Access: The TAC Blog
THE UNITED STATES IS EXPERIENCING A CRISIS unlike anything we have experienced before. The challenges associated with COVID-19 have significantly affected the systems that help people living with disabilities or experiencing homelessness. Every system, every provider, and every person affected by this crisis has needs.
State government agencies are stretched, with many employees working remotely and much existing work on hold in order to focus on the crisis. State resources will become limited due to the shock to our economic system. Cities are implementing public health plans and managing “stay-at-home” orders. Direct service providers, such as mental health and homelessness agencies, have had to reduce capacity and access due to staff shortages and social distancing, while continuing to provide safety net services. Hospitals are bracing to be overwhelmed by the number of people who will need hospital-level treatment. Complicating the situation, our personal health and that of our family members, friends, and colleagues is at risk, and many people are experiencing stressors such as loss of income, shrinking retirement plans and investments, working from home, homeschooling our children, and social distancing and stay-at-home orders.
Direct service providers are on the front lines in helping people living with disabilities and experiencing homelessness to remain healthy and stable in their communities during a crisis. Unfortunately, they are not typically the focus of disaster mitigation, preparedness, or response and recovery activities, leaving them to manage the crisis on their own. This can result in inefficient use of resources, lack of coordination and communication, and poor outcomes for the individuals being served. Vulnerable populations should be a focus for all aspects of disaster mitigation, including the current public health crisis, at the local, state, and federal levels.
Throughout my career, I have learned the importance of relying on a set of core principles to successfully manage major challenges, including systems-level crises and disasters. Whether you are reading this from the perspective of a federal or state government agency, a local system, a philanthropy, or as a provider, these four principles can serve as a framework in your work to help our communities navigate the Coronavirus crisis:
- An effective management structure is necessary in order to first control, then resolve the crisis, and finally implement recovery. Scattershot, piecemeal approaches delay access to critical resources and may exacerbate the crisis before it gets better. Management structures such as the Incident Command System and the U.S. Department of Health and Human Services’ Medical Surge Capacity and Capability (MSCC) Management System provide scalable approaches that can be used at any level as an organized way to manage the crisis. Incident command systems, such as command centers currently managing the COVID-19 crisis in most states, must involve direct services and homelessness systems in disaster response.
- Strong leadership, including both executive leadership and team leaders, is essential to crisis management and disaster recovery. Effective leaders demonstrate compassion and empathy to those impacted while simultaneously effectively managing the crisis as it is occurring. Strong leadership relies on a management framework that is informed and carried out by skilled subject matter experts.
- Large-scale crises and disasters are resolved successfully through collaboration, coordination, and partnerships — especially those established prior to the crisis. The needs of people living with disabilities and those experiencing homelessness cross into multiple systems and therefore require a multi-system, multi-level response.
- We emerge from a crisis because we are resilient. I am always amazed by the resilience of individuals who experience adversity, disability, stigma, oppression, racism, and disaster. A “culture of resilience,” as described in Disaster Resilience: A National Imperative (National Resource Council, 2012) is what is needed to collectively mitigate, prepare for, respond to, and recover from large-scale disasters like the one we are confronting now, and the ones that lie ahead.
These principles held true when, as deputy commissioner at the New Jersey Department of Human Services, I was involved in responding to various crises and disasters while overseeing the state’s public mental health system, as well as emergency preparedness and response with other state and local agencies. Some of the situations in which the principles were an invaluable tool to me included statewide hurricane preparedness, planning and response to the H1N1 swine flu pandemic in 2009, and operation and staffing of a mass shelter on a military base for citizens being evacuated to the United States in the immediate aftermath of the 2010 Haiti earthquake. During a state government shutdown in 2006, I used my disaster-related experience to ensure that the public mental health system remained functional during a temporary halt in government functions. These principles were also relevant earlier in my career when I was on a mental health team that responded to disasters such as plane crashes and flooding — and when, as a wildland firefighter, I joined others in responding to fires that threatened life and property.
As we experience the COVID-19 crisis now, there is significant uncertainty that lies ahead for all of us, both professionally and personally. The four principles above can help us begin to push past a sense of hopelessness and helplessness. History shows that we will emerge from this. Every crisis is unique — but lessons learned from other situations can nevertheless give us a sense of optimism and control as we understand that this crisis, like every other, can be managed.
