What makes effective supportive housing, particularly for persons experiencing homelessness who have chronic mental and physical health issues?

This question came from Ryan N. via our latest website survey.

Supportive housing comes in a variety of models and addresses the individual and structural contributors to homelessness. It can be transitional or permanent, and either can be effective depending on a person’s needs. Some supportive housing provides only a few services for people who are in transition and/or need a bit of assistance, while others have a wider array of services for people who have chronic or disabling conditions.

For this latter group, permanent supportive housing has become widely considered an evidence-based practice. Indeed, supportive housing is often effective for people with physical problems, mental health issues, or both. One streets-to-home study found that of 139 tenants in a supportive housing program who needed psychiatric services, 84.2% retained their housing over a 3-year period. Out of the comparison group, only 59.6% retained housing over a 2-year period.

Supportive housing works hat
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In terms of what makes permanent supportive housing effective, there are some general guidelines that have been established regardless of who is seeking it. The Corporation for Supportive Housing (CMSH) in the United States recommends that all supportive housing have the following components:

  • Engagement
  • Outreach
  • Medical care
  • Behavioural health care
  • Case management
  • Life skills training

Furthermore, the CMSH defines permanent supportive housing as “an approach to subsidized housing designed for people with very low incomes and chronic, disabling health conditions which provides voluntary access to a flexible and comprehensive array of supportive services and places no limits on length of tenancy as long as terms and conditions of the lease or agreement are met.” 

Choice, optional services, and protection of tenancy are integral components to successful supportive housing. A 2008 U.S. Department of Housing and Urban Development assessment (HUD) found that the ability to choose permanent supportive housing is key. It doesn’t seem to matter whether a site is scattered or multi-unit—the independence of choosing one’s home makes a big difference. The organization also emphasizes including:

  • Access: People do not have to meet “readiness” criteria to be housed (as we’ve written elsewhere, Housing First is a proven, effective model)
  • Affordability: Tenants should pay no more than 30% of their income on rent
  • Integrated treatment for co-occurring disorders
    A variety of substance abuse treatment services (inpatient, outpatient, and residential)
  • Psychiatric assessment and treatment
  • Health and dental care
  • Skills training
  • Case coordination services
  • Direct provision of or referrals to other services, such as counselling, HIV services, crisis intervention, child care, job placements, et cetera

Vancouver Coastal Health’s strategy outlines similar components. A report by the Centre for Applied Research in Mental Health and Addiction at Simon Fraser University (B.C.) also highlights similar areas, as well as explores different models of supportive housing in depth. The authors also highlight the need for work to be evenly distributed among housing and service workers to ensure success.

The Mental Health Commission of Canada adds that supportive housing for people with mental health issues must go beyond treatment to be recovery-oriented. The organization’s research (as well as research from the Centre for Addictions and Mental Health [CAMH]) has showed that with effective supportive housing, people tend to visit institutions and emergency services less; and people gain more from being able to lead their own recovery.

When it comes to case management in supportive housing, there is some evidence that lower caseloads allow workers to provide better service.

People have different needs

How many services are provided and in how they’re delivered is up to housing management and varies depending on the people living there. The needs of youth, for example, are different than those of adults.

One study on 51 youth experiencing homeless in Halifax and Toronto found that “…residing in supported housing contexts, as compared with independent housing, reported better community integration, quality of life, and mental health.” Another study amongst persistently homeless male youth found that participants thrived in scattered-site, integrated apartments with some elements of a custodial model.

Another study found independent housing with integrated support systems very effective for mothers and children. With growing numbers of families experiencing homelessness, supportive housing needs to consider the multiple needs of adults and children.

There are concerns among professionals that there hasn’t been enough research or implementation of supportive housing in northern and rural communities. While these studies are in progress, it’s important to remember that most of what we know about what makes supportive housing effective is based in work done in large urban areas.

We need more supportive housing

Across the country, supportive housing is lacking. According to CAMH, there are only 10,000 supportive housing units in Ontario with waitlists lasting from one to six years, depending on their location, and growing. Often, people wait for years in hospitals or other institutions for appropriate, affordable housing. 

In order for supportive housing to be truly effective, there simply needs to be more of it. The authors of The State of Homelessness in Canada 2014 report include a proposal that would “…produce 4,000+ new units annually of affordable housing for very low-income households, prioritizing permanent supportive housing for those with complex needs living in extreme poverty, for a ten-year total of 40,000 units.”

For more information, check out SAMSHA’s permanent supportive housing kit and the Center of Urban Studies’ guide to developing supportive housing.

This post is part of our Friday "Ask the Hub" blog series. Have a homeless-related question you want answered? E-mail us at thehub@edu.yorku.ca and we will provide a research-based answer.

Photo: Housing Works