End Chronic Homelessness Research Articles

Housing First is Not Enough

This policy brief critically examines the Housing First turn in U.S. homeless policy. Housing First is a popular model of homeless services that rehouses people experiencing chronic homelessness without preconditions like sobriety, treatment, or employment. The Department of Housing and Urban Development promotes Housing First as an evidence-based practice that grantees should adopt. While I laud this as a step in the right direction, this paper identifies three shortcomings of Housing First that limit its ability to end chronic homelessness. I then discuss two supply-side interventions (i.e., tax credit expansion and integrated public housing) that can compensate for these shortcomings.

Linked Administrative Data’s Role in Victoria’s First Social Impact Investment – Journey to Social Inclusion – Working to End Chronic Homelessness

The Journey to Social Inclusion (J2SI) Social Impact Investment (SII) is Victoria’s first social impact investment. It has two outcome payments, for stable housing and reduction in hospital bed days. Linked administrative data is being used to calculate the performance levels and outcome payments from the Victorian Government to J2SI. This paper discusses the methodologies and challenges encountered in the use of the linked administrative data for the calculation of the outcome payments for the J2SI SII.
 IntroductionJ2SI will receive half of the program costs for service delivery based on the level of performance of two outcome payments. The outcome payments are the difference between the results for the Intervention Group and the Control Group. The results are being calculated using linked administrative datasets for health, housing and justice, by the Centre for Victorian Data Linkage (CVDL) and the Centre for Social Impact, University of Western Australia (CSI UWA) respectively.
 Objectives and ApproachThe paper will outline the approach taken to calculate the results for the Intervention Group and the Control Group, explore the benefits and challenges of arising from different parties being involved in the calculations and present the lessons learned for future social impact bonds in Victoria and other States/Territories.
 ResultsThe work has highlighted the importance of clearly understanding and documenting all of the datasets and how they are to be used prior to the commencement of the calculations. High level descriptions are not adequate preparation for the precision required for the actual calculations. The work has also highlighted the differences is using linked data for research and service implementation.
 Conclusion / ImplicationsLinked administrative data is a robust source of data for the calculation of outcome payments for social impact investments. However, with the timeliness of payments important for service delivery and financing, thorough preparation for the calculation of the results and outcome payments is essential.

Linked administrative data’s role in Victoria’s first social impact investment, journey to social inclusion, working to end chronic homelessness

IntroductionIndigenous people worldwide are overrepresented and adversely effected by diabetes and its complications. Optimal glycemic control and lipid monitoring is fundamental to the management of diabetes. This study linked population level data to assess monitoring, treatment and control of blood sugars and lipids in First Nations’ people in Ontario. Objectives and ApproachWe linked 17 Ontario population-based health administration datasets at the individual level with the Indian Register dataset. The latter provides information on all registered or Status First Nations people in Canada . Age and sex-adjusted rates of HbA1c and lipid monitoring were calculated for each 12-month period from April 1, 1995, to March 31, 2015.). We assessed the proportion of individuals with diabetes whose HbA1c and lipid values were controlled. To capture prescriptions for antidiabetic drugs, we used the Drug Identification Number database to identify all antidiabetic drugs and linked these to the Ontario Drug Benefit database to capture prescription information. ResultsCompared with other people in Ontario, First Nations people with diabetes are monitored less for key indicators of diabetes control. In 2014/15, 37.0% of First Nations people with diabetes living in First Nations communities had their blood sugar levels monitored compared to 45.0% of other people in Ontario. A similar pattern was shown for lipid level monitoring, with 48.3% of First Nations people living in First Nations communities, and 65.8% of other people in Ontario having recorded lipid measurements. Conclusion / ImplicationsEarly screening for complications and screening for hemoglobin A1c is strongly recommended.

Changes in Physical Health After Supported Housing: Results from the Collaborative Initiative to End Chronic Homelessness.