Learn about TAC's technical assistance services in disaster preparedness and recovery.
There are fundamental reasons that patients with opioid use disorder (OUD) should be offered access to medications approved to treat their condition. For one, the evidence base is compelling: Medication-assisted treatment (MAT) improves patients’ quality of life; reduces substance misuse; and lowers emergency department and hospitalization costs, hepatitis B and HIV rates, and overdose death rates. National organizations dedicated to health care quality have endorsed quality measures assessing the use of pharmacotherapy for OUD, and propose adding them to widely used performance measurement sets. The U.S. Department of Justice has signaled that refusing to permit access to MAT and discriminating against persons receiving MAT are violations of the Americans with Disabilities Act. For policymakers and providers seeking to promote patient-centered care, information about medications available to treat a condition should be shared freely and objectively so that patients and their family members can make informed decisions based on the best scientific information available.
Opportunities for Alignment
Medication-assisted treatment and other practice approaches that embody the principles of patient-centered care are considered by many to be incompatible with abstinence-based addiction treatment models rooted in 12-step programs. The tension that sometimes forms between providers who include medication in the treatment of OUD and those who do not threatens to jeopardize recent investments in prevention, treatment, and recovery, and to fracture a community of stakeholders who need to work together. It is important that addiction care stakeholders recognize and build on the overlap between treatment approaches that involve MAT and harm reduction considerations, and interventions based on 12-step programs. Too often these models are presented as “either/or.” In this post, we’d like to highlight the opportunities for “both.”
Considerable progress has been made in recent years towards improving the availability of medications and services used to manage OUD. Commercial payers, sometimes in collaboration with state leadership, are trending towards removing prior authorization requirements for buprenorphine. At least 51 Medicaid programs have assigned preferred status to buprenorphine, and lifetime treatment limits have all but disappeared. Training resources abound, offering vital supports to primary care clinicians adopting MAT as a new therapy and OUD as a new condition to treat. Support has burgeoned for harm reduction approaches such as syringe service programs, safe injection facilities, and naloxone distribution initiatives, saving lives through overdose reversals and reduced incidence of viral and bacterial infections.
And yet, only 27 percent of specialty addiction treatment centers offer MAT. This unfortunate discrepancy is the result of many factors, including a shortage of medical practitioners who have received a waiver from SAMHSA to prescribe buprenorphine for opioid dependence treatment; obstacles to billing for sufficient reimbursement; and, often, a philosophical orientation informed by a particular interpretation of 12-step programs. Proponents of MAT and harm reduction modalities supporting patient-centered care often face opposition from some segments of the 12-step recovery community. Understanding the positions of 12-step organizations on the role of MAT and harm reduction is a key step to crossing this quality chasm.
A Closer Look at 12-Step Literature
The official literature of Alcoholics Anonymous (i.e., approved by the AA General Service Conference) shows significant alignment with harm reduction and MAT approaches. One AA pamphlet, The AA Member—Medications and Other Drugs, leads with the suggestion that “No AA member should ‘play doctor’; all medical advice and treatment should come from a qualified physician.” The pamphlet continues, “Because of the difficulties that many alcoholics have with drugs, some members have taken the position that no one in A.A. should take any medication. While this position has undoubtedly prevented relapses for some, it has meant disaster for others… they feel guilty because they are convinced that ‘A.A. is against pills.’”
The foundational text Alcoholics Anonymous explicitly supports the use of medications for withdrawal management, as in the chapter Working With Others: “Sometimes you will have to call a doctor and administer sedatives under his direction.” Further, the book notes the important role of clinicians, explaining in the chapter The Family Afterward that “We are convinced that a spiritual mode of living is a most powerful health restorative… But this does not mean that we disregard human health measures. God has abundantly supplied this world with fine doctors, psychologists, and practitioners of various kinds. Do not hesitate to take your health problems to such persons. Try to remember that though God has wrought miracles among us, we should never belittle a good doctor or psychiatrist. Their services are often indispensable in treating a newcomer and in following his case afterward.”
