Housing First: A Review of the Evidence

Housing First: A Review of the Evidence

Highlights

• Several studies have found that, compared with the treatment first model, Housing First approaches offer greater long-term housing stability, especially among people experiencing chronic homelessness.
• Some studies have found that Housing First programs may also reduce costs by shortening stays in hospitals, residential substance abuse programs, nursing homes, and prisons.
• Research suggests that Housing First programs successfully house people with intersecting vulnerabilities, such as veterans and people with a history of substance abuse, mental illness challenges, domestic violence, and chronic medical conditions such as HIV/AIDS.

The early 1980s marked the beginning of what could be considered the "modern era of homelessness."¹ A sequence that included two severe recessions at the start of the decade, persistent inflation, and an economic shift marked by deindustrialization hit many central cities hard. This economic shift, along with the widespread deinstitutionalization of individuals experiencing mental illness, cuts to core programs at HUD and other agencies funding social services, and an inadequate supply of affordable housing facilitated a dramatic rise in homelessness. In central areas of many major cities, zoning changes prohibited the boarding houses and single-room occupancy buildings that had traditionally accommodated individuals at risk of homelessness, and rising property values made them redevelopment targets. Most notably, since the early 1980s, rents in metropolitan areas have increased steadily while wages have stagnated.² These factors combined to change the frequency and nature of homelessness in America; a report from the National Academies of Sciences, Engineering, and Medicine notes, "The typical homeless person of the 1980s was younger (less than 40 years old), more impoverished, and had a higher burden of co-occurring medical, mental health, and substance use disorders than previous generations of persons experiencing homelessness."³ For the first time, women and families appeared in significant numbers among those seeking assistance.⁴ Previous typographies of those experiencing chronic homelessness as mainly poor, older alcoholic males or transient individuals unwilling to shackle themselves to the constraints of industrialized employment and modern society ("tramps" or "hobos") were fundamentally challenged by these developments.

Sam Tsemberis and his colleagues founded Pathways to Housing in New York City in 1992, allowing individuals experiencing homelessness to access housing and services with the only requirements that tenants pay 30 percent of their income toward rent by participating in a money management program and meet with a staff member at least twice a month.
Photo courtesy of Allison Zapata

In their study of the changing nature and demographics of homelessness in the 1990s, Kuhn and Culhane categorized homelessness into three temporal groups: transient (roughly 80% of those using a shelter), episodic (10% of all shelter users), and chronic (10% of all shelter users).⁵ Individuals experiencing transient homelessness do so briefly and only once, often because of an acute disruption such as loss of employment or a costly medical event. Individuals experiencing episodic homelessness have repeated, albeit brief, shelter stays. The final group, individuals experiencing chronic homelessness, are the hardest to house, often because they have significant medical issues, disabilities, or unique service needs. Related studies from the same authors found that adults experiencing chronic homelessness disproportionately used the shelter system, accounting for 53 percent of all shelter days despite representing only 18 percent of all homeless individuals assessed in the study.⁶ Stories about the disproportionate and costly use of hospital systems by individuals experiencing chronic homelessness were further reinforced by media reports, especially Malcolm Gladwell’s New Yorker story "Million Dollar Murray."⁷ A 2010 report from the U.S. Department of Health and Human Services (HHS) found similarly that "the top 5 percent of hospital users — overwhelmingly poor and housing insecure — are estimated to consume 50 percent of health care costs."⁸ Such chronically homeless individuals are more likely to have documented issues concerning substance use, mental health, trauma, and chronic medical conditions, including HIV/AIDS. Although this subpopulation of individuals experiencing homelessness is a minority of all individuals experiencing homelessness, this group is the most visible and is often a target of media coverage and political rhetoric.

The response to this contemporary rise in homelessness rates and the emergent, highly visible phenomenon of individuals experiencing chronic homelessness was a "treatment first" model — also frequently referred to as a "linear" or "staircase" model. In this model, individuals experiencing homelessness must be treated for underlying issues, such as addiction or mental health issues, before becoming eligible for independent, sustained housing. This model involves progression on a continuum of different types of assistance: emergency shelter, transitional living arrangements, and permanent housing.⁹ Often, this meant that individuals entered highly regulated, congregate facilities; accessed relevant treatment services while stabilizing in this transitional program; improved in treatment; and became ready for independent, permanent housing. Those who relapsed or left the program at any point forfeited their opportunity for housing assistance. This system came to prominence during the 1990s, a period when many policymakers in the federal government were deeply concerned about increasing household self-sufficiency and minimizing dependence on government programs — perhaps best captured in the epigraph of the United States Interagency Council on Homelessness’ 1994 strategic plan, in which President Clinton wrote, "Work organizes life." In other words, housing was available only to individuals experiencing homelessness who were willing to work for it.

