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Health Equity: Permanent Supportive Housing with Housing First (Housing First Programs)

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What the CPSTF Found

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 26 studies (search period through February 2018).

The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to health equity.

Context

Homelessness is associated with lower income and is more common among racial and ethnic minority populations. Homelessness is also associated with multiple health problems, increased mortality, and increased use of health care and other services. In 2017, nearly half of the people experiencing homelessness had a disabling condition, which the Department of Housing and Urban Development (HUD) defines as having limitations in conducting daily life activities or in working or living independently, or having a diagnosis of HIV infection (including AIDS; Henry et al., 2018).

In the United States, a common approach to serving people who are experiencing homelessness and have a disabling condition, has been referred to as Treatment First, or Continuum of Care (National Academies of Sciences, Engineering, and Medicine, 2018). This approach maintains that clients must take steps, including treatment and sobriety, to become “housing ready” before they receive permanent supportive housing, and they must remain “housing ready” after they are housed.

In contrast, Housing First programs propose that persons experiencing homelessness and living with a disabling condition can maintain a home when provided with services.

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The systematic review included 26 studies.

  • Twenty-three studies evaluated interventions that served clients living with disabling conditions (excluding those living with HIV). Compared with clients in Treatment First programs or control group participants receiving treatment as usual, clients in Housing First programs experienced the following:
    • Median 41% greater housing stability (13 studies)
    • Median 88% greater decrease in homelessness (5 studies)
    • Median 5% greater improvement in quality of life (4 studies)
    • Median 5% greater reduction in emergency department use (3 studies)
    • 7% and 36% greater reduction in hospitalization (2 studies)
  • There were no apparent differences in physical health, mental health, or substance abuse between the intervention and control groups.
  • Three studies evaluated interventions that served clients living with HIV. Compared with control group participants receiving treatment as usual, clients in Housing First programs experienced the following:
    • 63% greater housing stability (1 study)
    • 38% greater reduction in homelessness (1 study)
    • Median 22% greater improvement in physical health (2 studies with 4 data points)
    • 13% greater improvement in mental health (1 study)
    • 32% to 42% greater reduction in mortality (2 studies)
    • 41% greater reduction in emergency department use (1 study)
    • 36% greater reduction in hospitalization (1 study)

Summary of Economic Evidence

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

A systematic review of economic evidence shows the economic benefits exceed the intervention cost for Housing First Programs in the United States.

The economic review included 20 studies (search period through November 2019). Seventeen studies were from the U.S. and three were from Canada. All monetary values are reported in 2019 U.S. dollars.

Intervention Cost

  • The median cost per person per year for U.S. studies was $17,069 (17 estimates from 12 studies).
  • The median cost per person per year for all studies was $16,873 (23 estimates from 15 studies).

Economic Benefit

Economic benefit is the sum of savings from healthcare, emergency housing, judicial services, welfare and disability costs, and benefits from increased employment.

  • The median economic benefit per person per year for U.S. studies was $17,016 (19 estimates from 13 studies).
  • The median economic benefit per person per year for all studies was $17,750 (25 estimates from 16 studies).

Benefit to Cost Ratio

  • The median benefit to cost ratio for U.S. studies was 1.44, meaning there was a societal cost savings of $1.44 for every $1 invested (14 estimates from 9 studies).
  • The median benefit to cost ratio was 1.06 for all studies, meaning there was a societal cost savings of $1.06 for every $1 invested (20 estimates from 12 studies).

Applicability

The finding should be applicable to people who are living with a disabling condition and experiencing homelessness in urban and suburban areas.

Evidence Gaps

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

  • How effective are Housing First programs for families, youth, women, LGBTQ populations, and rural communities?
  • Which services do Housing First programs offer? How frequently do clients use offered services? How does program effectiveness vary by services available or used?
  • What is the long-term impact of Housing First programs on health outcomes?
  • What is the cost-effectiveness of Housing First programs?
  • What is the cost-benefit when interventions are implemented for youth or families, or in smaller urban or rural areas?

Study Characteristics

  • Studies were done in urban (24 studies), suburban (1 study), or a mix of urban and suburban (1 study) settings across the United States (23 studies) and Canada (3 studies). None of the included studies were conducted in rural settings.
  • Study participants had a mean age of 42.4 years (20 studies) and 74.0% were male.
  • Only one study examined a program targeted to families; none of the studies focused on women or racial/ethnic minority populations.
  • Study designs included individual randomized control trials (8 studies) and pre-post studies with concurrent comparison groups (18 studies).

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