The traditions of AA mirror central tenets of harm reduction. For example, Tradition 3 is: “The only requirement for AA membership is a desire to stop drinking.” AA members recognize that relapse can be part of recovery, and encourage even chronic relapsers to “keep coming back.” Indeed, many people begin attending meetings while still actively drinking alcohol or using substances. The fellowship’s response is to welcome these individuals with open arms. The refrain “We are glad you are here, especially the newcomer” is commonly used in preambles at the beginning of meetings. The underlying premise of Tradition 3 — in text and in practice — is meeting people where they are in their recovery, which is consistent with the core principles of harm reduction.
Nationwide, a patient-centered orientation of care within a framework of harm reduction is beginning to emerge in clinical practice. Guided with evidence amassed over the past few years, clinicians are revisiting restrictive protocols originally issued for buprenorphine care. Recent literature in an influential academic journal offers new clinical recommendations with respect to the incidence of relapse, patients’ use of other substances and benzodiazepines, and the expected duration of treatment. These evolving approaches both embody the model of harm reduction and are consistent with AA’s Tradition 3.
Another major 12-step organization, Narcotics Anonymous (NA), issued a pamphlet titled “Narcotics Anonymous and Persons Receiving Medication-Assisted Treatment” that notes, “Narcotics Anonymous does not express opinions — either pro or con — on civil, social, medical (including medically assisted treatment), legal, or religious issues.” Echoing AA, NA’s Tradition 3 states that the only requirement for membership is a desire to stop using. NA delegates to individual groups the question of whether members receiving MAT should be allowed to share their experience during meetings: “Each group is free to make its own decision on recovery meeting participation and involvement in group services for those receiving medication assistance for drug addiction.” The pamphlet encourages members receiving medications to find different meetings if they encounter strong opinions about MAT from other members.
Building Common Ground
There are promising examples in the addiction treatment community of providers beginning to weave MAT and harm reduction principles together with 12-step-based models. The Hazelden Betty Ford Foundation developed a clinical protocol and training materials to intentionally integrate MAT with 12-step concepts and therapies. Social Model Recovery Systems has served as a ‘provider champion,’ educating other 12-step-based providers that MAT is — as the organization’s medical director Donald Kurth asserts — “well worth including in our armamentarium.” Such initiatives can play an instrumental role in state, payer, and stakeholder efforts to promote dialogue about MAT and harm reduction.
Nationwide, treatment providers are revising discharge policies to better achieve the patient-centered goal of keeping patients engaged in care despite lapses in complete abstinence or in strict adherence to program rules. Too often, patients are administratively discharged — kicked out of treatment — for continued use of alcohol or substances, i.e., their presenting symptom. Encouragingly, providers are trending towards harm reduction in this respect. Administrative discharges have recently declined by half, from 16 percent of all discharges in 2002 to 7 percent of all discharges in 2010.
There are opportunities for policymakers as well. Regulators, accreditors, and payers managing provider networks may benefit from understanding the inclusive positions of 12-step organizations in their efforts to incorporate MAT and harm reduction models into policy requirements. Those seeking to mitigate ambivalence toward MAT and harm reduction must have a grasp of 12-step literature sufficient to address the concerns emanating from the recovery community. Yet to suggest that pharmacotherapy should replace the value offered by 12-step-based providers is a blind spot. There are historical reasons why 12-step-based providers staffed by individuals with lived experience are so common, including stigma and longstanding financial neglect of addiction research and services. The focus of the 12-step framework on addressing the spiritual dimensions of recovery can be a valuable part of OUD disease management; The American Society of Addiction Medicine acknowledges the spiritual manifestations of addiction in both its definition of addiction and its clinical assessment criteria. Rather than discount the abstinence-based provider network, stakeholders should seek opportunities to support 12-step-based providers and staff in integrating medication-based therapies and patient-centered harm reduction principles into their treatment paradigm.
Much of this work is unfolding. California, Massachusetts, and other states have issued guidance clarifying that residential providers are expected to admit patients treated by clinicians with MAT. Missouri requires all SUD treatment providers to offer or arrange for all forms of MAT. Virginia requires residential treatment organizations to demonstrate access to MAT through specified methods, and has issued policy guidance to establish harm reduction principles within its buprenorphine provider network. State Medicaid agencies implementing section 1115 SUD demonstrations must ensure that residential treatment facilities either offer MAT on-site to residents or facilitate off-site access, and are revising licensure, certification, policy, and contracting to promulgate and operationalize these new requirements.
