There are a few myths that Maria Raven hopes her new research will dispel, and at the top of the list is the idea that some chronically homeless people have such severe substance-abuse and physical- or mental-health issues that they simply can’t or don’t want to be housed for any significant period of time.
It’s not true, says Raven, an associate professor of emergency medicine at the University of California, San Francisco. And the experience of Project Welcome Home, a permanent supportive housing (PSH) initiative in Santa Clara County (whose county seat is San Jose), is the proof.
“Even for the very sickest of the sick, they were really able to get into housing and stay housed,” Raven says.
Project Welcome Home began in 2015 as a partnership between Santa Clara County and Abode Services, a California-based provider of housing for people experiencing homelessness. The goal, according to an early project overview, was “to measurably improve the lives of chronically homeless individuals in the County by connecting them to permanent supportive housing, and to reduce the degree to which they receive services from acute psychiatric facilities, jails, and other institutions that provide only short-term relief.” The project was financed using a “pay for success” model, meaning investors in the program would get returns based on how well the program worked. And in order to evaluate its success, Abode Services and the County partnered with researchers at UCSF’s Benioff Homelessness and Housing Initiative to conduct a randomized controlled trial of participants.
The results of that trial were published last month in the journal Health Service Research, in a paper co-authored by Raven and fellow UCSF faculty Matthew J. Niedzwiecki and Margot Kushel, who is also director of the Benioff Homelessness and Housing Initiative. The study included 423 participants — 199 of whom received housing and support services through Project Welcome Home (the intervention group) and 224 in a control group. All participants were “high users” of county health and social services. In the two years prior to the program, according to the paper, those in the intervention group had an average of 19 emergency room visits, 3.7 jail stays, and 36.7 days spent in homeless shelters, 6.5 outpatient substance use treatment visits and 26 outpatient mental health visits. Those in the control group had similar averages.
The findings show that Project Welcome Home has had varying impacts on participants. According to the paper, 86 percent of people in the intervention group were able to remain housed for 93 percent of the study period. Those in the intervention group had fewer emergency psychiatric visits and more regular mental health visits than the control group. They did not have substantially fewer emergency room visits or interactions with the criminal justice system. Also, for a range of reasons, like causing damage to units or inviting more people to live with them than their leases allowed, many in the intervention group needed to be placed in housing multiple times.
According to Raven, previous studies of permanent supportive housing have shown much larger reductions in use of emergency and social services. But those studies have not included control groups, and so they are tainted by “regression to the mean,” meaning that participants in the studies are often included during periods when they are using lots of services, and that use gradually declines toward more typical rates anyway. The report still concludes that permanent supportive housing can help keep chronically homeless people with severe health and substance-abuse issues housed.
“Even the most high-risk individuals can be successfully housed using a Housing First approach with intensive case management,” the report says. “The housing patterns we found, however, suggest the need for flexibility … The ability to offer a new housing placement is a key component of successful Housing First strategies when working with high complexity populations.”
In terms of the actual work of housing people, Project Welcome Home isn’t so different from Abode Services’ regular work, says Vivian Wan, the group’s chief operating officer. But it was especially attractive because it incorporated a randomized controlled trial — “the Rolls Royce of evaluation models,” Wan says, and something that the group hasn’t been able to afford to do on its own. And the level of funding allowed the group to continue finding housing for individuals in the intervention group, no matter how many times they had to be rehoused because they broke the terms of a lease, Wan says.
“We gave people lots of chances, and that’s what’s needed,” she says. “It shouldn’t be a one-chance thing.”
Another attractive feature was the pay for success financing, Wan says. Abode Services invested $500,000 in the $6.9 million program, with the remainder of the funding coming from The Reinvestment Fund, the Corporation for Supportive Housing, the Sobrato Family Foundation, the California Endowment, the Health Trust, the James Irvine Foundation, Google.org, and the Laura and John Arnold Foundation. The project was aimed at keeping at least 80 percent of tenants continuously housed for 12 months or more, because, according to a Project Welcome Home fact sheet, chronically homeless people who stay housed for a year or more are “less likely to utilize costly medical and behavioral health resources and more likely to experience improved wellbeing. Investors received “success payments” based on how well the program performed relative to that measure. That model also shifted the risk of the program not performing well to the investors, rather than the government, which made it more attractive to Santa Clara County as well.
Ky Le, the deputy county executive for Santa Clara County, says the trial shows that supportive housing alone can’t resolve every issue that chronically homeless people face, including the lingering impacts of previous interactions with the criminal justice system. (Researchers and support staff with Adobe Services were surprised by the number of people in the study who died — seventy in all, with 37 in the intervention group and 33 in the control group. Raven says the group wants to look more closely at the causes of death, but believes the rate is a reflection of how poor participants’ health was by the time they enrolled.)
But it also shows that those individuals can be housed long-term with the proper resources. And the researchers hope that’s what other jurisdictions and housing providers take away from the trial as well. Raven says it’s good to demonstrate that jurisdictions can spend less on services when more of their residents are stably housed, but to her, the main takeaway is that everyone deserves housing.
“I hope it gets used to promote permanent supportive housing as a solution for people that need to be housed,” Raven says. “Traditionally a lot of people, and I’ll include myself in that, have looked at reductions in medical services usage as a justification to provide people with housing … Because this is a subset of people that are really disenfranchised and poor, people feel like in order to house them you must show reductions in health services to justify it. And to me, housing is just the right thing to do for people, especially really, really impaired people who need a lot of help.”
This article is part of Backyard, a newsletter exploring scalable solutions to make housing fairer, more affordable and more environmentally sustainable. Subscribe to our weekly Backyard newsletter.
Jared Brey is Next City's housing correspondent, based in Philadelphia. He is a former staff writer at Philadelphia magazine and PlanPhilly, and his work has appeared in Columbia Journalism Review, Landscape Architecture Magazine, U.S. News & World Report, Philadelphia Weekly, and other publications.