Testing an alternate approach, Sam Tsemberis and his colleagues founded Pathways to Housing in New York City in 1992, allowing individuals experiencing homelessness to access scattered-site housing and assertive community treatment (ACT) services without requiring commitments to sobriety or treatment. Pathways to Housing’s only requirements were, first, that tenants pay 30 percent of their income (usually Supplemental Security Income) toward rent by participating in a money management program, and second, that tenants must meet with a staff member at least twice a month.¹⁰

This alternative to the treatment first approach was found to be more effective by several studies. As the model evolved and gained popularity, it came to be known as Housing First. The George W. Bush administration embraced Housing First principles, which contributed to a 30 percent reduction in homelessness rates in the United States between 2005 and 2007.¹¹ The HEARTH Act of 2009 further entrenched Housing First principles in federal policy, expanding the availability of permanent housing to families, youth, and nondisabled single adults and authorizing rapid rehousing (RRH) assistance.¹² In addition, this act mandated the creation of a national strategic plan to end homelessness, which was released in 2010.¹³ Since that time, Housing First principles have been guiding federal homeless response programs. This article summarizes the evidence that underpins the Housing First approach.

What the Evidence Says

The Limitations of Treatment First

Despite the widespread adoption of the treatment first model in federal programs, many of which had no actual permanent housing component, critics doubted the potential of this paradigm to address issues of contemporary homelessness — especially those concerning individuals experiencing chronic homelessness. Long before the rise of contemporary homelessness, sociologists such as Erving Goffman had questioned the intentions and efficacy of treatment models that imposed rigid conditions on patients, which often were intended as much to institutionalize and control the patient as to effect any sort of "cure." Moreover, emerging evidence suggested that the treatment first model lacked relative effectiveness. In a study evaluating outcomes for people experiencing chronic homelessness based on data from 11 communities receiving coordinated funding from HUD, HHS, and the U.S. Department of Veterans Affairs, Tsai et al. found that, although participants in both transitional housing and Housing First programs experienced improved psychosocial outcomes over time, participants in the Housing First program were independently housed for longer periods despite experiencing homelessness for longer periods at the study’s baseline.¹⁴ Because the study was not randomized, the authors caution that participants in the transitional housing programs group were more likely to have severe substance use issues and report greater satisfaction with transitional housing. Nevertheless, they conclude, "These results suggest that clients with substance use disorders do experience more problems living independently, but prior transitional/residential treatment may not particularly benefit them any more than Housing First approaches, especially on independent housing outcomes."¹⁵

A systematic literature review and metanalysis of four RCTs that compared the effectiveness of Housing First programs with treatment first programs found that Housing First significantly improved housing stability. Photo courtesy of U.S. Department of Housing and Urban Development Flickr

Other studies have found that the imposition of external values and lack of agency on the part of the consumer (i.e., individuals experiencing homelessness) critically limit the capability of the treatment first model. Henwood et al. note, "Providers in [treatment first] programs attempted to have consumers conform to system-centered goals, which at times appeared to overlook the individuals that the system was intended to serve, resulting in higher rates of disengagement from services."¹⁶ Put differently, the rigid nature of the treatment first model produces inferior housing stability outcomes for individuals experiencing homelessness and can result in disengagement from critical services. Furthermore, retrospective analysis from HUD’s Family Options Study indicates that families experiencing homelessness may face unique, relative barriers to accessing transitional housing. In addition, outcomes for families in the project-based transitional housing group were not significantly different than usual care.¹⁷

Chronic Homelessness

To assess the effectiveness of Housing First and the role of consumer choice, a randomized controlled trial (RCT) was performed on the Pathways to Housing program in 2004. Participants were assigned randomly to either a Housing First experimental group or a local Continuum of Care control group to receive treatment as usual (TAU). Eligibility for this study reflected key characteristics of the chronically homeless population: participants must have spent half of the previous month living on the street or in public places, exhibited a history of homelessness over the previous 6 months, and been diagnosed with an Axis I mental health disorder. The results indicate that Housing First participants experienced significantly faster decreases in homeless status and increases in stably housed status than the TAU group did, with no significant differences in either drug or alcohol use. Overall, the Housing First experimental group demonstrated a housing retention rate of approximately 80 percent, roughly 50 percentage points above that of TAU, which, the authors noted, "presents a profound challenge to clinical assumptions held by many Continuum of Care supportive housing providers who regard the chronically homeless as ‘not housing ready.’"¹⁸

