What factors predict if a homeless person will be able to engage in supported housing to attain and retain an apartment? What supportive services facilitate permanent exits from homelessness?
As a psychiatry resident, I worked at a community service agency in Los Angeles, treating chronically homeless patients with serious mental illness and substance use disorders (SUD) as they transitioned into permanent, community-based housing with supportive services (“supported housing”). Naively, I expected to see decreased mental health symptoms when these patients became housed. Instead, I was struck by their range of mental health outcomes and variable levels of success using supported housing to exit homelessness.
Today, as a psychiatrist who treats and studies adults who are experiencing homelessness, my patients continue to inspire important and unanswered questions: What factors predict if a homeless person will be able to engage in supported housing to attain and retain an apartment? What supportive services facilitate permanent exits from homelessness?
At a national level, the Department of Housing and Urban Development (HUD) recognizes housing status as a critical determinant of physical and mental health.1 After developing federal housing projects that unintentionally evolved into concentrated islands of poverty, HUD embraced the notion of “mobility” for homeless individuals or persons at risk for becoming homeless, offering Housing Choice (Section 8) vouchers to mobilize persons with socioeconomic disadvantage into “mainstream” communities.
For low-income persons, Housing Choice vouchers subsidize rental costs in apartments available to the public at large. Voucher recipients pay a portion of their income towards rent and the remainder of costs are subsidized by local Public Housing Authorities (not-for-profit entities that work with local governments and agencies to develop housing strategies for communities).2
However, particularly for homeless persons with mental health disorders, financial subsidies alone are often inadequate to facilitate exits from homelessness; supportive services (eg, case management, linkages to health care) are critical complements to financial assistance. Traditionally, supportive services were offered along a linear “continuum;” patients progressed from shelters, to transitional housing, to residential treatment, and eventually independent, community-based housing as they began to be adherent with their mental health care.3 In this model, a patient progressed along the continuum when mental health providers determined that he or she was “housing ready,” or able to stay involved with necessary services such as psychiatric care or substance use disorder (SUD) treatment.
With the emergence of recovery-oriented treatment for persons with mental illness and SUD, housing came to be viewed as a fundamental human right, distinct from an individual’s utilization of clinical services.4 In recent years, services shifted towards a supported housing paradigm (Figure), in which patients experiencing homelessness receive independent permanent housing (often with the assistance of Housing Choice vouchers) with community-based supportive services, including non-mandated referrals to psychiatric, medical, and substance use disorder treatment.3 In this approach, homeless patients are referred to services, but housing is provided regardless of an individual’s engagement in such; housing is recognized as a determinant of health in and of itself.4
Supported housing outcomes
A significant body of research substantiates the positive health and psychosocial outcomes (Table) of persons engaged in supported housing; this intervention increases days in stable housing, decreases substance use disorders, increases perceived autonomy, and is associated with marked reductions in use of acute care and correctional facilities.5,6 Supported housing is a widely accepted, evidence-based practice to address homelessness.7
Overall, persons with psychiatric and/or substance use disorders do well in supported housing. In a chronically homeless population-many of whom had mental health problems and/or SUD-a demonstration project in 2010 compared supported housing participants with individuals engaged in a traditional, “housing ready” program that mandated sobriety and treatment.8 Persons who received supported housing were housed more rapidly than the comparison group (35 vs 223 days, respectively). More importantly, the supported housing group was 8 times (odds ratio 8.3) more likely than the comparison group to retain stable housing for one year. These data suggest that with engagement in supported housing most homeless persons with mental illness and/or SUDs can live independently in their communities.
Achieving supported housing
In my first attending job, I worked on an Assertive Community Treatment (ACT) team for “high-risk” homeless individuals-adults who were chronically homeless, with serious mental illness and/or recalcitrant SUD-who sought supported housing. Although the literature touted the benefits of supported housing for this vulnerable population, many of my patients struggled to attain housing; among those that successfully rented an apartment, many had difficulty remaining housed, often ending up incarcerated, on the streets, or in higher levels of care (eg, board and care settings). This experience drove me to examine the research surrounding predictors of success in supported housing. Although challenges faced by psychiatric patients in supported housing programs are poorly understood, this area has been explored in several studies.
