A review of the literature on neighborhood impacts of permanent supportive housing (PSH) and emergency shelters for people experiencing homelessness

People experiencing chronic homelessness are trapped in a cycle of homelessness and trauma. Traditional approaches to homelessness attempt to address people’s trauma first and use housing as a reward for complying with treatment; such approaches fail because people cannot improve physically or psychologically while they are actively experiencing the trauma of homelessness. Our current responses to chronic homelessness do not work, but cities often justify the status quo as the only fiscally responsible option. Instead, these approaches are among the most expensive and least effective. Permanent Supportive Housing (PSH) flips the traditional order in which homelessness and trauma are addressed by providing non-time limited, low barrier housing, and offering — but not mandating — supportive services. Once housed, people formerly experiencing chronic homelessness can then improve their physical and mental health, address substance use, and seek education or employment. Research shows that PSH results in better housing stability than housing interventions that require sobriety or treatment compliance. Further, PSH is associated with better outcomes related to quality of life, emergency services, physical and psychiatric hospitalizations, and substance use. Better outcomes for residents also save money, making PSH the most cost-effective, long-term solution to chronic homelessness. When people experiencing chronic homelessness receive PSH, they are less likely to use emergency departments, hospitals, detoxification facilities, and shelters. PSH residents are also less likely to interact with law enforcement, get arrested, and be incarcerated. The decreased use of these expensive services is dramatic and results in savings. Often, cost savings equal or exceed the cost of PSH. PSH is a front-loaded investment that can replace ineffective traditional programming, show significant and persistent results, and save cities, states, and the federal government money over time. Although PSH is proven to be most cost-effective solution to chronic homelessness, existing studies radically underestimate the benefits. Most studies focus on just one or a few typical cost drivers associated with chronic homelessness, such as emergency services. No study accounts for the millions of dollars cities spend on sweeping encampments; the substantial costs for the entire criminal justice system process (from arrest through probation); the extraordinary demand for police and outreach services that do not result in issuing citations or criminal charges; the drag on each entity within the emergency response system (fire departments, EMTs, police, emergency rooms); the overtaxing of volunteers, members of the faith community, and community service providers; the clear economic impacts on local businesses, tourism, and travel; and the significant psychological and emotional tolls exacted from unsheltered people as well as the surrounding community. Thus, even the already impressive evaluations of PSH’s cost-effectiveness are vast underestimations of its impact. PSH is the most humane and cost-effective solution to chronic homelessness. Indeed, it is the most studied intervention in all of homelessness policy. Federal, state, and local governments must stop being pennywise but pound foolish, and instead take bold steps to bring PSH to scale to finally stem the crisis.

Homeless adults with serious mental illnesses and chronic substance abuse problems have few housing options, a problem compounded when a criminal background is present. This study compared the criminal backgrounds and other characteristics of homeless individuals who succeeded in housing (retained housing continuously for two years) and those who failed in housing. The study population consisted of homeless adults with behavioral health disorders who moved into supportive housing between January 1, 2000, and June 30, 2004, regardless of criminal background. Data about criminal history and other characteristics were extracted from existing records and analyzed for associations with housing success. Chi square tests and logistic regression analysis were used to find characteristics predictive of subsequent housing success or failure. Data were available for 347 participants. Most (51%) had a criminal record, and 72% achieved housing success. The presence of a criminal background did not predict housing failure. Younger age at move-in, the presence of a substance abuse problem, and higher numbers of drug crimes and property crimes were separately associated with more housing failure; however, when they were adjusted for each of the other variables, only move-in age remained associated with the outcome. The finding that criminal history does not provide good predictive information about the potential for housing success is important because it contradicts the expectations of housing operators and policy makers. The findings suggest that policies and practices that keep homeless people with criminal records out of housing may be unnecessarily restrictive.

Permanent supportive housing (PSH) programs, which have grown over the last decade, have been associated with changes in health care utilization and spending. However, little is known about the impact of such programs on use of prescription drugs critical for managing chronic diseases prevalent among those with unstable housing. To evaluate the effects of PSH on medication utilization and adherence among Medicaid enrollees in Pennsylvania. Difference-in-differences study comparing medication utilization and adherence between PSH participants and a matched comparison cohort from 7 to 18months before PSH entry to 12months post PSH entry. Pennsylvania Medicaid enrollees (n = 1375) who entered PSH during 2011-2016, and a propensity-matched comparison cohort of 5405 enrollees experiencing housing instability who did not receive PSH but received other housing services indicative of episodic or chronic homelessness (e.g., emergency shelter stays). Proportion with prescription fill, mean proportion of days covered (PDC), and percent adherent (PDC ≥ 80%) for antidepressants, antipsychotics, anti-asthmatics, and diabetes medications. The PSH cohort saw a 4.77% (95% CI 2.87% to 6.67%) relative increase in the proportion filling any prescription, compared to the comparison cohort. Percent adherent among antidepressant users in the PSH cohort rose 7.41% (95% CI 0.26% to 14.57%) compared to the comparison cohort. While utilization increased in the other medication classes among the PSH cohort, differences from the comparison cohort were not statistically significant. PSH participation is associated with increases in filling prescription medications overall and improved adherence to antidepressant medications. These results can inform state and federal policy to increase PSH placement among Medicaid enrollees experiencing homelessness.

