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Policy Innovation Profile

Removing Restrictions and Barriers to Supportive Housing for Late-Stage Alcoholics Reduces Alcohol Abuse, Alcohol-Related Symptoms, and Costs


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Snapshot

Summary

By departing from standard policies employed by most supportive housing programs, Downtown Emergency Services Center provides permanent housing to late-stage, active alcoholics who frequently use health care and crisis response systems. Known as 1811 Eastlake (the address of the facility), this "housing-first" program differs from traditional housing projects for the homeless in several ways. Rather than requiring residents to participate in addiction treatment programs or to abstain from alcohol use, Downtown Emergency Services Center's policy uses a harm-reduction, noncoercive approach that allows residents to choose if and how they work towards recovery. Staff employ motivational interviewing techniques and offer (but do not require participation in) onsite health care, social support, and case management services. Although Downtown Emergency Services Center uses the same harm reduction approach at all its housing facilities, priority placement in apartments at 1811 Eastlake goes to late-stage alcoholics who are the highest users of county crisis services. The program has been well accepted by the target population and has reduced alcohol abuse, related symptoms, and crisis service costs (including emergency health care services), yielding significant savings for the county.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of self-reported drinking habits and alcohol-related symptoms among participants, along with a comparison of crisis service costs among participants to a group of similar individuals on the program's wait list.
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Developing Organizations

Downtown Emergency Services Center (DESC)
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Use By Other Organizations

Homeless advocacy organizations in several cities in the United States use a housing-first approach modeled after this program. An annual conference now brings together those using and/or interested in this model from across the nation; the first such meeting took place in New Orleans in March 2012.

Date First Implemented

2005
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Patient Population

Vulnerable Populations > Homeless; Substance abusersend pp

Problem Addressed

Many housing programs will not offer permanent housing until a homeless individual proves he or she is "ready" for it. Prospective residents must stop using drugs or alcohol and enroll in treatment before being allowed to move into an apartment. This approach leaves many vulnerable individuals (especially late-stage alcoholics) living in temporary housing or on the streets and can prolong homelessness. The combined effects of years of housing instability and substance abuse often lead to multiple chronic conditions, low quality of life, premature death, and high costs.

  • Many ineligible for permanent housing: Most permanent housing programs prohibit use of alcohol and require prospective residents to be sober before allowing them to move in to permanent housing. These policies effectively eliminate permanent housing options for active homeless alcoholics. Even those who would like to quit drinking have difficulty doing so while homeless; the stresses of their unstable living situation and the pervasiveness of alcohol and drug use in areas where the homeless congregate pose challenges to sticking with treatment. Late-stage alcoholics have especially poor prognoses for success in traditional treatment programs. (The average number of treatment attempts among the original 1811 Eastlake residents was 16.)
  • Long-term homelessness and alcoholism leads to major medical problems, premature death, and high costs: Individuals who are homeless and abuse alcohol for long periods of time face increased risk of major medical problems and premature death, and tend to be heavy users of high-cost health care and crisis response systems, as outlined below:
    • Major health problems, including premature death: The long-term medical consequences of alcohol abuse include neurological, cardiovascular, psychiatric, and gastrointestinal problems.1 Homeless individuals who abuse alcohol face a dramatically higher risk of mortality—six times that of the typical homeless person, who already has higher mortality than people who are not homeless. In their last years, these individuals often suffer from conditions that greatly diminish quality of life, including cirrhosis of the liver, diabetes, seizure disorders, and other ailments. They typically die very young (in their 40s or 50s), with 30 to 70 percent of deaths being directly attributable to alcohol abuse.2
    • High use of costly health care and crisis response systems: Without access to ongoing medical care, late-stage alcoholics without permanent housing generally use high-cost acute care services rather than primary care. They also tax local crisis response systems; even in areas where public drunkenness is not considered a crime, late-stage alcoholics often face arrest and serve jail time for other offenses. In Seattle, 75 homeless, late-stage alcoholics cost the public more than $8 million a year, roughly 5 to 6 times the cost of homeless individuals able to access steady housing.2

