A Comparison of Treatment Outcomes Among Chronically Homelessness Adults Receiving Comprehensive Housing and Health Care Services Versus Usual Local Care

  • Alvin S. MaresEmail author
  • Robert A. Rosenheck
Original Paper


Service use and 2-year treatment outcomes were compared between chronically homelessness clients receiving comprehensive housing and healthcare services through the federal Collaborative Initiative on Chronic Homelessness (CICH) program (n = 281) a sample of similarly chronically homeless individuals receiving usual care (n = 104) in the same 5 communities. CICH clients were housed an average of 23 of 90 days (52%) more than comparison group subjects averaging over all assessments over a 2-year follow-up period. CICH clients were significantly more likely to report having a usual mental health/substance abuse treater (55% vs. 23%) or a primary case manager (26% vs. 9%) and to receive community case management visits (64% vs. 14%). They reported receiving more outpatient visits for medical (2.3 vs. 1.7), mental health (2.8 vs. 1.0), substance abuse treatment (6.4 vs. 3.6), and all healthcare services (11.6 vs. 6.1) than comparison subjects. Total quarterly healthcare costs were significantly higher for CICH clients than comparison subjects ($4,544 vs. $3,326) due to increased use of outpatient mental health and substance abuse services. Although CICH clients were also more likely to receive public assistance income (80% vs. 75%), and to have a mental health/substance provider at all, they expressed slightly less satisfaction with their primary mental health/substance abuse provider (satisfaction score of 5.0 vs. 5.4). No significant differences were found between the groups on measures of substance use, community adjustment, or health status. These findings suggest that access to a well funded, comprehensive array of permanent housing, intensive case management, and healthcare services is associated with improved housing outcomes, but not substance use, health status or community adjustment outcomes, among chronically homeless adults.


Chronic homelessness Supported housing Service use Treatment outcomes 



The CICH Funder’s Group representing HUD (PD&R and SNAPS), HHS (ASPE), and VA provided essential support and guidance to this evaluation. The CICH evaluation has been completed and the Federal Government is no longer involved. The views presented here are those of the authors, alone, and do not represent the position of any federal agency or of the United States Government. We wish to specifically thank the CICH evaluation site coordinators: Joyce Jones and Daniel White (Chattanooga), Eugene Herskovic (Chicago), Juanita Wilson (Columbus), Richard DiBlasio (Denver), Daniel Robbin and Elaine Stein (Ft. Lauderdale), John Nakashima (Los Angeles), Phyllis Larimore (Martinez), Julie Irwin (New York), Vincent Kane and Kimberly Lewis (Philadelphia), Lawrence Brennan (Portland), and Charlene Nason (San Francisco). We would also like to acknowledge Joe Morrissey and Martha Burt for providing assistance with survey construction and study design issues. Brandi Williams coordinated data management at the VA Northeast Program Evaluation Center (NEPEC), and computer programming support was provided by Dennis Thompson. Patricia Mares assisted with editing and proofreading.


