Time to move on: exploring the journey from supportive housing to independent living for people with past homelessness experience

Perceptions from emerging adults with a history of homelessness on their experiences with housing, health and other support services

Objectives The aims of the present study were to examine tenants' experiences of a model of integrated health care and supportive housing and to identify whether integrated health care and supportive housing improved self-reported health and healthcare access. Methods The present study used a mixed-method survey design (n=75) and qualitative interviews (n=20) performed between September 2015 and August 2016. Participants were tenants of permanent supportive housing in Brisbane (Qld, Australia). Qualitative data were analysed thematically. Results Integrated health care and supportive housing were resources for tenants to overcome systematic barriers to accessing mainstream health care experienced when homeless. When homeless, people did not have access to resources required to maintain their health. Homelessness meant not having a voice to influence the health care people received; healthcare practitioners treated symptoms of poverty rather than considering how homelessness makes people sick. Integrated healthcare and supportive housing enabled tenants to receive treatment for health problems that were compounded by the barriers to accessing mainstream healthcare that homelessness represented. Conclusions Extending the evidence about housing as a social determinant of health, the present study shows that integrated health care and supportive housing enabled tenants to take control to self-manage their health care. In addition to homelessness directly contributing to ill health, the present study provides evidence of how the experience of homelessness contributes to exclusions from mainstream healthcare. What is known about the topic? People who are homeless experience poor physical and mental health, have unmet health care needs and use disproportionate rates of emergency health services. What does the paper add? The experience of homelessness creates barriers to accessing adequate health care. The provision of onsite multidisciplinary integrated health care in permanent supportive housing enabled illness self-management and greater control over lifestyle, and was associated with self-reported improved health and life satisfaction in formerly homeless tenants. What are the implications for practitioners? Integrated health care and supportive housing for the formerly homeless can improve self-reported health outcomes, enable healthier lifestyle choices and facilitate pathways into more appropriate and effective health care.

This phenomenological study examines the lived experiences of adults who experienced homelessness during adolescence and survived prolonged trauma. The research focused on understanding how these individuals interpret and define their trauma and homelessness and what strategies they use to support their mental, emotional, and physical well-being in adulthood. The primary research questions explored how participants describe the trauma associated with their adolescent homelessness and how they currently manage their health and well-being: How do adults who experienced homelessness during adolescence understand and describe their homelessness experiences? How do adults who experienced homelessness during adolescence understand and describe the trauma associated with these experiences? and What strategies do these adults engage in to support their health and well-being in adulthood? Semi structured interviews with 10 participants residing in a supportive housing program operated by a nonprofit agency in Brooklyn, the New York City borough, were used to gather data. The study provides a nuanced look into the intersection of trauma, recovery, and resilience. A thematic analysis of the interview data revealed five major findings. Trauma and recovery--participants reflected on the lasting psychological and emotional impacts of homelessness, including abuse, neglect, and systemic failures. Resilience and coping--participants described adaptive strategies such as therapy, spirituality, creative expression, and community engagement. Sense of community--supportive housing fostered social connections and reduced isolation. Career and economic stability--access to education, job training, and employment services contributed to rebuilding independence. Mental health and well-being--participants emphasized the importance of trauma-informed care, peer support, and holistic wellness practices including yoga and meditation. This study contributes to the literature on trauma-informed supportive housing by centering on the voices of those with lived experience. It underscores the importance of integrating mental health care, stable housing, and holistic supports in service models aimed at youth and adults with histories of homelessness. The findings have implications for social work, policy development, and trauma recovery programs aimed at promoting long-term stability and healing. Keywords: Homelessness, adolescent trauma, supportive housing, resilience, recovery, trauma-informed care, mental health, physical health, well-being, coping strategies, lived experience, qualitative research.

