Permanent supportive housing improves health outcomes

People who stayed in permanent supportive housing for two years reported better mental health, higher quality of life, reduced substance use, and less social isolation, highlighting how stable housing and tailored support can work together to improve long-term wellbeing.

Study: Housing is Health: A Longitudinal Study of Individual and Social Factors Predicting Long Term Retention and Health Outcomes in Permanent Supportive Housing. Image credit: Fuss Sergey/Shutterstock.com

A recent single-city paper published in the Journal of Community Health found that among the homeless, long-term retention in permanent supportive housing (PSH) is associated with better health outcomes and identified individual and social factors that predict housing retention.

How permanent supportive housing supports long-term recovery

Permanent supportive housing (PSH) is a community-based housing-integrated social support model for homeless people. Homelessness is a complex condition, with such individuals often requiring multiple social and medical interventions apart from the need for shelter.

The “Housing First” approach is based on the premise that stable housing is fundamental to improvement in these areas. It aims to provide stable housing irrespective of whether an individual is mentally stable or agrees to undergo treatment for substance use disorders or mental ill-health.

In addition, the PSH concept incorporates support services to deal with the high rates of chronic illness, mental health conditions, substance use, and premature mortality observed among the homeless. These services include case management, healthcare, mental health, and substance use treatment.

Support for PSH in the USA has been rising over the last two decades, considering its cost-effectiveness and comprehensive nature as an intervention for the chronically homeless. Today, it is the dominant long-term housing model for people experiencing chronic homelessness.

Long-term housing may shape health improvements

The literature has shown that PSH provides greater housing security and stability than temporary shelters. However, its impact on health remains unclear due to mixed evidence. While some studies have shown small improvements in mental health symptoms over the short term, the association of such changes with long-term retention in PSH remains unknown.

In addition, PSH residents may move out for various reasons. For instance, they may shift out to other non-PSH stable housing or return to homelessness.

Who stays in permanent supportive housing longer

Several studies suggest that retention in PSH depends on both the individual and the environment.

Individual factors include mental illness, the use of available services, substance abuse, history of homelessness, age, sex, race, income, and history of jail time. For instance, older people are more likely to stay longer in PSH, while indigenous women are less than half as likely to remain.

Environmental factors include the type of program and housing, neighborhood characteristics, housing choice, staff, and social support. Case support has been associated with retention for at least a year, as is maturation of the housing facility.

Following PSH residents to understand long-term outcomes

The current study sought evidence to guide the design of such programs, examining the impact of PSH on health outcomes and the factors predicting retention in PSH. The study included 259 residents in Santa Clara County, California, and followed them for 2 years. About 32% of the participants were White, while the rest belonged to other ethnic/racial groups.

Key findings of the study

PSH retention vs other stable housing

The odds of remaining in PSH rather than moving into other stable housing were twice as high among men compared to women. The odds were slightly greater among older people.

The odds of remaining in PSH were approximately 30% to 40% lower among those with greater mental health symptom severity, severe post-traumatic stress disorder (PTSD) symptoms, or social isolation. Higher baseline substance use was associated with a marginally significant 17% increase in the likelihood of remaining in PSH rather than moving to other stable housing.

PSH retention versus homelessness

Residents who returned to homelessness were more likely to have greater baseline mental health symptom severity.

Better health outcomes with PSH

The study suggests that longer-term retention in permanent supportive housing is associated with better health outcomes. The findings support the idea that stable housing can serve as an important social determinant of health, rather than merely providing shelter.

Long-term PSH residents reported significantly better quality of life and greater satisfaction with their health. They had less severe mental health symptoms and PTSD. Behavioral health also improved, with participants reporting reduced substance use.

Social health outcomes also showed a positive association with PSH. Residents reported less social isolation. No statistically significant differences were observed across age, sex, or race.

Policy implications

The findings suggest that for people with histories of homelessness and complex health needs, PSH may do more than just prevent homelessness; it may help create the stability that supports improved or maintained health over the long term.

The authors note that the current coordinated entry system does not always match residents to PSH sites that best meet their supportive service needs. This is linked to lower retention rates caused by unmet needs. For instance, homeless individuals with substance use disorders and greater mental health needs might be better supported by PSH sites with appropriate services rather than the first available PSH facility.

Another issue they flag is the fact that supportive services for mental ill-health and substance use are mostly provided by third-party organizations. This leads to fragmented services, staff overload, and tight budgets. Miscommunication or logistical issues between PSH property managers and services staff may reduce access to or use of such services. As a result of such factors, “PSH staff report low confidence in on-site overdose prevention interventions.”

Building closer relationships, coordinating resource sharing between service providers and property staff, and providing additional training could help address these issues. Adequate on-site services would raise operational costs but would be better used by residents, as demonstrated by prior research.

According to the authors, PSH residents could be linked with expanded mental health and substance use services such as the California-based Full Service Partnership programs, complete with 24/7 crisis intervention services. The authors also highlight the need for stronger support services and better facility design that promotes social interaction and community building.

Single-city study limits wider applicability

The study provides evidence that longer PSH retention is linked to better healthcare outcomes. However, it has several limitations. 

The participants came from a single city, limiting its generalizability. Data collection occurred in part during the coronavirus disease 2019 (COVID-19) lockdown, which affected follow-up success and reduced the final sample size.

Although the study initially included 259 residents, only 57 participants who remained in PSH completed health assessments at both baseline and the two-year follow-up, reducing the statistical power of the analyses examining changes in health outcomes over time.

Relatively few residents returned to homelessness, limiting the study’s statistical power to identify factors that predicted remaining in PSH rather than returning to homelessness. The reasons for moving out of PSH to other stable housing remain unclear.

Stable housing supports healthier long-term outcomes

Long-term retention in permanent supportive housing is linked to better health outcomes. Both individual and environmental factors affect the retention rate.

The authors suggest that PSH should be treated as part of the healthcare intervention for homelessness, rather than as a separate component alongside housing. Their rationale is that PSH provides not only housing but a stable and supportive environment that may promote better health and wellbeing.

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