The permanent supported housing model is known to improve housing outcomes, but there has been sparse research on the effects of supported housing on physical health. Various organizations including the National Academy of Sciences have called for research in this area. This observational multi-site outcome study examined changes in physical health among chronically homeless adults participating in a comprehensive supported housing program and the associations between changes in physical health, housing status, and trust in primary care providers. Data are presented from an observational outcome study analyzed with mixed linear modeling and regression analyses. A total of 756 chronically homeless adults across 11 sites were assessed every 3months for 1year. The Collaborative Initiative to End Chronic Homelessness provided adults who were chronically homeless with permanent housing and supportive primary healthcare and mental health services. Days housed, physical health-related quality of life (HRQOL) measured by the Short Form-12 health survey, number of medical conditions, number of treated medical conditions, and number of preventive medical procedures received. Participants showed reduced number of medical problems and receipt of more preventive procedures over time, but there was no statistically significant change in physical HRQOL. Changes in housing were not significantly associated with changes in any physical health outcomes. Over time, participants' trust in primary care providers was positively associated with increased numbers of reported medical problems and preventive procedures received but not with physical HRQOL. Entry into supported housing with linked primary care services was not associated with improvements in physical HRQOL. Improvement in other medical outcome measures was not specifically associated with improved housing status.

Working Together in Montréal to Improve Veterans’ Well-Being: A Canadian Perspective

Services for veterans in Canada can be unclear and difficult to navigate for civilian service providers working with veterans. In this article, we feature two Montréal-based initiatives that aim to improve services for veterans through collaboration, the Old Brewery Mission and Respect Forum. We begin by providing background information about Canada’s recent history of military engagements and veterans affairs issues. The first example of collaboration presented is the Sentinelles de la rue (Sentinels of the Street) program, led by the Old Brewery Mission. The Mission works with Montréal’s homeless men and women, meeting their essential needs while finding practical and sustainable solutions to end chronic homelessness. The Mission is now developing a collaborative model in partnership with government departments, veterans peer support organizations, and local health and social services to house and support homeless military veterans. The second example is Respect Forum, a not-for-profit initiative that has been organizing networking events in Montréal, Québec since 2016. The aim of these events is to promote military–civilian and multisectoral collaboration to improve services for veterans. Respect Forum meetings have made it possible to begin bringing together and mapping out local and national service providers working with veterans.

Understanding Systems Change in Early Implementation of Housing First in Canadian Communities: An Examination of Facilitators/Barriers, Training/Technical Assistance, and Points of Leverage.

We present interim findings of a cross-site case study of an initiative to expand Housing First (HF) in Canada through training and technical assistance (TTA). HF is an evidence-based practice designed to end chronic homelessness for consumers of mental health services. We draw upon concepts from implementation science and systems change theory to examine how early implementation occurs within a system. Case studies examining HF early implementation were conducted in six Canadian communities receiving HF TTA. The primary data are field notes gathered over 1.5years and evaluations from site-specific training events (k=5, n=302) and regional network training events (k=4, n=276). We report findings related to: (a) the facilitators of and barriers to early implementation, (b) the influence of TTA on early implementation, and (c) the "levers" used to facilitate broader systems change. Systems change theory enabled us to understand how various "levers" created opportunities for change within the communities, including establishing system boundaries, understanding how systems components can function as causes of or solutions to a problem, and assessing and changing systems interactions. We conclude by arguing that systems theory adds value to existing implementation science frameworks and can be helpful in future research on the implementation of evidence-based practices such as HF which is a complex community intervention. Implications for community psychology are discussed.

Comprehensive services delivery and emergency department use among chronically homeless adults.

Homeless adults use emergency department (ED) services more frequently than other adults, but the relationships between homelessness, health status, outpatient service use, and ED utilization are poorly understood. Data from the Collaborative Initiative to Help End Chronic Homelessness (CICH) were used to compare ED use among chronically homeless adults receiving comprehensive housing, case management, mental health, addiction, and primary care services through CICH at 5 U.S. sites (n = 274) and ED use among comparison group clients receiving generally available community services (n = 116) at the same sites. Multiple imputation was used to account for missing data and differential rates of attrition between the cohorts. Longitudinal models were constructed to compare ED use between the 2 groups during the first year after initiation of CICH services. A mediation analysis was performed to determine the relative contributions of being housed, the receipt of outpatient services, and health status to group differences in ED utilization. Participants receiving CICH services were significantly less likely to report ED use (odds ratio = 0.78, 95% confidence interval [0.65, 0.93]) in the year after program entry. Decreased ED use was primarily mediated by decreased homelessness-not by increased access to other services or health status. This suggests that becoming housed is a key driver of reduced ED utilization and that efforts to provide housing for homeless adults may result in significantly decreased ED use. Further research is needed to determine the long-term effects of housing on health status and to develop services to improve health outcomes. (PsycINFO Database Record

