Dr. Catherine Crosland, medical director of emergency response sites at Unity Health Care, remembers an older man she used to care for — one of the first people admitted to DC’s Pandemic Emergency Program for Medically Vulnerable Individuals, or PEP-V, in the early days of the public health emergency. Prior to being housed in a PEP-V hotel, the man “spent his life” going back and forth between the Adams Place shelter and its day center, lacking the resources to go anywhere else that was safe. He would traverse the alley separating the two buildings in his wheelchair, with a backpack containing his many medications slung across the back, she said.
The man suffered from various debilitating health conditions. A stroke survivor with congestive heart failure, he was consistently short of breath, Crosland says, with chronic swelling in his legs and feet as well as oozing, infected ulcers that refused to heal. Both his age and his health made him an obvious candidate for a city-funded private hotel room with steady access to meals as well as on-site health care and social workers — an urgent attempt to protect unhoused and medically vulnerable people from a virus that would likely kill them.
The PEP-V program, which grew to four hotels at its peak in 2021, was designed to keep individuals like Crosland’s patient out of congregate shelters and off the streets during the pandemic while providing them with wraparound care. It’s now two years old and still going strong, but faces an uncertain future. Though Crosland knows PEP-V is “not forever,” she and other advocates say some of the lessons learned during its tenure are too critical to be abandoned and should inform how the city administers homeless services and housing programs in the future.
PEP-V has helped illuminate the ways in which private, temporary housing programs — collectively known as “bridge housing” — can help people transition from shelters or the streets to permanent supportive housing, according to Christy Respress, executive director of Pathways to Housing, a homeless services provider in DC. At the beginning of the pandemic, Pathways to Housing and Unity Health Care, a community health network that operates clinics at several DC shelters, joined with DC’s Department of Human Services (DHS) and the Interagency Council on Homelessness to conceptualize and implement PEP-V.
DC’s PEP-V program has achieved a high success rate in getting people placed in permanent housing fairly quickly. As of May 24, DHS reports that 681 residents have moved into permanent housing, and 254 have been matched to a housing voucher but not yet moved into their own place.
Once DC added a fourth hotel in April 2021, the program’s capacity grew from more than 600 residents to over 800. PEP-V has been federally funded through the Federal Emergency Management Agency with various extensions over the last two years; funding had been set to expire on April 1 until the most recent extension was announced one month prior. There is currently no end date, but the reimbursement rate will drop to 90% as of July 1, with local funds covering the difference.
One of DC’s PEP-V hotels — the Holiday Inn on Rhode Island Avenue NW — recently withdrew from the program as the result of a “business decision” by the management company, according to an email from Dena Hasan, the director of DHS’s Office of Policy and Program Support. Residents who did not move into permanent housing prior to the closure were placed in one of the remaining three hotels, Hasan wrote.
Urgency and innovation
Respress said PEP-V’s success in connecting residents with permanent housing stems largely from the stability it offers. Having a stable place to stay simplifies the search for permanent housing as well as the process of procuring the identification documents and paperwork needed to lease an apartment.
“They’re starting off on more stable footing,” Respress explained. “When you’re on the street and we have to find you because you’re moving around just to survive,” it’s harder for case managers to locate their clients and complete needed steps.
“It just makes much more sense that it’s going to be a faster, smoother process that way, when people are stable and getting three meals a day, and having access to health care that they need,” Respress said.
Pathways to Housing case manager Tisha Wright works with clients matched to Emergency Housing Vouchers, assisting them through the process of securing housing and providing continued support services thereafter. Wright said it typically takes between six weeks and six months to get clients placed in permanent housing from PEP-V, depending on each client’s particular needs and responsiveness. According to a DHS representative, the average time between receiving a housing voucher and signing a lease is four to nine months, with PEP-V residents falling on “the shorter end of that range.”