Four major RCTs have been performed to compare the effectiveness of Housing First programs with treatment first programs. Three of these RCTs were conducted in the United States, and the other was conducted in Canada. In a review of these RCTs, Tsai notes that two RCTs conclusively found that Housing First led to quicker exits from homelessness and greater housing stability than did TAU.¹⁹ In the Canadian trial, an RCT in five of Canada’s largest cities known as At Home/Chez Soi, analysis revealed that, in findings similar to those of the American RCTs, "Housing First participants spent 73% of their time in stable housing compared with 32% of those who received treatment as usual."²⁰ Baxter et al. also performed a systematic literature review and metanalysis of these four RCTs, finding that Housing First resulted in significant improvements in housing stability.²¹ This study also found that no clear differences existed between Housing First and TAU for mental health, quality of life, and substance use outcomes, ultimately concluding, "The combination of a strong, positive impact on housing with little additional impact on mental health and substance use, compared with TAU, is consistent with the findings of other reviews."²² Rog et al. performed a similarly extensive literature review to describe various permanent supportive housing (PSH) programs, assess the methodological quality of existing studies, and assess the effectiveness of PSH compared with TAU. In assessing the evidence base for PSH, which included a review of eight literature reviews, seven RCTs, and other quasi-experimental studies, Rog et al. were able to examine several major studies examining the effectiveness of Housing First, finding, "All studies found that participants in Housing First had significantly less homelessness compared with participants receiving standard care, day treatment with no housing, or housing that was contingent on treatment and sobriety."²³ These findings were confirmed in a more recent analysis by researchers from the Centers for Disease Control and Prevention (CDC) and HUD’s Office of Policy Development and Research (PD&R): in a systematic review of 26 studies comparing Housing First with treatment first or TAU programs, Peng et al. found that, compared with treatment first programs, Housing First programs decreased homelessness rates by 88 percent and improved housing stability by 41 percent.²⁴ This analysis also found that participants in Housing First programs reported improved quality of life, community integration, and positive life changes compared with clients in TAU programs.

In addition to the consistent evidence that Housing First programs increase housing stability among people experiencing chronic homelessness, some evidence indicates that Housing First programs may also limit costs more effectively than do treatment first programs. In a study of adults who had been homeless for at least a month and had a chronic medical condition, Sadowski et al. found that, using an intent-to-treat analysis, participants in Housing First reported a significant reduction in costly emergency room visits and hospitalizations compared with TAU — 24 percent and 29 percent, respectively.²⁵ Based on these findings, Basu et al. evaluated the relative costs of Housing First versus treatment first programs, assessing differences in hospital days, emergency room visits, outpatient visits, days in residential substance abuse programs, nursing home stays, legal services (including days in incarceration), days in shelter housing, and case management between the two programmatic models.²⁶ Basu et al. found that participants in Housing First programs had decreased costs because they spent fewer days in hospitals, emergency rooms, residential substance abuse programs, nursing homes, and prisons or jail. On the other hand, Housing First participants incurred higher costs from higher outpatient visits per year and a greater number of days in stable housing than TAU participants. Ultimately, a comprehensive cost analysis from this RCT found that Housing First saved $6,307 annually per homeless adult with a chronic medical condition, with the highest cost savings occurring for chronically homeless individuals, at $9,809 per year.²⁷ The authors note that, if scaled, these savings would amount to $5.5 billion over the next 10 years. However, note that this RCT was performed in only one U.S. city, and other studies have associated Housing First models with higher costs. For example, HUD’s own Family Options Study found that PSH for families was more expensive than TAU. The previously referenced report from the National Academies of Sciences, Engineering, and Medicine similarly concluded that sufficient evidence does not yet exist to conclude that PSH reduces healthcare costs. Nevertheless, although evidence about relative costs is less certain, evidence of positive outcomes is not; furthermore, evidence also exists for improved outcomes for important subpopulations that experience intersecting, challenging vulnerabilities.

Long-term evidence from HUD's Family Options Study indicates that having priority access to permanent housing offers substantial benefits for families.

