Pathways to Housing, Inc.

Pathways to Housing, Inc. (PTH) is a non-profit organization that provides stable and independent housing to chronically homeless mentally ill individuals. Unlike other housing assistance programs that require sobriety and substance abuse treatment from their participants, PTH does not require sobriety in order for individuals to receive housing assistance. Rather, PTH specializes in delivering housing to homeless individuals with dual diagnosis (mental health and substance abuse problems), who make up a majority of the chronically homeless mentally ill population in the United States. Following the delivery of housing assistance, PTH provides aid to its participants through an interdisciplinary assertive community treatment that is delivered by mental health professionals, substance abuse counselors, and money management consultants. By preventing their participants from entering psychiatric wards, shelters, and jails, PTH reduces the financial burden of homelessness on local communities. Initiated in New York City, the PTH model has been replicated in over forty cities around the world.

The goal of Pathways to Housing, Inc. is to provide independent housing, treatment services for physical and mental health, and employment to mentally ill individuals who are chronically homeless.

Pathways to Housing has received numerous awards for its projects in New York City, Philadelphia, and D.C. In addition to achieving large effects in terms of housing outcomes, compared with standard care in the community, Housing First also improves community functioning and quality of life.

In a randomized study conducted between 1996 and 2000 in New York City and reviewed by the NYU School of Social Work, PTH was found to maintain a participant retention rate (i.e., participants who maintained permanent housing) of 87% (n=99) over a four-year period. When the PTH group was compared to comparable treatment first programs (programs in which participants are required to receive treatment and maintain sobriety before receiving housing assistance, n=126), there was no significant difference between the two groups in self-reported alcohol and substance abuse over a four-year period of time. PTH succeeded in providing housing for homeless individuals with dual diagnosis with no negligible effect in terms of the substance abuse habits of its participants when compared with the control group. While individuals in the treatment first programs utilized treatment services more frequently than PTH participants, this had no significant impact on their substance abuse problems.

Initial research on the effectiveness of Pathways’ Housing First (HF) was conducted in large American cities and consisted of 2 single-site randomized controlled trials (RCTs) and 5 quasi-experimental studies. Both of the RCTs showed HF yielding better housing outcomes that included exiting homelessness earlier and remaining as stably housed as tenants in regular housing. One of the RCTs also reported that, compared with people receiving standard care, recipients of HF spent fewer days in psychiatric hospitals. No differences emerged between the 2 groups regarding improvements in the severity of psychiatric symptoms or substance use. Findings from 2 quasi-experimental studies also showed HF with assertive community treatment (ACT) produced better housing outcomes than standard care. Mixed findings are reported for non-housing outcomes, with either no differences in level of improvement over time or results favoring HF with decreased use of inpatient and emergency department services, decreased involvement in the justice system, and improved quality of life, compared with outpatient mental health services, and decreased substance use and a lower likelihood of leaving substance use treatment, compared with standard care. (Aubry et. al 2015)

The At Home–Chez soi (AH–CS) project reveals how this approach can be adapted in cities of different sizes and with diverse populations in Canada. The project entailed a randomized controlled trial conducted in 5 Canadian cities between 2009 and 2013. Mixed methods were used to examine the implementation of HF programs and participant outcomes, comparing 1158 people receiving HF to 990 people receiving standard care. The project examined delivering HF to 2 different groups of people with severe mental illness based on their level of need. People assessed with a high level of need received HF with assertive community treatment (ACT). Conversely, people with a moderate level of need were provided with intensive case management (ICM). Overall, in line with findings from the American studies, HF proved to be more effective than treatment as usual (TAU) in assisting people to exit homelessness and achieve stable housing. HF participants spent 73% of their time in stable housing, compared with 32% of TAU participants. In the last 6 months of the study, 62% of HF participants were housed all of the time, compared with 31% of TAU participants; 16% of HF participants were housed none of the time, compared to 46% of TAU participants. People with high needs receiving ACT and people with moderate needs receiving ICM experienced similarly superior housing outcomes, compared with those receiving standard care. (Aubry et. al 2015)