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Housing as a remedy for chronic homelessness.

Few sights are as distressing as a person living on the streets, under a freeway or in a bus shelter, in a cardboard box or a makeshift tent, pushing a wagon of possessions or draped in newspapers as protection against an oncoming rain. The chronically homeless have a high prevalence of mental illness, substance use, and physical health problems, as well as higher use of emergency department visits, hospitalization days, and mortality.1 Ten years ago the dominant approach for addressing homelessness was a Continuum of Care approach, also known as a treatment-first or stepwise approach. It was assumed that homeless persons were not ready to be housed, that they first needed to achieve sobriety, comply with psychiatric treatment, and learn the skills of independent living.2 Instead, best practice was to engage homeless persons with street outreach workers, enroll them in local economic assistance (ie, welfare or general assistance), encourage them to seek needed medical care, and direct them to substance abuse and mental health treatment. Individuals who progressed through these steps would be ready to be housed, usually in congregate transitional settings, which can be more challenging to live in for some people than independent housing because it requires interacting with a community of other clients and staff. If they did well, they would bemoved to permanent housing. Not surprisingly, few persons were able to progress through the continuum to be housed. Sobriety is difficult to achieve under the best of circumstances, let alone while living under the freeway. Gradually, the Continuum of Care approach has been replaced by Housing First as the dominant approach. In this model, homeless participants are housed first without being required to achieve specificmilestones.Once inhousing, case managers and nurses help patients to obtain needed substance abuse, mental health, and physical health treatment. Studies comparing Housing First models with usual care and wait-list controls,3,4 a continuum of care model,2 or a treatment-first5 model have reported that Housing First reduces homelessness,2,5 decreases alcohol use among persons with severe alcohol problems,4 decreases hospitalization and emergency department visits,3 and decreases service costs.4 In this issue of JAMA, Stergiopoulos and colleagues6 report the findings from their study that tested a Housing First interventionof scattered-sitehousing forhomelesspersons living in 4 Canadian cities. With scattered-site housing, homelesspersonsareplaced inavarietyofdifferentbuildings, rather than all being housed in a single building. Using adaptive randomization techniques, 689 persons were randomized to receivehousingsubsidies (interventiongroup)and509were randomizedtousual care (usual caregroup;withaccess tohousing and social supports available in their community). Casemanagers provided support to residents in the intervention group including referring them to needed services. The investigators found that persons randomized to scattered-site housing spentbetween33%and50%(dependingon thecity)moredays housedover the2-yearperiodthanthose intheusualcaregroup (ie, a difference in the absolute number of days housed ranging from 224-334 days over 2 years). Despite the success of the scattered-site housingmodel in keeping participants housed (the primary outcome of the study), the intervention did not improve their health-related quality of life asmeasured by the EuroQoL 5Dimensions (EQ5D)healthquestionnaire. Because staying inhousingwasvoluntary, andparticipants in the interventiongroupwerehoused substantially more days, it is safe to assume that people preferred being housed. Indeed, in an exploratory analysis, the authors report a small but statistically significant difference favoring the intervention group on generic quality of life as measured by the Lehman Quality of Life Interview 20 (QoLI20) index (an approximately 4-point between-group difference at 24months, asmeasured on a 140-point scale). Unlike the trial by Sadowski and colleagues,3 the study by Stergiopoulos et al did not find any difference between the 2 groups in the number of emergency department visits or the likelihood of being hospitalized. Thismay reflect that this population was not enrolled based on being hospitalized. With a large sample size, a randomized design, and an extensive data collection, the study confirms the ability to rapidly house and maintain previously homeless persons in housing. Demonstrating the success of a scattered-site model is important because it is much easier to implement than single-site housing. Scattered-site housing leverages empty units in existing housing stock; subsidies are provided directly to landlords by the organization sponsoring the program, thereby ensuring the landlord reliable income. Housing persons through the private market does not raise the same amount of concerns among local residents as can occur when choosing a location for a community building specifically for homeless persons. Adownsideofscattered-sitehousing is thatwiththismodel it is not economically feasible to provide as much support as canbeprovided in a single-site facilityusing anassertive community treatment model in which an interdisciplinary team ofcasemanagers,nurses,mentalhealthprofessionals,andphysicians can be located on premises to providemore intensive services. The study by Stergiopoulos et al cannot answer whether a scattered-site housing programwith casemanageRelated article page 905 Opinion