Homelessness is associated with high utilization of acute health care services. Among those who are homeless, a small proportion of individuals make up a large percentage of service use and likely face the most significant barriers to securing housing. For homelessness assistance services, engagement and retention in housing are critical priorities. New research from UC San Francisco suggests that an intervention of permanent supportive housing with voluntary supportive services can successfully house and retain chronically homeless individuals who are high users of public services.

The randomized control trial first published on September 25, 2020 and featured in the Health Services Research (HSR) 2020 Theme Issue on Drivers of Health is one of the first clinical trials to examine an approach to housing the most vulnerable chronically homeless people. Co-authored by Maria Raven, MD, MPH, Matthew Niedzwiecki, PhD, and Margot Kushel, MD of UCSF, the study focused on chronically homeless individuals with significant medical and other disabilities in Santa Clara County who are the most frequent users of county-funded services, such as emergency departments, hospitals and jails. Their results suggest that permanent supportive housing and appropriate services can house and retain a vast majority of high‐risk individuals and reduce the use of certain public services.

The study found that 86% of participants randomized to a permanent supportive housing modeldefined in the study as “subsidized housing with closely linked, voluntary supportive services (eg, case management, physical and mental health services, substance use treatment services)”provided by Abode Services were successfully housed and remained in housing for an average of 28.8 monthsor 93% of the study period. In comparison, 36% of those receiving “usual care” in the control group were housed. (Some  participants in the control group received similar services through a permanent supportive housing program implemented by the county at the time of the study.) When comparing how long participants were housed over one-year spans during the study period, those who received the intervention were housed 84.4% of a given span versus 20.1% for the control group.

According to Margot Kushel, “The bottom line is that even really high-risk folks can be housed. It takes a bit of time, and they need the flexibility to be moved to a new place when the first one didn’t work out.”

Findings also revealed that intervention group members had lower rates of psychiatric ED visits (1.3 visits per year compared to 1.9 visits by the control group) and shelter use (nearly two‐thirds fewer days in shelter compared to the control group). But, the intervention group did not demonstrate reductions in the use of medical emergency departments, hospitals, or encounters with the criminal justice system. Considering the high medical needs of participants in the study, the researchers explained that it would be a mistake to expect permanent supportive housing to reduce the need for all medical services. 

“These people are so far down the road in their illnesses, you’re so far from primary prevention,” said Maria Raven. “It is an effective intervention, but it’s late in their life course.”

In fact, permanent supportive housing may enhance people’s ability to access needed care. For example, individuals in the intervention group had higher rates of outpatient mental health treatment (37.3 times per year) versus the control group (19.7 times per year).

Although a permanent supportive housing intervention cannot be expected to reduce the need for medical care in individuals with neglected chronic conditions, the study clearly demonstrates that a Housing First approach with intensive case management can be effective for housing and retaining chronically homeless frequent users of public services.

“People have lost faith, stopped believing that people with severe impairments want to be and can be housed,” Kushel said. “This study shows that even these individuals can be housed using subsidized housing with intensive case management services.”