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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, the standard approach to serving people who are experiencing homelessness and have a disability 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 continue after they are housed.

In contrast, Housing First programs propose that persons or families experiencing homelessness and living with a disability are capable of maintaining 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 disabilities (excluding those living with HIV). Compared with clients in Treatment First programs, clients in Housing First programs experienced the following:
    • 30.7% greater housing stability (5 studies)
    • 88.4% greater decrease in homelessness (5 studies)
    • 4.9% greater improvement in quality of life (4 studies)
    • 5.0% greater reduction in emergency department use (3 studies)
    • 6.8% and 30.8% greater reduction in hospitalization (2 studies)
  • There were no apparent differences in physical health, mental health, or substance abuse between the two programs.
  • Three studies evaluated interventions that served clients living with HIV. Compared with clients in Treatment First programs, clients in Housing First programs experienced the following:
    • 63.0% greater housing stability (1 study)
    • 21.7% greater improvement in physical health (2 studies)
    • 13.0% greater improvement in mental health (1 study)
    • 30.0% to 40.0% greater reduction in mortality (2 studies)
    • 40.5% greater reduction in emergency department use (1 study)
    • 36.2% greater reduction in hospitalization (1 study)

Summary of Economic Evidence

A systematic review of economic evidence has not yet been conducted.

Applicability

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

Evidence Gaps

Additional research and evaluation are needed to answer the following questions and fill existing gaps in the evidence base.

  • 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?

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).