“Do You Have a Way, If I Become Feeble, That I Still Can Be Safe?”: Client and Service Provider Perspectives on the Coordinated Entry System

Permanent supportive housing (PSH) is an evidence-based solution to chronic homelessness. There are two common PSH models: place-based (PB) programs where clients live in one building with services provided onsite and scattered-site (SS) programs, which use community apartments coupled with mobile case management and support. Understanding the relative strengths and weaknesses of PB and SS is important for PSH planning and service delivery. This paper explores homeless service provider perspectives on these two models after the onset of the COVID-19 pandemic. Service providers (N = 37) from across 5 PSH agencies in Los Angeles that provided either PB or SS services during the pandemic participated in focus groups. Discussions were recorded, transcribed, and analyzed using template analysis, grounded theory, and inductive techniques. Providers identified four major differences between PB and SS services: (1) challenges in finding placements; (2) managing relationships with landlords/property managers; (3) frequency of contact; and (4) community integration. Advantages of PB included ease of finding units, ease of managing relationships with landlords/property managers, greater ability to serve clients efficiently, more frequent client contact, and more community among residents. SS was seen to provide tenants with more opportunities to grow, live in healthier environments, and develop independence. During the pandemic, finding units for SS clients became more difficult, while differences between PB and SS related to frequency of contact and community integration became more attenuated. PB can be advantageous for clients with higher levels of acuity, whereas SS could be more appropriate for clients who are more stable and independent. PB programs are seen to have practical and logistical advantages, but some providers prefer SS services. Clients and providers should be matched to PSH configurations that best match their needs and preferences, and providers should be aware that public health emergencies may impact PB and SS settings differently.

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

A body of research documents the empirical benefits of permanent supportive housing (PSH) at the individual and societal levels. This study aimed to understand how formerly homeless adults experience living in PSH and how service providers experience working with residents of PSH. Semi-structured interviews were conducted with 13 residents and 12 service providers across three PSH sites in Northern California. Using thematic analysis, we constructed four themes that highlight the complexities of housing chronically homeless adults with severe mental illness and co-occurring substance use disorders. Interviewees discussed the ways in which housing provided a foundation for residents to make positive life changes, including achieving housing stability, improving physical and mental health, finding a sense of purpose, and (re)building relationships. Interviewees also discussed challenges with project-based PSH, such as appropriateness of fit between new and existing residents, and provision of services. Residents and service providers alike highlighted substance use as the primary threat to housing stability for both the person using and those who have minimized use or stopped using. These findings provide support for the Housing First principles underlying PSH, but also highlight the need for considering individual consumers’ needs in the development of housing programs and implementation of supportive services.

Though unemployment and homelessness are closely intertwined, vocational services are rarely prioritized for homeless-experienced individuals engaging in housing services. Our goal was to examine associations between vocational service use and housing outcomes among homeless-experienced Veterans engaged in permanent supportive housing. We obtained data from Veterans Health Administration (VHA) medical record and homelessness registry data for homeless-experienced Veterans engaged in U.S. Department of Veterans Affairs (VA) Greater Los Angeles' permanent supportive housing program from October 2016 to September 2017 (n = 1,200). We used multivariate logistic regression to examine whether vocational service use was associated with housing attainment and/or premature permanent supportive housing exits. We found that Veterans in permanent supportive housing who used vocational services were more likely to attain housing (OR = 2.52, p < .001) than their peers who did not use these services. There were no between-group differences in the odds of premature exits from the permanent supportive housing program (OR = 1.92, p = .425). Our study suggests that, among homeless-experienced Veterans engaged in permanent supportive housing programs, those who use vocational services potentially may be more likely to attain housing. However, future research can better elucidate the pathways underlying vocational service use and housing outcomes for individuals in permanent supportive housing programs. Greater integration of vocational services and permanent supportive housing programs, and encouragement of vocational service use may enhance housing outcomes among permanent supportive housing participants. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Provider perspectives of housing programs for young adults 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.

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.

The provision of high-quality medical care has become a key challenge in many countries. At the same time, there is a growing awareness that the early detection of chronic diseases can reduce mortality rates. Therefore, it is important to identify service needs which influence to participate in health screening. To date, little research has been conducted into the perspectives of service providers on this topic. In this preliminary study, we aimed to explore the perspectives of service providers who work in a community-based setting in order to identify perceived barriers to chronic disease screening and incentives which can increase participation rates. In-depth interviews were conducted with 10 experienced health service providers from October 2017 to December 2017. Interviewees included physicians and community health representatives who had been working in a community-based health screening service for at least 3 years. The study identified several aspects of health screening services for chronic diseases that are in need of improvement, including a shortage of appropriate health service providers, inadequate attendance promoting measures, a lack of continually accessible and affordable medical services, healthcare professionals who possess inadequate communication skills, and rural-urban health care disparities. Service providers believe that current services do not fulfill community needs. Older adults who live in rural areas experience especially significant screening-related health disparities, which are mainly affected by structural service barriers. To improve the quality of medical services, healthcare screening services should be evaluated according to the perspectives of both participants and service providers.

