In 2008, the Mental Health Commission of Canada launched At Home/Chez Soi, one of the most ambitious research projects ever about homelessness.
Specifically, researchers set out to test the effectiveness of "housing first,” an approach that focuses on moving homeless people into permanent housing and then providing additional supports and services as needed.
The $110-million study involved more than 2,000 homeless people with mental illness in five cities, with participants randomly assigned to housing first or treatment as usual. Each site zeroed in on a specific sub-population: Vancouver, people with problematic substance use; Winnipeg, urban Indigenous homeless; Toronto, ethno-racialized populations, including new immigrants; Montreal, which added a component on vocational training; Moncton, which examined the particular challenges of providing services in smaller communities.
The demonstration projects, which lasted two years, were all successful – meaning they got some homeless people off the streets for a while.
But they didn’t save money, as some had hoped. An economic analysis showed that for every $10 invested in housing first, $9.60 was saved in other government services. Essentially, it was a wash.
This being Canada - the land of pilot projects - some of the initiatives continued, some were expanded and some ended.
But, if the goal is to end homelessness, what really matters is whether housing first works in the long-term.
Now, researchers have published the first long-term data, covering six years, in the medical journal Lancet Psychiatry. The findings are, at once, encouraging and sobering.
The good news is that housing first continues to work. The clients with the most high needs were “stably housed” 42-per-cent more than those who had the usual services.
But that’s a relative benefit. After six years, people with support and access to housing were stably housed 85 per cent of the time in the final year of the study, compared to 60 per cent for those with treatment as usual. The retention rates drop off over time.
This is a reminder that people who have severe mental illness (often untreated or under-treated) have difficult lives. Despite some notable success stories, most people don’t magically get better when housing is available.
On the surface, tackling homelessness by housing people seems glaringly self-evident.
But people with severe mental-health issues, substance-use disorders and the other illnesses and social challenges that come along with them need a lot of support.
Housing first is a way to provide that support – be it intensive case management, assertive community treatment or other approaches – in a coherent manner.
While the housing-first approach is not a panacea, it’s certainly preferable to our well-ingrained approaches such as shelters, which, by providing only temporary accommodation, perpetuate homelessness.
People who are housed rather than sheltered have more agency (for example, shelters ban drugs and alcohol, giving people no choice in the matter), and stability provides more opportunities for recovery.
The economic analysis that accompanies the new six-year study is not yet complete, but we can guess it won’t show dramatic savings. Again, that doesn’t much matter.
Homelessness is expensive, individually and collectively. It takes a $7-billion bite out of the economy annually.
About 30,000 people experience homelessness in Canada on any given night – 235,000 over the course of a year – and about one in 10 are chronically on the streets.
An analysis by the Homes First Society found that chronically homeless people accumulate about $161,000 a year in costs when you consider medical care, interactions with police (up to one in four calls involve homeless people) and the criminal justice system, shelter costs and social supports like disability payments.
Remember, living on the streets is quite unhealthy, and homeless people are often arrested on petty nuisance charges such as trespassing, public urination and shoplifting, and find themselves in an endless revolving door of streets, shelter and jail.
A month in provincial jail costs about $9,400, in a hospital ward $13,900 and in a shelter $2,129. Social housing costs an average of $1,545. But supports are also required.
People living on the streets are not lost causes. Rather, they are people society has neglected. More than anything, life on the streets is cruel and undignified.
Housing first is a way of saying we haven’t given up on people and on the belief that homelessness can be, if not eliminated, at least managed more effectively and humanely.
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