    What They Did

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    Description of the Innovative Activity

    By departing from standard policies employed by most supportive housing programs, Downtown Emergency Services Center (DESC) provides permanent, low-cost housing to late-stage active alcoholics who frequently use health care and crisis response systems. This "housing-first" program differs from traditional ones in several ways. It makes available but does not require residents to enroll in drug/alcohol treatment programs, allows residents to use alcohol on the premises, and makes available (but again does not require participation in) onsite health care, social support, and case management services. Key policy elements are outlined below:
    • Noncoercive, harm reduction approach to treatment and support: Unlike traditional programs that force residents to enroll in treatment programs, 1811 Eastlake seeks to reduce the effects of long-term alcohol toxicity by providing stable housing, engaging residents in the community, and making available (but not mandating enrollment in) drug and alcohol treatment and case management services. For example, instead of insisting that residents abstain from alcohol use, staff work with residents to reduce alcohol consumption or to switch to a less potent alcoholic beverage (i.e., whiskey to wine or beer).
    • Supportive services offered but not required: Staff use motivational interviewing techniques to help activate each resident's capability and desire for change. The program offers the following services on a completely voluntary basis:
      • Onsite social support: The facility provides a supportive community that seeks to draw residents out and engage them in the life of the building, thus reducing stress and the associated need to turn to alcohol. Staff and residents set up onsite support groups based on their interests or backgrounds, with most residents participating in one or more groups.
      • Drug and alcohol treatment: While not required to participate, residents can take advantage of onsite programs through DESC, a licensed drug and alcohol treatment agency. They can also enroll in offsite programs sponsored by the county or by other organizations.
      • Residential services plan: The onsite case management staff (called clinical support specialists) work with interested residents to develop a residential services plan. Based on each individual’s housing challenges (including substance abuse and other behaviors that contribute to marginalization), personal strengths, and ambitions, this plan typically addresses personal hygiene, activities of daily living, mental health services, and transition to alcohol-free housing if desired and appropriate. If residents attain and maintain sobriety for several months, staff may encourage—but will not force—them to consider moving to an alcohol-free building.
    • Eligibility based on excessive use of crisis services, not "readiness" or need: While other housing programs offer apartments based on "readiness" or need, 1811 Eastlake offers them based on use of county services. When an apartment becomes available for a new resident, program leaders contact the county to find out the top users of crisis services, including care at publicly funded emergency departments, homeless shelters, police response services, and county jails. Program staff attempt to locate the top user in collaboration with DESC and other homeless shelters, the health care and corrections systems, and other centers frequented by the target population. If they do not find the top user within 5 business days, they try to find the second highest user. If they find the top user but he or she is already in a crisis institution (for example, jail or hospital), they hold the vacant apartment for 60 days.
      • Lease agreement featuring low (or no) rent, permitting alcohol use: Potential residents receive a standard lease agreement with some modifications, including a rental rate based on income. Unlike most such programs, the agreement allows use of alcohol. After agreeing to the terms, residents can move in with few if any restrictions or barriers. Key provisions of the agreement are outlined below:
        • Rent based on income: All units are Federally subsidized with rents of no more than 30 percent of income. Consequently, if the resident has no income (as is the case for most homeless, late-stage alcoholics), he or she pays no rent.
        • Good-neighbor commitment, but alcohol use allowed: Residents must agree not to engage in illegal, antisocial, or uncivil behaviors in the neighborhood in which the building is located. Alcohol and alcohol use is permitted in the building.
        • Careful monitoring of visitors: Recognizing that some visitors can create disturbances and may have a negative impact on residents, the building has controlled entry, with all visitors entering through the front desk. Visitors must supply the name and room number of the resident they wish to visit, and the resident must approve the visit. Visitors must show and surrender valid State identification while at the facility. If the resident accepts the visit, he or she must come to the front desk to greet the visitor and must accompany him or her at all times. Residents must obtain permission for overnight guests at least 24 hours in advance, with some exceptions in the case of family members.
      • Onsite health care services: The facility offers a variety of personalized medical services and encourages residents to use them, with the goal of reducing reliance on high-cost acute and emergency services.
        • Initial assessment and ongoing care from nurse: The facility's full-time nurse (employed by Harborview Medical Center and funded through DESC) provides initial clinical assessments and ongoing care, as outlined below:
          • Baseline assessment: Upon entry into the program, each resident is offered a basic clinical examination to assess acute and chronic health care needs. As an employee of Harborview Medical Center, the nurse has access to the hospital’s electronic health record and DESC's information management system.
          • Ongoing care for chronic and acute conditions: The nurse provides ongoing chronic care management and routine, acute medical care (e.g., for infections, minor injuries).
          • Regular visits from outside physicians and specialists: As possible, DESC makes arrangements for physicians and specialists to visit the facility to provide care to residents. For example, through an agreement with the Veteran’s Administration, physicians visit the facility regularly to provide care to veterans, who make up roughly 30 percent of residents.

