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Housing First

strength of evidence

Considerable reliable evidence

Cost effectiveness

No cost effectiveness studies available

Impact

Multiple high quality studies show a positive impact

What is this intervention?

Housing First offers accommodation to homeless people with multiple and complex needs with minimal obligations or conditions being placed upon the participant. Housing First provides safe and stable housing to all individuals, regardless of criminal background, mental instability, substance abuse, or income.

Housing First programmes share some common principles: (1) the participant is provided housing immediately, with minimal conditions and no obligation to prove they are ready for independent housing; (2) the client makes the decisions around the location of the housing and the services they receive; (3) support and services to aid the individual’s recovery are provided in line with the clients wishes; (4) social integration with the local community and meaningful engagement with positive activities is encouraged.


What is its goal?

The primary goal of Housing First is to provide homeless people with complex needs with access to safe and stable long-term accommodation. Once settled in their home, the aim is that they will engage with support services and treatment, which in turn will lead to recovery, and ultimately improved wellbeing and integration into the wider community.

Homeless people often lead very chaotic lives and have multiple and complex needs. These factors make it difficult for them to engage in treatment and support to recover and move away from homelessness. By providing immediate accommodation with minimal conditions, Housing First provides homeless people with complex needs with the stability to help them engage with services and begin their recovery. Many alternative housing programmes require a commitment to treatment before accommodation can be accessed, which can lead to the homeless person rejecting the offer of support.

Housing First uses a client-centred approach promoting empowerment and participant satisfaction. The individual makes their own choices about where they live and the type of support they wish to receive.


What does the evidence tell us?

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Housing First programmes produce positive effects relating to housing stability, crime, and employment. These findings are consistent across the included studies and durable over time.

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Cost data are available but there are no cost effectiveness studies.

Where does the evidence come from?

Of the 30 studies included in this summary, 29 were conducted in the US, while a systematic review included studies from Australia, Finland, and the US. Various study designs are included in this summary:

  • 3 systematic reviews
  • 5 RCTs (n=8,001)
  • 3 quasi-experimental designs (n=377)
  • 3 mixed-method designs (2 studies report effects on 2,233 participants; one study not reported)
  • 3 qualitative designs (n=626)
  • 2 case-control studies (n=107)
  • and one cohort study (n=91).

Six studies measured one outcome in their evaluation of Housing First programmes (20%); ten studies measured two outcomes (33%); while the remaining 14 studies measured three or more outcomes (47%).

Of the 30 included studies, 21 measured outcomes relating to health and substance misuse; 20 measured outcomes related to housing stability; 14 looked at capabilities and wellbeing; nine were interested in access to services; seven measured outcomes related to justice including crime; four looked at the effects of Housing First on employment and income; and five measured the cost of the intervention.

The effectiveness of Housing First is measured across this range of outcomes at various time points. The longest follow-up of included participants was 47 months (three years 11 months).



Which groups does it affect?

Various

The participants included in the summarised Housing First programmes were varied. The majority of studies included participants who have or had a recent history of mental illness; participants who have substance abuse issues; and participants who have complex needs including a dual diagnosis. Less frequently occurring participants in this category of programmes are ex-prisoners, young people, veterans, people with disabilities, and those discharged from health facilities.

Which outcomes does it affect? 

Health and Substance misuse

For outcomes related to health and substance misuse, the benefits of Housing First are generally inconclusive. Regarding substance misuse treatment, one study reported that 52% of Housing First participants remained in methadone treatment at a three-year follow-up compared to 20% of the control group. However, another study found that at their two-year follow-up use of substance misuse treatment was significantly higher for the control group. Three studies found no reduction in substance use, which remained the case at the 24-month follow-up (one study). One study found that the Housing First group had significantly lower rates of substance misuse. One study measured suicide attempts and found that the Housing First programme did not reduce the rate of suicide attempts, measured at two-year follow-up.

Housing Stability

All studies that measured housing stability reported positive effects. One study reported that the young people included in the Housing First programme were stably housed for 65% of the time, compared to 31% of the young people receiving usual treatment. In another study, the results were even more impressive with 90% of the Housing First participants housed at the one-year follow-up, compared to 35% of the control group. One study followed HF participants for three years and found that the rate of housing retention was 68% compared to 3% of the control group, while another study followed the Housing First participants for almost four years (47 months) and found that the majority of them had maintained stable housing. These findings are consistent and the studies described above demonstrate that these effects are maintained over a relatively long period.

Capabilities and Wellbeing

The studies that measured outcomes relating to the participants’ capabilities and wellbeing were mainly positive. Self-report measures of quality of life and positive feelings about recovery were more positive in the Housing First population and these findings were consistent in two follow-up studies at 12 and 18 months. Three studies found that the participants involved in a Housing First programme showed significant improvements in community functioning and integration and these findings were robust at a two-year follow-up interview. Conversely, one RCT measuring the effects of Housing First across 950 participants found that, although gains in community functioning and quality of life were measured in year one, by year two these gains had dropped.

Justice

Two studies reported that Housing First was more effective than usual care in terms of decreasing criminal activities and incarceration, and findings were maintained at a one-year follow-up. No negative effects of Housing First on these outcomes were reported.

Employment

Regarding employment and income, findings demonstrated that in a study with a median follow-up of two years Housing First did not appear to significantly increase income. However, among Housing First participants, people who were already employed at baseline, males, and younger participants had greater likelihood of finding employment compared to control participants at two years.

Cost

Cost data are available but there are not enough primary studies or effectiveness reviews to provide a reliable cost-effectiveness rating at this point. The primary studies that measured the cost-effectiveness of Housing First generally demonstrated durable and consistent cost-effectiveness compared to alternative programmes. One study described how the cost of controls in alternative housing programmes averaged $2449 (USD) per person per month more than the entire costs incurred by the Housing First participants. However, a systematic review including 34 studies demonstrated inconclusive results on the cost-effectiveness of Housing First. Both shelter and emergency department costs decreased with Housing First, but the impact on hospitalisation and justice costs were less certain. The review also revealed that although studies using a pre-post design reported a net decrease in overall costs with Housing First, experimental studies reported a net increase in overall costs associated with Housing First.

considerations for IMPLEMENTATION

Invest in maintaining a skilled workforce

If you are implementing a Housing First programme, ensure your team have practical, problem-solving and people skills and sufficient time to make a connection with each service user and maintain engagement. They also need to be able to build and maintain links with other organisations to ensure that service users benefit from intensive, multi-agency support.

Manage service users’ expectations

Staff should ensure that individual service users understand the ethos of Housing First, primarily that it offers unconditional, long-term support. Service users also need to have realistic expectations about what the programme can offer, particularly in terms of housing. Encourage staff to discuss the quality and location of potential housing with service users.

Explore alternative housing supply options

Access to suitable and affordable housing can be a major barrier. Many private landlords will initially be reluctant to rent to service users but some can be persuaded; compare different approaches and evaluate what works. Explore a range of move-on accommodation options and plan ahead to facilitate availability of suitable housing.

Focus on staff relationship-building skills

Develop your team’s relationship building skills to help them form closer bonds with landlords and estate agents and can help to ensure a good supply of housing stock. At the same time, ensure that their time is appropriately balanced between liaising with housing providers and their primary role as support providers.

Consider location and type of housing

Staff should consider carefully the location of the housing being offered and whether the type meets the service user’s preferences and needs. Scattered-site housing is more popular than congregate accommodation, but it can mean that service users are living far from the project and at risk of becoming more isolated.

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