Background: Permanent supportive housing (i.e., subsidized housing coupled with on-going support services) has been a widely advocated intervention shown to be effective in enhancing the residential outcomes for persons with serious mental illness (Rog, 2004). However, while prior research has found that housing tenure is limited for a minority but significant portion of permanent supportive housing (PH) participants, little is known about the circumstances surrounding departure from PH and the residential careers of participants once they left PH.

Methods: This is a longitudinal tracking study of PH participants using administrative and interview data. The sample consisted of 953 residents of 27 PH programs in a large metropolitan area during 2001-2004. Data on socio-demographics, psychiatric diagnoses, substance abuse treatment history and service use characteristics were extracted from an integrated administrative database comprising of PH stays, public shelter use, Medicaid eligibility and claims, and non-Medicaid publicly-funded behavioral health services. Chi-square, t-test, and stepwise logistical regression analyses were used to conduct the statistical tests. A sub-sample of 96 leavers was recruited and their post-PH careers (including employment status) documented through monthly in-person or phone interviews. The case study method was used to categorize the scenarios of departure from PH and the post-PH careers.

Results: Consistent with prior research findings, housing retention rates in PH were 75% in one year, 60% in two years, and 50% in three years. Regression analysis results suggest that socio-demographic and psychiatric diagnostic characteristics are not associated with departure from PH. Instead, behavioral health service use characteristics during participants' tenure in PH, particularly the use of psychiatric emergency (OR=1.78, p<0.01) and in-patient services (OR=2.31, p<0.001), are significant predictors of leaving. Two types of PH departures were discerned in the data: voluntary departures (61%) involving agreed-upon discharges to more appropriate housing suited to participants' needs and preferences (including housing with higher levels of independence), and involuntary departures (39%) involving poor resident-staff relationship, relapses and aggravated drug and alcohol problem, and poor housing and neighborhood characteristics of PH. Follow-up comparisons found that the higher level of behavioral health service use among PH leavers (compared to non-leavers) are attributable to those who departed PH involuntarily. As expected, involuntary leavers were more likely than voluntary leavers to experience unfavorable post-PH residential careers including high rates of homeless shelter use and psychiatric hospitalization. The employment rate during the post-PH career was consistently low (around 20%), regardless of the departure status (voluntary vs. involuntary).

Implications: Our findings suggest that monitoring behavioral health service use may be an effective mechanism for identifying PH participants at risk for unfavorable discharges. The implementation of an “early warning system” may help to target intensive services for those in greatest need. Interventions are needed to support and facilitate PH participants who are ready to move on to more independent settings. These may include the availability of long-term housing subsidies, encouragement of public-private partnership to develop housing units and provision of specialized services to enhance the employability of PH participants.