Health, Housing, and Service Supports for Three Groups of People Experiencing Chronic Homelessness. 1.2. Supportive Service Components


Supportive services are required during all phases of the person’s engagement with PSH. The types of services vary, and are described below.

1.2.1. From First Contact to Moving Into P ermanent Supportive Housing

The supportive services that bring people into PSH have three elements that are conceptually distinct but often happen concurrently in practice:

  • Outreach and client identification--walking the streets and checking at drop-in or resource centers, hospital emergency rooms, jails, soup kitchens, sobering centers, shelters, and other locations frequented by homeless people. This first step is essential and is done largely beyond office walls, because that is where the people will be found.

  • Engagement--interactions over days or months to establish a trusting relationship and start linking people to treatment, services, and benefits. During this time, health professionals and other outreach staff help people apply for food stamps, get treatment for obvious health problems (e.g., skin diseases), start the application process for Supplemental Security Income (SSI), and establish Medicaid eligibility in states where that is a process independent of being an SSI beneficiary.

  • Finding housing--helping homeless people apply for subsidies, identify units, work with landlords, move into housing, and acquire household goods. This work may be done by outreach staff, regular case managers, or specialized housing/landlord liaison personnel. In “housing first” approaches it begins immediately after first contact. It is often facilitated by: arrangements with local housing agencies that administer rent subsidy programs; well-cultivated and longstanding relationships with a pool of cooperative landlords; or registries of affordable housing developments.

1.2.2. Stabilizing People in Housing

Once programs succeed in getting people housed, the work of housing stabilization begins.

  • Case managers or community/housing support teams--helping clients learn to live in housing, pay rent on time, get along with neighbors, and perform basic tasks such as shopping and minimal cooking.

  • Linking to benefits and services--helping clients access public benefits for which they are eligible if the clients do not already receive them, helping clients to make and keep health care appointments and follow recommended treatment.

  • Keeping housing units in good condition--helping newly housed clients learn to maintain their unit so it does not attract vermin and is free of fire hazards.

  • Creating a support system--buildings dedicated to PSH often also include common rooms, communal activities, and tenant governance organizations to help make the building’s residents into a community, as well as easy access to staff.

1.2.3. Early and Ongoing Health Care for Permanent Supportive Housing Tenants

Services for those already in PSH and for those still homeless ideally include care for physical and behavioral health conditions, although actual provision of this care varies widely, as described later in this paper. These health care activities include:

  • Primary care includes--ongoing treatment for acute and chronic health conditions; preventive health care; and medications management, including clinical pharmacy services to help avoid over-medication and negative side effects from conflicting medications. Dental care is often the top health care need. Vision and hearing care are often needed, for homeless people of every age but especially for those who are getting older. Primary care is provided by health care professionals, usually in clinics but sometimes through outreach. Increasingly PSH providers seek to incorporate primary care into their supportive services structure, but, for most PSH residents, primary care remains largely outside that structure.

  • Mental health services include--counseling and coaching to reduce social isolation and restore functioning impaired by mental illness; assessment and support for recovery and self-management of symptoms and medications; prescribing and adjusting medications; being alert to signs that clients are beginning to have problems related to the symptoms of their mental illnesses; intervening with crisis counseling; and offering respite or urgent care if needed. Mental health services are provided by mental health professionals and sometimes by paraprofessionals and peer counselors, usually from mental health service agencies but sometimes on the staff of PSH housing providers.

  • Services to address substance use disorders include--Alcoholics Anonymous/Narcotics Anonymous or other peer support, detoxification, harm reduction/stages of change strategies, and residential treatment. Services may involve motivational interviewing, individual and group counseling, and coaching. The intent is to help people establish recovery or harm reduction goals and to achieve and maintain them. In today’s PSH, this work is done mostly by staff of PSH service-provider agencies and by integrated treatment teams. Rarely do chronically homeless clients go to residential treatment programs, but they have often used detoxification and sobering centers before entering housing.

1.2.4. Care Coordination and Integration

An essential but not always achieved element of services for residents of PSH involves keeping all the activities related to health care on the right track and working to complement each other rather than in isolation or opposition. Care coordination and integration start with considering a prospective client’s “whole picture” from the beginning, when the agency makes the decision to enroll people in its programs and engages them in identifying their own needs, goals, and priorities. Activities include team meetings and case conferences, records integration, attention to care transitions, and ongoing in-home contact. Care coordination often involves cross-agency connections and teamwork.

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