Differences in Health and Social Support between Homeless Men and Women Entering Permanent Supportive Housing

BackgroundPermanent supportive housing (PSH) is the leading intervention to end chronic homelessness. Little is known, however, about gender differences, including potential disparities in physical and mental health and social support, that might inform services available through PSH. MethodsThis study included 421 homeless adults, at least 39 years old, English- or Spanish-speaking, who were moving into PSH through 26 different agencies in the Los Angeles area. ResultsCompared with men entering PSH, homeless women (28% of the sample) were younger (p < .01), less likely to have achieved at least a high school education (p < .05), and had lower incomes (p < .01). Women had more chronic physical health conditions (p < .01), were more likely to have any chronic mental health condition (odds ratio, 2.5; p < .01), and had more chronic mental health conditions than men (p < .01). Women had more relatives in their social networks (Coefficient, 0.79, p < .01) and more relatives who provided support (coefficient, 0.38; p < .05), but also more relatives with whom they had conflict (coefficient, 0.19; p < .01). Additionally, women were less likely to have caseworkers (coefficient, −0.59; p < .001) or physical and mental health care providers in their networks (coefficient, −0.23 [p < .01]; coefficient, −0.37 [p < .001], respectively). However, after correcting for multiple testing, three outcomes lost significance: number of chronic physical health conditions, number of relatives who provided any support, and number of relatives with whom there was conflict. ConclusionsThere is evidence of gender differences in mental health and social support among homeless adults moving into PSH. PSH cannot be a one-size-fits-all approach. Supportive services within housing should be tailored based on gender and other individual needs.

Factors Affecting Emergency Department Use by a Chronically Homeless Population.

Homeless adults make extensive use of emergency department (ED) services. This study examined factors associated with moderate and high ED use in a cohort of chronically homeless individuals. A cross-sectional analysis identified factors related to ED use in a cohort of 755 individuals at 11 sites at entry into the Collaborative Initiative to Help End Chronic Homelessness (CICH). Bivariate analyses identified sociodemographic, housing status, health status, and service-related factors associated with moderate and high ED use. Independent risk factors were then identified by using a multivariate multinomial model. Hierarchical regression was used to compare the strengths of association between ED use and blocks of factors composed of sociodemographic, housing, health, and service-related characteristics. In a three-month period, 30% of participants visited the ED one or two times (moderate ED use) and 12% visited three or more times (high-ED use). ED use was most strongly associated with poor health and utilization of other non-ED services and to a lesser extent with housing status. Increased ED utilization was associated with both general medical and psychiatric morbidity and greater use of non-ED services. Thus ED use was related to high need and acuity and was not ameliorated by use of other services. Housing instability and homelessness contributed less robustly to increased ED use. More coordinated services may better address the complex medical, housing, and psychosocial needs of chronically homeless individuals.

Psychosis, Lack of Job Skills, and Criminal History: Associations With Employment in Two Samples of Homeless Men.

This study examined factors associated with employment among homeless men with mental illness, particularly history of criminal justice involvement. Data from 569 homeless men in the 11-site Collaborative Initiative to Help End Chronic Homelessness (2004-2009) and 1,101 homeless male veterans in the U.S. Department of Housing and Urban Development-Veterans Affairs Supportive Housing program at 19 sites (1992-2003) were analyzed. In neither sample was criminal or incarceration history significantly associated with job attainment or earnings for either black or white participants. In contrast, psychotic disorders and public-support income were negatively associated with job attainment and earnings. The majority of homeless veterans reported lifetime occupations as skilled or unskilled manual workers. These findings highlight the high rate of nonemployment among homeless men and suggest that employment among homeless men is not significantly impeded by a criminal record but by psychiatric problems and reliance on public-support income.