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

Poor physical and mental health and substance use disorder can be causes and consequences of homelessness. Approximately 2.1 million persons per year in the United States experience homelessness. People experiencing homelessness have high rates of emergency department use, hospitalization, substance use treatment, social services use, arrest, and incarceration. A standard approach to treating homeless persons with a disability is called Treatment First, requiring clients be "housing ready"-that is, in psychiatric treatment and substance-free-before and while receiving permanent housing. A more recent approach, Housing First, provides permanent housing and health, mental health, and other supportive services without requiring clients to be housing ready. To determine the relative effectiveness of these approaches, this systematic review compared the effects of both approaches on housing stability, health outcomes, and health care utilization among persons with disabilities experiencing homelessness. A systematic search (database inception to February 2018) was conducted using 8 databases with terms such as "housing first," "treatment first," and "supportive housing." Reference lists of included studies were also searched. Study design and threats to validity were assessed using Community Guide methods. Medians were calculated when appropriate. Studies were included if they assessed Housing First programs in high-income nations, had concurrent comparison populations, assessed outcomes of interest, and were written in English and published in peer-reviewed journals or government reports. Housing stability, physical and mental health outcomes, and health care utilization. Twenty-six studies in the United States and Canada met inclusion criteria. Compared with Treatment First, Housing First programs decreased homelessness by 88% and improved housing stability by 41%. For clients living with HIV infection, Housing First programs reduced homelessness by 37%, viral load by 22%, depression by 13%, emergency departments use by 41%, hospitalization by 36%, and mortality by 37%. Housing First programs improved housing stability and reduced homelessness more effectively than Treatment First programs. In addition, Housing First programs showed health benefits and reduced health services use. Health care systems that serve homeless patients may promote their health and well-being by linking them with effective housing services.

