Homelessness Policy and Health-Related Social Needs

Background & Purpose

Housing instability, the direst extreme of which is homelessness, is a major health-related social need; housing instability has been associated with worse self-rated health, less access to healthcare and worse outcomes for chronic diseases. People experiencing homelessness (PEH) demonstrate elevated risk of infectious disease, traumatic injury, and serious mental illness.

Over time, permanent supportive housing (PSH) has been highlighted by the Department of Housing and Urban Development (HUD) for its potential to address health disparities among PEH. It was affirmed by the Homelessness Emergency Assistance and Rapid Transition to Housing (HEARTH) in 2009. Despite this affirmation, it is still unclear how changes over time to homelessness policy manifest in priorities locally, and what ultimate effects these changes have on health in impacted populations.

In light of this research gap this study aimed to describe the relevant federal policy and priority milestones since 2009 related to the implementation of health-related homeless services focusing on PSH.

Methods

Methods were a literature review of policy milestones since 2009 and a document analysis of priorities expressed in HUD Continuum of Care (CoC) Notices of Funding Opportunity (NOFOs) from 2009 to 2022. NOFOs include point-based evaluation criteria determined by HUD priorities that influence the amount of funding CoCs receive. To better understand how points reflected priority changes over the study period inductive themes discovered from the literature review were applied deductively to organize each NOFO’s point priorities into categories. Major policy themes are presented; proportions of points by themes were displayed in graphs.

Results

Literature revealed the HEARTH act was the most important federal homelessness policy legislation during the study period. Other major emergent priorities were CoC implementation and service directives, permanent housing, coordinated entry and assessment system, race and racial equity, partnerships with medical services, COVID-era priorities, and a final category entitled data management, performance, and the homeless management information system (HMIS). The HEARTH act affirmed PSH as a service orientation, included rapid re-housing (RRH) as a permanent housing option, and set specific standards around HMIS. Quantitative analysis shows CoC implementation and data management were most prioritized by proportion of NOFO points, followed by permanent housing—though permanent housing is a heterogenous category consisting of housing first, permanent housing, PSH and rapid re-housing. Proportions of each fluctuate over the study period.

Conclusions & Implications

Federal policy is not a major mechanism by which changes to homeless program delivery happens. NOFOs are both reflective of given priorities and establish them for agencies. Analysis of NOFOs suggest that relatively speaking permanent housing is an incentivized priority on aggregate. However, the style of permanent housing changes and is heterogenous if disaggregated, and terminology for service delivery changes. Health in and of itself is a small priority emerging in recent years. Future work could examine how these priorities result in on-the-ground changes in the number of beds, and further, how this prioritization could affect health.