Over time, homeless assistance programs have served single individuals who are homeless for various reasons from people who are working but experiencing a short-term crisis to those who are experiencing long-term homelessness and have complex service needs. Given the recent emphasis on addressing chronic homelessness, permanent and transitional housing programs serving single individuals who are homeless usually focus on people with a disabling condition such as mental illness, physical or medical disability, substance use disorder, or HIV/AIDS. Permanent housing funded under the McKinney-Vento Shelter Plus Care program can only be used for people with disabilities.
Emergency shelters often do not have an explicit focus on people with disabilities in their admissions process, but people with disabilities are heavily represented among those who use shelters frequently or for long periods. Homeless individuals with disabling conditions are considered particularly difficult to serve, especially if they have been homeless for extended periods and the symptoms of their disabilities have gone untreated.
Programs designed to serve these populations may take several forms. Because these are some of the most vulnerable people, some communities have emergency shelter programs specifically designed for them. Safe havens, which can be permanent or transitional housing, are designed to serve chronically mentally ill people who are homeless and who have been reluctant to enter the shelter system. Safe havens offer housing and make services available but in a low demand environment.
Transitional housing programs may provide next step housing to clients with substance use disorders after they have completed detoxification to prepare them for mainstream permanent housing without intensive supports. A permanent supportive housing program is sometimes used as a further next step for homeless individuals after a transitional program, but often is offered directly to homeless people coming from the streets or from emergency shelters under one or another variant of a housing first approach.
Research has shown that persons with severe mental illness who are offered the opportunity to live in permanent supportive housing experience reductions in shelter use, hospitalizations, length of stay per hospitalization, and time incarcerated (Culhane et al., 2002; Martinez & Burt 2006; Mayberg 2003). There has been some disagreement, however, on which model works best for this population: a model that requires clients to move through two or more housing placements before achieving permanent housing, or a housing first model that places clients directly in permanent housing with community-based supports.
Safe havens. Safe havens may be the first step off the streets for some of the most severely mentally ill homeless people. The Ward Family Foundation (2005) surveyed safe haven programs to collect information on program characteristics and effectiveness in transitioning safe haven residents to permanent housing. Seventy-nine of the 118 programs identified (about 85 percent of which were HUD-funded) responded to the survey. The findings on program characteristics are consistent with what we expect safe havens to provide. The programs serve people who are extremely vulnerable mentally ill and homeless and rarely refuse admission to anyone who meets those criteria. Participation in services or activities is rarely imposed. Most programs (72 percent) have no limit on length of stay; with the average length of stay among programs surveyed 262 days.
The program administrators surveyed said that, overall, just over half their residents exit to some kind of permanent housing, while about 14 percent return to homelessness. The most common reasons cited for residents not moving to permanent housing are that the residents condition is too unstable (64 percent), the community lacks housing with appropriate supports (63 percent), and the community does not have subsidies to make the housing affordable (59 percent).
The researchers identified the characteristics of programs that had a high rate of successful referrals to permanent housing based on results from 15 programs that achieved an average referral rate of 85.2 percent. This compares to an average referral rate of 41.6 percent for the remaining 64 programs. The programs with higher successful referral rates were smaller, more likely to offer private rooms, and more likely to operate at full capacity. These programs were more likely to require that clients come from the street and be severely mentally ill, but were also more likely to refuse admission to clients with felony or sexual violence convictions. The proportion of programs with a rich variety of services offered on site appears higher in the group with higher referral rates. The programs with higher referral rates had only a slightly higher average annual cost per bed ($43,089 compared to $41,534 for those with lower referral rates).
Transitional programs. The concept of transitional housing grew out of halfway houses for people released from prisons or mental institutions. HUDs transitional housing program began as separate from the permanent housing program. Both were later brought under the Supportive Housing Program component of the McKinney programs, although each with its own set of distinguishing rules (Burt, 2006). However, there was not a strong theoretical framework for applying this concept to homeless individuals. Only recently, with transitional housing challenged by shifting federal funding priorities and by the housing first model, have researchers begun to create a theory of transitional housing that goes beyond the simple McKinney-Vento programmatic rule that a transitional housing stay may not last more than two years. Much of the research on outcomes for individuals participating in transitional programs focuses on comparisons of supportive housing programs serving homeless individuals with mental illness (who often also have co-occurring substance use disorders and other disabilities) with traditional mental health treatment without a housing component. There have been few studies of transitional programs that compare them to other housing models.