Homelessness affects individuals who are experiencing life without safe, adequate or stable housing. Conceived in this way, homeless not only describes those individuals who are visibly homeless and living on the street, but also those precariously housed individuals who; stay in emergency accommodation, sleep in crowded or inadequate housing, and those who are not safe in their living environment. Kuhn and Culhane (1998) further classify individuals experiencing homelessness as those who are chronically homeless, those who are transitionally homeless and those who experience episodic bouts of homelessness. There are causal relationships between various situational and personal factors which lead to an individual experiencing homelessness (Anderson & Christian, 2003; Morse, 1992). Most researchers do agree that important factors include (but are not limited to); a lack of affordable and adequate housing, poverty caused by unemployment or lack of available resources, absence or reduction of health and social services, breakdowns of personal relationships (Crisis, 2020). Global data suggests that at least 1.6 billion people lack adequate housing (Habitat for Humanity, 2017). In the European context this figure continues to rise across all European Union member states with the exception of Finland where homelessness has been on the decline since 1987 (FEANTSA 2017; Y-Foundation, 2017). Without access to housing, individuals are exposed to disease, poverty, isolation, mental health issues, prejudice and discrimination, and are under constant and significant threat to their personal safety. Therefore, having access to safe, stable and adequate housing is internationally recognised as a basic human right (OHCHR, 2009) and is central to developing a population who are living healthy, safe and happy lives. Individuals who are currently experiencing poorer physical and mental health are overrepresented in the homeless population (Link, 2014). Additionally, for the large population who are currently living without homes they continue to suffer due to social inequalities which are persistent and enduring and continue to widen over time. These social inequalities coupled with poor health make the pathways out of homelessness especially challenging. Some of these obstacles include; inability to hold steady employment (Rosenberg & Kim, 2018), encountering prejudice and discrimination while trying to access services (Ramsay, Hossain, Moore, Milo, & Brown, 2019), and addiction issues (Tsemberis, 2011). Homelessness is recognised as a multifaceted and complex issue and many accommodation-based approaches have evolved across the globe to incorporate additional support and services beyond delivery of housing while other interventions deliver only temporary housing which is insufficient to meet peoples basic needs. Interventions included in this review are those which primarily seek to meet the user's accommodation needs through provision of a short-term shelter and bed or a long-term home. These interventions may be provided alongside additional support and services. These interventions will be referred to as accommodation-based approaches/interventions throughout this protocol. Accommodation-based approaches with or without additional components is not a new phenomenon and stems from a seemingly accidental combination of global ideas, progression of evidence-based policy and practice, and establishment of welfare states. Some of the major accommodation-based interventions are diverse in their approach which makes classification especially difficult. This coupled with inconsistent descriptions of interventions has rendered current categorisations meaningless. In this protocol we will describe how the review team created a new and meaningful typology to categorise included interventions, however, initially we will briefly describe some of the familiar interventions found in the evidence base that will fall into the new typology. These interventions have been selected as they are well known to policymakers and are mainly representative of interventions targeting those vulnerable to homelessness, however there is often an inconsistent understanding of what they may look like on the ground in different contexts. For example, although the intervention may be called "Housing First," there are often discrepancies in how this intervention in implemented across countries and contexts. This section aims to clarify what the main interventions are: HF interventions offer housing to homeless individuals with minimal obligation or preconditions being placed upon the participant. HF programmes share some common themes: (a) the participant is provided access to permanent housing immediately, without conditions, (b) decisions around the location of the home and the services received are made by the client, (c) support and services to aid the individual recovery are provided alongside housing placement, (d) social integration with local community and meaningful engagement with positive activities is encouraged. HF is based on the principle that housing should be made available in the first instance and preconditions such as sobriety and involvement in treatment programmes are unnecessary barriers placed upon homeless individuals. Through the removal of these common obstacles, it is believed that the individual has a better chance of achieving stabilisation in appropriate housing and feeling more willing or able to accept treatment. Hostels provide accommodation for both short-term housing needs. Homeless hostels often impose strict rules on the persons who stay there relating to abstinence, behaviour and curfews. The individuals who frequent hostels vary but may include homeless individuals, homeless families, homeless couples and homeless individuals with pets. Sleeping arrangements are variable with some offering dormitory style sleeping alongside communal kitchen, living and shower areas while others have bedsit flats. The type of support offered by a homeless hostel varies, often determined by the resources available and individuals they are able to house. However, some common types of support offered in homeless hostels include a support plan to move to more stable accommodation, practical help with form filling and obtaining necessary governmental documents, or treatment for substance abuse issues. Homeless shelters are a basic form of temporary accommodation where a bed is provided in a shared space overnight. One of the key features of a homeless shelter is that it is transitory and not usually seen as stable forms of accommodation as the individual is often subject to overcrowding, physical altercations, theft, substance abuse, and unhygienic sleeping conditions. Similarly to hostels, homeless shelters often place additional requirements on potential users including night time curfews. Additional services that may or may not be provided by the homeless shelter are warm meals for dinner and breakfast or support from volunteers who help individuals make connections to other services. Supported housing is an extremely complex intervention type. To be categorised as supported housing, the intervention will combine housing with additional supportive services as an integrated package. The housing offered can be permanent or temporary; nonabstinent contingent or abstinent-contingent; staffed group homes, community based or in a private unit; and the subsidies towards rent also vary. Supportive services will be offered directly to the individual or through referrals to the relevant body. Supportive services might include those to help with mental health issues, substance misuse, those interventions which increase access to health services, support to continue education or find employment, help with accessing benefits, or those services which focus on social aspects of the individual's life such as positive interactions with society, or community engagement. Suttor (2016) argues that while it may be advantageous to create interventions tailored to the individual's unique needs, there is a need to classify approaches. Indeed, most commentators acknowledge the challenges of lack of clear definition of the many terminologies used to describe accommodation-based interventions. One example of this is highlighted in a study which identified 307 unique terms across 400 articles on supported accommodation (Gustafsson et al., 2009 cited in McPherson, Krotofil, & Killaspy, 2018). Additionally, the HF model initially seems like an approach where categorisation is straightforward, however, there exists significant inconsistencies regarding implementation. Various researchers observe that this may be due to the way the HF model has deviated from the original "Pathways to Housing" intervention (Tsemberis & Eisenberg, 2000) due in part to the progression of services and support (Johnson, Parkinson, & Ahuri, 2012; Phillips et al., 2011). Due to these inconsistencies in the literature it became apparent that the review team must create meaningful categorisations for accommodation-based interventions to allow functional and useful comparison between various intervention types. The importance of these categorisations cannot be understated, as it provides an international framework from which policy makers and funders can work to provide change on homelessness. Furthermore, it takes an evidence-based approach to identify what accommodation interventions work best for individuals experiencing homelessness and what components make them most effective. To develop the typology further, we selected a random sample of five accommodation-based interventions included in the evidence and gap map (EGM) of homelessness interventions, (White, Saran, Teixeira, Fitzpatrick, & Portes, 2018) upon which this review is based. Second, two review team members then independently coded the characteristics, hypotheses and concepts related to each intervention and compared notes when each reviewer had completed their five papers. This independent analysis of the sampled papers ensured both objectivity and consistency in this step of the process and allowed the reviewers to investigate substantial amounts of data without bias or a predetermined hypothesis. Third, emerging themes were collated, and reviewers communicated to better understand the patterns which appeared through the sampled studies. Finally, through this iterative process we conclude that the most suitable way to create meaningful categorisations would be based around the intensity (defined as the level of the support offered) of the intervention and the expectations posited to the client during it as there was significant diversity in approaches taken. One such taxonomy already exists and is based on an international evidence review of 533 interventions on rough sleepers. This review was led by one of the current review authors (Mackie & Wood, 2017) and was created to differentiate between types of temporary accommodation, namely shelters and hostels. The review team adapted this taxonomy to help create categorisation for the network of accommodation-based interventions alongside Lipton and colleagues' (Lipton, Siegel, Hannigan, Samuels, & Baker, 2000) descriptive categorisation of low, moderate, or high intensity housing which is based on the amount of structure and level of independence offered to their 2,937 study participants. A further category (Housing only) was added to fit interventions which focused on giving the individual accommodation for an extended period of time without further support or services offered. It was deemed to be more than just meeting the basic needs of the individual, but not intense enough to meet the criteria of the moderate category, as they were not receiving any additional services or help. Furthermore, interventions varied on the conditions the client was required to abide by. These conditions include needing to be sober from alcohol and/or drugs, abstain from criminal activity or to gain employment after a certain amount of time. To accurately incorporate these into the categories, it must be stated whether the intervention required such a behavioural condition (conditional) or whether there were no behavioural conditions imposed (unconditional). The typology is as follows: Interventions that meet the client's basic human needs only. This would be the provision of a bed and other basic subsistence such as food. There are no named additional services or support offered to the client. This type of intervention focuses more on the short-term benefit to the client. The accommodation or support offered may require further conditions from the client upon admission such as sobriety or punctuality. An example of this intervention type would be if clients were given one night in a hostel with a meal on the condition that they arrive by 11 pm. Interventions which offer only minimal sleeping facilities to the client without additional services or support. Unlike the type of intervention describe above, there are no behavioural expectations placed on the individual. An example of this would be if clients were provided access to a shelter without exception. The clients are provided a form of discounted or free accommodation for an extended period, with conditions, but without additional support or services. An example of this is shown in Siegel et al. (2006): one