Families With Children

The Housing First model has been adopted largely by programs that serve individuals — that is, single adults in households without children rather than families — in part because chronic homelessness is much less common among households with minor children. However, many of the most effective tools for serving families experiencing homelessness broadly adhere to the core principles of the Housing First model. Beginning in 2010, HUD began enrolling families in emergency shelters in the Family Options Study, an RCT performed in 12 communities to gather evidence about which types of housing and services programs work best for homeless families. Families were assigned to one of four treatment groups: permanent housing subsidies (SUB), community-based rapid rehousing (CBRR), project-based transitional housing (PBTH), and usual care (UC). Of these four, the first two — SUB, in which families receive priority access to a permanent housing subsidy with no dedicated supportive services, and CBRR, in which families receive priority access to temporary rental assistance — represent strategies that are broadly aligned with the principles of Housing First in that they do not require service participation or have preconditions for receiving assistance. The other two groups — PBTH, in which families receive temporary accommodation, often with intensive service requirements, and UC — represent alternatives to the Housing First approach in the form of transitional and emergency shelters. Long-term evidence from the Family Options Study indicates that having priority access to deep, permanent housing offers substantial benefits for families. Specifically, "assignment to the SUB group more than halved most forms of residential instability, improved multiple measures of adult and child well-being, and reduced food insecurity."²⁸ Families assigned to the CBRR group had housing stability outcomes that were comparable to those of UC families but at a substantially lower cost because they avoid the use of costly transitional housing programs. Perhaps most important, compared with UC, the treatment first group (PBTH) exhibited no impacts on eight indicators concerning family well-being and self-sufficiency, and assignment to the PBTH intervention did not facilitate improved family preservation or child well-being outcomes compared with UC. The authors conclude, "The striking impacts of assignment to the SUB group in reducing subsequent stays in shelter and places not meant for human habitation provide support for the view that, for most families, homelessness is a housing affordability problem that can be remedied with permanent housing subsidies without specialized homeless-specific psychosocial services."²⁹ As for the more treatment first-aligned PBTH group, the authors state that "[o]verall, 3 years after assignment, the study did not find evidence that the goals of this distinctive approach to assisting families facing unstable housing situations were achieved relative to leaving families to find their way out of shelf without priority access to the program."³⁰

Rapid Rehousing

Housing First can also include RRH programs, in which individuals experiencing homelessness are given temporary assistance that quickly moves them into private housing while providing time-limited services in some cases. This programmatic model corresponds with Housing First principles and can be an effective intervention for individuals and families who fit the typology of experiencing episodic or transient homelessness. A review of RRH program outcomes by Abt Associates for PD&R confirms this expectation; in a review of 18 studies measuring exits to permanent housing from RRH programs, the expected range for successful transition to permanent housing was 71 to 84 percent.³¹ RRH programs within a Housing First framework also are successful at avoiding returns to homelessness, thus preventing many individuals and families from experiencing episodic or chronic homelessness. The largest study examining returns to homelessness from RRH programs to date is the Supportive Services for Veteran Families program, which provided RRH assistance for homeless veterans and their families. This study found that RRH assistance prevented 84 percent of individuals and 91 percent of families from returning to homelessness after 1 year.³² Another study found that, of the 1,500 families who exited from RRH programs, only 6 percent were found to have returned to homelessness after 1 year.

Housing First and Relevant Subpopulations

According to the Substance Abuse and Mental Health Services Administration, in 2010, 26.2 percent of all sheltered persons who were homeless had a severe mental illness, and 34.7 percent of all sheltered adults who were homeless had chronic substance use issues. Of those who experienced chronic or long-term homelessness, approximately 30 percent had a mental health condition and 50 percent had co-occurring substance use problems.³³ In addition, previous studies have found that having HIV/AIDS-positive status and experiencing homelessness frequently co-occur, with Culhane et al. finding that individuals using homeless shelters in Philadelphia had nine times the risk of having HIV/AIDS-positive status than did the general population.³⁴

Individuals Experiencing Mental Illness

As mentioned previously, the first major RCT in the United States examining the effect of Housing First on homelessness was the Pathways to Housing evaluation, which concluded, "Our findings indicate that ACT programs that combine a consumer-driven philosophy with integrated dual diagnosis treatment based on a harm-reduction approach positively affect residential stability and do not increase substance use or psychiatric symptoms."³⁵

