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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness. Washington, DC: The National Academies Press. doi: 10.17226/25133.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness. Washington, DC: The National Academies Press. doi: 10.17226/25133.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness. Washington, DC: The National Academies Press. doi: 10.17226/25133.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness. Washington, DC: The National Academies Press. doi: 10.17226/25133.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness. Washington, DC: The National Academies Press. doi: 10.17226/25133.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness. Washington, DC: The National Academies Press. doi: 10.17226/25133.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness. Washington, DC: The National Academies Press. doi: 10.17226/25133.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness. Washington, DC: The National Academies Press. doi: 10.17226/25133.
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Page xiii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness. Washington, DC: The National Academies Press. doi: 10.17226/25133.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness. Washington, DC: The National Academies Press. doi: 10.17226/25133.
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Permanent Supportive Housing Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness Committee on an Evaluation of Permanent Supportive Housing Programs for Homeless Individuals Science and Technology for Sustainability Program Policy and Global Affairs Board on Population Health and Public Health Practice Health and Medicine Division A Consensus Study Report of

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by a grant from Blue Shield of California Foundation under award number P-1602-08122, California Health Care Foundation under award number 19157, Elsevier, Bill & Melinda Gates Foundation under award number OPP1139235, the Conrad N. Hilton Foundation under award number 20150347, The Kresge Foundation under award number R-1508-252812, Mel- ville Charitable Trust under award number 2015-050, and the U.S. Department of Veterans Affairs under award number VA268-16-C-0033/642-C60241. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-44704-8 International Standard Book Number-10: 0-309-47704-2 Digital Object Identifier: https://doi.org /10.17226/25133 Additional copies of this publication are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2018 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness. Washing- ton, DC: The National Academies Press. doi: https://doi.org/10.17226/25133.

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org.

Consensus Study Reports published by the National Academies of Sci- ences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independ- ent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineer- ing, and Medicine chronicle the presentations and discussions at a work- shop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Acad- emies, please visit www.nationalacademies.org/about/whatwedo.

COMMITTEE ON AN EVAULATION OF PERMANENT SUPPORTIVE HOUSING PROGRAM FOR HOMELESS INDIVIDUALS Kenneth W. Kizer (NAM) (Chair), Distinguished Professor, School of Medicine and Betty Irene Moore School of Nursing, and Director, Institute for Population Health Improvement, University of California, Davis Barbara Brush, Carol J. and F. Edward Lake Professor in Population Health, Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing Seiji Hayashi, Director of Medicine, Human Diagnosis Project (Human Dx) Stephen Hwang, Centre for Urban Health Solutions, St. Michael’s Hospital Mitchell Katz (NAM), President and Chief Executive Officer, NYC Health + Hospitals Mahasin Mujahid, Associate Professor, Epidemiology, University of California, Berkeley School of Public Health James O’Connell, President, Boston Health Care for the Homeless Program Barbara Samuels, Managing Attorney, American Civil Liberties Union of Maryland Marybeth Shinn, Professor and Cornelius Vanderbilt Chair, Department of Human and Organizational Development, Peabody College of Education and Human Development, Vanderbilt University Ping Wang, Seigle Family Distinguished Professor of Arts and Sciences, Department of Economics, Washington University in St. Louis Suzanne Wenzel, Richard and Ann Thor Professor in Urban Social Development, Chair, Department of Adult Mental Health and Wellness Suzanne Dworak-Peck School of Social Work and Department of Psychology, University of Southern California Science and Technology for Sustainability Program Staff Michael Dorsey, Senior Program Officer (through December 2017) Emi Kameyama, Associate Program Officer Nicole Lehmer, Senior Program Assistant Jennifer Saunders, Consultant Vaughan Turekian, Executive Director, Policy and Global Affairs Jerry Miller, Director (through May 2017) Carlo Altamirano, Christine Mirzayan Science and Technology Policy Graduate Fellow (January to April 2017) v

vi Board on Population Health and Public Health Practice Staff Karen M. Anderson, Senior Program Officer Rose Marie Martinez, Senior Board/Program Director Anna Martin, Senior Program Assistant