of the interventions described provide the participants with housing where they are helped to pay for it financially by their own specific agency. Tenants were responsible for their own meals and utility expenses. An example of the behavioural expectations imposed on clients receiving this type of intervention may be that they must enter paid employment within 6 months. Provision of housing for an extended period but without further support and services offered to the client. The participant is not required or obligated to meet any behavioural expectation to retain their housing. Moderate levels of support and/or services are provided in addition to housing. The level of support and type of service offered will remain general and aimed towards the homeless population as a single entity, and not specific to individual personal needs. This housing coupled with general support and services will be offered on the condition that an individual meets a behavioural expectation. For example, in Sosin, Bruni and Reidy (1996), a housing intervention alongside a moderately intensive drug case management intervention was offered. To take part, participants had to sign a contract agreeing to abstain from drugs and or alcohol. Interventions in this category are the same as the above category except there will not be a behavioural expectation placed on the client. For example, Lim et al. (2017) focused on accessing cheaper housing and services to prevent youth from becoming homeless. The participants were encouraged to attend but it was not strictly enforced and there were no conditions placed upon the individuals to partake in the intervention. These interventions provide housing and actively and assertively work to improve client's long-term outcomes. The intervention provides assertive, individualised services and interventions for clients. They often focus specifically on the personal needs of the client. The intervention can involve improving housing stability, health, and employment, among other specific needs. The accommodation or support offered may place a behavioural expectation upon the person upon admission to the intervention. For example, participants in Schumacher et al. (2003) were provided housing alongside intensive treatment and other services. All participants were routinely tested for drugs and alcohol and were not allowed to continue with the intervention until were they deemed sober. Interventions in this category are the same as the above category except there will not be a behavioural expectation placed on the client. For example, Levitt et al. (2013) intervention included providing housing, meals and on-site care services. On-site case managers would consistently work with each individual participant on their substance use and life goals. The participant did not need to be sober to partake in the intervention. Interventions in this category would be those that do not actively work to improve the lives of the clients. The client is not offered a bed/food or any additional support by the researchers. An example of this is shown in Sosin et al. (1996) article. The control group used in this experiment received no additional aid from those conducting it. Those in the control received some minimal information on where they could receive help in the form of abuse agencies or welfare offices but were not offered any additional help or services by researchers. The distinctive component shared by all accommodation-based interventions is that accommodation will be provided to individuals (even if only for the short-term). Some interventions may also provide accommodation alongside the service and support they require to continue life independently without the risk of future homelessness. By providing accommodation, individuals will have a greater opportunity to concentrate their efforts on gaining support to address other areas of their lives, for example, in health care, education or employment. As suggested in the new typology, accommodation programmes may provide additional supportive services, creating more opportunities for individuals to access services onsite where they live. This integrated support can importantly provide necessary individualised services within a familiar and welcoming context. The intensity of the intervention is also related to this; if the intervention provides intensive individualised support, the individual is more likely to engage and take advantage of the services available. Regarding conditionality, if certain conditions such as sobriety or compulsory attendance are required as part of the accommodation agreement, this can also increase engagement with services or improve the individuals health outcomes. However, conditionality can be detrimental to individualised entrenched in homelessness, as they may be unwilling to change their situation without ownership over the decision. The aim of this systematic review and network meta-analysis is to establish the effectiveness of accommodation-based approaches though a robust and rigorous synthesis of the available literature. The network meta-analysis will also allow us to rank the effectiveness of interventions according to the categorisations described in the typology outlined earlier. Study characteristics will be examined through moderator analysis and investigation of potential heterogeneity. Through investigation of the sources of variance, review authors can explain potential differences in effect sizes. This will be particularly important in the field of homelessness research which embraces a complex systems perspectives and experts are not only drawn to a "what works" linear cause and effect but also towards an understanding of what works, for whom, and in what circumstances? This systematic review will be based on evidence already identified in two existing EGMs commissioned by the Centre for Homelessness Impact (CHI) and built by White et al. (2018). The EGMs present studies on the effectiveness and implementation of interventions aimed at people experiencing, or at risk of experiencing, homelessness. The EGMs identified various systematic reviews which assess the effectiveness of interventions like HF (Beaudoin, 2016; Woodhall-Melnik & Dunn James, 2016) and supported housing (Burgoyne, 2013; Nelson, Aubry, & Lafrance, 2007; Richter & Hoffmann, 2017), and interventions which were conducted in hostel and shelter settings (Haskett, Loehman, & Burkhart, 2016; Hudson, Flemming, Shulman, & Candy, 2016). However, a network meta-analysis of accommodation-based interventions for a homeless population does not exist. Various systematic reviews which synthesise accommodation-based interventions more generally, differ from the proposed review in several ways: Bassuk et al. (2014) systematically reviewed and narratively reported the findings of six studies which looked at the effectiveness of housing interventions and housing combined with additional services. The interventions included HF, rapid rehousing, vouchers, subsidies, emergency shelter, transitional housing and permanent supportive housing. However, authors limited the population to American families who were experiencing homelessness and so any final conclusions on the efficacy of accommodation-based interventions on the wider population of individuals experiencing homelessness are impossible to reach. Fitzpatrick-Lewis et al. (2011) conducted a rapid systematic review on the effectiveness of interventions to improve the health and housing status of individuals experiencing homeless which located 84 relevant studies. Only those studies published between January 2004 and December 2009 were included in this review and so the current review will be more current and much broader in scope. Additionally, the primary purpose of the review was to identify literature which improved health outcomes for those experiencing homelessness and so other important outcomes were not included. A title form has been to the by et al. which at how various interventions the physical and mental health of homeless individuals alongside other social outcomes. One in the title form is to the of the current will assess are the of housing on the health outcomes of homeless and housed compared to or no However, the current review will have a wider by including additional outcomes across a wider A review by the effectiveness of both housing and case management programmes for people experiencing, or at risk of experiencing homelessness. The main outcomes of to the authors were reduction in homelessness and housing the literature until January and meeting the predetermined did not include research or data related to the of the interventions, which are of to this proposed Finally, a review by the what for et al., 2018) included studies which included of HF supported housing recovery housing housing interventions for housing interventions for vulnerable youth and complex interventions at those with poor mental health a of both and however, due to were to independent of the potential studies and risk bias in the Additionally, only studies published after were included in this review and so the current review will be broader in scope. Finally, the authors was to create a and evidence map between housing and and so the were not but described narratively makers and have had a and to individuals experiencing or at risk of experiencing homelessness from the of living without a home. Due to these many researchers have to understand which accommodation-based interventions may work for whom, and in which Through synthesis of the available and most robust this review will provide the best of by more data than a primary research study is the effect of accommodation-based interventions on outcomes for individuals experiencing or at risk of experiencing category of intervention is compared to other interventions and compared to as do accommodation-based interventions work best people or Individuals with high or complex or single the of housing or the outcomes by individuals experiencing or at risk of experiencing implementation and process factors intervention will include all study where a comparison group was This and other study that to the of the intervention on homelessness appropriate As are as more rigorous than the potential of a study on effect will be as part of the analysis of heterogeneity. treatment. as where people receive their level of support or intervention. where individuals or are to receive the intervention at a where participants receive some from researchers but both participants and researchers are that this is not an intervention. where participants that they are receiving an but the researchers the treatment as with no control or comparison or with no to control for relevant will not be included. or will also be Homelessness affects individuals who are experiencing life without safe, or stable housing. Conceived in this way, homelessness not only describes those individuals who are visibly homeless and living on the street, but also those precariously housed individuals who; stay in emergency accommodation, sleep in crowded or inadequate housing and those who are not safe in their living environment. further classify individuals experiencing homelessness as those who are those who are and those who experience or inadequate housing This systematic review will focus on all individuals who are currently experiencing, or at risk of experiencing homelessness of or The included studies will include from as by the Homelessness is as those individuals who are sleeping as those in temporary accommodation as shelters and those in accommodation as those or in or and those in inadequate accommodation which are unhygienic and/or Interventions will include those based on the typology in This typology is enough to include all accommodation-based approaches which meet These are based on the and characteristics of the intervention and not on the by the study Interventions will be tested a control group or through to with an treatment. can include various such no or treatment This review primarily how interventions can homelessness and increase housing for those individuals experiencing, or at risk of experiencing, homelessness. might be described time homeless, of participants housed or time in specific to and and and These outcomes the used in the et al., 2018). where these accommodation-based interventions take place may be varied and might include hostels, and community housing. This systematic review will be based on evidence already identified in two existing EGMs commissioned by the and built by White et al. (2018). The EGMs present studies on the effectiveness and implementation of interventions aimed at people experiencing, or at risk of experiencing, homelessness in high The used a and one was to map the included studies in an existing review on homelessness & 2018), two was a of and systematic review for primary studies and systematic included for of included studies and with experts to identify additional literature. terms can be found in the protocol et al., 2018). Interventions will include and effectiveness of accommodation-based approaches a control group or through to with an treatment. authors will data on the same participants across more than one this to effect within each single The meta-analysis will use robust to for effect & The for & will be

