Housing status among single adults following Homelessness Prevention and Rapid Re-housing Program participation in Indianapolis

Race matters in addressing homelessness: A scoping review and call for critical research

Structural racism contributes to homelessness in the United States, as evidenced by the stark racial disparities in who experiences it. This paper reviews research at the intersections of race and homelessness to advance efforts to understand and address racial inequities. Part 1 offers a synthesis of homelessness research from the 1980s to 2015, where several scholars examined the role of race and racism despite mainstream efforts to present the issue as race-neutral. Part 2 presents the results of a systematic scoping review of research at the intersections of race and homelessness from 2016 to 2021. The 90 articles included demonstrate a growing, multidisciplinary body of literature that documents how needs and trajectories of people experiencing homelessness differ by race, examines how the racialized structuring of society contributes to homelessness risk, and explores how programs, policies, and grassroots action can address inequities. In addition to charting findings and implications, included studies are appraised against research principles developed by Critical Race Theory scholars, mapping the potential of existing research on race and homelessness to challenge racism.

Exploring the effect of case management in homelessness per components: A systematic review of effectiveness and implementation, with meta-analysis and thematic synthesis

Background

Adequate housing is a basic human right. The many millions of people experiencing homelessness (PEH) have a lower life expectancy and more physical and mental health problems. Practical and effective interventions to provide appropriate housing are a public health priority.

Objectives

To summarise the best available evidence relating to the components of case-management interventions for PEH via a mixed methods review that explored both the effectiveness of interventions and factors that may influence its impact.

Search Methods

We searched 10 bibliographic databases from 1990 to March 2021. We also included studies from Campbell Collaboration Evidence and Gap Maps and searched 28 web sites. Reference lists of included papers and systematic reviews were examined and experts contacted for additional studies.

Selection Criteria

We included all randomised and non-randomised study designs exploring case management interventions where a comparison group was used. The primary outcome of interest was homelessness. Secondary outcomes included health, wellbeing, employment and costs. We also included all studies where data were collected on views and experiences that may impact on implementation.

Data Collection and Analysis

We assessed risk of bias using tools developed by the Campbell Collaboration. We conducted meta-analyses of the intervention studies where possible and carried out a framework synthesis of a set of implementation studies identified by purposive sampling to represent the most 'rich' and 'thick' data.

Main Results

We included 64 intervention studies and 41 implementation studies. The evidence base was dominated by studies from the USA and Canada. Participants were largely (though not exclusively) people who were literally homeless, that is, living on the streets or in shelters, and who had additional support needs. Many studies were assessed as having a medium or high risk of bias. However, there was some consistency in outcomes across studies that improved confidence in the main findings.

Case Management and Housing Outcomes

Case management of any description was superior to usual care for homelessness outcomes (standardised mean difference [SMD] = -0.51 [95% confidence interval [CI]: -0.71, -0.30]; p < 0.01). For studies included in the meta-analyses, Housing First had the largest observed impact, followed by Assertive Community Treatment, Critical Time Intervention and Intensive Case Management. The only statistically significant difference was between Housing First and Intensive Case Management (SMD = -0.6 [-1.1, -0.1]; p = 0.03) at ≥12 months. There was not enough evidence to compare the above approaches with standard case management within the meta-analyses. A narrative comparison across all studies was inconclusive, though suggestive of a trend in favour of more intensive approaches.

Case Management and Mental Health Outcomes

The overall evidence suggested that case management of any description was not more or less effective compared to usual care for an individual's mental health (SMD = 0.02 [-0.15, 0.18]; p = 0.817).

Case Management and Other Outcomes

Based on meta-analyses, case management was superior to usual care for capability and wellbeing outcomes up to 1 year (an improvement of around one-third of an SMD; p < 0.01) but was not statistically significantly different for substance use outcomes, physical health, and employment.

Case Management Components

For homelessness outcomes, there was a non-significant trend for benefits to be greater in the medium term (≤3 years) compared to long term (>3 years) (SMD = -0.64 [-1.04, -0.24] vs. -0.27 [-0.53, 0]; p = 0.16) and for in-person meetings in comparison to mixed (in-person and remote) approaches (SMD = -0.73 [-1.25,-0.21]) versus -0.26 [-0.5,-0.02]; p = 0.13). There was no evidence from meta-analyses to suggest that an individual case manager led to better outcomes then a team, and interventions with no dedicated case manager may have better outcomes than those with a named case manager (SMD = -0.36 [-0.55, -0.18] vs. -1.00 [-2.00, 0.00]; p = 0.02). There was not enough evidence from meta-analysis to assess whether the case manager should have a professional qualification, or if frequency of contact, case manager availability or conditionality (barriers due to conditions attached to service provision) influenced outcomes. However, the main theme from implementation studies concerned barriers where conditions were attached to services.

Characteristics of Persons Experiencing Homelessness

No conclusions could be drawn from meta-analysis other than a trend for greater reductions in homelessness for persons with high complexity of need (two or more support needs in addition to homelessness) as compared to those with medium complexity of need (one additional support need); effect sizes were SMD = -0.61 [-0.91, -0.31] versus -0.36 [-0.68, -0.05]; p = 0.3.

