Examining mortality among formerly homeless adults enrolled in Housing First: An observational study

BACKGROUND: Adults who experience prolonged homelessness have mortality rates 3 to 4 times that of the general population. Housing First (HF) is an evidence-based practice that effectively ends chronic homelessness, yet there has been virtually no research on premature mortality among HF enrollees. In the United States, this gap in the literature exists despite research that has suggested chronically homeless adults constitute an aging cohort, with nearly half aged 50 years old or older. METHODS: This observational study examined mortality among formerly homeless adults in an HF program. We examined death rates and causes of death among HF participants and assessed the timing and predictors of death among HF participants following entry into housing. We also compared mortality rates between HF participants and (a) members of the general population and (b) individuals experiencing homelessness. We supplemented these analyses with a comparison of the causes of death and characteristics of decedents in the HF program with a sample of adults identified as homeless in the same city at the time of death through a formal review process. RESULTS: The majority of decedents in both groups were between the ages of 45 and 64 at their time of death; the average age at death for HF participants was 57, compared to 53 for individuals in the homeless sample. Among those in the HF group, 72 % died from natural causes, compared to 49 % from the homeless group. This included 21 % of HF participants and 7 % from the homeless group who died from cancer. Among homeless adults, 40 % died from an accident, which was significantly more than the 14 % of HF participants who died from an accident. HIV or other infectious diseases contributed to 13 % of homeless deaths compared to only 2 % of HF participants. Hypothermia contributed to 6 % of homeless deaths, which was not a cause of death for HF participants. CONCLUSIONS: Results suggest HF participants face excess mortality in comparison to members of the general population and that mortality rates among HF participants are higher than among those reported among members of the general homeless population in prior studies. However, findings also suggest that causes of death may differ between HF participants and their homeless counterparts. Specifically, chronic diseases appear to be more prominent causes of death among HF participants, indicating the potential need for integrating medical support and end-of-life care in HF

Introducing Housing First in a Rural Service System: A Multistakeholder Perspective

Housing First (HF) represents a fundamental shift in thinking about how to address chronic homelessness that has taken place during the past two decades. Whether and how the logic of HF fits in rural systems of care has not been previously explored in the research literature. Using a case study approach and thematic analysis of accounts from 20 key stakeholders, this study investigated whether and how the introduction of HF into a small, rural state in the Northeastearn United States affected the dominant institutional logic. The overall account by multiple stakeholders remained largely consistent: The introduction of an outside HF program brought new resources and expertise, which resulted in a previously underserved population being effectively engaged in services. The extent to which the introduction of an outside provider with a specific, well-defined HF philosophy fit within the existing social services system was complicated by existing providers’ limited knowledge about or input during the grant submission that provided funding for the HF program. Numerous social forces and concerns regarding limited resources also influenced stakeholder perceptions. The impact of HF on existing institutional logics was not always clearly identified by stakeholders, yet HF’s emphasis on providing service options and allowing for client choice, as well as the demonstrated effectiveness of the approach, emerged as influential. Features of local environments (including systems of care but also funding, political, and cultural contexts) and their potential for triggering transformative change may influence the relative merits of implementing HF services by an outside provider with known expertise or supporting an existing provider to develop the infrastructure and foster a service philosophy based on an HF logic

Introducing Housing First in a Rural Service System: A Multistakeholder Perspective

Housing First (HF) represents a fundamental shift in thinking about how to address chronic homelessness that has taken place during the past two decades. Whether and how the logic of HF fits in rural systems of care has not been previously explored in the research literature. Using a case study approach and thematic analysis of accounts from 20 key stakeholders, this study investigated whether and how the introduction of HF into a small, rural state in the Northeastearn United States affected the dominant institutional logic. The overall account by multiple stakeholders remained largely consistent: The introduction of an outside HF program brought new resources and expertise, which resulted in a previously underserved population being effectively engaged in services. The extent to which the introduction of an outside provider with a specific, well-defined HF philosophy fit within the existing social services system was complicated by existing providers’ limited knowledge about or input during the grant submission that provided funding for the HF program. Numerous social forces and concerns regarding limited resources also influenced stakeholder perceptions. The impact of HF on existing institutional logics was not always clearly identified by stakeholders, yet HF’s emphasis on providing service options and allowing for client choice, as well as the demonstrated effectiveness of the approach, emerged as influential. Features of local environments (including systems of care but also funding, political, and cultural contexts) and their potential for triggering transformative change may influence the relative merits of implementing HF services by an outside provider with known expertise or supporting an existing provider to develop the infrastructure and foster a service philosophy based on an HF logic

Policy Recommendations for Meeting the Grand Challenge to End Homelessness

This brief was created forSocial Innovation for America’s Renewal, a policy conference organized by the Center for Social Development in collaboration with the American Academy of Social Work & Social Welfare, which is leading theGrand Challenges for Social Work initiative to champion social progress. The conference site includes links to speeches, presentations, and a full list of the policy briefs