Supportive housing has become the dominant model in the United States to provide housing to the chronically homeless and to improve their housing stability and health. Most supportive housing programs follow a "housing first" paradigm modeled after the Pathways to Housing program in New York City. However, components of housing first supportive housing models were poorly defined, and supportive models have varied considerably in their dissemination and implementation to other parts of the country. Recently, research has been conducted to determine the fidelity by which specific housing programs adhere to the Pathways Housing First model. However, evidence regarding which combination of components leads to better health outcomes for particular subpopulations is lacking. This article presents results from qualitative interviews with supportive housing providers in the Chicago, Illinois, metropolitan area. Supportive housing varied according to housing configuration (scattered-site vs. project-based) and service provision model (low-intensity case management, intensive case management and behavioral health), resulting in 6 basic types. Supportive housing programs also differed in services they provided in addition to case management and the extent to which they followed harm-reduction versus abstinence policies. Results showed advantages and disadvantages of each of the 6 basic types. Comparative effectiveness research may help identify which program components lead to better health outcomes among different subpopulations of homeless. Future longitudinal research will use the identified typology and other factors to compare the housing stability and health outcomes of supportive housing residents in programs that differ along these dimensions. (PsycINFO Database Record

BackgroundAcquired brain injury (ABI) can significantly impact mental health, vulnerability to addictions, and housing stability, yet the intersection of these challenges is understudied. Individuals living with ABI are disproportionately represented among populations experiencing homelessness and have a high prevalence of concurrent mental health and substance use (MHSU) disorders, leading to poorer health outcomes and lower quality of life. The objective of this study was to identify barriers and facilitators to housing and healthcare services for people experiencing homelessness with ABI and concurrent MHSU disorders.MethodsData were collected during a one-day workshop as part of the British Columbia Consensus for Brain Injury, Mental Health and Addiction project. Semi-structured focus groups involving ABI survivors, service providers, and community stakeholders explored barriers, facilitators, and recommendations for service improvements. Using manifest content analysis, data were analyzed in accordance with a well-validated conceptual framework for healthcare access.ResultsA total of 163 stakeholders (M = 46.40, SD = 13.80, 72% female) including 74 with lived experience of ABI and/or homelessness, participated in the focus groups. Manifest content analysis revealed five barriers and five facilitators: Barriers included (1) Stigma, (2) Insufficient Investment, (3) Siloed Systems, (4) Generalized Approaches to Housing, and (5) Policies that do not Support Complex Needs, while facilitators included (1) Increasing Discourse on the Intersections of ABI, MHSU, and Homelessness, (2) Government Commitment to Systemic Change, (3) Collaboration Across Organizations, (4) Community-Based Services, and (5) Supportive Housing Models.ConclusionsThese findings highlight gaps in existing policies and services while identifying effective approaches to supporting individuals experiencing these intersections. Efforts to address barriers and leverage existing facilitators may support the development of accessible services that address unmet health and housing needs among people experiencing homelessness with concurrent ABI and MHSU conditions.

