UAB Synopsis, Vol. 28, No. 24, June 22, 2009
Kertesz, SG; Weiner, SJ. Housing the Chronically Homeless. JAMA. 2009; 301(17):1822-1824.
Traditional approaches to ending chronic homelessness usually require participation in rehabilitative activities such as medical, addictive, or psychiatric treatment.
Stefan G. Kertesz, MD, MSc, assistant professor of medicine, UAB Division of Preventive Medicine, and Saul J. Weiner, MD, of the University of Illinois at Chicago, penned an editorial in The Journal of the American Medical Association (JAMA) on two studies in the April 1 and May 6 issues that evaluate a different approach known as Housing First.
Traditional policies have worked for many but not for those who have lived on the streets or in shelters for years. Severely debilitated, chronically homeless persons often cycle through treatment programs, hospitals, and jails, requiring major social services expenditures.
Housing First offers permanent housing to homeless individuals without requiring evidence of rehabilitative activities. The theory is that individuals who have stable housing will have reduced need for other public resources, saving taxpayers money.
In Seattle, chronically homeless persons with severe alcohol dependence and histories of heavy use of health and judicial resources were offered permanent housing in a renovated building with individual apartments, explicitly permitting residents to drink alcohol in their rooms.
Addiction treatment was offered (but not required) along with many other services. The study compared costs of public resources given to 91 housed clients with a control group of 35 who were on the waiting list. It reported a savings of $3822 per housed person per month, after housing costs were considered. The study also showed a declining alcohol intake, by a median of 5.1 drinks per day.
Dr. Kertesz cautions that capital costs were not included in the analysis, noting that, “The capacity to raise such capital will determine which communities are able to consider Housing First at all.”
The second study, conducted in Chicago, was prospective and randomized. It reported on chronically homeless persons with medical illnesses in medical settings. The investigators randomly assigned half of 407 volunteers to a medical respite care program followed by expedited placement to one of several community-based housing programs. The control group had access to standard care, including a hospital social worker.
66% Still in Housing
Results at 18 months showed 66% of the intervention group still in housing, compared with 10% of the control group. The intervention group’s housing success was accompanied by reductions in health services use. The Chicago participants had been less dependent on public resources prior to enrollment, so cost savings are expected to be less impressive compared with the Seattle experiment, the authors say.
Dr. Kertesz, who has published studies showing that homeless respite care curbs hospital readmission rates, believes the two studies show how the provision of secure housing to the sickest of the chronically homeless can be a win-win situation for all.
Because the strictly economic benefits will likely diminish or disappear when Housing First is offered to a less severely debilitated population, the central question raised in the editorial is: How far should such programs be expanded?
“The ethical value of relieving misery and the civic impact of reducing homelessness justify additional societal expense, but sometimes the ethical argument is less persuasive to policy makers than a case for cost savings,” the authors write.
The authors also raise questions about the applicability of Housing First programs for those with active and severe addictions — if alcohol is allowed, what about illegal drugs?
But the experiences in Seattle and Chicago “add to the increasing evidence that at least some large US cities cannot afford not to house some who live on their streets” and “the studies demonstrate that for the most frequent users of costly public services, service use substantially abates when individuals have stable housing.”