      Context of the Innovation

      Opened in 1979, DESC provides survival services, clinical services, and housing to nearly 2,100 chronically homeless individuals each day in Seattle/King County. In the course of a year, DESC serves 7,000 unduplicated people, including 400 to 500 who are late-stage alcoholics. The center also offers clinical services, drop-in centers, information and referrals, and supportive housing.

      In the early 1970s, a series of court cases decriminalized public intoxication in Washington State, exacerbating the problem of late-stage alcoholics living on the streets of downtown Seattle, as the city lost one of the few tools it had (jail) to remove homeless alcoholics from the streets. As a result, these individuals frequently remained on the streets, in many cases dying there.

      Seeking solutions for homeless alcoholics, center leaders became increasingly frustrated by the policies of most supportive housing programs, which use a “housing-readiness” model that requires prospective residents to attain and maintain sobriety before being given permanent housing. This requirement seemed unrealistic for late-stage alcoholics, who often suffer from mental health conditions and frequently fail to achieve long-term sobriety, even after going through treatment programs multiple times. As a result, these leaders decided to try another approach that did not include such onerous, unrealistic requirements.

      Did It Work?

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      Results

      The program has been well accepted by the target population and has reduced alcohol abuse, related symptoms, and crisis service costs (including emergency health care services), yielding significant savings for the county.
      • High acceptance: The vast majority (95 percent) of those approached about the program thus far have signed a lease and moved into the facility.2 In its first year of operation, 95 people accepted housing in the building. Two individuals who initially refused entry eventually accepted an apartment. Since its opening in December 2005, 225 individuals have lived at the facility.
      • Higher sobriety rate than traditional treatment programs: Of the first 79 residents who moved into the facility, 11 percent achieved sobriety—much higher than the estimated 5 percent success rate often cited for late-stage alcoholics in traditional programs.
      • Less alcohol abuse: In the first year of the program, residents reduced alcohol consumption by roughly 30 percent, with the median number of drinks per day falling from 15.7 to 10.6. Residents reported fewer days of drinking to intoxication, which fell from 28 out of every 30 days at program entry to 10 out of every 30 days after a year.2 Alcohol use has continued to decline over time. For every 3 months in the program, participants cut alcohol use by 7 to 8 percent. After being in the program for 2 years, nearly three-quarters of residents reported at least 1 day per month in which they did not drink to intoxication.3
      • Fewer symptoms of alcohol abuse: The proportion of participants reporting episodes of delirium tremens (a set of symptoms, including hallucinations, restlessness, impaired memory and incoherence, caused by alcohol poisoning) fell from 65 to 23 percent, while other symptoms of alcohol dependence fell by 4 percent for every 3 months in the program.3
        • Significant cost savings: Residents' average monthly crisis service costs (including emergency health care services) were $3,569 less than in a group of similar individuals on the wait list for the program. Even after considering the $1,120 average monthly cost for supported housing, net savings averaged $2,449 per person per month. Overall, first-year program savings for the county totaled more than $4 million compared to the year before implementation. The majority (58 percent) of savings came from reduced Medicaid expenditures due to residents using onsite medical care rather than emergency department care.2 Cost savings were even greater in subsequent years, as residents’ medical conditions stabilized further.