Alcohol Minimum Unit Pricing (MUP) was introduced in Scotland in May 2018. Existing evidence suggests MUP can reduce alcohol consumption in the general population, but there is little research about its impact on vulnerable groups. This qualitative study explored experiences of MUP among people with experience of homelessness. We conducted qualitative semi-structured interviews with a purposive sample of 46 people with current or recent experience of homelessness who were current drinkers when MUP was introduced. Participants (30 men and 16 women) were aged 21 to 73 years. Interviews focused on views and experiences of MUP. Data were analysed using thematic analysis. People with experience of homelessness were aware of MUP but it was accorded low priority in their hierarchy of concerns. Reported impacts varied. Some participants reduced their drinking, or moved away from drinking strong white cider, in line with policy intentions. Others were unaffected because the cost of their preferred drink (usually wine, vodka or beer) did not change substantially. A minority reported increased involvement in begging. Wider personal, relational and social factors also played an important role in responses to MUP. This is the first qualitative study to provide a detailed exploration of the impact of MUP among people with experience of homelessness. Our findings suggest that MUP worked as intended for some people with experience of homelessness, while a minority reported negative consequences. Our findings are of international significance to policymakers, emphasising the need to consider the impact of population level health policies on marginalised groups and the wider contextual factors that affect responses to policies within these groups. It is important to invest further in secure housing and appropriate support services and to implement and evaluate harm reduction initiatives such as managed alcohol programmes.

