In 1989, Sam Tsemberis was trying to keep homeless people alive.

“We were thinking about survivability: Is this person going to make it through the night?” he says. A clinical psychologist, Tsemberis directed Project H.E.L.P., a program that provided emergency services to chronically homeless people on the sidewalks where they live.

Many of his clients suffered both mental illness and addiction, but their biggest health problem was the fact they were homeless. Homelessness makes it difficult to treat mental illness and addiction and creates innumerable other health problems, from heat stroke to hypothermia.

Tsemberis began to prioritize homelessness as the first problem he needed to treat, not the last, for the people he called his consumers.

He founded Pathways to Housing in 1992 to put into practice his Housing First model. In the two decades since, Pathways  has housed more than 600 people in New York City and now has offices in Washington, D.C., Philadelphia, and Vermont. In addition, Pathways has been tremendously influential—a growing number of agencies, advocates, and developers who work with homeless people have adopted Tsemberis’ Housing First model.

“Sam has helped lead the supportive housing movement throughout the country,” says Deborah De Santis, president and CEO of CSH, formerly known as the Corporation for Supportive Housing. “Pathways’ model serves as an effective tool for addressing chronic homelessness, demonstrating that people can succeed in housing with the appropriate services.”

No prerequisites

Homeless people typically say their most immediate need is to find a place to live.

But homeless programs often refuse to provide housing immediately. The Continuum of Care model once followed by many homeless shelters and hospitals attempted to treat issues like addiction and mental illness before providing permanent housing.

“To get into a home, you had to meet all of these services qualifications,” says Tsemberis. The mental illness and addiction issues experienced by many of Tsemberis’ clients made it impossible to qualify. “People who could not or would not do what was asked—that was the group that you see over and over.”

Many of these chronically homeless people cycled in and out of hospitals, jail, and drop-in centers where homeless people could find food or a blanket. The Housing First model helps homeless people by addressing their lack of housing without any prerequisites for psychiatric treatment or sobriety.

“Housing First ends homelessness,” Tsemberis says.

Pathways arranges for its clients to move into privately owned buildings mostly occupied by conventional residents. “The homeless are integrated back into the community, like everyone else,” says Tsemberis.

Pathways program participants can access supportive services from Pathways 24 hours a day, seven days a week, including social workers, nurses, psychiatrists, vocational and substance abuse counselors, and a housing specialist. Customers aren’t forced to access these services or prove that they have stayed sober or taken their medications to keep their housing.

They do have to comply with the rules set by their private-market landlord, who has the same right any landlord has to evict a tenant who breaks the terms of his or her lease. Tenants can’t, for example, wake their neighbors with loud noise or bring disruptive guests into the building. They must also pay their share of the rent on time—often a percentage of the tenant’s income from Social Security payments.

The Housing First model assumes that if someone with psychiatric symptoms can survive on the streets, that person can manage their own apartment.

Keeping their new home is apparently a powerful motive for most of Pathways’ consumers. About 85 percent of the people helped by the organization are able to stay housed—a tremendously high success rate considering the challenges they face.

Growing influence

Housing First has had an enormous influence on the ways advocates attempt to help homeless people.

“Sam Tsemberis is a true leader in the supportive housing world,” says Brenda Rosen, executive director of Common Ground.

In the late 1980s, developers like Common Ground set out to build or renovate apartments that provide permanent housing with intensive supportive services to homeless people. They went on to build thousands of units of supportive housing in New York City and across the county. “We are proud to use the Housing First model,” says Rosen. “We know it works— providing safe, permanent homes without conditions is how we have helped more than 5,000 people overcome homelessness and get a second chance at life.”

However, a number of properties that go by the name “supportive housing” hesitate to fully embrace the Housing First model. Many still ask potential residents to remain sober for a period of time before they can move in and require people who suffer from mental illness to already be taking relevant medication. Many others will not take people who come directly from the streets, have criminal histories, or even just have bad credit reports. “The people we were dealing with were never going to get into those buildings,” says Tsemberis.

Officials and advocates now embrace the Housing First model. In October 2012, the U.S. Department of Veterans Affairs (VA) made Housing First the official policy of the Department of Housing and Urban Development–Veterans Affairs Supportive Housing program, which combines rental assistance from HUD with case management and other services from the VA.

The U.S. Interagency Council on Homelessness has also embraced Housing First. “We know what works. The research is clear that permanent supportive housing using a Housing First approach is the primary solution,” according to a fact sheet from the Council.

Tsemberis’ Housing First model has even spread north, to Canada, where the early results of its Housing First program, called At Home/Chez Soi, have been very positive.

“For every dollar that is spent on Housing First, 54 cents is saved through the reduction in other shelter and health care services,” according to a September 2012 progress report from the Mental Health Commission of Canada (MHCC).

More than 900 people are no longer homeless because of Housing First, says MHCC, which found that 86 percent of participants remain in their first or second housing unit.