Canada’s multicity At Home/Chez Soi study was launched in 2008 to test the effectiveness of Housing First as an approach for addressing homelessness among people experiencing severe mental illness. Canada, like the United States, saw a wave of deinstitutionalization during the 1970s. Following federal policy changes during the 1990s that slashed the number of affordable housing units created, significant numbers of people with severe psychiatric disabilities living on deficient incomes found themselves no longer able to sustainably access housing, leading to a rise in homelessness rates.³⁶ As with the Pathways for Housing evaluation, the At Home/Chez Soi experimental group received priority access to housing and supportive services, and the control group received TAU.³⁷ In findings much like those of similar U.S. studies, Housing First proved to be more effective than TAU at achieving housing stability: During the 2-year course of the study, Housing First participants spent 73 percent of their time stably housed, whereas the control group was stably housed only 32 percent of the time. In the last 6 months of the study, 62 percent of Housing First participants were housed the entire time compared with 31 percent of TAU participants. Moreover, Housing First participants also displayed greater improvements in community functioning and quality of life than did TAU participants, although these effects began to fade for the "high need" experimental subgroup receiving ACT after 2 years.³⁸

Individuals With Substance Use Issues

As mentioned previously, studies have found elevated substance use among individuals experiencing homelessness; one major study found that the occurrence of drug and alcohol disorders was as high as 78 percent of all individuals experiencing chronic homelessness. In addition, for these individuals, substance use can be a barrier to accessing housing, with many expressing concern that providing housing to such individuals will result in property damage, worsening addiction, and community harm — all of which imply the need for transitional, treatment first housing programs. Davidson et al. assessed the relationship between Housing First program components and substance use across nine scattered-site projects in New York City. More specifically, the authors examined the relationship between programmatic fidelity and substance use outcomes, hypothesizing that clients in programs with higher fidelity to Housing First principles (lower barriers) would experience superior housing stability and lower rates of substance use at followup than clients in lower fidelity programs. As with all previous studies, clients in programs that maintained higher fidelity to Housing First principles were less likely to be discharged from the program, and they remained stably housed. The study also assessed alcohol, cannabis, and stimulant or opioid use during the evaluation period. The authors conclude that "[t]here was no association between fidelity in implementation of supportive housing components and client substance use. On the other hand, clients in consumer participation–consistent programs were less likely than others to report using stimulants or opiates at follow-up."³⁹ In other words, programs maintaining greater fidelity to Housing First principles resulted in increased therapeutic trust and alignment with supportive services, which, in turn, reduced high-risk substance use even when the programs did not mandate sobriety.

Roosevelt Gardens in Austin, Texas, provides 40 units of supportive affordable housing for people living with HIV. All units receive HUD’s HOPWA assistance. Photo courtesy of Jleitner Photography

Individuals Living With HIV/AIDS

Since the emergence of HIV/AIDS in the early 1980s, the association between HIV and homelessness has been clear. A report from the Congressional Research Service notes, "In the earlier years of the epidemic, as individuals became ill, they found themselves unable to work, while at the same time facing health care expenses that left few resources to pay for housing."⁴⁰ Without stable housing, individuals with HIV who are experiencing homelessness may not have a secure location to receive, store, and take medications, often leading to decreased adherence to treatment protocols and increased viral loads that increase the likelihood of transmission. Nearly four decades later, the financial and medical vulnerability associated with HIV/AIDS continues to increase the likelihood that an individual will experience homelessness. Because of intersecting areas of vulnerability involving healthcare access, financial precarity, lack of shelter, and socioeconomic stigma, individuals experiencing homelessness are more likely to engage in high-risk behaviors that increase the likelihood of HIV transmission such as needle sharing, transactional sexual relationships, and unprotected sex. Accordingly, Congress enacted the Housing Opportunities for Persons with AIDS (HOPWA) housing program as part of the Cranston-Gonzalez National Affordable Housing Act of 1990. HOPWA is a grant program administered by HUD that distributes funds by formula allocation and competitive grant competitions to eligible metropolitan statistical areas that meet minimum HIV/AIDS case requirements based on CDC data. To be eligible for HOPWA assistance, individuals must test positive for HIV/AIDS and earn incomes that do not exceed 80 percent of the area median income. HIV-positive individuals and their families receive housing assistance and supportive services as part of the program. However, jurisdictions can use HOPWA funds to develop and operate multifamily residences; fund short-term rental, mortgage, and utility assistance programs as well as rental assistance programs for PSH; construct or acquire and rehabilitate property for single-room occupancy housing; provide supportive services; and offer housing counseling and referral services.⁴¹ HOPWA funds are used primarily for housing assistance; HUD data indicate that, for the 2014 to 2015 program year, 69 percent of all HOPWA grant funds were used for housing assistance.