We investigated associations between (1)housing status (four categories measuring housing stability) and outcomes along the HIV care continuum (not currently on antiretroviral therapy [ART]; sub-optimal ART adherence [< 95% in the last 3-4 weeks]; unsuppressed viral load [> 200 copies/ml], median CD4 < 200 in the last six months), and (2) housing status and unmet primary, dental and mental health care needs in the last six months among WLWH. Housing status was defined according to the Canadian Definition of Homelessness and had four categories: unsheltered (i.e., living in ≥ 1 unsheltered location [e.g., street, abandoned buildings]), unstable (i.e., living in ≥ 1 unstable location [e.g., shelter, couch surfing]), supportive housing (i.e., only living in supportive housing), and stable housing (i.e., only living in one's own housing; reference). At baseline, in the last six months, 47.3% of participants reported unstable housing, followed by 24.4% unsheltered housing, 16.4% stable housing, and 11.9% supportive housing. Overall, 19.1% of the full sample (N = 336, 2010-2019) reported not currently on ART; among participants on ART, 28.0% reported sub-optimal ART adherence. Overall, 32.1% had recent unsuppressed viral load. Among a subsample (n = 318, 2014-2019), 15.7% reported unmet primary care needs, 26.1% unmet dental care needs, and 16.4% unmet mental health care needs. In adjusted models, being unsheltered (vs. stable housing) was associated with not currently on ART, unsuppressed viral load, and unmet primary and dental care needs. Housing and health services need to be developed with and for WLWH to address structural inequities and fulfill basic rights to housing and health.

To assess the impact of a New York City supportive housing program on housing stability and preventable emergency department (ED) visits/hospitalizations among heads of homeless families with mental and physical health conditions or substance use disorders. Multiple administrative data from New York City and New York State for 966 heads of families eligible for the program during 2007-12. We captured housing events and health care service utilization during 2years prior to the first program eligibility date (baseline) and 2years postbaseline. We performed sequence analysis to measure housing stability and compared housing stability and preventable ED visits and hospitalizations between program participants (treatment group) and eligible applicants not placed in the program (comparison group) via marginal structural modeling. We matched electronically collected data. Eighty-seven percent of supportive housing tenants experienced housing stability in 2years postbaseline. Compared with unstably housed heads of families in the comparison group, those in the treatment group were 0.60 times as likely to make preventable ED visits postbaseline (95% CI=0.38, 0.96). Supportive housing placement was associated with improved housing stability and reduced preventable health care visits among homeless families.

