Does housing chronically homeless adults lead to social integration?

OBJECTIVE: Supported housing programs have been successful in helping homeless adults obtain housing. This study examined whether improvements in social integration occur after clients obtain supported housing. METHODS: Measures of social integration were examined for 550 chronically homeless adults with mental illness who participated in the 11-site Collaborative Initiative to Help End Chronic Homelessness. Social integration was conceptualized as a multidimensional construct of variables in six domains: housing, work, social support, community participation, civic activity, and religious faith. Changes in baseline measures related to the six domains and their interrelationships were examined at six and 12 months after entry into the supported housing program. RESULTS: Chronically homeless adults showed substantial improvements in housing but remained socially isolated and showed limited improvement in other domains of social integration, which were only weakly correlated with one another. CONCLUSIONS: More attention is needed to develop rehabilitation interventions in supported housing programs to improve social integration of chronically homeless adults. Because improvements in some domains of social integration were only weakly related, it may be necessary to intervene in multiple domains simultaneously.

Gender differences in quality of life among Canadian adults with epilepsy.

The clinical literature suggests epilepsy may impact quality of life in males and females differently. Previous research on gender issues has focused primarily on biological-biomedical factors over psychological and social factors. In this study we compare subjective and objective quality of life in adult persons with epilepsy to persons without epilepsy by gender using the biopsychosocial model in the Canadian Community Health Survey (CCHS), a large epidemiological survey that covers 98% of the Canadian population. Logistic regression analyses were conducted using self-rated health status and the Health Utility Index(®) 3 (HUI3) as the outcomes. Quality of life was significantly moderated after controlling for the biological-biomedical variables in all analyses except the HUI3. Males with epilepsy were more likely to have HUI3 scores of 0.70 or greater than males without epilepsy (OR = 1.61, 95%CI 1.32-1.96). For males with epilepsy the HUI3 was further moderated, but remained significantly better in the final model that controlled for biological, psychological and social factors (OR = 1.43, 95%CI 1.17-1.76). Our findings provide support for treatment approaches that focus on the whole person. Such approaches should take into account gender differences when examining objective quality of life.

Do homeless veterans have the same needs and outcomes as non-veterans?

Although veterans have been found to be at increased risk for homelessness as compared to non-veterans, it is not clear whether those who are homeless have more severe health problems or poorer outcomes in community-based supported housing. This observational study compared 162 chronically homeless veterans to 388 non-veterans enrolled in a national-supported housing initiative over a 1-year period. Results showed that veterans tended to be older, were more likely to be in the Vietnam era age group, to be male, and were more likely to have completed high school than other chronically homeless adults. There were no differences between veterans and non-veterans on housing or clinical status at baseline or at follow-up, but both groups showed significant improvement over time. These findings suggest that the greater risk of homelessness among veterans does not translate into more severe problems or treatment outcomes. Supported housing programs are similarly effective for veterans and non-veterans.

Housing satisfaction among chronically homeless adults: identification of its major domains, changes over time, and relation to subjective well-being and functional outcomes.

There is limited consensus on the critical domains of housing satisfaction among chronically homeless adults and little information on changes in housing satisfaction over time or whether housing satisfaction at initial entry into housing is correlated with subsequent subjective well-being or other outcomes. The current study tracked housing satisfaction over a 2-year period in a multi-site supported housing initiative and examined the predictive value of clients' housing satisfaction when they were first housed on various subjective and functional outcomes. A total of 756 participants from 11 sites were enrolled in the study. Six domains of housing satisfaction were identified: good environment, control and consumer choice, physical quality, geographic proximity to desirable resources, positive case manager contact, and frequency of landlord interaction. Over 2 years, there were slight declines in housing satisfaction on physical quality of housing and satisfaction with case manager contact, and an increase in satisfaction with landlord interaction. Consistent with some previous research, housing satisfaction was not predictive of housing tenure, clinical outcomes, or duration of program participation. While becoming housed is a significant gain for chronically homeless people, their satisfaction with housing did not predict functional outcomes.

Chronically homeless women report high rates of substance use problems equivalent to chronically homeless men.

