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Comparison of the Housing First and Treatment First Methods of Reducing Homelessness

Info: 3186 words (13 pages) Nursing Case Study
Published: 22nd May 2020

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Tagged: homelessness

A Comparison of the Housing First and Treatment First Methods of Reducing Homelessness: What is Best for Spokane, Washington?


This purpose of this research is to compare the Housing First and Treatment First programs to understand more clearly which program is more efficient, cost effective, and successful in terms of retention and long term goals to be implemented in the city of Spokane, Washington. This research serves to provide policy recommendations for the City of Spokane to help understand what will work best to assist with the homelessness epidemic the city is enduring. The design of this research is a comparative case study to analyze already existing pertinent research on the Housing First and Treatment First programs. Results/Implementations to come.

A Comparison of the Housing First and Treatment First Methods of Reducing Homelessness: What is Best for Spokane, Washington?

The United States has been facing a homelessness problem for decades. In 2018, over a half a million people, or 552,830, were homeless on any given night (HUD.GOV). According to the National Alliance to end homelessness, the homeless population increased from 2017 to 2018 by a relatively small 0.3 percent, or 1,834 people (National Alliance to End Homelessness, 2016 ). With this, the question of how to approach a solution to homelessness has been a popular topic of debate. Methods such as providing emergency shelters to the homeless, treatment programs to the homeless, providing housing to the homeless population, and simply providing necessities like food and other needed items to the homeless have been researched in the past to understand what process may be more efficient and successful to get our citizens off the streets. While this debate occurs, other debates about criminalizing the homeless and making it hard for them to live or trying to move them out of specific areas have also arose when trying to tackle the issue that is homeless in America. Politicians and policy makers have continued to make long term plans to eradicate homelessness in the United States by assessing researched based solutions which include the Housing First and the Treatment First program. With every city, town, and locality having its own unique needs, wants, and populations, I wanted to do research on what policy implementation may be best for mid-sized cities with these unique populations and needs, like Spokane, Washington.

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Spokane, Washington is an quaint city in Eastern Washington lclose to the border of Idaho. The mid-sized city is home to the beautiful Spokane River, the Selkirk Mountains, and a growing, bustling downtown with a beautiful waterfront park and many thriving new businesses. Spokane is a unique city because of its demographics. Spokane has a population of about 217,000 people, making it a mid-sized city and the second largest city in Washington state. Additionally, Spokane is not very diverse, with 85.3% of its population identifying as while. As for income, Spokane had a median earning of $32,343 in 2017 according the U.S. Census Bureau. Like many other cities in America, Spokane also has a homelessness issue. Currently, Spokane has a homeless population of about 1,300 people, up about 0.3% from 2018 (City of Spokane). According to the Department of Housing and Urban Development, Spokane is listed in the top five “largely urban” cities for the highest numbers of people experiencing homelessness (HUD.GOV). With the homelessness population in Spokane growing, the question many policy makers are asking is: “what can we do differently?”. There has been research done to explore this question for bigger cities, but not a lot has been researched for cities the size of Spokane. What will work for a city of Spokane’s size?

The goal of this capstone is to provide a planning process, policy recommendations, and potential implementations for what methods may be best for the City of Spokane to take to help their homelessness population. With this, I will compare the multiple methods of ending homelessness that are currently being implemented in other cities to better understand what method may work to decrease and potentially eradicate homelessness in Spokane, Washington. I will be using the comparative research method to compare relevant literature on the topic, specifically looking at the older “Treatment First” method and the newer “Housing First method”. I hope to observe their effectiveness, success in other cities and what it specifically looked like, and the efficiency of the programs.

Using relevant literature, I ask the following research questions: 1) Which method of assistance for the homelessness (Housing First and Treatment First) has worked better thus far according to research? 2) Which method is more cost effective and efficient? For the short term? For the long term? 3) Which program or policy could be implemented to help Spokane, Washington’s homelessness problem best? How would this have to be done?

In the following literature review, I first discuss the history of homelessness in Spokane, what the population currently looks like, and the policies the City of Spokane government currently has in place. Then, I discuss literature of both the Housing First and Treatment First methods and compare the two methods in terms of effectiveness, efficiency, and success. After analyzing the documentation and research used, I will then provide evidence for my research questions. Lastly, I will conclude with policy recommendations specified for the City of Spokane for the future of helping to get their homeless citizens off the streets.

Literature Review

There are many methods of reducing homelessness that have been implemented within the United States’ many different cities and localities. Housing First and Treatment First, however, are two of the most debated methods of reducing homelessness. This capstone looks upon literature for both the Housing Fist and Treatment first programs. It specifically outlines the history and development of policy implementations to reduce homelessness in the United States over time. Then, a discussion of both the Housing First and Treatment First methods take place, including how and when each plan was implemented first, and the data for each method in terms of effectiveness, efficiency and success.