In general, states are setting expectations and developing policies to promote access to MAT to better align with the established scientific consensus, the interest of national quality measurement organizations, recognition of potential legal liabilities, and, perhaps above all, the goal of providing patient-centered care to individuals who want to reclaim their lives. These objectives are achievable within the context of a 12-step framework for recovery, which is a prominent and longstanding feature of the specialty treatment field.
Disclaimer: The views expressed in this post are those of the authors and are not intended to represent the views of Alcoholics Anonymous or Narcotics Anonymous.
A Home, Defined by a Disaster — How Focusing on a Community’s Most Vulnerable Residents Can Transform Disaster Recovery Efforts
A home is so much more than a house, an apartment, or a couch at a friend’s place. A home means many different things to different people. But nowhere do we see “home” more wrongfully or woefully defined than in communities struggling to recover from a disaster.
The Stafford Act, which guides federal efforts in areas where a disaster has been declared, is focused on restoring people who are “disaster impacted” to their pre-disaster living conditions. When a storm damages a homeowner’s single-family dwelling, the path forward to restore that homeowner to their pre-disaster living conditions is relatively clear. But what about the same storm’s impact on people who were living on the street, or with family or friends? It is not as obvious how to restore such people to their pre-disaster living conditions. How do we help restore their homes when so many people responding to the disaster do not understand what their situations are? And even more importantly, how do we take disaster recovery a step further and begin to create more resilient communities?
I’ve worked in disaster recovery mode in Louisiana for over ten years, and more recently in North Carolina and California as well. But it only takes responding to one disaster to learn how powerfully the lowest-income members of a community are affected. In fact, a disaster’s effect on them is likely to involve a uniquely complex set of challenges because of their greater vulnerability to what is called “indirect impact.” For example, if a disaster takes public transportation off line for an extended period, a person without alternative options for getting to work might lose their job. Without that income, a couple of months later that person might lose whatever home they had, perhaps a room they rented in a friend’s apartment. This person may now experience episodes of literal homelessness, between short stays with family and friends. This can go on for years, if — as is the case in many areas — a rental market that was tight before the disaster becomes even more challenging.
How can we help this person recover from their disaster impact and return them to their pre-disaster state? And is that even the right thing to do?
The Second Wave
Even with the help of subsidy programs, people who were already experiencing homelessness before a disaster face increased difficulties finding housing afterwards, as the housing market is overwhelmed by displaced homeowners and renters. Rental rates surge quickly after a disaster — sometimes daily — and property owners may place more restrictions on which tenants they will accept. Some evict lower-income households in favor of tenants who can afford a higher rent. Such behavior can result in a secondary wave of people experiencing homelessness after a disaster. I’ve even seen some owners rent out disaster-damaged rental units without making any repairs, forcing families without other options to live in substandard conditions while paying exorbitant rent. The post-traumatic stress caused by such situations can exacerbate health conditions, lead to depression and substance use, and increase instances of domestic violence.
(Un)fortunately, a string of major disasters in the U.S. over recent years has opened up opportunities to develop more inclusive recovery strategies. And thanks to the Department of Housing and Urban Development, and in particular its Special Needs Assistance Programs (SNAPS) office, the definition of the official term “disaster-impacted” is at last beginning to expand.
Drawing on Homeless Services Expertise
After responding to multiple disasters, I can attest that each one is unique. What is not unique, however, is that as each temporary post-disaster recovery program eventually comes to an end, it is always the most vulnerable populations that are left behind — and too often, it is only then that homeless services leaders are brought into the disaster response. This must change. Those of us in the homelessness arena understand that every day is a disaster for people experiencing homelessness, and the knowledge and skills our field can bring should inform response and recovery efforts at every stage.
It used to be that I was only ever brought in at the end of a response to help all those people whom no one else was prepared to help, or who were not considered disaster-impacted, or who were imagined to be somehow gaming the system. (If you have never been inside a disaster shelter, I can tell you that it is not a home, and not somewhere people want to be.) These days, however, I am more often tapped while response and recovery plans are still being developed, and this represents real progress. I have taught Federal Emergency Management Agency (FEMA) officials what it means to be “couch surfing.” During the Great Flood of 2016 in Louisiana, those of us with homelessness expertise were able to help both HUD and FEMA to officially recognize and define the term “precariously housed.”
