U.S. flag

An official website of the United States government

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Policy and Global Affairs; Science and Technology for Sustainability Program; Committee on an Evaluation of Permanent Supportive Housing Programs for Homeless Individuals. Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness. Washington (DC): National Academies Press (US); 2018 Jul 11.

Cover of Permanent Supportive Housing

Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness.

Show details

Preface

In 1988, the Institute of Medicine (IOM) published its landmark report Homelessness, Health, and Human Needs, which analyzed the scientific evidence regarding the causes and consequences of homelessness and associated health problems. The report noted that “the fundamental problem encountered by homeless people—lack of a stable residence—has a direct and deleterious impact on health. Not only does homelessness cause health problems, it perpetuates and exacerbates poor health by seriously impeding efforts to treat disease and reduce disability” (p. 141). Cited by practitioners and policy makers in the field as being foundational to their work, the report recommended federal action to improve health services, housing, and income to reduce homelessness. Now, 30 years later—and notwithstanding some progress in addressing the problem—homelessness remains a major societal and public policy challenge. Particularly important are people experiencing chronic homelessness. Revisiting the housing and health care needs of this population is especially timely and critical to moving the discussion forward and improving the health outcomes of these persons.

Homelessness is linked to the occurrence of numerous acute health problems and exacerbates many serious health conditions including cardiovascular disease, diabetes, and HIV/AIDS. The prevalence of mental illness and substance use, along with co-occurring chronic medical conditions, is significantly higher for some groups within the population of persons experiencing homelessness. This has important implications for the delivery and cost of health care and other services. For example, individuals who are homeless are more likely to rely on emergency care because they lack health insurance and a regular health care provider. Reliance on emergency services may not result in the ongoing health care that is needed and incurs significant preventable costs for the health care system and public resources.

A wide range of housing and other services have been developed to address the needs of persons experiencing homelessness. Permanent supportive housing (PSH), which provides affordable housing matched with ongoing, appropriate services to tenants, is an important example of the types of services designed to keep individuals experiencing chronic homelessness stably housed. Other similar but less intensive interventions have been developed to address the health and housing needs of families experiencing homelessness or of young adults exiting the foster care system who may be at risk of homelessness. These types of services are growing, and it has become increasingly apparent that there is a need to understand how programs designed to house and provide services to populations experiencing homelessness can affect their health outcomes.

Recognizing the timeliness and importance of this issue, the Conrad N. Hilton Foundation and the Bill & Melinda Gates Foundation funded a National Academies of Sciences, Engineering, and Medicine (National Academies) workshop in November 2014 to explore the impact of the changing U.S. health care system under the Affordable Care Act on individuals experiencing homelessness in urban areas. A meeting summary, published in February 2015, describes the discussions held during the event (available at www.nationalacademies.org/healthequityrt or www.nas.edu/sustainability).

Discussions during the 2014 the National Academies workshop and a subsequent scoping session that included more than 30 experts in homelessness policy and research highlighted gaps in the evidence regarding PSH. In brief, empirical and experiential studies of the effectiveness of housing and other types of interventions address the problem of homelessness, but they substantially vary in terms of rigor, scale, and outcomes measured. Consequently, the aggregate findings are unclear, creating a pressing need to more systematically assess the effectiveness of these interventions, both in terms of improving health-related outcomes and cost-effectiveness.

To more fully evaluate interventions and policy options for addressing homelessness, and especially with regard to PSH, the National Academies convened an expert committee in April 2016 to evaluate a fundamental question: To what extent have permanent supportive housing programs improved health outcomes and affected health care costs in people experiencing homelessness? This report presents the findings of the committee's evaluation of the evidence available to answer this question.

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report: Dennis Culhane, University of Pennsylvania; Kelly Doran, New York University; Irwin Feller, American Association for the Advancement of Science; Lillian Gelberg, University of California, Los Angeles; Benjamin Henwood, University of Southern California; Kim Hopper, Nathan S. Kline Institute for Psychiatric Research; John Lozier, National Health Care for the Homeless Council; Linda McCauley, Emory University; David Meltzer, University of Chicago; Vincent Mor, Brown University; Robert Rosenheck, Yale School of Medicine; Molly Scott, Urban Institute; John Tracy, Optiv Security Inc.; and Carol Wilkins, Independent Consultant.

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by Joseph Newhouse, Harvard University, and Bobbie Berkowitz, Columbia University. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

The report would not have been possible without the sponsors of this study, including Blue Shield of California Foundation, California Health Care Foundation, Elsevier, Bill & Melinda Gates Foundation, the Conrad N. Hilton Foundation, The Kresge Foundation, Melville Charitable Trust, and the U.S. Department of Veterans Affairs.

The committee gratefully acknowledges the following individuals for making presentations to the committee: Rebecca Alvarez, Peacock Commons; Katie Bonamasso, Denver Social Impact Bond Initiative; Matthew Doherty, U.S. Interagency Council on Homelessness; Lorraine Flores, Bill Wilson Center; Ann Gabriel, Elsevier; Alison George, Colorado Department of Local Affairs; Sandra Hernandez, California Health Care Foundation; Brenton Hutson, Volunteers of America, Denver; Andrea Iloulian, Hilton Foundation; Ky Le, Santa Clara County; Shea Leibfreid, The Action Center; Jennifer Loving, Destination Home; Marcella Maguire, Corporation for Supportive Housing; Mandy May, Colorado Coalition for the Homeless; Thomas O'Toole, U.S. Department of Veterans Affairs; Kathy Robinson, Charities Housing Development Corporation; Gary Sanford, Metropolitan Denver Homeless Initiative; Richard Thomason, Blue Shield of California Foundation; Helen Tong-Ishikawa, MidPen Housing; Kristin Toombs, Colorado Department of Local Affairs; Sam Tsemberis, Pathways to Housing; and Mary Wickersham, Social Impact Solutions. The information provided during the presentations is used throughout this report and provided important perspectives that the committee used in its findings and conclusions.

I also would like to thank the staff from the National Academies who guided the committee through the study process. Michael Dorsey and Karen Anderson directed the study, with significant guidance from Rose Marie Martinez. Emi Kameyama and Anna Martin provided research and administrative support. Marilyn Baker and consultant Jennifer Saunders assisted in the final stages of completing the report.

Finally, I especially thank the members of the committee for their tireless efforts throughout the development of this report.

Kenneth W. Kizer, Chair

Committee on an Evaluation of Permanent Supportive Housing Programs for Homeless Individuals

Copyright 2018 by the National Academy of Sciences. All rights reserved.
Bookshelf ID: NBK519586

Views

  • PubReader
  • Print View
  • Cite this Page
  • PDF version of this title (2.5M)

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...