The literature identifies the major differences and similarities between the Treatment First and Housing First programs, including their successes and downfalls researched over the years. The literature also suggests the direction the United States is going in terms of programs to help the epidemic of homelessness.

The Treatment First Approach

The Treatment First approach programs offer temporary housing, substance abuse programs, and sobriety for those suffering from homelessness and substance abuse issues. This program requires sobriety to enter the program and stay within the program. Treatment First programs also tend to require housing readiness before being able to go into independent housing. Treatment First has become the main, widely used program in the United States since the 1980’s and 1990’s (Locke et al 2007). This approach was first brought together in the early 1980’s after mental health systems were some of the first to respond to the homelessness epidemic in the United States (Ellen, O’Flaherty, 2010). The Treatment First programs were built to start with volunteers reaching out to those in need, helping them to begin treatment within transitional housing, and finish with permanent housing (Ellen, O’Flaherty, 2010). The Treatment First program is the most popular in many communities within the United States and has been funded by the federal government for the last couple decades.


In terms of success, one study found that Treatment First participants were more likely to utilize the treatment for substance abuse. This is because this was integrated into their program and they were required to not use during their stay within transitional housing. In comparison, the Housing First program does not require this aspect in the program (Padgett, et. al., 2011). Treatment First participants were also ten times more likely to use the substance abuse services the year after entering the program compared to the participants in the Housing First program (Padgett, et. al., 2011).

The Housing First Approach

The Housing First Approach is an approach that values putting those enduring homelessness into housing as the first step in their road to recovery instead of putting them through a substance abuse treatment program first so they are able to improve their quality of life first and foremost (National Alliance to End Homelessness, 2016). Ultimately, this approach is based on the belief that people suffering in homelessness are better off with life’s basic needs first such as food, water, and shelter. This approach also focuses on other needs before treatment like finding a stable job (National Alliance to End Homelessness, 2016). Housing First is different compared to Treatment First because it does not require someone to have prerequisites to access housing. This means that someone who is experiencing homelessness does not have to go through a program first to qualify for housing, like a lot of treatment first programs do. The Housing First model was built to be able to be flexible in that it can serve families and individuals alike.

There are two common program models within the Housing First approach which include Permanent Supportive Housing (PSH) and Rapid Re-Housing (National Alliance to End Homelessness, 2016). Permanent Supportive Housing includes a longer term option for those who are homeless. Usually, PSH helps with rental assistance and other programs and services for those who need treatment for mental illness, disabilities, or even substance abuse (National Alliance to End Homelessness, 2016). The second model, or Rapid Re-Housing, is an option that focuses more on short term assistance with renting. This program also has less services than PSH. The purpose of this model is to get those enduring homelessness into housing as quick as possible to promote independent living (National Alliance to End Homelessness, 2016).

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According to the Department of Housing and Urban Development, the first use of the Housing First program was in New York City in 1992 called Pathways to Housing (HUD.GOV). Pathways to Housing provides those faciing homelessness who also have substance abuse or psychiatric disorders a path to services that provide permanent apartments that promote autonomy. Additionally, Pathways to Housing does not have a requirement for mandatory participation in some type of treatment program for entry (Tsemberis, Gulcur, and Nakae, 2004). With this, the programs for people seeking these services are separated. This means they rent apartments, and then the services to help with other parts of their life are there for support along with the team from Pathways to Housing.


Per one study, people who enter a Housing First model are more likely to remain housed after entering the program an access housing quicker at the beginning. (Gulcur, Stefancic, Shinn, Tsemberis, Fishcer, 2003). Additionally, research has shown that the Housing First method is lower in costs, promotes choice for residents who are enduring homelessness, and has shown that individuals who start with Housing First are more residentially stable and more likely to stay residentially stable. (Greenwood et al. 2005; Gulcur et al. 2003; Tsemberis et al. 2004). Furthermore, studies have shown that Rapid Re-Housing gets people into housing quicker than Treatment First, with an average of two months (HUD.GOV). This study also showed that individuals helped by Rapid Re-Housing remained in housing compared to those who enter a Treatment First program (HUD.GOV).


