Housing First is a Matter of Health


Vanessa Davis, Housing for Health Lead, Kaiser Permanente
Ann Oliva, Chief Executive Officer, National Alliance to End Homelessness

Managing a chronic illness while homeless can be an impossible challenge. This was the case for Rosa Williams, 60, who was living in her car while trying to manage stage 3 kidney disease and diabetes. “I went from living with my son to [living in] a hotel, and then I ran out of money and got very sick,” said Williams. “Just imagine me living in a car and being really sick with all my medications. It was horrible.”

Chronic homelessness is linked to poor health outcomes and higher risk of mortality. People experiencing homelessness often experience trauma on the street or in shelters, which creates long-standing adverse impacts. Having safe, stable housing is essential to a person’s health. Without a safe place to call home, it’s nearly impossible to focus on basic health and medical needs.

Fortunately, Kaiser Permanente’s care team referred Rosa to its Project HOME initiative. Project HOME uses a “Housing First” approach, which prioritizes giving people experiencing homelessness – particularly those with acute needs – stable, permanent housing without preconditions. Once housed, they are then connected with the social services, mental health, or substance use disorder services that they need.

Housing First

Originally introduced in 1992, Housing First gained traction at the federal level in 2003 as an evidence-based approach to reduce, prevent, and end chronic homelessness in the United States. Between 2010 and 2016, Housing First became a core organizing principle in the federal government’s response to housing. The overall number of people experiencing homelessness declined each year, resulting in a total decline of 13.1 percent. There were even more dramatic reductions among certain subpopulations:

  • Chronic homelessness fell 27 percent;
  • Veterans’ homelessness was cut by nearly half and was eliminated in dozens of places across the country; and
  • Homelessness among families with children decreased 23 percent.

In 2017, the number of people becoming homeless each year outpaced the number of people exiting homelessness to permanent housing. Some people inferred that these increases resulted from Housing First approaches, often misunderstanding the fundamental tenets of Housing First as “housing only,” rather than “housing first along with other supports.”

Increasing levels of homelessness result from many underlying systemic and economic factors, however, that are driving large numbers of people into homelessness. This makes it difficult for any homelessness intervention to handle the increased need. Not enough affordable housing is being built or preserved, and economic challenges are leading to increasing numbers of people entering homelessness. A recent study of homelessness in California found that, for most of the participants, the cost of housing has simply become unsustainable.

Efforts are underway to address these underlying systemic challenges. At the same time, the nation also needs an effective system that supports people experiencing homelessness. Housing First is a best practice for getting people out of homelessness and connecting them to needed supports.

A foundation for improving health

Beginning in 2019, Kaiser Permanente funded a series of large Housing First initiatives, starting with a partnership with Bay Area Community Services to provide long-term housing for 515 homeless older adult residents in Oakland, California. The following year, Kaiser Permanente partnered with Health Share of Oregon in the Portland, Oregon metro area to help 416 homeless older adults transition into long-term housing.

Clients got housing and other services, too. Clients housed through these partnerships saw a 28 percent increase in behavioral health services, and a 37 percent decrease in emergency department utilization. This resulted in a 27 percent reduction in health care costs overall, thanks to the shift from emergency to preventive care.

Building on the success of those initiatives, Kaiser Permanente funded the three-year Housing First pilot, Project HOME, in 2022, which supports unhoused high utilizers of our care delivery system. Similar to the other programs, the program stabilizes people’s housing situations and then provides additional supports. Eligible patients are referred to community partners for housing navigation, financial assistance, and tenancy-sustaining services. A flexible fund allows service providers to pay for rent, application fees, housing deposits, and other expenses that can be barriers to rapid rehousing. Once housed, participants address their medical, mental, and behavioral health needs.

Since the program began, Project HOME patients have received an average of 48 services, including social services, care coordination, and tenancy support. Among participants, 95 percent are receiving housing navigation services, and more than 60 percent are being connected to additional social and/or health care services. Patient self-reporting shows early positive trends in physical and mental health, including reductions in stress and frequent mental distress.

For Rosa, the Housing First approach of Project HOME worked. Her Kaiser Permanente medical care teams collaborated with housing and social service providers to address her housing, social services, and medical care coordination needs. Williams settled into a 1-bedroom apartment in a senior living community, preventing her medical conditions from deteriorating.

The value of Housing First

Kaiser Permanente’s initiatives build on the evidence that Housing First works for people in crisis and allows for effective use of resources that promote public health:

  • By addressing the primary need for a place to call home, Housing First creates a foundation of stability for individuals, allowing them to focus on other aspects of their lives such as their health and well-being.
  • Housing stability leads to cost savings. People experiencing homelessness who face challenges in accessing healthcare services are more likely to use the emergency room as a primary source of medical care. When housed, individuals are in a better position to receive timely medical attention and preventive care thus reducing demand on more costly emergency departments and hospitals.

As policymakers at all levels of government discuss policies to address homelessness, the evidence of Housing First’s successes should not be ignored. Health systems, community organizations, and policymakers should continue to advance Housing First initiatives that combine voluntary services, including health care and social services, with access to housing.

Our experiences at Kaiser Permanente and the National Alliance to End Homelessness have shown us the stability, improved health and well-being, and cost savings of these Housing First approaches and their ability to improve the lives of individuals experiencing homelessness.

Housing First

Sam Tsemberis, a clinical psychologist and then founder and CEO of a homeless services agency, developed Housing First in the 1990s to focus on housing as foundational to stability and not a reward for adherence to treatments.

The Housing First approach is based on several principles:

  1. Housing with no preconditions. People shouldn’t be subject to preconditions to get housing and services, that is, people in need of housing and services shouldn’t be discriminated against on the basis of religion, income, criminal status, employment status, drug status, or sobriety.
  1. Housing and services; not housing only. People should be connected to supportive services, ranging from help with housing stability to clinical interventions, such as mental health care and treatment for substance use disorder.
  1. People are presumed ready for housing. People don’t need to prove themselves, shouldn’t languish in shelters, or spend a certain amount of time in transitional housing. Getting people into housing faster is better for them and cheaper for taxpayers.
  1. Individualized and person-driven services. People who have lived experience—who have been homeless themselves—should be heard because they usually have good ideas for helping to end homelessness. People experiencing homelessness, like all people, deserve to make choices about their own lives.