Community integration is recognized as a meaningful goal that is highly relevant to the long-term success of supportive housing programs. Research to date highlights concerns that some individuals in permanent supportive housing remain socially isolated and have limited success in other domains of community integration. However, we know little about what factors impact formerly homeless veterans’ ability to achieve community integration. To identify factors associated with community integration among homeless veterans housed through the Department of Veterans Affairs’ (VA’s) Supportive Housing program (HUD-VASH), we performed secondary database analyses of Veterans (n = 560) housed via HUD-VASH in the VA Greater Los Angeles Healthcare System from 10/1/14–9/30/15. We conducted ordinal and logit regressions to examine associations between baseline HUD-VASH participant characteristics, supportive housing voucher type, health service utilization in the year post-housing, and three types of community integration outcomes (i.e., change in community adjustment, status of housing stability, and change in employment). Data were obtained from HOMES (VA’s homeless registry) and Corporate Data Warehouse (CDW) (VA’s a national administrative dataset of VA inpatient and outpatient care). Mental health service utilization was negatively associated with community adjustment, housing stability, and employment. Employment at baseline was positively associated with housing stability and employment. Also, substance use disorder visits was positively associated with employment, and combined medical and substance use disorder diagnoses was positively associated with change in community adjustment. We considered 29 variables and found relatively few were associated with community integration. Consistent with previous research, our study highlights the importance of mental health needs, and suggests that utilization of mental health services is an important indicator of improvements in community adjustment, housing stability, and employment.

High-risk issues, such as overdose, suicidality, hoarding, violence, property damage, and apartment takeovers, are known challenges in supportive housing and Housing First programs. However, the effects of these incidents on residents, service providers, and programs have been minimally studied. The objective of this mixed-methods study was to understand what service providers perceived as the impacts of various high-risk issues in supportive housing and Housing First programs, with an emphasis on housing tenure. This descriptive study used an exploratory sequential mixed-methods design, with unequal weighting (QUAL→quan). In-depth interviews were held with 32 service providers working in supportive housing and Housing First programs, followed by an online survey of 202 additional service providers across Canada. In the qualitative dataset, high-risk issues were identified as having three types of potentially harmful impacts: [1] "we have to evict certain people sometimes" (residents' housing stability); [2] "we're exposed to these traumas as well" (service providers' mental health); and [3] "we're losing our stock, basically" (organizational relationships with landlords and access to housing units). Convergence was generally found in the quantitative findings, with high-risk issues affecting other individuals and property being perceived as more likely to cause housing loss. Service providers working in scattered-site programs reported that hoarding, overdose, and apartment takeovers were significantly more likely to cause housing loss than did participants of single-site programs. Overall, study findings underscore how high-risk issues, particularly those affecting others and property, can be potential housing trajectory-altering events and that this is further shaped by housing and support models.

ABSTRACTHomelessness and housing instability continue to be significant social issues facing low-income families, suggesting a need for more comprehensive, family-based approaches to housing services. This study explored the experiences of 10 HIV-positive women and their children in a Midwestern supportive housing program via in-depth interviews and 5 supportive housing staff. This study explored the challenges associated with housing stability, the availability and limitations of available supportive services, and the effect of permanent supportive housing in the lives of families impacted by HIV/AIDS. Narratives of case managers and housing participants provide a unique perspective into the challenges and strengths of supportive housing programs. Findings reveal the complex needs of HIV-positive mothers in supportive housing, including accessing housing in safe and affordable neighborhoods, and highlight the effectiveness of permanent supportive housing and comprehensive case management services in helping HIV-positive women maintain their health. Findings from this study can help improve case management and social services for women and children living in supportive housing and highlight the need for specific child- and family-centered services. Additional longitudinal research is needed to document sustained effects of supportive housing.

While experiences of later-life homelessness are known to vary, classification of shelter, housing and service models that meet the diverse needs of older people with experiences of homelessness (OPEH) are limited. To address this gap, a scoping review was conducted of shelter/housing options, supports and interventions for OPEH. Fourteen databases were searched for English-language peer-reviewed and/or empirical literature published between 1999 and 2019, resulting in the inclusion of 22 sources. Through a collaborative, iterative process of reading, discussing and coding, data extracted from the studies were organised into six models: (1) long-term care, (2) permanent supportive housing (PSH), including PSH delivered through Housing First, (3) supported housing, (4) transitional housing, (5) emergency shelter settings with health and social supports, and (6) case management and outreach. Programme descriptions and OPEH outcomes are described and contribute to our understanding that multiple shelter/housing options are needed to support diverse OPEH. The categorised models are considered alongside existing ‘ageing in place’ research, which largely focuses on older adults who are housed. Through extending discussions of ageing in the ‘right’ place to diverse OPEH, additional considerations are offered. Future research should explore distinct sub-populations of OPEH and how individual-level supports for ageing in place must attend to mezzo- and macro-level systems and policies.