Still, having a more stable platform to jump from is not the only factor that has sped up the process of moving from homelessness to permanent housing, Respress said. An influx of federal funding from both the Coronavirus Aid, Relief and Economic Security Act (CARES Act) and the American Rescue Plan Act (ARPA) not only increased the number of vouchers available but also came with streamlined procedures. Respress described the reduced time it takes to get someone into permanent housing as a “phenomenal” development that justifies making these changes permanent across the country.
The ARPA-originated EHV program — which has supplied DC with 707 vouchers — incentivized housing organizations, tenants and landlords alike to participate by expediting the process. Changes included loosened ID requirements as well as funding to cover security deposits and application fees, avoiding the need to help applicants find alternative sources.
Respress noted that the DC Housing Authority has worked to apply many of these innovations across voucher programs, whether an individual or family is receiving an EHV, federally funded Housing Choice voucher, or a locally funded voucher — all of which cap recipients’ contribution to their monthly rent at about 30% of their income. This allows low-income residents of cities such as DC, where housing costs are especially high, to remain stably housed.
In addition to instilling added urgency among city leaders to place people experiencing homelessness into stable housing, conditions sparked by the pandemic led to other positive changes. Those included conducting housing inspections and briefings for voucher holders virtually, which significantly shortened wait times in DC, Respress said.
Housing first with a bridge to get there
Respress noted that bridge housing such as PEP-V differs from so-called “transitional housing” because it is designed to be low-barrier and is focused on harm reduction — in keeping with the approach of the widely accepted Housing First model. Transitional housing, on the other hand, typically refers to rules-based programs where residents must “prove themselves ready” for permanent housing by overcoming various hurdles such as addiction, untreated mental health issues and lack of employment. Housing First, meanwhile, is built on the premise that positive change is best achieved from a position of stability, and that people have the capacity to address challenges more effectively once housed.
Housing First was accepted as best practice for housing the chronically homeless during President Barack Obama’s administration, according to Hilary Silver, professor of sociology, international affairs, and public policy and public administration at George Washington University. Nonetheless, the U.S. Department of Housing and Urban Development (HUD) has continued to fund shelter providers largely rooted in the charitable sector. These providers were absorbed into local “continuums of care” established to address a growing need for homeless services in the U.S. in the 1980s because they comprised the bulk of existing homelessness infrastructure at the time. Historically, Silver said, charitable shelter providers by and large embraced the transitional “staircase method” wherein people must prove that “they’re deserving, rather than just entitled” to permanent housing.
DC was an early adopter of Housing First beginning in 2004 when Pathways to Housing began using the model, and it has since become foundational to the provision of most homeless services in the District, including those administered by DHS. Yet there remained an entrenched model of an emergency shelter system embedded with other homeless services and a concurrent widespread rejection of the philosophy of “deservingness” that shaped traditional approaches to transitional housing. Ultimately, it took nothing short of a crisis to overcome those factors and effect significant change with the introduction of low-barrier bridge housing over the last two years.
“Let’s face it, people were dying during COVID, and there wasn’t much that shelters could do about that, because shelters concentrated all these people who could get sick. So, what COVID did was undermine shelters, in a sense. So the search for alternatives was strengthened,” Silver said. “And so they put people in hotels and discovered that lo and behold, it’s easier to place people in permanent housing from a hotel” than from a shelter or the streets.
Respress agrees that PEP-V represents yet another “creative solution” that arose from the pandemic. “It’s a great tool in our toolkit now,” she said. But “it’s also very expensive, so we have to decide how to use it.”
Most of the District’s funding to end homelessness should be used for permanent housing, Respress said. She envisions PEP-V continuing on a smaller scale once federal funding ends — perhaps as bridge housing for people who are “highly medically vulnerable” and waiting to be permanently housed.
