Permanent supportive housing (PSH) holds potential for improving the health outcomes for the homeless, and there is evidence that it improves outcomes among individuals with HIV/AIDS. However, evidence of its impact on other health conditions is lacking, largely because of multiple limitations in the research conducted so far.
That's the findings from a team of leading experts on population health who examined evidence on whether providing a combination of stable housing and supportive services to the homeless improves their health. Their report posted online today from the National Academies of Sciences, Engineering (NASEM), and Medicine.
“Homelessness is not good for health. Housing is an important determinant for health in general, and we believe that stable housing has an especially important impact on the ability to care for certain conditions and on the health of people who have them,” said Kenneth W. Kizer, chair of the committee that wrote the report, and a distinguished professor and director of the Institute for Population Health Improvement at the University of California, Davis. “More and better research is needed to help identify those housing-sensitive conditions.”
The committee’s 18-month study focused particularly on persons experiencing chronic homelessness. In 2017 about 87,000 people in the U.S. were considered chronically homeless. Persons who are chronically homeless are at higher risk for multiple types of infectious diseases, serious traumatic injuries, death due to exposure to extreme heat or cold, violence, and death due to chronic alcoholism and drug overdoses, among other health problems.
While a number of programs have been developed to address the needs of people experiencing homelessness, this report focuses on one specific type of intervention, permanent supportive housing (PSH), which provides housing along with voluntary comprehensive services such as mental health care, medical services, and development of skills for daily life tasks. PSH programs are supported by the U.S. departments of Housing and Urban Development, Health and Human Services, and Veterans Affairs, as well as numerous nonprofit and philanthropic organizations.
The report observes that studies ranging up to two years have shown PSH to be effective in maintaining housing stability for most people experiencing chronic homelessness, indicating that it is possible to reduce chronic homelessness. However, the report found that there is a substantial and ongoing unmet need for PSH and a shortfall in the funding to provide it, among other problems. The report urges HHS and HUD to work with nonprofit and philanthropic organizations and state and local governments to increase the supply of PSH.
“The evidence shows that reducing chronic homelessness is a solvable problem, given sufficient political will and a commitment of adequate resources,” said Kizer. “We hope this report will stimulate the action, including additional research, that is needed to move the field forward and advance efforts to eliminate chronic homelessness and improve health in this country.”
The committee found many limitations in the existing research base -- including inconsistent use of definitions of PSH, limited follow-up periods for studies, and data systems not designed to integrate data on homelessness and health -- that precluded strong conclusions about the impacts of PSH on health.
“We were surprised and disappointed to find so many limitations in the research that has been done to date on permanent supportive housing and health outcomes,” Kizer said. “An interagency examination of research and policy on PSH is needed. The U.S. Department of Health and Human Services, in collaboration with the U.S. Department of Housing and Urban Development, should convene subject matter experts to assess how research and policy could be used to facilitate access to PSH and ensure the availability of needed support services, including access to health care.”
One high-priority area for research should be longitudinal studies of more than two years in duration aimed at determining which health conditions, or combinations of conditions, are especially sensitive to housing or its absence. Studies showing that housing improves health outcomes in individuals with HIV/AIDS who are homeless could serve as a basis for research into other conditions whose outcomes are likely affected by housing.
The report also finds that additional research is needed in analyzing the cost-effectiveness of permanent supportive housing in improving health outcomes, and in determining the types of supportive services provided as part of PSH and the costs associated with them.
A number of policy and program barriers exist to bringing PSH and other housing models to scale to meet the needs of those experiencing chronic homelessness, the report says. Funding streams and policy regulations for PSH are siloed and often impose substantive restrictions on how funds may be used. This lack of coordination complicates efforts to combine funds from different sources and efficiently use available funding. The report recommends that HUD and HHS review their programs and policies for PSH with the goal of maximizing flexibility and the coordinated use of funding streams for supportive services, health-related care, housing-related services, the capital costs of housing, and operating funds such as Housing Choice Vouchers.
The study was sponsored by the Conrad Hilton Foundation, California Health Care Foundation, Melville Charitable Trust, Kresge Foundation, Bill & Melinda Gates Foundation, Blue Shield of California Foundation, U.S. Department of Veterans Affairs, and Elsevier. The National Academies of Sciences, Engineering, and Medicine are private, nonprofit institutions that provide independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, technology, and medicine. The National Academies operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Lincoln. For more information, visit http://national-academies.org.