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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

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THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

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.
×

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, Melville 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.

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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. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25133.

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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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.

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.
×

images

Consensus Study Reports published by the National Academies of Sciences, 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 independent 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, Engineering, and Medicine chronicle the presentations and discussions at a workshop, 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 Academies, please visit www.nationalacademies.org/about/whatwedo.

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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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)

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.
×

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

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.
×

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 homeless people—lack of a stable residence—has a direct and deleterious impact on health. Not only does homelessness cause health problems, it perpetuates and exacerbates 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—homelessness 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 discussion forward and improving the health outcomes of these persons.

Homelessness is linked to the occurrence of numerous acute health problems 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 provider. 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 services 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 growing, 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.

Page viii 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.
×

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) workshop 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.nationalacademies.org/healthequityrt or www.nas.edu/sustainability).

Discussions during the 2014 the National Academies workshop and a subsequent 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-effectiveness.

To more fully evaluate interventions and policy options for addressing homelessness, 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 affected 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 manuscript 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 recommendations 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

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.
×

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 Foundation, Elsevier, Bill & Melinda Gates Foundation, the Conrad N. Hilton Foundation, The Kresge Foundation, Melville Charitable Trust, and the U.S. Department of Veterans Affairs.

The committee gratefully acknowledges the following individuals for making presentations to the committee: Rebecca Alvarez, Peacock Commons; Katie Bonamasso, Denver Social Impact Bond Initiative; Matthew Doherty, U.S. Interagency 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 Affairs; 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 provided during the presentations is used throughout this report and provided important 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. Marilyn Baker and consultant Jennifer Saunders assisted in the final stages of completing 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 Supportive Housing Programs for Homeless Individuals

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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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

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.
×
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

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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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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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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