Permanent Supportive Housing: Addressing Homelessness and Health Disparities?
Chronic homelessness is a significant determinant of poor health. Lengthy
exposure to weather, infections, drugs, and violence coupled with limited access to
ongoing health care is associated with a high incidence of acute and chronic health
problems and premature mortality.1,2 Launched in 1985 through pilot programs funded by
the Robert Wood Johnson Foundation and the Pew Charitable Trust, Health Care for the
Homeless programs now exist in cities throughout the United States and are designed to
address the significant disease burden of this vulnerable population.3,4 In addition, efforts
to address the rise of homelessness during the past 4 decades have resulted in the
recognition that provision of housing is an important part of health care service delivery
for persons who have experienced homelessness,5 and is cost effective6-8 and consistent
with basic human rights.9 These factors have contributed to a remarkable shift in U.S.
policy toward addressing chronic homelessness through permanent supportive housing
(PSH) rather than relying on shelters and transitional housing.10
PSH denotes programs that provide access to affordable community-based
housing along with flexible support services intended to meet a broad array of health and
psychosocial needs.11 Typically, housing can be a congregate residence with services
provided on site (i.e. single-site model)12 or an apartment rented from a private landlord
with services provided by mobile community treatment teams (i.e. scatter site).13 Today,
there are nearly 240,000 PSH units across the country, a figure that has increased by an
average of 12,000 units annually since 2006.14
Missing from the public health literature is evidence on whether and how PSH
improves physical health outcomes. Instead, research on PSH has focused on residential
stability and behavioral health outcomes.15 This focus is not surprising given that PSH
predominantly serves individuals with serious mental illness and substance abuse
problems who represent a disproportionate number of those who are chronically
homeless.1,16 Yet the omission of physical health outcomes is particularly problematic
because in addition to homelessness, significantly higher morbidity and mortality rates
exist among people with serious mental illness (SMI).17 Compared to the general
population, people with SMI die at a younger age largely due to preventable medical
conditions (e.g., diabetes, cardiovascular disease), suboptimal medical care, elevated
rates of cardiovascular risk factors (e.g., smoking, lack of physical activity), and the
uncontrolled or unmanaged cardiometabolic side effects of antipsychotic medications.18
Those entering PSH carry a significant disease burden based on multiple and significant
risk categories (i.e., homeless and serious mental illness) that exacerbate known health
As a first step to considering whether PSH improves physical health outcomes
and has the potential to reduce health disparities, this paper examines how PSH could
affect physical health conditions and disease burden. Drawing from distinct and diverse
areas of research, we consider different pathways through which PSH could impact
health outcomes—namely, through health care and health interventions; through the
provision of housing itself; and through the neighborhood and built environment in which
it is located. Findings can be used to guide public health research and action.
Health Care and Health Interventions
Improved access to quality medical care in PSH is a clear pathway to addressing
health outcomes. The delivery of health services connected to PSH, however, has
traditionally involved psychiatric care without the integration of physical health care.
Whether services are located on-site or delivered through mobile community treatment
providers, professional resources and funding have primarily come from the public
mental health system.20
As the need for holistic care has become increasingly apparent, two dominant
approaches to integrating physical and mental health care have emerged: embedding
mental health services in primary care settings21 and embedding medical care in mental
health services.22 The latter approach leverages existing community mental health
services already connected to the majority of PSH programs. The articulation of such
models has begun to emerge within the literature on PSH. 5, 23,24 For example, a program
providing scatter-site housing partnered with a local academic medical center to include a
primary care physician as a member of a multi-disciplinary community treatment team,
which in addition to providing direct care fostered increased awareness of physical health
co-morbidities among its mental health practitioners.23,24 This enabled relatively high
rates of documentation of several healthcare quality indicators suggesting further
development and testing of this integrated model.25
A variety of integrated models are also being developed and evaluated through
government-funded demonstration projects such as those supported by the Substance
Abuse and Mental Health Services Administration and the Centers for Medicare &
Medicaid Services.26 Although some of these models may be incorporated in PSH,
unique challenges may emerge when housing and health service providers overlap or
attempt to coordinate care.27 Addressing such challenges will be critical because the
availability of PSH is growing to include those most vulnerable and medically frail
regardless of mental health diagnosis.