In 2003, CDC and HUD initiated the Housing and Health Study, an RCT assessing the effects of HOPWA rental assistance on the health and housing outcomes of unstably housed individuals living with HIV/AIDS. Treatment group members received HOPWA housing and services, whereas individuals in the control group received only social and health services. After 18 months, 82 percent of the treatment group members were stably housed compared with 51 percent of control group members. After the same amount of time, 15 percent of the treatment group were unstably housed compared with 44 percent of the control group. Individuals in the treatment group experienced relative mental health improvements, with notable improvements in perceived stress and depression. Although some issues with research design generally limited the study’s ability to compare the two groups, participants who were homeless during followup had 2.5 times the odds of having a detectable viral load compared with those who had been stably housed.⁴² Another similar RCT, the Chicago Housing for Health Partnership study, found that after 12 months the group that received housing assistance, had higher rates of intact immunity and were more likely to have undetectable viral loads. These findings were recently confirmed in a 2020 analysis performed by CDC, HUD, and academics.⁴³ Providing housing also reduced the use of high-cost emergency health services. The authors note, "Compared to those in the usual care group, those in the treatment group showed 29% reduction in hospitalizations, a 29% reduction in the number of days spent in the hospital, and a 24% reduction in visits to the emergency room."⁴⁴

Domestic Violence

Another group shown to benefit from Housing First programs is survivors of domestic violence. An analysis from the National Center for Children in Poverty found that, among mothers with children who were experiencing homelessness, 80 percent were survivors of domestic violence.⁴⁵ A 2005 study of homelessness in four major Florida cities found that approximately one out of every four women experiencing homelessness lacked stable housing primarily because of experiences with violence.⁴⁶ Individuals experiencing homelessness, in turn, will also experience domestic violence because of their publicly exposed daily activities, sleeping patterns, and routines. Recently, a team from Michigan State University, with support from the Washington State Coalition Against Domestic Violence, the Office of the Assistant Secretary for Planning and Evaluation in HHS, and the Gates Foundation completed a study to assess the effects of Housing First programmatic assistance on domestic violence survivors experiencing homelessness. For this program, adherence to the Domestic Violence Housing First (DVHF) model included mobile, housing-focused advocacy; flexible financial assistance for housing and other needs; and community engagement. The study found that adherence to this survivor-centered, low-barrier service model yielded a statistically significant difference between DVHF recipients and those receiving TAU, with DVHF recipients experiencing improved outcomes⁴⁷ in the categories of housing instability, physical abuse, emotional abuse, stalking, economic abuse, use of the children as an abuse tactic, depression, anxiety, posttraumatic stress disorder, and children’s prosocial behaviors.

Conclusion

Overwhelming evidence from several rigorous studies indicates that Housing First programs increase housing stability and decrease rates of homelessness. The best available evidence indicates that Housing First programs successfully house families and individuals with intersecting vulnerabilities, such as veterans, individuals experiencing substance use or mental health issues, survivors of domestic violence, and individuals with chronic medical conditions such as HIV/AIDS. Although findings concerning the relative costs of Housing First programs — as well as the model’s ability to facilitate secondary outcomes such as sobriety or mental stability — are less certain, preliminary evidence indicates that the Housing First approach does not facilitate negative outcomes compared with treatment first programs. Rather, Housing First programs appear to reduce the use of hard drugs, improve the health status of people living with HIV/AIDS, and reduce the use of costly emergency services, all of which are indicators of improved health.