A national study of supported housing participants in the VA system employed secondary database analyses (N = 9967) and in-person surveys (n = 508), using logistic regression analyses to identify predictors of achievement of supported housing (ie, the rental of a unit after enrollment in a supported housing program).9 In this sample, 15% of participants exited supported housing before supported housing placement. Having a schizophrenia spectrum or other psychotic disorder, military service during the Iraq and Afghanistan conflicts, the presence of a disability worsened by or caused by military service (“service-connected disabilities”), or having an Emergency Department visit in the 90 days after supported housing admission significantly decreased the odds of becoming housed. However, receiving outpatient psychiatric or other mental health care in the 90 days before supported housing admission and use of outpatient care in the 90 days after supported housing enrollment significantly increased the odds of achieving housing.
This relationship between adherence to outpatient care and supported housing receipt was supported by a related study that we conducted in Los Angeles.10 Overall, these data suggest that psychiatric disorders closely interplay with service receipt to influence the acquisition of supported housing. Though supported housing cannot mandate engagement in health care, these findings stress the importance of adequate linkages to psychiatric and related mental health care pre- and post-supported housing enrollment, particularly for vulnerable individuals with serious mental illness and/or substance use disorders.
Among persons who achieve supported housing (ie, move into a rental unit), a multi-site, quantitative study identified several factors that increase risk for premature exits from supported housing programs.11 Specifically, days intoxicated in the month before supported housing enrollment (a proxy for SUD intensity), lower income, and institutionalization history (eg, in the mental health system), were associated with shorter program tenure.
Building from this work, we conducted a mixed methods study of supported housing enrollees in Los Angeles.12 Our goal was to understand the extent of the general medical, mental health, and psychosocial factors with potential implications for supported housing retention. Nearly all variables relevant to exits from supported housing were linked to mental health problems. A national study corroborated these findings, which suggests that admissions to inpatient SUD treatment settings and psychiatric hospitalizations, along with Emergency Department visits, predicted exits from supported housing into recidivistic homelessness.13
Even for persons who achieve and retain supported housing, a fundamental problem remains: “recovery” from homelessness extends beyond the acquisition of permanent housing. Extrapolated from the mental health literature, recovery from homelessness for persons with psychiatric disorders or SUDs encompasses a deeper process of building a meaningful and fulfilling life, with autonomy and social relationships.14 Yet, little is known about the social support and community involvement of formerly homeless persons who are engaged in supported housing, although findings suggest that supported housing participants remain socially isolated even after achieving housing.15 Additional work is needed to conceptualize and improve recovery for homeless persons engaged in supported housing.
Despite these challenges and knowledge gaps, I find psychiatric practice in supported housing settings to be immensely rewarding. In mental health clinics with few embedded social services, it is often challenging to treat patients’ depression or other psychiatric symptoms that are closely tied to social vulnerabilities. Sitting with patients who are experiencing homelessness-living in their vehicle or on the streets-and discussing their low mood without concrete resources to offer, can feel immobilizing. In contrast, including permanent, community-based housing with field-based case management-the tenants of supported housing-in a patient’s treatment plan (alongside traditional medication management and psychotherapy) can be immensely powerful. I am continually amazed by patients with serious mental illness-often untreated for years-who engage in supported housing and thrive in their own apartment.
My clinical skills are sometimes inadequate to predict who will succeed and who will fail in independent, supported housing with field-based case management. Psychiatrists are integral members of supported housing teams, working closely with social workers, psychologists, nurses, and consumer providers to engage a population with tremendous unmet mental health needs, but who are often disengaged from care. However, as a community psychiatrist, I often wonder if I practice a different sort of psychiatry than I learned in medical school and residency-care that is centered in harm reduction, the patient’s goals and needs (often focused on housing and social services, rather than mental health symptoms or substance abuse), and building rapport.