Impact of Health Insurance Status and a Diagnosis of Serious Mental Illness on Whether Chronically Homeless Individuals Engage in Primary Care

We evaluated the impact of a diagnosis of serious mental illness on use of a primary care provider (vs the emergency department [ED]) as a source of care by people who were chronically homeless. We used data from 750 chronically homeless adults enrolled in the 11-site Collaborative Initiative to Help End Chronic Homelessness and identified demographic and clinical characteristics independently associated with using a primary care provider rather than an ED. The factor most strongly associated with using the ED as a regular source of medical care was previous-year lack of health insurance. Despite high rates of serious mental illness, neither a diagnosis of serious mental illness nor increased severity of psychiatric symptoms was associated with such use. Findings suggest that people who are chronically homeless and have chronic medical illness would be more likely to access care if they had health insurance. Individual states' deciding not to expand Medicaid coverage will likely have a tremendous impact on the health outcomes and health care costs associated with this and other vulnerable populations.

Smoking Among Chronically Homeless Adults: Prevalence and Correlates

Cigarette smoking is one of the leading preventable causes of death, and adults who are chronically homeless have among the highest death rates. This study examined the prevalence and correlates of smoking in this population. Data were analyzed for 754 chronically homeless adults who were receiving mental health, primary care, and supported housing services at 11 U.S. sites in a federal initiative, the Collaborative Initiative to Help End Chronic Homelessness. The prevalence of current smoking (past three months), sociodemographic and clinical correlates of smoking, and change in smoking status (nonsmoker, self-limiting smoker, or regular smoker) over a one-year period were examined by use of stepwise multinomial regression analysis. Overall, 80% of the 754 chronically homeless adults reported current cigarette smoking; 48% of the smokers reported trying to limit their smoking, and 75% of the smokers had discussed smoking with a health care professional. No significant overall change in smoking status was found during the study year; however, change in alcohol and drug use was associated with change in smoking status in the same direction. Having a diagnosis of posttraumatic stress disorder and reducing alcohol use predicted quitting or limiting smoking. A large majority of chronically homeless adults reported being current smokers. Smoking cessation interventions, integrated with alcohol and drug treatment, that target this population are needed.

Does Housing Chronically Homeless Adults Lead to Social Integration?

Supported housing programs have been successful in helping homeless adults obtain housing. This study examined whether improvements in social integration occur after clients obtain supported housing. Measures of social integration were examined for 550 chronically homeless adults with mental illness who participated in the 11-site Collaborative Initiative to Help End Chronic Homelessness. Social integration was conceptualized as a multidimensional construct of variables in six domains: housing, work, social support, community participation, civic activity, and religious faith. Changes in baseline measures related to the six domains and their interrelationships were examined at six and 12 months after entry into the supported housing program. Chronically homeless adults showed substantial improvements in housing but remained socially isolated and showed limited improvement in other domains of social integration, which were only weakly correlated with one another. More attention is needed to develop rehabilitation interventions in supported housing programs to improve social integration of chronically homeless adults. Because improvements in some domains of social integration were only weakly related, it may be necessary to intervene in multiple domains simultaneously.

Sustaining the Occupy Movement

Sustaining the Occupy Movement

Moving From Street to Home: Health Status of Entrants to a Housing First Program

Housing First (HF) is an evidence-based practice that ends chronic homelessness for individuals with serious mental illness by providing immediate access to permanent independent housing and team-based community supports. Little is known about the health status of homeless individuals entering HF programs. Through a cross-sectional analysis, this paper reports on the chronic physical disease burden of people entering a newly established HF program and examines whether these individuals recognize and request support for ongoing health-related issues. The authors' evaluation confirmed significantly higher rates of chronic disease (60%) and fair/poor self-reported health status (47%) than the general urban population of Philadelphia. The majority of clients reported they wanted to address both medical (67%) and mental health (68%) problems, but a much lower percentage reported wanting to reduce substance use (23%) or take psychiatric medications (25%). The authors conclude that formerly homeless entrants to HF programs have a high burden of chronic disease with complex health-related needs. Additionally, these individuals look to the program for health-related assistance. As the HF model is disseminated throughout the United States to end chronic homelessness, these findings support the development of flexible, integrated, person-centered health services within the HF service delivery system as a potentially effective method to address complex health needs.

Supportive Housing Approaches in the Collaborative Initiative to Help End Chronic Homelessness (CICH)

The Federal Collaborative Initiative to Help End Chronic Homelessness funded 11 sites to expand permanent housing and offer supportive services to persons experiencing chronic homelessness and suffering from mental and substance use disorders. This study examines qualitative data on how the projects used US Department of Housing and Urban Development funding and three housing approaches (scattered units, congregate/clustered, or a combination) for rapid placement of clients. Each housing approach called for adaptations by the services teams and property personnel in order to support clients with independent living skills, prevent housing loss, and promote their overall health in line with Initiative goals. Property personnel reported taking on new roles with clients and forming new collaborative arrangements with services teams. The authors discuss the lessons reported by sites that were associated with housing configuration, type of lease, and role of property personnel.

