Homelessness, and especially chronic homelessness, is a highly complex problem that communities across the country are struggling to address. Despite the diligent efforts of federal agencies and nonprofit and philanthropic organizations to develop and implement programs to address the challenges of homelessness, the large number of Americans who continue to experience homelessness makes clear that much remains to be done to solve this pressing societal problem.
Permanent supportive housing (PSH) is a housing model designed to primarily serve individuals and families experiencing chronic homelessness, a population having different needs from those individuals and families who experience acute episodic or temporary homelessness. This committee was charged to examine the connection between PSH and improved health outcomes, addressing the primary question, “To what extent have permanent supportive housing programs improved health outcomes and affected health care costs in people experiencing chronic homelessness?” This chapter offers the committee’s overall conclusions about the evidence on the effect of PSH on health outcomes, as well as research and policy recommendations.
Evaluating the Impact of PSH on Health: Assessment and Limitations of the Evidence
During the course of the study, the committee examined the published and unpublished literature and conducted a variety of other data-gathering efforts, including site visits. The committee found that interpreting the research relevant to PSH and health outcomes was challenging because, as discussed in the report, common terms have different meanings within and between homelessness lexicons used by various agencies, nongovernmental organizations, researchers, and advocates (USICH, 2011). The lack of precise definitions of the housing models
reported upon and the paucity of detail about the exact nature and extent of supportive services provided in different housing models and in control or comparison groups further complicated the interpretation of reported findings.
In addition, data about PSH programs are generally siloed, uncoordinated, and fragmented. There are multiple barriers to collecting and sharing these data across agencies or programs, and there is a need for much greater interoperability of the data. The paucity of comparable data available across agencies makes it difficult to assess a variety of outcomes, and complicates efforts to provide the array of housing and social services that may be needed by individuals experiencing homelessness (Culhane, 2016). See Chapter 8 for an in-depth discussion of related research gaps.
On the basis of currently available studies, the committee found no substantial evidence that PSH contributes to improved health outcomes, notwithstanding the intuitive logic that it should do so and limited data showing that it does do so for persons with HIV/AIDS. There are significant limitations in the current research and evidentiary base on this topic. Most studies did not explicitly include people with serious health problems, who are the most likely to benefit from housing. Of the studies that were more rigorous, the committee found that, in general, housing increases the well-being of persons experiencing homelessness.
The committee found no substantial published evidence that PSH improves health; however, PSH increases an individual’s ability to remain housed and plausibly alleviates a number of conditions that negatively impact health. However, few randomized controlled trials or other methodologically rigorous studies have evaluated the role of PSH in producing improved health outcomes. Consistent data in this regard are presently lacking. While the committee recognizes that there are moral and ethical reasons that make it problematic to carry out randomized controlled trials with this population, an overarching finding of this study is that more rigorous research is needed to determine how health outcomes per se are influenced by PSH. Different types of studies might pose fewer ethical concerns, such as stepped-wedge study designs, which are increasingly being used in the evaluation of health care research (Simmons et al., 2017).
Housing has long been acknowledged as a key social determinant of health, and extensive literature has accumulated over the past two centuries showing that housing is foundational for good health. The United Nations adopted the Universal Declaration of Human Rights in Paris in 1948 in response to the devastation of World War II, declaring that the right to housing was among the rights to which all humans should be entitled. The United States was among the 48 signatories of this declaration. More recently, safe housing was noted as fundamental to the health of populations by the World Health Organization’s Commission on Social Determinants of Health (CSDH, 2008).
While safe, secure, and stable housing contributes to good health, there is extensive literature also showing it is not sufficient. The quality and location of housing make a difference. Robust public health studies have shown the untoward health consequences of inadequate housing, including asthma, the spread of communicable diseases, exposure to toxins such as lead and radon, injuries, childhood
malnutrition, mental health conditions, violence, and the harmful effects of air pollution. Population studies have also shown that a person’s neighborhood matters a great deal with regard to health outcomes, with safe streets, safe schools, and economic opportunity essential for good health and well-being.
The committee acknowledges the importance of housing in improving health in general, but it also believes that some persons experiencing homelessness have health conditions for which failure to provide housing would result in a significant worsening of their health. Said differently, notwithstanding that housing is good for health in general, the committee believes that stable housing has an especially important impact on the course and ability to care for certain specific conditions and, therefore, the health outcomes of persons with those conditions. The committee refers to these conditions as “housing-sensitive” conditions and recommends that high priority be given to conducting research to further explore whether there are health conditions that fall into this category and, if so, what those specific conditions are. The evidence of the impact of housing on HIV/AIDS in individuals experiencing chronic homelessness may serve as a basis for more fully examining this concept. Chapter 3 describes the current research and the concept of housing-sensitive conditions in more detail.
Scaling Up PSH: Policy and Program Barriers
As part of its charge, the committee was asked to identify the “key policy barriers and research gaps associated with developing programs to address the housing and health needs of homeless populations.” While the committee found no substantial published evidence that PSH improves health, the intervention increases an individual’s ability to remain housed and that plausibly alleviates a number of conditions that negatively impact health. Based on its position that PSH holds potential for reducing the number of persons experiencing chronic homelessness and for improving their health outcomes, the committee describes the key policy and program barriers to bringing PSH and other housing models to scale to meet the needs of those experiencing chronic homelessness (discussed in greater detail in Chapter 7).
There are many barriers to bringing PSH to scale to meet the current level of need. As is often the case with housing and social service providers generally, PSH programs operate in an environment of scarcity with often inadequate and unreliable funding. The siloed nature of the programs and funding streams for PSH is an important barrier to scaling up. PSH providers working at the ground level to fulfill an already challenging mission are further challenged by the need to pool or braid together funding from multiple agencies and levels of government, each with its own requirements.