Analysis of data on transitional housing has emphasized the rate of placements in permanent housing. This is one of HUDs GPRA performance measures for the McKinney-Vento programs, with a current goal that 61 percent of those exiting HUD-supported transitional housing be placed in permanent housing. An early study of the Supportive Housing Program, when it was funded as a demonstration, provided qualitative evidence that the housing and supportive services offered clients in transitional housing contributed to successful placement into permanent housing for 56 percent of clients studied (Matulef, et al. 1995).
Evaluations of local Supportive Housing Demonstration programs in Boston, Chicago, and Michigan also yielded promising findings on housing stability, although little change in the level of functioning of the clients served was observed. For example, as described in Brown (2004), in 1995, 114 undomiciled patients of a state psychiatric hospital in Chicago were randomly assigned to a supportive housing program (n=48) or to a controlled treatment (n=47) that provided links to whatever community service was available and no ongoing case management. According to data from case managers, experimental group participants were more than twice as likely to be housed. At six-month follow-up, none of the experimental group had returned to homelessness and 68 percent of the experimental group remained in supportive housing.
Permanent supportive housing. In contrast to the paucity of research on transitional housing programs for individuals with disabilities, a number of studies of permanent supportive housing have looked at both housing outcomes and service approaches.
A recent evaluation of the Connecticut Supportive Housing Demonstration Program examined the supportive housing concept in mid-sized cities such as New Haven and Hartford as well as in smaller communities such as New Britain and Middletown (Arthur Andersen, LLC and University of Pennsylvania, 2002). The Connecticut demonstration served people who were homeless or at-risk, many of whom also had mental illness, histories of addiction, or HIV/AIDS. The purpose of the study was to assess whether stable housing reduces the need for expensive social services over time, enhances residents quality of life, and allows residents to attend to employment and vocational needs. Connecticuts supportive housing approach provides permanent housing in which participants hold their own leases in projects developed by the state with multiple state, federal, and private funding sources. Some services are offered on site, but participation is voluntary.
Findings on client outcomes from the 4.5 year study included that tenants decreased their use of costly acute care health services while increasing their use of necessary routine and preventive health care, compared to their use of those services before they were placed in permanent supportive housing. Tenants were satisfied with most aspects of the program, functioned at high levels, and were able to move toward greater independence. Employment increased modestly. Of some concern, however, was that about 39 percent of the tenants exited housing during the study period, and 36 percent of leavers (14 percent of all tenants) left under negative circumstances. The researchers found that the negative departures were associated with substance abuse, some aspects of functioning (e.g., self care, daily chores, using transportation), not working toward goals in life, unemployment, and social isolation, but cautioned that the small sample sizes did not permit conclusive analysis of reasons for leaving.
The state of California has devoted substantial resources to serving vulnerable groups who had been inadequately served, including people who are seriously mentally ill and homeless, insufficiently housed, or returning from jails or prisons. The programs are known as AB2034 programs after the section of legislation that funded them. Mayberg (2003) found the programs resulted in reductions in homelessness, emergency room use, hospitalizations, and incarcerations. In a study prepared for the Corporation for Supportive Housing, Burt and Anderson (2005) found that clients with stable housing were more likely to stay enrolled in the program that is, to stay engaged in mental health services. Housing approaches vary across the 53 programs operating in 34 counties; AB2034 funds can be used for housing development, securing dedicated voucher assistance from PHAs, or providing ongoing rental subsidies through Shelter Plus Care or state funds. The program has achieved promising outcomes in helping clients, including those deemed hard to serve, obtain and retain housing, The researchers note that:
Programs with a high proportion of consumers who are homeless, recently incarcerated, or diagnosed with a co-occurring substance use disorder have similar outcomes to other programs [T]he data [also] show that those who disenroll from the AB2043 programs are no more likely than current enrollees to have lived on the streets, been incarcerated, or have a diagnosed substance abuse disorder.
An evaluation of the Closer to Home Initiative offers insights into the outcomes of six programs designed to engage and house people with disabilities, long histories of homelessness, and repeated use of emergency services (Barrow et al., 2004). The six programs are located in four cities: three in New York and one each in Chicago, San Francisco and Los Angeles. The purpose of the study was to describe the program models, document implementation over time, and assess outcomes for an initial cohort of participants.
The Closer to Home programs fell into two general program models. Three programs attempted to engage long-term residents of shelters or lodging houses to encourage them to move to permanent housing. The results of the assertive engagement efforts at these shelter/lodging house programs were modest:
The programs developed relationships with most residents, provided a range of direct services, and initiated housing referrals for a substantial proportion of the individuals at the sites. But engagement in complex services and housing remained low, and most residents still lived at the sites two years later. Moreover, the predictive analyses failed to confirm that building relationships with long-term residents would improve housing outcomes a key premise of these programs but did show better outcomes for residents who had entitlements and who became engaged around housing. . . . [T]hose who had been homeless longest were least likely to be housed, indicating a need to prevent long-term homelessness at earlier stages.
