Based on our review of the literature on consumer roles in research, policy, planning, and services delivery and our assessment of consumer-driven service/housing approaches, we offer the following inventory of unresolved policy issues and a set of recommendations about the research necessary to address them.
Can the lessons learned about approaches to and consequences of consumer integration in multisite research initiatives be extended to policy and planning settings? In what ways will policies developed with full integration of people who have experienced homelessness differ from policies made with more limited or no consumer involvement? Consumer voices were not prominent in the processes that led to current systems of homeless services. As a starting point to assess whether and how consumer integration changes not only the process of planning and policy-making but the direction of policy itself, we recommend using qualitative approaches (ethnography, oral history, elicited narratives) to document processes and impacts of consumer involvement on policy bodies, such as HUD continuum of care planning committees, HCH governing bodies, and other homelessness policy and planning venues. The work of the consumer panels of the several homelessness-related SAMHSA multisite research initiatives offers important lessons on the supports needed to overcome barriers to consumer integration as well as approaches to documenting process and impact of consumer participation.
How can efforts to expand consumer integration in homelessness research, policy, planning and services address the experiences of consumers of color and avoid replicating the exclusions and stigmatization that are structured by societal mechanism of racial exclusion and poverty? Structural mechanisms (racial exclusion, poverty, lack of housing) that promote homelessness and direct its impact to poor communities of color also inhibit consumer integration in homelessness research, policy, planning and service delivery. Multi-level research and advocacy collaborations are needed to explore the links between these systemic processes and the barriers consumers of color experience, educate all involved with homelessness about these links, and connect consumers and advocates with broader social movements that address racial exclusion.
Research shows peer-staffed programs provide clients who are homeless with equivalent services and achieve outcomes equivalent to those achieved by non-consumer teams. Will expansion of peer employment opportunities through policies to certify and obtain Medicaid reimbursement for peer services affect staffing in homeless services, and with what impact on outcomes of individuals receiving services? The recent growth of various types of certified peer specialist programs offers an important opportunity to assess the impact of key dimensions of variation (training, certification, Medicaid reimbursement) on consumer employment in homeless service settings. In addition to documenting the range of program approaches deployed in these settings, research should address effects of CPS programs and other peer employment on peer staff as well as in promoting housing stability and other desired outcomes for persons who are homeless.
Experimental research on recovery-focused consumer-operated service programs has demonstrated effects on well-being. Can such services be effective in resolving homelessness and extending housing tenure? The research evidence for consumer-operated service programs has not specifically examined how such programs address homelessness and with what impact. Although findings are suggestive, there is need for research that specifically examines how consumer-operated services address homelessness and with what effects.
As housing first programs are replicated in different contexts and with new populations, what variations are introduced? How are outcomes affected? Much of the evidence for housing first is based on research on the Pathways to Housing program where the model originated. Fidelity studies currently in process will facilitate necessary further research on the models effectiveness and cost effectiveness in varied contexts with differently structured housing markets and contrasting service cultures as well as in diverse homeless subgroups (families, young adults aging out of foster care, and justice-involved individuals).
Is harm reduction housing a viable alternative to existing abstinence policies for people with long-term substance addictions and homelessness? While harm reduction has been part of the housing first approach as applied in programs for people with co-occurring mental illness and substance use, harm reduction housing for persons with histories of chronic homelessness and long-standing alcohol dependence or extensive drug use is relatively new and as yet untested. Descriptive studies are needed to document these interventions and their outcomes as are more rigorous controlled studies that evaluate their effectiveness in addressing homelessness and their impact on quality of life, health, and other outcomes. Anecdotal evidence supports the cost-effectiveness of these interventions; however little is known of outcomes and costs over time. Although the approach may remain controversial, it may offer new hope for those who have not found abstinence-focused programs to be a viable route to recovery.
A Final Note. As consumers increase their presence in the venues where decisions are made about homelessness research, policy, and service delivery, it is tempting to see consumer integration as the answer to homelessness. For many individuals who have been homeless, such participation will surely hasten personal recovery and social reintegration following homelessness, and their involvement will surely produce more responsive and effective policies. To expect that consumer integration or consumer-driven service programs alone will end homelessness at a societal level, however, is to overlook the multiple exclusionary processes from global to local that have generated homelessness by concentrating wealth, reducing the stock of affordable housing, skewing the distributions of opportunities for income and educational achievement, and marginalizing large segments of minority and poor populations in prisons or other institutions. Consumer voices will articulate priorities, create and validate useful service approaches, and energize the social resolve to address homelessness. If we are serious about ending homelessness, all voices must join together to demand the creation of housing and the other tools necessary to get the job done.