Factors Associated with Access to Permanent Supportive Housing Among People with Serious Mental Illness

Background/Purpose: According to the World Health Organization, access to safe and affordable housing is one of the most basic and influential social determinants of health. Permanent Supportive Housing (PSH) is an evidence-based practice that combines permanent affordable housing with comprehensive and flexible support services. It is recognized as a cost-effective intervention for homeless individuals who have a serious mental illness or substance use problem. Delayed access to supportive housing has been found to negatively affect housing stability. However, there is a relative dearth of research detailing the factors associated with accessing PSH among persons with a serious mental illness. Specifically, little is known about the characteristics of applicants for PSH who are declined service by housing providers. Consequently, this study aimed to address the following research question: What individual-level factors are associated with being declined mental health supportive housing by supportive housing providers?

Methods:An analysis of waitlist data for PSH from a coordinated access service (CAS) in Toronto, Canada (population 2.7 million) was undertaken to examine the relationship between applicant characteristics, needs and service request outcomes. The CAS provides access to PSH operated by 29 non-profit supportive housing providers. Application and placement outcome data for applicants’ first service request for supportive housing collected by the CAS were used for analyses. Between August 2013 and October 2015, 1,870 applicants had at least one outcome related to a service request for supportive housing: 252 (14%) had a service provider decline service, 972 (52%) refused a housing offer by a housing provider, and 646 (35%) were successfully placed in supportive housing. Chi-square analyses were used to compare the demographic, clinical, service preference and need profile of applicants who had a housing provider decline service to applicants who were successfully placed in PSH.

Results:Compared to applicants who were successfully placed in PSH, those whose first service request was declined were more likely to be homeless at referral (73% versus 62%), have a secondary mental health diagnosis (40% versus 26%), and to report having a substance use problem (55% versus 39%). Applicants who were declined also had some distinct support needs and past risk behaviors. Compared to applicants who were successfully placed, they were more likely to endorse support needs related to avoiding crises (52% versus 39%) and managing drug and alcohol misuse (50% versus 36%). They were also more likely to report past suicidal ideation (48% versus 35%), suicidal attempts (28% versus 16%) and violence towards others (32% versus 21%).

Conclusion and Implications: Supportive housing providers may not feel that they have adequate capacity to successfully house and serve homeless applicants with criminogenic needs, substance use and behavioral challenges. Provision of training on evidence-based interventions targeting these issues may increase service providers’ confidence in supporting applicants with this clinical profile. Moreover, a Housing First approach toward admissions which features a low barrier assessment process and eligibility criteria ought to be adopted to minimize the unintentional exclusion of some of the most vulnerable homeless populations.