Housing first programs using a harm reduction approach to services have been shown to be successful in housing chronically homeless adults. Much less is known about their success in connecting residents with healthcare and other services nor strategies for engaging residents who are reluctant to engage in these services. This paper presents findings from a qualitative study of a housing first permanent supportive housing (PSH) program. The program uses an interdisciplinary support team with case management, integrated healthcare, and mental health clinicians to extend the benefits of housing first beyond housing. Program participants have the highest service needs based on SPDAT (Service Prioritization Decision Assistance Tool) scores and the experience of chronic homelessness. This study sought to understand the impact of this intervention from both resident and program staff perspectives. Our goal was also to identify and highlight strategies to increase access to health and human services within a housing first program using a harm reduction model.
Semi-structured interviews were conducted with 27 PSH residents and 18 program staff. Convenience, snowball, and purposive sampling led to the selection of participants. Participants ranged in age from 20-65 years and had lived in PSH from one month to five years. The program staff sample included case managers, a nurse, behavioral health clinicians, supervisors, and administrators. Interviews followed an interview guide that addressed issues such as experiences in PSH, client engagement, impact of relationship with staff on access to services, use of healthcare and other services, and perceptions in changes of quality of life. Data in the form of field notes and audio recordings from interviews were analyzed using qualitative data analysis software (NVivo 11) through a hybrid deductive and inductive thematic analysis approach.
This research identifies patterns of client engagement with medical and human services professionals, as well as strategies used by the PSH program staff to identify barriers to service usage, overcome housing threats, and improve connections to needed healthcare and behavioral health services. The enhanced team’s collaborative process as well as interdisciplinary staff specialization in this model were able to create a “bridge” to healthcare services for reluctant clients as they overcome barriers such as mental health problems, substance abuse issues, and medical and mental health care trauma.
Conclusions and Implications:
Key relationship building strategies were used by program staff to increase clients’ willingness to engage in healthcare and behavioral health care services. The themes identified in this study indicate the importance of the relationship building and bridging processes used in connecting PSH residents to community services. This study highlights the need for programs to use relationship-building strategies within a harm reduction framework for improving access and receptiveness to services. Housing first as a policy works to get people in housing, but relationships are what matter in connecting reluctant residents to needed services. Results indicate the need for future research with PSH residents who remain unwilling to engage in services.