‘Street to Home’ program (‘S2H’) evaluations

on Wednesday, 28 August 2013.

On August 16, FaHCSIA released a number of evaluations, based on longitudinal research, of delivery of this ‘core NPAH output’ in Sydney, Melbourne, Brisbane and urban areas of SA, WA and the NT. The studies were funded under FaHCSIA’s National Homelessness Research Agenda.

National overview

 In Street to Home: A National Comparative Analysis (June 2013), Cameron Parsell, Guy Johnson and Eleanor Button concluded that, while the rigour of some of the evaluation methods used could be improved, separate evaluations of S2H in Sydney, Melbourne and Brisbane showed that:

 The Street to Home programs were successfully able to identify and work with people [who] had experienced chronic homelessness (frequently rough sleeping, and often rough sleeping at the point of engagement with Street to Home); [those who] were disengaged from the labour market; [those who] used homelessness, criminal justice and acute health services at disproportionate rates; [and those who] reported chronic health conditions, and also reported high rates of mental illness/psychological distress.

The most consistent [theme] identified from the qualitative interviews with stakeholders was the challenges that all Street to Home program[s] experienced accessing secure housing for service users. In Sydney, Melbourne and Brisbane positive housing outcomes (access and retention after 12 months) were reported; nevertheless[,] in these sites access to housing represented a significant limitation to the model.

The three longitudinal studies conducted in Brisbane, Sydney and Melbourne demonstrate that people with chronic experiences of rough sleeping and social and health problems in addition to their homelessness were able to exit homelessness and sustain housing over a 12 month period. Consistent with an emerging body of evidence from the United States, the Australian research demonstrates that the problems that occur disproportionately among homeless populations or indeed even problems that [constitute] causes of homelessness did not need to be addressed prior to people accessing and sustaining (for 12 months) secure housing. (emphasis added)

Melbourne

 In their April 2013 Evaluation of Melbourne Street to Home Program: 12 month outcomes, Guy Johnson and Chris Chamberlain of RMIT University examined two cohorts of S2H users and revisited the outcomes of one of them after 12 months. They observedthat:

 ...Street to Home has maintained its focus on chronically homeless people in poor health. Seventy-nine per cent in Cohort 1 and 88 per cent in Cohort 2 had slept rough for three years or more and most people in both cohorts had either physical and/or mental health issues....

[After a year in the program, there is] clear evidence of many positive changes in [participants’] lives...

... [T]hree-quarters (77 per cent) of the participants were in good quality housing 12 months after joining the program. The data suggests that long-term rough sleepers can maintain their housing if they are given appropriate accommodation and long-term support...

...[There were also] marked improvements in the participants’ physical health and emotional well-being. Nearly two-thirds (63 per cent) said their general health was better than a year ago and the number who reported moderate to extreme bodily pain had declined from 54 per cent to 24 per cent.

... [M]ost people were no longer regular IV drug users or drinking alcohol excessively. The provision of ongoing support by Street to Home has helped to mitigate people’s feelings of hopelessness that can make excessive drug and alcohol use attractive.

...[P]atterns of service use ha[d] changed over 12 months. There was a notable decline in the use of homeless services and meals programs. There was also a sharp decline in the number of times people had used hospital emergency departments.

...[M]any clients had begun to improve their relationships with family and friends.... Street to Home [case] workers have the capacity to provide intensive support both before and after participants have secured housing. This underpins much of the success of the Street to Home approach.

Overall, the Street to Home service is delivering promising outcomes, but some challenges still remain. The most pressing problem is to find suitable housing for the clients. Housing options in the inner city are limited and the failure to integrate the provision of housing into the model is a major policy oversight. Despite this limitation, the early signs are that Street to Home is making significant progress in resolving long-term homelessness. (Emphasis added)

Brisbane

Cameron Parsell, Wojtek Tomaszewski and Andrew Jones of University of Queensland’s Institute of Social Science Research reviewed this program in March 2013. Their An Evaluation of Brisbane Street to Home: Final Report found that:

Service users: Brisbane’s Street to Home program has successfully identified and engaged with a rough sleeping population that have experienced multiple combined years of homelessness and who report health, social problems and exclusion in addition to homelessness.