Although PSH has been identified as a viable locus of integrated health care,5
alternatives include using health care navigators to help link tenants to already existing
health care services. Indeed, health care manager programs have been shown to increase
the engagement in preventive primary care (e.g., screenings, vaccinations, physical
examinations) and improve the quality of cardiometabolic care among adults with serious
mental illness.28 Through the inclusion of either physical health services or more
effective care coordination mechanisms, PSH may be uniquely suited to realize the
concept of the person-centered medical home for those who have experienced
In addition to improving access to quality health care, PSH can also serve as a
venue for health promotion interventions. Lifestyle interventions that focus on weight
loss and management, improved nutrition, and physical activity show great promise in
helping people with serious mental illness reduce their risk of cardiovascular disease and
other chronic medical conditions.29,30, 31 In fact, a recent study found that PHS tenants
would welcome lifestyle interventions, particularly if they are led by peers, help tenants
develop skills to change their eating habits and navigate food environments, incorporate
opportunities to participate in physical activities, and employ experiential teaching
methods (e.g., cooking and shopping demonstrations) to support health behavior
change.32 Interventions such as the Stanford Chronic Disease Self-Management
Program,33 perhaps the most-studied self-management program in the United States,34
can be implemented in conjunction with PSH.35 This peer-led model has been previously
modified for use with individuals with serious mental illness.36
PSH provides an ideal service platform for reducing health disparities as it
represents a critical point of services for many people with serious mental illness and
chronic medical conditions, helps bring existing health care and health promotion
interventions closer into the community, and fits within a mission to improve wellness
and recovery among this population.37 Further research is needed to establish the
effectiveness and sustainability of these health care and health interventions in PSH.
If homelessness is a determinant of poor health, then having housing should
improve one’s health through reduced exposure to the elements, infections, and violence.
It should also confer a sense of security and stability missing from life on the streets or in
shelters. Although it is unclear whether the benefits of housing can buffer the negative
impact of cumulative adversity including high rates of trauma documented over the life
course of people who experience chronic homelessness,38 permanent housing can at least
reduce stress associated with the ongoing concern about safety experienced while
homeless. Although research has identified psychological benefits of having a home that
increases “ontological security,”39 physical health benefits may also result from
decreased cortisol levels.40
Housing should optimally provide a foundation for health (a bed, refrigerator,
heat, electricity), and the physical space needed to engage in healthy behaviors. For
example, adequate housing means having a convenient and safe place to store
medication, including insulin that requires refrigeration. It also means that people can
more easily buy, store, and prepare food that is affordable and of their choosing rather
than rely on food pantries, soup kitchens and prepared foods that have contributed to the
hunger-obesity paradox among homeless populations.41 Having a home makes it
logistically possible to hang a calendar, use an alarm clock, perform daily exercise, tend
to personal hygiene and more easily keep track of medical appointments.
The assumption that housing improves health is supported by existing research.
Research has shown that poor housing quality is associated with morbidity related to
infectious and chronic diseases, injuries, poor nutrition, asthma, neurological damage,
and mental disorders.42 Additionally, living in crowded conditions can exacerbate poor
health and increase the likelihood of infectious diseases such as tuberculosis.
What is less clear, however, is how transitioning from homelessness to housing
affects health-related perceptions and behaviors.35 Whether persons in PSH make
healthier lifestyle choices remains to be seen, and it remains unclear what interventions
and additional supports may be required to enable such choices (e.g., cooking classes,
budgeting skills training, etc.). Access to housing may result in a more sedentary
lifestyle, especially given concerns that people tend to remain isolated in housing due to
past traumas and stigma from having lived on the streets.43 Food insecurity experienced
while homeless may lead to more frequent overeating when food can be stored and is
more readily available,41 and people may lack the skills to prepare healthy foods. Such
factors may increase the already elevated risk of cardiovascular disease in a population
that has experienced homelessness and serious mental illness, and require lifestyle
interventions, as referenced above, to be specifically tailored to the needs of this
population. Clearly, permanent housing could positively influence the health of those
who have experienced homelessness, yet negative influences may also exist depending on
the condition of the housing and lifestyle choices that new tenants adopt. This leads to a
third, and related, pathway to health outcomes.