        Evidence Rating (What is this?)

        Moderate: The evidence consists of pre- and post-implementation comparisons of self-reported drinking habits and alcohol-related symptoms among participants, along with a comparison of crisis service costs among participants to a group of similar individuals on the program's wait list.

        How They Did It

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        Planning and Development Process

        Key steps included the following:
        • Identifying allies: Although late-stage alcoholics rarely attract the support of politicians and community activists, center leaders identified downtown businesses, Harborview Medical Center (the main public hospital serving the indigent in Seattle), and the Seattle Police Department as potential allies with a common interest: getting homeless alcoholics off the streets. Business owners worried about panhandlers harassing customers; hospital officials worried about the high cost of providing emergency care to those who really need ongoing chronic care management; and police felt that responding to complaints about the homeless sometimes prevented them from responding to more serious crimes. The executive director of DESC reached out to these groups and found common ground. These allies played an important role in convincing politicians to endorse this controversial change in approach to treatment for late-stage alcoholics.
        • Forming task force: King County and Seattle officials also began tackling the problem as well. A study found that the city and county spent millions of dollars each year on health care, crisis response, and other services for late-stage alcoholics, yet still did not meet their needs. To address this problem, the county formed a task force that included representatives from law enforcement, public health, downtown businesses, elected officials from the city and county, and homeless and addiction treatment providers. After meeting monthly for a little over a year, the task force made two recommendations: restrict the sale of alcohol products favored by this population and develop a “prerecovery” housing program that tolerates alcohol consumption on site and focuses on engaging residents and reducing harm rather than insisting on abstinence. The center's board approved the approach, with DESC's executive director taking the lead in developing this program.
        • Identifying site and funding source: Over the next 2 years, the executive director and his colleagues found a site for the facility in a primarily commercial district, procured the property, and proceeded with design and construction. City officials decided to fund the project primarily through tax dollars; see the Funding Sources section for more details.

        Resources Used and Skills Needed

        • Staffing: Staff at 1811 Eastlake include 13 residential counselors available around the clock, 5 mental health and chemical dependency specialists, 1 full-time registered nurse, and 2.5 full-time equivalent staff devoted to maintenance and janitorial work. Other DESC employees and staff of other social service agencies visit the site regularly to provide employment counseling, drug and alcohol treatment, and other services.
        • Costs: Upfront costs for land acquisition and construction totaled roughly $11.4 million. Annual operating costs run approximately $1.1 million (75 percent for personnel and 25 percent for other ongoing expenses).
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          Funding Sources

          King County, Washington State; City of Seattle
          Program development and operating costs have been funded almost entirely through public dollars, including the Seattle Housing Levy, King County Housing Opportunity Fund, Low Income Housing Tax Credit Program, Section 8 Rent Subsidies, Clinical Treatment Subsidy, and the Washington State Housing Trust Fund. Tenant rents provide roughly $50,000 a year to cover operating costs. In addition, the Robert Wood Johnson Foundation provided support for formal evaluation of the program.end fs

          Tools and Other Resources

          DESC developed a vulnerability assessment tool that helps with the development of individual residential service plans; the tool is not used to determine eligibility for housing at 1811 Eastlake. More information is available at: http://www.desc.org/vulnerability.html.

          Adoption Considerations

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          Getting Started with This Innovation

          • Be ready to face opposition: Even with data showing the high cost of caring for homeless late-stage alcoholics, center leaders faced stiff opposition to the facility from neighboring property owners. Although eventually victorious in court, DESC faced 2 years of delay due to the legal proceedings, with the case ultimately being decided by the State Supreme Court. Even after prevailing in court and starting construction on the facility, the center still had to deal with charges that the program "enabled" and/or "subsidized" drunken behavior. Staff have become adept at using data to combat these accusations.
          • Maintain relationships with allies and elected officials when confronting opposition: The relationships forged in the early developmental stages proved especially important when the media tried to sensationalize the controversy about 1811's housing-first model. The firm support of the downtown business community and police department helped convince elected officials to stay the course despite opposition. DESC also found additional allies in the Fair Housing Office and other organizations that protect the rights of the disabled.
          • Develop methodology for evaluation: Program leaders used the delays to partner with a group of research scientists to design a robust, controlled evaluation of the project. They applied for and received funding for this evaluation from the Robert Wood Johnson Foundation and were ready to collect data when the first cohort moved into 1811 Eastlake.