INTRODUCTION: The U.S. federal government recently committed itself to ending chronic homelessness within 5 years. Women constitute one out of four chronically homeless adults and represent a particularly vulnerable group, but have been little studied. To identify potentially unique needs in this group, we report characteristics and 2-year outcomes in a large sample of male and female chronically homeless adults participating in a multisite, supportive housing program. METHODS: Men and women participating in the outcome evaluation of the 11-site Collaborative Initiative on Chronic Homelessness (n = 714) supportive housing program and who received at least one follow-up assessment were compared on baseline characteristics and up to 2-year follow-up outcomes. Mixed model multivariate regression adjusted outcome findings for baseline group differences. RESULTS: Few significant baseline differences existed between males and females, with both sexes self-reporting very high rates of lifetime mental health (83% women, 74% men) and substance use (68% women, 73% men) problems. Throughout the 2-year follow-up, both men and women dramatically increased the number of days housed, showed minimal changes in substance use patterns, and had modest improvements in mental health outcomes, without significant differences between genders. CONCLUSION: Unlike other U.S. populations, chronically homeless adults do not demonstrate substantial gender differences on mental health or addiction problems. Policy and service delivery must address these remarkably high rates of substance use and mental illness.

Does active substance use at housing entry impair outcomes in supported housing for chronically homeless persons?

OBJECTIVE: Recent clinical and policy trends have favored low-demand housing (provision of housing not contingent on alcohol and drug abstinence) in assisting chronically homeless people. This study compared housing, clinical, and service use outcomes of participants with high levels of substance use at time of housing entry and those who reported no substance use. METHODS: Participants in the outcome evaluation of the 11-site Collaborative Initiative on Chronic Homelessness (N=756), who were housed within 12 months of program entry and received an assessment at time of housing and at least one follow-up (N=694, 92%), were classified as either high-frequency substance users (>15 days of using alcohol or >15 days of using marijuana or any other illicit drugs in the past 30 days; N=120, 16%) or abstainers (no days of use; N=290, 38%) on entry into supported community housing. An intermediate group reporting from one to 15 days of use (N=284, 38%) was excluded from the analysis. Mixed-model multivariate regression adjusted outcome findings for baseline group differences. RESULTS: During a 24-month follow-up, the number of days housed increased dramatically for both groups, with no significant differences. High-frequency substance users maintained higher, though declining, rates of substance use throughout follow-up compared with abstainers. High-frequency users continued to have more frequent or more severe psychiatric symptoms than the abstainers. Total health costs declined for both groups over time. CONCLUSIONS: Active-use substance users were successfully housed on the basis of a low-demand model. Compared with abstainers, users maintained the higher rates of substance use and poorer mental health outcomes that were observed at housing entry but without relative worsening.

A comparison of treatment outcomes among chronically homelessness adults receiving comprehensive housing and health care services versus usual local care.

Service use and 2-year treatment outcomes were compared between chronically homelessness clients receiving comprehensive housing and healthcare services through the federal Collaborative Initiative on Chronic Homelessness (CICH) program (n = 281) a sample of similarly chronically homeless individuals receiving usual care (n = 104) in the same 5 communities. CICH clients were housed an average of 23 of 90 days (52%) more than comparison group subjects averaging over all assessments over a 2-year follow-up period. CICH clients were significantly more likely to report having a usual mental health/substance abuse treater (55% vs. 23%) or a primary case manager (26% vs. 9%) and to receive community case management visits (64% vs. 14%). They reported receiving more outpatient visits for medical (2.3 vs. 1.7), mental health (2.8 vs. 1.0), substance abuse treatment (6.4 vs. 3.6), and all healthcare services (11.6 vs. 6.1) than comparison subjects. Total quarterly healthcare costs were significantly higher for CICH clients than comparison subjects ($4,544 vs. $3,326) due to increased use of outpatient mental health and substance abuse services. Although CICH clients were also more likely to receive public assistance income (80% vs. 75%), and to have a mental health/substance provider at all, they expressed slightly less satisfaction with their primary mental health/substance abuse provider (satisfaction score of 5.0 vs. 5.4). No significant differences were found between the groups on measures of substance use, community adjustment, or health status. These findings suggest that access to a well funded, comprehensive array of permanent housing, intensive case management, and healthcare services is associated with improved housing outcomes, but not substance use, health status or community adjustment outcomes, among chronically homeless adults.

A geographic analysis of chronically homeless adults before and after enrollment in a multi-site supported housing initiative: community characteristics and migration.