Neighborhood and the Built Environment
When considering the effects of housing on health, research suggests that location
matters. One of the limitations of research on PSH, however, is that it often overlooks the
impact of place and environment.44 Limited research regarding location has focused on
how PSH affects property values (they increase)45 and crime rates (they do not change).46
Public health researchers have identified the mechanisms by which community
characteristics influence health. The built environment, which is understood to
encompass a range of physical and social elements that constitute the structure of a
community, has been a focus.47,48 For example, assessments of “walkability” have shown
that neighborhood factors such as residential density, land-use mix including the amount
of retail, residential, and entertainment areas, and the connectivity of street networks are
associated with physical activity and level of obesity.49-51 Whether these associations
apply to those living in PSH may be dependent on mediating factors of community
integration, stigma, and discrimination.52
Overall paucity of resources in neighborhoods of lower socioeconomic status, or
“neighborhood deprivation,” has also been shown to impede engagement in health
behaviors.53,54 Some clear examples include limited access to affordable healthy food and
fewer areas for recreation and safe physical activity, which contribute to health disparities
and increased chronic disease burden in these underserved communities.55,56 PSH is
disproportionately located in these communities57 with concentrated disadvantages.58
Even when resources are available, concerns about crime can impede physical activity59
and social norms may reinforce inactivity, smoking rates, substance use, and poor diet60,61
--- familiar habits from time spent homeless. The communities into which PSH tenants
move may influence lifestyle choices, and hence health outcomes, yet there has been no
research to date that considers aspects of the neighborhood or built environment with
regard to PSH.
Developing an Agenda
Advancing planning and research on physical health outcomes in conjunction
with efforts to end homelessness through PSH can occur through consideration of the
roles of health care, health promotion, housing quality, and characteristics of the
neighborhood and the built environment. In order to develop a roadmap for future efforts,
however, priorities must be made. Recognizing housing as a critical social determinant of
health, for example, leads to obvious policy questions about whether and how
collaboration will occur between healthcare and housing systems at the level of service
provision and in coordinated funding. This raises further questions about whether
healthcare dollars will be spent on housing, and if so who will be “prescribed” this
treatment. Will the provision of housing be rationed only for those whose disease burden
would otherwise result in expensive care or should housing be part of universal
coverage? Such conversations have rarely been made explicit yet are close to the surface
when considering the differential health impact of housing insecurity and neighborhood
Although these larger structural issues may best explain the causes of health
disparities and chronic homelessness, more proximal goals may better serve the
development of a research agenda. The Patient Protection and Affordable Care Act has
made equity in healthcare delivery the most apparent focus. PSH programs have been
recognized as critical partners in some state health home initiatives62 and could serve as
the basis for patient-centered medical homes for persons with serious mental illness.63
Yet as models of integrated care are being developed within the context of PSH, there are
important considerations that have not yet been articulated. For example, research that
focuses on how universal design (housing that can be modified depending on residents’
needs) can help people successfully age in place can be applied to aging tenants of PSH
who already have rates of disability nearing 80%.14 It should be noted that given the
significant disease burden carried by those with histories of chronic homelessness, an
important outcome to track can be the number of people who die with dignity in their
own home or with access to end-of-life care. Similarly, although active-living research
has shown that the built environment can affect health and lifestyle choices differently
based on race, gender, and resources,64 researchers can empirically investigate whether
stigma, discrimination, and mental health symptoms may also have a differential impact
for persons living in PSH that impedes increased physical activity and healthy diet.
Research that considers neighborhood effects on PSH residents would need to
consider whether the PSH is single-site or scatter-site, the two predominant models.
