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Health Care and Public Service Use and Costs Before and After Provision of Housing for Chronically Homeless Persons With Severe Alcohol Problems

DOI:10.1001/jama.2009.414
Authors:
Mary E Larimer
Mary E Larimer
Mary E Larimer
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Daniel K Malone
Daniel K Malone
Daniel K Malone
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Michelle D Garner at University of Washington Tacoma
Michelle D Garner
David C Atkins at University of Washington Seattle
David C Atkins
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Abstract

Chronically homeless individuals with severe alcohol problems often have multiple medical and psychiatric problems and use costly health and criminal justice services at high rates. To evaluate association of a "Housing First" intervention for chronically homeless individuals with severe alcohol problems with health care use and costs. Quasi-experimental design comparing 95 housed participants (with drinking permitted) with 39 wait-list control participants enrolled between November 2005 and March 2007 in Seattle, Washington. Use and cost of services (jail bookings, days incarcerated, shelter and sobering center use, hospital-based medical services, publicly funded alcohol and drug detoxification and treatment, emergency medical services, and Medicaid-funded services) for Housing First participants relative to wait-list controls. Housing First participants had total costs of $8,175,922 in the year prior to the study, or median costs of $4066 per person per month (interquartile range [IQR], $2067-$8264). Median monthly costs decreased to $1492 (IQR, $337-$5709) and $958 (IQR, $98-$3200) after 6 and 12 months in housing, respectively. Poisson generalized estimating equation regressions using propensity score adjustments showed total cost rate reduction of 53% for housed participants relative to wait-list controls (rate ratio, 0.47; 95% confidence interval, 0.25-0.88) over the first 6 months. Total cost offsets for Housing First participants relative to controls averaged $2449 per person per month after accounting for housing program costs. In this population of chronically homeless individuals with high service use and costs, a Housing First program was associated with a relative decrease in costs after 6 months. These benefits increased to the extent that participants were retained in housing longer.
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... Between 30% and 50% of adults experiencing homelessness have alcohol use disorder (Fazel et al., 2008;Fischer and Breakey, 1991). Though housing-first interventions can be cost-effective, their effects on alcohol use have not been demonstrated (Larimer et al., 2009). To address the related problems of addiction, unemployment, and poverty, our research team has developed the Therapeutic Workplace, a contingency management intervention that uses employment-based abstinence reinforcement (Silverman et al., 2019). ...
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... -29Housing first models do not require abstinence for housing and this model has shown promising outcomes. 8 Housing first incorporates harm reduction as a principle and such programs tolerate but do not manage substance use.30 , 31 Yet, substance use continues to be a factor behind exits from housing first, resulting in a return to homelessness.32 ...
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... After accounting for housing and other costs, average per-month total costs for program participants were $2,449 lower per person compared with the control group at 6 months' postintervention. 6 The promise of programs such as 1811 Eastlake is reinforced in a 2014 report concluding that a person experiencing chronic homelessness costs taxpayers approximately $35,500 annually; this amount is nearly halved when housing is provided, to $17,611. After counting the cost of supportive housing at about $12,000, the net savings are about 13%, or $4,800resulting from decreased usage of jail services, emergency medical services, and hospitalizations. ...
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There’s No Place Like Home: Importance of Housing Stability for Reentry
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Article
Full-text available
  • May 2023
Background: Adequate housing is a basic human right. The many millions of people experiencing homelessness (PEH) have a lower life expectancy and more physical and mental health problems. Practical and effective interventions to provide appropriate housing are a public health priority. Objectives: To summarise the best available evidence relating to the components of case-management interventions for PEH via a mixed methods review that explored both the effectiveness of interventions and factors that may influence its impact. Search methods: We searched 10 bibliographic databases from 1990 to March 2021. We also included studies from Campbell Collaboration Evidence and Gap Maps and searched 28 web sites. Reference lists of included papers and systematic reviews were examined and experts contacted for additional studies. Selection criteria: We included all randomised and non-randomised study designs exploring case management interventions where a comparison group was used. 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Preprint
Full-text available
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Outcome of a Controlled Trial of the Effectiveness of Intensive Case Management for Chronic Public Inebriates
Article
  • Oct 1998
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