ABSTRACTObjectives: While permanent housing, addictions, and mental health treatment are often critical needs to achieve housing stability and community reintegration, few studies have systematically integrated them into a single comprehensive approach for people experiencing chronic homelessness. This pilot study examined the feasibility and preliminary outcomes of systematically integrating permanent supportive housing and an evidence-based co-occurring disorders intervention called Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking (MISSION). Methods: This single-group open pilot enrolled 107 people with co-occurring disorders experiencing chronic homelessness from two Massachusetts inner-city and rural areas. Enrolled subjects were interested in receiving permanent supportive housing along with 1 year of MISSION services. Data were collected through baseline and 6- and 12-month follow-up assessments. Results: Participants (Mage = 49.52 years, SD = 10.61) were mostly male (76.6%), Caucasian (52.3%), and unemployed (86.0%), with an average of 8.34 years (SD = 8.01) of homelessness. Self-reported lifetime problems with anxiety (75.7%) and depression (76.6%) were common, as was use of alcohol (30.8%), cannabis (31.8%), and cocaine (15.9%). Almost all participants (95.3%) were placed into permanent housing, which took on average 42.6 days from enrollment (SD = 50.09). Among those placed, nearly 80% of the clients were able to retain housing through the end of the study. Overall retention was high, with 86.0% remaining in MISSION treatment until the end of the study. While there were no significant changes in rehospitalization, service utilization, or substance use, there were modest significant mental health symptom improvements from baseline to program completion. Conclusions: This pilot study suggests that co-occurring disorder interventions like MISSION are feasible to integrate with permanent supportive housing despite the somewhat differing philosophies, and preliminary data suggested substantial improvements in housing and modest improvements in mental health symptoms. While caution is warranted given the lack of a comparison group, these findings are consistent with other rigorous studies using MISSION among homeless individuals who did not receive permanent supportive housing.

Effectiveness of permanent supportive housing and income assistance interventions for homeless individuals in high-income countries: a systematic review

Permanent supportive housing is an effective intervention for stably housing most people experiencing homelessness and mental illness who have complex support needs. However, high-risk behaviours and challenges are prevalent among this population and have the potential to seriously harm health and threaten housing tenures. Yet, the research on the relationship between high-risk issues and housing stability in permanent supportive housing has not been previously synthesized. This rapid review aimed to identify the housing-related outcomes of high-risk behaviours and challenges in permanent supportive housing settings, as well as the approaches used by agencies and residents to address them. A range of high-risk behaviours and challenges were examined, including risks to self (overdose, suicide/suicide attempts, non-suicidal self-injury, falls/fall-related injuries), and risks to multiple parties and/or building (fire-setting/arson, hoarding, apartment takeovers, physical/sexual violence, property damage, drug selling, sex trafficking). The search strategy included four components to identify relevant academic and grey literature: (1) searches of MEDLINE, APA PsycINFO, and CINAHL Plus; (2) hand searches of three journals with aims specific to housing and homelessness; (3) website browsing/searching of seven homelessness, supportive housing, and mental health agencies and networks; and (4) Advanced Google searches. A total of 32 articles were eligible and included in the review. Six studies examined the impacts of high-risk behaviours and challenges on housing tenancies, with overdose being identified as a notable cause of death. Twenty-six studies examined approaches and barriers to managing high-risk behaviours and challenges in PSH programs. These were categorized into eight types of approaches: (1) clinical, (2) relational/educational, (3) surveillant, (4) restrictive, (5) strategic, (6) design-based, (7) legal, and (8) self-defence. Consistent across all approaches was a lack of rigorous examination of their effectiveness. Further, some approaches that are legal, restrictive, surveillant, or strategic in nature may be used to promote safety, but may conflict with other program objectives, including housing stability, or resident empowerment and choice. Research priorities were identified to address the key evidence gaps and move toward best practices for preventing and managing high-risk behaviours and challenges in permanent supportive housing.

