Cameron Zenger and Faculty Mentor: Paul Godfrey, Department of Organizational Leadership and Strategy

Introduction

Housing is closely related to mental and physical health. Extensive research demonstrates that even relatively basic housing features such as cement floors or running water create life-altering improvements in the health of occupants. Predictably, homeless populations benefit from such interventions. Utah provides a unique environment to study the transition from homelessness to housing, and from health crises to health care. After a study revealed the cost effectiveness and savings of moving homeless people from the streets to housing, Utah implemented the Housing First program in Salt Lake City, a system that addresses homelessness by providing homeless individuals (clients) with housing as quickly as possible, and then by supplying social and medical services as needed. The clients of Housing First are the chronically homeless, individuals who have faced extended periods of homelessness, and also suffer from mental and/or substance abuse issues that have rendered more traditional treatment plans ineffective. This study provides an initial assessment of the ways that the Housing First Initiative has impacted the health outcomes and health-seeking behaviors among clients served by the program, with the intent of catalyzing further and more focused research on the program and the problems it seeks to address.

Methodology

I conducted a semi-structured interview protocol with six clients of the Housing First program and with eight case managers from the Road Home and HiFI (Housing First for Individuals). The Road Home and HiFI employ the case managers and support staff in charge of implementing Housing First. The focus of the study was on the individual narrative, and also the generalizability of experience. Although this study has no control group of individuals who didn’t receive housing, the clients had failed out of housing again and again before finally stabilizing in a Housing First home. The historical unreliability of the client narrative made the study difficult. Chronically homeless individuals are often plagued with mental health and substance issues. However, the client observations were corroborated by both repetition and the case managers’ findings.

Results—Case Managers

All of the case managers interviewed agreed that Housing First creates substantive and positive changes in the health and health seeking behaviors of their clients. Two themes dominated the feedback about the value added by housing. In five of eight interviews, case managers argued that the house itself was integral to changes in a client’s health outcome. Homelessness is a crisis situation, and being able to close a door against homelessness is a reprieve from crisis. Clients can sleep without pervasive and reasonable fear of violence and theft. One manager discussed a certain client who had lived on the streets for twenty-two years and was afflicted with multiple chronic diseases which went untreated. Although the client mistrusted doctors and the healthcare system because of mistreatment and confusion in the past, once he was able to lock his door and secure his own safety and privacy, he was able and willing to address his health challenges. The change in health seeking behaviors was gradual, but the house allowed him to begin that process. In four interviews, the case managers emphasized the importance of the social services support that accompanied housing in the Housing First model. They argued that this “safety net” was integral to the change in health for a client. A case manager with Housing First takes clients to doctor appointments, helps clients get signed up for insurance and Medicaid/Medicare, learns their prescriptions, and ensures their clients are taking those medications. One of the tenets of the Housing First program is that no matter how many times a client is evicted or relapses, the case managers continue working with them, attempting to get them back into housing. According to the managers, the success of Housing First resides exactly in that persistence.

Results—Clients of Housing First

No two clients had the same story for how they ended up on the streets, or why they stayed there. But their reasons for moving into housing were nearly identical: their health had deteriorated to a point that they needed the safety of a home in order to survive. One client called his choice to move into housing a “necessity.” He had attempted suicide and was suffering from brain and nerve damage, and decided that he could no longer live outside, especially in the dead of winter. One woman visited the emergency room over twenty times for her health problems. Since being housed, she has support and medical attention. All clients reported that their health had improved in housing, although with some qualifications. One client joked that it was devastating to realize that his methamphetamine use had not, in fact, lead to a “tummy ache,” but rather to Hepatitis C, cirrhosis, and end-stage liver failure, for which he is receiving treatment. Sometimes, he said, just ignoring the problem was easier than dealing with it.

Discussion

Although the specifics varied, the overall narratives about health and health-seeking behaviors were remarkably parallel: housing is integral to better health outcomes for previously homeless individuals. One manager clarified this opinion pointing to a recently housed client whose coronary heart disease had taken a turn for the worse. The manager shared, “[The client] couldn’t take care of himself outside of that home. And that’s the point. If he did not have that home, he would have died.” Many times, clients will pass away within the first few years of being housed, succumbing to accumulation of years of hard living and neglected health issues. Health success in the program, then, depended entirely on the individual characteristics of a client. A house doesn’t only meet a physiological need. Health is larger and more complex than just physical. I interviewed a former convict, imprisoned in part for his alcoholism. We talked about his little dog, who sat at his side and provided much-needed companionship. The apartment we sat in, he said, was the only reason he qualified for the medication that cured his hepatitis and saved his life. But equally important, it provided him with a reason to keep on living.

Conclusion

While this research provides a snapshot of the changes in the health of Housing First clients, its scope was limited by time constraints and client access. In order to form a complete picture about how housing improves health among the homeless population in Utah, I would recommend a cohort study of clients entering the Housing First program.