The other three programs provided housing to adults referred from various community service providers; the emphasis in the services provided by these programs was on housing retention. The housing settings included buildings housing only program clients and buildings with a mix of program clients and other residents. In all cases, the service approach was characterized as low demand, although one of the three programs screened prospective residents for those willing to participate in services and accommodate its buildings clean and sober environment.
In the three programs that provided housing directly, housing outcomes were more promising than the outcomes of programs that focused on engagement and referrals to permanent housing. After two years, more than half (55 percent) of the residents in the shelter/lodging house programs were still at their original location, and 18 percent had moved to other temporary settings. Only 25 percent had moved to longer-term settings, defined by the researchers to include permanent housing, transitional housing, adult homes, or nursing homes. By contrast, in the programs that provided housing, 77 percent of residents remained housed, and a large majority of tenants were engaged in clinical or social services. Mental health referrals significantly increased housing stability, according to the researchers, who further conclude: Across diverse housing approaches for homeless individuals with long-term homelessness and other barriers, housing works.
Despite these promising findings, there have been concerns about the fact that departure rates from permanent housing are as high as they are. In 2004, according to data reported by HUD-funded permanent supportive housing providers, roughly one-quarter of residents in HUD-funded permanent housing that year left after stays of two years or less. A recent HUD-sponsored study explored the reasons residents may leave permanent supportive housing programs (Morris Davis and Company, 2006). The study focused on programs serving people with serious mental illness. The researchers examined patterns among participants in 28 permanent housing programs in Philadelphia. Based on patterns observed among a cohort of people who entered permanent housing in 2001, the authors estimate that only half of those entering permanent housing would maintain residency for three years or more. More than 10 percent of the 2001 cohort left within six months.
The researchers found that about one-third of leavers were positive leavers who went to stable alternative housing. The remaining two-thirds were non-positive leavers who went to congregate settings, institutional settings, homelessness, or other unspecified destinations. Some 61 percent left voluntarily, while the remaining 39 percent left involuntarily. Positive leavers tended to leave in order to improve their living situations. Negative leavers had more severe levels of mental illness, greater incidence of substance abuse, and higher supportive services needs. The study authors encourage initial and on-going monitoring of permanent housing residents to identify and address issues for those most at risk of leaving under negative circumstances.
Housing first. The recent interest in the housing first approach as applied to homeless individuals with disabilities has led to studies of programs that move the most vulnerable homeless people rapidly to permanent housing with limited or no transitional placements. A number of studies have been published on the Pathways to Housing program in New York City (Tsemberis & Eisenberg, 2000; Padgett, Gulcur & Tsemberis, 2006; Siegel et al., 2006). In the Pathways program, participants are offered scattered-site permanent apartments with limited or no transitional stays. Neighborhood-based, multidisciplinary support teams work with clients to maintain their housing and, if the client chooses, address other supportive services needs. A study comparing the outcomes of homeless persons with serious mental illness placed in community residential treatment facilities (where service participation and sobriety are typically required to obtain and retain housing) with those in the Pathways to Housing program found that the Pathways to Housing supportive housing approach resulted in greater housing stability. After five years, 88 percent of Pathways to Housing participants remained housed, whereas only 47 percent of the residents in the residential treatment system remained housed (Tsemberis & Eisenberg, 2000).
In a HUD-sponsored study, researchers examined outcomes in the Pathways to Housing program along with two other programs that have adopted the housing first approach Downtown Emergency Services Center (DESC) in Seattle and Reaching Out and Engaging to Achieve Consumer Health (REACH) in San Diego (Pearson et al., in press). The three programs share some features: they serve clients with severe mental illness (including many with co-occurring substance use disorders) and long histories of homelessness; they offer permanent housing with access to a wide variety of services, but service participation is voluntary; and efforts to provide services continue even if the client leaves program housing for as long as 90 days. The housing types vary, however. While Pathways to Housing leases scattered-site units in privately owned buildings, DESC offers housing in several buildings the organization owns or controls. REACH (a program funded by Californias AB2034 program discussed above) has access to (but neither owns nor controls) a variety of housing units funded by Shelter Plus Care subsidies, project-based Section 8, and state funds. Some units are clustered in a safe haven and several downtown SRO buildings, while others are scattered site-apartments in complexes throughout the county. While REACH does not require service participation, a number of the housing providers associated with the program do have occupancy rules regarding alcohol and drugs, curfews, noise, and other issues.