Looking Beyond Recovery
By helping those with the fewest resources to become more resilient, a community itself becomes stronger, too — and better prepared for overall disaster recovery. Strategies to support this goal include the development of mixed income rental housing with dedicated units for permanent supportive housing and for extremely low-income households; flexible rapid rehousing programs that provide case management services even after rental assistance ends; supportive services for persons with disabilities; and job creation for low- and moderate-income community members.
Disasters are awful tragedies for communities. However, Louisiana’s disaster-born permanent supportive housing program is a hallmark of recovery from hurricanes Katrina and Rita. You don’t have to go through a hurricane to create a permanent supportive housing program like Louisiana did. But if your community does experience a disaster that triggers an allocation of Community Development Block Grants for Disaster Recovery or other resources, then use that infusion to the best advantage! These resources can allow communities to rebuild beyond simply restoring pre-disaster conditions.
Until it is recognized that all of us are disaster-impacted just by virtue of living in a disaster-impacted area, there will be no equity in recovery efforts. We must think first of those who were already most vulnerable, and find ways not just to return them to their pre-disaster state, but to create more resilient people and communities.
HUD’s Disaster Recovery Homelessness Toolkit includes information and resources for local planning, immediate response, and disaster recovery.
Learn about TAC's technical assistance services in disaster preparedness and recovery.
Improving Homelessness Response Systems in California’s Counties
Under a new contract with California’s Department of Housing and Community Development, TAC is providing capacity-building technical assistance (TA) to help California’s communities enhance their homeless crisis response systems. First, TAC staff traveled with state officials and TA peers to meet with homeless system representatives from around the state, learning about their needs and introducing potential TA resources. Since then, TAC has been engaged by several communities, including Butte County where we are helping with disaster recovery after the devastating 2018 Camp Fire.
In Vermont, a Focus on Ending Youth Homelessness
Through the U.S. Department of Housing and Urban Development, the Vermont Balance of State Continuum of Care became an official Youth Homelessness Demonstration Program site in the summer of 2018. This award provides support to the CoC and its Youth Action Board (YAB) as they develop a plan to prevent and end youth homelessness in 13 of Vermont's 14 counties. TAC Associates Lauren Knott and Ellen Fitzpatrick are helping CoC leaders to develop and drive the planning process - focusing especially on strengthening youth voice, analyzing local data, and defining the CoC's vision for the initiative. With the CoC's written plan to HUD submitted and now approved, TAC is now helping with project selection and the implementation process. TAC staff members were also fortunate to participate in a two-day Youth Collaboration training facilitated on-site by True Colors United and including both YAB members and CoC leaders. TAC has supported the Vermont Balance of State CoC as it incorporate takeaways from this training and creates a system in which authentic youth collaboration is at the forefront of all planning to prevent and end youth homelessness in Vermont.
TAC Staff in Action
More than 700 leaders and managers from Supportive Services for Veteran Families (SSVF) grantee organizations attended five regional meetings in January, focused on rapid resolution — with TACsters Phil Allen, Ellen Fitzpatrick, Marie Herb, Ashley Mann-McLellan, Naomi Sweitzer, Douglas Tetrault, and Jim Yates providing coordination and giving presentations; Associate Ashley Mann-McLellan presented on “Designing Coordinated Entry Systems and Prioritization to Better Serve Individual Adults” at the Solutions for Individual Homeless Adults conference sponsored by the National Alliance to End Homelessness (BONUS: Check out Ashley’s blog post on what’s working in coordinated entry!); and Senior Associate Rachel Post led two sessions on Assertive Community Treatment and intensive case management at the Fairbanks (AK) Symposium on Homelessness.
The destructive nature of substance use disorders and the influence of active addiction on people’s behavior can often lead to homelessness. In fact, The Substance Abuse and Mental Health Administration (SAMHSA) estimates that 38 percent of individuals experiencing homelessness are dependent on alcohol, while 26 percent abuse other drugs, including opioids. With growing recognition of housing as a critical determinant of health and recovery, we must thoughtfully consider what kinds of housing can best help people with addictions optimize their potential for recovery and re-stabilize their lives.