Permanent supportive housing (PSH) programs have the potential to improve health and reduce Medicaid expenditures for beneficiaries experiencing homelessness. However, most research on PSH has been limited to small samples of narrowly defined populations. To evaluate the effects of PSH on Medicaid enrollees across New Jersey. Linked data from the Medicaid Management Information System and the Homeless Management Information System were used to compare PSH-placed Medicaid enrollees with a matched sample of other Medicaid enrollees experiencing homelessness. Comparisons of Medicaid-financed health care utilization and spending measures were made in a difference-in-differences framework 6 quarters before and after PSH placement. A total of 1442 Medicaid beneficiaries enrolled in PSH and 6064 Medicaid-enrolled homeless individuals not in PSH in 2013-2014. PSH placement is associated with a 14.3% reduction in emergency department visits (P<0.001) and a 25.2% reduction in associated spending (P<0.001). PSH also appears to reduce inpatient utilization and increase pharmacy spending with neutral effects on primary care visits and total costs of care (TCOC). Placement in PSH is associated with lower hospital utilization and spending. No relationship was found, however, between PSH placement and TCOC, likely due to increased pharmacy spending in the PSH group. Greater access to prescription drugs may have improved the health of PSH-placed individuals in a way that reduced hospital episodes with neutral effects on TCOC.

The objective of this study was to identify individual- and program-level characteristics associated with veterans' ability to move into permanent housing following receipt of a housing voucher and to identify factors associated with more rapid placement into housing. This study used secondary quantitative and primary quantitative and qualitative data collected from veterans participating in the U.S. Department of Housing and Urban Development and U.S. Department of Veterans Affairs Supportive Housing program at four locations between 2008 and 2014 (N=9,967). Interviewers conducted in-person surveys with a subsample of the cohort (N=508). The study assessed two outcomes: whether a veteran accessed permanent supportive housing and the number of days required for veterans to move in. A logistic regression analysis identified predictors of becoming housed and a multiple regression model determined factors that influenced the time required for veterans to move into housing after admission to the program. Most (85%) veterans who received a permanent housing subsidy identified and moved into permanent housing. Receipt of outpatient behavioral health care in the 90 days before program admission and use of outpatient medical, behavioral health, or substance use care in the 90 days after increased the odds of becoming housed. Program-level policies may contribute to enhanced access to housing among veterans seeking permanent supportive housing, specifically a holistic approach to the frequent provision of supportive services-including both health care and case management-immediately after program admission.

Approximately 3.5million youth experience homelessness in the United States. Assisting youth to exit homelessness as quickly as possible through various housing venues aims to prevent adverse health impacts that prolonged homeless experiences may have on youth. Rapidre-housing (RRH) is a recent, short-term, less costly housing option than permanent supportive housing that provides temporary housing supports and services to counter homelessness. Although previous literature indicates that youth are likely to achieve stable homelessness exits via RRH, the duration of wait times for youth and potential disparities in RRH waiting periods remain unclear. We used administrative data from 16 communities across the United States (N = 10,920) to gain a greater understanding about RRH wait times among homeless youth. In addition, we adopted a competing risk survival analysis to investigate potential disparities (i.e., race and ethnicity, gender, rurality, sexual orientation, and previous homelessness condition) in RRH wait times while taking into consideration the presence of other homelessness exit options (e.g., permanent supportive housing). Study results indicate that RRH is a common homelessness exit for homeless youth and is prioritized for youth assessed as mid-vulnerability, per commonly accepted assessment measures of youth vulnerability. However, youth who received RRH waited, on average, 131days following their housing eligibility assessment. Furthermore, being a minor (i.e., 17years old or younger), experiencing homelessness in rural communities, and lower engagement in homeless services (e.g., emergency shelters and transitional living programs) were all associated with lower probability of exiting into RRH over time, taking into account the possibility of other competing homelessness exits. Expansion of the short-term housing supports offered through RRH may be a promising strategy to counter homelessness among youth in a timely manner. However, such an expansion should also address the potential disparities underlying youths' wait time to receive RRH in order to reduce prolonged homelessness experiences within this vulnerable population.

A community-academic partnership to develop an implementation support package for overdose prevention in permanent supportive housing

Impact of Permanent Supportive Housing on the Use of Acute Care Health Services by Homeless Adults

Permanent supportive housing (PSH) programs are being implemented nationally and on a large scale. However, little is known about PSH for transition-age youths (ages 18 to 24). This study estimated health services costs associated with participation in PSH among youths and examined the relationship between fidelity to the Housing First model and health service outcomes. Administrative data were used in a quasi-experimental, difference-in-differences design with a propensity score-matched contemporaneous control group to compare health service costs among 2,609 youths in PSH and 2,609 youths with serious mental illness receiving public mental health services in California from January 1, 2004, through June 30, 2010. Data from a survey of PSH program practices were merged with the administrative data to examine changes in service use among 1,299 youths in 63 PSH programs by level of fidelity to the Housing First model. Total service costs increased by $13,337 among youths in PSH compared with youths in the matched control group. Youths in higher-fidelity programs had larger declines in use of inpatient services and larger increases in outpatient visits compared with youths in lower-fidelity programs. PSH for youths was associated with substantial increases in costs. Higher-fidelity PSH programs may be more effective than lower-fidelity programs in reducing use of inpatient services and increasing use of outpatient services. As substantial investments are made in PSH for youths, it is imperative that these programs are designed and implemented to maximize their effectiveness and their impact on youth outcomes.