  • Housing outcomes: The program has assisted many people to exit rough sleeping and access and sustain secure housing. Drawing on a 12 month longitudinal sample, 95 per cent of people (40 of 42) sustained housing over a 12 month period.
  • Housing experiences: People widely experienced their housing in positive terms and most had come to see their house as their home. They articulated housing stability in terms of support from Street to Home, automatic rent deduction and personal decisions and life changes. On the other hand, neighbourhood problems were commonly described as the only or primary problems experienced in housing, and as such, the great threat to tenancy sustainment.
  • Relationships: In terms of caring for dependent children or forming cohabitating relationships, the low rates at baseline remained stable at 12-month follow up. Nevertheless, at the 12 month follow up people continued to express the importance they placed on establishing greater relationships and extending their social networks.
  • Employment, education and training: with the exception of one person that [sic] commenced labour market participation, the extremely low rates of participation in the labour market, education and training identified at baseline remained stable after 12 months. Similarly, there was a slight decrease in reported job seeking behaviours at 12-month follow up compared to baseline.
  • Drug and alcohol use: At baseline the overwhelming majority of people reported smoking cigarettes on a daily basis. There was a small decrease in report daily rates of smoking: at baseline 39 people, at 12 month follow up 37 people reported daily use of cigarettes. At both baseline and 12 month follow up, less than half the sample (17 people) reported daily consumption of alcohol, but there was a significant increase in the reported weekly consumption of alcohol: at baseline 19 per cent, and at the 12 month follow up 34 per cent of the sample reported weekly alcohol consumption. Cannabis was the most widely reported illicit substance used. At baseline 6 people reported daily use, whereas as 12 month follow up 8 people, representing a slight increase, reported daily cannabis use. Surprisingly, there was an unexpected increase in the reported use of opiates. At baseline, no one reported daily opiate use, whereas at the 12 month follow up 2 people reported daily opiate use. Very few people believed that their drug or alcohol use led to daily health, social, legal or financial problems.
  • Health, wellbeing and quality of life: Using validated measures, people reported reduced symptoms of psychological distress between the 12 month follow up and baseline. While the Street to Home sample’s baseline and 12 month follow reported distress were higher than population averages, time spent in secure housing was associated with reduced distress. Similarly, measures of quality and life and satisfaction showed improvement between baseline and 12 month follow up.
  • Service utilisation: Street to Home service users access emergency health services and have contact with the criminal justice system at disproportionate rates. There were either no or very modest decreases in emergency health service utilisation between baseline and 12 month follow up. On the other hand, accessing and sustaining housing was associated with reductions in contact with the criminal justice system. Ten fewer people at the 12 month follow up, for instance, were held overnight in police custody compared to baseline.
  • Perspectives on Street to Home: Service user[s] widely rated the Street to Home service in highly positive terms. More than half of all participants rated Street to Home as ‘excellent’ (59 per cent), as ‘extremely’ useful to them (61 per cent), and as ‘client directed’ (63 per cent). No participant rated the service on any negative dimension. Underpinning the positive ratings of Street to Home were participants descriptions of Street to Home as a service that had enabled them to access housing and had continued to provide them with practical day-to-day support. (Emphasis added.)

The authors concluded:

  • ...Brisbane’s Street to Home service has (1) systematically targeted, identified and engaged people sleeping rough with experiences of chronic homelessness and multiple exclusions; (2) assisted a large number of people to move directly from ‘the streets’ into secure housing, and (3) directly provided ongoing services that have contributed to high rates of tenancy sustainment and thus exits from homelessness. ...[It]... can significantly contribute toward... reducing the incidence of homelessness and offering supported accommodation to people sleeping rough. Systematic, persistent and client directed street outreach can successfully engage with highly vulnerable [people] and people with long-term experiences of homelessness and rough sleeping in particular.
  • Without access to secure housing options, street outreach has a constrained capacity to assist people to exit homelessness.
  • In order for Street to Home to be successful, or any social program charged with the objectives of assisting people to exit homelessness, housing policy and institutional arrangements must be conceptualised and resourced to enable secure and affordable housing to be accessed. As it currently stands, Street to Home programs are judged on their capacity to assist people sleeping rough or experiencing chronic homelessness to access housing, but policy and administrative decisions that fundamentally determine housing access are beyond the remit of Street to Home programs.
  • Results from this research indicate that interrelated factors that cause homelessness, such as poverty, unemployment, drug and alcohol use, and social isolation, do not need to be addressed for people to first exit homelessness, or to sustain their housing (for 12 months at least).
  • Many people that [sic] have experienced chronic homelessness and multiple and enduring exclusions will require the ongoing provision of a range of health and social services. Brisbane Street to Home program is not resourced to provide multidisciplinary services directly, and there are a paucity of services provided in the mainstream sector (i.e., not homeless) that are successfully engaging with this client group in an ongoing basis. If Street to Home programs are conceptualised and funded to primarily assist people to exit homelessness (as they are), the planning and resources need to be put in place so that mainstream services can successfully work with people post-homelessness. Additionally, it should be noted that there is currently no supportive housing policy in Queensland.

Sydney

The Brisbane S2H reviewers also reviewed the Sydney Way2Home program, reporting on their longitudinal findings in May 2013. An evaluation of Sydney Way2Home Program: policy, practice, clients, outcomes. Final Report reached very similar conclusions to the Brisbane evaluation. The main differences in the two iterations of S2H were:

-          A slightly lower rate of housing sustained over a 12-month period in Sydney (90 per cent, compared with 95 per cent in Brisbane);

-          Greater stability in reported use of alcohol and most other drugs over the 12-month period in Sydney, with a notable reduction in opiate use;

-          (perhaps because of differences in state supported housing policies), no specific recommendation by Sydney review regarding additional investments in multi-disciplinary services.

