunities to get a job, go back to school or pursuing other projects that were tenants have been involved in school, vocational training or employment activities in the last twelve months (AEIPS, 2018).(AEIPS, 2018). Noteworthy is the satisfaction of tenants with the privacy, security and comfort provided by the house and the ways the team helps them to solve problems and access to community resources. Homelessness as unfairness 117Overall, tenants reported having more hope and better stability to reorganize their lives.Under the 2010 European Year for Combating Poverty and Social Exclusion, Casas Primeiro program was selected by the European Commission as an example of innovation and good practice in social investment. A short video was produced and released at the European level. Another important public recognition was the Calouste Gulbenkian Foundation Prize, a major national award for social innovation received in 2011. In 2019 the project was also selected as a Good Practice in Mental Health & Well Being by the European Commission.Program sustainability and public policesThe incorporation of research into the Casas Primeiro program made it possible to document the effectiveness of the intervention and the social return on public investment. Collaboration with ISPA-University Institute was essential to ensure a credible evaluation process, to undertake new studies project (2011-2013) and more recently in the Home_EU project (2017-2019), which have provided additional evidence of model effectiveness. Evaluation reports were used to communicate the program's positive outcomes and to negotiate with the City Council the funding support for maintaining the intervention beyond the pilot phase.AEIPS has widely disseminated the Housing First model throughout the country. The lectures given at model, describe the program, communicate its results, and disseminate the tenants' personal recovery from other organizations, members of government agencies, and even by the President of the Republic. The interest expressed by other organizations and municipalities was an opportunity to broaden the Housing First intervention in the national context. AEIPS recognizes that program scaling-up, either through program expansion or replication, will generate impacts on a larger scale that could leverage more political support for the intervention. In 2012, AEIPS started a new project in the village of Cascais with the support of the local Municipality. In the following years, AEIPS has also provided technical consultation to the implementation of two other Housing First projects: one in Lisbon (Crescer) and other in Braga (Portuguese Red Cross). All of these experiences led to the establishment of the Housing First National Network, with social organizations and city councils from different cities throughout the country that are implementing or intend to implement projects in their territories. This network has been holding regular meetings to share information, collaborate in projects planning, and delineate strategies to make the case and negotiate with policymakers at local and national levels. International contacts have also contributed to the Housing First Conference which brought together professionals, researchers, academics, policymakers and HF tenants from different European countries, Canada and the United States. The presentation of Housing First experiences, carried out in different communities but with similar results, contributed to 118 Homelessness as unfairnessreinforce the validity of the approach in addressing homelessness.The sustainability and generalization of Housing First approach depends on favorable public policies. With this purpose, AEIPS has participated in local and national committees and policy working groups. The Lisbon City Council has been taking a leadership role. Under the city Plan for Homeless People of Housing First projects. Moreover, this funding stream incorporated HF principles as application requisites, particularly concerning housing structure, only funding rental of individualized and scattered apartments, and to support services that focus on wellness and community participation.the major axe of intervention. The Plan intends to provide all 361 homeless people living on the streets with a housing solution.  To accomplish this goal the Plan will invest in a larger number of HF apartments from the current 82 to 400 till 2021. As Lisboa is the major city in the country we believe that this Plan will have a spillover effect on other Portuguese cities.At a national level, the second National Strategy for the Integration of Homeless People (2017-2023) projects mainly projects using a Housing First approach.Combining intervention with research we were able to sustain the initial project and to scale up the approach as the main response to end homeleness in Portugal.ReferencesAEIPS (2018). Relatório de execução do projeto Casas Primeiro: Housing First para pessoas sem-abrigo com problemas de saúde mental.Barnes, S. (2012). Review of trends, policies, practices and implications of scattered site housing. Toronto: Wellesley Institute.Ornelas, J., & Duarte, T. (2018). Housing First au Portugal: Un exemple de changement social. Vie Sociale. Ornelas, J., Duarte, T., Almas. I, & Madeira, T. (2011). Relatório dos dois anos de implementação do projecto Casas Primeiro, na cidade de Lisboa. Lisboa: AEIPS.Ornelas, J., Duarte, T., & Jorge-Monteiro, F. (2014). Transformative organizational change in community mental health. In G. Nelson, B. Kloos, & J. Ornelas (Eds), Community psychology and community Press.Homelessness as unfairness 119 Ornelas, J., Martins, P., Zilhão, M.T., & Duarte, T. (2014). Housing First: An ecological approach to promoting Salzer, M., & Baron, R. (2014). Who is John? Community integration as a paradigm for transformative change in community mental health. In G. Nelson, B. Kloos, & J. Ornelas (Eds), Community psychology and community mental health: Towards a transformative change (pp. 228-249). New York: Oxford University Press.Tondora, J., Miller, R., Slade, M., & Davidson, L. (2014). Partnering for recovery in mental health: A practical guide to person-centered planning. Oxford, UK: Wiley Blackwell.Yanos, P., Felton, B., Tsemberis, S., & Frye, V. (2007). Exploring the role of housing type, neighborhood characteristics, and lifestyle factors in the community integration of formerly homeless persons diagnosed with mental illness. Journal of Mental Health, 16 (6), 703-717.

Casas Primeiro Program: Ten years of Housing First in Portugal

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Casas Primeiro Program: Ten years of Housing First in Portugal

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