The current study examined the community characteristics and migration of chronically homeless adults before and after entry into a multi-site supported housing initiative. A total of 394 participants were geocoded at baseline and 12-month follow up. Data from geographic information systems indicate that the median distance participants traveled from their last residence to their residence 1 year after program entry was 4.6 miles and 12% of participants traveled more than 100 miles. Participants moved into communities with higher population densities, larger proportions of Whites, and smaller proportions of Blacks following their entry into supported housing, but continued to live in communities with higher crime rates, lower education levels, and lower income levels then the state average. At 12 months, Black participants residing in communities with higher population densities and larger Black populations reported higher social support and lower subjective distress. This underscores the importance of considering client preferences in housing. Together, these findings suggest that supported housing programs may be successful in finding housing for homeless clients, but are not placing them in improved communities. Special attention may also be needed for some clients who travel long distances between residences.

A multi-site comparison of supported housing for chronically homeless adults: "Housing first" versus "residential treatment first"

Both direct placement in supported community housing and pre-treatment with time-limited residential treatment are used as approaches to helping chronically homeless adults exit from homelessness but relative effectiveness and cost remains untested. The current observational study utilized data from a national, multi-site housing project to determine whether clients who receive residential treatment or transitional housing before being placed into independent housing achieve superior outcomes than clients who are immediately placed into independent housing, and whether they incur greater healthcare costs. A total of 709 participants (131 and 578 participants in the respective groups) were assessed every 3 months for 2 years on housing outcomes, community adjustment, work and income, mental and physical health, and health service costs. Clients who received immediate, independent housing had more days in their own place, less days incarcerated, and reported having more choice over treatment; but no differences on other clinical or community adjustment outcomes. In this observational study, there were no clinical advantages for clients who had residential treatment or transitional housing prior to entry into community housing, but they incurred higher substance abuse service costs. Studies using randomized controlled trials of these conditions are needed to establish causation.

Twelve-month client outcomes and service use in a multisite project for chronically homelessness adults.

Collaborative Initiative to Help End Chronic Homelessness clients (N = 734) were enrolled into an evaluation wherein assessments at program entry and quarterly thereafter addressed sociodemographic characteristics, health status, and a wide range of service use and outcomes data. Mixed linear regression analysis was used to test for significant changes over time. The average number of days housed during the previous 3 months increased dramatically from 18 at baseline to 83 by year's end. Significant improvements of more modest magnitude were also observed in overall quality of life, mental health functioning, and reduced psychological distress. Alcohol and drug problems remained largely unchanged over time, among clients overall. However, among baseline drug users crack, cocaine, and marijuana use decreased by 28-50% over the follow-up period. Total quarterly health cost estimates declined by 50%, as well, from $6,832 to $3,376. These findings suggest that adults who have experienced chronic homelessness may be successfully housed and can maintain their housing, when provided with comprehensive services.

Client-level measures of services integration among chronically homeless adults.

INTRODUCTION: While several major studies have examined services integration at the system or interagency level, there has been far less effort to measure the integration of services at the client-level and its correlates. METHODS: This study presents three client-level measures of services integration, two objective measures, representing the proportion of needed services received and the number of outpatient services received by each client, and one subjective measure, a five-item scale measuring perceived coordination of care among clients' service providers. Data from the evaluation of the collaborative initiative to help end chronic homelessness (CICH) are used to examine bivariate and multivariate relationships of these three client-level measures to two system-level measures of services integration, one addressing interagency services coordination/planning and the other interagency trust/respect as well as to baseline client characteristics among 734 chronically homeless adults in 11 cities. RESULTS: Client-level measures of service integration were not strongly associated to each other or to the system-level measures, except for weak associations (r = 0.10) between one objective client measure and the system-level measure of service coordination and planning, and another between client-level use of outpatient mental health services and system-level trust and respect. Multivariate analysis showed that clients who received a greater array of needed services received more service overall and were more likely to have a diagnosis of PTSD and more medical problems, but less serious alcohol problems. Clients who reported more outpatient mental health and substance abuse visits were significantly more likely to be married, to be veterans, to have more serious drug problems, and to be dually diagnosed. Clients with more serious drug problems reported poorer coordination among their service providers on the subjective measure of client-level service integration. CONCLUSION: Three client-level measures of services integration were, at best, weakly associated with measures of system-level integration. Positive associations between client-level measures of integration and health status, outpatient service use and negative relationships with indicators of substance abuse suggest they may usefully represent the experiences of chronically homeless clients, even though they are not strongly related to system-level measures.

Implementation of supported employment for homeless veterans with psychiatric or addiction disorders: two-year outcomes.

