In 2009, The Journal of the American Medical Association published a study done by Mary E. Larimer, PhD; Daniel K. Malone, MPH; and Michelle D. Garner, MSW, PhD that worked to examine the health costs and savings associated with the “Housing First” model for chronically homeless individuals.
Objective To evaluate association of a “Housing First” intervention for chronically homeless individuals with severe alcohol problems with health care use and costs.
Design, Setting, and Participants 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.
Main Outcome Measures 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.
Results 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.
Conclusions 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.
Concerns about high public system costs incurred by chronically homeless individuals have inspired nationwide efforts to eliminate chronic homelessness.1,2 Homeless people have high barriers to health care access generally but use acute care services at high rates.3– 5 Mortality rates among homeless adults are 3 or more times that of the general population.6,7
Chronically homeless people with severe alcohol problems, sometimes referred to as chronic public inebriates, are highly visible on the streets and are costly to the public through high use of publicly funded health and criminal justice systems resources.8– 12 Typical interventions such as shelters, abstinence-based housing, and treatment programs fail to reverse these patterns for this population.10,13 Health conditions and mortality rates within this population are similar to those found in developing countries.14,15 Average age at death is estimated to be 42 to 52 years, with 30% to 70% of deaths related to alcohol.7,16,17
The provision of housing reduces hospital visits, admissions, and duration of hospital stays among homeless individuals,5,18,19 and overall public system spending is reduced by nearly as much as is spent on housing.19 One type of supportive housing, called Housing First, removes the requirements for sobriety, treatment attendance, and other barriers to housing entrance.20 Thus far, Housing First (HF) approaches have primarily targeted homeless people with serious mental illnesses and co-occurring substance use disorders.20,21
An HF program in Seattle—known as 1811 Eastlake—targets homeless adults with severe alcohol problems who use local crisis services at the highest levels. The project has been controversial because residents are allowed to drink in their rooms. The current study evaluated outcomes of the project on public use and costs for housed participants compared with wait-list controls and secondarily evaluated changes in reported alcohol use for housed participants and the effects of housing duration on service use.
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