Research That Matters (January 17 - 20, 2008)

Background and Purpose As a persistent social problem affecting the fabric of communities, homelessness remains a significant issue throughout the United States. The intersection of mental health with homelessness presents unique challenges involving the basic provision of shelter and resources, choice of treatment approaches, and engaging individuals in services. Using the Housing First paradigm, supported housing programs address these multiple problems. This study examined the implementation of an enhanced supported housing program for individuals and families facing homelessness and psychiatric disabilities. Drawing on both the housing first model and harm reduction approaches to service delivery, permanent supported housing was enhanced with community-based nursing and peer support services.

Methods A mixed method longitudinal panel design was used to follow (N=61) participants for two years following program entry to evaluate achievement of desired program and individual outcomes. Administrative data were combined with primary quantitative and qualitative data. Participants completed 3 waves of surveys using both standardized measures and original items addressing both individual and organizational level domains. Qualitative interviews and focus groups were held with program staff and consumers. Qualitative data were analyzed using template analysis. Finally, cost-effectiveness and cost benefit analyses using a willingness to pay cost estimation approach, along with a sensitivity analysis, were used to evaluate the economic impact of the program.

Results Statistically significant findings from paired t-tests, and chi-square analyses included increased housing stability, reduced rehospitalization, reduced incarceration, increased housing satisfaction, increased choice in housing, improved physical and mental health, and increased satisfaction with quality of life. No findings were seen in more global personal domains like self-esteem, locus of control, and empowerment. Qualitative results suggest that consumers were well served by this intervention model and greatly benefited from both the peer support and harm reduction components. Areas for program growth and improvement were also identified, with the operationalization of peer support principles a key example. The cost analysis results further supported the positive findings in the quantitative and qualitative analyses.

Implications for practice This study highlights an innovative though high cost approach to providing housing and supports for a population characterized as difficult to serve and retain in care. Findings suggest the intervention was not only effective in promoting housing stability and decreasing homelessness, but was also cost-effective, given the high costs associated with non-entry into housing and the subsequent utilization of expensive public services. The most significant cost savings were generated in the first year following program entry, indicating the need for creative financial thinking and differential resource deployment as participants reach longer term program stays. The use of intensive (and higher cost) support services upon initial program entry, followed by slow titration over time, is consistent with the supported housing literature and would also allow for innovative ways to address the challenges of empowerment and promoting self sufficiency for participants. Social workers are a natural fit in advocating for and implementing such programs, and the use of a consumer-centered, harm reduction approach represents a valuable step toward the social work ideals of empowerment.