Across the country, the federal government, states, and communities have made a commitment to the goal of ending chronic homelessness. In so doing, a wide range of housing and service strategies tailored to the needs of people experiencing chronic homelessness have been developed.
Some important and influential research has been conducted in recent years, and a great deal of program development has been informed by evidence-based practice in the treatment of mental illness, co-occurring substance use disorders, and other health conditions. The development and implementation of innovative programs to address chronic homelessness, particularly for people with severe mental illness, substance abuse, and medical comorbidities, have outpaced the conduct of rigorously designed research studies that examine this population. As a result, while available research suggests promising approaches and implications for practice, it sometimes falls short of meeting the highest standards for defining evidence-based practice.
It will take a more substantial investment in research on homelessness to demonstrate with precision the efficacy of some of these promising practices, and to answer important questions about what works best for whom. Meanwhile, however, a growing number of practitioners and their partners in government and philanthropy are gaining experience in serving people who have had long and repeated spells of homelessness. In some cases consistent patterns and useful insights are emerging from available information from research studies, administrative data, qualitative and quantitative program evaluations describing outcomes, and expert opinion to suggest best practices that can guide the development of housing and services for chronically homeless people. Formative evaluations of promising housing and services innovations can guide the development of randomized controlled trials to firmly establish their efficacy. Here we list best practices based on current evidence presented in prior sections of this manuscript.
Outreach to homeless people who are living on the street and in shelters is often a first step in the process of engagement in the service system for consumers with long histories of servicelessness, but outreach cannot end homelessness unless it is tied to housing placement and support. The transition process from chronic homelessness to permanent housing, however, is likely a critical period that requires further study and evaluation.
Discharge planning needs to be linked to appropriate short-term and permanent housing options and effectively targeted to those most at risk of long-term homelessness. While there is yet no evidence that adequate discharge planning can prevent long-term homelessness for people discharged from psychiatric hospitals, jails and prisons, or foster care settings, the critical juncture of institutional release remains an important area for research and for the development of effective interventions. As demonstrated by Critical Time Intervention, as well as emerging research on medical respite shelter linked to permanent supportive housing, a comprehensive program of housing placement and treatment combined with case management can assist in the transition from a shelter to stable residence in the community. Moreover, tenancy preservation efforts could be initiated in the discharge planning process to prevent homelessness onset when it is apparent that the existing living situation is unstable or inadequate.
Case management and assertive community treatment have been established as optimal techniques for the delivery of mental health and substance abuse treatment services to people with severe mental illness and histories of residential instability. Assertive community treatment that integrates the direct delivery of services to address substance use problems appears to be more cost-effective than assertive community treatment with linkages to parallel substance abuse treatment in the management of homeless people with dual disorders.
Permanent supportive housing increases housing stability and decreases use of costly institutional services such as shelters, hospitals, emergency departments, and jails and prisons.
Housing retention appears to be greatest when housing is combined with services, regardless of the specific model of housing. The needs and preferences of homeless people vary. Some will prefer to live in housing with on-site supportive services, while others may seek apartments that provide opportunities for community integration with people who do not have disabilities or recent experience with homelessness. Supportive services that are individualized and delivered to people in their homes and in community settings can help many people who were previously chronically homeless succeed in their own living setting, wherever that may be.
Housing type (e.g., supportive housing with on-site services or independent apartments) and program models (housing first/low demand or high demand) should be geared to the clinical and social characteristics and preferences of consumers in order to achieve optimal housing outcomes. People with long histories of homelessness, particularly men who have challenging behavior problems, may be more successful in supportive housing programs that are site based. The integration of housing and case management services (e.g., programs in which the housing provider shares the goal of helping program participants maintain stable housing in spite of problems that might lead to eviction in private-market housing) may facilitate greater housing stability and life satisfaction, particularly for male consumers with greater clinical vulnerability.
Low demand models that include housing first (transitional housing, Safe Havens, and some permanent supportive housing) hold promise for engaging severely disabled chronically homeless individuals, who are often considered service-resistant and have longstanding substance abuse problems, in a process of recovery and eventual housing stability.