  1. Anderson, L. A., & Dedrick, R. F. (1990). Development of the Trust in Physician Scale: A measure to assess the interpersonal trust in patient-physician relationships. Psychological Reports, 67, 1091–1100.PubMedGoogle Scholar
  2. Bond, G. R., Drake, R. E., Mueser, K. T., & Latimer, E. (2001). Assertive Community Treatment for people with severe mental illness: Critical ingredients and impact on patients. Disease Management Health Outcomes, 9(3), 141–159.CrossRefGoogle Scholar
  3. Burt, M. R. (2007). The Skid Row Collaborative-2003–2007: Process evaluation. Washington, DC: Urban Institute.Google Scholar
  4. Burt, M. R., Aron, L. Y., Douglas, T., Valente, J., Lee, E., & Iwen, B. (1999). Homelessness: Programs and the people they serve: Findings of the National Survey of Homeless Assistance Providers and Clients. Washington, DC: Urban Institute.Google Scholar
  5. Burt, M. R., Aron, L. Y., Lee, E., & Valente, J. (2001). Helping America’s homeless: Emergency shelter or affordable housing?. Washington, D.C.: The Urban Institute Press.Google Scholar
  6. Central City Concern. (2010). Community Engagement Program. Retrieved on 12/15/2010 at
  7. Center for Mental Health Services. (2001). The CMHS housing initiative. Rockville, MD: Substance Abuse and Mental Health Services Administration.Google Scholar
  8. Chattanooga Regional Homeless Coalition. (2008). The blueprint to end homelessness in the Chattanooga region. Appendix C. Retrieved on 12/15/2010 at
  9. Cheng, A.-L., Lin, H., Kasprow, W., & Rosenheck, R. A. (2007). Impact of supported housing on clinical outcomes: Analysis of a randomized trial using multiple imputation technique. Journal of Nervous and Mental Disease, 195(1), 83–88.PubMedCrossRefGoogle Scholar
  10. Coldwell, C. M., & Bender, W. S. (2007). The effectiveness of assertive community treatment for homeless populations with severe mental illness: A meta-analysis. American Journal of Psychiatry, 164(3), 393–399.PubMedCrossRefGoogle Scholar
  11. Culhane, D. P., Metraux, S., & Hadley, T. (2001). The impact of supportive housing for people who are homeless with severe mental illness on the utilization of the public health, corrections and emergency shelter systems. Washington, D.C.: Fannie Mae Foundation.Google Scholar
  12. Derogatis, L. R., & Spencer, N. (1982). The brief symptom index; Administration, scoring and procedure manual. Baltimore MD: Johns Hopkins.Google Scholar
  13. Dohrenwend, B. (1982). Psychiatric Epidemiology Research Interview (PERI). New York: Columbia University Social Psychiatry Unit.Google Scholar
  14. Foster, S., LeFauve, C., Kresky-Wolff, M., & Rickards, L. D. (2010). Services and supports for individuals with co-occurring disorders and long-term homelessness. The Journal of Behavioral Health Services and Research, 37(2), 239–251.CrossRefGoogle Scholar
  15. Greenberg, G. A., & Rosenheck, R. A. (2010). An evaluation of an initiative to improve coordination and service delivery of homeless services networks. The Journal of Behavioral Health Services and Research, 37(2), 184–196.CrossRefGoogle Scholar
  16. Heslin, K. C., Andersen, R. M., & Gelberg, L. (2003). Case management and access to services for homeless women. Journal of Health Care for the Poor and Underserved, 14(1), 34–51.PubMedGoogle Scholar
  17. HomeBase/The Center for Common Concerns. (2005). Responding to Chronic Homelessness Project profile. San Francisco. Retrieved on 12/15/2010 at
  18. Katz, A. H. (1963). Social adaptation in chronic illness: A study of hemophilia. American Journal of Public Health and the Nation’s Health, 53(10), 1666.PubMedCrossRefGoogle Scholar
  19. Kertesz, S. G., Crouch, K., Milby, J., Cusimano, R. A., & Schumacher, J. (2009). Housing first for homeless persons with active addiction: Are we overreaching? The Milbank Quarterly, 87(2), 495–534.PubMedCrossRefGoogle Scholar
  20. Kresky-Wolff, M., Larson, M. J., O’Brien, R. W., & McGraw, S. A. (2010). Supportive housing approaches in the Collaborative Initiative to Help End Chronic Homelessness (CICH). The Journal of Behavioral Health Services and Research, 37(2), 213–225.CrossRefGoogle Scholar
  21. Kuhn, R., & Culhane, D. (1998). Applying cluster analysis to test a typology of homelessness by pattern of shelter utilization: Results from the analysis of administrative data. American Journal of Community Psychology, 26(2), 207–232.PubMedCrossRefGoogle Scholar
  22. Lehman, A. (1988). A quality of life interview for the chronically mentally ill. Evaluation and Program Planning, 11, 51–62.CrossRefGoogle Scholar
  23. Mares, A. S., & Rosenheck, R. A. (2007). HUD/HHS/VA Collaborative Initiative to Help End Chronic Homelessness national performance outcomes assessment preliminary client outcomes report. West Haven, CT: Northeast Program Evaluation Center. Retrieved on 12/15/2010 at
  24. Mares, A. S., & Rosenheck, R. A. (2009). HUD/HHS/VA Collaborative Initiative to Help End Chronic Homelessness national performance outcomes assessment final client outcomes report. West Haven, CT: Northeast Program Evaluation Center.Google Scholar