A rising tide drowns unstable boats: how inequality creates homelessness

Is income inequality a driver of homelessness at the community level? We theorize that inequality affects homelessness both by crowding out low-income households from the rental market (what we call an “income channel”) and by causing home prices to rise (a “price channel”). We construct a dataset of information on inequality, homelessness, rent burden, and housing prices in 239 communities from 2007 to 2018 and use it to assess the income inequality–homelessness relationship. Our results suggest that income inequality is a significant driver of community homelessness and that the “income channel” is the more likely mechanism through which homelessness is created. We argue that broader policy efforts to reduce income inequality are likely to have the collateral effect of reducing homelessness, and we discuss the need for national and local policies to help low-income households afford housing.Accepted manuscrip

Fidelity to the Housing First Model and Variation in Health Service Use Within Permanent Supportive Housing

Permanent supportive housing (PSH) programs are being implemented throughout the United States. This study examined the relationship between fidelity to the Housing First model and health service use among clients in PSH programs in California.Data from a survey of PSH program practices were merged with administrative data on service utilization to examine the association between fidelity to a benchmark program, the Housing First model, and health service use among 5,067 clients in 77 PSH programs. Regression analyses were used to compare inpatient, crisis and residential, and outpatient mental health service use between high-, mid-, and low-fidelity programs in a pre-post design.During the preenrollment period, clients in mid- and high-fidelity PSH programs, compared with low-fidelity programs, used inpatient and crisis and residential services more but used outpatient mental health services less. Postenrollment, patients in high-fidelity programs showed the largest increase in the number of outpatient visits, followed by clients in mid- and low-fidelity programs: 71.6 versus 48.2 and 29.0, respectively.Clients in housing programs with higher fidelity to the Housing First model had greater increases in outpatient visits. Compared with lower-fidelity programs, higher-fidelity programs also enrolled clients who used fewer mental health outpatient services in the year before enrollment. Higher-fidelity programs may be more effective than lower-fidelity programs in increasing outpatient service utilization and in their outreach to and engagement of clients who are not appropriately served by the public mental health system

Fidelity to the Housing First Model and Variation in Health Service Use Within Permanent Supportive Housing.

Permanent supportive housing (PSH) programs are being implemented throughout the United States. This study examined the relationship between fidelity to the Housing First model and health service use among clients in PSH programs in California.Data from a survey of PSH program practices were merged with administrative data on service utilization to examine the association between fidelity to a benchmark program, the Housing First model, and health service use among 5,067 clients in 77 PSH programs. Regression analyses were used to compare inpatient, crisis and residential, and outpatient mental health service use between high-, mid-, and low-fidelity programs in a pre-post design.During the preenrollment period, clients in mid- and high-fidelity PSH programs, compared with low-fidelity programs, used inpatient and crisis and residential services more but used outpatient mental health services less. Postenrollment, patients in high-fidelity programs showed the largest increase in the number of outpatient visits, followed by clients in mid- and low-fidelity programs: 71.6 versus 48.2 and 29.0, respectively.Clients in housing programs with higher fidelity to the Housing First model had greater increases in outpatient visits. Compared with lower-fidelity programs, higher-fidelity programs also enrolled clients who used fewer mental health outpatient services in the year before enrollment. Higher-fidelity programs may be more effective than lower-fidelity programs in increasing outpatient service utilization and in their outreach to and engagement of clients who are not appropriately served by the public mental health system

A picture is worth…?: photo-elicitation interviewing with formerly homeless adults

We report on the use of photo elicitation interviewing (PEI) with 13 participants in a qualitative study of formerly homeless men and women with serious mental illness. Following a respondentcontrolled approach, participants were asked to take up to 18 photographs visually portraying positive and negative aspects of their lives and to subsequently narrate the meaning of the photos in a one-on-one interview. Thematic analysis of the photos (N = 205) revealed two approaches to PEI: (a) a “slice of life” and (b) “then vs. now.” Examples show how PEIs yielded deeper, more elaborate accounts of participants’ lives compared to earlier verbal-only interviews. Participants spoke of the benefits of PEI and preferred taking positive as opposed to negative photographs depicting their lives. Implications of PEI as a means of complementing verbal-only data are discussed. By moving away from predetermined content and meaning, respondent-controlled PEIs enhance empowerment and enable creativity.Peer reviewe

The Grand Challenge of Ending Homelessness

The notion that homelessness in the United States can be ended, rather than managed, represents a fundamental shift in expectations that has occurred over the past three decades. Many U.S. cities now have plans to end homelessness. Yet homelessness and housing instability are substantial problems that afflict a diverse group of subpopulations such as families, youth, veterans, and chronically homeless single adults. Ending homelessness for each of these populations may require tailored interventions that are responsive to specific individualized needs. These factors make tackling homelessness a difficult task. Although evidencebased solutions exist for some subpopulations, such as housing first for chronically homeless adults, scaling up best practices remains a challenge. For other subpopulations, such as transitional aged youth, evidence-based interventions need to be developed. In this paper we argue that ending homelessness is a Grand Challenge that is big, important, and compelling—one that the profession of social work should be adopt. Meeting this challenge will require a focused, organized response from social work researchers, clinicians, and policymakers. Ending homelessness will require innovation and interdisciplinary or cross-sector collaboration