Given the robust linkages between social vulnerabilities and emotional health, community psychiatrists have a unique ability to advocate for the underserved, particularly for strengthened linkages between social services and mental health care. There may be value in implementation work to adapt evidence-based practices for psychiatric patients (eg, motivational interviewing, social skills training, and/or critical time intervention) to the context and setting of supported housing. Housing is a critical determinant of health and a fundamental human right; increasing access to supported housing will benefit many of our sickest patients.
Dr Gabrielian is Psychiatrist and Health Services Researcher, VA Greater Los Angeles; Assistant Professor, Department of Psychiatry and Biobehavioral Sciences, UCLA David Geffen School of Medicine; and Affiliated Researcher, National Center on Homelessness Among Veterans, Los Angeles, CA.
Dr Gabrielian reports no conflicts of interest concerning the subject matter of this article.
1. Bostic RW, Thornton RLJ, Rudd EC, Sternthal MJ. Health in all policies: the role of the US Department of Housing and Urban Development and present and future challenges. Health Aff. 2012;31:2130-2137.
2. US Department of Housing and Urban Development. Housing Choice Vouchers Fact Sheet. https://www.hud.gov/program_offices/public_indian_housing/programs/hcv/about/fact_sheet. Accessed April 13, 2018.
3. Greenwood RM, Schaefer-McDaniel NJ, Winkel G, Tsemberis SJ. Decreasing psychiatric symptoms by increasing choice in services for adults with histories of homelessness. Am J Comm Psychol. 2005;36:223-238.
4. Hopper K, Barrow SM. Two genealogies of supported housing and their implications for outcome assessment. Psychiatr Serv. 2003;41:50-54.
5. Fitzpatrick-Lewis D, Ganann R, Krishnaratne S, et al. Effectiveness of interventions to improve the health and housing status of homeless people: a rapid systematic review. BMC Pub Health. 2011;11:638.
6. Culhane DP, Metraux S, Hadley T. Public service reductions associated with placement of homeless persons with severe mental illness in supportive housing. Housing Policy Debate. 2002. https://shnny.org/uploads/The_Culhane_Report.pdf. Accessed April 13, 2017.
7. Hwang SW, Burns T. Health interventions for people who are homeless. The Lancet. 2014:384:1541-1547.
8. Montgomery AE, Hill LL, Kane V. Housing chronically homeless veterans: Evaluating the efficacy of a Housing First approach to HUD-VASH. J Community Psychol. 2013;41:505-514.
9. Montgomery AE, Cusack M, Blonigen DM, et al. Factors associated with veterans’ access to permanent supportive housing. Psychiatr Serv. 2016;67:870-877.
10. Gabrielian S, Burns AV, Nanda N, et al. Factors associated with premature exits from supported housing. Psychiatr Serv. 2016;67:86-93.
11. O’Connell M, Kasprow W, Rosenheck RA. National dissemination of supported housing in the VA: model adherence versus model modification. Psychiatr Rehab J. 2010;33:308-319.
12. Gabrielian S, Hamilton AB, Alexandrino A Jr. “They’re homeless in a home”: retaining homeless-experienced consumers in supported housing. Psychol Serv. 2017;14:154-166.
13. Cusack M, Montgomery AE, Blonigen D, et al. Factors that influence returns to homelessness following an exit from permanent supportive housing: health and supportive services utilization proximal to program exit. Fam Soc. 2016:97:221-229.
14. Lloyd C, Waghorn G. Conceptualising recovery in mental health rehabilitation. Br J Occupat Ther. 2008;71:321-328.
15. Tsai J, Mares AS, Rosenheck RA. Does housing chronically homeless adults lead to social integration? Psychiatr Serv. 2012;63:427-434.