In December 2022, the Biden-Harris administration released All In: The Federal Strategic Plan to Prevent and End Homelessness.⁴⁸ The plan aims to decrease overall homelessness in the United States by 25 percent by January 2025. As noted in the introduction message by HUD Secretary Marcia Fudge, this new strategic plan restores the Housing First approach as the nation’s guiding policy for addressing homelessness, coupling Housing First principles with homelessness prevention resources and strategies to reduce inflows into homelessness. In addition, the plan recommends a person-centered, trauma-informed approach that employs evidence-based solutions. By prioritizing housing stability and restoring the dignity of those experiencing homelessness, this policy presents a more humane, proven strategy than treatment first approaches. President Biden eloquently summarizes the benefits of the strategic plan in his conclusion: "When we provide access to housing to people experiencing homelessness, they are able to take steps to improve their health and well-being, further their education, seek steady employment, and bring greater stability to their lives and to the community that surrounds them.... By ensuring more Americans have safe, stable, and affordable homes, we can build a stronger foundation for our entire Nation."⁴⁹

1. National Academies of Sciences, Engineering, and Medicine. 2018. Permanent Supportive Housing; Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness, Washington, DC: The National Academies Press.
2. Bruce Katz. 2006. "Racial Division and Concentrated Poverty in U.S. Cities," presentation at Urban Age Conference, Johannesburg, South Africa.
3. National Academies of Sciences, Engineering, and Medicine.
4. Peter H. Rossi. 1990. "The old homeless and the new homelessness in historical perspective," American Psychologist 45:8, 954–9.
5. Dennis P. Culhane and Randall Khun. 1998. "Patterns and Determinants of Public Shelter Utilization Among Homeless Adults in New York City and Philadelphia," Journal of Policy Analysis and Management 17:1, 23–43.
6. Ibid.
7. See Malcolm Gladwell. 2006. "Million-Dollar Murray: Why problems like homelessness may be easier to solve than to manage," The New Yorker, 5 February.
8. National Academies of Science, Engineering, and Medicine.
9. Stephen Eide. 2020. "Housing First and Homelessness: The Rhetoric and Reality," The Manhattan Institute.
10. Sam Tsemberis, Leyla Gulcur, and Maria Nakae. 2004. "Housing First, Consumer Choice, and Harm Reduction for Homeless Individuals with a Dual Diagnosis," American Journal of Public Health 94, 651–6.
11. Kim Johnson. 2021. "Additional Housing Programs: Housing First," 2021 Advocates' Guide, National Low Income Housing Coalition.
12. Josh Leopold. 2019. "Five Ways the HEARTH Act Changed Homelessness Assistance," Urban Wire, Urban Institute.
13. See United States Interagency Council on Homelessness. 2010. "Opening Doors: Federal Strategic Plan to Prevent and End Homelessness."
14. Jack Tsai, Alvin S. Mares, Robert A. Rosenheck. 2010. "A multi-site comparison of supported housing for chronically homeless adults: 'Housing first' versus 'residential treatment first,'" Psychological Services 7:4, 219–32.
15. Ibid.
16. Benjamin F. Henwood, Leopoldo J. Cabassa, Catherine M. Craig, and Deborah K. Padgett. 2013. "Permanent supportive housing: Addressing homelessness and health disparities?" American Journal of Public Health 103: Suppl 2, S188–192. See also Michael Allen. 2003. "Waking Rip van Winkle: Why developments in the last 20 years should teach the mental health system not to use housing as a tool of coercion," Behavioral Sciences & the Law 21:4, 503–21; Victoria Stanhope, Benjamin F. Henwood, and Deborah K. Padgett. 2009. "Understanding service disengagement from the perspective of case managers," Psychiatric Services 60, 459–64.
17. Daniel Gubits, Marybeth Shinn, Michelle Wood, Stephen Bell, Samuel Dastrup, Claudia D. Solari, Scott R. Brown, Debi McInnis, Tom McCall, and Utsav Kattel. 2016. "Family Options Study: 3-Year Impacts of Housing and Services Interventions for Homeless Families," U.S. Department of Housing and Urban Development, Office of Policy Development and Research.
18. Tsemberis et al.
19. Jack Tsai. 2020. "Is the Housing First Model Effective? Different Evidence for Different Outcomes," American Journal of Public Health 110:9, 1376–7.
20. Ibid.