Preface In 1988, the Institute of Medicine (IOM) published its landmark report Homelessness, Health, and Human Needs, which analyzed the scientific evidence regarding the causes and consequences of homelessness and associated health problems. The report noted that “the fundamental problem encountered by home- less people—lack of a stable residence—has a direct and deleterious impact on health. Not only does homelessness cause health problems, it perpetuates and ex- acerbates poor health by seriously impeding efforts to treat disease and reduce disability” (p. 141). Cited by practitioners and policy makers in the field as being foundational to their work, the report recommended federal action to improve health services, housing, and income to reduce homelessness. Now, 30 years later—and notwithstanding some progress in addressing the problem—homeless- ness remains a major societal and public policy challenge. Particularly important are people experiencing chronic homelessness. Revisiting the housing and health care needs of this population is especially timely and critical to moving the dis- cussion forward and improving the health outcomes of these persons. Homelessness is linked to the occurrence of numerous acute health prob- lems and exacerbates many serious health conditions including cardiovascular disease, diabetes, and HIV/AIDS. The prevalence of mental illness and substance use, along with co-occurring chronic medical conditions, is significantly higher for some groups within the population of persons experiencing homelessness. This has important implications for the delivery and cost of health care and other services. For example, individuals who are homeless are more likely to rely on emergency care because they lack health insurance and a regular health care pro- vider. Reliance on emergency services may not result in the ongoing health care that is needed and incurs significant preventable costs for the health care system and public resources. A wide range of housing and other services have been developed to address the needs of persons experiencing homelessness. Permanent supportive housing (PSH), which provides affordable housing matched with ongoing, appropriate ser- vices to tenants, is an important example of the types of services designed to keep individuals experiencing chronic homelessness stably housed. Other similar but less intensive interventions have been developed to address the health and housing needs of families experiencing homelessness or of young adults exiting the foster care system who may be at risk of homelessness. These types of services are grow- ing, and it has become increasingly apparent that there is a need to understand how programs designed to house and provide services to populations experiencing homelessness can affect their health outcomes. vii

viii Recognizing the timeliness and importance of this issue, the Conrad N. Hilton Foundation and the Bill & Melinda Gates Foundation funded a National Academies of Sciences, Engineering, and Medicine ( National Academies) work- shop in November 2014 to explore the impact of the changing U.S. health care system under the Affordable Care Act on individuals experiencing homelessness in urban areas. A meeting summary, published in February 2015, describes the discussions held during the event (available at www.nationalacade- mies.org/healthequityrt or www.nas.edu/sustainability). Discussions during the 2014 the National Academies workshop and a subse- quent scoping session that included more than 30 experts in homelessness policy and research highlighted gaps in the evidence regarding PSH. In brief, empirical and experiential studies of the effectiveness of housing and other types of interventions address the problem of homelessness, but they substantially vary in terms of rigor, scale, and outcomes measured. Consequently, the aggregate findings are unclear, creating a pressing need to more systematically assess the effectiveness of these interventions, both in terms of improving health-related outcomes and cost-effec- tiveness. To more fully evaluate interventions and policy options for addressing home- lessness, and especially with regard to PSH, the National Academies convened an expert committee in April 2016 to evaluate a fundamental question: To what extent have permanent supportive housing programs improved health outcomes and af- fected health care costs in people experiencing homelessness? This report presents the findings of the committee’s evaluation of the evidence available to answer this question. This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manu- script remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: Dennis Culhane, University of Pennsylvania; Kelly Doran, New York University; Irwin Feller, American Association for the Advancement of Science; Lillian Gelberg, University of California, Los Angeles; Benjamin Henwood, University of Southern California; Kim Hopper, Nathan S. Kline Institute for Psychiatric Research; John Lozier, National Health Care for the Homeless Council; Linda McCauley, Emory University; David Meltzer, University of Chicago; Vincent Mor, Brown University; Robert Rosenheck, Yale School of Medicine; Molly Scott, Urban Institute; John Tracy, Optiv Security Inc.; and Carol Wilkins, Independent Consultant. Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommenda- tions of this report nor did they see the final draft before its release. The review of this report was overseen by Joseph Newhouse, Harvard University, and Bobbie Berkowitz, Columbia University. They were responsible for making certain that

