In response to the Veterans Affairs waiting list scandal at the Phoenix Health Care System, President Obama unveiled a sweeping new veterans health initiative. Cornerstones of the initiative included increased funding for mental health services and increased efforts to reduce homelessness for veterans. In a speech in late August to the American Legion announcing the initiative, Mr. Obama called housing for veterans “a basic commitment that we have to uphold.” What the president did not mention is that providing housing is itself an evidence-based mental health treatment, recognized by organizations as diverse as the Substance Abuse and Mental Health Services Administration and the United Nations, that not only reduces homelessness and alleviates poverty but also improves mental and physical health outcomes for patients with high rates of health service use.
Over the last 25 years, health service researchers have recognized the value of housing as a behavioral health intervention. But this was not always the case. Traditionally, homeless patients with mental health and substance issue were transitioned to permanent housing in a series of graduated steps – from the street to homeless shelter, to more transitional living quarters, to group housing settings, and finally to permanent single-family housing. Individuals were assessed for their readiness for a higher level of housing based on their engagement with psychiatric, psychosocial, and abstinence-related programs.
In the late 1980s, first in Los Angeles and later in New York City, housing advocates developed the alternative Housing First model, which has since been adopted widely both in the United States and abroad. In contrast to the traditional model, hallmarks of the Housing First model are 1) immediate access to permanent housing; 2) supportive case management with attention to enhancing linkages to health services and social service agencies; and 3) no requirement for sobriety or treatment adherence, consistent with a harm-reduction approach to substance abuse.
A Housing First approach to chronic homelessness has been shown to reduce use and costs of health services and social services. In one study, Mary E. Larimer, Ph.D., and her colleagues at the University of Washington, Seattle, enrolled 95 alcohol-dependent individuals in a Housing First program and compared them with wait-list controls. Over 12 months, health care expenditures for housed group were $2,449 less per person per month, compared with those maintained on the wait-list, even after subtracting housing expenses. More surprisingly, subjects in the housing group significantly reduced their overall alcohol consumption and the number episodes of intoxication, despite no requirement to reduce drinking in the program (JAMA 2009;301:1439-57).
In another study, T.E. Martinez and M.R. Burt examined the health services use of 236 individuals who received supportive housing in San Francisco between 1994 and 1998 (Psychiatric Serv. 57;922:9). During the 2 years after securing housing, individuals had significantly fewer emergency room visits and hospitalizations than during the 2 years before housing.
Proponents of the Housing First approach have based their advocacy for the program on the cost-effectiveness of supportive housing interventions, rather than wading into any moral or policy debates regarding the right to shelter. In this era of fiscal austerity, such an approach has won adherents from both liberal and conservative policymakers while avoiding traditional areas of policy conflict.
State and local jurisdictions have taken notice of the potential cost savings of supportive housing for the chronically physically and mentally ill. In late 2013, New York State announced plans to use federal funds earmarked for Medicaid Redesign under the Affordable Care Act to construct port of housing and provide accompanying case management. In an editorial in the New England Journal of Medicine, Dr. Nirav R. Shah, the New York state health commissioner and his colleagues wrote, “We envision a [public] system in which spending on social determinants of health such as housing is not only allowable, but recognized as a best practice” (N. Engl.J. Med. 2013;369:2374-7).
Such a shift would likely produce tangible benefits both for the individuals with mental illness directly affected and for the public mental health systems already strained by limited budgets and ever-increasing demand for services.
Dr. Brodsky is an assistant clinical professor of psychiatry at the University of California, Los Angeles, and the medical director of Bridges to Recovery in Pacific Palisades, Calif.