21. Andrew J. Baxter, Emily J. Tweed, Srinivasa Vittal Katikireddi, and Hilary Thomson. 2019. "Effects of Housing First approaches on health and well-being of adults who are homeless or at risk of homelessness: systematic review and meta-analysis of randomised controlled trials," Journal of Epidemiology and Community Health 73:5, 379–87.
22. Ibid.
23. Debra J. Rog, Tina Marshall, Richard H. Dougherty, Preethy George, Allen S. Daniels, Sushmita Shoma Ghose, and Miriam E. Delphin-Rittmon. 2014. "Permanent Supportive Housing: Assessing the Evidence," Psychiatric Services 65:3, 287–94.
24. Yinan Peng, Robert A. Hahn, Ramona K. C. Finnie, Jamaicia Cobb, Samantha P. Williams, Jonathan E. Fielding, Robert L. Johnson, Ann Elizabeth Montgomery, Alex F. Schwartz, Carles Muntaner, Veronica Helms Garrison, Beda Jean-Francois, Benedict I. Truman, Mindy T. Fullilove; Community Preventive Services Task Force. 2020. "Permanent Supportive Housing with Housing First to Reduce Homelessness and Promote Health among Homeless Populations with Disability: A Community Guide Systematic Review," Journal of Public Health Management Practice 26:5, 404-–11.
25. Laura S. Sadowski, Romina A. Kee, Tyler J. VanderWeele, and David Buchanan. 2009. "Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial," Journal of the American Medical Association 301:17, 1771–8.
26. Anirban Basu, Romina Kee, David Buchanan, and Laura S. Sadowski. 2012. "Comparative Cost Analysis of Housing and Case Management Program for Chronically Ill Homeless Adults Compared to Usual Care," Health Services Research 47:1, 523–43.
27. Ibid.
28. Gubits et al., 2016.
29. Ibid.
30. Ibid.
31. Ibid. Note: These studies were weighted according to size.
32. Daniel Gubits et al. 2018. "Understanding Rapid Re-housing: Systematic Review of Rapid Re-housing Outcomes Literature," U.S. Department of Housing and Urban Development, Office of Policy Development and Research.
33. Substance Abuse and Mental Health Administration. 2011. "Current Statistics on the Prevalence and Characteristics of People Experiencing Homelessness in the United States."
34. Dennis P. Culhane, Erica Gollub, Randall Kuhn, and Mark Shpaner. 2001. "The Co-Occurrence of AIDS and Homelessness: Results from the Integration of Administrative Databases for AIDS Surveillance and Public Shelter Utilisation in Philadelphia," Journal of Epidemiology and Community Health 55, 515–20.
35. Tsemberis et al.
36. Aubry et al. 2015.
37. The experimental group was further divided into two groups: "High need" individuals received ACT while "moderate need" individuals received ICM. Tim Aubry, Paula Goering, Scott Veldhuizen, Carol E. Adair, Jimmy Bourque, Jino Distasio, Eric Latimer, Vicky Stergiopoulos, Julien Somers, David L. Streiner, and Sam Tsemberis. 2016. "A Multiple-City RCT of Housing First with Assertive Community Treatment for Homeless Canadians with Serious Mental Illness," Psychiatric Services 67:3, 275–81.
38. Aubry et al. 2016.
39. Clare Davidson, Charles Neighbors, Gerod Hall, Aaron Hogue, Richard Cho, Bryan Kutner, and Jon Morgenstern. 2014. "Association of housing first implementation and key outcomes among homeless persons with problematic substance use," Psychiatric Services 65:11, 1318–24. Note: "Consumer participation-consistent" is used to refer to programs with greater fidelity to Housing First principles.
40. Congressional Research Service. 2016. "Housing for Persons Living with HIV/AIDS."
41. Ibid.
42. Richard J. Wolitski, Daniel P. Kidder, Sherri L. Pals, Scott Royal, Angela Aidala, Ron Stall, David R. Holtgrave, David Harre, and Cari Courtenay-Quirk. 2010. "Randomized trial of the effects of housing assistance on the health and risk behaviors of homeless and unstably housed people living with HIV," AIDS Behavior 14:3.
43. Peng et al.
44. Sadowski et al.
45. Yumiko Aratani. 2009. "Homeless Children and Youth: Causes and Consequences," National Center for Children in Poverty, Mailman School of Public Health – Columbia University. More recent data from HUD's Family Options Study found that 49 percent of all homeless individuals had experienced domestic violence as an adult. For more see: Gubits et al.
46. Jana L. Jasinski, Jennifer K. Wesely, Elizabeth Mustaine, and James D. Wright. 2005. "The Experience of Violence in the Lives of Homeless Women: A Research Report."
47. Judy Chen and Cris M. Sullivan. 2022. "Domestic Violence Housing First Demonstration Evaluation Project: Final Report of Findings through 24 Months," Prepared for Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services.
48. United States Interagency Council on Homelessness. 2022. "All in: The Federal Strategic Plan to Prevent and End Homelessness."
49. Ibid.