This study assessed whether permanent supportive housing (PSH) participation is associated with health service use among a population of adults with disabilities, including people transitioning into PSH from community and institutional settings. Our primary data sources were 2014 to 2018 secondary data from a PSH program in North Carolina linked to Medicaid claims. We used propensity score weighting to estimate the average treatment effect on the treated of PSH participation. All models were stratified by whether individuals were in institutional or community settings prior to PSH. In weighted analyses, among individuals who were institutionalized prior to PSH, PSH participation was associated with greater hospitalizations and emergency department (ED) visits and fewer primary care visits during the follow-up period, compared with similar individuals who largely remained institutionalized. Individuals who entered PSH from community settings did not have significantly different health service use from similar comparison group members during the 12-month follow-up period.

Background:Permanent Supportive Housing (PSH), which provides subsidies for independent housing and supportive services, is an evidence-based practice that improves health and housing for homeless experienced persons. Though most PSH is scattered-site, that is, housing dispersed throughout the mainstream rental market, project-based PSH offers housing and supportive services in dedicated facilities with on-site services. In 2013, the Veterans Health Administration (VA) at Greater Los Angeles opened a novel project-based PSH program located on a VA campus. To inform plans to expand project-based PSH at this VA, we examined participants’ experiences in this program. We aimed to identify participant characteristics that suggested they were well suited for the planned PSH expansion; to characterize services that participants found valuable in this setting; and to highlight gaps between participants’ needs and PSH services provided.Methods:We performed semi-structured interviews with a convenience sample (n = 24) of participants who had engaged in this project-based PSH program. Interviews asked why participants selected housing on a VA campus and explored valued program characteristics, designs, and services. Using rapid analysis methods, we generated templated summaries of each participant’s responses across the domains of our interview guide, then used matrix analyses to identify salient themes across the interviews.Key Findings:Participants appreciated the ease of access to medical and mental health services; however, as services were assumed to be optimized by virtue of co-location with VA healthcare, their PSH providers often did not link them with non-VA social services as assertively as desired. Many participants raised concerns about building safety and on-site substance use. A lack of participant engagement in program oversight, often leading to conflicts with staff and building management, was also highlighted in our interviews.Discussion:Given the value placed on ease of access to healthcare, these data suggest the value of this PSH model for persons with healthcare vulnerabilities. Specific recommendations for the planned PSH expansion include: (1) continuation of proximate, open-access healthcare; (2) clear tenant policies; (3) tenant councils for each development; (4) staff knowledgeable of non-VA resources and social services; (5) Veteran-preferred hiring practices by Property/Service management; (6) gender-specific accommodations; and (7) robust 24/7 security on-site.

Objective: Among individuals experiencing chronic homelessness, there is a high rate of co-occurring mental health and substance use, which has traditionally been addressed through the delivery of permanent supportive housing along with substance use and mental health services. However, this population often has difficulty engaging in treatment for co-occurring disorders, which can result in exacerbation of symptoms and housing loss. Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking (MISSION) is a co-occurring mental health and substance use wraparound approach that was pilot-tested alongside Permanent Supportive Housing (PSH) to improve treatment access and engagement. This pilot was part of a state plan to end homelessness in the Boston metro area. Methods: This open pilot study enrolled 136 individuals who were chronically homeless and offered one year of MISSION along with PSH. Program participants also received baseline and 6- and 12-month follow-up assessments. Results: At one-year follow-up, 82.4% of the program participants were housed in PSH. However, due to limited affordable housing in the Boston metro area, it took on average 6.20 months to house the program participants. Furthermore, while MISSION was feasible to implement alongside PSH, fidelity to the MISSION model was lower than expected. This pilot also examined the role of housing status on clinical outcomes and found that the program participants who were housed at the time of discharge displayed a statistically significant improvement in emergency room visits for mental health complaints, the Psychosis subscale of the Behavior and Symptom Identification Scale (BASIS-32), illegal drug use, and pharmacotherapy treatment. Conclusions: This pilot study demonstrated that systematically integrating PSH and MISSION can improve access and engagement in care, housing retention, and mental health outcomes. Despite the preliminary success and while taking into account the limitations of the open single-group pre/post design, this study also identified the lack of affordable housing as a potential barrier to placement as well as the critical role of housing for improved clinical outcomes. Randomized controlled trials are needed to test MISSION with PSH as well as perhaps PSH with and without MISSION to tease apart the effects of integrating both approaches simultaneously.