Two recognized housing approaches intended to help people with substance use disorders (SUDs) transition from homelessness are “recovery housing” and Housing First. These approaches operate differently and have unique histories — yet rather than advocate for one over the other, I suggest that fully supporting both approaches should be our priority.
Alcohol and drug-free (recovery) housing is a critically important and currently under-resourced intervention. It can be operated with tiered levels of supports that are matched with the needs of residents, including more intensive supportive services for those exiting homelessness to self-governed Oxford Houses or Recovery Homes. Many residents of recovery housing attest to their need for this safe and supportive living environment in order to promote their long-term recovery from addiction, their health and wellness, and their ability to stay stably housed.
In the Housing First model, the top priority for service providers is to help individuals and families secure permanent housing. Often the term “low-barrier” is applied in this model, indicating that there are no conditions on tenancy, such as sobriety or participation in treatment. Housing First is based on evidence that stable, lease-based housing plus voluntary acceptance of services can help people make progress on addressing their mental health and addiction disorders.
My advocacy for both models is rooted in 17 years of work on programs designed to help this population. Indeed, my work starting Housing First programs at Central City Concern (CCC) in Portland, Oregon and at Colorado Coalition for the Homeless in Denver was inspired in part by wanting to make sure we were "throwing everything that worked” at ending chronic homelessness and addiction. At CCC, the idea of adding Housing First programming was initially met with some resistance, especially by colleagues who were themselves in long-term recovery. Over time, however, people began to see the value and successful outcomes of offering housing that was paired with individuals’ choices.
Recovery housing can be very effective for clients who are self-initiating detox and treatment. When evidence-based supported employment services, peer recovery mentors, and coordinated outpatient treatment were incorporated into CCC’s recovery housing, we found that high percentages of individuals with primary SUDs who had been homeless completed treatment and remained housed and employed one year post-exit.
With evidence supporting both approaches to housing for people with SUDs, providers and policymakers must be open to a range of approaches to address the diverse preferences and needs of the individuals they hope to serve. For this reason, when I shared the effectiveness of CCC’s recovery housing programs with federal agencies and stakeholders around the country, I also spoke (and still do) about the importance of ensuring housing choice for homeless people with SUDs.
Likewise, the Department of Housing and Urban Development (HUD) discussed in its 2015 Recovery Housing Policy Brief the value of promoting individual choice among housing options for homeless individuals. The brief encouraged expanding the supply of permanent supportive housing and other models that use a low-barrier, Housing First approach, so as not to exclude a large number of people who are unprepared to meet sobriety or abstinence requirements. But HUD also affirmed the importance of providing recovery housing options for people who want and need a sober-living environment. HUD’s Policy Brief outlines the characteristics, practices, and outcomes it expects from recovery housing funded with its homeless dollars.
The expansion of recovery housing received broader federal support in the 2016 Surgeon General’s Facing Addiction in America report, and in another report issued in 2017 by the President’s Commission on Combating Drug Addiction and the Opioid Crisis. Earlier this year, the National Council for Behavioral Health (NCBH) issued a Recovery Housing Guide to help states include high-quality recovery housing among the options offered by their behavioral health systems. NCBH followed this guide with a letter to every Single State Agency, alerting them to SAMHSA’s unprecedented decision to allow State Opioid Response Grants ($930 million) to fund supportive services for individuals with opioid use disorders in recovery housing.
Research is needed on the long-term effectiveness of both recovery housing and Housing First programs for people with primary SUDs. For now, states and local jurisdictions can use the practices described in the HUD and NCBH policy briefs to expand the capacity of recovery housing and improve the practices of existing programs. Recovery housing can promote housing tenure, long-term recovery, reunification with families and children, economic and educational advancement, improved health and wellness, and community involvement. Many of my colleagues whose experience of recovery housing helped cultivate my understanding of the model also report perhaps the most significant outcome of all: They say they owe their lives to it.
Current legislation in Congress addressing the nation’s opioid crisis has wide bipartisan support and includes several provisions to provide housing-related assistance for people in recovery from SUDs. As the final bill becomes law, states and communities working to combat both addiction and homelessness will become better able to offer housing choice that includes robust recovery housing programs.