ix an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. The report would not have been possible without the sponsors of this study, including Blue Shield of California Foundation, California Health Care Founda- tion, Elsevier, Bill & Melinda Gates Foundation, the Conrad N. Hilton Founda- tion, The Kresge Foundation, Melville Charitable Trust, and the U.S. Department of Veterans Affairs. The committee gratefully acknowledges the following individuals for mak- ing presentations to the committee: Rebecca Alvarez, Peacock Commons; Katie Bonamasso, Denver Social Impact Bond Initiative; Matthew Doherty, U.S. Inter- agency Council on Homelessness; Lorraine Flores, Bill Wilson Center; Ann Gabriel, Elsevier; Alison George, Colorado Department of Local Affairs; Sandra Hernandez, California Health Care Foundation; Brenton Hutson, Volunteers of America, Denver; Andrea Iloulian, Hilton Foundation; Ky Le, Santa Clara County; Shea Leibfreid, The Action Center; Jennifer Loving, Destination Home; Marcella Maguire, Corporation for Supportive Housing; Mandy May, Colorado Coalition for the Homeless; Thomas O’Toole, U.S. Department of Veterans Af- fairs; Kathy Robinson, Charities Housing Development Corporation; Gary Sanford, Metropolitan Denver Homeless Initiative; Richard Thomason, Blue Shield of California Foundation; Helen Tong-Ishikawa, MidPen Housing; Kristin Toombs, Colorado Department of Local Affairs; Sam Tsemberis, Pathways to Housing; and Mary Wickersham, Social Impact Solutions. The information pro- vided during the presentations is used throughout this report and provided im- portant perspectives that the committee used in its findings and conclusions. I also would like to thank the staff from the National Academies who guided the committee through the study process. Michael Dorsey and Karen Anderson directed the study, with significant guidance from Rose Marie Martinez. Emi Kameyama and Anna Martin provided research and administrative support. Mar- ilyn Baker and consultant Jennifer Saunders assisted in the final stages of com- pleting the report. Finally, I especially thank the members of the committee for their tireless efforts throughout the development of this report. Kenneth W. Kizer, Chair Committee on an Evaluation of Permanent Support- ive Housing Programs for Homeless Individuals

Contents ABBREVIATIONS AND ACRONYMS ....................................................... xiii SUMMARY ........................................................................................................ 1 1 INTRODUCTION .................................................................................... 12 2 ADDRESSING HOMELESSNESS IN THE UNITED STATES .......... 19 3 EVIDENCE OF EFFECT OF PERMANENT SUPPORTIVE HOUSING ON HEALTH .............................................. 38 4 COST-EFFECTIVENESS OF PERMANENT SUPPORTIVE HOUSING ....................................................................... 58 5 EFFECT OF INDIVIDUAL AND PROGRAM CHARACTERISTICS ON OUTCOMES IN PERMANENT SUPPORTIVE HOUSING ............................................ 81 6 IMPACT OF PERMANENT SUPPORTIVE HOUSING ON FAMILIES AND YOUTH................................................................. 95 7 PROGRAM AND POLICY BARRIERS TO PERMANENT SUPPORTIVE HOUSING .......................................... 104 8 RESEARCH GAPS ................................................................................. 125 9 CONCLUSIONS AND RECOMMENDAIONS ................................... 135 10 REFERENCES........................................................................................ 141 APPENDIXES A COMMITTEE ON AN EVALUATION OF PERMANENT SUPPORTIVE HOUSING PROGRAMS FOR HOMELESS INDIVIDUALS: BIOGRAPHICAL INFORMATION ....................... 169 B THE HISTORY OF HOMELESSNESS IN THE UNITED STATES................................................................................... 175 xi

xii Contents C COUNTING THE NUMBER OF INDIVIDUALS EXPERIENCING HOMELESSNESS .................................................. 185 D EXAMPLES OF HOMELESS SERVICE PROGRAMS IN DENVER AND SAN JOSE .................................................................... 189 E STUDIES OF EFFECTIVENESS OF PERMANENT SUPPORTIVE HOUSING ..................................................................... 195 TABLES 3-1 Key Findings of Randomized Controlled Trials and Observational Studies ............................................................................... 47 4-1 Summary of Select Studies Examining Cost-Effectiveness of PHS ............ 66 4-2 Measures of Effectiveness for Incorporating into Individual Quality of Life Index (QLI)............................................................................................... 68 4-3a Summary of Program Costs Reported in Key Studies of Cost-Effectiveness of PSH ...................................................................................................... 69 4-3b Summary of Average and Induced Cost changes in Key Studies of Cost-Effectiveness of PSH ....................................................................... 70 4-3c Raw Net Costs for Select Studies of Cost-Effectiveness of PSH ............... 73 5-1 Features of Single-Site Versus Scattered-Site PSH .................................... 86 BOXES 2-1 Veterans Experiencing Homelessness ......................................................... 22 7-1 A Hypothetical Illustration ....................................................................... 107 B-1 Definition of Homeless Person ................................................................. 181

