The central insight of the program, obvious in retrospect: the chronically homeless need the stability of a home before they can address their problems; the strung out and schizophrenic, bouncing from shelter to street, can hardly be expected to keep regular appointments with the doctor – much less clean up and apply for a job.

Advocates did not require engagement with substance abuse counselors and case managers, for fear of alienating the most compromised. But providers, who often struggled to find clients on the street, now knew where to look. They kept showing up. Kept offering help.

The hope was that the approach would actually save money – or at least break even – by cutting back on expensive visits to the emergency room and easing the strain on the shelter system. Indeed, Dennis Culhane, a researcher at the University of Pennsylvania, had found that 10 percent of the homeless use some 50 percent of the services.

And the promise of cost-cutting made housing first attractive to even the coldest of fiscal conservatives. This was a program that had bipartisan appeal. That is not to say that housing first was always an easy sell. After all, it asks the public to underwrite the housing of single alcoholics while the “deserving poor” – a homeless mother and her children, say – are relegated to shelters.

But housing first has shown promising results. A recent New York Times story told the tale of the last homeless man in Times Square. Cities from Columbus, Ohio to San Francisco have reported significant gains. And some of the ethical questions surrounding the approach have begun to fade as the program morphs into settled policy around the country and policymakers start to apply its principles to homeless families, too.

Here in Rhode Island, Nan Roman, president and CEO of the National Alliance to End Homelessness, gave the idea an important nudge forward with a visit and speech in 2002. Four years later, Rhode Island Housing First, a pilot program run by Riverwood Mental Health Services, was up and running with funding from the state and the United Way.

Don Boucher, the program director, says the effort was jarring at first, even for homeless advocates: “It’s a very loaded initial presentation – we’re going to provide permanent housing to people who have been homeless for at least seven years, who have a major persistent mental illness and a co-occurring substance abuse disorder and we’re going to do that, often times, within two weeks of initially meeting them.”

But advocates were convinced of the idea’s power pretty quickly. Case managers were reaching a hard-to-reach population. Health indicators were improving. And a transient population was finding stability.

A subsequent evaluation by Eric Hirsch, a professor of sociology at Providence College, found that more than 90 percent of the 41 clients tracked in his study remained in permanent housing a year into the program. And he estimated that housing first saved an estimated $8,000 per client each year.

Of course the program, which now houses 140 people in apartments scattered across Providence, Pawtucket, and Central Falls, has had its share of challenges. Advocates say some clients, for whom street survival was a full-time job, have felt isolated and aimless in their apartments.

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