          Sustaining This Innovation

          • Add or modify services based on resident needs: The facility added job training and placement services after residents began showing an interest in and/or readiness for employment. In addition, clinical services specialists started using an “intentional alcohol intervention protocol” that they hope will increase participation in drug and alcohol treatment programs while remaining noncoercive in nature.
          • Adapt to restrictions on health information: When the program was first conceived, the center received a full set of utilization data from King County and Harborview that was used to inform eligibility decisions. However, provisions of the Health Insurance Portability and Accountability Act later prevented the center from getting some of this information. At present, King County generates a list of high utilizers based on Medicaid expenditures and jail records.
          • Reach out to groups who support residents: Through a growing relationship with the local Veteran’s Administration, the facility now provides additional services to the many veterans who live there. In addition to support groups and a twice-monthly clinic, this outreach program has reconnected veterans with the benefits to which they are entitled. As a result, these veterans now have an income, which not only gives them spending money but also a sense of validation, pride, and accomplishment about being able to pay a portion of their rent.
          • Do not depend on the utilization model for all housing options for the homeless: While high utilization of crisis services usually indicates vulnerability, many vulnerable homeless people resist crisis services. Homeless women, for example, may actively avoid health care and other services because of fear of harassment by homeless men or because they feel ashamed of their situation. By moving to eligibility based on utilization, counties and organizations may actually force these vulnerable homeless individuals further down between the cracks.

          Use By Other Organizations

          Homeless advocacy organizations in several cities in the United States use a housing-first approach modeled after this program. An annual conference now brings together those using and/or interested in this model from across the nation; the first such meeting took place in New Orleans in March 2012.

          More Information

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          Contact the Innovator

          Bill Hobson
          Executive Director
          DESC
          515 Third Ave
          Seattle, WA 98104
          Phone: 206-464-1570
          E-mail: bhobson@desc.org

          Innovator Disclosures

          Mr. Hobson reported that DESC has received consulting fees and travel expense reimbursement for providing consulting services to cities, counties, and organizations that serve the homeless. The organization has also received funding from the organizations listed in the Funding Sources section of this profile.

          References/Related Articles

          Collins SE, Malone DK, Clifasefi SL, et al. Project-based housing first for chronically homeless individuals with alcohol problems: within-subjects analyses of 2-year alcohol trajectories. Am J Public Health. 2012 Mar;102(3):511-9. [PubMed]

          Larimer ME, Malone DK, Garner MD, et al. Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA. 2009 Apr 1;301(13):1349-57. [PubMed]

          Footnotes

          1 Centers for Disease Control. “Alcohol Use and Health,” October 28, 2011. Available at: http://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm.
          2 Larimer ME, Malone DK, Garner MD, et al. Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA. 2009 Apr 1;301(13):1349-57. [PubMed]
          3 Collins SE, Malone DK, Clifasefi SL, et al. Project-based housing first for chronically homeless individuals with alcohol problems: within-subjects analyses of 2-year alcohol trajectories. Am J Public Health. 2012 Mar;102(3):511-9. [PubMed]
          Comment on this Innovation

          Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

          Original publication: August 29, 2012.
          Original publication indicates the date the profile was first posted to the Innovations Exchange.

          Last updated: April 23, 2014.
          Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

          Back Story
          With the publication of the formal evaluation of 1811 Eastlake in the Journal of the American Medical Association in 2009, DESC received a great deal of media attention. While initial news coverage of the project carried headlines like “Bunks for Drunks,” now several reporters wanted to hear about “success stories” that illustrate...

          Read more

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