OBJECTIVE: There has been growing interest in the dissemination of supported employment, but few studies have used a control group to examine the benefits of multisite dissemination efforts for clients or have addressed the needs of homeless persons with psychiatric disorders, addiction disorders, or both. This study examined a low-intensity training approach for implementing the individual placement and support (IPS) model at nine Department of Veterans Affairs (VA) programs and compared client outcomes before (phase 1) and after (phase 2) the program was implemented (phase 1). METHODS: Special funds and sustained training, which was based primarily on teleconferencing, were used to support implementation of the IPS model of supported employment at nine VA programs for homeless veterans. A comparison cohort (phase 1) (N=308) was recruited from the nine sites before IPS was implemented. A postimplementation cohort (phase 2) (N=321) was recruited at the same sites and offered IPS. Mixed models were used to compare quarterly employment outcomes over two years in phase 1 and phase 2, adjusting for significant baseline differences (N=629). RESULTS: Measures of both client-level service delivery and site-level fidelity to IPS suggest that implementation was successful at most, but not all, sites. Overall, compared with veterans in the phase 1 group, those in the phase 2 group had a better long-term work history at the time of program entry. When the analyses controlled for baseline differences, the mean number of competitive employment days per month over the two-year follow-up period was 15% higher for veterans in phase 2 (8.4 days compared with 7.3 days; p<.001) and the mean number of days housed during follow-up was also higher in phase 2 (34.1 days compared with 29.8 days; p=.04), but there were no differences for other outcome measures. CONCLUSIONS: A sustained training program can be used to implement IPS in systems that have had little past experience with this approach. This effort was associated with improved employment outcomes and more rapid housing placement.

Disability benefits and clinical outcomes among homeless veterans with psychiatric and substance abuse problems.

This study examined the relationship between disability payment status and clinical outcomes among 305 homeless veterans entering VA treatment. Disability status and clinical outcomes were characterized using self-report data at program entry, and quarterly for 2 years thereafter. Seeking or already receiving disability benefits at program entry was not associated with any of the 8 clinical outcomes examined. Those seeking or receiving disability benefits during the 2 years that followed showed more serious mental health problems and lower levels of mental health functioning, but no greater risk of substance use or not being employed nor worse housing outcomes than those who remained uninterested in applying for disability benefits. This study does not, therefore, support the notion that disability orientation results in poorer clinical outcomes, at least not among homeless veterans.

Association between community and client characteristics and subjective measures of the quality of housing.

OBJECTIVE: The objective of this study was to examine the relationship between subjective perceptions of the quality of housing among mental health consumers and both client characteristics and objective measures of the client's neighborhood. METHODS: A cross-sectional survey of a random sample of 468 male clients who were recruited from three mental health centers in Connecticut was used to assess client characteristics, including sociodemographic and clinical status, and measures of subjective quality of housing that reflected perception of both the client's residence and the neighborhood. Data describing the objective characteristics of the 233 census-tract block-group neighborhoods in which clients lived were obtained from the 2000 decennial census, from which three measures were created by using principal components analysis: average household income, affordability, and availability of plumbing and cooking facilities. Ordinary-least-squares regression analyses were used to identify client and neighborhood correlates of subjective quality of housing. RESULTS: Neither psychiatric diagnosis nor substance abuse were found to be significantly associated with any of the subjective housing quality measures. Clients who were living in their own place with others, those who were less bothered by side effects of medications, and those who were living in higher-income neighborhoods were more satisfied with the overall quality of their housing. CONCLUSIONS: Client assessments of subjective quality of housing, both overall and along specific subdimensions, are largely independent of commonly used diagnostic and symptom measures of mental health status. Consumers' subjective experience of housing quality are significantly associated with objective measures of neighborhood characteristics, particularly the mean household income of the neighborhood.

Outcomes of supported housing for homeless veterans with psychiatric and substance abuse problems.

This study examines the effect of previous participation in time limited residential treatment and other factors on treatment outcomes among homeless veterans with serious mental illness placed into permanent supported housing. The sample consisted of 655 veterans placed into supported housing at 18 sites through the VA's Healthcare for Homeless Veterans (HCHV) Supported Housing Program during the period 1993-2000. Data on client and program characteristics, and treatment outcomes, were documented by HCHV case managers staffing these programs. Data on use of VA services, including time limited residential treatment received 6 months prior to entry into supported housing, were extracted from VA administrative files. The relationship of prior residential treatment, as well as other measures of client characteristics, service use, and program characteristics, to outcomes were assessed using both bivariate and multivariate Cox proportional hazards regression and logistic regression. After adjusting for client characteristics, service use, and program characteristics, no differences in outcomes were found between clients who had received prior residential treatment and those placed directly into permanent supported housing. Prior residential treatment appears to have little effect on treatment outcomes among formerly homeless veterans placed into permanent supported housing programs providing indirect support for the direct placement supported housing model.