Single-site, permanent supportive housing (PSH) buildings with a Housing First approach have become an increasingly common solution to homelessness in many North American cities. Because people who have experienced long-term homelessness are also likely to have experienced trauma, trauma-informed care has become a key tenet of service providers working with residents in PSH. Trauma-informed design (TID), however, is newer. Relatively little research or theory exists about its implementation in PSH. This paper explores recently constructed, single-site, Housing First PSH buildings in the United States to understand how trauma-informed design principles are manifest in the common areas of those buildings. Data for the study consisted of interviews with social service providers, observations of the TID spaces, and photographs and floor plans of the buildings, and, for three buildings, minutes from the TID process meetings. The analysis revealed four approaches to trauma-informed PSH: 1) provide multiple common areas to maximize resident choice and safety; 2) separate spaces with walls but connect them with interior windows to provide safety; 3) supply a central third stair to encourage social engagement and 4) design places for future resident empowerment and voice. This research contributes a necessary, heretofore missing, spatialization to existing scholarship on PSH.

Permanent supportive housing (PSH), which combines affordable public housing with social services, has become the dominant model in the United States for providing housing to formerly homeless people. PSH has been effective in reducing re-entry to homelessness, yet has shown limited evidence of improving formerly homeless individuals' mental health and quality of life. This study aimed to understand the lived experiences of formerly homeless adults' adjustment to tenancy in PSH, with a focus on how living in PSH has affected their meaningful activity and social engagement. Based on a phenomenological approach, a thematic analysis was conducted using semi-structured interviews with 17 individuals living in three PSH buildings in New York City. Results suggested that PSH was beneficial in fulfilling formerly homeless individual's basic needs and facilitating lifestyle improvements, yet many were dissatisfied with their living conditions and lacked meaningful activity, social integration, and community belongingness. These issues were found to develop in large part as a result of formerly homeless individuals' disharmonious relationships within the social context of PSH, consisting of staff members, other residents, and people in the surrounding community. The effects of the COVID-19 pandemic and implications for PSH social services are discussed.

Permanent supportive housing (PSH) is an effective intervention to improve residential stability and reduce the utilization of costlier healthcare services for the chronically homeless. However, there has been little focus on health-related quality of life (HRQL) once they enter PSH, and the potential influence of other factors including the PSH model. Study results can shed light on the HRQL of the PSH population and inform strategies to improve PSH program effectiveness in this area. In this cross-sectional study, survey methods were used to assess the HRQL of PSH residents in the Chicago metropolitan area. The survey also included questions on socio-demographics, health behaviors, housing and neighborhood characteristics, and housing satisfaction. The SF-36 was used to obtain physical (PCS) and mental component summary (MCS) scores for HRQL. Other variables were selected using the Wilson and Cleary HRQL model. Statistical analyses included summary statistics, bivariate analyses, and fully adjusted linear regression models. The study sample included 855 adults currently in PSH. The sample was predominantly African American men with an average age of 53years. Mean scores for PCS and MCS were 39.4 and 46.1, respectively, (out of 100). In adjusted analyses, older age and being on disability were associated with worse PCS. Having HIV was associated with better PCS. Being non-Hispanic Black, living in fixed-sited housing, and being in PSH for longer durations were associated with better MCS. More depressive symptoms was associated with worse PCS and MCS. While both aspects of the PSH model (housing configuration and service provision) were initially associated with HRQL in unadjusted analyses, housing configuration was the only PSH model variable that remained significant once accounting for other factors. Depressive symptomology and the social environment also appear to be important correlates of HRQL and are potential areas to target in PSH programs.

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.

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.

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

ABSTRACTThis research seeks to understand goals and the gender differences in goals among men and women who are transitioning into permanent supportive housing. Men and women experience homelessness differently. Data collected for this study come from a longitudinal investigation of HIV risk behavior and social networks among women and men transitioning from homelessness to permanent supportive housing. As part of this study, 421 baseline interviews were conducted in English with homeless adults scheduled to move into permanent supportive housing; participants were recruited between September 2014 and October 2015. This paper uses goals data from the 418 male-or female-identified respondents in this study. Results identified goal differences in education and general health between men and women that should be taken into account when service providers, policy makers, and advocates are addressing the needs of homeless women.