One study done for the Community of Mental Health Journal showed that participants in the Housing First program were more likely to not abuse substances in the first year of the study in comparison to participants within the Treatment First program. Additionally, participants in the Housing First program were less likely to use substance abuse services or leave their program early (Padgett et. al., 2011). According to the study, of the 31 out of the 48 people in the Treatment First group who abused substance during the study, 26 left early from the program and 14 relapsed. For the people participating in the Housing First study, 8 of the 27 participants who reported using substances all stayed in the program including two who relapsed. 3 people from the Housing First program left the program, but left to stay with their family and did not relapse (Padgett, Stanhope, Henwood, Stefancic, 2011). This study also reported that participants in the Treatment First program were 3.4 times more likely to abuse alcohol or drugs in the year following the finishing of their program compared to Housing First participants. (Padgett et al., 2011). The report overall concluded that the Housing First clients are more likely to stay engaged in a program and be residentially stable (Padgett et al., 2011).


As for cost, studies show that the Housing First program has been proven to cost a lot less than its counterpart, the Treatment First program. According to a study on the Denver Housing First Collaborative with a cost benefit analysis, “The total emergency related costs for the sample cohort for the 24 months prior to entry in the DHFC program was $821,539. The total emergency related costs for this group after entering the program was $222,186, a reduction of $599,356 or 72.95%. The total costs savings amounts to an average of $31,545 per participant” (Perlman, Parvensky, 2006). Additionally, according to Tsemberis et. al., the Housing First program could potentially cost up to $23,000 less per consumer per year than a shelter program.


This research study was performed by using a comparative case study. I felt this method would be the best for this research because “comparative case studies involve the analysis and synthesis of the similarities, differences and patterns across two or more cases that share a common focus or goal in a way that produces knowledge that is easier to generalize about causal questions – how and why particular programs or policies work or fail to work” (Goodrick, UNICEF).

The first stage of collecting data was reviewing pertinent literature of both the Housing First and Treatment First programs in both Washington and in other states. I focused more on cities that have already implemented each program instead of strictly comparing only cities that are similar in size to Spokane. The Housing First and Treatment First programs were identified within many published research documents . To qualify, each report had to have research on effectiveness, efficiency, and success of either program.

I was able to analyze the data effectively by organizing the information in a table by study, including each factor: effectiveness, efficiency, and success. If necessary, a second table with specific quantitative data will be made. The following table shows the information gathered and included:

Location of program(s):
Cost of program(s):
Amount of time for implementation:
Time since program(s) implemented:
Success of method based on: retention, data collected:
Amount of resources used:





  • 2020 Strategic Plan to Homelessness. (n.d.). Retrieved from https://static.spokanecity.org/documents/chhs/plans-reports/planning/2015-2020-strategic-plan-to-end-homelessness.pdf
  • The Applicability of Housing First Models to Homeless Persons with Serious Mental Illness. (n.d.). Retrieved from US Department of Housing and Urban Development website: https://www.hud.govuser.gov/portal/publications/hsgfirst.pdf
  • Denver Housing First Collaborative: Cost Benefit Analysis and Program Outcomes Report. (n.d.). Retrieved from https://housingis.org/content/denver-housing-first-collaborative-cost-benefit-analysis-and-program-outcomes-report-0
  • Ellen, I. G., & O’Flaherty, B. (2010). How to House the Homeless. New York, NY: Russell Sage Foundation.
  • Gulcur, L., Stefancic, A., Shinn, M., Tsemberis, S., & Fishcer, S. Housing, Hospitalization, and Cost Outcomes for Homeless Individuals with Psychiatric Disabilities Participating in Continuum of Care and Housing First programs. 2003.
  • Housing First Fact Sheet. (n.d.). Retrieved from National Alliance to End Homelessness website: http://endhomelessness.org/wp-content/uploads/2016/04/housing-first-fact-sheet.pdf
  • Kusmer, K. L. (2003). Down and Out, on the Road: The Homeless in American History. Oxford, England: Oxford University Press on Demand.
  • Life after Transition. (n.d.). Retrieved from US Department of Housing and Urban Development website: https://www.hud.govuser.gov/portal/publications/LifeAfterTransition.pdf
  • Locke, G., Khadduri, J., & O’Hara, A. (2007). Housing models. Paper presented at the National Symposium on Homelessness Research, Washington, DC.
  • Padgett, D., Stanhope, K., Henwood, V., & Stefancic, B. (2011). Substance Use Outcomes Among Homeless Clients with Serious Mental Illness: Comparing Housing First with Treatment First Programs. Community Mental Health Journal, 47(2), 227-232.
  • UNICEF Office of Research – Innocenti. (n.d.). Comparative Case Studies: Methodological Briefs – Impact Evaluation No. 9. Retrieved from https://www.unicef-irc.org/publications/754-comparative-case-studies-methodological-briefs-impact-evaluation-no-9.html


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Homelessness occurs for a variety of different reasons. Economic strain, loss of jobs as well as the inability to find more work, drug and alcohol abuse, mental illness, and gross financial management just to name a few. It is imperative that primary prevention strategies such as information, education, and interventions be given to those persons at risk of becoming homeless.

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