Abbreviations and Acronyms ACA Affordable Care Act ACT Assertive Community Treatment ADA American with Disabilities Act AHAR Annual Homeless Assessment Report AIDS acquired immune deficiency syndrome AMI area median income CABHI Cooperative Agreements to Benefit Homeless Individuals CD4 cluster of differentiation 4 CDBG Community Development Block Grant CDC Centers for Disease Control and Prevention CEA cost-effectiveness analysis CI confidence intervals CMS Centers for Medicare & Medicaid Services CoC Continuum of Care CPI Consumer Price Index CSH Corporation for Supportive Housing DHS Department of Homeland Security DOL Department of Labor ED emergency department EMS emergency medical services FCTI Family Critical Time Intervention FEMA Federal Emergency Management Agency FFP federal financial participation FHA Federal Housing Administration FQHC Federally Qualified Health Center FUP Family Unification Program GAO Government Accountability Office GBHI-SSH Grants for the Benefit of Homeless Individuals – Services in Supportive Housing HCH Health Care for the Homeless HCV Housing Choice Voucher HF Housing First HHS Department of Health and Human Services HIV human immunodeficiency virus HMIS Homelessness Management Information System HOME HOME Investment Partnership HOPWA Housing Opportunities for People with AIDS HRSA Health Resources and Services Administration HUD Department of Housing and Urban Development xiii

xiv Abbreviations and Acronyms HUD-VASH HUD-Veterans Affairs Supportive Housing ICD-10 International Classification of Diseases, Version 10 ICM intensive case management IOM Institute of Medicine JAMA Journal of the American Medical Association KIDS Kids Integrated Data System LGBTQ lesbian, gay, bisexual, transgender, and questioning LIHTC Low-Income Housing Tax Credit MCAS Multnomah Community Ability Scale MFP Money Follows the Person (initiative) NED non-elderly disabled NIDA National Institute on Drug Abuse NIMBY not-in-my-backyard ODPHP Office of Disease Prevention and Health Promotion, HHS OHQS Observer-Rated Housing Quality Scale PATH Projects for Assistance in Transition from Homelessness PBV Project-Based Voucher PHA Public Housing Agency PIT point-in-time system PSH permanent supportive housing PTSD post-traumatic stress disorder QALY quality adjusted life year QofL quality of life QoLI Quality of Life Interview RCT randomized controlled trial RPCEHM Report of the Panel on Cost-Effectiveness in Health and Medicine RWJF Robert Wood Johnson Foundation SAMHSA Substance Abuse and Mental Health Services Administration SHF Supportive Housing for Families SIB Social Impact Bond SPDAT Service Prioritization Decision Assistance Tool SRHHI Skid Row Homeless Health Care Initiative SRO Single room occupancy SSI Supplemental Security Income SSVF Supportive Services for Veteran Families TANF Temporary Assistance for Needy Families USDA Department of Agriculture USICH Interagency Council on Homelessness VA Department of Veterans Affairs VAGLA VA Greater Los Angeles VASH VA Supportive Housing VI Vulnerability Index WHO World Health Organization

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Chronic homelessness is a highly complex social problem of national importance. The problem has elicited a variety of societal and public policy responses over the years, concomitant with fluctuations in the economy and changes in the demographics of and attitudes toward poor and disenfranchised citizens. In recent decades, federal agencies, nonprofit organizations, and the philanthropic community have worked hard to develop and implement programs to solve the challenges of homelessness, and progress has been made. However, much more remains to be done. Importantly, the results of various efforts, and especially the efforts to reduce homelessness among veterans in recent years, have shown that the problem of homelessness can be successfully addressed.

Although a number of programs have been developed to meet the needs of persons experiencing homelessness, this report focuses on one particular type of intervention: permanent supportive housing (PSH). Permanent Supportive Housing focuses on the impact of PSH on health care outcomes and its cost-effectiveness. The report also addresses policy and program barriers that affect the ability to bring the PSH and other housing models to scale to address housing and health care needs.

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