  25. Mares, A. S., & Rosenheck, R. A. (2010). Twelve-month client outcomes and service use in a multisite project for chronically homelessness adults. The Journal of Behavioral Health Services and Research, 37(2), 167–183.CrossRefGoogle Scholar
  26. McGraw, S. A., Larson, M. J., Foster, S. E., Kresky-Wolff, M., Botelho, E. M., Elstad, E. A., et al. (2010). Adopting best practices: Lessons learned in the Collaborative Initiative to Help End Chronic Homelessness (CICH). The Journal of Behavioral Health Services and Research, 37(2), 197–212.CrossRefGoogle Scholar
  27. McLellan, A., Luborsky, L., O’Brien, C. P., & Woody, G. E. (1980). An improved diagnostic evaluation instrument for substance abuse patients: The Addiction Severity Index. Journal of Nervous and Mental Disease, 168, 26–33.PubMedCrossRefGoogle Scholar
  28. National Technical Assistance Center (NTAC). (2006). Unpublished summary of field notes taken during visits to CICH sites.Google Scholar
  29. Neale, M. S., & Rosenheck, R. A. (1995). Therapeutic alliance and outcome in a VA intensive case management program. Psychiatric Services, 46(7), 719–723.PubMedGoogle Scholar
  30. Nelson, G., Aubry, T., & Lafrance, A. (2007). A review of the literature on the effectiveness of housing and support, assertive community treatment, and intensive case management interventions for persons with mental illness who have been homeless. American Journal of Orthopsychiatry, 77(3), 350–361.PubMedCrossRefGoogle Scholar
  31. NOFA. (2003). Notice of funding availability for the collaborative initiative to help end chronic homelessness. Federal Register, 68(17), January 27, 2003.Google Scholar
  32. Olivet, J., McGraw, S., Grandin, M., & Bassuk, E. (2010). Staffing challenges and strategies for organizations serving individuals who have experienced chronic homelessness. The Journal of Behavioral Health Services and Research, 37(2), 226–238.CrossRefGoogle Scholar
  33. Padgett, D. K., Gulcur, L., & Tsemberis, S. (2006). Housing First services for people who are homeless with co-occuring serious mental illness and substance abuse. Research on Social Work Practice, 16, 74–83.CrossRefGoogle Scholar
  34. Post, P. A. (2008). Defining and funding the support in permanent supportive housing: Recommendations of Health Centers Serving Homeless People. Washington, DC: Corporation for Supportive Housing.Google Scholar
  35. Rickards, L. D., McGraw, S. A., Araki, L., Casey, R. J., High, C. W., Hombs, M. E., et al. (2010). Collaborative initiative to help end chronic homelessness: introduction. The Journal of Behavioral Health Services and Research, 37(2), 149–166.CrossRefGoogle Scholar
  36. Rosenheck, R. A., Lam, J., Morrissey, J. P., Calloway, M. O., Stolar, M., & Randolph, F. (2002). Service systems integration and outcomes for mentally ill homeless persons in the ACCESS program. Psychiatric Services, 53(8), 958–966.PubMedCrossRefGoogle Scholar
  37. Rosenheck, R. A., Leslie, D., Sindelar, J., Miller, E. A., Lin, H., Stroup, S., et al. (2006). Cost-effectiveness of second generation antipsychotics and perphenazine in a randomized trial of treatment for chronic schizophrenia. American Journal of Psychiatry, 163(12), 2080–2089.PubMedCrossRefGoogle Scholar
  38. Stein, L. I., & Test, M. A. (1980). Alternative to mental hospital treatment: I. Conceptual model, treatment program, and clinical evaluation. Archives of General Psychiatry, 37(4), 392–397.PubMedGoogle Scholar
  39. Tsemberis, S. (1999). From streets to homes: An innovative approach to supported housing for homeless adults with psychiatric disabilities. Journal of Community Psychology, 27(2), 225–241.CrossRefGoogle Scholar
  40. Tsemberis, S., & Eisenberg, R. F. (2000). Pathways to housing: supported housing for street-dwelling homeless individuals with psychiatric disabilities. Psychiatric Services, 51(4), 487–493.PubMedCrossRefGoogle Scholar
  41. Tsemberis, S., Gulcur, L., & Nakae, M. (2004). Housing first, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal of Public Health, 94(4), 651–656.PubMedCrossRefGoogle Scholar
  42. Tsemberis, S., Rogers, E. S., Rodis, E., Dushuttle, P., & Skryha, V. (2003). Housing satisfaction for persons with psychiatric disabilities. Journal of Community Psychology, 31(6), 581–590.CrossRefGoogle Scholar
  43. Vaux, A., & Athanassopulou, M. (1987). Social support appraisals and network resources. Journal of Community Psychology, 15, 537–556.CrossRefGoogle Scholar
  44. Ware, J. E., Kosinski, M., & Keller, S. E. (1998). How to score the SF-12 physical and mental health summary scales (3rd ed.). Lincoln, Rhode Island: Quality Metric Inc.Google Scholar
  45. Zerger, S. (2002). Substance abuse treatment: What works for homeless people? A review of the literature. Nashville, TN: National Health Care for the Homeless Council.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.College of Social WorkThe Ohio State UniversityColumbusUSA
  2. 2.VA New England Mental Illness, Research, Education and Clinical CenterWest HavenUSA
  3. 3.Departments of Psychiatry, Epidemiology and Public HealthYale Medical SchoolNew HavenUSA

Personalised recommendations