Research on the scatter-site approach, which places people in different locations, would
have to account for variability not present in single site. For new development of single-
site PSH buildings, a health impact assessment could inform where such projects are
located as well as the architectural design of those projects.65 Conducting research that
considers neighborhood effects will require increasingly sophisticated mixed-method
designs and multilevel modeling66 to develop concrete ramifications for public policy that
is sensitive to the connection between housing, the built-environment, and health.67
Regardless of their location model, PSH programs could contribute to a healthier
community and environment through social action and community advocacy. PSH
programs and tenants could become valuable partners in healthy communities programs
sponsored by the Centers for Disease Control and Prevention (CDC). This would require
a strengths-based approach when working with PSH tenants that has not been
consistently articulated within the literature. Nevertheless, from personal experience we
know of PSH programs that support tenant participation in community programs, such as
community gardens, walking groups, and neighborhood watch. Such activities can
contribute to the health of the community and promote greater integration of PSH
residents68 and suggest that community based participatory research based on academic
and community partners should include PSH programs. 32,35
We have argued that in addition to improved access to quality health care and
health interventions, social determinants of health including housing and characteristics
of the neighborhood and the built environment are plausible pathways that affect health
outcomes for formerly homeless individuals now living in PSH. Together, these should
be considered when developing a national agenda on homelessness and health disparities.
The U.S. Interagency Council on Homelessness released its first national research agenda
in October 2012, in part outlining the need to consider neighborhoods in terms of
receptivity to PSH or lack thereof (e.g, the NIMBY, or “not in my backyard,”
phenomenon); the relationship between neighborhoods and tenant health was not
identified in this agenda.
On a national level, campaigns to end homelessness such as those organized by
the U.S. Department of Veterans Affairs or nonprofits such as Community Solutions (the
latter responsible for the 100,000 Homes Campaign69) can interact and align with the
efforts of others to build healthy communities. Collaboration at the federal level with
supporting agencies such as the CDC, HUD, or the National Institute of Environmental
Health Sciences could facilitate such consideration.
Within this essay we have identified several priorities including: policy
discussions about funding implications given that housing is a key social determinant of
health; development of integrated care models and health promotion interventions that
incorporate the specific needs of an aging population including restricted mobility and
end-of-life care; research on the links between neighborhood characteristics, the built-
environment and tenants health behaviors and outcomes; research on the impact of
stigma, discrimination, and mental health symptoms on the physical activity and diet of
those who have transitioned from homelessness to PSH; and the inclusion of PSH within
community-academic partnerships focusing on health disparities. In addition to
suggesting that collaboration at the federal level is key to developing such an agenda,
individuals working to end homelessness could find key collaborators in public health
researchers who not only assess the physical health outcomes of those who are homeless
but also include those living in PSH.
Permanent supportive housing (PSH) is an effective intervention to address chronic
homelessness. Supporting evidence has resulted in a remarkable shift in U.S. policy
toward the use of PSH rather than relying on shelters and transitional housing. Despite
recognizing that individuals transitioning from homelessness to PSH experience a high
burden of disease and health disparities, public health research has not considered
whether and how PSH improves physical health outcomes. Drawing from distinct and
diverse areas of research, we argue that in addition to improved access to quality health
care, social determinants of health including housing itself and characteristics of the
neighborhood and built environment are plausible pathways that affect health outcomes.
Through this discussion we identify implications for practice and research, and conclude
that federal and local efforts to end chronic homelessness can interact and align with
concurrent efforts to build healthy communities.
About the Authors
Benjamin Henwood, PhD, MSW, Assistant Professor, University of Southern California,
School of Social Work
Leopoldo Cabassa, PhD, Assistant Professor Columbia University, School of Social
Catherine Craig, MPA, MSW, Independent Consultant (formerly at Community
Deborah K. Padgett, PhD, MPH, Professor, New York University, Silver School of
Corresponding Author Contact Information:
University of Southern California
School of Social Work
1150 S. Olive Street, 14th floor
Los Angeles, CA 90015-2211
Acceptance Date: May 24, 2013
Contributor Statement: The first three authors jointly conceived the topic and outline for
this paper. Benjamin F. Henwood originally drafted the article with input from Leopoldo
Cabassa and Catherine Craig. Deborah K. Padgett critically reviewed and provided
feedback on the article. All authors approved the final article.
Acknowledgments: A version of this paper was presented at Housing First Partners
Conference, New Orleans, LA on March 23, 2012.
Human Participant Protection: human subjects not involved.
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