Perceived relationship between military service and homelessness among homeless veterans with mental illness.

This study examined the perceived relationship between military service and the risk of homelessness after discharge and identified specific aspects of military service that homeless veterans experience as having increased their risk for becoming homeless. A cross-sectional survey was conducted among 631 homeless veterans enrolled in the VA Therapeutic Employment Placement and Support Program from January 2001 through September 2003. Associations of sociodemographic characteristics, clinical status, and military service characteristics (independent variables) were examined in relation to perceptions of increased risk for homelessness and time to first episode of homelessness after leaving the military (two dependent variables), using analysis of variance, logistic regression, and multiple regression statistical analyses. Fewer than one third (31%) of the homeless veterans in this study reported that military service increased their risk for homelessness--either somewhat (18%) or very much (13%). Among those veterans who perceived military service as increasing their risk for becoming homeless, the three aspects of military service most commonly identified included a) substance abuse problems that began in the military (75%), b) inadequate preparation for civilian employment (68%), and c) loss of a structured lifestyle. The relatively small proportion of homeless veterans who attributed homelessness to their military service, coupled with the long 14-year average lag time between discharge and their first episode of homelessness, is consistent with epidemiological data suggesting that military service itself does not substantially increase the risk for becoming homeless among veterans.

One-year housing arrangements among homeless adults with serious mental illness in the ACCESS program.

OBJECTIVE: This study examined the various living arrangements among formerly homeless adults with mental illness 12 months after they entered case management. METHODS: The study surveyed 5,325 clients who received intensive case management services in the Access to Community Care and Effective Services and Supports (ACCESS) program. Living arrangements 12 months after program entry were classified into six types on the basis of residential setting, the presence of others in the home, and stability (living in the same place for 60 days). Differences in perceived housing quality, unmet housing needs, and overall satisfaction were compared across living arrangements by using analysis of covariance. RESULTS: One year after entering case management, 37 percent of clients had been independently housed during the previous 60 days (29 percent lived alone in their own place and 8 percent lived with others in their own place), 52 percent had been dependently housed during the previous 60 days (11 percent lived in someone else's place, 10 percent lived in an institution, and 31 percent lived in multiple places), and 11 percent had literally been homeless during the previous 60 days. Clients with less severe mental health and addiction problems at baseline and those in communities that had higher social capital and more affordable housing were more likely to become independently housed, to show greater clinical improvement, and to have greater access to housing services. After the analysis adjusted for potentially confounding factors, independently housed clients were more satisfied with life overall. However, no significant association was found between specific living arrangements and either perceived housing quality or perceived unmet needs for housing. CONCLUSIONS: Living independently was positively associated with satisfaction of life overall, but it was not associated with the perception that the quality of housing was better or that there was less of a need for permanent housing.

Residential environment and quality of life among seriously mentally ill residents of board and care homes.

This study examined the relationship between residential environment of seriously mentally ill patients living in board and care homes and quality of life. Participants included 162 seriously mentally ill veteran patients living in 26 board and care homes in Los Angeles. Data from structured interviews were used to assess subjective quality of life (satisfaction with living situation and general well-being) and objective quality of life (social functioning and daily activities). Independent variables examined in multivariate analyses included individual socio-demographic and clinical characteristics, objective characteristics of the home, and subjective resident assessments of social climate within the home. Adjusting for individual characteristics, social climate was significantly and positively associated with both satisfaction with current living situation and with general well-being. Interpersonal conflict was negatively associated with general well-being. Number of beds within the home and median income in the neighborhood were significantly associated (positively and negatively, respectively) with social functioning outside the home. Living environment characteristics explained between 3 and 9% of the total variation in three of four quality of life measures, and 27% of the variation in the fourth, satisfaction with living situation. Satisfaction with living situation among seriously mentally ill residents of board and care homes may be enhanced by making the social climate more positive, and reducing conflict within the home. Social functioning outside of the home may be enhanced by placing patients into a home with more beds, and/or a home located in a lower income neighborhood.