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Objectives. We examined the longitudinal effects of a Housing First program for homeless, mentally ill individuals' on those individuals' consumer choice, housing stability, substance use, treatment utilization, and psychiatric symptoms.
Methods. Two hundred twenty-five participants were randomly assigned to receive housing contingent on treatment and sobriety (control) or to receive immediate housing without treatment prerequisites (experimental). Interviews were conducted every 6 months for 24 months.
Results. The experimental group obtained housing earlier, remained stably housed, and reported higher perceived choice. Utilization of substance abuse treatment was significantly higher for the control group, but no differences were found in substance use or psychiatric symptoms.
Conclusions. Participants in the Housing First program were able to obtain and maintain independent housing without compromising psychiatric or substance abuse symptoms. (Am J Public Health. 2004;94:651-656)
Current rates of homelessness in New York City are the highest ever documented.1 A small percentage of this population remains chronically homeless, either living on the streets or other public places or intermittently using emergency rooms, shelters, jails, and other short-term services, but never successfully ending their homelessness.2 Members of this chronically homeless group typically have a history of mental illness,3 compounded by substance use disorders.4,5,6 Although much is known about the chronically homeless, these individuals continue to elude existing program efforts.
The predominant service delivery model designed to address the needs of this chronically homeless population, called the Continuum of Care, consists of several program components. It begins with outreach, includes treatment and transitional housing, and ends with permanent supportive housing. The purpose of outreach and transitional residential programs is to enhance clients' "housing readiness" by encouraging the sobriety and compliance with psychiatric treatment considered essential for successful transition to permanent housing. This approach assumes that individuals with severe psychiatric disabilities cannot maintain independent housing before their clinical status is stabilized. Furthermore, the model presumes that the skills a client needs for independent living can be learned in transitional congregate living. Research in psychiatric rehabilitation indicates, however, that the most effective place to teach a person the skills inquired for a particular environment is within that actual setting.7
Consumers' perception of the Continuum of Care offers another divergent perspective. Consumers experience the Continuum as a series of hurdles-specifically, ones that many of them...