Staffing Challenges and Strategies for Organizations Serving Individuals who have Experienced Chronic Homelessness

Hiring and retaining appropriate staff is essential for programs serving those who have experienced chronic homelessness. This paper describes specific staffing challenges and strategies from the Collaborative Initiative to Help End Chronic Homelessness (CICH), an 11-site, multi-agency Federal program designed to serve people experiencing chronic homelessness who also have a disabling condition such as substance use or mental health problems. This paper addresses approaches to staffing including team structures, staff supervision, and training. Challenges identified include low pay, high rates of burnout and turnover, limited time for supervision, and multiple staff training needs. This paper also explores specific staffing strategies based on the experience of the CICH sites, and concludes with implications for practice, research, and policy, including recommendations for ongoing staff training, suggestions for future mixed-methods research, and a call for an enhanced focus on strengthening the homeless services workforce.

Services and Supports for Individuals with Co-occurring Disorders and Long-Term Homelessness

Co-occurring mental health and substance use disorders are highly prevalent among individuals experiencing long-term homelessness. This paper describes strategies used by 11 projects funded by the Federal Collaborative Initiative to Help End Chronic Homelessness (CICH) to serve individuals with co-occurring disorders (COD) as they transition from homelessness to permanent-supported housing. Findings are based on the observations of clients, program team members, and administrators. This paper presents findings organized around three themes: characteristics and needs of CICH clients with COD, strategies employed to respond to those needs, and challenges associated with implementing an integrated approach to COD. Client characteristics include histories of untreated or intermittently treated mental health and substance use disorders, often further complicated by trauma and chronic illness. Project teams endorsed a variety of services and supports such as engagement, stabilization, motivational techniques, groups, and trauma-informed interventions as useful for their clients with COD. Challenges identified include difficult client behavior, the extended time required for change to occur within this population, inadequate staffing and community resources, and system barriers. The paper concludes with recommendations for further research into the effectiveness of various combinations of service strategies for this population in non-traditional settings during the earliest stage of recovery, along with a call for overcoming workforce and system-level barriers to providing integrated care.

Adopting Best Practices: Lessons Learned in the Collaborative Initiative to Help End Chronic Homelessness (CICH)

The Collaborative Initiative to Help End Chronic Homelessness (CICH) was established to provide housing and supportive services for individuals experiencing chronic homelessness. As part of this initiative, 11 projects across the country received funding to apply models of best practices to support their clients in housing. This paper reports on the experiences of the CICH projects in their use of Assertive Community Treatment (ACT) and Motivational Interviewing (MI), clinical practice models commonly used by CICH projects. A qualitative analysis identified five areas of challenge for the projects: (1) Incomplete and underdeveloped staff teams; (2) Incomplete understanding of the practice models; (3) Using the elements of the practice models; (4) Interagency teaming; and (5) Competing expectations of multiple federal agencies. The paper describes the specific challenges in each of the five areas as well as training approaches and gaps in training and the perceived benefits of the practice models as reported by project staff.

Twelve-Month Client Outcomes and Service Use in a Multisite Project for Chronically Homelessness Adults

Collaborative Initiative to Help End Chronic Homelessness clients (N = 734) were enrolled into an evaluation wherein assessments at program entry and quarterly thereafter addressed sociodemographic characteristics, health status, and a wide range of service use and outcomes data. Mixed linear regression analysis was used to test for significant changes over time. The average number of days housed during the previous 3 months increased dramatically from 18 at baseline to 83 by year's end. Significant improvements of more modest magnitude were also observed in overall quality of life, mental health functioning, and reduced psychological distress. Alcohol and drug problems remained largely unchanged over time, among clients overall. However, among baseline drug users crack, cocaine, and marijuana use decreased by 28-50% over the follow-up period. Total quarterly health cost estimates declined by 50%, as well, from $6,832 to $3,376. These findings suggest that adults who have experienced chronic homelessness may be successfully housed and can maintain their housing, when provided with comprehensive services.