\r\n
Housing, income assistance, and case management improve housing outcomes for persons with lived experience of homelessness
\r\n
Permanent supportive housing interventions appear to improve short- and long-term housing stability for persons with lived experience of homelessness. Income assistance and intensive mental health interventions show moderate benefits in housing outcomes, and evidence on standardised case management suggests potential to improve housing stability. Peer support alone does not impact housing stability. Inconsistent results on mental health, substance use and other social outcomes require additional research.
\r\n
What is this review about?
\r\n
Homelessness greatly magnifies morbidity and mortality and worsens preventable health and social inequities. We present evidence on a wide range of interventions targeting homelessness: permanent supportive housing (PSH); income assistance; standard case management and peer support; mental health interventions such as assertive community treatment (ACT), intensive case management (ICM), critical time intervention (CTI), and injectable antipsychotics; and substance use interventions such as supervised consumption facilities, managed alcohol programmes and pharmacological interventions for opioid use disorders.
\r\n
What is the aim of this review?
\r\n
This systematic review and meta-analysis examines the effects of a broad range of interventions on housing stability, mental health, quality of life, substance use, hospitalisations and health service utilisation, as well as employment and income among individuals with lived experience of homelessness.
\r\n
What studies are included?
\r\n
We included 86 studies across 128 publications among individuals with lived experience of homelessness. The vast majority of studies followed a randomised controlled design. Most took place in the USA (73). The rest were undertaken in Canada (8), the UK (2), The Netherlands (2) and Australia (1).
\r\n
What are the main findings of this review?
\r\n
Studies on housing interventions showed significant improvements in housing stability, with potential sustained benefit for up to 5.4 years.
\r\n
Income assistance interventions also appeared to be effective in improving housing outcomes. Standard case management carried the potential to improve housing, with mixed evidence suggesting its added benefit, whereas peer support programmes demonstrated no impact on housing relative to usual care.
\r\n
Intensive mental health interventions demonstrated moderate improvements in housing stability and often worked in synergy with permanent housing.
\r\n
Cost-analysis studies of housing interventions reported mixed economic results. Income assistance was associated with increased costs that were offset by its added benefits. Intensive mental health interventions, such as ACT, ICM, and CTI, were found to be economically beneficial. In contrast, standard case management did not offer good value for money compared to other interventions.
\r\n
No economic evidence was found for peer support, injectable antipsychotics or substance use interventions.
\r\n
What do the findings of the review mean?
\r\n
Permanent supportive housing may improve and maintain housing stability. Further examination of implementation barriers of housing programmes is needed to inform decisionmakers.
\r\n
Income assistance, standard case management and intensive mental health interventions carry the potential to improve housing outcomes, but more research is needed to examine their mechanisms. Our results on mental health and other social outcomes were mixed and inconclusive. This could be attributed to the significant proportion of study participants who were suffering from chronic mental health or substance use conditions.
\r\n
What are the implications for research and policy?
\r\n
More longitudinal research is needed to better examine non-housing outcomes. Furthermore, poor reporting, lack of blinding and allocation bias reduced the certainty and precision of our results.
\r\n
There are other ongoing gaps that warrant more investigation, including peer support programmes, community substance use interventions, and programmes targeted towards special populations. Further examination of implementation barriers of housing programmes is also needed.
\r\n
The absence of evidence on substance use interventions for people living with homelessness represents an important research and policy gap.
\r\n
How up-to-date is this review?
\r\n
The review authors searched for studies that had been published up to 10 February 2020.