SA, WA and the NT

In their March 2013 study of 82 rough sleepers in urban areas of SA, WA and the NT , Thunder in the soul: Experiences of sleeping rough and interventions in three Australian locations Eleanor Button and Jo Baulderstone of Flinders University

... found that once people have begun to receive assistance from [S2H] services they are quickly assisted into some form of temporary or transitional accommodation.... [S2H] services were viewed as offering intensive assistance much-needed by people who had many problems by the time they had become clients. Participants were grateful of [sic] the range of assistance, the ‘friendship’ of [S2H] workers and on-going offers of support. Once housed in long-term accommodation our participants were settled and able to concentrate on improving other aspects of their lives. The health of many participants improved and although chronic conditions rarely disappeared, a stable base enabled participants to better manage their conditions.

Reviewing the circumstances of people who had lived in their accommodation for one year or more, we found that once [S2H] services withdrew there were few other services available to work with participants in the holistic way of [S2H] services...

We conclude that where [S2H] services intersect with homelessness pathways they offer a significant service to vulnerable people who are living on the streets. However, their input generally begins once homelessness has occurred. In addition, whilst [S2H] services are highly adept at securing resources for people who are or who were sleeping rough which results in them being able to access accommodation, health and other services, there appears to be no structure for people to ensure on-going support is available if needed and opportunities to connect to their local communities (and beyond) are facilitated (emphasis added).

In Keeping off the Streets: Update on service models in three states (February 2013), the same authors document the SA, WA and NT ‘rough sleeper’ service models, identifying key characteristics of those that report against S2H objectives and ‘contextual factors and service system attributes which support the attainment and maintenance of sustainable tenancies for people sleeping rough’.

 This research focuses on ‘[S2H]-associated initiatives located in city centres or inner-metropolitan areas’ only. As NPAH prescribes no S2H service model, states and territories are free to devise quite different initiatives – eg by placing programs in a government department, as occurs in SA, or by delivering a mix of capital works and programs not specifically badged as ‘S2H’ in the context of the wider Commonwealth ‘Intervention’, as in the NT.

 In their first (2011) report, Button and Baulderstone

 concluded that there was great variation between the approaches adopted in the three jurisdictions and in particular, that the lack of affordable housing meant that clients waited long periods of time before being permanently accommodated in public housing, and that in the NT not all services were built around housing options focused on securing long-term public housing options for clients.

This time around,

Again, we conclude that the shape of each service is unique and that all play a critical role in their local homelessness service system. While individuals in all jurisdictions may benefit in many ways from the services they receive, the lack of affordable and appropriate housing means that there is no capacity for Housing First solutions. Services assist with accommodation needs as an urgent priority but this is predominantly focused on short, medium-term or transitional housing while longer-term options are explored and pursued. The emphasis on [S2H] services in all jurisdictions is therefore on case management and the capacity of workers to elicit resources to meet the diverse needs of their clients and to also ‘hold them in place’ whilst longer-term solutions are secured

…In each jurisdiction the ways in which the services were organised and funded reflected local priorities, policy preferences and service delivery cultures. Statistics reported in NPAH Homelessness Implementation Plan Annual Reports (and the [S2H] Program evaluation in WA) suggest that performance measures were often exceeded… (emphasis added)

The authors ‘found the following strategies important in the quest to reduce rough sleeping’:

a) Engaging People on the Streets:

-          Deploying streetwork/outreach workers to locations where people are sleeping rough or congregating and ensuring a persistent presence in the above areas;

-          Ensuring streetwork/outreach work is based on sound principles that facilitate respectful approaches;

-          Invoking work practices that provide opportunities for workers to engage and build rapport with people sleeping rough;

-          Adopting a ‘help first’ approach that can demonstrate the capacity of the service to facilitate change in people’s circumstances;

-          Using mechanisms that enable a potential client’s circumstances to be holistically documented in order that clear priorities for action can be established if they are accepted as clients;

-          Ensuring ‘intake’ processes are speedy in order that vulnerable people can receive the help they need as quickly as possible; and

-          Service resourcing to ensure workers can be effective.

b) Moving People Off the Streets:

-          Case management-led approaches designed to ‘hold people in place’ whilst longer-term options are considered and secured;

-          Work practices built around client-centred approaches, flexible services that build self-esteem; that ‘hold people in place’ and that involve practical assistance;

-          Client participation approaches built around active participation by the client in working towards long-term changes, supported and facilitated by case managers;

-          Securing resources from elsewhere — staff with strong advocacy skills in order to access an array of resources held by government, non-government and private (for profit) agencies to address client needs.

c) Sustaining Housing:

-          Flexibility with regard to ending case management arrangements to enable clients to continue to receive support and to re-connect if necessary;

-          Separation of tenancy management and case management so that there is an independent advocate.

d) System Architecture:

-          The separate provision of housing and health services to address chronic health and housing problems;

-          Mechanisms that effectively break down barriers to services for people sleeping rough;

-          Stable, respectful working relationships across sectors that facilitate access to resources and enable long-term housing and health needs to be met.

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