Silver points out that PEP-V’s prohibition of the use of alcohol or illicit drugs on the premises presents a barrier for potential residents and thus does not align with the Housing First model. Crosland says that although substances were tolerated in the beginning, especially when DC was under a stay-at-home order, program leadership subsequently went “back and forth” on permitting their use as the city opened up and residents were able to use alcohol or drugs off-site. Ultimately, she says, leadership decided a few months ago to ban substance use at all PEP-V hotels, as it was intensifying “behavioral health issues” and causing incidents such as physical fights among residents “that were jeopardizing their ability to stay in the program.”
The future of bridge housing
Within the last year, DHS has expanded bridge housing in the District by contracting two local organizations — Community of Hope and Friendship Place — to provide this service to people experiencing homelessness who have already secured a housing voucher and are working with case management on housing placement. Since December 2021, the Community of Hope has operated the Bridge at Girard program in Northwest in a single room occupancy-style building for individuals or couples without children. The program’s goal is to transition residents to permanent housing within 90 to 100 days, said Kalifia Thomas, the group’s senior director of temporary housing programs.
At a DC Council budget oversight hearing on March 31, DHS Director Laura Zeilinger cited the recent creation of bridge housing as one way the successes of the PEP-V model have already influenced other housing programs. She said the agency also intends to partner with the DC Department of Housing and Community Development (DHCD) to develop single room occupancy housing with on-site services. In terms of the future of PEP-V itself, a DHS representative subsequently told The DC Line and Street Sense Media that discussions are “in the infancy stages and we don’t have any plans or ideas to share at this time.”
DHCD received a portion of the $5 billion that was allocated by the ARPA to reduce homelessness and increase housing stability nationwide. Richard Livingstone, DHCD deputy chief of staff and communications director, said the agency expects to release a plan in July laying out how these funds will be used. Currently, the Interagency Council on Homelessness Housing Solutions Committee “is working through the needs of people in the homeless services system that are not met by recent expansions of permanent supportive housing,” as well as conducting focus groups with people experiencing homelessness, he said via email. Once HUD has approved a plan, developers will be invited to submit proposals.
For her part, Crosland would like to see PEP-V continue on a smaller scale to fill gaps in the “scattered site” model of vouchered permanent housing, where chronically homeless individuals are housed in an apartment on their own, with visits twice a month from a housing case manager able to provide support. For a subset of PEP-V residents, however, this level of support is simply not enough, Crosland says.
These individuals, while usually able to care for themselves at a basic level, typically struggle with what are called “independent activities of daily living,” such as grocery shopping, cleaning, paying bills and taking medications — tasks that are necessary to maintain a household as well as one’s health. If they want to live alone, they might benefit from a home health aide, Crosland says, but some prefer to live in a community setting and tend to be more successful under those circumstances. She also predicts some cost savings in site-based housing where staff can tend to several individuals at once, versus having one home health aide for each person.
Crosland calls this model “Permanent Supportive Housing Plus,” or site-based housing for a medically vulnerable population with meal service, health care and support staff on premises. She notes that Mayor Muriel Bowser’s Homeward DC 2.0 Plan to end homelessness includes the development of just such a model — a “more intensive … site-based PSH to ensure individuals with the most extensive barriers receive the supports needed,” according to the document.
Crosland explains that the only current option for individuals who need and prefer this level of care is assisted living, which is more intensive and restrictive than the PEP V-like model. In addition, Medicaid-funded individuals in assisted living must contribute all but $100 of their monthly income to pay for their care — a rule that Crosland says sometimes deters people who would benefit from assisted living. In her vision, PSH+ residents would contribute a third of their income, just like other voucher recipients.
When Crosland visited her now-former Adams Place patient just one week after he moved to PEP-V, he was transformed and “looked amazing,” she says, with no shortness of breath, reduced swelling in his legs, wounds clear of infection, and his medications “lined up on his dresser where he could see them.” Nothing had changed with regard to his medical care, Crosland says — the difference was “that he had a safe place to sleep, to elevate his legs, to put his medications, and to shower.”
“That’s just an image I keep in my mind of how housing is health care,” she says.