The Broader Context of Delivery of Case Management Programmes

Other major themes from the implementation studies included the importance of interagency partnership; provision for non-housing support and training needs of PEH (such as independent living skills), intensive community support following the move to new housing; emotional support and training needs of case managers; and an emphasis on housing safety, security and choice.

Cost Effectiveness

The 12 studies with cost data provided contrasting results and no clear conclusions. Some case management costs may be largely off-set by reductions in the use of other services. Cost estimates from three North American studies were $45-52 for each additional day housed.

Authors' Conclusions

Case management interventions improve housing outcomes for PEH with one or more additional support needs, with more intense interventions leading to greater benefits. Those with greater support needs may gain greater benefit. There is also evidence for improvements to capabilities and wellbeing. Current approaches do not appear to lead to mental health benefits. In terms of case management components, there is evidence in support of a team approach and in-person meetings and, from the implementation evidence, that conditions associated with service provision should be minimised. The approach within Housing First could explain the finding that overall benefits may be greater than for other types of case management. Four of its principles were identified as key themes within the implementation studies: No conditionality, offer choice, provide an individualised approach and support community building. Recommendations for further research include an expansion of the research base outside North America and further exploration of case management components and intervention cost-effectiveness.

Predictors of homeless service utilization and stable housing status among Veterans receiving services from a nationwide homelessness prevention and rapid rehousing program

Homelessness prevention and rapid rehousing (RRH) programs are increasingly important components of the homeless assistance system in the United States. Yet, there are key gaps in knowledge about the dynamics of the utilization of these programs, with scant attention paid to examining the duration of homelessness prevention and RRH service episodes or to patterns of repeated use of these programs over time. To address these gaps, we use data from the U.S. Department of Veterans Affairs' (VA) Supportive Services for Veteran Families (SSVF) program-the largest program in the country providing homelessness prevention and RRH services-to assess the relationship between individual and program-level factors and exits to stable housing, length of service episodes, and patterns of repeated service use over time. We analyze data for a primary cohort of 570,798 of Veterans who received SSVF services during Fiscal Years (FY) 2012-2021, and for separate cohorts of Veterans who received SSVF prevention and RRH services, respectively, during FY 2016-2021. We find that participants' income, indicators of their health status, their use of other VA homeless programs, and rurality are consistent predictors of our outcomes. These findings have implications for how to allocate homelessness prevention and RRH resources in the most efficient manner to help households maintain or obtain stable housing.

Transitioning to independent living: Experiences of homeless young adults in rapid rehousing

Rapid rehousing (RRH) is an intervention that is being adopted nationally to assist adolescents and emerging adults who are homeless. RRH provides short-term rental assistance for independent scattered-site housing, in addition to an array of support services for approximately 12-24 months. The aim of this study is to explore the experiences of young adults (18-23 years old) who had previously been homeless and who were enrolled in RRH programs set in two urban Northeastern cities, and their subsequent preparedness for independent living. Our sample mostly consisted of non-Hispanic Black females, many of whom identified as LGBTQ. Semi-structured interviews (n = 15) were conducted after participants had been in the program for nine months - three months prior to their initial program completion date. Thematic analysis revealed three themes: the importance of tangible support, communication among all parties: staff lead the way, and "I gotta start learning to do it on my own". These domains provided essential assistance for young people to attain their goals and through this process they learned skills to live independently and transition into adulthood. These findings suggest that rapid rehousing programs and service providers should focus on these domains to facilitate successful transition to independent living for this population.

Identifying a typology of homelessness based on self-sufficiency: Implications for rapid re-housing interventions

Limited research exists on the characteristics of individuals experiencing homelessness who achieve positive housing outcomes in rapid re-housing (RRH) interventions. We aimed to identify a typology of homelessness based on Self-Sufficiency Matrix (SSM) domains and examine its relation to sociodemographic characteristics and housing placement through RRH. Homeless Management Information System data, including sociodemographics, SSM domains, and housing outcomes, were obtained for 261 Homelessness Prevention and Rapid Re-housing Program participants in Indianapolis, Indiana, from 2009 to 2012. Latent class analysis (LCA) and latent class regression (LCR) were used to identify subgroups and predict associations between the identified typology and sociodemographic variables and housing placement outcome, respectively. LCA revealed three classes based on SSM domains: "High Self-Sufficiency," "Low Socioeconomic Self-Sufficiency," and "Low Psychosocial Self-Sufficiency." LCR revealed that race significantly predicted class membership such that Black individuals had a significantly higher probability of being in the High Self-Sufficiency class than the other two classes. Latent class membership significantly predicted immediate housing placement. The Low Psychosocial Self-Sufficiency group was the least likely to exit RRH to a permanent housing placement compared to the two other subgroups. Results affirm that individuals with greater psychosocial self-sufficiency have better housing outcomes through RRH than those with more complex support needs. Future research is needed to understand factors influencing differential self-sufficiency, as measured by the SSM, among Black and White individuals.