Multiple barriers also exist at the local level in meeting the need for PSH. As highlighted in the committee’s site visits in Denver and San Jose (see Appendix D), operationalizing PSH programs is a very complicated and lengthy process, often taking many years to complete single-site projects. The high capital costs
and long development process are a substantive barrier to the replicability of successful programs. In the case of single-site PSH developments, myriad local land-use, permitting, and other regulatory barriers, which may be undergirded by prejudicial stereotypes and neighborhood opposition, makes land unavailable, leads to protracted delays, drives up development costs by as much as 20-35 percent, and generally impairs the efficiency of government assistance programs (see, e.g., van den Berk-Clark, 2016). Experts and government officials across the political spectrum have long recognized these barriers, but few of the many recommendations over the years for eliminating unnecessary regulatory barriers, streamlining processes, and more vigorously enforcing anti-discrimination laws have been implemented. Until such recommendations are effectively implemented, single-site PSH will not be a sufficient answer to address the need.
Scattered-site approaches, which generally make use of Housing Choice Vouchers (HCV) to lease existing housing stock, avoid some of the barriers relevant to single-site PSH and appear to offer promise for scaling up PSH in a shorter time. But scattered-site programs also face challenges when operating in high-priced housing markets and markets where state and local laws allow property owners to refuse to accept vouchers. It also can be more difficult for residents to access supportive services when not directly available on-site. Moreover, federal funding for the HCV program has been at best stable and at worse declining, forcing PSH providers and clients to compete with others on long waiting lists for vouchers.
The committee developed the following recommendations based on its assessment of the evidence that it hopes will guide research and federal action on this issue. The recommendations flow from the specific questions posed to the committee in the statement of task, including research needs related to assessing PSH and health outcomes, the cost-effectiveness of PSH, and key policy and program barriers to bringing PSH and other housing models to scale to meet the needs of those experiencing chronic homelessness.
Recommendation 3-1: Research should be conducted to assess whether there are health conditions whose course and medical management are more significantly influenced than others by having safe and stable housing (i.e., housing-sensitive conditions). This research should include prospective longitudinal studies, beyond 2 years in duration, to examine health and housing data that could inform which health conditions, or combinations of conditions, should be considered especially housing sensitive. Studies also should be undertaken to clarify linkages between the provision of both permanent housing and supportive services and specific health outcomes. (See Chapter 3.)
Recommendation 3-2: The Department of Health and Human Services, in collaboration with the Department of Housing and Urban Development, should call
for and support a convening of subject matter experts to assess how research and policy could be used to facilitate access to permanent supportive housing and ensure the availability of needed support services, as well as facilitate access to health care services. (See Chapter 3.)
Recommendation 4-1: Incorporating current recommendations on cost-effectiveness analysis in health and medicine (Sanders et al., 2016), standardized approaches should be developed to conduct financial analyses of the cost-effectiveness of permanent supportive housing in improving health outcomes. Such analyses should account for the broad range of societal benefits achieved for the costs, as is customarily done when evaluating other health interventions. (See Chapter 4.)
Recommendation 4-2: Additional research should be undertaken to address current research gaps in cost-effectiveness analysis and the health benefits of permanent supportive housing. (See Chapter 4.)
Recommendation 5-1: Agencies, organizations, and researchers who conduct research and evaluation on permanent supportive housing should clearly specify and delineate: (1) the characteristics of supportive services, (2) what exactly constitutes “usual services” (when “usual services” is the comparator), (3) which range of services is provided for which groups of individuals experiencing homelessness, and (4) the costs associated with those supportive services. Whenever possible, studies should include an examination of different models of permanent supportive housing, which could be used to elucidate important elements of the intervention. (See Chapter 5.)
Recommendation 5-2: Based on what is currently known about services and housing approaches in permanent supportive housing (PSH), federal agencies, in particular the Department of Housing and Urban Development, should develop and adopt standards related to best practices in implementing PSH. These standards can be used to improve practice at the program level and guide funding decisions. (See Chapter 5.)
Recommendation 7-1: The Department of Housing and Urban Development and the Department of Health and Human Services should undertake a review of their programs and policies for funding permanent supportive housing with the goal of maximizing flexibility and the coordinated use of funding streams for supportive services, health-related care, housing-related services, the capital costs of housing, and operating funds such as Housing Choice Vouchers. (See Chapter 7.)
Recommendation 7-2: The Centers for Medicare & Medicaid Services should clarify the policies and procedures for states to use to request reimbursement for allowable housing-related services, and states should pursue opportunities to ex-
pand the use of Medicaid reimbursement for housing-related services to beneficiaries whose medical care cannot be well provided without safe, secure, and stable housing. (See Chapter 7.)
Recommendation 7-3: The Department of Health and Human Services and the Department of Housing and Urban Development, working with other concerned entities (e.g., nonprofit and philanthropic organizations and state and local governments) should make concerted efforts to increase the supply of PSH for the purpose of addressing both chronic homelessness and the complex health needs of this population. These efforts should include an assessment of the need for new resources for the components of PSH, such as health care, supportive services, housing-related services, vouchers, and capital for construction. (See Chapter 7.)
Chronic homelessness and related health conditions are problems that require an appropriate multidimensional strategy and an ample menu of targeted interventions that are premised on a resolute commitment of resources. More precisely defined and focused research to refine the menu of needed interventions, and a materially increased supply of PSH are part of the multidimensional strategy. The committee hopes that this report will help to stimulate research and federal action to move the field forward and further efforts to address chronic homelessness and improved health in this country.