The researchers tracked 25 to 29 clients at each site for 12 months to examine housing tenure patterns, among other outcomes. Overall, the programs had similar outcomes, but the findings reveal that there are nuances to housing stability. While a large majority of clients (84 percent) were still housed at the end of 12 months, not all had stayed in program housing throughout the tracking period. Across all three programs, 43 percent of the clients stayed in housing for the full 12 months. Some 41 percent experienced at least one departure to another living environment, but returned to program housing. The remaining 16 percent left or died during the follow-up period. The researchers did not observe substantial changes in clients mental health or substance use status, but this was not expected given the relatively short follow-up period. As has been seen in other studies, clients who entered housing from the streets and had more severe psychiatric impairment or co-occurring substance use disorders were more likely to leave.
The San Francisco Department of Public Healths Direct Access to Housing (DAH) program offers another housing first approach. DAH provides permanent housing with on-site supportive services for formerly homeless adults, most of whom have mental health, substance abuse, and chronic medical conditions. The program is targeted to high users of the citys public health system and describes itself as a low threshold program that accepts single adults into permanent housing without requiring service participation or abstinence from substance use. The housing consists of 876 units that include nine SRO hotels, three newly developed buildings, and one licensed residential care facility (or board and care). The program also secures blocks of units in several buildings owned by nonprofit providers. To access this large stock of housing, DAH has identified buildings that are vacant or nearly vacant and then negotiated with the owners to renovate the buildings in exchange for entering a long-term lease with DAH. When a building is ready for occupancy, DAH contracts with service providers to provide on-site services.
The DAH program pays particular attention to health outcomes, given that the program targets high users of emergency services. According to program data, emergency department use was reduced by 58 percent after program entry. In the two years after program entry, participants had 57 percent fewer inpatient episodes compared to the two years prior to program entry. Numbers of days of hospitalization also declined for participants with histories of mental illness and psychiatric hospitalization (Trotz, 2005).
Research comparing service approaches in permanent supportive housing. Researchers have attempted to tease out the roles of different housing and services models for permanent supportive housing in affecting tenure outcomes. One small-scale, New York Citybased study conducted interviews with 224 residents from 10 developments financed by the Enterprise Foundation; the researchers also used case management data. Most residents in the study had their own apartments with kitchen and bathroom, and paid subsidized rents. On-site and off-site services were offered, but not mandatory. The study found positive outcomes in housing stability, as well as increased incomes and strong client satisfaction with services (Bayer & Barker, 2002).
In a larger study of homeless persons with severe mental illness served in the New York, New York Initiative, Lipton and colleagues (2000) followed a total of nearly 3,000 persons placed in high-, moderate-, and low-intensity housing for a period of five years. Intensity levels were determined by the researchers and refer to the degree of structure in the program, including the level of scheduling, house rules, and requirements for program participation. The degree of clients independence, including control over decisions about the living environment, activities, income, medications, and privacy, was also factored into intensity.
Clients placed in housing with different levels of intensity had somewhat different characteristics. Clients placed in high-intensity settings (30 percent of the sample) tended to be younger, referred from hospitals, and to have a history or diagnosis of substance abuse. Clients placed in moderate-intensity housing (18 percent of the sample) were more likely to be female and were least likely to have substance abuse problems. Individuals in low-intensity settings (52 percent of the sample) were more likely to be referred from city shelters where they had lived for four or more months.
Lipton examined tenure outcomes, classified as follows: consumers who were continuously housed either stayed in their initial placement or moved to another stable setting. Those classified as discontinuously housed became homeless, moved to an unstable setting, or were imprisoned. Consumers who died, were hospitalized for medical reasons, or could not be located were not classified. The study found that, for the sample overall, 75 percent, 64 percent, and 50 percent of consumers were continuously housed for one, two and five years, respectively. The risk of being discontinuously housed was highest in the first four months following housing placement, and this risk was greatest for those in high-intensity housing. The researchers also found that older age was associated with longer tenure, while a history of substance abuse was associated with shorter tenure. In addition, consumers referred from psychiatric hospitals were more likely to have poor housing outcomes regardless of the type of housing. The authors conclude:
Discussions about housing for this population have at times unnecessarily pitted the residential continuum model against the supported housing model. Although some individuals will initially benefit from normalized housing, others may require various degrees of structure, interpersonal intensity, and support. Varied types of housing are needed to meet the heterogeneous needs of a diverse consumer group.